Publications by authors named "Ruben De Groote"

27 Publications

  • Page 1 of 1

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

Eur Urol 2021 Apr 7. Epub 2021 Apr 7.

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

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

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

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

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

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

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

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

Patient Summary: We report our experience with robot-assisted surgery for removal of the bladder in the management of urinary problems after radiation therapy for prostate cancer. When performed by highly experienced surgeons, this is a feasible procedure with outcomes and early and late complication rates that are acceptable.
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http://dx.doi.org/10.1016/j.eururo.2021.03.023DOI Listing
April 2021

Robot-assisted Boari flap and psoas hitch ureteric reimplantation: technique insight and outcomes of a case series with ≥1 year of follow-up.

BJU Int 2021 Apr 8. Epub 2021 Apr 8.

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

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

Patients And Methods: A total of 37 patients with distal ureteric disease were treated between 2010 and 2018. Of these, 81% and 19% underwent RAPHUR and RABFUR, respectively. Intra-, peri- and postoperative outcomes were assessed. The 90-day postoperative complications were reported according to the standardised methodology proposed by the European Association of Urology Ad Hoc Panel. Functional outcomes (creatinine, estimated glomerular filtration rate [eGFR]) and postoperative symptoms (visual analogue pain scale) were assessed.

Results: The median operating time and blood loss were 180 min and 100 mL, respectively. There were no conversions to open surgery and no intraoperative transfusions. The median length of stay, bladder catheter indwelling time and stent removal were 4, 7 and 30 days, respectively. The median follow-up was 24 months. Overall, 10 patients (27%) had postoperative complications and of these, eight (22%) and two (5.4%) were Clavien-Dindo Grade I-II and III, respectively. At the last follow-up, the median postoperative creatinine level and eGFR were 0.9 mg/dL and 73.5 mL/min/1.73 m , respectively. At the last follow-up, five (13.5%) and three (8%) patients had Grade 1 hydronephrosis and mild urinary symptoms, respectively. The study limitations include its retrospective nature.

Conclusion: In the present study, we present our RABFUR and RAPHUR techniques. We confirm the feasibility and safety profile of both approaches in patients with distal ureteric disease relying on the largest single-centre series with ≥1 year of follow-up.
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http://dx.doi.org/10.1111/bju.15421DOI Listing
April 2021

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

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

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

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

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

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

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

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

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

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

Patient Summary: We assessed a new technique in robotic surgery to remove part of the kidney because of kidney cancer. Our new technique involves selective suturing or no suturing of the area from where the tumor is removed. We found that the rate of complications did not increase and the operating time and length of hospital stay were shorter using this new technique.
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http://dx.doi.org/10.1016/j.euf.2021.03.019DOI Listing
March 2021

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

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

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

Adenoid cystic carcinoma (ACC) is a rare malignant tumor, usually arising from salivary glands and rarely found in other locations. ACC is characterized by asymptomatic course, slow growth pattern, perineural invasion and high incidence of late metastasis. Renal localization of metastasis is rare. Only 12 cases of renal metastasis were published and, to our best knowledge, no case of bilateral metastasis to the kidney has ever been reported. We present a case of a 58 years old woman with bilateral renal metastasis from ACC of the right lung after fourteen years from lobectomy and radiotherapy for the primary presentation. The patient underwent bilateral robot-assisted partial nephrectomy in a two-stage approach. Despite its rare incidence and slow growth, ACC metastasis may simulate primary papillary renal carcinoma and occur many years after primary treatment. Therefore, lifelong follow-up, including abdominal imaging, is recommended.
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http://dx.doi.org/10.1007/s13730-021-00589-8DOI Listing
March 2021

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

Eur Urol 2021 Feb 27. Epub 2021 Feb 27.

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

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

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

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

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

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

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

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

Patient Summary: We investigated the effect of previous prostate surgery (PPS) on surgical outcomes after robot-assisted removal of the bladder. We found that patients with PPS have a higher risk of complications and longer hospitalization after bladder removal. These patients deserve closer evaluation before this type of bladder operation.
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http://dx.doi.org/10.1016/j.eururo.2021.02.029DOI Listing
February 2021

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

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

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

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

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

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

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

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

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

Patient Summary: The Simplified PADUA REnal (SPARE) score is a reproducible and simple nephrometry score, offering better predictive capabilities of surgical success and complications.
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http://dx.doi.org/10.1016/j.euf.2020.11.003DOI Listing
November 2020

Objective assessment of intraoperative skills for robot-assisted radical prostatectomy (RARP): results from the ERUS Scientific and Educational Working Groups Metrics Initiative.

BJU Int 2020 Nov 29. Epub 2020 Nov 29.

