Publications by authors named "Jihad Kaouk"

488 Publications

Initial Experience with Single-port Robotic-assisted Kidney Transplantation and Autotransplantation.

Eur Urol 2021 Mar 30. Epub 2021 Mar 30.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.

Background: Compared with the standard open approach, multiport robotic-assisted kidney transplantation (RAKT) has emerged as a less morbid alternative. The use of a single-port robotic approach for kidney transplantation (KT) is presented in this study as having the potential for further reducing the morbidity of KT.

Objective: To present the technique and evaluate perioperative and short-term (≤1 yr) postoperative outcomes of single-port RAKT.

Design, Setting, And Participants: Prospective evaluation of peri- and postoperative outcomes in patients who underwent allograft KT (n = 6) or kidney autotransplantation (n = 3). The IDEAL model (www.ideal-collaboration.net/framework) for safe surgical innovation was used.

Surgical Procedure: Kidney allografts from living or deceased donors were transplanted into six patients with end-stage renal disease. Single-port robotic surgery was performed through a 5-cm midline periumbilical abdominal incision with transperitoneal or extraperitoneal approaches. With similar incision and technique, the right or left kidney was removed and autotransplantation was performed in three patients.

Measurements: Intra- and postoperative variables, and outcomes were assessed with a descriptive analysis.

Results And Limitations: Single-port RAKT procedures were completed successfully, with total operative and vascular anastomosis times ranging from 300 to 450 mins and from 52 to 92 mins, respectively. All six patients had excellent graft function with serum creatinine levels at the last follow-up (2 wk to 1 yr), ranging from 1.2 to 1.5 mg/dl. Renal autotransplantation was also completed successfully with a single-port robotic approach in three patients. The total operative and vascular anastomosis times ranged from 510 to 600 mins and from 65 to 83 mins, respectively. In all three cases, serum creatinine levels remained normal after the surgery and during follow-up, and all remained symptom-free at the time of this writing (4-8 mo after their surgeries).

Conclusions: In this initial experience, single-port RAKT is feasible with potential benefits such as offering true single-site minimally invasive surgery, extraperitoneal approach, less morbidity, and comparable short-term graft functional outcomes.

Patient Summary: We presented the initial experience with the application of single-port robotic surgery for kidney transplantation and autotransplantation. This technique was found to be safe and effective, with promising postoperative outcomes and potentially with less morbidity.
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http://dx.doi.org/10.1016/j.eururo.2021.03.002DOI Listing
March 2021

Reply to editorial letter : Outpatient Extraperitoneal Single-port Robotic Radical Prostatectomy.

Urology 2021 Feb 26. Epub 2021 Feb 26.

Department of Urology, Section of Laparoscopic & Minimally Invasive Surgery Center, Glickman Urological Institute, Cleveland Clinic, Cleveland, OH. Electronic address:

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http://dx.doi.org/10.1016/j.urology.2021.02.020DOI Listing
February 2021

Predictive factors of postoperative complications and hospital readmission after implementation of the single-port robotic platform: A single-center and single-surgeon experience.

Int J Urol 2021 Feb 2. Epub 2021 Feb 2.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Objectives: To measure the incidence, and identify potential risk factors of conversion, postoperative complication and readmission for patients treated with urological robotic single-port surgery.

Methods: All consecutive urological surgery procedures carried out with the single-port robotic platform by the same surgeon in a single institution between September 2018 and March 2020 were included in this retrospective analysis. Demographic data, main perioperative outcomes and information related to the surgical technique were gathered and analyzed. A logistic regression model was used to assess predictive factors for any grade and high-grade (e.g. Clavien grade ≥3) postoperative complications, as well as predictive factors for readmission.

Results: Analysis included 221 patients, of whom 194 (88%) underwent pelvic surgery and 27 (12.2%) underwent upper urinary tract surgery. Only one patient was converted to open surgery in the entire cohort. A total of 40 patients (18.1%) experienced postoperative complications, with grade ≥3 postoperative complications in 7.6% of the entire cohort. On multivariable analysis, the factors significantly associated with the risk of postoperative complication of any grade were diabetes (P < 0.001), perineal approach (P < 0.01) and postoperative pain management with opioids (P = 0.01). Only diabetes (P = 0.03) predicted a grade ≥3 complication. Overall, 17 patients (7.7%) were readmitted during the 3 months after surgery. A body mass index >30 kg/m was the only identified predictor of readmission (P = 0.01).

Conclusion: A wide range of pelvic, extraperitoneal and upper-tract urological procedures can be carried out using the robotic single-port platform with a minimal conversion rate and low complication or readmission rate.
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http://dx.doi.org/10.1111/iju.14503DOI Listing
February 2021

Robot-assisted Radical Prostatectomy Using Single-port Perineal Approach: Technique and Single-surgeon Matched-paired Comparative Outcomes.

Eur Urol 2021 Mar 21;79(3):384-392. Epub 2020 Dec 21.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: Radical perineal prostatectomy (RPP) has been revived with the advent of single-port (SP) robotic surgery. However, its interest and precise role need to be evaluated and better defined.

Objective: To describe in detail the technique of SP-RPP and compare initial perioperative outcomes with those of multiport robot-assisted transperitoneal radical prostatectomy (MP-RARP).

Design, Setting, And Participants: From October 2018 to June 2020, perioperative data of 26 consecutive patients who underwent SP-RPP for localized prostate cancer (PCa) in a single institution were prospectively entered into an institutional review board-approved database. Data of 86 consecutive patients treated from September 2017 to September 2018 with MP-RARP by the same surgeon, before the beginning of the SP experience, were used as comparators.

Surgical Procedure: SP-RPP was performed using the SP robotic platform (Intuitive Surgical, Sunnyvale, CA, USA) according to the technique described in the supplementary video.

Measurements: Demographics, and intra- and postoperative data were analyzed in a matched-paired design with a 1:1 ratio on the following factors: age at surgery, prostate-specific antigen level, preoperative Gleason score, and history of abdominal surgery.

Results And Limitations: After matching, baseline characteristics were comparable except for the rate of prior laparotomy, which was higher in the SP-RPP group (52% vs 8%, p < 0.001). In the SP-RPP group, 84% of the patients had a high risk and an unfavorable intermediate risk of positive surgical margins (PSMs) versus 57% in the MP-RARP group (p = 0.03). While the rate of nonlimited PSMs (ie, >3 mm) was higher in the SP-RPP group (38.5% vs 7.7%, p < 0.01), the number of patients with biochemical recurrence at 1 yr was comparable between SP-RPP and MP-RARP (1 vs 3, p = 0.3).

