Radical Prostatectomy Procedures Research Articles

Peri-operative outcomes following radical prostatectomy in the setting of advanced prostate cancer.

To compare the peri-operative outcomes of radical prostatectomy (RP) for locally advanced, node-positive, and metastatic prostate cancer (PCa), as determined through pathological staging, using the American College of Surgeons National Surgical Quality Improvement Project. We identified RP procedures performed between 2019 and 2021. Patients were stratified by pathological staging to compare the effect of locally advanced disease (T3-4), node positivity (N+) and metastasis (M+) vs localised PCa (T1-2 N0 M0). Baseline demographics and 30-day outcomes, including operating time, length of hospital stay (LOS), 30-day mortality, readmissions, reoperations, major complications, minor complications and surgery-specific complications, were compared between groups. Pathological staging data were available for 9276 RPs. Baseline demographics were comparable. There was a slightly higher rate of minor complications in the locally advanced cohort, but no significant difference in major complications, 30-day mortality, readmissions, or rectal injuries. Node positivity was associated with longer operating time, LOS, and some slightly increased rates of 30-day complications. RP in patients with metastatic disease appeared to be similarly safe to RP in patients with M0 disease, although it was associated with a longer LOS and slightly increased rates of certain complications. For patients with pathologically determined locally advanced, node-positive, and metastatic PCa, RP appears to be safe, and is not associated with significantly higher rates of 30-day mortality or major complications compared to RP for localised PCa. This study adds to the growing body of literature investigating the role of RP for advanced PCa; further studies are needed to better characterise the risks and benefits of surgery in such patients.

Marked variations in medical provider and out-of-pocket costs for radical prostatectomy procedures in Australia.

Objectives Unwarranted clinical variations in radical prostatectomy (RP) procedures are frequently reported, yet less attention is given to the variations in associated costs. This issue can further widen disparities in access to care and provoke questions about the overall value of the procedure. The present paper aimed to delve into the disparities in hospital, medical provider and out-of-pocket costs for RP procedures in Australia, discussing plausible causes and potential policy opportunities. Methods A retrospective cohort study using Medibank Private claims data for RP procedures conducted in Australian hospitals between 1 January 2015 and 31 December 2020 was undertaken. Results Considerable variations in both medical provider and out-of-pocket costs were observed across the country, with variations evident between different states or territories. Particularly striking were the discrepancies in the costs charged by medical providers, with a notable contrast between the 10th and 90th percentiles revealing a substantial difference of A$9925. Hospitals in Australia exhibited relatively comparable charges for RP procedures. Conclusions Initiatives such as enhancing transparency regarding individual medical provider costs and implementing fee regulations with healthcare providers may be useful in curbing the variations in RP procedure costs.

Antimicrobial Prophylaxis in Robot-Assisted Laparoscopic Radical Prostatectomy: A Systematic Review.

It remains unclear whether antibiotic prophylaxis (AP) should be recommended or discouraged in robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer (PCa). The development of microbial resistance and side effects are risks of antibiotic use. This systematic review (SR) investigates the evidence base for AP in RALP. A systematic literature search was conducted until 12 January 2023, using Embase, MEDLINE, Cochrane CENTRAL, Cochrane CDSR (via Ovid) and CINAHL for studies reporting the effect of AP on postoperative infectious complications in RALP. Of 436 screened publications, 8 studies comprising 6378 RALP procedures met the inclusion criteria. There was no evidence of a difference in the rate and severity of infective complications within 30 days after RALP surgery between different AP protocols. No studies omitted AP. For patients who received AP, the overall occurrence of postoperative infectious complications varied between 0.6% and 6.6%. The reported urinary tract infection (UTI) rates varied from 0.16% (4/2500) to 8.9% (15/169). Wound infections were reported in 0.46% (4/865) to 1.12% (1/89). Sepsis/bacteraemia and hyperpyrexia were registered in 0.1% (1/1084) and 1.6% (5/317), respectively. Infected lymphoceles (iLC) rates were 0.9% (3 of 317) in a RALP cohort that included 88.6% pelvic lymph node dissections (PLND), and 3% (26 of 865) in a RALP cohort where all patients underwent PLND. Our findings underscore that AP is being administered in RALP procedures without scientifically proven evidence. Prospective studies that apply consistent and uniform criteria for measuring infectious complications and antibiotic-related side effects are needed to ensure the comparability of results and guidance on AP in RALP.

Early and late urinary continence outcomes after unilateral and bilateral nerve-sparing robot-assisted radical prostatectomy: A retrospective multicentre cohort study in Japan (the MSUG94 group).