Orsi Academy, Melle, Belgium.

Objective: To develop and seek consensus from procedure experts on the metrics that best characterise a reference robot-assisted radical prostatectomy (RARP) and determine if the metrics distinguished between the objectively assessed RARP performance of experienced and novice urologists, as identifying objective performance metrics for surgical training in robotic surgery is imperative for patient safety.

Materials And Methods: In Study 1, the metrics, i.e. 12 phases of the procedure, 81 steps, 245 errors and 110 critical errors for a reference RARP were developed and then presented to an international Delphi panel of 19 experienced urologists. In Study 2, 12 very experienced surgeons (VES) who had performed >500 RARPs and 12 novice urology surgeons performed a RARP, which was video recorded and assessed by two experienced urologists blinded as to subject and group. Percentage agreement between experienced urologists for the Delphi meeting and Mann-Whitney U- and Kruskal-Wallis tests were used for construct validation of the newly identified RARP metrics.

Results: At the Delphi panel, consensus was reached on the appropriateness of the metrics for a reference RARP. In Study 2, the results showed that the VES performed ~4% more procedure steps and made 72% fewer procedure errors than the novices (P = 0.027). Phases VIIa and VIIb (i.e. neurovascular bundle dissection) best discriminated between the VES and novices.

Limitations: VES whose performance was in the bottom half of their group demonstrated considerable error variability and made five-times as many errors as the other half of the group (P = 0.006).

Conclusions: The international Delphi panel reached high-level consensus on the RARP metrics that reliably distinguished between the objectively scored procedure performance of VES and novices. Reliable and valid performance metrics of RARP are imperative for effective and quality assured surgical training.
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http://dx.doi.org/10.1111/bju.15311DOI Listing
November 2020

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

Eur Urol 2020 Sep 14. Epub 2020 Sep 14.

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

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

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

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

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

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

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

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

Patient Summary: A revised robot-assisted radical prostatectomy technique applicable to prostate cancer patients with posterior iT3a or iT3b lesion at magnetic resonance imaging was described. This novel technique is feasible and safe in expert hands.
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http://dx.doi.org/10.1016/j.eururo.2020.09.009DOI Listing
September 2020

Development and validation of the objective assessment of robotic suturing and knot tying skills for chicken anastomotic model.

Surg Endosc 2020 Aug 28. Epub 2020 Aug 28.

ORSI Academy, Melle, Belgium.

Background: To improve patient safety, there is an imperative to develop objective performance metrics for basic surgical skills training in robotic surgery.

Objective: To develop and validate (face, content, and construct) the performance metrics for robotic suturing and knot tying, using a chicken anastomotic model.

Design, Setting And Participants: Study 1: In a procedure characterization, we developed the performance metrics (i.e., procedure steps, errors, and critical errors) for robotic suturing and knot tying, using a chicken anastomotic model. In a modified Delphi panel of 13 experts from four EU countries, we achieved 100% consensus on the five steps, 18 errors and four critical errors (CE) of the task. Study 2: Ten experienced surgeons and nine novice urology surgeons performed the robotic suturing and knot tying chicken anastomotic task. The mean inter-rater reliability for the assessments by two experienced robotic surgeons was 0.92 (95% CI, 0.9-0.95). Novices took 18.5 min to complete the task and experts took 8.2 min. (p = 0.00001) and made 74% more objectively assessed performance errors than the experts (p = 0.000343).

Conclusions: We demonstrated face, content, and construct validity for a standard and replicable basic anastomotic robotic suturing and knot tying task on a chicken model. Validated, objective, and transparent performance metrics of a robotic surgical suturing and knot tying tasks are imperative for effective and quality assured surgical training.
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http://dx.doi.org/10.1007/s00464-020-07918-5DOI Listing
August 2020

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

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

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

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

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

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

Conclusions: Relying on a standardized methodology to report complications, we observed that highly comorbid patients who undergo ICUD have lower risk of postoperative complications relative to those patients who received ECUD.
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http://dx.doi.org/10.1007/s00345-020-03237-5DOI Listing
March 2021

Single-setting robot-assisted kidney transplantation consecutive to single-port laparoscopic nephrectomy in a child and robot-assisted living-related donor nephrectomy: initial Ghent experience.

J Pediatr Urol 2019 Oct 16;15(5):578-579. Epub 2019 Aug 16.

Department of Urology, Ghent University Hospital, Ghent, Belgium.

Introduction: Kidney transplantation (KT) is the gold-standard treatment for end-stage renal disease (ESRD) in children. Robot-assisted kidney transplantation (RAKT) in adults is becoming increasingly common with potentially improved morbidity compared with open KT. The study objective was to evaluate feasibility and outcomes of RAKT in children.

