Publications by authors named "Lance J Hampton"

44 Publications

Single stage Xi® robotic radical nephroureterectomy for upper tract urothelial carcinoma: surgical technique and outcomes.

Minerva Urol Nephrol 2021 Mar 29. Epub 2021 Mar 29.

Division of Urology, VCU Health System, Richmond, VA, USA -

Background: Radical nephroureterectomy (RNU) represents the standard of care for high grade upper tract urothelial carcinoma (UTUC). Open and laparoscopic approaches are well-established treatments, but evidence regarding robotic RANU is growing. The introduction of the Xi® system facilitates the implementation of this multi-quadrant procedure. The aim of this video-article is to describe the surgical steps and the outcomes of Xi® robotic RNU.

Methods: Single stage Xi® robotic RNU without patients repositioning and robot re-docking were done between 2015 and 2019 and collected in a large worldwide multi-institutional study, the ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST). Institutional review board approval and data share agreement were obtained at each center. Surgical technique is described in detail in the accompanying video. Descriptive statistics of baseline characteristics and surgical, pathological, and oncological outcomes were analyzed. RESULTSː Overall, 148 patients were included in the analysis; 14% had an ECOG >1 and 68.2% ASA ≥3. Median tumor dimension was 3.0 (IQR:2.0-4.2) cm and 34.5% showed hydronephrosis at diagnosis. Forty-eight% were cT1 tumors. Bladder cuff excision and lymph node dissection were performed in 96% and 38.1% of the procedures, respectively. Median operative time and estimated blood loss were 215.5 (IQR:160.5-290.0) minutes and 100.0 (IQR: 50.0-150.0) mL, respectively. Approximately 56% of patients took opioids during hospital stay for a total morphine equivalent dose of 22.9 (IQR:16.0-60.0) milligrams equivalent. Postoperative complications were 26 (17.7%), with 4 major (15.4%). Seven patients underwent adjuvant chemotherapy, with median number of cycles of 4.0 (IQR:3.0-6.0).

Conclusions: Single stage Xi® RNU is a reproducible and safe minimally invasive procedure for treatment of UTUC. Additional potential advantages of the robot might be a wider implementation of LND with a minimally invasive approach.
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http://dx.doi.org/10.23736/S2724-6051.21.04247-8DOI Listing
March 2021

Management of Bladder Neck Contracture in the Age of Robotic Prostatectomy: An Evidence-based Guide.

Eur Urol Focus 2021 Jan 30. Epub 2021 Jan 30.

Division of Urology, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA. Electronic address:

The incidence of bladder neck contracture (BNC), or postprostatectomy vesicourethral anastomosis, has declined since the advent of robotic surgery. However, men with peripheral vascular comorbidities, among other factors, still have a high risk of developing this complication after any surgery that involves manipulation of the prostate. The best strategy for BNC management remains uncertain because of inconsistency in success for different approaches across studies. We reviewed the available evidence on BNC, including the results for endoscopic treatments, scar modulation therapies, and open and robotic bladder neck reconstruction. On the basis of these data, we propose a management flowchart. Patient baseline status and subjective goals and preferences remain crucial in management choices. PATIENT SUMMARY: Contracture of the bladder neck can occur as a complication after surgery to the prostate. We reviewed the evidence for various treatment approaches and propose a flowchart for management of this condition.
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http://dx.doi.org/10.1016/j.euf.2021.01.007DOI Listing
January 2021

Evolution of robotic-assisted kidney transplant: successes and barriers to overcome.

Curr Opin Urol 2021 Jan;31(1):29-36

Department of Transplant Surgery, Virginia Commonwealth University, Richmond, Virginia, USA.

Purpose Of Review: The aim of this study was to provide an updated review of robotic-assisted kidney transplant (RAKT) with an emphasis on advantages over the open kidney transplant (OKT), utility in special populations and resources available to overcome the learning curve of robotic surgery.

Recent Findings: The majority of the reported studies showed that RAKT and OKT have similar functional outcomes including similar ischemia times and time to postoperative normalization of creatinine. However, RAKT results in fewer wound complications, decreased estimated blood loss and pain. Given these benefits, RAKT is a promising approach for obese patient across BMI subtypes and several studies showed decreased wound complications in this population compared with the open approach. Moreover, new 3D-print techniques are promising resources for robotic simulation, which may decrease the learning curve of robotic surgery.

Summary: Overall, RAKT is a feasible approach especially in obese patients. However, more data with long-term follow-up are needed to fully elucidate the advantages over OKT before universal implementation of this approach is possible.
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http://dx.doi.org/10.1097/MOU.0000000000000834DOI Listing
January 2021

Robot-assisted Radical Nephrectomy: A Systematic Review and Meta-analysis of Comparative Studies.

Eur Urol 2020 Nov 17. Epub 2020 Nov 17.

Division of Urology, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA. Electronic address:

Context: Radical nephrectomy (RN) is the gold standard treatment for large and locally advanced renal tumors. Although robot-assisted radical nephrectomy (RRN) is being increasingly adopted, it remains unclear whether it offers benefits over standard laparoscopic radical nephrectomy (LRN) or open radical nephrectomy (ORN).

Objective: To compare the outcomes of robotic surgery to those of laparoscopic and open surgery in patients undergoing RN for renal cell carcinoma (RCC).

Evidence Acquisition: A systematic search was performed across MEDLINE, EMBASE, and Web of Science for retrospective and prospective studies comparing RRN to LRN or ORN. A meta-analysis evaluated perioperative safety, effectiveness, survival, and cost-effectiveness outcomes. The weighted mean difference (WMD) and odds ratio (OR) were used to compare continuous and dichotomous variables, respectively. Quality was assessed using the Newcastle-Ottawa scale. Sensitivity analyses were performed to assess the robustness of the estimates.