Conclusions: SP-RPP is a complex procedure for patients with a complex surgical history and high-risk localized PCa with limited alternative therapeutic options.

Patient Summary: Our study suggests that patients with high-risk localized prostate cancer and limited treatment options due to a complex abdominal surgical history (ie, frozen pelvis) may be suitable candidates for single-port radical perineal prostatectomy.
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http://dx.doi.org/10.1016/j.eururo.2020.12.013DOI Listing
March 2021

Predictive factors for opioid-free management after robotic radical prostatectomy: the value of the SP® Robotic Platform.

Minerva Urol Nefrol 2020 Dec 1. Epub 2020 Dec 1.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA -

Background: The objective was to evaluate perioperative factors associated with opioid-free management after robotic radical prostatectomy in a single institution.

Methods: From January 2019 to January 2020, data from patients who underwent robotic radical prostatectomy was retrospectively entered in a pre-approved IRB database. Data were analyzed according to the postoperative opioid administration in hospital and/or after discharge. Robotic radical prostatectomy was performed using either the standard multi-port Da Vinci Si robotic platform with a transperitoneal approach(MP-RALP) or the novel DaVinci SP® robotic platform with an extraperitoneal approach(SP-EPP). Patients undergoing minimally invasive surgery were included in the "enhanced recovery after surgery"(ERAS) protocol regardless of the surgery approach.

Results: During the study period, 210 patients matched the selection criteria. Of those, 158(75%) patients received opioids during the hospital stay or after discharge and 52(25%) patients never received opioids. SP-EPP surgical approach and shorter LOS were predictors of never receiving opioids (Odds Ratio [OR]=4.97, (95% CI 1.81-14.77, p=0.002 and OR=0.56, CI 95% 0.35-0.86, p=0.011, respectively). SP-EPP surgical approach was increasing the odds of remaining opioid free whether in-hospital or after discharge (OR= 11.97, 95% CI 4.8 - 32, p<0.0001 and OR=11.6, 95% CI 4.6-31, p<0.0001, respectively). Finally, a high BMI increased the odds of receiving opioid in hospital or after discharge (OR=0.89, 95% CI 0.82-0.96, p=0.003 and OR=0.89, 95% CI 0.82-0.96, p=0.002, respectively).

Conclusions: In this series, after robotic radical prostatectomy the use of a less invasive approach (SP-EPP), a shorter LOS and a lower BMI, were predictive of opioid-free status.
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http://dx.doi.org/10.23736/S0393-2249.20.04038-2DOI Listing
December 2020

Pure Single-site Robot-assisted Radical Prostatectomy Using Single-port Versus Multiport Robotic Radical Prostatectomy: A Single-institution Comparative Study.

Eur Urol Focus 2020 Nov 4. Epub 2020 Nov 4.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: Pure single-site robot-assisted extraperitoneal prostatectomy (EPP) using a single-port (SP) robotic platform has been shown to be feasible and safe in previous descriptive studies.

Objective: To compare the perioperative outcomes of patients undergoing SP-EPP versus conventional multiport (MP) transperitoneal robot-assisted radical prostatectomy (RARP).

Design, Setting, And Participants: From January 2019 to January 2020, data of 100 consecutive patients who underwent SP-EPP performed by the same surgeon and 110 consecutive patients who underwent MP-RARP by three surgeons from the same institution were prospectively collected.

Intervention: All SP-EPPs were performed in a pure single-site fashion without Trendelenburg.

Outcome Measurements And Statistical Analysis: Demographic characteristics as well as intra- and postoperative data of patients in both groups were analyzed. Quantitative data were described in terms of median and quartiles.

Results And Limitations: After SP-EPP, the rate of patients discharged the same day was nine times higher than that after MP-RARP (p < 0.001), and the median length of postoperative hospital stay was significantly shorter: 4.3 h (interquartile range [IQR] 3.3-17.4) versus 26.1 h (IQR 21.5-44.8). The rate of opioid use in the hospital and after discharge in the SP group was at least half that in the MP group (respectively, 32% vs 64%, p < 0.001, and 35% vs 87%, p < 0.001). The overall positive surgical margin rate as well as continence rate at 12 mo (85% vs 88%, p = 0.97) and the prostate-specific antigen relapse-free survival (p = 0.09) were statistically comparable between the SP and MP groups.

Conclusions: Pure single-site SP-EPP was associated with a shorter length of stay as well as a decreased need for postoperative pain medication and narcotic administration in comparison with conventional transperitoneal multiport prostatectomy, with comparable postoperative complications and readmission rate.

Patient Summary: Surgical treatment of localized prostate cancer using a single-port robotic platform allows for a shorter hospital stay, less pain, and less opioid use than conventional robotic surgery without more morbidity. TAKE  HOME MESSAGE: Pure single-site single-port extraperitoneal prostatectomy was associated with a shorter length of stay as well as a decreased need for postoperative pain medication and narcotic administration in comparison with conventional transperitoneal multiport prostatectomy, with comparable postoperative complication and readmission rate.
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http://dx.doi.org/10.1016/j.euf.2020.10.006DOI Listing
November 2020

Active surveillance for small renal masses in elderly patients does not increase overall mortality rates compared to primary intervention: a propensity score weighted analysis.

Minerva Urol Nefrol 2020 Sep 29. Epub 2020 Sep 29.

Department of Urology, Instituto Valenciano de Oncología (IVO), Valencia, Spain -

Background: To test the effect of active surveillance (AS) versus primary intervention (PI) on overall mortality (OM) in elderly patients diagnosed with SRM.

Methods: Elderly patients (75 years or older) diagnosed with SRMs (< 4cm) and treated with either PI [i.e. partial nephrectomy or kidney ablation] or AS between 2009 and 2018 were abstracted from the REnal SURGery in the Elderly (RESURGE) and Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) datasets, respectively. OM rates were estimated among groups with Kaplan Meier method and Cox proportional hazards regression models after applying inverse probability of treatment weighting (IPTW). Multivariable logistic regression model was used to estimate IPTW. Covariates of interest were those unbalanced and/or significantly correlated with the treatment choice or with OM.

Results: A total of 483 patients were included; 121 (25.1%) underwent AS. 60 patients (12.4%) died. Overall, 6.7% of all deaths were related to cancer. IPTW-Kaplan Meier curves showed a 5-year overall survival rates of 70.0 ± 3.5% and 73.2 ± 4.8% in AS and PI groups, respectively (IPTW-Log-rank p-value=0.308). IPTW-Cox regression model did not show meaningfully increased OM rates in AS group (HR=1.31, 95% CI: 0.69-2.49).