Patients & Methods: An 8-years-old boy with ESRD received a kidney transplant from his mother. Simultaneously in two operation theatres, the boy underwent single-port (GelPOINT®) right laparoscopic nephro-ureterectomy (LNU), and his mother underwent robot-assisted left donor nephrectomy (RADN).Two full surgical teams were operating at the same time. Subsequently, the boy underwent RAKT, introducing the graft through the GelPOINT®.

Results: Total operative time for LNU, RADN, and RAKT was 180, 140, and 195 min, respectively, with warm, cold, and rewarming ischemia times 1.5, 200, and 47 min, respectively. Blood loss was 300, 20, and 50 cc, respectively. No intraoperative complications were noted. Convalescence of both donor and recipient was uneventful, with good kidney function at 1-year follow-up.

Conclusion: RAKT in children is technically feasible and safe, resulting in excellent graft function. Concomitant nephrectomy can be done laparoscopically through the single-site GelPOINT®. An experienced RAKT team with the full support of pediatric nephrologists is mandatory.
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http://dx.doi.org/10.1016/j.jpurol.2019.08.005DOI Listing
October 2019

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

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

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

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

Objective: To compare RAPN and OPN.

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

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

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

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

Patient Summary: Robot-assisted partial nephrectomy is associated with a better morbidity profile than open partial nephrectomy (OPN) and provides the same cancer control and renal function preservation observed after OPN.
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http://dx.doi.org/10.1016/j.euo.2018.01.001DOI Listing
May 2018

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

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

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

Robot-Assisted NephroUreterectomy (RANU) represents a minimally invasive alternative to open NephroUreterectomy (NU) for management of Upper Tract Urothelial Carcinoma (UTUC) but its oncologic safety is still controversial. The objective of this study was to investigate the peri-operative, pathologic and oncologic outcomes of RANU for UTUC. From 2008 to 2017, 78 patients diagnosed with UTUC and elected for RANU at 3 high-volume robotic surgery centres were retrospectively assessed. Surgery was performed using da Vinci Si and Xi systems. RANU was done adhering to oncological principles as in open surgery. The outcomes of the study were: (1) peri-operative morbidity, namely intra- and post-operative complications, blood loss, length of hospital stay and operative time; (2) oncologic outcomes, namely overall survival (OS) and recurrence-free survival (RFS). Peri-operative overall complication rate was 24.4% and high-grade complication rate was 2.6%. Median blood loss, length of hospital stay and operative time were 124 ml, 4 days and 167 min. Lymphadenectomy was performed in 31 (41%) patients. Lymph-node involvement was present in 9 (29%) patients. At median follow-up of 15 months, 2- and 4-year OS were 79% and 66%, respectively, and RFS was 63% and 53%. Peritoneal dissemination was recorded in 1 (1.3%) patient with pT4N2R1 UTUC. Our study is limited by the relatively small cohort of patients and its retrospective character. RANU as minimally invasive treatment for patients with UTUC is safe and feasible. Post-operative morbidity is low and major complications are rare. Oncologic outcomes are acceptable and no evidence of increased risk of peritoneal dissemination is recorded. Long-term data are needed. RANU should be regarded as an alternative to open surgery for UTUC that can offer good peri-operative and oncologic results.
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http://dx.doi.org/10.1007/s11701-019-00965-8DOI Listing
February 2020

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

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

Department of Urology, OLV, Aalst, Belgium.

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

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

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

Conclusions: In experienced centers, RARP allows optimal oncologic outcomes at long term follow-up. Adverse pathologic characteristics are independent predictors of BCR and CR.
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http://dx.doi.org/10.23736/S0393-2249.18.03285-XDOI Listing
February 2019

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

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

Department of Urology, OLV Ziekenhuis, Aalst, Belgium.

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

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

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

Conclusions: Robot-assisted partial nephrectomy can be safely and effectively carried out by experienced surgeons in a high-volume center with similar perioperative, functional and oncological outcomes for both elective or imperative indications.
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http://dx.doi.org/10.1111/iju.13754DOI Listing
September 2018

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

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

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

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

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

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

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

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

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

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

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

Patient Summary: We describe a novel approach for apical dissection during robot-assisted radical prostatectomy. Our technique reduces the rates of apical surgical margins in case of apical tumor at preoperative magnetic resonance imaging and leads to optimal continence recovery.
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http://dx.doi.org/10.1016/j.euf.2018.01.004DOI Listing
September 2018

Metachronous metastasis of renal cell carcinoma to the urinary bladder: a case report.

Ther Adv Urol 2018 Jan 3;10(1):29-32. Epub 2017 Nov 3.