The impact of unilateral and bilateral nerve-sparing robot-assisted laparoscopic radical prostatectomy (NS-RARP) procedures on continence and the time to continence recovery have not been established. We retrospectively reviewed a total of 2801 patients who underwent RARP in 9 institutions. Procedures were classified as NS or non-NS; NS procedures were further classified as unilateral or bilateral. The recovery of continence was analysed using propensity score matching method. The pad-free rates at 12months after surgery were higher in the NS group (95% confidence interval of odds ratio, 1.06-1.51). Pad-free rates at all time points within 12months of surgery did not significantly differ between the unilateral and bilateral NS groups. NS-RARP resulted in better urinary continence outcomes than non-NS-RARP in the first 12months after surgery. Urinary recovery rates did not significantly differ between unilateral and bilateral NS-RARP.

Real-life Perioperative Outcomes of Radical Prostatectomy using the French National Registry: A Plea for Promotion of Centralized Care and Access to Minimally Invasive Approaches

Radical prostatectomy (RP) can be performed using an open (ORP), laparoscopic (LRP) or robotic (RARP) approach. Most studies, even in experienced centers, have not provided solid evidence demonstrating better outcomes when using the robotic approach. In addition, one of the remaining concerns about RARP is its cost effectiveness, leading to no reimbursement for this surgical technique in some countries and thus health care inequality. We used data from a French national registry to improve knowledge of RP outcomes in a real-world scenario in order to guide and inform health care decision-makers. A total of 21 213 RP procedures were performed in 645 French centers in 2021 (ORP 20%, LRP 25%, and RARP 55% of cases). ORP was associated with longer hospital stay (p < 0.001), higher rates of postoperative complications (p < 0.001), fewer days out of hospital within 90 d of surgery (81.7 vs 83.6 vs 84.9 d for ORP vs LRP vs RARP; p < 0.00), and higher hospitalization costs (€2424 vs €1789 vs €1302). RARP is an optimal and cost-effective approach, with several advantages over ORP. Our data can be used by health care decision-makers to facilitate access to and reimbursement for the robotic approach for RP indications. Patient summaryFor men with prostate cancer for whom surgery is recommended, surgeons can remove the prostate using open surgery or a keyhole approach with or without robot assistance. Open surgery has higher costs, more complications, and longer hospital stays.

Comparison of senhance and da vinci robotic radical prostatectomy: short-term outcomes, learning curve, and cost analysis.

The Senhance® Robotic System is a new laparoscopy-based platform that has been increasingly used in radical prostatectomy (RP) procedures. The purpose of this study is to compare the outcome of Senhance RP (SRP) with da Vinci RP (DRP) cases. From August 2019 to April 2022, we prospectively recruited 63 cases of SRP. We compared the perioperative data, postoperative complication rates, short-term surgical outcomes (3-month postoperative undetectable prostate-specific antigen (PSA) and incontinence rates), learning curves, and cost analysis with data from 63 matched da Vinci Xi RP cases. There was no difference in BL (180 versus 180 ml, p = 0.86) and postoperative surgical complication rate (Clavient -Dindo grade I-IV, 25.3 versus 22.2%, p = 0.21) between the SRP cases and the DRP. Regarding the oncologic and continence function, there was no difference between positive margin rate (36.5% versus 41.3%, p = 0.58), rate of undetectable PSA level at postoperative 3 months (68.3 versus 66.7%, p = 0.85), and incontinence rate (14.3 versus 15.9%, p = 1.0) at postoperative 3 months between the two cohorts. The learning curve showed a quick downward slope for laparoscopic experienced surgeons. The median pocket cost for SRP patients in our hospital was $4170, which was lower than $7675 for the DRP patients. Safety and short-term outcomes are comparable between SRP and DRP. For experienced LRP surgeons, using the Senhance system to perform RP is straightforward. With a more affordable price as its biggest advantage, the Senhance system may serve as a safe and effective alternative for robotic RP.