Conclusions: AS represents an appealing treatment option for very elderly patients presenting with SRM, as it avoids the risks of a PI while not compromising the survival outcomes of these patients.
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http://dx.doi.org/10.23736/S0393-2249.20.03785-6DOI Listing
September 2020

EDITORIAL COMMENT.

Urology 2020 Sep;143:31-32

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.

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http://dx.doi.org/10.1016/j.urology.2020.03.068DOI Listing
September 2020

Contemporary Techniques of Prostate Dissection for Robot-assisted Prostatectomy.

Eur Urol 2020 10 1;78(4):583-591. Epub 2020 Aug 1.

Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA.

Background: Over the years, several techniques for performing robot-assisted prostatectomy have been implemented in an effort to achieve optimal oncological and functional outcomes.

Objective: To provide an evidence-based description and video-based illustration of currently available dissection techniques for robotic prostatectomy.

Design, Setting, And Participants: A literature search was performed to retrieve articles describing different surgical approaches and techniques for robot-assisted radical prostatectomy (RARP) and to analyze data supporting their use. Video material was provided by experts in the field to illustrate these approaches and techniques.

Surgical Procedure: Multiple surgical approaches are available: extraperitoneal, transvesical, transperitoneal posterior, transperitoneal anterior, Retzius sparing, and transperineal. Surgical techniques for prostatic dissection sensu strictu are the following: omission of the endopelvic fascia dissection, bladder neck preservation, incremental nerve sparing by means of an antegrade or retrograde approach, and preservation of the puboprostatic ligaments and dorsal venous complex. Recently, techniques for total or partial prostatectomy have been described.

Measurements: Different surgical approaches and techniques for robotic prostatectomy have been analyzed.

Results And Limitations: Two randomized controlled trials evaluating the extraperitoneal versus the transperitoneal approach have demonstrated similar results. Level I evidence on the Retzius-sparing approach demonstrated earlier return to continence than the traditional anterior approach. The question whether Retzius-sparing RARP is associated with a higher rate of positive surgical margins is still open due to the intrinsic bias in terms of surgical expertise in the available comparative studies. This technique also offers an advantage in patients who have received kidney transplantation. Retrospective evidence suggests that the more the anatomical dissection (eg., more periprostatic tissue is preserved), the better the functional outcome in terms of continence. Yet, two randomized controlled trials evaluating the different techniques of dissection have so far been produced. Partial prostatectomies should not be offered outside clinical trials.

Conclusions: Several techniques and approaches are available for prostate dissection during RARP. While the Retzius-sparing approach seems to provide earlier return to continence than the traditional anterior transperitoneal approach, no technique has been proved to be superior to other(s) in terms of long-term outcomes in randomized studies.

Patient Summary: We have summarized available approaches for the surgical treatment of prostate cancer. Specifically, we described the different techniques that can be adopted for the surgical removal of the prostate using robotic technology.
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http://dx.doi.org/10.1016/j.eururo.2020.07.017DOI Listing
October 2020

Head to Head Impact of Margin, Ischemia, Complications, Score Versus a Novel Trifecta Score on Oncologic and Functional Outcomes After Robotic-assisted Partial Nephrectomy: Results of a Multicenter Series.

Eur Urol Focus 2020 Jul 13. Epub 2020 Jul 13.

Department of Urology, Regina Elena National Cancer Institute, Rome, Italy.

Background: There is a paucity of data describing the ability of margin, ischemia, complications, score (MIC) and trifecta in predicting long-term outcomes of robotic-assisted partial nephrectomy (RAPN).

Objective: To compare a novel trifecta (negative margins, no significant complications, and perioperative estimated glomerular filtration rate [eGFR] decrease ≤30%) versus standard MIC as predictors of oncologic and functional results in a large series of RAPNs.

Design, Setting, And Participants: Between 2009 and 2019, a multicenter dataset was queried for patients with nonmetastatic renal masses who underwent RAPN at eight participating institutions.

Intervention: RAPN.

Outcome Measurements And Statistical Analysis: MIC and trifecta achievement were determined for the overall cohort and a subgroup undergoing off-clamp RAPN (ocRAPN), respectively. The overall survival (OS), recurrence-free survival (RFS), and new onset of end-stage renal disease (ESRD; defined as eGFR <30 ml/min) probabilities were assessed by the Kaplan-Meier method. Cox regression analyses were used to identify predictors of OS, RFS, and ESRD. For all analyses, two-sided p < 0.05 was considered significant.

Results And Limitations: Out of 1807 patients, MIC and trifecta were achieved in 71.1% (n = 1285) and 82.6% (n = 1492), respectively, and once restricted to the ocRAPN cohort, in 95.6% (n = 625) and 81.6% (n = 534), respectively. On Kaplan-Meier analysis, both MIC and trifecta achievement predicted higher OS and lower ESRD probabilities (all p < 0.014), while only trifecta achievement was a predictor of RFS probabilities (p = 0.009). On multivariable Cox regression, MIC did not predict any of the endpoints independently, while trifecta achievement was an independent predictor of higher OS (hazard ratio [HR] 0.4, 95% confidence interval [CI] 0.18-0.86; p = 0.019) and lower ESRD development probabilities (HR 0.32, 95% CI 0.15-0.72; p = 0.005).

Conclusions: Trifecta, initially described as comprehensive measures of perioperative outcomes, needs to stand the test of time. Compared with MIC, the recent trifecta was an independent predictor of clinically significant endpoints, namely, survival and ESRD development probabilities.

Patient Summary: Our novel trifecta represents a reliable method for estimating survival and development of end-stage renal disease after robotic-assisted partial nephrectomy.
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http://dx.doi.org/10.1016/j.euf.2020.06.021DOI Listing
July 2020

Combined robotic radical prostatectomy and left partial nephrectomy by a single port ap-proach.

Int Braz J Urol 2020 Sep-Oct;46(5):869

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.

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http://dx.doi.org/10.1590/S1677-5538.IBJU.2019.0336DOI Listing
May 2019

Single-institution Cost Comparison: Single-port Versus Multiport Robotic Prostatectomy.

Eur Urol Focus 2020 Jul 4. Epub 2020 Jul 4.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: In the era of efficient value-based health care, each surgical innovation should be proven to be cost-effective for the patient and the hospital administration.