Evidence Synthesis: Twelve studies involving 64 221 patients were identified and included in the analysis. Compared to LRN, RRN was associated with statistically significant longer operative time (WMD 37.44 min; p =  0.03), shorter length of stay (WMD -0.84 days; p =  0.02) and higher total costs (WMD US$4700; p < 0.001). Compared to ORN, RRN was associated with shorter length of stay (WMD -3.06 days; p =  0.002), fewer overall complications (OR 0.56; p <  0.001), lower estimated blood loss (WMD -702 ml; p =  0.01), and higher total hospital costs (WMD US$4520; p =  0.004). There was high heterogeneity across all analyses.

Conclusions: In patients undergoing RN for RCC, RRN seems to offer some key advantages compared to ORN, including shorter hospitalization and fewer complications. Compared to LRN, RRN provides similar surgical outcomes but at higher total costs. These findings should be interpreted within the limitations of this type of analysis, given high heterogeneity between studies and poor robustness for most outcomes. Randomized clinical studies with long-term follow-up are needed to obtain more definitive results.

Patient Summary: In patients with renal cell carcinoma, robot-assisted radical nephrectomy shows perioperative advantages compared to open radical nephrectomy, but not compared to laparoscopic radical nephrectomy.
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http://dx.doi.org/10.1016/j.eururo.2020.10.034DOI Listing
November 2020

Robot-assisted partial nephrectomy: 7-year outcomes.

Minerva Urol Nefrol 2020 Nov 17. Epub 2020 Nov 17.

Division of Urology, VCU Health, Richmond, VA, USA -

Background: The role of robot-assisted partial nephrectomy (RAPN) in the management of renal masses has exponentially grown over the past 10 years. Nevertheless, data on long term outcomes of the procedure remains limited. Herein we report oncological and functional outcomes of patients who underwent RAPN for a malignant mass with a median follow-up of 7-yr, the longest follow-up to date.

Methods: A retrospective analysis of an international multicenter database was performed. All consecutive patients undergoing surgery between 2009 and 2013 with a minimum of 3-yr follow-up and complete data on renal function were included. Demographics, surgical and perioperative outcomes were analyzed. Overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS) were evaluated using Kaplan-Meier analysis.

Results: Overall, our study cohort was composed of eighty-five patients with a median follow-up of 88mo. Median clinical tumor size was 3cm, with mostly (74.1%) clinical stage T1a, and median R.E.N.A.L. score 6. Final histopathologic analysis revealed clear cell RCC in 76.5% of cases. PSM was present in 7 patients (8.2%). Eleven overall deaths (12.9%) occurred in the cohort during the follow-up period. Two of these (2.33%) were attributed to metastatic RCC. The OS, CSS, and DFS rates were 91.7, 97.7, and 91.7% at 84mo, respectively. Regarding the renal functional outcomes, seventeen patients (20.1%) presented a CKD upstaging in our cohort.

Conclusions: Our findings show excellent 7-year oncologic and functional outcomes of the procedure, which duplicate those achieved in historical series of open and laparoscopic surgery.
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http://dx.doi.org/10.23736/S0393-2249.20.04151-XDOI Listing
November 2020

Single overnight stay after robot-assisted partial nephrectomy: a bi-center experience.

Minerva Urol Nefrol 2020 Nov 17. Epub 2020 Nov 17.

Division of Urology, VCU Health, Richmond, VA, USA -

Background: Despite hospital length of stay (LOS) being shorter for robot-assisted partial nephrectomy (RAPN) compared to its open counterpart, several series in the literature report on average a LOS of 2-3 days or more. We aimed to assess factors predicting a prolonged length of stay (beyond a single overnight stay) in patients undergoing RAPN.

Methods: Patients who underwent RAPN between 2010 and 2019 at two U.S. Centers were included and divided into two groups according to LOS: the study group included all patients who were discharged on POD1, whereas the control group included patients with LOS≥2 days. Demographics, surgical and perioperative outcomes were compared between the groups. Multivariable logistic regression analyses were used to identify independent predictors of LOS≥2.

Results: Overall, 173 (60.5%) patients discharged on POD1, and 113 (39.5%) discharged on POD≥2. Patients in the study group presented a lower mean BMI (29 vs. 32, p=0.02). Retroperitoneal approach was performed in 13.3% patients with shorter LOS (p<0.001). There was a statistically significant difference in median OT (144 vs. 168min, p=0.005) and WIT (19 vs. 23min, p=0.001). We observed six postoperative complications (3.6%) in patients discharged on POD1 and 35 (30.5%) in control group (p<0.001). Major complications (Clavien-Dindo grade≥III) were observed in 3 of POD1 patients (1.8 vs. 6.1%, p<0.001). There was no difference in hospital readmission rate. On logistic regression analysis, independent predictors of prolonged LOS were OT (OR 1.01, 95%C.I.: 1.0-1.2, p=0.001), and occurrence of a postoperative complication (OR 2.2, 95%C.I. 2.0-2.5, p<0.001).

Conclusions: Our findings confirm that a single overnight stay after RAPN is feasible and safe. In our experience, and within the limitations of the present analysis, prolonged operative time and occurrence of immediate postoperative complications translate into higher risk of prolonged hospital stay. Besides adopting a minimally invasive approach, surgeons should also implement perioperative care pathways facilitating early discharge without increasing the risk of readmission.
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http://dx.doi.org/10.23736/S0393-2249.20.04054-0DOI Listing
November 2020

Robotic-assisted Partial Nephrectomy for "Very Small" (<2 cm) Renal Mass: Results of a Multicenter Contemporary Cohort.

Eur Urol Focus 2020 Nov 3. Epub 2020 Nov 3.

Division of Urology, VCU Health, Richmond, VA, USA. Electronic address:

Background: Patient with "very small" (<2 cm) renal mass can be offered active surveillance, thermal ablation, or partial nephrectomy. The management strategy will consider patient preferences and prioritize potential harms associated with each of these options. To date, outcomes of robot-assisted partial nephrectomy (RAPN) in patients with "very small" renal masses have not been reported.

Objective: To assess the outcomes of RAPN among patients with "very small" renal masses.