Department of Urology, OLV Hospital Aalst, Aalst, Belgium.

We report a case of intravesical metastasis of a clear cell renal cell carcinoma. In renal cell carcinoma 16% of patients present with metastatic disease. Renal cell carcinoma can metastasize to nearly every organ, although metastatic spread to the urinary bladder is rare, with fewer than 70 described cases. The route and pattern of metastatic spread is not yet fully understood and different pathways are suggested. Gross haematuria is the presenting symptom in the majority of cases. These intravesical metastases may be synchronous or metachronous and can be solitary or part of polymetastatic disease. No standard treatment can be suggested due to the rare nature of this phenomenon, and treatment varies from transurethral resection, partial or complete cystectomy to systemic therapy. Prognosis in patients with a solitary bladder lesion that developed metachronously is rather good, whereas poor prognosis can be expected in patients with synchronous and multiple metastases.
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http://dx.doi.org/10.1177/1756287217738986DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5761917PMC
January 2018

MRI Displays the Prostatic Cancer Anatomy and Improves the Bundles Management Before Robot-Assisted Radical Prostatectomy.

J Endourol 2018 04;32(4):315-321

1 Department of Urology, University of Bologna , Bologna, Italy .

Objectives: To evaluate the impact of multiparametric magnetic0 resonance imaging (mpMRI) to guide the nerve-sparing (NS) surgical plan in prostate cancer (PCa) patients referred to robot-assisted radical prostatectomy (RARP).

Methods: One hundred thirty-seven consecutive PCa patients were submitted to RARP between September 2016 and February 2017 at two high-volume European centers. Before RARP, each patient was referred to 1.5T or 3T mpMRI. NS was recorded as Grade 1, Grade 2, Grade 3, and Grade 4 according to Tewari and colleagues classification. A preliminary surgical plan to determinate the extent of NS approach was recorded based on clinical data. The final surgical plan was reassessed after mpMRI revision. The appropriateness of surgical plan change was considered based on the presence of extracapsular extension or positive surgical margins (PSMs) at level of neurovascular bundles area at final pathology. Furthermore, we analyzed a control group during the same period of 166 PCa patients referred to RARP in both institutions without preoperative mpMRI to assess the impact of the use of mpMRI on the surgical margins.

Results: Considering 137 patients with preoperative mpMRI, the mpMRI revision induced the main surgeon to change the NS surgical plan in 46.7% of cases on patient-based and 56.2% on side-based analysis. The surgical plan change results equally assigned between the direction of more radical and less radical approach both on patient-based (54.7% vs 54.3%) and on side-based levels (50% vs 50%), resulting an overall appropriateness of 75%. Moreover, patients staged with mpMRI revealed significant lower overall PSMs compared with control group with no mpMRI (12.4% vs 24.1%; p ≤ 0.01).

Conclusions: mpMRI induces robotic surgeons to change the surgical plan in almost half of individuals, thus tailoring the NS approach, without compromising the oncologic outcomes. Compared to patients treated without mpMRI, the use of preoperative mpMRI can significantly reduce the overall PSMs.
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http://dx.doi.org/10.1089/end.2017.0701DOI Listing
April 2018

Robotic Assisted Simple Prostatectomy versus Holmium Laser Enucleation of the Prostate for Lower Urinary Tract Symptoms in Patients with Large Volume Prostate: A Comparative Analysis from a High Volume Center.

J Urol 2017 04 8;197(4):1108-1114. Epub 2016 Sep 8.

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

Purpose: We report a comparative analysis of robotic assisted simple prostatectomy vs holmium laser enucleation of the prostate in patients who had benign prostatic hyperplasia with a large volume prostate (greater than 100 ml).

Materials And Methods: A total of 81 patients underwent robotic assisted simple prostatectomy and 45 underwent holmium laser enucleation of the prostate in a 7-year period. Patients were preoperatively assessed with transrectal ultrasound and uroflowmetry. Functional parameters were assessed postoperatively during followup. Perioperative outcomes included operative time, postoperative hemoglobin, catheterization time and hospitalization. Complications were reported according to the Clavien-Dindo classification.