Objective: To compare the costs associated with robot-assisted prostatectomy using a single-port (SP) or multiport (MP) robotic platform.

Design, Setting, And Participants: Costs for surgical care for consecutive patients with localized prostate cancer treated from November 2018 to November 2019 were itemized and evaluated.

Intervention: Patients were treated using either the SP (n = 78) or MP (n = 97) platform.

Outcome Measurements And Statistical Analysis: Demographics, perioperative data, and costs for surgical care of patients in both groups were analyzed.

Results And Limitation: The mean cost for prostatectomy was comparable between SP ($13 512 ± $1615) and MP ($13 284 ± $1360; p = 0.32). The main cost differences between the groups were the cost of hospitalization, which was lower in the SP group (p < 0.001), offset by the cost of disposables in the operating room, which was higher in the SP group (p < 0.001). The mean length of stay was significantly shorter in the SP group (9.84 ± 11.3 vs 35.5 ± 29.1 h; p < 0.001) and the proportion of patients discharged home on the day of surgery was higher in the SP group (70% vs 5%; p < 0.001). The main limitation of this study is its retrospective design.

Conclusions: Overall, the costs for SP and MP prostatectomy are comparable. The higher SP cost for consumable surgical materials is offset by the lower cost associated with hospitalization, which was largely due to a shorter hospital stay after SP surgery.

Patient Summary: In this report, we found that implementation of the new single-port robotic platform for radical prostatectomy was not associated with higher surgical care costs compared to conventional multiport surgery.
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http://dx.doi.org/10.1016/j.euf.2020.06.010DOI Listing
July 2020

Outpatient Extraperitoneal Single-Port Robotic Radical Prostatectomy.

Urology 2020 Oct 30;144:142-146. Epub 2020 Jun 30.

Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, OH. Electronic address:

Objective: To assess the safety and feasibility of extraperitoneal single-port robotic assisted laparoscopic radical prostatectomy using the da Vinci SP robotic platform for same-day surgery.

Methods: Extraperitoneal single-port robotic prostatectomy (ESRP) using the da Vinci SP platform was performed on 60 patients with clinically localized prostate cancer and no prior definitive therapy. An enhanced recovery protocol was used in the perioperative period and minimal to no opiates were used in these patients. Preoperative, perioperative, and postoperative data were collected in a prospectively maintained institutional review board approved database and evaluated in a retrospective fashion.

Results: Mean operative time was 198 minutes and mean estimated blood loss was 179 mL. No patients required blood transfusion and there were no intraoperative complications. Pain at discharge was 0-1 in 37% of patients. Forty-five patients (75%) were discharged home the day of surgery, including patients with all surgical start times. When excluding patients that were planned for an overnight stay preoperatively or patients whose surgery finished after 6 PM, 88% of patients were discharged home the day of surgery and 96% were discharged within 24 hours of surgery. Median length of stay was 4.2 hours. Fourty-eight percent of patients required 0-1 pads at 30 days postoperatively in patients with 30 day follow data (n = 58) and 76% of patients reported requiring 0-1 pads per day by 90 days postoperatively (n = 37).

Conclusion: ESRP using the da Vinci SP platform can be performed safely and reproducibly as a same-day outpatient surgery with minimal to no opiate use, excellent pain control, and acceptable short term functional and oncological outcomes.
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http://dx.doi.org/10.1016/j.urology.2020.06.029DOI Listing
October 2020

Floating docking technique: a simple modification to improve the working space of the instruments during single-port robotic surgery.

World J Urol 2020 Jun 29. Epub 2020 Jun 29.

Department of Glickman Urological and Kidney Institute, Center for Laparoscopic and Robotic Surgery, Institute Vice-Chair for Surgical Innovations, Cleveland Clinic, 9500 Euclid Ave, Q-10, Cleveland, OH, 44195, USA.

Objective: To compare the range of motion and ergonomic characteristics of single-port robotic instruments in the setting of the "floating" versus "flat" docking technique using the GelPOINT system.

Material And Methods: The basic principle of the floating docking technique resides in the GelSeal cap and trocar (s) being 8 cm off the skin level with the Alexis acting as a conduit between the trocar (s) and the body while preserving insufflation. In the setting of a dry lab study, we measured the range of motion of one robotic instrument with the "floating" and the "flat" docking technique in two different situations depending on whether the distance between the incision and the target was more or less than 10 cm.

Results: The minimum required distances between the target and the tip of the cannula for activation of the wrist and elbow were 5 and 10 cm, respectively. When the target was near to the cannula (i.e., less than 10 cm), the floating technique was associated with a significant increase in the range of motion of the instrument in all directions. The working space volume of the instrument was increased by more than 390% (from 101 to 497 cm) when the surgeon switched from flat (standard) to the floating technique in the setting of a target close (i.e., less than 10 cm) to the cannula CONCLUSION: The floating docking technique is a simple and effective way to increase the working surgical space, especially in confined and narrow surgical fields with a target closer than 10 cm from the skin.
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http://dx.doi.org/10.1007/s00345-020-03307-8DOI Listing
June 2020

Predictors Associated with a Prolonged Hospital Stay After Single-Port Extraperitoneal Robotic Radical Prostatectomy: A Comparative Analysis of Outpatient Versus Inpatient Care.

J Endourol 2020 Oct 15;34(10):1049-1054. Epub 2020 Sep 15.

Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.

To compare the perioperative characteristics of patients receiving outpatient inpatient care and to define predictors of inpatient care after single-port extraperitoneal robotic radical prostatectomy (RRP). Data on 120 patients who underwent single-port extraperitoneal RRP were collected and categorized into two groups: Group I ( = 98) included patients who received outpatient care (i.e. discharged on postoperative day 0) and Group II ( = 22) comprised patients with inpatient care. Demographics and perioperative data were recorded and analyzed between the two groups. Multivariable binary logistic regression was used to determine factors associated with inpatient care. Most patients (98/120: 81.7%) were discharged in few hours (median: 4.1 hours) after surgery (outpatient care: Group I [ = 98]), whereas others (Group II [ = 22]) received inpatient care (median hospital stay: 25.4 hours);  < 0.00001. Most patients with inpatient care (13/22, 59.1%) were among the first initial 40 cases, whereas 37 out of last 40 patients received outpatient care ( = 0.005). Operative time was significantly shorter in patients with outpatient prostatectomy ( = 0.015). The amount of narcotics per patient (if administered) was also significantly greater in Group II ( = 0.006). With regression analysis, having medical comorbidities (odds ratio [OR]: 3.41 95% confidence interval [CI]: 2.05-5.64;  = 0.014), a longer operative time (OR: 1.15 95% CI: 1.10-1.28,  = 0.017), as well as a higher dose of administered narcotics after operation (OR: 1.31 95% CI: 1.08-1.61,  = 0.005) were significant predictors of inpatient care after single-port extraperitoneal RRP. A safe transition to outpatient care is feasible in patients undergoing single-port extraperitoneal RRP. In addition to associated medical comorbidities, a longer operative time and the amount of received narcotic after procedure were the most significant predictors of prolong hospital stay after single-port extraperitoneal RRP. These later modifiable predictors can be optimized with improvement of surgical techniques, intraoperative and postoperative pain management protocols through quality improvement initiatives.
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http://dx.doi.org/10.1089/end.2020.0389DOI Listing
October 2020