Design, Setting, And Participants: This was a retrospective analysis of a multi-institutional database including RAPN cases performed at eight high-volume US and European centers between 2009 and 2019. Patients were stratified into two groups according to clinical tumor size: <2 cm ("very small" renal mass, study group) and 2-4 cm (control group).

Intervention: RAPN for renal masses.

Outcome Measurements And Statistical Analysis: Baseline characteristics and intraoperative, pathological, and postoperative data were compared between the study and the control group. A "trifecta" was used as surrogate of "surgical quality."

Results And Limitations: Overall, a total of 1019 patients were included in the analysis. Of these, 352 had a renal mass of <2 cm (34.5%) and 667 (65.5%) had a renal mass of 2-4 cm. At baseline, the study group presented a lower rate of chronic kidney disease ≥stage III (p < 0.001), a lower RENAL score (p = 0.001), and lower rates of hilar (p = 0.04) and endophytic (p = 0.02) masses. Warm ischemia time was shorter for the study group (median 14 vs 18 min, p < 0.001), which also showed a lower rate of overall postoperative complications (9.6% vs 14.7%, p < 0.001) and no major complications. In terms of oncological outcomes, three and ten patients developed a local recurrence in the study and the control group, respectively (p = 0.1). In the study group, higher estimated glomerular filtration rates were found at discharge (p = 0.001) and at the last follow-up (p = 0.007), which showed a "trifecta" achievement of 90.6%. The retrospective design may limit the generalizability of the findings.

Conclusions: Whenever an active treatment is indicated or warranted, RAPN represents a minimally invasive management option for "very small" renal masses, as it carries minimal risk of complications and has minimal impact on renal function. While both active surveillance and kidney ablation remain valid management options in these cases, RAPN can be offered and discussed with patients as it provides excellent outcomes with low morbidity.

Patient Summary: In this report, we observed that robot-assisted partial nephrectomy represents a true minimally invasive active treatment for "very small" renal masses (<2 cm), as it carries minimal risk of complications and has minimal impact on renal function.
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http://dx.doi.org/10.1016/j.euf.2020.10.001DOI 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.
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http://dx.doi.org/10.5173/ceju.2020.0179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7587491PMC
September 2020

Outcomes of robot-assisted partial nephrectomy for completely endophytic renal tumors: A multicenter analysis.

Eur J Surg Oncol 2020 Aug 16. Epub 2020 Aug 16.

Division of Urology, VCU Health, Richmond, VA, USA. Electronic address:

Introduction: Multicenter retrospective analysis of robotic partial nephrectomy for completely endophytic renal tumors (i.e. 3 points for the 'E' domain of the R.E.N.A.L. nephrometry score) was performed.

Materials And Methods: Patients' demographics, tumor characteristics, perioperative, functional, pathological and oncological data were analyzed and compared with those of patients with exophytic and mesophytic masses (i.e. 1 and 2 points for the 'E' domain, respectively). Multivariable logistic regression analysis was used to assess variables for trifecta achievement (negative margin, no postoperative complications, and 90% estimated glomerular filtration rate [eGFR] recovery).

Results: Overall, 147 patients were included in the study group. Patients with a completely endophytic mass had bigger tumors (mean 4.2 vs. 4.1 vs. 3.2 cm; p < 0.001) on preoperative imaging and higher overall R.E.N.A.L. score. There was no difference in mean operative time. Estimated blood loss was higher in the endophytic group (mean 177.75 vs. 185.5 vs. 130 ml; p = 0.001). Warm ischemia time was shorter for the exophytic group (median 16 vs. 21 vs. 22 min; p < 0.001). Postoperative complications were more frequent in patients with endophytic tumor (24.8% vs. 19.5% vs. 14.8%; p < 0.001). Six (4.5%) patients had positive surgical margins, there was no difference between groups. Trifecta was achieved in 44 patients in endophytic group (45.4 vs. 68.8 and 50.9%, p < 0.001). Multivariable analysis for trifecta revealed that clinical tumor size (odds ratio: 0.667, 95% confidence interval: 0.56-0.79, p < 0.001) was only significant predictor for trifecta achievement.

Conclusions: Our findings confirm that RAPN in case of completely endophytic renal masses can be performed with acceptable outcomes in centers with significant robotic expertise.
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http://dx.doi.org/10.1016/j.ejso.2020.08.012DOI Listing
August 2020

Universal Mismatch Repair Protein Screening in Upper Tract Urothelial Carcinoma.

Am J Clin Pathol 2020 11;154(6):792-801

Department of Pathology, Virginia Commonwealth University School of Medicine, Richmond.

Objectives: Universal screening of upper tract urothelial carcinoma (UTUC) for Lynch syndrome by mismatch repair (MMR) protein immunohistochemistry (IHC) has been recommended by some investigators. Herein, we assess this recommendation retrospectively by simulating its performance on a retrospective, unselected cohort of UTUCs, with comparison to the established setting of colorectal and endometrial adenocarcinoma.

Methods: We assessed for complete loss of MMR protein (MLH1, MSH2, MSH6, and PMS2) IHC in 74 consecutive cases of UTUC and then tabulated clinical and pathologic factors. MMR findings from same-institution colorectal and endometrial adenocarcinomas were tabulated for comparison.

Results: We observed loss of at least one MMR protein in 12% in our UTUC cohort (three MSH2/MSH6, three MSH6 only, one MLH1/PMS2, and two PMS2 only). Of these nine cases (seven males, two females, median age 67 years, five associated with colorectal adenocarcinoma), at least three (4% of the overall cohort) proved to be Lynch syndrome. Overall, MMR loss in UTUC was comparable to colorectal (11%; 50 of 471 cases) and endometrial (12%; 12 of 101 cases) adenocarcinomas.