Associations of flow disruptions with patient, staff, and process outcomes: a prospective observational study of robotic-assisted radical prostatectomies

BackgroundTechnological advancements in the operating room (OR) have sparked new challenges for surgical workflow, OR professionals, and patient safety. Disruptive events are frequent across all surgical specialties, but little is known about their effects on patient outcomes and the influence of systemic factors. The aim was to explore the associations of intraoperative flow disruptions (FDs) with patient outcomes, staff workload, and surgery duration.MethodsProspective, single-center, and multi-source study comprising direct and standardized OR observations of urologic surgical procedures, clinical patient outcomes, and staff- and patient-reported outcome data (PROMs; 3-month follow-up). All data were recorded between 01/2020 and 10/2021. FDs were assessed using standardized procedure observations. Linear and logistic regression analyses including multiple system factors were used to explore the effects of FDs on surgical outcomes.Results61 robotic-assisted radical prostatectomy procedures were captured (with 61 patients and 243 staff reports). High rates of FDs were observed; however, our analyses did not show significant relationships with patient complication rates. Equipment- and patient-related FDs were associated with increased staff workload. No association was found between higher rates of FDs and procedure duration.ConclusionsFDs were not related to inferior patient outcomes. Our findings may inform future OR investigations that scrutinize the complex interplay of human, team, process, and technological components that mitigate the effects of FDs during surgery.Graphical abstract

Perioperative safety and outcomes following radical prostatectomy in setting of locally advanced, node positive, and metastatic prostate cancer.

e17108 Background: Historically, definitive surgical management with radical prostatectomy (RP) has only been considered an option for the treatment of localized prostate cancer (PCa). However, recent data may suggest a role for RP in advanced PCa treatment. Currently, there is limited data on the safety and perioperative outcomes of RP in this setting. Here, we aim to compare the perioperative outcomes of RP for locally advanced, node positive, and metastatic PCa using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) new procedure targeted database. Methods: RP procedures performed between 2019-2020 were identified. Patients were stratified to compare the effect of locally advanced disease (T3-4), node-positivity (N+), and metastasis (M+) against patients with localized (T1-2 N0 M0) PCa. Baseline demographics and 30-day outcomes, including operative time, hospital length-of-stay, 30-day mortality, readmissions, reoperations, major complications, minor complications, and surgery-specific complications, were compared between groups. Results: Pathologic staging data was available for 9,276 RPs. Baseline demographics were comparable. There was a slightly higher rate of minor-complications in the locally-advanced cohort, but no significant difference in major-complications, 30-day-mortality, readmissions, or rectal injuries. In comparison, while node-positivity was associated with longer operative time, LOS, and incidence of 30-day renal failure, it was not associated with a higher rate of any major, minor or surgery-specific complication. Similarly, RP for metastatic cases appeared to be comparably safe to those with M0 disease, although they were associated with a slightly higher rate of bleeding, prolonged-NG-tube use, and ureteral obstruction. Conclusions: RP for patients with locally advanced, node positive, and metastatic prostate cancer appears to be safe, and is not associated with significantly higher rates of 30-day mortality or major complications compared to localized prostate cancer. Given the previously demonstrated survival benefit in treating the primary tumor in advanced disease with radiation therapy, there may be a role for the RP in treating advanced PCa. Further studies are needed to better characterize the risks and benefits of surgery in these patients.

Single-Port Robot-Assisted Radical Prostatectomy: Where Do We Stand?

In 2018, the da Vinci Single Port (SP) robotic system was approved by the US Food and Drug Administration for urologic procedures. Available studies for the application of SP to prostate cancer surgery are limited. The aim of our study is to summarize the current evidence on the techniques and outcomes of SP robot-assisted radical prostatectomy (SP-RARLP) procedures. A narrative review of the literature was performed in January 2023. Preliminary results suggest that SP-RALP is safe and feasible, and it can offer comparable outcomes to the standard multiport RALP. Extraperitoneal and transvesical SP-RALP appear to be the two most promising approaches, as they offer decreased invasiveness, potentially shorter length of stay, and better pain control. Long-term, high-quality data are missing and further validation with prospective studies across different sites is required.

Case report - sulfonylurea poisoning mimicking vertebrobasilar acute ischemic stroke

Background: We report the case of sulfonylurea induced hypoglycemia manifesting as acute encephalopathy with focal neurological signs misdiagnosed as posterior circulation acute ischemic stroke (AIS) and discuss the potential effects of hypoglycemia on central nervous system, as well as its differentiation from AIS. Case presentation: A 64-year-old patient with type II diabetes treated with glimepiride was transferred to the Department of Neurology after the procedure of radical prostatectomy. On admission, the patient was unconscious with four limb paresis and bilateral Babinski sign. Non-contrast head CT and CT angiography vessels did not reveal any abnormalities. Due to exceeded therapeutic window the patient was disqualified from intravenous thrombolysis. At the admission hypoglycemia was observed and promptly corrected with the 5% dextrose infusion. For the next 72 hours repeated intravenous glucose infusions were needed to maintain its levels above 70 mg/dl. Based on the absence of ischemic changes on MRI and repeated decreases in glucose level for the next 3 days, glimepiride induced hypoglycemic encephalopathy was diagnosed. Within 24 hours of admission the patient regained consciousness and eventually presented four-limb paresis as a result of prolonged neuroglycopenia. Conclusions: Prolonged insufficient brain nutrition can result in permanent or long-lasting brain damage, manifesting as impaired consciousness and focal neurological signs. Perioperative sulfonylureas intake may result in prolonged hypoglycemia.