On-clamp versus purely off-clamp robot-assisted partial nephrectomy in solitary kidneys: comparison of perioperative outcomes and chronic kidney disease progression at two high- volume centers.

Minerva Urol Nefrol 2020 Jun 22. Epub 2020 Jun 22.

Department of Urology, Regina Elena National Cancer Institute, Rome, Italy.

Background: Minimal literature describes the impact of hilar control on the progression to chronic kidney disease (pCKD) after robotic partial nephrectomy (RPN) in solitary kidneys (SK). The aim of this study was to compare purely off-clamp (ocRPN) vs on-clamp robotic partial nephrectomy (onRPN) in SK and to identify predictors of pCKD at two high-volume centers.

Methods: Between December 2013 and October 2019, 54 patients with SK underwent ocRPN and onRPN for renal tumors at two institutions. Baseline and perioperative data were analyzed. Newly onset of CKD stage 3b,4,5 (CKD3b,4,5) was assessed by Kaplan-Meier curves and compared for warm ischemia time (WIT) with the log-rank test. Cox regression analysis was used to identify predictors of pCKD.

Results: At a median follow-up of 13 months (IQR 6.3-34), newly onset of CKD3b and CKD 4,5 were observed in 11.1% and 7.4% of patients, respectively. onRPN was associated with a higher risk of progression to CKD 3b,4,5 stages (Fig 1; p=0.034) and higher rate of perioperative complications (p=0.03). On univariable analysis eGFR at discharge (eGFRd), positive surgical margins status (PSM) and WIT were predictors of newly onset of CKD3b,4,5 (each p <0.05). Multivariable analysis identified eGFRd (HR 0.88; CI 95% 0.81-0.96) and WIT (HR 1.09; CI 95% 1.02-1.16) as independent predictors of pCKD (each p <0.01). Main limitations include the retrospective nature of the study, the short-term follow-up and the lack of data adjustment for parenchymal volume loss.

Conclusions: eGFRd and WIT during RPN are independent predictors of pCKD in SK. In this setting a critical reduction of WIT should be achieved according to the oncologic outcome. In patients with SK, WIT represents the only surgical modifiable factor of RPN for avoiding a quicker onset of pCKD.
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http://dx.doi.org/10.23736/S0393-2249.20.03795-9DOI Listing
June 2020

Single-Port Robot-Assisted Dismembered Pyeloplasty With Mini-Pfannenstiel or Peri-Umbilical Access: Initial Experience in a Single Center.

Urology 2020 Sep 4;143:147-152. Epub 2020 Jun 4.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Objective: To assess the feasibility and describe the surgical technique for single-port robotic-assisted laparoscopic pyeloplasty using the new da Vinci SP surgical platform (Intuitive Surgical Inc., Sunnyvale, CA), and to describe the approach through a mini-pfannenstiel incision.

Methods: Data from a prospectively maintained single-institution database on all patients undergoing single-port robotic-assisted pyeloplasty between November 2018 and November 2019 were reviewed. Pyeloplasty was performed with the da Vinci SP system through a pure single site approach (except for the first patient). The initial procedures were performed through a midline incision and the technique evolved to a mini-pfannenstiel incision. Patient demographics, intraoperative data, post-operative data and surgical outcomes were collected.

Results: Overall, 10 patients were included and underwent the procedure without intraoperative complications or conversion to an alternate approach. The patients' ages ranged between 11 and 75 years. Mean operative time was 166 minutes (interquartile range [IQR] 146-181) and EBL was minimal. Pfannenstiel incision was performed for 6 patients and 4 patients had a vertical midline incision. The only complication recorded was a postoperative urinary tract infection treated with antibiotics. The median postoperative hospital stay was 21 hours (7-24). Postoperative pain management after discharge was managed exclusively with non-opioid medication. Overall success rate defined as the absence of pain and renal obstruction on post-operative imaging at 3 months after surgery was 100%.

Conclusion: Single-port robotic-assisted laparoscopic pyeloplasty is a safe and feasible procedure through a mini-pfannenstiel incision.
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http://dx.doi.org/10.1016/j.urology.2020.05.041DOI Listing
September 2020

AUTHOR REPLY.

Urology 2020 Jun;140:84

Zegarac-Pollock Professor of Surgery, Director, Center for Laparoscopic and Robotic Surgery Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.

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http://dx.doi.org/10.1016/j.urology.2019.11.088DOI Listing
June 2020

Technical advancements in robotic prostatectomy: single-port extraperitoneal robotic-assisted radical prostatectomy and single-port transperineal robotic-assisted radical prostatectomy.

Transl Androl Urol 2020 Apr;9(2):848-855

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.

Background: To describe our step-by-step techniques for single-port robotic-assisted extraperitoneal and perineal radical prostatectomy as recent technical advancements in this field.

Methods: An English-language literature review was done using search terms including extraperitoneal, transperineal, single-port, robotic surgery, prostate cancer, radical prostatectomy in various combinations. Unique features of the da Vinci SP platform are discussed. Details of surgical techniques with single-port robotic platform are also covered.

Results: The relatively recent introduction of the da Vinci SP platform has led to the development of novel techniques for radical prostatectomy. Unique features of this platform including intracorporeal triangulation and double-articulating instruments will likely lead to widespread applications of this novel system. The principles of radical prostatectomy are reproducible with both extraperitoneal and perineal approaches via a single incision.

