Publications by authors named "Geert De Naeyer"

51 Publications

Robot-assisted Cystectomy with Intracorporeal Urinary Diversion After Pelvic Irradiation for Prostate Cancer: Technique and Results from a Single High-volume Center.

Eur Urol 2021 Apr 7. Epub 2021 Apr 7.

Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium.

Background: Radiation therapy (RT) for prostate cancer (PCa) treatment is burdened by high rates of late urinary adverse events (UAEs). The feasibility of robot-assisted cystectomy (RAC) with intracorporeal urinary diversion (ICUD) for treatment of high-grade UAEs has never been assessed.

Objective: To report perioperative outcomes, early (≤90 d) and late (>90 d) complications among patients undergoing RAC for UAEs after RT.

Design, Setting, And Participants: We retrospectively evaluated 32 patients undergoing RAC with ICUD for UAEs in a single tertiary centre.

Surgical Procedure: Surgery was performed using a da Vinci Xi system with adaptation for the primary treatment.

Measurements: Perioperative outcomes included estimated blood loss (EBL), operative time (OT), intraoperative complications, and length of stay (LOS). Data for early and late postoperative complications were collected using the quality criteria recommended by the European Association of Urology. Univariate logistic regressions were performed to test the effect of baseline and perioperative characteristics on early postoperative complications.

Results And Limitations: The median age-adjusted Charlson comorbidity index (ACCI) was 6 (IQR 5-7). The indication for RAC was hemorrhagic radiation cystitis in 29 cases (91%), contracted bladder in two cases (6.2%), and urinary fistula in one case (3.1%). The median EBL, OT, and LOS were 250 ml, 330 min, and 10 d, respectively. A total of 31 (97%) patients received an ileal conduit. The 90-d rate of Clavien-Dindo grade ≥IIIa complications was 28%. The late complication rate was 46% and the perioperative mortality rate was 0%. On univariate analyses, ACCI was the only parameter correlated with the risk of early complications (odds ratio 1.75, 95% confidence interval 1.05-2.9; p =  0.03). The median follow-up was 30 mo (IQR 15-40). The lack of comparison with open cystectomy represents the main limitation.

Conclusions: RAC for UAEs in patients with a history of pelvic irradiation is a feasible option in high-volume centers. The use of new technologies can help to overcome some of the technical difficulties and reduce the risk of perioperative and late complications.

Patient Summary: We report our experience with robot-assisted surgery for removal of the bladder in the management of urinary problems after radiation therapy for prostate cancer. When performed by highly experienced surgeons, this is a feasible procedure with outcomes and early and late complication rates that are acceptable.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eururo.2021.03.023DOI Listing
April 2021

Robot-assisted boari flap and psoas hitch ureteral reimplantation: Technique insight and outcomes of a case series with at least 1 year of follow-up.

BJU Int 2021 Apr 8. Epub 2021 Apr 8.

Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.

Objective: To describe step-by-step surgical techniques and report outcomes of the largest single centre series of patients with distal ureteral disease exclusively treated with robot-assisted ureteral reimplantation (RAUR) with Boari Flap (RABFUR) and Psoas Hitch (RAPHUR), with a minimum follow-up of 1 year and complete postoperative data.

Subjects/patients And Methods: 37 patients with distal ureteral disease were treated between 2010 and 2018. Of these, 81 and 19% underwent RAPHUR and RABFUR, respectively. Intra-, peri- and postoperative outcomes were assessed. 90-day postoperative complications were reported according to the standardized methodology proposed by the European Association of Urology ad hoc panel. Functional outcomes (creatinine, eGFR) and postoperative symptoms (VAS pain scale) were assessed.

Results: Median operating time and blood loss were respectively 180 min and 100 ml. No conversion to open surgery and no intraoperative transfusions were observed. Median length of stay, bladder catheter and stent removal were 4, 7 and 30 days, respectively. Median follow-up was 24 months. Overall, 27% (n=10) experienced postoperative complications. Of these, 8 (22%) and 2 (5.4%) were CD I-II and III, respectively. At last follow-up, median postoperative creatinine and eGFR were 0.9 mg/dl and 73.5 ml/min/1.73m2, respectively. Overall, 13.5% (n=5) and 8% (n=3) had respectively Grade 1 hydronephrosis and mild urinary symptoms at last follow-up. The study limitations include its retrospective nature.

Conclusion: We presented our RABFUR and RAPHUR technique. We confirmed the feasibility and safety profile of both approaches in patients with distal ureteral disease relying on the largest single-centre series with at least one year of follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/bju.15421DOI Listing
April 2021

Selective Suturing or Sutureless Technique in Robot-assisted Partial Nephrectomy: Results from a Propensity-score Matched Analysis.

Eur Urol Focus 2021 Mar 25. Epub 2021 Mar 25.

Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium.

Background: Despite efforts aimed at preserving renal function, the functional decline after robot-assisted partial nephrectomy (RAPN) is not negligible. To address the risk of intraparenchymal vessel injuries during renorrhaphy, with consequent loss of functional renal parenchyma, we introduced a new surgical technique for RAPN.

Objective: To compare perioperative patient outcomes between selective-suturing or sutureless RAPN (suRAPN) and standard RAPN (stRAPN).

Design, Setting, And Participants: Ninety-two consecutive patients undergoing RAPN for a renal mass performed by a high-volume surgeon at a European tertiary center were included. Propensity-score matching was used to account for baseline differences between suRAPN and stRAPN patients.

Intervention: RAPN using a selective-suturing or sutureless technique versus standard RAPN.

Outcome Measurements And Statistical Analysis: Perioperative outcomes included operative time, blood loss, length of stay, and intraoperative and 30-d postoperative complications. We also evaluated trifecta achievement (warm ischemia time ≤25 min, negative surgical margins, and no perioperative complications) and the incidence of postoperative acute kidney injury (AKI). We applied χ tests, t tests, and Kruskal-Wallis tests to assess differences in perioperative outcomes between suRAPN and stRAPN.

Results And Limitations: Overall, 29 patients (31%) were treated with suRAPN. Only one suRAPN patient experienced intraoperative complications (p = 0.9). Two suRAPN patients (6.9%) and four stRAPN patients (13.8%) experienced 30-d postoperative complications (p = 0.3). Operative time (110 vs 150 min; p < 0.01) and length of stay (2 vs 3 d; p = 0.02) were shorter for suRAPN than for stRAPN. The trifecta outcome was achieved in 25 suRAPN patients (86%) and 20 stRAPN patients (70%; p = 0.1). Only one suRAPN patient (3.4%) versus five stRAPN patients (17%) experienced postoperative AKI (p = 0.2). Finally, the decrease in the estimated glomerular filtration rate at 6-mo follow-up was lower in the suRAPN (-5.2%) than in the stRAPN group (-9.1%; p < 0.01). Lack of randomization represents the main study limitation.

Conclusions: A selective-suturing or sutureless technique in RAPN is feasible and safe. Moreover, suRAPN is a lower-impact surgical procedure. We obtained promising results for trifecta and functional outcomes, but prospective randomized trials are needed to validate the impact of selective suturing or a sutureless technique on long-term functional outcomes.