Results: Compared to the holmium laser enucleation group, patients treated with prostatectomy were significantly younger (median age 69 vs 74 years, p = 0.032) and less healthy (Charlson comorbidity index 2 or greater in 62% vs 29%, p = 0.0003), and had a lower rate of suprapubic catheterization (23% vs 42%, p = 0.028) and a higher preoperative I-PSS (International Prostate Symptom Score) (25 vs 21, p = 0.049). Both groups showed an improvement in the maximum flow rate (15 vs 11 ml per second, p = 0.7), and a significant reduction in post-void residual urine (-73 vs -100 ml, p = 0.4) and I-PSS (-20 vs -18, p = 0.8). Median operative time (105 vs 105 minutes, p = 0.9) and postoperative hemoglobin (13.2 vs 13.8 gm/dl, p = 0.08) were similar for robotic assisted prostatectomy and holmium laser enucleation, respectively. Median catheterization time (3 vs 2 days, p = 0.005) and median hospitalization (4 vs 2 days, p = 0.0001) were slightly shorter in the holmium laser group. Complication rates were similar with no Clavien grade greater than 3 in either group.

Conclusions: Our results from a single center suggest comparable outcomes for robotic assisted simple prostatectomy and holmium laser enucleation of the prostate in patients with a large volume prostate. These findings require external validation at other high volume centers.
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http://dx.doi.org/10.1016/j.juro.2016.08.114DOI Listing
April 2017

Robot-assisted Salvage Lymph Node Dissection for Clinically Recurrent Prostate Cancer.

Eur Urol 2017 09 3;72(3):432-438. Epub 2016 Sep 3.

OLV Vattikuti Robotic Surgery Institute, Melle, Belgium.

Background: Salvage lymph node dissection has been described as a feasible treatment for the management of prostate cancer patients with nodal recurrence after primary treatment.

Objective: To report perioperative, pathologic, and oncologic outcomes of robot-assisted salvage nodal dissection (RASND) in patients with nodal recurrence after radical prostatectomy (RP).

Design, Setting, And Participants: We retrospectively evaluated 16 patients affected by nodal recurrence following RP documented by positive positron emission tomography/computed tomography scan.

Surgical Procedure: Surgery was performed using DaVinci Si and Xi systems. A pelvic nodal dissection that included lymphatic stations overlying the external, internal, and common iliac vessels, the obturator fossa, and the presacral nodes was performed. In 13 (81.3%) patients a retroperitoneal lymph node dissection that included all nodal tissue located between the aortic bifurcation and the renal vessels was performed.

Measurements: Perioperative outcomes consisted of operative time, blood loss, length of hospital stay, and complications occurred within 30 d after surgery. Biochemical response (BR) was defined as a prostate-specific antigen level <0.2 ng/ml at 40 d after RASND.

Results And Limitations: Median operative time, blood loss, and length of hospital stay were 210min, 250ml, and 3.5 d. The median number of nodes removed was 16.5. Positive lymph nodes were detected in 11 (68.8%) patients. Overall, four (25.0%) and five (31.2%) patients experienced intraoperative and postoperative complications, respectively. Overall, one (6.3%) and four (25.0%) patients had Clavien I and II complications within 30 d after RASND, respectively. Overall, five (33.3%) patients experienced BR after surgery. Our study is limited by the small cohort of patients evaluated and by the follow-up duration.

Conclusions: RASND represents a feasible procedure in patients with nodal recurrence after RP and provides acceptable short-term oncologic outcomes, where one out of three patients experience BR immediately after surgery. Long-term data are needed to confirm the effectiveness of this approach.

Patient Summary: We report our initial experience with robot-assisted salvage nodal dissection for the management of patients with lymph node recurrence after radical prostatectomy. This technique represents a feasible and effective approach, where no high-grade complications were recorded and one out of three patients experienced biochemical response at 40 d after surgery.
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http://dx.doi.org/10.1016/j.eururo.2016.08.051DOI Listing
September 2017

Robot-assisted Radical Prostatectomy and Extended Pelvic Lymph Node Dissection in Patients with Locally-advanced Prostate Cancer.

Eur Urol 2017 02 18;71(2):249-256. Epub 2016 May 18.

OLV Vattikuti Robotic Surgery Institute, Melle, Belgium.

Background: Limited data are available on the role of robot-assisted radical prostatectomy (RARP) in patients with locally advanced prostate cancer (PCa).

Objective: To describe our surgical technique of extrafascial RARP and extended pelvic lymph node dissection (ePLND) in locally advanced PCa.

Design, Setting, And Participants: Ninety-four patients with clinical stage ≥T3 undergoing RARP with ePLND at three European centers between 2011 and 2015 were retrospectively evaluated.

Surgical Procedure: Surgery was performed using the DaVinci Si system. The anatomically defined ePLND included nodes overlying the external iliac axis, those in the obturator fossa, and around the internal iliac artery up to the ureter. RARP was performed using an extrafascial approach where the Denonvillers' fascia was dissected free and left on the posterior surface of the seminal vesicles.