Conclusions: A better cosmetic results as well as a quick recovery maybe potential advantages of single-port extraperitoneal/transperineal robotic prostatectomy. By avoiding the peritoneal cavity, a lower rate of bowel related complications and minimum systemic CO absorption can be expected. Adverse effects of steep Trendelenburg positioning can be avoided with these techniques. Evaluation of the oncological and functional outcomes of these techniques will be necessary. Comparative trials with standard robotic surgery and cost-analysis studies remain hot topics for research after implementation of these new platforms at any institute.
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http://dx.doi.org/10.21037/tau.2019.11.35DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214976PMC
April 2020

Outcomes and predictors of benign histology in patients undergoing robotic partial or radical nephrectomy for renal masses: a multicenter study.

Cent European J Urol 2020 23;73(1):33-38. Epub 2020 Mar 23.

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

Introduction: Theaim of this study was to assess preoperative factors associated with benign histology in patients undergoing surgical removal of a renal mass and to analyze outcomes of robotic partial nephrectomy (PN) and radical nephrectomy (RN) for these masses.

Material And Methods: Overall, 2,944 cases (543 benign and 2,401 malignant) who underwent robotic PN and RN between 2003-2018 at 10 institutions worldwide were included. The assessment of the predictors of benign histology was made at the final surgical pathology report. Descriptive statistics, Mann-Whitney U, Pearson's χ, and logistic regression analysis were used.

Results: Patients in the benign group were mostly female (61 vs. 33%; p <0.001), with lower body mass index (BMI) (26.0 vs. 27.1 kg/m; p <0.001). The benign group presented smaller tumor size (2.8 vs. 3.5 cm; p <0.001), R.E.N.A.L. score (6.0 vs. 7.0; p <0.001). There was a lower rate of hilar (11 vs.18%; p = 0.001), cT≥3 (1 vs. 4.5%; p <0.001) tumors in the benign group. There was a statistically significant higher rate of PN in the benign group (97 vs. 86%; p <0.001) as well as a statistically significant lower 30-day re-admission rate (2 vs. 5%; p = 0.081). Multivariable analysis showed male gender (OR: 0.52; p <0.001), BMI (OR: 0.95; p <0.001), and cT3a (OR: 0.22; p = 0.005) to be inversely associated to benign histology.

Conclusions: In 18% of cases, a benign histologic type was found. Only 3% of these tumors were treated with RN. Female gender, lower BMI, and higher T staging showed to be independent predictors of benign histology.
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http://dx.doi.org/10.5173/ceju.2020.0019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7203778PMC
March 2020

Single-Port Laparoscopic Surgery in Urology 'What is Now Proved was Only Once Imagined'.

Urology 2020 Nov 21;145:324-325. Epub 2020 Apr 21.

Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, OH.

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http://dx.doi.org/10.1016/j.urology.2020.04.030DOI Listing
November 2020

A comparative propensity score-matched analysis of perioperative outcomes of intracorporeal vs extracorporeal urinary diversion after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

BJU Int 2020 08 16;126(2):265-272. Epub 2020 May 16.

Roswell Park Cancer Institute, Buffalo, NY, USA.

Objective: To compare the perioperative outcomes of intracorporeal (ICUD) vs extracorporeal urinary diversion (ECUD) after robot-assisted radical cystectomy (RARC).

Patients And Methods: We retrospectively reviewed the prospectively maintained International Robotic Cystectomy Consortium (IRCC) database. A total of 972 patients from 28 institutions who underwent RARC were included. Propensity score matching was used to match patients based on age, gender, body mass index (BMI), American Society of Anesthesiologists Score (ASA) score, Charlson Comorbidity Index (CCI) score, prior radiation and abdominal surgery, receipt of neoadjuvant chemotherapy, and clinical staging. Matched cohorts were compared. Multivariate stepwise logistic and linear regression models were fit to evaluate variables associated with receiving ICUD, operating time, 90-day high-grade complications (Clavien-Dindo Classification Grade ≥III), and 90-day readmissions after RARC.

Results: Utilisation of ICUD increased from 0% in 2005 to 95% in 2018. The ICUD patients had more overall complications (66% vs 58%, P = 0.01) and readmissions (27% vs 17%, P = 0.01), but not high-grade complications (21% vs 24%, P = 0.22). A more recent RC era and ileal conduit diversion were associated with receiving an ICUD. Higher BMI, ASA score ≥3, and receiving a neobladder were associated with longer operating times. Shorter operating time was associated with male gender, older age, ICUD, and centres with a larger annual average RC volume. Longer intensive care unit stay was associated with 90-day high-grade complications. Higher CCI score, prior radiation therapy, neoadjuvant chemotherapy, and ICUD were associated with a higher risk of 90-day readmissions.

Conclusions: Utilisation of ICUD has increased over the past decade. ICUD was associated with more overall complications and readmissions compared to ECUD, but not high-grade complications.
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http://dx.doi.org/10.1111/bju.15083DOI Listing
August 2020

Comprehensive long-term assessment of outcomes following robot-assisted partial nephrectomy for renal cell carcinoma: the ROMe's achievement and its predicting nomogram.

Minerva Urol Nefrol 2020 Aug 16;72(4):482-489. Epub 2020 Apr 16.

Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy.

Background: We proposed a new tool (named ROMe's) to summarize long-term outcomes after partial nephrectomy (PN), identified its predictors and generated a predicting nomogram.

Methods: A retrospective analysis of a multicenter dataset of patients with non-metastatic pT1-3a renal cell carcinoma was performed. Baseline demographic, clinical, pathologic and perioperative data were collected. ROMe's was defined as the concomitant lack of cancer-recurrences, death and newly onset Chronic Kidney Disease (CKD), at long term follow-up. Kaplan-Meier method investigated the predictive role of Trifecta on ROMe's achievement. Univariable and multivariable Cox regression analyses identified its predictors. A nomogram was generated and its accuracy was quantified using concordance index (CI). A calibration plot was obtained with 200 bootstraps resampling to explore nomogram performance at 5 years and decision curve analyses (DCA) assessed the net benefit of the model at 12, 36 and 60 months.

Results: We included 927 patients. The rates of ROMe's were 82%, 72% and 56% at 1, 3 and 5 years follow-up. At Kaplan-Meier analysis, patients who achieved Trifecta displayed a significantly higher probability of ROMe's (log rank P<0.001). Young age (OR=0.982; P=0.001), low RENAL score (OR=0.86; P=0.037), high preoperative filtration rate (OR=1.02; P<0.001) and Trifecta achievement (OR=2.03; P=0.015), were independent predictors of ROMe's. The nomogram showed a CI of 0.76 at 60 months. The 5-years calibration plot confirmed a good discrimination accuracy (0.74); on DCA, the net benefit of using the model was evident for probabilities >30%.