V10-04 STEP-BY-STEP DESCRIPTION OF ROBOT-ASSISTED RADICAL PROSTATECTOMY WITH THE NOVEL HUGO RAS ROBOTIC SYSTEM USING THE “AALST TECHNIQUE”

You have accessJournal of UrologyCME1 Apr 2023V10-04 STEP-BY-STEP DESCRIPTION OF ROBOT-ASSISTED RADICAL PROSTATECTOMY WITH THE NOVEL HUGO RAS ROBOTIC SYSTEM USING THE “AALST TECHNIQUE” Marco Paciotti, Carlo Andrea Bravi, Mottaran Angelo, Luigi Nocera, Luca Sarchi, Rui Farinha, Adele Piro, Maria Peraire Lores, Eleonora Balestrazzi, Federico Piramide, Frederiek D'Hondt, Geert De Naeyer, Aalst, Belgium, Ruben De Groote, and Alexandre Mottrie Marco PaciottiMarco Paciotti More articles by this author , Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Mottaran AngeloMottaran Angelo More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Rui FarinhaRui Farinha More articles by this author , Adele PiroAdele Piro More articles by this author , Maria Peraire LoresMaria Peraire Lores More articles by this author , Eleonora BalestrazziEleonora Balestrazzi More articles by this author , Federico PiramideFederico Piramide More articles by this author , Frederiek D'HondtFrederiek D'Hondt More articles by this author , Geert De NaeyerGeert De Naeyer More articles by this author , Aalst Aalst More articles by this author , Belgium Belgium More articles by this author , Ruben De GrooteRuben De Groote More articles by this author , and Alexandre MottrieAlexandre Mottrie More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The HUGO™ RAS is a competitor for leadership in the field of robotic surgery. However, concerns remain about the ease of use of this device by new adopters. We performed the first robot-assisted radical prostatectomy (RARP) procedure in Europe with Hugo RAS. In this video, we described our surgical technique for bilateral nerve-sparing (NS) RARP performed using this novel platform. We also reported surgical setting and outcomes of our case series. METHODS: The procedure shown in the video was performed by an experienced robotic surgeon (AM) using HUGO RAS in March 2022. This robotic platform consists of four independent arm carts, novel design hand controllers and an open console. We described a RARP performed according the “Aalst technique”, including useful surgical tips. Moreover, we reported perioperative, pathological and short-term functional outcomes of consecutive patients affected by low- or intermediate-risk prostate cancer (PCa) who underwent NS RARP with HUGO RAS between February and October 2022 at our Center. RESULTS: Patients were in Trendelemburg position. One eleven-mm endoscope port was placed on the midline above the umbilicus, while other three 8 mm robotic ports were placed on a transversal line 5 cm below the optic port. Two laparoscopic ports were positioned in the right hemi-abdomen. Three arm carts were docked from the left of the operative bed, and one from the right. RARP was performed with a trans-peritoneal, anterior approach following validated metrics. Some of the specific characteristics our of technique, described in the video, are: sparing of the median umbilical ligament, postero-lateral approach to the bladder neck, antero-lateral release of the neurovascular bundles, dissection of the apex according to the “collar technique”, posterior muscolofascial reconstruction incorporated into urethrovesical anastomosis. Overall, 76 patients affected by low- or intermediate-risk PCa underwent RARP with HUGO RAS using this technique. In every case, all the steps of the procedure were completed. No intraoperative complication was recorded. Full outcomes are reported in the video. CONCLUSIONS: In this video, we described a step-by-step NS RARP performed according to our technique using the novel HUGO RAS. We provided useful tips to perform critical phases of the procedure. Experienced surgeons were able to easily perform all the surgeries with optimal perioperative, pathological, and functional outcomes. Therefore, we showed that surgical experience can be easily transferred to this novel platform. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e927 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marco Paciotti More articles by this author Carlo Andrea Bravi More articles by this author Mottaran Angelo More articles by this author Luigi Nocera More articles by this author Luca Sarchi More articles by this author Rui Farinha More articles by this author Adele Piro More articles by this author Maria Peraire Lores More articles by this author Eleonora Balestrazzi More articles by this author Federico Piramide More articles by this author Frederiek D'Hondt More articles by this author Geert De Naeyer More articles by this author Aalst More articles by this author Belgium More articles by this author Ruben De Groote More articles by this author Alexandre Mottrie More articles by this author Expand All Advertisement PDF downloadLoading ...