Conclusions: The rate of MMR loss observed in UTUC was comparable to that in the established setting of colorectal and endometrial adenocarcinomas, supporting universal UTUC screening at our institution and others.
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http://dx.doi.org/10.1093/ajcp/aqaa100DOI Listing
November 2020

Utilization of Multiparametric MRI of Prostate in Patients under Consideration for or Already in Active Surveillance: Correlation with Imaging Guided Target Biopsy.

Diagnostics (Basel) 2020 Jun 29;10(7). Epub 2020 Jun 29.

Department of Urology, Virginia Commonwealth University Health System, 401 North 12th Street, Richmond, VA 23298, USA.

This study sought to assess the value of multiparametric magnetic resonance image (mp-MRI) in patients with a prostate cancer (PCa) Gleason score of 6 or less under consideration for or already in active surveillance and to determine the rate of upgrading by target biopsy. Three hundred and fifty-four consecutive men with an initial transrectal ultrasound-guided (TRUS) biopsy-confirmed PCa Gleason score of 6 or less under clinical consideration for or already in active surveillance underwent mp-MRI and were retrospectively reviewed. One hundred and nineteen of 354 patients had cancer-suspicious regions (CSRs) at mp-MRI. Each CSR was assigned a Prostate Imaging Reporting and Data System (PI-RADS) score based on PI-RADS v2. One hundred and eight of 119 patients underwent confirmatory imaging-guided biopsy for CSRs. Pathology results including Gleason score (GS) and percentage of specimens positive for PCa were recorded. Associations between PI-RADS scores and findings at target biopsy were evaluated using logistic regression. At target biopsy, 81 of 108 patients had PCa (75%). Among them, 77 patients had upgrading (22%, 77 of 354 patients). One hundred and forty-six CSRs in 108 patients had PI-RADS 3 = 28, 4 = 66, and 5 = 52. The upgraded rate for each category of CSR was for PI-RADS 3 (5 of 28, 18%), 4 (47 of 66, 71%) and 5 (49 of 52, 94%). Using logistic regression analysis, differences in PI-RADS scores from 3 to 5 are significantly associated with the probability of disease upgrade (20%, 73%, and 96% for PI-RADS score of 3, 4, and 5, respectively). Adding mp-MRI to patients under consideration for or already in active surveillance helps to identify undiagnosed PCa of a higher GS or higher volume resulting in upgrading in 22%.
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http://dx.doi.org/10.3390/diagnostics10070441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7400343PMC
June 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

Robotic-assisted surgery for the treatment of urologic cancers: recent advances.

Expert Rev Med Devices 2020 Jun 13;17(6):579-590. Epub 2020 May 13.

Division of Urology, VCU Health System , Richmond, Virginia, USA.

Introduction: As the medical field is moving toward personalized and tailored approaches, we entered the era of precision surgery for the management of genitourinary cancers1. This is facilitated by the implementation of new technologies, among which robotic surgery stands out for the significant impact in the surgical field over the last two decades.

Areas Covered: This article reviews the latest evidence on robotic surgery for the treatment of urologic cancers, including prostate, kidney, bladder, testis, and penile cancer. Functional and oncologic outcomes, new surgical techniques, new imaging modalities, and new robotic platforms are discussed.

Expert Opinion: Robotic surgery had a growing role in the management of genitourinary cancers over the past 10 years. Despite a lack of high-quality evidence comparing the effectiveness of robotic to open surgery, the robotic approach allowed a larger adoption of a minimally invasive surgical approach, translating into lower surgical morbidity and shorter hospital stay. New robotic platforms might allow to explore novel surgical approaches, and new technologies might facilitate surgical navigation and intraoperative identification of anatomical structures, allowing a more tailored and precise surgery. It is an exciting time for robotic surgery, and upcoming technological advances will offer better outcomes to urologic cancer patients.
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http://dx.doi.org/10.1080/17434440.2020.1762487DOI Listing
June 2020

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

Predictive Value of Nephrometry Scores in Nephron-sparing Surgery: A Systematic Review and Meta-analysis.

Eur Urol Focus 2020 05 24;6(3):490-504. Epub 2019 Nov 24.

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

Context: Over the last decade, several nephrometry scores (NSs) have been introduced with the aim of facilitating preoperative decision making, planning, and counseling in the field of nephron-sparing surgery. However, their predictive role remains controversial.

Objective: To describe currently available nephrometry scores and to determine their predictive role for different outcomes by performing a systematic review and meta-analysis of the literature.

Evidence Acquisition: PubMed, Embase®, and Web of Science were screened to identify eligible studies. Identification and selection of the reports were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). A pooled analysis of NS predictive role of intraoperative, postoperative, oncological, and functional outcomes was performed. Odds ratio was considered the effect size. All the analyses were performed using Stata 15.0, and statistical significance was set at p≤ 0.05.

Evidence Synthesis: Overall, 51 studies meeting our inclusion criteria were identified and considered for the analysis. Except for one prospective randomized trial, all the studies were retrospective. All the studies were found to be of intermediate quality, except for one of high quality. Most studies assessed the predictive role of the Radius-Exophytic/Endophytic-Nearness-Anterior/Posterior-Location (RENAL) and Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) scores, mostly regarding complications after nephron-sparing surgery. RENAL was an independent predictor of an on-clamp procedure (p< 0.001). Mayo Adhesive Probability score was related to adhesive perinephric fat (p= 0.005). Continuous and high-complexity RENAL scores were predictors of warm ischemia time (WIT; p= 0.006 and p< 0.001, respectively). Continuous (p< 0.001) and high-complexity (p< 0.001) PADUA scores were related to WIT. Continuous and high-complexity RENAL scores were predictors of overall complications (p= 0.002 and p< 0.001, respectively). PADUA score was related to complications both as continuous (p< 0.001) and as a categorical value (p< 0.002). The RENAL scores R=3 (p= 0.008), E=2 (p= 0.039), and hilar location (p= 0.006) were predictors of histological malignancy. Continuous and categorical RENAL scores were independent predictors of an estimated glomerular filtration rate (eGFR) increase (p= 0.006 and p< 0.001, respectively). The Diameter-Axial-Polar score (p= 0.018) and Peritumoral Artery Scoring System (PASS; p= 0.02) were also independent predictors.