Patient Summary: We assessed a new technique in robotic surgery to remove part of the kidney because of kidney cancer. Our new technique involves selective suturing or no suturing of the area from where the tumor is removed. We found that the rate of complications did not increase and the operating time and length of hospital stay were shorter using this new technique.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euf.2021.03.019DOI Listing
March 2021

Robot-assisted segmental ureterectomy with psoas hitch ureteral reimplantation: Oncological, functional and perioperative outcomes of case series of a single centre.

Arch Ital Urol Androl 2021 Mar 22;93(1):101-106. Epub 2021 Mar 22.

ORSI Academy, Melle; Department of Urology, Onze Lieve Vrouw Hospital, Moorselbaan, Aalst.

Introduction: According to the Urology guidelines, in selected cases of distal upper tract urothelial carcinoma (UTUC) segmental ureterectomy (SU) can be offered. There is no consensus in the surgical technique of preference. Robot-assisted SU could be an option to overcome all the limitations of open and laparoscopic techniques. We describe our first experience of robot assisted SU with psoas hitch ureteral reimplantation (RAPHUR).

Materials And Methods: 11 patients underwent RAPHUR for distal UTUC between 2013 and 2017 in a single centre. Pre-, intra-, and postoperative outcomes were assessed. Conventional imaging was performed after 1, 3, 6 months and 1 year from surgery as follow up protocol. We retrospectively evaluated the technical feasibility, oncological and functional outcomes.

Results: Median age was 71 years (57-91). The median length of the ureteral defect was 23 mm (10-40). Median preoperative creatinine level was 1.22 mg/dl (0.7-1.85) and median eGFR was 57.5 ml/min/1.73m2 (31-80). Five (45.5%) patients were symptomatic and 7 (63.6%) had hydronephrosis. Median operative time was 185 min (120-240), with a median blood loss of 100 ml (50-300). No case required conversion to open surgery. Overall, only 1 (9%) patient developed Clavien Dindo ≥ 3 postoperative complications. Average hospital stay was 7 (2-9) days. Mean postoperative creatinine was 1.05 mg/dl (0.8-1.85) and mean postoperative eGFR was 72 (36-83). During a median follow up time of 25.5 months (12-53), 4 (36.4%) patients experienced recurrence of urothelial cancer at conventional imaging follow up and 2 (18.2%) died due to its progression.

Conclusions: In our initial experience RAPHUR can be proposed to selected cases of distal ureteral carcinoma with optimal perioperative and functional outcomes. However, cancer control may be undermined compared to nephroureterectomy. Thus, further prospective studies are needed to confirm our findings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4081/aiua.2021.1.101DOI Listing
March 2021

Bilateral kidney metastases from adenoid cystic carcinoma of lung: a case report and literature review.

CEN Case Rep 2021 Mar 8. Epub 2021 Mar 8.

Department of Urology, Onze-Lieve-Vrouw Hospital, Moorselbaan 164, 9300, Aalst, Belgium.

Adenoid cystic carcinoma (ACC) is a rare malignant tumor, usually arising from salivary glands and rarely found in other locations. ACC is characterized by asymptomatic course, slow growth pattern, perineural invasion and high incidence of late metastasis. Renal localization of metastasis is rare. Only 12 cases of renal metastasis were published and, to our best knowledge, no case of bilateral metastasis to the kidney has ever been reported. We present a case of a 58 years old woman with bilateral renal metastasis from ACC of the right lung after fourteen years from lobectomy and radiotherapy for the primary presentation. The patient underwent bilateral robot-assisted partial nephrectomy in a two-stage approach. Despite its rare incidence and slow growth, ACC metastasis may simulate primary papillary renal carcinoma and occur many years after primary treatment. Therefore, lifelong follow-up, including abdominal imaging, is recommended.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13730-021-00589-8DOI Listing
March 2021

The Impact of Previous Prostate Surgery on Surgical Outcomes for Patients Treated with Robot-assisted Radical Cystectomy for Bladder Cancer.

Eur Urol 2021 Feb 27. Epub 2021 Feb 27.

Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium.

Background: The feasibility and safety of robot-assisted radical cystectomy (RARC) may be undermined by unfavorable preoperative surgical characteristics such as previous prostate surgery (PPS).

Objective: To compare perioperative outcomes for patients undergoing RARC with versus without a history of PPS.

Design, Setting, And Participants: The study included 220 consecutive patients treated with RARC and pelvic lymph node dissection for bladder cancer at a single European tertiary centre. Of these, 43 had previously undergone PPS, defined as transurethral resection of the prostate/holmium laser enucleation of the prostate (n=21) or robot-assisted radical prostatectomy (n=22).

Surgical Procedure: RARC in patients with a history of PPS.

Measurements: Data on postoperative complications were collected according to the quality criteria for accurate and comprehensive reporting of surgical outcomes recommended by the European Association of Urology guidelines. Multivariable logistic, linear, and Poisson regression analyses were performed to test the effect of PPS on surgical outcomes.

Results And Limitations: Overall, 43 patients (20%) were treated with RARC after PPS. Operative time (OT) was longer in the PPS group (360 vs 330min; p<0.001). Patients with PPS experienced higher rates of intraoperative complications (19% vs 6.8%) and higher rates of 30-d (67% vs 39%), and Clavien-Dindo >3 (33% vs 16%) postoperative complications (all p<0.05). Moreover, the positive surgical margin (PSM) rate after RARC was higher in the PPS group (14% vs 4%; p=0.03). On multivariable analyses, PPS at RARC independently predicted higher risk of intraoperative (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.04-6.21; p=0.01) and 30-d complications (OR 2.26, 95% CI 1.05-5.22; p=0.02), as well as longer OT (relative risk [RR] 1.03, 95% CI 1.00-1.05; p=0.02) and length of stay (RR 1.13, 95% CI 1.02-1.26; p=0.02). Lack of randomization represents the main limitation.

Conclusions: RARC in patients with a history of PPS is feasible, but it is associated with a higher risk of complications and longer OT and length of stay. Moreover, higher PSM rates have been reported for these patients. Thus, measures aimed at improving surgical outcomes appear to be warranted.

Patient Summary: We investigated the effect of previous prostate surgery (PPS) on surgical outcomes after robot-assisted removal of the bladder. We found that patients with PPS have a higher risk of complications and longer hospitalization after bladder removal. These patients deserve closer evaluation before this type of bladder operation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eururo.2021.02.029DOI Listing
February 2021

Multi-institutional Retrospective Validation and Comparison of the Simplified PADUA REnal Nephrometry System for the Prediction of Surgical Success of Robot-assisted Partial Nephrectomy.

Eur Urol Focus 2020 Nov 30. Epub 2020 Nov 30.

Department of Urology, Humanitas Clinical and Research Institute IRCCS, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy.