Measurements: Perioperative outcomes consisted of operative time, blood loss, length of hospital stay, and complications occurred within 30 d after surgery. Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values ≥0.2ng/ml. Kaplan-Meier analyses assessed time to BCR and clinical recurrence. Multivariable Cox regression analyses assessed predictors of BCR.

Results And Limitations: Median operative time, blood loss, and length of hospital stay were 230min, 200ml, and 6 d. Overall, 12 (12.7%) patients experienced complications and five (5.3%), four (4.3%), and three (3.2%) patients had Clavien I, II, and III/IV complications. Overall, 72 (76.6%), 35 (37.2%), and 30 (32.3%) patients had pT3/4, pN1, and positive margins. The median number of nodes removed was 16. Overall, 19 (20.2%) and 21 (22.3%) patients received adjuvant radiotherapy and hormonal therapy. The median follow-up was 23.5 mo. At 3-yr follow-up, the BCR- and clinical recurrence-free survival rates were 63.3% and 95.8%. Pathologic stage, Gleason score, and positive margins represented predictors of BCR (all p≤0.03). Our study is limited by its retrospective nature and by the follow-up duration.

Conclusions: RARP represents a well-standardized, safe, and oncological effective option in patients with locally advanced PCa. Pathologic stage, Gleason score, and positive margins should be considered to select patients for multimodal approaches.

Patient Summary: Robot-assisted surgery represents a well-standardized, safe, and oncological effective option in men with locally advanced prostate cancer. Two out of three patients treated with this approach are free from recurrence at 3-yr follow-up. Pathologic stage, Gleason score, and positive surgical margins represent predictors of BCR and should be considered to select patients for multimodal approaches.
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http://dx.doi.org/10.1016/j.eururo.2016.05.008DOI Listing
February 2017

Robot-Assisted Radical Cystectomy for Bladder Cancer in Octogenarians.

J Endourol 2016 07 6;30(7):792-8. Epub 2016 Jun 6.

1 Department of Urology, O.L.V. Hospital , Aalst, Belgium .

Objective: To evaluate perioperative morbidity and mortality rate, a 3-year recurrence-free survival, and cancer-specific mortality rate in patients older than 80 years undergoing robot-assisted radical cystectomy (RARC).

Materials And Methods: We retrospectively collected data of 155 consecutive patients who received RARC for muscle-invasive or high-risk nonmuscle-invasive urothelial carcinoma of the bladder between 2003 and 2014 at a high-volume robotic center. Diversion was performed intra- or extracorporeally according to the surgeon's preferences. Complications were graded according to the Clavien-Dindo system. Logistic regression analyses were used to assess the impact of age on postoperative outcomes.

Results: Of 155 consecutive patients, 22 (14.2%) patients were 80 years or older. Octogenarians did not significantly differ from younger patients in ASA score (p = 0.4) and Charlson comorbidity index (p = 0.4). Prevalence of any grade and high-grade complications was similar in both groups (all p ≥ 0.6). Older patients had a significantly higher pathologic tumor grade (p = 0.04) and a lower use of pelvic lymphadenectomy (p < 0.001). No perioperative mortality rate was recorded within 90 days from surgery. Elderly patients had a similar risk of 3-year oncologic recurrence after surgery compared with their younger counterparts (odds ratio [OR] 1.63; p = 0.2). Conversely, the risk of cancer-specific mortality rate was significantly higher (OR 2.78; p = 0.02).

Conclusions: Patients 80 years or older undergoing RARC for bladder cancer did not have a higher risk of peri- and postoperative morbidity and mortality rate and had a similar 3-year recurrence-free survival, suggesting that RARC can be safely performed in selected elderly patients by experienced surgeons.
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http://dx.doi.org/10.1089/end.2016.0050DOI Listing
July 2016

Early Catheter Removal after Robot-assisted Radical Prostatectomy: Surgical Technique and Outcomes for the Aalst Technique (ECaRemA Study).

Eur Urol 2016 05 11;69(5):917-23. Epub 2015 Nov 11.

Department of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium; OLV Vattikuti Robotic Surgery Institute, Melle, Belgium.

Background: Robot-assisted radical prostatectomy (RARP) is a widespread option for the treatment of patients with clinically localised prostate cancer. Modifications in the surgical technique may help to further improve functional outcomes.

Objective: To assess the outcome of early catheter removal 48h after surgery, as opposed to standard catheter removal 6 d after surgery following RARP, using a newly developed surgical technique for posterior reconstruction and anastomosis (Aalst technique).

Design, Setting, And Participants: Patients scheduled for RARP were prospectively scheduled for early catheter removal at postoperative d 2 (group A, n=37) and standard catheter removal at postoperative d 6 (group B, n=37).