Conclusions: The literature regarding nephrometry scoring systems is sparse, and mostly focused on RENAL and PADUA, which are easy to calculate and have a good correlation with most outcomes. Renal Pelvic Score is the best predictor of pelvicalyceal entry/repair and urine leak, whereas Surgical Approach Renal Ranking and PASS strongly predict surgical approach and renal function variation, respectively. Other nephrometry scores based on mathematical models are limited by their complexity, and they lack evidence supporting their predictive value.

Patient Summary: We reviewed the medical literature regarding the use and value of so-called "nephrometry scores," which are scoring systems based on radiological imaging and made to grade the complexity of a renal tumor. We analyzed whether these scoring systems can predict some of the outcomes of patients undergoing surgical removal of renal tumors.
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http://dx.doi.org/10.1016/j.euf.2019.11.004DOI Listing
May 2020

Robotic versus other nephroureterectomy techniques: a systematic review and meta-analysis of over 87,000 cases.

World J Urol 2020 Apr 26;38(4):845-852. Epub 2019 Nov 26.

Division of Urology, VCU Health System, VCU Medical Center, PO Box 980118, Richmond, VA, 23298-0118, USA.

Purpose: To perform a systematic review and meta-analysis of the literature inherent robotic nephroureterectomy (RNU) and to compare its outcomes with those of other nephroureterectomy (NU) techniques.

Methods: A systematic literature search was performed up to April 2019 using PubMed, Embase®, and Web of Science. The Preferred Reporting Items for Systematic Review and Meta-analysis Statement was followed for study selection. The following data were extracted for each study: baseline features, surgical outcomes, oncological outcomes, and survival outcomes. Stata® 15.0 was used for statistical analysis.

Results: Literature search identified 80 studies eligible for the meta-analysis and overall 87,291 patients were included in the analysis: open NU (ONU; n = 45,601), hand-assisted laparoscopic NU (HALNU; n = 442), laparoscopic NU (LNU n = 31,093), and RNU (n = 10,155). RNU was more likely to be performed in those patients with multifocal tumor location (proportion: 0.19; 95% CI 0.14, 0.24) and high-grade disease (proportion: 0.70; 95% CI 0.53, 0.68). The lowest EBL was recorded in the RNU group (weighted mean (WM) 163.31 mL; 95% CI 88.94, 237.68), whereas the highest was in the ONU group (414.99 mL; 95% CI 378.52, 451.46). Operative time was shorter for ONU (224.98 mL; 95% CI 212.26, 237.69). RNU had lower rate of intraoperative complications (0.02; 95% CI 0.01, 0.05). ONU showed higher odds of transfusions (0.20; 95% CI 0.15, 0.25). LOS was statistically significantly shorter for the RNU group (5.35 days; 95% CI 4.97, 5.82). HALNU seemed to present lower risk of PSM (0.02; 95% CI - 0.01, 0.05), and lower risk of recurrence (0.22; 95% CI 0.15, 0.30), metastasis (0.07; 95% CI 0.05, 0.10), and cancer-related death (0.03; 95% CI 0.01, 0.06). ONU showed the lowest 5 years cancer specific survival (proportion: 0.77; 95% CI 0.74, 0.80). No correlation was found between the surgical technique and recurrence-free and cancer-specific survival.

Conclusions: Evidence regarding RNU for the treatment of UTUC is increasing but it remains quite sparse and of low quality. Despite this, RNU seems to be safe, and to offer the advantages of a minimally invasive approach without impairing the oncological outcomes. Nevertheless, ONU, HALNU, and LNU still represent a valid, and commonly used surgical treatment option. As RNU becomes more popular, and concerns related to its use remain, the best surgical technique for NU remains to be determined.
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http://dx.doi.org/10.1007/s00345-019-03020-1DOI Listing
April 2020

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

On-clamp versus off-clamp robotic partial nephrectomy: A systematic review and meta-analysis.

Urologia 2019 May;86(2):52-62

3 Division of Urology, VCU Health System, Richmond, VA, USA.

Background: The debate on the pros and cons of robot-assisted partial nephrectomy performed with (on-clamp) or without (off-clamp) renal artery clamping is ongoing. The aim of this meta-analysis is to summarize the available evidence on the comparative studies assessing the outcomes of these two approaches.

Material And Methods: A systematic review of the literature on PubMed, ScienceDirect, and Embase was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA). Only comparative and case-control studies were submitted to full-text assessment and meta-analysis. RevMan 5.3 software was used.

Results: From the initial retrieval of 1937 studies, 15 fulfilling inclusion criteria were selected and provided 2075 patients for analysis (702 off-clamp, 1373 on-clamp). Baseline tumor's features showed a significant difference in size (weighted mean difference: -0.58 cm; 95% confidence interval: [-1.06, -0.10]; p = 0.02) and R.E.N.A.L. score (weighted mean difference: -0.53; 95% confidence interval: [-0.81, -0.25]; p = 0.0002), but not in the exophytic property, the location, and the PADUA score. Pooled analysis revealed shorter operative time (p = 0.02) and higher estimated blood loss (p = 0.0002) for the off-clamp group. Overall complication and transfusion rates were similar, while higher major complication rate was observed in the on-clamp approach (5.6% vs 1.9%, p = 0.03). No differences in oncological outcomes were found. Finally, functional outcomes (assessed by estimated glomerular filtration rate at early postoperative, 3 month, 6 month, and last available follow-up) were not statistically different.

Conclusion: This meta-analysis shows that off-clamp robot-assisted partial nephrectomy is reserved to smaller renal masses. Under such conditions, no differences with the on-clamp approach emerged.
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http://dx.doi.org/10.1177/0391560319847847DOI Listing
May 2019

Minimally Invasive Radical Prostatectomy after Previous Bladder Outlet Surgery: A Systematic Review and Pooled Analysis of Comparative Studies.