Sphincter preservation techniques during radical prostatectomies: Lessons learned

Abstract Prolonged urinary incontinence represents one of the most severe complications after a radical prostatectomy procedure, significantly affecting patients’ quality of life. In an attempt to ameliorate postprostatectomy continence rates, several sphincter preservation techniques have been reported. The purpose of this article is to report several different sphincter preservation techniques and identify the ones which affect postoperative outcomes the most. For our narrative review, PubMed was searched using the keywords “sphincter,” “continence,” “preservation,” “techniques,” and “prostatectomy.” Other potentially eligible studies were identified using the reference lists of included studies. Sphincter preservation techniques can be summarized into bladder neck preservation, minimizing injury to the external urethral sphincter, and preserving the maximal length of the external sphincter and of the membranous urethra. Three anatomical structures must be recognized and protected in an attempt to maintain the sphincter complex: the bladder neck, the external urethral sphincter and the musculature of the membranous urethra. While there is strong evidence supporting the importance of bladder neck preservation, the role of maximal preservation of the external sphincter and of the intraprostatic part of the membranous urethra in improving continence rates has not yet been reported in a statistically significant manner by high-quality studies.

Video labelling robot-assisted radical prostatectomy and the role of artificial intelligence (AI): training a novice

Video labelling is the assigning of meaningful information to raw videos. With the evolution of artificial intelligence and its intended incorporation into the operating room, video datasets can be invaluable tools for education and the training of intelligent surgical workflow systems through computer vision. However, the process of manual labelling of video datasets can prove costly and time-consuming for already busy practising surgeons. Twenty-five robot-assisted radical prostatectomy (RARP) procedures were recorded on Proximie, an augmented reality platform, anonymised and access given to a novice, who was trained to develop the knowledge and skills needed to accurately segment a full-length RARP procedure on a video labelling platform. A labelled video was subsequently randomly selected for assessment of accuracy by four practising urologists. Of the 25 videos allocated, 17 were deemed suitable for labelling, and 8 were excluded on the basis of procedure length and video quality. The labelled video selected for assessment was graded for accuracy of temporal labelling, with an average score of 93.1%, and a range of 85.6–100%. The self-training of a novice in the accurate segmentation of a surgical video to the standard of a practising urologist is feasible and practical for the RARP procedure. The assigning of temporal labels on a video labelling platform was also studied and proved feasible throughout the study period.

Impact of COVID-19 on the curative treatment of prostate cancer: a national cross-sectional study.

BackgroundCOVID-19 pandemic affected access to cancer treatment worldwide. However, there is a lack of data about the impact in developing countries. The objective was to evaluate COVID-19 impact on curative prostate cancer (Pca) treatment in Brazil.Materials and methodsWith data extracted from the Brazilian Ministry of Health database, the Non-COVID and COVID periods were analyzed to compare the absolute number of radical prostatectomy (RP) and radiotherapy (RT) executed in the country and regions.ResultsWith data from 50,169 Pca patients (Non-COVID = 28,106 cases and COVID = 22,063) treated with RP or RT in Brazil, a significant decline in patients receiving RT or RP (−6.043 cases; p = 0.0001) was detected. Both treatment procedures (RT or PR) were reduced in all five Brazilian regions comparing the Non-COVID and COVID periods. Overall, there was a reduction on RP and RT procedures in 92% (24/25) and 76% (19/25) of the evaluated states, respectively. Comparing the variation of RT and RP per state between COVID and Non-COVID period, there is a significant difference (−18.6% vs. −29%, p = 0.03) with a higher negative impact on the RP group. The RT and RP variation had no significant relationship with the incidence of COVID cases in the states. Limitations include the non-evaluation of treatment combinations, the impact of hypofractionated radiotherapy, and other factors influencing the treatment choice.ConclusionsDuring the COVID-19 pandemic, the curative treatment with RP and RT of Pca was abruptly limited and affected. However, the number of RP was more impacted than RT during the COVID period.