Surgical Procedure: RARP was performed using the Da Vinci Si system. The Aalst technique for the urethro-vesical anastomosis including posterior reconstruction was used as previously described.

Outcome Measurements And Statistical Analysis: The primary endpoint was spontaneous voiding after catheter removal. Secondary endpoints were rate of anastomotic urinary leakage after catheter removal, presence and severity of urethral, perineal, and abdominal pain, as well as patient's bother after catheter removal using visual analogue scale (VAS) scores. Rate and severity of urinary incontinence after catheter removal were assessed using the International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms Module (ICIQ-MLUTS) questionnaire.

Results And Limitations: There was no significant difference between the groups with regard to baseline and perioperative parameters, as well as pathological features; however, significantly more patients underwent bilateral nerve-sparing procedures in group A (34 vs 23, p=0.008). After catheter removal, patients in both groups showed spontaneous voiding, whereas only 11% and 8% of the patients in group A and group B experienced urinary retention after catheter removal (p=0.7). Patients in group B had significantly higher maximum flow rates, but lower voided volumes after catheter removal in comparison with patients in group A (21ml/s vs 10ml/s, p≤0.001 and 170ml vs 200ml, p≤0.001, respectively). ICIQ-MLUTS questionnaire and VAS scores showed no significant differences between the groups at any time point.

Conclusions: The Aalst technique allows the removal of catheters 2 d after RARP and results in spontaneous voiding. Early removal showed no increased rate of urinary leakage, no negative impact on short-term continence and on perineal, urethral or penile pain, and no increase in urinary retention rates. Future studies have to confirm these results with longer follow-up including detailed parameters on return to daily activity.

Patient Summary: We provide evidence that it is possible to remove the bladder catheter as early as 2 d after robot-assisted radical prostatectomy without any negative effects on voiding and pain parameters. Thus, leaving the hospital early without a catheter in place could represent a significant and relevant benefit for the patient.
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http://dx.doi.org/10.1016/j.eururo.2015.09.052DOI Listing
May 2016

Oncologic Outcomes of Robot-Assisted Radical Cystectomy: Results of a High-Volume Robotic Center.

J Endourol 2016 Jan 24;30(1):75-82. Epub 2015 Sep 24.

1 OLV Vattikuti Robotic Surgery Institute , Melle, Belgium .

Background And Purpose: The aim of our study was to assess the oncologic outcomes of robot-assisted radical cystectomy (RARC) in patients with bladder cancer (BCa) treated in a high-volume robotic center.

Materials And Methods: We retrospectively collected data of 155 consecutive patients who received RARC for urothelial BCa from January 2004 to May 2014. Kaplan-Meier analyses were used to assess time to recurrence, cancer-specific mortality (CSM) rate, and overall mortality rate. Uni- and multivariable Cox regression models addressed the predictors of recurrence and CSM.

Results: Median follow-up for survivors was 42 months. Overall, 43%, 34%, 55%, and 18% of the patients had pT ≤1, pT2, pT3/4, and pN1-3 disease, respectively. Overall, 76% of the patients had high-grade disease at final pathology. The positive surgical margin rate was 9%. The 5-year recurrence-free, CSM-free, and overall survival estimates were 53.7%, 73.5%, and 65.2%, respectively. Among patients who experienced recurrence, 12.0%, 4.0%, and 84.0% had local, peritoneal, and distant recurrence, respectively. In multivariable Cox regression analyses, pathologic stage and nodal status represented independent predictors of recurrence and CSM (all p ≤ 0.04).

Conclusions: In a high-volume robotic center, RARC provides acceptable oncologic outcomes in patients with urothelial BCa. Tumor stage and nodal status represent independent predictors of recurrence and CSM in this setting.
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http://dx.doi.org/10.1089/end.2015.0482DOI Listing
January 2016

Robot-assisted simple prostatectomy for treatment of lower urinary tract symptoms secondary to benign prostatic enlargement: surgical technique and outcomes in a high-volume robotic centre.

Eur Urol 2015 Sep 14;68(3):451-7. Epub 2015 Apr 14.

Department of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium; OLV Vattikuti Robotic Surgery Institute, Melle, Belgium.

Background: Robot-assisted simple prostatectomy (RASP) is a minimally invasive procedure for treatment of patients with lower urinary tract symptoms (LUTS) due to large benign prostatic enlargement (BPE).

Objective: To present the perioperative and short-term functional outcomes of RASP in a large series of patients with LUTS due to BPE treated in a high-volume referral center.

Design, Setting, And Participants: We retrospectively collected data for 67 consecutive patients who underwent RASP from October 2008 to August 2014.

Surgical Procedure: RASP was performed using a Da Vinci S or Si system with a transvesical approach.