Background: The use of a nephron-sparing surgery for the treatment of localized renal masses is being pushed to more challenging cases. However, this procedure is not devoid of risks, and the Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location (RENAL) and Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classifications are commonly employed in the prediction of complications. Recently, the Simplified PADUA REnal (SPARE) scoring system has been proposed with the aim to provide a more simple system, to improve its reproducibility to predict postoperative risks.

Objective: We aim to retrospectively validate and compare the proposed new SPARE system in a multi-institutional population.

Design, Setting, And Participants: The Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group collected data from 737 patients subjected to robot-assisted partial nephrectomy (RAPN) between 2010 and 2016 at three tertiary care referral centers. Of these patients, 536 presented complete demographic and clinical data.

Outcome Measurements And Statistical Analysis: Renal masses were classified according to the SPARE, RENAL, and PADUA nephrometry scores, and surgical success was defined according to the margin, ischemia, and complication scores.

Results And Limitations: Of 536 patients, 340 were male; the median age was 61 (53-69) yr and preoperative tumor size was 30 (22-43) mm. The margin, ischemia, and complication score was achieved in 399 of cases (74.4%). All three nephrometry scores were significant predictors of surgical outcomes both in univariate and in adjusted multivariate logistic regression model analysis. In accuracy analysis, the area under the curve (AUC) of the SPARE scoring system (0.73) was significantly higher than those of the PADUA (0.65) and RENAL (0.68) nephrometry scores in predicting surgical success.

Conclusions: The SPARE score appears to be a promising and reliable score for the prediction of surgical outcomes of RAPN, showing a higher accuracy relative to the traditional PADUA and RENAL nephrometry scores. Further, prospective studies are warranted before its introduction in clinical practice.

Patient Summary: The Simplified PADUA REnal (SPARE) score is a reproducible and simple nephrometry score, offering better predictive capabilities of surgical success and complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euf.2020.11.003DOI Listing
November 2020

Outcomes of minimally invasive partial nephrectomy among very elderly patients: report from the RESURGE collaborative international database.

Cent European J Urol 2020 8;73(3):273-279. Epub 2020 Sep 8.

Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Milan, Italy.

The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass. The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used. Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m. PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST] -4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01). In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5173/ceju.2020.0179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7587491PMC
September 2020

Technical Refinements in Superextended Robot-assisted Radical Prostatectomy for Locally Advanced Prostate Cancer Patients at Multiparametric Magnetic Resonance Imaging.

Eur Urol 2020 Sep 14. Epub 2020 Sep 14.

Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium; ORSI Academy, Melle, Belgium.

Background: The feasibility and efficacy of robot-assisted radical prostatectomy (RARP) in locally advanced prostate cancer (PCa) patients with iT3 lesion at magnetic resonance imaging (MRI) are currently not explored.

Objective: To describe our revised RARP technique (ie, superextended RARP [SE-RARP]) for PCa patients with posterior iT3a or iT3b at MRI.

Design, Setting, And Participants: Data from 89 patients with posterior iT3a or T3b disease who underwent SE-RARP at a single high-volume centre between 2015 and 2018 were analysed.

Surgical Procedure: RARP was performed using a DaVinci Xi system. The surgical approach provided an inter- or extrafascial RARP where Denonvilliers' fascia and perirectal fat were dissected free and left on the posterior surface of the seminal vesicles.

Measurements: Perioperative outcomes, and intra- and postoperative complications were assessed. Postoperative outcomes were assessed in patients with complete follow-up data (n = 78). Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values of ≥0.2 ng/ml. Urinary continence (UC) recovery was defined as the use of zero or one safety pad. Kaplan-Meier and multivariable Cox regression models were used.

Results And Limitations: The median operative time, blood loss, and length of stay were 204 min, 300 ml, and 5 d, respectively. The median bladder catheterisation time was 5 d. Overall, 28%, 28%, and 27% of patients had pathological grade group (GG) 4-5, pT3b, and positive surgical margins (PSMs), respectively. Three patients (3.4%) experienced intraoperative complications. Among patients with available follow-up data (n = 78), 14 (18%) experienced 30-d postoperative complications. The median follow-up was 19 mo. Overall, 11 patients received additional treatment. At 2 yr of follow-up, BCR-free and additional treatment-free survival were 55% and 66%, respectively. Pathological GG 4-5 (hazard ratio [HR] 3.2) and PSM (HR 5.8) were independent predictors of recurrence, as well as of additional treatment use (HR 5.6 for GG 4-5 and 5.2 for PSM). The 1-yr UC recovery was 84%.

Conclusions: We presented our revised RARP technique applicable to patients with posterior iT3a or iT3b at preoperative MRI. This technique is associated with good morbidity and continence recovery rates, and might guarantee biochemical control of the disease and postpone the use of additional treatments in patients with low-grade and negative surgical margins.

Patient Summary: A revised robot-assisted radical prostatectomy technique applicable to prostate cancer patients with posterior iT3a or iT3b lesion at magnetic resonance imaging was described. This novel technique is feasible and safe in expert hands.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eururo.2020.09.009DOI Listing
September 2020

Robot-assisted radical cystectomy with intracorporeal urinary diversion decreases postoperative complications only in highly comorbid patients: findings that rely on a standardized methodology recommended by the European Association of Urology Guidelines.

World J Urol 2021 Mar 17;39(3):803-812. Epub 2020 May 17.

Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.

Introduction: The available studies comparing robot-assisted radical cystectomy (RARC) with intracorporeal (ICUD) vs. extracorporeal (ECUD) urinary diversion have not relied on a standardized methodology to report complications and did not assess the effect of different approaches on postoperative outcomes.

Materials: Two hundred and sixty seven patients treated with RARC at a single center were assessed. A retrospective analysis of data prospectively collected according to a standardized methodology was performed. Multivariable logistic regression models (MVA) assessed the impact of ICUD vs. ECUD on intraoperative complications, prolonged length of stay (LOS), 30-day Clavien Dindo (CD) ≥ 2 complications and readmission rate. Interaction terms tested the impact of the approach on different patient subgroups. Lowess graphically depicted the probability of CD ≥ 2 after ICUD or ECUD according to patient baseline characteristics.

Results: Overall, 162 ICUD vs 105 ECUD (61 vs. 39%) were performed. Intraoperative complications were recorded in 24 patients. The median LOS and readmission rate were 11 vs. 13 (p = 0.02) and 24 vs. 22% (p = 0.7) in ICUD vs. ECUD, respectively. Overall, 227 postoperative complications were recorded. The overall rate of CD ≥ 2 was 35 and 43% in patients with ICUD vs. ECUD, respectively (p = 0.2). At MVA, the approach type was not an independent predictor of any postoperative outcomes (all p ≥ 0.4). Age-adjusted Charlson Comorbidity Index (ACCI) was associated with an increased risk of CD ≥ 2 (OR: 1.2, p = 0.006). We identified a significant interaction term between ACCI and approach type (p = 0.04), where patients with ICUD had lower risk of CD ≥ 2 relative to those with ECUD with increasing ACCI.