This Month in Adult Urology

You have accessJournal of UrologyThis Month in Adult Urology1 Jul 2022This Month in Adult Urology D. Robert Siemens D. Robert SiemensD. Robert Siemens More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002683AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail A Deep Dive into Nocturnal Polyuria Despite the negative effects on patient’s quality of life and general health, nocturia does not command the public health attention that it rightly deserves. Beyond chronic sleep disturbance, Åkerla et al recently added to the mounting evidence that nocturia may be associated with an increased mortality risk, potentially via its detrimental effects on sleep and other associated comorbidities.1 Nocturia is of course a multifactorial condition that coexists with other lower urinary tract symptoms, although nocturnal polyuria (NP) as the most common causal factor has not been well studied, particularly by sex or gender. In a multi-institutional study, Bosch et al (page 144) present an epidemiological study assessing the prevalence of NP in a nationally representative sample from the U.S. within the Epidemiology of Nocturnal Polyuria survey.2 Beyond the survey they also were able to attain nearly 2,000 3-day bladder diaries. The authors characterize in detail different NP subgroups and bother by gender (women/men), and conclude that these observations may provide insight into management by parsing out issues affecting bladder capacity versus nighttime urine production. Cytoreductive Nephrectomy in the Real World Despite informative prospective, randomized trials examining the role of cytoreductive nephrectomy for patients with metastatic renal cell carcinoma (mRCC) relative to systemic therapy initiation, questions remain about the management of patients with primary mRCC particularly in the era of immune-checkpoint inhibitors. To help clarify, Ghatalia et al (page 71) from Philadelphia, Pennsylvania report on a retrospective comparative analysis of about 1,900 patients with conventional clear cell renal cell carcinoma from multiple centers within the Flatiron Health Database.3 Patients with synchronous mRCC had received systemic therapy alone, or either up-front or deferred cytoreductive nephrectomy. Importantly, several different statistical methods were used to try and control for the inherent selection biases when comparing survival outcomes between these groups. The authors point out that the adjusted overall survival was significantly improved for patients undergoing a cytoreductive nephrectomy regardless of the sequencing with systemic therapy. They conclude that although patient selection is of course key to consider surgery in those with primary mRCC, cytoreductive nephrectomy likely plays an important oncologic role in either the up-front or deferred setting. Prostate Biopsy Techniques and Infectious Complications There has been ongoing debate around the strength of evidence and clinical translation of modifying prostate biopsy techniques to mitigate early complications, specifically serious infections. The growing evidence that transperineal approaches, and perhaps minimizing the number of cores taken, are associated with less infection has only slowly changed practice in some jurisdictions. Adding to this discussion, Tops et al (page 109) from the Netherlands report a large retrospective analysis of post-biopsy infections in nearly 4,000 patients between 2012 and 2019.4 All patients managed at 2 hospitals using very different techniques were included. The results confirm that a transperineal approach is associated with fewer infectious complications than transrectal biopsy with an adjusted odds ratio of 0.29 (95% CI, 0.09–0.73). Interestingly, targeted magnetic resonance imaging (MRI)-based transrectal biopsies with limited cores (approximately 3) were also associated with less infection within 7 days. The authors’ observations further support current trends toward a transperineal approach for prostate biopsies, at least to help mitigate serious post-biopsy infection. First Look at Robot-Assisted Radical Prostatectomy Using a New Surgical Robot The urological world is closely watching the increasing reports of safety and efficacy of new surgical robotic platforms as promising alternatives to the currently available systems. Fan et al (page 119) from China report their single-site experience utilizing the new Chinese robot: KangDuo Surgical Robot-01 system.5 They nicely describe these initial 16 robot-assisted radical prostatectomy procedures performed by 1 surgeon, including the patient cohort and early outcomes as well as surgeon-reported metrics of ergonomics. All procedures were completed without significant intraoperative or postoperative complications. The authors conclude that the system is, therefore, safe and effective, and they should be congratulated in bringing a new robotic system into use for patients with prostate cancer. Cost-Effectiveness of Serial Magnetic Resonance Imaging in Active Surveillance The management of those diagnosed with lower-risk prostate cancer has completely shifted over the last decade, with the role of multiparametric (mp) MRI continuing to expand. Despite real issues with availability and some vagaries in expert interpretation, the promise of an impressive negative-predictive value of mpMRI for significant prostate cancer has helped drive its incorporation into the surveillance armamentarium. But at what cost? Magnani et al (page 80) from Stanford, California provide a thorough cost-effectiveness analysis of mpMRI using a large representative trial sample for the initial model, and a second large and separate active surveillance sample for validation.6 They perform microsimulation of patient trajectories assessing up-front treatment as well as surveillance protocols incorporating routine biopsies or serial mpMRI. The authors show that active surveillance outperformed up-front definitive therapy. On surveillance, the highest expected cost benefit was attained using mpMRI as a triage tool to determine the need for biopsy. Using imaging to guide these decisions resulted in fewer biopsies while still improving cancer outcomes. They conclude that triaging biopsy decisions based on sequential MRI is likely the most cost-effective strategy for those on active surveillance. Mortality following an Initial Negative Prostate Biopsy The recent evolution of mpMRI has unsettled our current toolkit for prostate cancer diagnosis, either de novo or for those patients with a high suspicion of clinically significant disease after a negative transrectal ultrasound (TRUS) biopsy. Although a victory may relate more to its negative predictive value, MRI-informed targeted biopsies will undoubtedly find many high-grade cancers in those with a simultaneous negative systematic biopsy. The burning issue is to understand the ultimate relevance of finding a potentially small amount of Gleason pattern 4 disease, as our current notion is that higher grade (and its volume) is the key biological driver of prostate cancer progression. Kawa et al (page 100) from Denmark add to this discussion, reporting on a Danish national registry analyzing the mortality after an initial negative TRUS biopsy.7 In the cohort of nearly 40,000 men with an initial negative TRUS biopsy, the 15-year prostate cancer-specific mortality was only 1.9%. This risk of course increased with prostate specific antigen, but mortality after re-biopsy (12% were eventually diagnosed with Gleason score ≥7) was unchanged. The authors provocatively conclude that these results raise concerns with routine use of MRI targeting for initial prostate biopsy, and they suggest that MRI targeting should be relegated to men with prostate specific antigen >10 ng/ml after negative biopsy.