Measurements: Complications were graded according to the Clavien-Dindo system. Continuous variables are reported as median and interquartile range (IQR). Comparison of preoperative and postoperative outcomes was assessed by Wilcoxon test. A two-sided value of p<0.05 was considered statistically significant.

Results And Limitations: The median preoperative prostate volume was 129ml (IQR 104-180). For the 45 patients who did not have an indwelling catheter, the median preoperative International Prostate Symptom Score (IPSS) was 25 (20.5-28), the median maximum flow rate (Qmax) was 7ml/s (IQR 5-11), and the median post-void residual volume (PVRV) was 73ml (IQR 40-116). The median operative time was 97min (IQR 80-127) and the median estimated blood loss was 200ml (IQR 115-360). The postoperative complication rate was 30%, including three cases (4.5%) with grade 3b complications (major bleeding requiring cystoscopy and coagulation). The median catheterization time was 3 d (IQR 2-4) and the median length of stay was 4 d (IQR 3-5). The median follow-up was 6 mo (IQR 2-12). At follow-up, the median IPSS was 3 (IQR 0-8), the median Qmax was 23ml/s (IQR 16-35), and the median PVRV was 0ml (IQR 0-36) (all p<0.001 vs baseline values). The retrospective design is the major study limitation.

Conclusions: Our data indicate good perioperative outcomes, an acceptable risk profile, and excellent improvements in patient symptoms and flow scores at short-term follow-up following RASP.

Patient Summary: We analyzed the perioperative and functional outcomes of robot-assisted simple prostatectomy in the treatment of male patients with lower urinary tract symptoms due to large prostatic adenoma. The procedure was associated with a relatively low risk of complications and excellent functional outcomes, including considerable improvements in symptoms and flow performance. We can conclude that the procedure is a valuable option in the treatment of such patients. However, comparative studies evaluating the efficacy of the procedure in comparison with endoscopic treatment of large prostatic adenomas are needed.
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http://dx.doi.org/10.1016/j.eururo.2015.03.003DOI Listing
September 2015

Long-term evaluation of survival, continence and potency (SCP) outcomes after robot-assisted radical prostatectomy (RARP).

BJU Int 2013 Aug 7;112(3):338-45. Epub 2013 Mar 7.

OLV Robotic Surgery Institute, Aalst, Belgium.

Objective: To report combined oncological and functional outcome in a series of patients who underwent robot-assisted radical prostatectomy (RARP) for clinically localised prostate cancer in a single European centre after 5-year minimum follow-up according to survival, continence and potency (SCP) outcomes.

Patients And Methods: We extracted from our prostate cancer database all consecutive patients with a minimum follow-up of 5 years after RARP. Biochemical failure was defined as a confirmed PSA concentration of >0.2 ng/mL. All patients alive at the last follow-up were evaluated for functional outcomes using the Expanded Prostate Cancer Index Composite (EPIC) and Sexual Health Inventory for Men (SHIM) questionnaires. Oncological and functional outcomes were reported according to the SCP system. Specifically, patients were classified as using no pad (C0), using one pad for security (C1), and using ≥1 pad (C2) (not including the prior definition). Patients potent (SHIM score of >17) without any aids were classified as P0 category; patients potent (SHIM score of >17) with use of phosphodiesterase type 5 inhibitorsas P1; and patients with erectile dysfunction (SHIM score of <17) as P2 category. Patients who did not undergo a nerve-sparing technique, who were not potent preoperatively, who were not interested in erections, or who did not have sexual partners were classified as Px category.

Results: The 3-, 5- and 7-year biochemical recurrence-free survival rates were 96.3%; 89.6% and 88.3%, respectively. At follow-up, 146 (79.8%) were fully continent (C0), 20 (10.9%) still used a safety pad (C1) and 17 (9.3%) were incontinent using ≥1 pad (C2). Excluding Px patients, 52 patients (47.3%) were classified as P0; 41 patients (37.3%) were classified as P1 and 17 patients (15.5%) were P2. In patients preoperatively continent and potent, who received a nerve-sparing technique and did not require any adjuvant therapy, oncological and functional success was attained by 77 (80.2%) patients. In the subgroup of 67 patients not evaluable for potency recovery (Px), oncological and continence outcomes were attained in 46 patients (68.7%).

Conclusions: Oncological and functional success was attained in a high percentage of patients who underwent RARP at ≥5 years follow-up. Interestingly, this study confirmed that excellent oncological and functional outcomes can be obtained in the 'best' category of patients, i.e. those preoperatively continent and potent and with tumour characteristics suitable for a nerve-sparing technique.
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http://dx.doi.org/10.1111/bju.12001DOI Listing
August 2013