Conclusions: Relying on a standardized methodology to report complications, we observed that highly comorbid patients who undergo ICUD have lower risk of postoperative complications relative to those patients who received ECUD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00345-020-03237-5DOI Listing
March 2021

The Effect of Surgical Experience on Perioperative and Oncological Outcomes After Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Evidence from a Referral Centre with Extensive Experience in Robotic Surgery.

Eur Urol Focus 2021 Mar 13;7(2):352-358. Epub 2020 Feb 13.

ORSI, Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.

Background: Evidence on the learning curve for robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is limited.

Objective: To assess the effect of surgical experience (SE) on perioperative and intermediate-term oncological outcomes in a large contemporary cohort of RARC patients after accounting for the impact of intersurgeon variability.

Design, Setting, And Participants: The study cohort included 164 patients treated with RARC and ICUD by two surgeons between 2004 and 2017 at a single European referral centre.

Outcome Measurements And Statistical Analysis: For each patient, SE was defined as the total number of RARCs performed by each surgeon before the patient's operation. The relationship between SE and operative time (OT), lymph node yield (LNY), positive surgical margins (PSMs), Clavien-Dindo grade ≥2 30-d postoperative complication (CD≥2), and oncological outcomes (18-mo recurrence rate) was evaluated in multivariable linear and logistic regression models, clustering at a single-surgeon level.

Results And Limitations: After adjusting for case mix, SE was associated with shorter OT (p= 0.003), lower probability of postoperative CD≥2 rates (p= 0.01), and lower 18-mo recurrence rates (p= 0.002). Conversely, SE did not predict lower PSM rates (p= 0.3) and higher LNY (p= 0.4). The relationship between SE and OT was nonlinear, with a plateau observed after 50 cases. Conversely, the relationship between SE and CD≥2 and 18-mo recurrence was linear without reaching a plateau after 88 procedures.

Conclusions: SE affects perioperative and oncological outcomes after RARC with ICUD in a linear fashion, and its beneficial effect does not reach a plateau. Conversely, after 50 cases, no further improvement was observed for OT.

Patient Summary: Robot-assisted radical cystectomy with intracorporeal urinary diversion is a complex surgical procedure with a relatively long learning curve.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euf.2020.01.016DOI Listing
March 2021

Upstaging to pT3a disease in patients undergoing robotic partial nephrectomy for cT1 kidney cancer: Outcomes and predictors from a multi-institutional dataset.

Urol Oncol 2020 04 16;38(4):286-292. Epub 2020 Jan 16.

Division of Urology, Department of Surgery, VCU Health System, Richmond, VA. Electronic address:

Objectives: Surgically treated clinical T1 (cT1) kidney cancer has in general a good prognosis, but there is a risk of upstaging that can potentially jeopardize the oncological outcomes after partial nephrectomy (PN). Aim of this study is to analyze the outcomes of robot-assisted PN (RAPN) for cT1 kidney cancer upstaged to pT3a, and to identify predictors of upstaging.

Material And Methods: The study cohort included 1,640 cT1 patients who underwent RAPN between 2005 and 2018 at 10 academic institutions. Multivariate logistic regression model was used to assess the predictors of upstaging. Kaplan-Meier curves and multivariable Cox regression analyses were used to evaluate recurrence-free survival and overall survival.

Results: Overall, 74 (4%) were upstaged cases (cT1/pT3a). Upstaged patients presented larger renal tumors (3.1 vs. 2.4 cm; P = 0.001), and higher R.E.N.A.L. score (8.0 vs. 6.0; P = 0.004). cT1/pT3a group had higher rate of intraoperative complications (5 vs. 1% P = 0.032), higher pathological tumor size (3.2 vs. 2.5 cm; P < 0.001), higher rate of Fuhrman grade ≥3 (32 vs. 17%; P = 0.002), and higher number of sarcomatoid differentiation (4 vs. 1%; P = 0.008). Chronic kidney disease (CKD) stage ≥3 (OR: 2.54; P < 0.014), and clinical tumor size (OR: 1.07; P < 0.001) were independent predictors of upstaging. cT1/pT3a group had worse 2-year (94% vs. 99%) recurrence-free survival (P < 0.001).

Conclusions: Upstaging to pT3a in patients with cT1 renal mass undergoing RAPN represents an uncommon event, involving less than 5% of cases. Pathologic upstaging might translate into worse oncological outcomes, and therefore strict follow-up protocols should be applied in these cases.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.urolonc.2019.12.024DOI Listing
April 2020

Artificial intelligence and robotics: a combination that is changing the operating room.

World J Urol 2020 Oct 27;38(10):2359-2366. Epub 2019 Nov 27.

ORSI Academy, Melle, Belgium.

Purpose: The aim of the current narrative review was to summarize the available evidence in the literature on artificial intelligence (AI) methods that have been applied during robotic surgery.

Methods: A narrative review of the literature was performed on MEDLINE/Pubmed and Scopus database on the topics of artificial intelligence, autonomous surgery, machine learning, robotic surgery, and surgical navigation, focusing on articles published between January 2015 and June 2019. All available evidences were analyzed and summarized herein after an interactive peer-review process of the panel.

Literature Review: The preliminary results of the implementation of AI in clinical setting are encouraging. By providing a readout of the full telemetry and a sophisticated viewing console, robot-assisted surgery can be used to study and refine the application of AI in surgical practice. Machine learning approaches strengthen the feedback regarding surgical skills acquisition, efficiency of the surgical process, surgical guidance and prediction of postoperative outcomes. Tension-sensors on the robotic arms and the integration of augmented reality methods can help enhance the surgical experience and monitor organ movements.

Conclusions: The use of AI in robotic surgery is expected to have a significant impact on future surgical training as well as enhance the surgical experience during a procedure. Both aim to realize precision surgery and thus to increase the quality of the surgical care. Implementation of AI in master-slave robotic surgery may allow for the careful, step-by-step consideration of autonomous robotic surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00345-019-03037-6DOI Listing
October 2020

Usefulness of the Indocyanine Green (ICG) Immunofluorescence in laparoscopic and robotic partial nephrectomy.

Arch Esp Urol 2019 10;72(8):723-728

ORSI Academy. Melle. Belgium. Department of Urology. Onze Lieve Vrouw Hospital. Aalst. Belgium.

The trend towards the organ sparing and robotic assisted surgeries is clear and is going to expand in the future. Hence, the tools surgeons need to facilitate such minimallly invasive approaches are going to be even more important. The Indocyanine green (ICG) is a water-soluble, relatively hydrophobic dye which bounds to plasma protein and can be used intraoperatively as real time contrast agent. Near infrared fluorescence (NIRF) helps in differentiating the renal planes, and the most common reagent used for the NIRF is ICG. The combination is used frequently during nephron sparing surgery in urology to ensure the ischemia of the kidney after clamping the renal artery, moreover it can help to identify the arterial blood supply to the tumor allowing selective clamping and thus minimizing the ischemia time. Several studies assessed the role of ICG in nephron-sparing surgery and provided evidence that its use allows to improve perioperative and oncological outcomes. This review provides an overview of the articles published regarding the use of ICG during partial nephrectomy, about the oncological outcomes and safety.
View Article and Find Full Text PDF

Download full-text PDF

Source
October 2019

Robotic partial nephrectomy versus radical nephrectomy in elderly patients with large renal masses.