Conclusions: We conceived a triad to summarize the main long-term oncologic and functional outcomes after PN and generated a predicting nomogram.
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http://dx.doi.org/10.23736/S0393-2249.20.03813-8DOI Listing
August 2020

Robotic partial nephrectomy vs minimally invasive radical nephrectomy for clinical T2a renal mass: a propensity score-matched comparison from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group.

BJU Int 2020 07 15;126(1):114-123. Epub 2020 Jun 15.

Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA.

Objective: To compare outcomes of minimally invasive radical nephrectomy (MIS-RN) and robot-assisted partial nephrectomy (RAPN) in clinical T2a renal mass (cT2aRM).

Patients And Methods: Retrospective, multicentre, propensity score-matched (PSM) comparison of RAPN and MIS-RN for cT2aRM (T2aN0M0). Cohorts were PSM for age, sex, body mass index, American Society of Anesthesiologists (ASA) class, clinical tumour size, and R.E.N.A.L. score using a 2:1 ratio for RN:PN. The primary outcome was disease-free survival (DFS). Secondary outcomes included overall survival (OS), complication rates, and de novo estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m . Multivariable (MVA) and Kaplan-Meier survival analyses (KMSA) were conducted.

Results: In all, 648 patients (216 RAPN/432 MIS-RN) were matched. There were no significant differences in intraoperative complications (P = 0.478), Clavien-Dindo Grade ≥III complications (P = 0.063), and re-admissions (P = 0.238). The MVA revealed high ASA class (hazard ratio [HR] 2.7, P = 0.044) and sarcomatoid (HR 5.3, P = 0.001), but not surgery type (P = 0.601) to be associated with all-cause mortality. Increasing R.E.N.A.L. score (HR 1.31, P = 0.037), high tumour grade (HR 2.5, P = 0.043), and sarcomatoid (HR 2.8, P = 0.02) were associated with recurrence, but not surgery (P = 0.555). Increasing age (HR 1.1, P < 0.001) and RN (HR 3.9, P < 0.001) were predictors of de novo eGFR of <45 mL/min/1.73 m . Comparing RAPN and MIS-RN, KMSA revealed no significant differences for 5-year OS (76.3% vs 88.0%, P = 0.221) and 5-year DFS (78.6% vs 85.3%, P = 0.630) for pT2 RCC, and no differences for 3-year OS (P = 0.351) and 3-year DFS (P = 0.117) for pT3a upstaged RCC. The 5-year freedom from de novo eGFR of <45 mL/min/1.73 m was 91.6% for RAPN vs 68.9% for MIS-RN (P < 0.001).

Conclusions: RAPN had similar oncological outcomes and morbidity profile as MIS-RN, while conferring functional benefit. RAPN may be considered as a first-line option for cT2aRM.
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http://dx.doi.org/10.1111/bju.15064DOI Listing
July 2020

Single-Port Robotic Urological Surgery Using Purpose-Built Single-Port Surgical System: Single-Institutional Experience With the First 100 Cases.

Urology 2020 Jun 3;140:77-84. Epub 2020 Mar 3.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.

Objectives: To present a comprehensive report regarding our experience with single-port robotic surgery in our first 100 consecutive patients. We describe the diversity of procedures that can be performed with this platform as well as the challenges and complications we had with the application of this novel technology.

Methods: Between September 2018 and August 2019, data on 100 patients who underwent single-port robotic surgery were consecutively collected. Preoperative, intraoperative and early postoperative outcomes after various urologic procedures were recorded and analyzed.

Results: During the study period, 100 patients (age [range] 35-84 years; 88 [88%] Male) underwent various single-port robotic surgeries for different indications (Retroperitoneal [n = 14], Pelvic surgeries [n = 86]). Transperitoneal (n = 37), extraperitoneal (n = 53) and transvesical (n = 10) approaches have been used to access the target organs. Of these procedures, 73 (73%) were for different oncological indications: Radical prostatectomy (n = 60), Partial nephrectomy (n = 6), Retroperitoneal lymph node dissection (n = 1) and Radical cystectomy with intracorporeal diversion (n = 6). Surgery was successfully completed in all but 1 patient, in whom the surgery was converted to open surgery due to dense adhesions and failure to progress. Grades II-III postoperative complications were detected in (n = 9) patients.

Conclusion: The purpose-built single-port robotic platform can be safely incorporated into the minimally invasive armamentarium. A wide range of pelvic and retroperitoneal urological procedures can be done with different approaches using this platform. Randomized trials with adequate sample size and postoperative follow up period is advisable for further evaluation of the outcomes and to determine the added value of this emerging technology.
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http://dx.doi.org/10.1016/j.urology.2019.11.086DOI Listing
June 2020

Postoperative Renal Function in Patients Undergoing Unilateral Nephrectomy: Development of a Prediction Model Using Preoperative Risk Factors and Cr-EDTA Clearance.

J Endourol 2020 03 2;34(3):394-399. Epub 2020 Mar 2.

Department of Urology, Clinicas Hospital, University of Sao Paulo, Sao Paulo, Brazil.

To analyze the preoperative variables associated to the postoperative glomerular filtration rate (GFR) outcomes after nephrectomy for benign and malignant conditions, measured by the reference isotopic technique Cr- (Cr-EDTA) and to create a model to predict the short-term postoperative GFR. Secondary aim was to evaluate which of the common equations for GFR estimation (Cockcroft-Gault, Modification of Diet in Renal Disease [MDRD] or Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]) has the best correlation with the Cr-EDTA. Patients undergoing unilateral nephrectomy from 2014 to 2018 were selected. Pre- and postoperative variables were prospectively collected. Univariate and multivariate analyses were done to identify independent risk factors associated with renal function outcomes and to create a model to predict the postoperative GFR. Correlation analyses were performed to evaluate the performance of various serum creatinine-based equations for GFR estimation compared with Cr-EDTA. In total, 107 patients were evaluated. After univariate and multivariate analyses, older age ( = 0.008), higher split function of the operated kidney on dimercaptosuccinic acid (DMSA) scintigraphy ( < 0.001), and lower preoperative Cr-EDTA ( < 0.001) were independent risk factors for higher GFR decline. Correlation analyses showed that GFR estimated by CKD-EPI equation had the best concordance to GFR measured by Cr-EDTA. Based on our findings age, DMSA and lower preoperative Cr-EDTA are predictors of postoperative renal function after unilateral nephrectomy. For the assessment of estimated GFR, CKD-EPI equation appears to have the best concordance with Cr-EDTA.
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http://dx.doi.org/10.1089/end.2019.0546DOI Listing
March 2020

Effect of Obesity and Overweight Status on Complications and Survival After Minimally Invasive Kidney Surgery in Patients with Clinical T Renal Masses.