Preoperative antibiotic prophylaxis in a single tertiary hospital in Slovenia—the role of education in recommendation compliance

Purpose: The aim of the present study was to evaluate the impact of an educational intervention package on perioperative antimicrobial prophylaxis (PAP) prescription practice in three elective procedures—total hip arthroplasty (THA), caesarean section (CS), and radical prostatectomy (RP)—in a single tertiary care hospital in Slovenia.&#x0D; Methods: An interventional study was performed to evaluate the impact of an educational intervention package on PAP compliance. PAP prescription practices for three elective types of surgery (THA, CS, and RP) were observed. Thirty operative reports for each type of surgical procedure were evaluated according to indication, timing of preoperative prophylaxis administration, antibiotic selection and dosage, and total prophylaxis duration. This was followed by an educational intervention package that included a discussion with department leaders led by an infectious disease specialist and an educational seminar and discussion for surgeons, supplemented by PAP recommendations provided as pocket reminders. Then, the compliance with PAP recommendations for the same types of procedures performed in the post-interventional period (3–6 months after the intervention) was evaluated again.&#x0D; Results: Complete pre-interventional compliance with local guidelines was observed in 67%, 70%, and 3.3% of THA, CS, and RP cases, respectively. A major deviation from PAP recommendations was observed in the timing of preoperative PAP administration before surgery and in the total PAP duration A deviation from recommendations for RP, which is a major surgical procedure, was observed as a longer postoperative PAP duration compared to the intraoperative course. In the post-interventional period, an improvement in total compliance with PAP recommendations was observed in 80.0%, 90.0%, and 50.0% of THR, CS, and RP procedures, respectively.&#x0D; Conclusion: Our study revealed an improvement in adherence to PAP recommendations after an educational intervention package for selected procedures at the University Medical Centre Maribor. This simple intervention can have an important impact on patient care quality by reducing antimicrobial medication use, resistance development, and treatment cost.

Improving oncological outcomes after robot-assisted radical prostatectomy: what novel tools do we have?

The recent application of novel technologies to the robot-assisted radical prostatectomy (RARP) procedure has provided a new perspective and demonstrated potential usefulness in surgical planning, intraoperative navigation, and education of both patients and healthcare professionals, allowing for a patient-tailored prostate cancer (PCa) treatment. Integration of novel techniques into robotic surgery has improved the accuracy of surgery and has demonstrated a potential benefit in functional and oncological outcomes in patients with PCa. However, further randomized and prospective studies are needed to assess and validate the role of these technologies in clinical practice. The aim of this review is to summarize the current evidence on the new emerging techniques, such as three-dimensional (3D) imaging and printing, augmented reality (AR), and confocal microscopy (CM), and their impact on RARP and its oncological outcomes.

Longer preserved urethral length in robot-assisted radical prostatectomy significantly contributes to post-operative urinary continence recovery.