Minerva Urol Nefrol 2020 Feb 13;72(1):99-108. Epub 2019 Sep 13.

Division of Urology, Virginia Commonwealth University Health System, Richmond, VA, USA -

Background: Recent evidence suggests that the "oldest old" patients might benefit of partial nephrectomy (PN), but decision-making for this subset of patients is still controversial. Aim of this study is to compare outcomes of robotic partial (RPN) or radical nephrectomy (RRN) for large renal masses in patients older than 65 years.

Methods: We identified 417≥65 years old patients who underwent RRN or RPN for cT1b or ≥cT2 renal mass at 17 high volume centers. Propensity score match analysis was performed adjusting for age, ASA≥3, pre-operative eGFR, and clinical tumor size. Predictors of complications, functional and oncological outcomes were evaluated in multivariable logistic and Cox regression models.

Results: After propensity score analysis, 73 patients in the RPN group were matched with 74 in the RRN group. R.E.N.A.L. Score (9.6±1.7 vs. 8.6±1.7; P<0.001), and high complexity (56 vs. 15%; P=0.001) were higher in the RRN. Estimated blood loss was higher in the RPN group (200 vs. 100 mL; P<0.001). RPN showed higher rate of overall complications (38 vs. 23%; P=0.05), but not major complications (P=0.678). At last follow-up, RPN group showed better functional outcomes both in eGFR (55.4±22.6 vs. 45.7±15.7 mL/min; P=0.016) and lower eGFR variation (9.7 vs. 23.0 mL/min; P<0.001). The procedure type was not associated with recurrence free survival (RFS) (HR: 0.47; P=0.152) and overall mortality (OM) (0.22; P=0.084).

Conclusions: RPN in elderly patients with large renal masses provides acceptable surgical, and oncological outcomes allowing better functional preservation relative to RRN. The decision to undergo RPN in this subset of patients should be tailored on a case by case basis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S0393-2249.19.03583-5DOI Listing
February 2020

The safety of urologic robotic surgery depends on the skills of the surgeon.

World J Urol 2020 Jun 19;38(6):1373-1383. Epub 2019 Aug 19.

ORSI Academy, Melle, Belgium.

Purpose: To assess the available literature evidence that discusses the effect of surgical experience on patient outcomes in robotic setting. This information is used to help understand how we can develop a learning process that allows surgeons to maximally accommodate patient safety.

Methods: A literature search of the MEDLINE/PubMed and Scopus database was performed. Original and review articles published in the English language were included after an interactive peer-review process of the panel.

Results: Robotic surgical procedures require high level of experience to guarantee patient safety. This means that, for some procedures, the learning process might be longer than originally expected. In this context, structured training programs that assist surgeons to improve outcomes during their learning processes were extensively discussed. We identified few structured robotic curricula and demonstrated that for some procedures, curriculum trained surgeons can achieve outcomes rates during their initial learning phases that are at least comparable to those of experienced surgeons from high-volume centres. Finally, the importance of non-technical skills on patient safety and of their inclusion in robotic training programs was also assessed.

Conclusion: To guarantee safe robotic surgery and to optimize patient outcomes during the learning process, standardized and validated training programs are instrumental. To date, only few structured validated curricula exist for standardized training and further efforts are needed in this direction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00345-019-02901-9DOI Listing
June 2020

The Impact of Surgical Strategy in Robot-assisted Partial Nephrectomy: Is It Beneficial to Treat Anterior Tumours with Transperitoneal Access and Posterior Tumours with Retroperitoneal Access?

Eur Urol Oncol 2021 Feb 22;4(1):112-116. Epub 2019 Jan 22.

Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; ORSI, Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium. Electronic address:

Available comparison of transperitoneal robot-assisted partial nephrectomy (tRAPN) and retroperitoneal robot-assisted partial nephrectomy (rRAPN) does not consider tumour's location. The aim of this study was to compare perioperative morbidity, and functional and pathological outcomes after tRAPN and rRAPN, with the specific hypothesis that tRAPN for anterior tumours and rRAPN for posterior tumours might be a beneficial strategy. A large global collaborative dataset of 1169 cT1-2N0M0 patients was used. Propensity score matching, and logistic and linear regression analyses tested the effect of tRAPN versus rRAPN on perioperative outcomes. No differences were observed between rRAPN and tRAPN with respect to complications, operative time, length of stay, ischaemia time, median 1-yr estimated glomerular filtration rate (eGFR), and positive surgical margins (all p>0.05). Median estimated blood loss and postoperative eGFR were 50 versus100ml (p<0.0001) and 82 versus 78ml/min/1.73 m (p=0.04) after rRAPN and tRAPN, respectively. At interaction tests, no advantage was observed after tRAPN for anterior tumours and rRAPN for posterior tumours with respect to complications, warm ischaemia time, postoperative eGFR, and positive surgical margins (all p>0.05). The techniques of rRAPN and tRAPN offer equivalent perioperative morbidity, and functional and pathological outcomes, regardless of tumour's location. PATIENT SUMMARY: Robot-assisted partial nephrectomy can be performed with a transperitoneal or a retroperitoneal approach regardless of the specific position of the tumour, with equivalent outcomes for the patient.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euo.2018.12.010DOI Listing
February 2021

Time to Move On: The Impending Need for a New Disease-specific Comorbidity Index for Bladder Cancer Patients Undergoing Robot-assisted Radical Cystectomy.

Eur Urol Focus 2021 Jan 11;7(1):139-141. Epub 2019 Jun 11.

Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium; ORSI Academy, Melle, Belgium.

The Charlson comorbidity index is an outdated comorbidity assessment tool which is not disease specific and is not applicable to contemporary BCa patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euf.2019.05.015DOI Listing
January 2021

Is Robot-assisted Surgery Contraindicated in the Case of Partial Nephrectomy for Complex Tumours or Relevant Comorbidities? A Comparative Analysis of Morbidity, Renal Function, and Oncologic Outcomes.

Eur Urol Oncol 2018 05 15;1(1):61-68. Epub 2018 May 15.

ORSI Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Ziekenhuis, Aalst, Belgium.

Background: Available comparisons between open partial nephrectomy (OPN) and robot-assisted partial nephrectomy (RAPN) are scarce, incomplete, and affected by non-negligible risk of bias.

Objective: To compare RAPN and OPN.

Design, Setting, And Participants: This was an observational study of 472 patients diagnosed with a cT1-2cN0cM0 renal mass and treated with RAPN or OPN assessed in two prospective institutional databases.

Outcome Measurements And Statistical Analysis: The study outcomes were morbidity, complications, warm ischaemia time, renal function, positive surgical margins, and oncologic outcomes. Propensity score matching for age at diagnosis, gender, Charlson comorbidity index, preoperative estimated glomerular filtration rate (eGFR), single kidney status, tumour size and side, total PADUA score, any individual PADUA score item, and year of surgery was used to account for baseline confounders. The effect of surgical approach was estimated using linear and logistic regressions for continuous and categorical outcomes. An interaction test was used for subgroup analyses.