J Urol 2019 09 8;202(3):511-517. Epub 2019 Aug 8.

Division of Urology, Department of Surgery, VCU Health, Richmond, Virginia.

Purpose: Prostate cancer surgery after previous bladder outlet surgery of benign prostatic hyperplasia is an uncommon yet challenging scenario. We performed a systematic review and pooled analysis of comparative studies on laparoscopic and robotic minimally invasive radical prostatectomy after bladder outlet surgery.

Materials And Methods: We searched the literature on PubMed®, Embase® and Web of Science™ up to February 2019 according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to identify eligible studies. Surgical, oncologic and functional outcomes in patients who underwent minimally invasive radical prostatectomy after bladder outlet surgery were compared to those without a history of bladder outlet surgery. Sensitivity analysis was done according to surgical technique (laparoscopic or robotic). RevMan 5.3 was used for statistical analysis.

Results: A total of 12 comparative studies were included in analysis. Patients who underwent minimally invasive radical prostatectomy after bladder outlet surgery were older (p ≤0.00001) and had a smaller prostate (p = 0.04) and lower prostate specific antigen (p = 0.003). The previous bladder outlet surgery group had lower odds of nerve sparing procedures, longer operative time, a higher rate of bladder neck reconstruction (each p <0.0001) and longer catheter time (p = 0.03). They were at higher risk for intraoperative (p = 0.001), overall (p <0.00001) and major complications (p = 0.0008), a higher positive surgical margin rate (p = 0.0005) and biochemical recurrence (p = 0.05). Moreover, potency (p = 0.03) and continence recovery (p = 0.007) at 12 months were lower in men with previous bladder outlet surgery. Robotic surgery seemed to offer better outcomes than laparoscopy.

Conclusions: Minimally invasive radical prostatectomy after previous bladder outlet surgery represents a challenging surgical task with a higher risk of complications, and higher odds of worse functional and oncologic outcomes. Patients should be aware of these drawbacks and these factors should be considered during patient counseling. When surgery is pursued, robot-assisted radical prostatectomy should be preferred over laparoscopic radical prostatectomy since it can offer superior outcomes. The overall literature on this topic is of low quality and further efforts should be made to obtain higher levels of evidence.
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http://dx.doi.org/10.1097/JU.0000000000000312DOI Listing
September 2019

Technical innovations to optimize continence recovery after robotic assisted radical prostatectomy.

Minerva Urol Nefrol 2019 Aug 5;71(4):324-338. Epub 2019 Apr 5.

Unit of Urology, Santa Maria della Misericordia Academic Medical Center Hospital, Udine, Italy -

Urinary incontinence is one of the most significant causes of concern among patients who get surgical treatment for prostate cancer, even after the introduction of the robot. The aim of this study is to summarize current knowledge of the factors influencing urinary continence (UC) and the technical innovations to optimize UC recovery after robotic assisted radical prostatectomy (RARP). A non-systematic review was conducted from January 2000 to October 2018 to identify original and review articles in English describing the anatomy of the prostate and pelvis. An emphasis was addressed to article describing technical innovations to optimize UC after RARP. Improved knowledge of the normal structure in the pelvis should lead to a greater understanding of the pathophysiology of urinary incontinence, and further development of intraoperative techniques to improve the outcomes of UC. The literature has shown certain technique modification to meliorate UC as potential benefit to reduce the risk of urinary incontinence after RARP. These techniques might be divided in 3 categories to improve an early return to UC: 1) preservation, 2) reconstruction and 3) reinforcement of the anatomic structures in the pelvis, which will make new supporting system after RARP. In the present review, the authors summarize factors influencing incontinence after RARP and outline a common denominator for all the surgical techniques described in the literature for UC recovery.
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http://dx.doi.org/10.23736/S0393-2249.19.03395-2DOI Listing
August 2019

Outcomes of Partial and Radical Nephrectomy in Octogenarians - A Multicenter International Study (Resurge).

Urology 2019 Jul 23;129:139-145. Epub 2019 Mar 23.

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

Objective: To analyze the outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) in octogenarian patients.

Methods: The RESURGE (REnal SUrgery in the Eldely) multi-institutional database was queried to identify patients ≥80 years old who had undergone a PN or RN for a renal tumor. Multivariable binary logistic regression estimated the association between type of surgery and occurrence of complications. Multivariable Cox regression model assessed the association between type of surgery and All-Causes Mortality.

Results: The study analyzed 585 patients (median age 83 years, IQR 81-84), 364 of whom (62.2%) underwent RN and 221 (37.8%) PN. Patients undergoing RN were older (P = .0084), had larger tumor size (P < .0001) and higher clinical stage (P < .001). At multivariable analysis for complications, the only significant difference was found for lower risk of major postoperative complications for laparoscopic RN compared to open RN (OR: 0.42; P = .04). The rate of significant (>25%) decrease of eGFR in PN and RN was 18% versus 59% at 1 month, and 23% versus 65% at 6 months (P < .0001). After a median follow-up time of 39 months, 161 patients (31%) died, of whom 105 (20%) due to renal cancer.

Conclusion: In this patient population both RN and PN carry a non-negligible risk of complications. When surgical removal is indicated, PN should be preferred, whenever technically feasible, as it can offer better preservation of renal function, without increasing the risk of complications. Moreover, a minimally invasive approach should be pursued, as it can translate into lower surgical morbidity.
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http://dx.doi.org/10.1016/j.urology.2019.03.009DOI Listing
July 2019

Near-infrared Fluorescence Imaging with Indocyanine Green in Robot-assisted Partial Nephrectomy: Pooled Analysis of Comparative Studies.

Eur Urol Focus 2020 05 21;6(3):505-512. Epub 2019 Mar 21.

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

Context: The use of near-infrared fluorescence (NIRF) imaging was described to facilitate selective clamping during robot-assisted partial nephrectomy (RAPN).