J Endourol 2020 03;34(3):289-297

Department of Medical, Oral and Biotechnological Sciences, Urology Unit, SS Annunziata Hospital, "G.D'Annunzio" University of Chieti, Chieti, Italy.

To evaluate the effect of obesity and overweight on surgical, functional, and survival outcomes in patients with large kidney masses after minimally invasive surgery. Within a multicenter multinational dataset, patients found to have ≥cT renal mass and treated with minimally invasive (laparoscopic or robotic) kidney surgery (radical or partial nephrectomy) during the period 2003 to 2017 were abstracted. They were stratified according to the body mass index classes as normal weight (18.5-24.9 kg/m), overweight (25.0-29.9 kg/m), and obese (≥30.0 kg/m). Mixed models and Cox proportional hazard regression tested differences in complication rates, estimated glomerular filtration rate (eGFR) change over time, overall mortality (OM), and disease recurrence (DR) rates. Of 812 patients, 30.6% were normal weight, 42.7% were overweight, and 26.7% obese. Overweight (odds ratio 0.82, 95% confidence interval [CI]: 0.51-1.31,  = 0.406) and obese patients (OR: 0.81, 95% CI: 0.44-1.47,  = 0.490) experienced similar complication rates than normal weight. Moreover, no statistically significant differences in eGFR were found for overweight ( = 0.129) or obese ( = 0.166) patients compared to normal weight. However, higher OM rates were recorded in overweight (hazard ratio [HR] 3.59, 95% CI: 1.03-12.51,  = 0.044), as well as in obese, patients (HR 7.83, 95% CI: 2.20-27.83,  = 0.002). Similarly, higher DR rates were recorded in obese (HR 2.76, 95% CI: 1.40-5.44,  = 0.003) patients. Obese and overweight patients do not experience higher complication rates or worse eGFR after minimally invasive kidney surgery, which therefore can be deemed feasible and safe also in this subset of patients. Nevertheless, obese and overweight patients seem to carry a higher risk of OM, and therefore, they should undergo a strict follow-up after surgery.
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http://dx.doi.org/10.1089/end.2019.0604DOI Listing
March 2020

Extraperitoneal versus Transperitoneal Single Port Robotic Radical Prostatectomy: A Comparative Analysis of Perioperative Outcomes.

J Urol 2020 06 17;203(6):1135-1140. Epub 2019 Dec 17.

Department of Urology, College of Medicine, University of Illinois at Chicago, Chicago, Illinois.

Purpose: We compared intraoperative and perioperative outcomes between extraperitoneal and transperitoneal radical prostatectomy performed using a "purpose-designed" single port robotic platform.

Materials And Methods: A total of 98 patients underwent single port robotic prostatectomy using the da Vinci SP® robotic system with extraperitoneal (group I, 52) vs transperitoneal (group II, 46) approach. Demographics and perioperative data including postoperative recovery outcomes were recorded and compared between the 2 groups.

Results: Groups were similar in terms of demographics and prostate cancer risk category. Mean operative time (201±37.5 vs 248.2±42.3 minutes, p <0.00001) as well as median postoperative hospital stay (4.3 vs 25.7 hours p <0.0001) was significantly shorter with the extraperitoneal approach. Overall need for pain medications or narcotics as well as the required amount of narcotics per patient (if administered) were significantly lower with the extraperitoneal approach. Extraprostatic extension was detected in 48.1% vs 41.3% of patients in groups I and II, respectively. Surgical margins were positive in 26.9% in group I vs 41.3% in group II (p=0.13). More than 80% of patients with positive surgical margins had high risk features on final surgical pathology. The 90-day continence rate was similar between the 2 groups (60% vs 62.5%, p=0.82).

Conclusions: Extraperitoneal and transperitoneal single port robotic radical prostatectomy are safe and feasible approaches. The extraperitoneal approach is associated with a significantly shorter postoperative hospital stay and decreased need for postoperative narcotics. Randomized trials with adequate sample size and postoperative followup are advisable for further evaluation of the outcomes to clarify patient selection criteria for each approach.
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http://dx.doi.org/10.1097/JU.0000000000000700DOI Listing
June 2020

Surgical quality, cancer control and functional preservation: introducing a novel trifecta for robot-assisted partial nephrectomy.

Minerva Urol Nefrol 2020 Feb 12;72(1):82-90. Epub 2019 Dec 12.

Department of Urology, Regina Elena National Cancer Institute, Rome, Italy.

Background: In order to improve standard reporting of outcomes after partial nephrectomy, different "trifecta" systems have been conceived. The subjective assessment of the included parameters and the unreliability for off-clamp procedures limited their reproducibility; their role in predicting functional and oncologic outcomes has never been assessed. We propose a new trifecta, based on standardized parameters, that summarizes PN outcomes regardless the clamping technique used and predicts main clinical outcomes.

Methods: A retrospective analysis of a multicenter, multi-national dataset of patients with non-metastatic cT1-2 renal masses undergoing Robot-assisted partial nephrectomy was performed. Baseline demographic, clinical, pathologic and perioperative data were collected. Trifecta was defined as the coexistence of negative margins, no Clavien-Dindo ≥3 complications and ≤30% postoperative estimated glomerular filtration rate reduction. Univariable and multivariable regression analyses identified predictors of trifecta achievement. Kaplan-Meier method assessed differences in oncological outcomes between patients achieving trifecta or not. Univariable and multivariable Cox regression analysis identified predictors of newly onset chronic kidney disease stage ≥IIIa, recurrence-free and overall survival.

Results: Overall, 1492 patients achieved trifecta. This cohort displayed significantly lower incidence of newly onset IIIa-V chronic kidney disease stages (all P<0.001), higher recurrence-free (P=0.009) and overall (P=0.014) survival probabilities. Patients achieving trifecta had a 65% reduced risk of developing newly onset stage IIIb-V Chronic Kidney Disease and a 55% reduced risk of overall mortality. Heterogeneity of surgical technique is a limitation.

Conclusions: This novel reproducible trifecta is based on standardized parameters and is an independent predictor of severe chronic kidney disease development and mortality.
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http://dx.doi.org/10.23736/S0393-2249.19.03570-7DOI Listing
February 2020