Results And Limitations: Relative to OPN, RAPN was associated with lower rates for overall (21% vs 36%; p<0.0001) and major (3% vs 9%; p=0.03) complications. This benefit was consistent in patients with high PADUA scores, high CCI, large tumours, and low preoperative eGFR (all p>0.05, interaction test). No difference between the groups was observed for warm ischaemia time, postoperative and 1-yr eGFR, and positive surgical margins (all p>0.05). After median follow-up of 41 mo, there was no difference between the groups for the 5-yr rates of local recurrence-free, systemic progression-free, and disease-free survival (all p>0.05).

Conclusions: RAPN is associated with overall better perioperative morbidity and lower rates of complications, regardless of characteristics such as tumour complexity and patient comorbidity status. Functional and oncologic outcomes are equal after RARP and OPN.

Patient Summary: Robot-assisted partial nephrectomy is associated with a better morbidity profile than open partial nephrectomy (OPN) and provides the same cancer control and renal function preservation observed after OPN.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euo.2018.01.001DOI Listing
May 2018

Current role of robotic bladder cancer surgery.

Minerva Urol Nefrol 2019 Aug 7;71(4):301-308. Epub 2019 May 7.

Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden.

Introduction: Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in urology, that is not devoid of postoperative complications. Minimally invasive surgery, and especially robot-assisted RC (RARC) has emerged as an alternative to open RC (ORC) in an attempt to minimize surgical morbidity and facilitate the surgical approach. The aim of this paper was to present the current knowledge on the oncological efficacy and complication outcomes of RARC.

Evidence Acquisition: A non-systematic review on all relevant studies with the keywords "Radical cystectomy," "Open," "Robot-assisted," "Complications," "Recurrence," "Survival," "Neobladder," "Potency," "Continence" and "Intracorporeal" was performed using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) Guidelines.

Evidence Synthesis: RARC shows similar lymph node yields and positive surgical margin rates as well as perioperative complication outcomes compared with ORC. RARC exhibits significantly less blood loss and less intra- and postoperative blood transfusion. Moreover, survival and recurrence rates are not related to the surgical approach. Finally, RARC seems to be more expensive and has a longer operating time compared to the open technique.

Conclusions: As current evidence shows, RARC seems as a technically feasible and safe procedure, providing equivalent perioperative and oncological results compared to ORC. More prospective, randomized-controlled trials are necessary to draw definitive conclusions on all comparative aspects.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S0393-2249.19.03435-0DOI Listing
August 2019

Robot-assisted nephroureterectomy for upper tract urothelial carcinoma: results from three high-volume robotic surgery institutions.

J Robot Surg 2020 Feb 30;14(1):211-219. Epub 2019 Apr 30.

Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.

Robot-Assisted NephroUreterectomy (RANU) represents a minimally invasive alternative to open NephroUreterectomy (NU) for management of Upper Tract Urothelial Carcinoma (UTUC) but its oncologic safety is still controversial. The objective of this study was to investigate the peri-operative, pathologic and oncologic outcomes of RANU for UTUC. From 2008 to 2017, 78 patients diagnosed with UTUC and elected for RANU at 3 high-volume robotic surgery centres were retrospectively assessed. Surgery was performed using da Vinci Si and Xi systems. RANU was done adhering to oncological principles as in open surgery. The outcomes of the study were: (1) peri-operative morbidity, namely intra- and post-operative complications, blood loss, length of hospital stay and operative time; (2) oncologic outcomes, namely overall survival (OS) and recurrence-free survival (RFS). Peri-operative overall complication rate was 24.4% and high-grade complication rate was 2.6%. Median blood loss, length of hospital stay and operative time were 124 ml, 4 days and 167 min. Lymphadenectomy was performed in 31 (41%) patients. Lymph-node involvement was present in 9 (29%) patients. At median follow-up of 15 months, 2- and 4-year OS were 79% and 66%, respectively, and RFS was 63% and 53%. Peritoneal dissemination was recorded in 1 (1.3%) patient with pT4N2R1 UTUC. Our study is limited by the relatively small cohort of patients and its retrospective character. RANU as minimally invasive treatment for patients with UTUC is safe and feasible. Post-operative morbidity is low and major complications are rare. Oncologic outcomes are acceptable and no evidence of increased risk of peritoneal dissemination is recorded. Long-term data are needed. RANU should be regarded as an alternative to open surgery for UTUC that can offer good peri-operative and oncologic results.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11701-019-00965-8DOI Listing
February 2020

The ERUS Curriculum for Robot-assisted Partial Nephrectomy: Structure Definition and Pilot Clinical Validation.

Eur Urol 2019 06 9;75(6):1023-1031. Epub 2019 Apr 9.

ORSI Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.

Background: No validated training program for robot-assisted partial nephrectomy (RAPN) exists.

Objective: To define the structure and provide a pilot clinical validation of a curriculum for robot-assisted partial nephrectomy (RAPN).

Design, Setting, And Participants: A modified Delphi consensus methodology involving 27 experts defined curriculum structure. One trainee completed the curriculum under the mentorship of an expert. A total of 40 patients treated with curriculum RAPN (cRAPN) were compared with 160 patients treated with standard of care (sRAPN).

Outcome Measurements And Statistical Analysis: To define curriculum structure, consensus was defined as ≥90% expert agreement. To investigate curriculum safety, perioperative morbidity, renal function, and pathologic outcomes were evaluated. To investigate curriculum efficacy, RAPN steps and modules attempted and completed by the trainee were evaluated. Propensity score matching identified comparable cRAPN and sRAPN cases. Mann-Whitney U test, chi-square test, and linear regression were used to investigate the impact of the curriculum on patient's outcome and the impact of trainee's experience on surgical independence.

Results And Limitations: Consensus-based key statements defined curriculum structure. No difference was recorded between cRAPN and sRAPN with respect to intraoperative or overall and grade-specific postoperative complications, blood loss, ischemia time, postoperative estimated glomerular filtration rate, and positive surgical margins (all p>0.05). Conversely, operative time was longer after cRAPN (p<0.0001). The trainee completed all phases of the curriculum and the trainee's experience was associated with more steps attempted/completed and increasing complexity of module attempted/completed (all p<0.0001). The limitations of the study are the enrolment of a single trainee at a single institution and the small sample size. Accordingly, the large confidence intervals observed cannot exclude inferior outcomes in case of cRAPN and further study is required to confirm safety.

Conclusions: The European Association of Urology (EAU) Robotic Urology Section (ERUS) curriculum for RAPN can protect patients from suboptimal outcome during the learning curve of the surgeon and can aid surgeons willing to start an RAPN program.

Patient Summary: Patients should be aware that structured training programs can reduce the risk of suboptimal outcome due to the learning curve of the surgeon.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eururo.2019.02.031DOI Listing
June 2019

What's new in robotic partial nephrectomy.