ObjectivesTo assess the relationship between the surgical procedure of robot‐assisted radical prostatectomy (RARP) and urinary continence recovery by reviewing the video database.MethodsVideo and data about men diagnosed with prostate cancer and underwent RARP were extracted and reviewed. Preserved urethral length (PUL) was semi‐quantitatively measured using the lateral width of a 16‐Fr urethral balloon catheter while cutting the urethra on a video screen. In addition, by reviewing intraoperative RARP video database, other surgical skill outcomes were also collected. Kaplan–Meier analysis with log‐rank test was used to compare the urinary continence recovery rate, stratified by the PUL. Univariate and multivariate analyses were performed using the Cox proportional hazards model, and p‐values of <0.05 were considered significant.ResultsThe number of patients included in this study was 213. In univariate analysis, a PUL of ≥16 mm, a body mass index of <23.1 kg/m2 and a resected prostate volume of <44.3 g were statistically significant factors that influenced urinary continence recovery [hazard ratio (HR) 1.58, p = 0.036; HR 0.67, p = 0.021; and HR 0.58, p = 0.005, respectively]. Those factors also remained statistically significant in the multivariate analysis (HR 1.87, p = 0.022; HR 0.54, p = 0.001; and HR 0.57, p = 0.005, respectively). One year post‐operatively, the recovery rate from urinary continence was 79.0% for patients with a PUL of ≥16 mm and 66.5% for patients with a PUL of <16 mm.ConclusionThese results suggest that patients with longer PUL in RARP have a significantly higher rate of post‐operative urinary continence recovery.

Comparison of Multi-Parametric MRI of the Prostate to 3D Prostate Computer Aided Designs and 3D-Printed Prostate Models for Pre-Operative Planning of Radical Prostatectomies: A Pilot Study

To evaluate the use of 3D computed aided designs and 3D-printed models as pre-operative planning tools for urologists, in addition to radiologist interpreted mp-MRIS, prior to radical prostatectomy procedures. Ten patients with biopsy-positive lesions detected on mp-MRI were retrospectively selected. Radiologists identified lesion locations using a Prostate Imaging-Reporting and Data System (PI-RADS) map and segmented the prostate, lesion(s), and surrounding anatomy to create 3D-CADs and 3D-printed models for each patient. 6 uro-oncologists randomly reviewed three modalities (mp-MRI, 3D-CAD, and 3D-printed models) for each patient and identified lesion locations which were graded for accuracy against the radiologists' answers. Questionnaires assessed decision confidence, ease-of-interpretation, and usefulness for preoperative planning for each modality. Using 3D-CADs and 3D-printed models compared to mp-MRI, urologists were 2.4x and 2.8x more accurate at identifying the lesion(s), 2.7x and 3.2x faster, 1.6x and 1.63x more confident, and reported it was 1.6x and 1.7x easier to interpret. 3D-CADs and 3D-printed models were reported significantly more useful for overall pre-operative planning, identifying lesion location(s), determining degree of nerve sparing, obtaining negative margins, and patient counseling. Sub-analysis showed 3D-printed models demonstrated significant improvements in ease-of-interpretation, speed, usefulness for obtaining negative margins, and patient counseling compared to 3D-CADs. 3D-CADs and 3D-printed models are useful adjuncts to mp-MRI in providing urologists with more practical, accurate, and efficient pre-operative planning.

Localized Prostate Cancer, Retropubic Radical Prostatectomy: Surgical Complications, Single Centre Study.

Background: For organ-confined disease in carcinoma of prostate the primary curative procedure that is well identified is the retro pubic radical prostatectomy. Objective: To assess the complications related to surgery of prostate after open retro pubic radical prostatectomy. Materials and Methods: Retropubic radical prostatectomy was performed in 75 subjects suffering from localized cancer of prostate in last 05 years, at the urology department. Open retropubic radical prostatectomy procedure represented by Walsh as a classic method was adapted. Disease progression and caliber of life indices like potency and urinary continence were noted during the follow up. Result: There were total 75 patients in current study. Mean age of patients was 63.3 years. Out of 75 patients, 70 were married and 05 patients were unmarried, 25 were from urban areas, while 50 were from rural area, 35 were educated and 45 were uneducated, 05 patients had positive family history for prostatic malignancy, while 70 patients had no family history of prostatic carcinoma. Out of 75 patients, 63, 65 and 69 patients were continent, at 10, 06 and 12 months; however, 05, 04 and 04 had stress incontinence at 10, 06 and 12 months; and 07, 03 and 01 had mixed incontinence urge and stress at 06 and 12 months; 05, 03 and 01 had total incontinence at 06 and 12 months. Subjects with incontinence are trained exercises concerned with pelvic floor. Conclusion: The retro-pubic thorough prostatectomy is the typical management of early cancer of prostate and a number of complications are associated with this technique of surgery. It had a vertical knowledge curl. Large figure of patients and improvement in techniques are needed to attain the perfect outcomes. Keywords: Carcinoma, prostate, radical, prostatectomy.