Objective: To perform a systematic review and cumulative analysis of available studies comparing the outcomes of RAPN with or without use of this technology (NIRF).

Evidence Acquisition: A systematic review of the literature was performed to identify relevant studies up to December 2018 through PubMed and EMBASE databases. A meta-analysis was conducted with the RevMan 5.3 software.

Evidence Synthesis: Six comparative studies were identified. Overall, 369 cases were included for the analysis (171 NIRF-RAPN and 198 standard RAPN). No significant difference was identified between groups in baseline characteristics, operating time, and estimated blood loss; however, a shorter clamping time was recorded for the NIRF-RAPN group. Functional outcomes revealed higher overall estimated glomerular filtration rate (eGFR) values in the NIRF-RAPN group at short-term (1-3 mo) postoperative follow-up (weighted mean difference [WMD]: 9.26ml/min; 95% confidence interval [CI]: 6.46, 12.06; p<0.001). In two studies, a renal scan-based assessment of split eGFR was available, and pooled analysis revealed higher split eGFR for NIRF-RAPN (WMD: 7.91ml/min; 95% CI: 4.26, 11.56; p < 0.001), and lower Δ % between preoperative and 1-mo eGFR (WMD: -7.84%; 95% CI: -8.85, -6.83; p<0.00001).

Conclusions: Current evidence regarding the use of NIRF-guided selective clamping during RAPN is based on a limited number of studies from high-volume institutions. Notwithstanding these limitations, NIRF-RAPN can be safely performed, and it might offer better short-term renal functional outcomes. It remains to be determined whether this can ultimately translate into a clinical benefit for patients undergoing RAPN, especially in the long term.

Patient Summary: We assessed the outcomes of robot-assisted partial nephrectomy (RAPN) performed with or without the use of near-infrared fluorescence (NIRF) imaging. NIRF-RAPN appeared to be a safe procedure with potential better short-term functional outcomes.
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http://dx.doi.org/10.1016/j.euf.2019.03.005DOI Listing
May 2020

Robot assisted laparoscopic prostatectomy in liver transplant recipient.

Minerva Urol Nefrol 2019 Apr 18;71(2):185-188. Epub 2019 Mar 18.

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

Robotic assisted laparoscopic prostatectomy (RALP) in liver transplant recipients (LTRs) is not well documented. We present two cases of RALP in LTRs with localized prostate cancer (PCa). In both cases, a transperitoneal approach was used, and they were successfully completed without perioperative complications. Thus, RALP seems to be a feasible, safe and effective treatment for PCa in LTRs. Significant modifications to the surgical technique do not seem to be required, and patient optimization in preparation for surgery remains the key factor. History of liver transplant should not discourage embarking in a RALP in Centers with adequate robotic expertise.
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http://dx.doi.org/10.23736/S0393-2249.19.03334-4DOI Listing
April 2019

Robotic versus laparoscopic radical nephrectomy: a large multi-institutional analysis (ROSULA Collaborative Group).

World J Urol 2019 Nov 7;37(11):2439-2450. Epub 2019 Feb 7.

Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.

Objective: To compare the outcomes of robotic radical nephrectomy (RRN) to those of laparoscopic radical nephrectomy (LRN) for large renal masses.

Methods: This was a retrospective analysis of RRN and LRN cases performed for large (≥ cT2) renal masses from 2004 to 2017 and collected in the multi-institutional international database (ROSULA: RObotic SUrgery for LArge renal masses). Peri-operative, functional, and oncologic outcomes were compared between each approach. Descriptive analyses were performed and presented as medians with interquartile ranges. Inverse probability of treatment weighting-adjusted multivariable analyses were used to identify predictors of peri-operative complications. Kaplan-Meier analysis and Cox regression models were used to assess survival outcomes.

Results: A total of 941 patients (RRN = 404, LRN = 537) were identified. There was no difference in terms of gender, age, and clinical tumor size. Over the study period, RRN had an annual increase of 11.75% (95% CI [7.34, 17.01] p < 0.001) and LRN had an annual decline of 5.39% (95% CI [-6.94, -3.86] p < 0.001). Patients undergoing RRN had higher BMI (27.6 [IQR 24.8-31.1] vs. 26.5 [24.1-30.0] kg/m, p < 0.01). Operative duration was longer for RRN (185.0 [150.0-237.2] vs. 126 [90.8-180.0] min, p < 0.001). Length of stay was shorter for RRN (3.0 [2.0-4.0] vs. 5.0 [4.0-7.0] days, p < 0.001). RRN cases presented more advanced disease (higher pathologic staging [pT3-4 52.5 vs. 24.2%, p < 0.001], histologic grade [high grade 49.3 vs. 30.4%, p < 0.001], and rate of nodal disease [pN1 5.4 vs. 1.9%, p < 0.01]). Surgical approach did not represent an independent risk factor for peri-operative complications (OR 1.81 95% CI [0.97-3.39], adjusted p = 0.2). The main study limitation is the retrospective design.

Conclusions: This study represents the largest known multi-center comparison between RRN and LRN. The two procedures seem to offer similar peri-operative outcomes. Notably, RRN has been increasingly utilized, especially in the setting of more advanced and surgically challenging disease without increasing the risk of peri-operative complications.
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http://dx.doi.org/10.1007/s00345-019-02657-2DOI Listing
November 2019

Optimization of renal function preservation during robotic partial nephrectomy.

Ther Adv Urol 2019 Jan-Dec;11:1756287218815819. Epub 2019 Jan 8.

VCU Health and Division of Urology, Department of Surgery, McGuire VA Medical Center, 1200 East Broad St, Richmond, VA 23249, USA.