Arch Esp Urol 2019 04;72(3):283-292

General Surgery and Urology. OLV Hospital. Belgium.

Objective: Robot assisted partial nephrectomy (RAPN) is a minimally invasive option for patients with small renal masses undergoing partial nephrectomy. In this review we provide an update on the oncological safety and renal functional outcomes following RAPN. We also discuss the novel techniques and technological advances that have contributed to the outcomes of RAPN.  METHODS: A Medline search using the keywords "partial nephrectomy", "robotic partial nephrectomy", "robot assisted partial nephrectomy", "robot assisted laparoscopic partial nephrectomy" and "laparoscopic partial nephrectomy" was conducted to identify original articles, review articles, and editorials on RAPN.

Results: A review of the literature suggests that RAPNis emerging as the preferred approach to minimally invasive nephron sparing surgery. RAPN is superior to laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) in terms of perioperative outcomes with equivalent mid-term oncological outcomes. RAPN has proven safety and efficacy even in complex renal tumors with equivalent oncological and functional outcomes. Novel techniques and advances in technology have contributed to the safety and efficacy of RAPN. CONCLUSION: RAPN can be considered to be the gold standard approach to minimally invasive nephronsparing surgery with equivalent oncological and  renal functional outcomes and superior perioperative outcomes when compared to OPN. Newer techniques and developments in robotic technology have contributed to improved outcomes following RAPN.
View Article and Find Full Text PDF

Download full-text PDF

Source
April 2019

Robot-assisted versus open partial nephrectomy: comparison of outcomes. A systematic review.

Minerva Urol Nefrol 2019 Apr 18;71(2):113-120. Epub 2019 Mar 18.

Department of Urology, OLV, Aalst, Belgium.

Introduction: Robot-assisted partial nephrectomy (RAPN) is increasingly used for the surgical management of renal masses. Aim of this study was to analyze the available literature regarding the outcomes of RAPN compared to those of open partial nephrectomy (OPN).

Evidence Acquisition: A literature search was performed up to October 2018 using PubMed, MEDLINE and Embase. Article selection followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) principles and Population, Intervention, Comparator, Outcomes (PICO) methodology was used. Population (P) was patients with renal masses who underwent RAPN (I). RAPN was compared with OPN (C). Outcomes of interest were perioperative, oncological and functional outcomes of both surgical procedures (O). Inclusion criteria were: randomized controlled studies andobservational cohort studies comparing RAPN versus OPN, which reported at least one outcome of interest.

Evidence Synthesis: Twenty-two manuscripts met our inclusion criteria and were included in the systematic review. RAPN was superior to OPN in terms of complication rate in 11 studies while similar results were observed in 9 studies. Positive surgical margins were similar in 13 studies while RAPN had lower surgical margins in 6 studies. Operative and warm ischemia times were longer in OPN in 13 and 10 studies, respectively. Seventeen and 19 studies showed that estimated blood loss and length of hospital stay were higher in RAPN. Estimated glomerular filtration rate decline and chronic kidney disease upstaging decline were similar in the majority of studies.

Conclusions: Current evidence demonstrate that RAPN is a reasonable alternative to OPN with regard to oncological and early functional outcomes with a straightforward advantage of improved perioperative morbidity, as expected by minimally invasive techniques. Nevertheless, there is still a great need for well-designed randomized studies with an extended follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S0393-2249.19.03391-5DOI Listing
April 2019

Oncologic outcomes in prostate cancer patients treated with robot-assisted radical prostatectomy: results from a single institution series with more than 10 years follow up.

Minerva Urol Nefrol 2019 Feb 14;71(1):38-46. Epub 2018 Dec 14.

Department of Urology, OLV, Aalst, Belgium.

Background: Robot-assisted radical prostatectomy (RARP) has gained increasing diffusion as standard of care in the surgical treatment of prostate cancer (PCa) patients, even in the absence of robust long-term oncologic comparative data. This article is a report of oncologic outcomes of RARP at more than 10 years follow-up.

Methods: We retrospectively evaluated 173 consecutive PCa patients underwent RARP between 2002 and 2005 at a single European center with complete clinic and pathologic data and potential follow-up of at least 10 years. Kaplan-Meier analyses assessed biochemical recurrence free survival (BCR-FS), clinical recurrence free survival (CR-FS), cancer specific mortality free survival (CSM-FS), other causes mortality free survival (OCM-FS) in the overall population and CR-FS after stratification according to pathologic stage and Gleason score. Multi-variable Cox regression analyses were performed to assess the predictors of BCR and CR.

Results: Median follow-up (Interquatile Range [IQR]) was 133 (123-145) months. The BCR-FS, CR-FS, CSM-FS and OCM-FS rates at median follow-up were 73.4%, 81.1%, 95.7%, and 68.6%, respectively. Patients staged as pT3b-T4 and men with Gleason score 8-10 experienced significantly lower CR-FS rates as compared to those with less aggressive pathologic features (all P≤0.001). At multivariable analysis, pathologic Gleason score 8-10 (Hazard Ratio [HR]: 2.85), pathologic stage pT3b-pT4 (HR: 2.76) and adjuvant therapy (HR: 2.09 for radiotherapy [RT] and HR: 13.66 for androgen deprivation therapy [ADT]) were independent predictors of BCR (all p≤0.02). While, pathologic Gleason score 8-10 (HR: 4.05) and pathologic stage pT3b-pT4 (HR: 6.78) were found to be independently related to higher risk of CR (all P≤0.03). Retrospective data and limited number of patients included could have affected our analyses.

Conclusions: In experienced centers, RARP allows optimal oncologic outcomes at long term follow-up. Adverse pathologic characteristics are independent predictors of BCR and CR.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S0393-2249.18.03285-XDOI Listing
February 2019

The Learning Curve for Robot-assisted Partial Nephrectomy: Impact of Surgical Experience on Perioperative Outcomes.

Eur Urol 2019 02 19;75(2):253-256. Epub 2018 Sep 19.

ORSI Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.

Robot-assisted partial nephrectomy (RAPN) outcomes might be importantly affected by increasing surgical experience (EXP). The aim of the study is to investigate the effect of EXP on warm ischemia time (WIT), presence of at least one Clavien-Dindo ≥2 postoperative complication (CD ≥ 2), and positive surgical margins (PSMs) to define the learning curve for RAPN. We evaluated 457 consecutive patients diagnosed with a cT1-T2 renal mass were evaluated. EXP was defined as the total number of RAPNs performed by each surgeon before each patient's operation. Median WIT was 14min and the rate of CD ≥ 2 and PSMs was 15% and 4%, respectively. At multivariable regression analyses adjusted for case mix, EXP resulted associated with shorter WIT (p<0.0001) and higher probability of CD ≥ 2-free postoperative course (p=0.001), but not with PSMs (p=0.7). The relationship between EXP and WIT emerged as nonlinear, with a steep slope reduction within the first 100 cases and a plateau observed after 150 cases. Conversely, the relationship between EXP and CD ≥ 2-free course resulted linear, without reaching a plateau, even after 300 cases. Patient summary: Perioperative outcomes after robot-assisted partial nephrectomy (RAPN) are importantly and individually affected by surgeon's experience. After 150 RAPNs, no further improvement is observed with respect to ischemia time, but the learning curve appears endless with respect to complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eururo.2018.08.042DOI Listing
February 2019

Assessing perioperative, functional and oncological outcomes of patients with imperative versus elective indications for robot-assisted partial nephrectomy: Results from a high-volume center.

Int J Urol 2018 09 21;25(9):826-831. Epub 2018 Aug 21.

Department of Urology, OLV Ziekenhuis, Aalst, Belgium.

Objective: To determine the impact of imperative or elective indications on the perioperative, functional and oncological outcomes of patients undergoing robot-assisted partial nephrectomy.

Methods: Between June 2006 and September 2016, data of patients who underwent robot-assisted partial nephrectomy at the Onze-Lieve-Vrouwziekenhuis Hospital in Aalst, Belgium, were retrospectively reviewed from a prospectively collected database. Only patients with non-metastatic, clinical T1-T2 graded tumors were included. Perioperative, functional and oncological outcomes were recollected. A comparative analysis was carried out after dividing patients into two groups: those who underwent robot-assisted partial nephrectomy for an elective indication (group 1, n = 194), and for an imperative indication (group 2, n = 57) caused by a solitary kidney (n = 20), impaired renal function (n = 2) or both (n = 35).

Results: Patients in group 2 were older (74 vs 71 years, P < 0.001), and had a higher Charlson Comorbidity Index (P < 0.001) and American Society of Anesthesiologists score (P < 0.001). No differences were observed concerning laterality, sex, preoperative aspects and dimensions used for an anatomical score or clinical stage. Surgical outcomes considering estimated blood loss, surgical time, ischemia time and transfusion rate showed no significant difference between groups. The complication rate according to Clavien-Dindo showed no difference between groups (P = 0.6). No difference was found between groups with regard to percentage decrease of estimated glomerular filtration rate (7.4 vs 4.8%, P < 0.15).

Conclusions: Robot-assisted partial nephrectomy can be safely and effectively carried out by experienced surgeons in a high-volume center with similar perioperative, functional and oncological outcomes for both elective or imperative indications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/iju.13754DOI Listing
September 2018

Outcomes of Robot-assisted Partial Nephrectomy for Clinical T2 Renal Tumors: A Multicenter Analysis (ROSULA Collaborative Group).

Eur Urol 2018 08 19;74(2):226-232. Epub 2018 May 19.

Division of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy.

Background: While partial nephrectomy (PN) represents the standard surgical management for cT1 renal masses, its role for cT2 tumors is controversial. Robot-assisted PN (RAPN) is being increasingly implemented worldwide.

Objective: To analyze perioperative, functional, and oncological outcomes of RAPN for cT2 tumors.

Design, Setting, And Participants: Retrospective analysis of a large multicenter, multinational dataset of patients with nonmetastatic cT2 masses treated with robotic surgery (ROSULA: RObotic SUrgery for LArge renal mass).

Intervention: Robotic-assisted PN.

Outcome Measurements And Statistical Analysis: Patients' demographics, lesion characteristics, perioperative variables, renal functional data, pathology, and oncological data were analyzed. Univariable and multivariable regression analyses assessed the relationships with the risk of intra-/postoperative complications, recurrence, and survival.

Results And Limitations: A total of 298 patients were analyzed. Median tumor size was 7.6 (7-8.5) cm. Median RENAL score was 9 (8-10). Median ischemia time was 25 (20-32) min. Median estimated blood loss was 150 (100-300) ml. Sixteen patients had intraoperative complications (5.4%), whereas 66 (22%) had postoperative complications (5% were Clavien grade ≥3). Multivariable analysis revealed that a lower RENAL score (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.21-0.65, p=0.02) and pathological pT2 stage (OR 0.51, 95% CI 0.12-0.86, p=0.001) were protective against postoperative complications. A total of 243 lesions (82%) were malignant. Twenty patients (8%) had positive surgical margins. Ten deaths and 25 recurrences/metastases occurred at a median follow-up of 12 (5-35) mo. At univariable analysis, higher pT stage was predictive of a likelihood of recurrences/metastases (p=0.048). While there was a significant deterioration of renal function at discharge, this remained stable over time at 1-yr follow-up. The main limitation of this study is its retrospective design.

Conclusions: RAPN in the setting of select cT2 renal masses can safely be performed with acceptable outcomes. Further studies are warranted to corroborate our findings and to better define the role of robotic nephron sparing for this challenging indication.

Patient Summary: This report shows that robotic surgery can be used for safe removal of a large renal tumor in a minimally invasive fashion, maximizing preservation of renal function, and without compromising cancer control.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eururo.2018.05.004DOI Listing
August 2018

A Novel Approach for Apical Dissection During Robot-assisted Radical Prostatectomy: The "Collar" Technique.

Eur Urol Focus 2018 09 7;4(5):677-685. Epub 2018 May 7.

Department of Urology, OLV Aalst, Belgium; ORSI Academy, Melle, Belgium. Electronic address:

Background: Apical dissection in robot-assisted radical prostatectomy (RARP) affects not only cancer control, but also continence recovery.

Objective: To describe a novel approach for apical dissection, the collar technique, to reduce apical positive surgical margins (PSMs).

Design, Setting, And Participants: A total of 189 consecutive patients (81 in the control group, 108 in the collar technique group) underwent RARP at a single center.

Primary Outcome: rates of apical PSMs; secondary outcome: urinary continence.

Intervention: The urethral sphincter complex is incised 2-3mm distally to the apex, to stay farther from it and reduce PSMs; the underlying smooth muscle is exposed and incised closer to the apex to preserve the maximal length of the lissosphincter.

Outcome Measurements And Statistical Analysis: Mann-Whitney U and chi-square tests compared median and proportions between the two groups, respectively. Univariate logistic regression tested the association between technique employed and risk of apical PSMs.

Results And Limitations: Fourteen patients (7.4%) revealed apical PSMs (9.9% in the control group, 5.6% in the collar group; p=0.7). When the collar technique was used, significantly lower rates of apical PSMs occurred in pT2 disease (0% vs 7.1%; p=0.03). In case of apical tumor at preoperative magnetic resonance imaging (MRI; n=43), the collar technique determined significantly lower overall (9.7% vs 42%) and apical (3.2% vs 42%) PSMs (all p≤0.02). Continence recovery in the collar and control groups was similar. When preoperative MRI showed an apical tumor, the collar technique had a significantly lower risk of apical PSMs (odds ratio: 0.05, p=0.009).

Conclusions: The collar technique reduces the rates of apical PSMs in case of apical tumor, preserving the length of the lissosphincter.

Patient Summary: We describe a novel approach for apical dissection during robot-assisted radical prostatectomy. Our technique reduces the rates of apical surgical margins in case of apical tumor at preoperative magnetic resonance imaging and leads to optimal continence recovery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euf.2018.01.004DOI Listing
September 2018