Over the past few years, the role of robotic-assisted partial nephrectomy (RPN) has exponentially grown. Multiple recognized factors contribute to postoperative renal function in patients undergoing RPN. The aim of this review is to identify these potential factors, and to evaluate strategies that may help optimize the goal of renal function preservation. A nonsystematic literature review was performed to retrieve the most recent evidence on factors contributing to renal function post-RPN. Analyzed elements include baseline factors (tumor complexity and patient characteristics), intraoperative (surgical) factors (control of the renal hilum and type of ischemia, resection technique, renorrhaphy technique), and pharmacotherapeutics. In conclusion, the advantages of robotic surgery in the setting of partial nephrectomy (PN) are becoming well established. Maximal preservation of renal function remains a priority goal of the procedure, and it is influenced by a plethora of factors. Adequate patient selection using radiomics, control of comorbidities, utilization of evidence-based intraoperative techniques/strategies, and postoperative care are key components of postoperative preservation of renal function. Further investigations regarding these factors and their effects on long-term renal function are necessary and will continue to aid in guiding appropriate patient care.
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http://dx.doi.org/10.1177/1756287218815819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329014PMC
January 2019

Rationale for Robotic-assisted Simple Prostatectomy for Benign Prostatic Obstruction.

Eur Urol Focus 2018 09 20;4(5):643-647. Epub 2018 Jul 20.

Division of Urology, Department of Surgery, VCU Health and McGuire VA Medical Center, Richmond, VA, USA. Electronic address:

Current evidence supports the role of robotic-assisted simple prostatectomy as safe and effective minimally invasive surgical treatment of benign prostatic obstruction.
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http://dx.doi.org/10.1016/j.euf.2018.07.007DOI Listing
September 2018

Prediction of Aggressive Histology: The Ongoing Dilemma of Renal Masses in the "Omics" Era.

Eur Urol 2018 10 13;74(4):498-500. Epub 2018 Jul 13.

Division of Urology, VCU Health and McGuire VA Medical Center, Richmond, VA, USA. Electronic address:

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http://dx.doi.org/10.1016/j.eururo.2018.06.046DOI Listing
October 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.
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http://dx.doi.org/10.1016/j.eururo.2018.05.004DOI Listing
August 2018

Retroperitoneal Robotic Partial Nephrectomy: Systematic Review and Cumulative Analysis of Comparative Outcomes.

J Endourol 2018 07 29;32(7):591-596. Epub 2018 May 29.

3 Division of Urology, Virginia Commonwealth University , Richmond, Virginia.

Objectives: To compare the outcomes of retroperitoneal vs transperitoneal approach for robot-assisted partial nephrectomy (RAPN).

Materials And Methods: A systematic review of the literature was performed through January 2018 using PubMed, Scopus, and Ovid databases. Article selection proceeded according to the search strategy based on PRISMA criteria. Only studies comparing retroperitoneal to transperitoneal approach for RAPN were deemed eligible for inclusion.

Results: Seven retrospective case-control studies were identified and included in the analysis, with a total number of 1379 patients (866 for transperitoneal group; 513 for retroperitoneal group). In the retroperitoneal group, tumors were slightly larger [weighted mean difference (WMD): 0.29 cm; 95% confidence interval (CI): 0.04-0.54; p = 0.02], and more frequently located posterior/lateral (odds ratio: 0.61; 95% CI: 0.41-0.90; p = 0.01). In two of the studies only posterior tumors had been included. Both operating time (WMD 20.17 min; 95% CI 6.46-33.88; p = 0.004) and estimated blood loss (WMD 54.57 mL; 95% CI 6.73-102.4; p = 0.03) were significantly lower in the retroperitoneal group. In addition, length of stay was significantly shorter in the retroperitoneal group (WMD 0.46 days; CI 95% 0.15-0.76; p = 0.003). No differences were found regarding overall (p = 0.67) and major (p = 0.82) postoperative complications, warm ischemia time (p = 0.96), and positive surgical margins (p = 0.95).

Conclusions: Retroperitoneal RAPN can offer in select patients similar outcomes to those of the most common transperitoneal RAPN. Furthermore, it may be particularly advantageous for posterior upper pole and perihilar tumors and associated with reduction in operative time and hospital stay. Robotic surgeons should be ideally familiar with both approaches to adapt their surgical strategy to confront renal neoplasms from a position of technical advantage and ultimately optimize outcomes.
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http://dx.doi.org/10.1089/end.2018.0211DOI Listing
July 2018

Robotic assisted simple prostatectomy: recent advances.

Curr Opin Urol 2018 05;28(3):309-314

Division of Urology, Virginia Commonwealth University.

Purpose Of Review: Robotic assisted simple prostatectomy (RASP) represents a minimally invasive evolution of traditional open simple prostatectomy for the surgical treatment of severe lower urinary tract symptoms (LUTS) because of benign prostatic enlargement (BPE). Aim of the present review is to summarize the most recent evidence on this novel procedure, and to better define its current role in the surgical armamentarium for the treatment of BPE.

Recent Findings: Several studies demonstrated that RASP can be safely and effectively performed in centers with sufficient expertise. The procedure can duplicate its open counterpart with the advantage of lower perioperative morbidity, and ultimately faster patient recovery. Overall, the status of RASP seems to be well beyond that of an 'investigational' procedure, and guidelines should be amended accordingly.Nevertheless, it remains to be determined what the place of the RASP procedure in the surgical armamentarium for the treatment of symptomatic BPE will be. Over the most recent years, few comparative studies have been reported, allowing in part to draw some conclusions. RASP seems to be attractive when compared with open simple prostatectomy as it can offer less blood loss, and shorter hospital stay. However, its advantages over transurethral enucleation techniques - such as HoLEP - remain unclear. There are some specific indications, such as the presence of concomitant bladder diverticula or stones, for example, where a robotic approach could represent an appealing solution. Ultimately, further research should look at a cost analysis to determine which technique can be more cost effective. Last, the issue of the learning curve for the different procedures for symptomatic BPE remain to be further scrutinized.

Summary: RASP offers potential advantages over other available techniques for the treatment of large prostate glands. In centers, wherever a solid robotic program is already in place, this procedure is likely to be increasingly implemented.
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http://dx.doi.org/10.1097/MOU.0000000000000499DOI Listing
May 2018