Publications by authors named "Umberto Carbonara"

28 Publications

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Robotic vs laparoscopic nephroureterectomy for upper tract urothelial carcinoma: a multicenter propensity-score matched pair "tetrafecta" analysis (ROBUUST collaborative group).

J Endourol 2022 Jan 12. Epub 2022 Jan 12.

Changhai hospital, the second military medical university, the department of Urology, Changhai Road NO. 163, Shanghai, Shanghai, China, 200433;

Purpose: To compare the outcomes of robotic radical nephroureterectomy (RRNU) and laparoscopic radical nephroureterectomy (LRNU) within a large multi-institutional worldwide dataset.

Material And Methods: The ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST) includes data from 17 centers worldwide regarding 877 RRNU and LRNU performed between 2015 and 2019. Baseline features, perioperative and oncological outcomes, were included. A 2:1 nearest-neighbor propensity-score matching with a 0.001 caliper was performed. An univariable and a multivariable logistic regression model were built to evaluate the predictors of a composite "tetrafecta" outcome defined as occurrence of bladder cuff excision + LND + no complications + negative surgical margins.

Results: After matching, 185 RRNU and 91 LRNU were assessed. Patients in the RRNU group were more likely to undergo bladder cuff excision (81.9% vs 63.7%; p<0.001) compared to the LRNU group. A statistically significant difference was found in terms of overall postoperative complications (p=0.003) and length of stay (p<0.001) in favor of RRNU. Multivariable analysis demonstrated that LRNU was an independent predictor negatively associated with achievement of "tetrafecta" (OR: 0.09; p=0.003).

Conclusions: In general, RRNU and LRNU offer comparable outcomes. While the rate of overall complications is higher for LRNU in this study population, this is mostly related to low grade complications, and therefore with more limited clinical relevance. RRNU seems to offer shorter hospital stay but this might also be related to the different geographical location of participating centers. Overall, the implementation of robotics might facilitate achievement of a "tetrafecta" outcome as defined in the present study.
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http://dx.doi.org/10.1089/end.2021.0587DOI Listing
January 2022

PSA and PSA Kinetics as Predictors for 18F-Fluciclovine PET/CT Positivity in Biochemically Recurrent Prostate Cancer.

Urol Int 2021 Dec 21:1-8. Epub 2021 Dec 21.

Department of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy.

Introduction: 18F-Fluciclovine PET/CT is one of the imaging techniques currently employed to restage prostate cancer (PCa). Due to the conflicting results reported in the literature, it is not yet known at what PSA threshold 18F-fluciclovine PET/CT could reliably demonstrate the presence of recurring disease. We explored the association between 18F-fluciclovine PET/CT positivity and prescan PSA, PSA doubling time, and PSA velocity in patients with biochemical recurrence (BCR) of PCa after curative-intent treatment.

Methods: Data from 59 patients who underwent 18F-fluciclovine PET/CT for BCR after radical prostatectomy or radiotherapy were retrieved from a single institution database. Patients already undergone salvage treatments at the time of PET/CT, with newly diagnosed PCa or with initial diagnosis of metastatic PCa were excluded. A 2-sided independent samples Bayesian t test and Bayesian Mann-Whitney U test were used to assess the association between PET/CT and prescan PSA, PSA doubling time, and PSA velocity.

Results: Evidence for no difference between PET/CT-positive and -negative patients for log-transformed PSA was found (BF01 3.61, % error: 0.01). Robustness check and sequential analysis showed stability across a wide range of prior distribution specifications. The hypothesis of no difference in terms of PSA-dt and for PSA-vel between groups was found to be more likely compared to the alternative hypothesis (BF01 of 3.44 and 3.48, respectively).

Conclusion: PSA and PSA kinetics are unlikely to be associated with 18F-fluciclovine PET/CT positivity in patients with BCR, and none of these serum biomarkers might be used as single predictors of PET/CT detection. Larger studies might be needed to evaluate the role of different predictors.
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http://dx.doi.org/10.1159/000520684DOI Listing
December 2021

Impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for renal cancer: a systematic review.

Minerva Urol Nephrol 2021 Oct 29. Epub 2021 Oct 29.

Department of Urology, Campus Bio-Medico University, Rome, Italy.

Background: Frailty has been recognized as a major risk factor for adverse perioperative and oncological outcomes in patients with genitourinary malignancies. Yet, the evidence supporting such an association in patients with renal cell carcinoma (RCC) is still sparse. Herein we provide an updated comprehensive overview of the impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for RCC.

Evidence Acquisition: A systematic review of the English-language literature was conducted using the MEDLINE (Via PubMed), Web of Science and the Cochrane Library databases according to the principles highlighted by the EAU Guidelines Office and the PRISMA statement recommendations. The review protocol was registered on PROSPERO (CRD42021242516). The overall quality of evidence was assessed according to GRADE recommendations.

Evidence Synthesis: Overall, 18 studies were included in the qualitative analysis. Most of these were retrospective single-centre series including patients undergoing surgery for non-metastatic RCC. The overall quality of evidence was low. A variety of measures were used for frailty assessment, including the Canadian Study of Health and Aging Frailty Index, the five-item frailty index, the Modified Rockwood's Clinical Frailty Scale Score, the Hopkins Frailty score, the Groningen Frailty Index, and the Geriatric nutritional risk index. Sarcopenia was defined based on the Lumbar skeletal muscle mass at cross-sectional imaging, the skeletal muscle index, the total psoas area, or the psoas muscle index. Overall, available studies point to frailty and sarcopenia as potential independent risk factors for worse perioperative and oncological outcomes after surgery or ablation for different RCC stages. Increased patient's frailty was indeed associated with higher risk of perioperative complications, healthcare resources utilization, readmission rates and longer hospitalization periods, as well as potentially lower cancer specific or overall survival.

Conclusions: Frailty has been consistently associated with worse outcomes after surgery for RCC, reinforcing the value of preoperative frailty assessment in carefully selected patients. Given the low quality of the available evidence (especially in the setting of tumour ablation), prospective studies are needed to standardize frailty assessments and to identify patients who are expected to benefit most from preoperative geriatric evaluation, aiming to optimize decision-making and postoperative outcomes in patients with RCC.
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http://dx.doi.org/10.23736/S2724-6051.21.04583-3DOI Listing
October 2021

Current management of radiation cystitis after pelvic radiotherapy: a systematic review.

Minerva Urol Nephrol 2021 Oct 29. Epub 2021 Oct 29.

Department of Urology, Campus Bio-Medico University, Rome, Italy.

Introduction: We aimed to summarize current literature about radiation cystitis treatments, providing physician of a summary of current management options.

Evidence Acquisition: A systematic literature review searching on PubMed (Medline), Scopus, and Web of Science databases was performed in March 2021. PRISMA guidelines were followed. Population consisted of patients with a diagnosis of radiation cystitis after pelvic radiotherapy (P). We focused our attention on different treatments, such as conservative or surgical one (I). Single or multiple arms studies were deemed eligible with no mandatory comparison (C). Main outcomes of interest were symptoms control and adverse events rates (O).

Evidence Synthesis: The search identified 1,194 records. Of all, four studies focused on the use of hyperbaric oxygen therapy showing complete response rates ranging from 52 to 87% approximately. Oral administration of cranberry compounds was investigated in one study showing no superiority to placebo. Intravesical instillation of different compounds were investigated in five studies showing the highest complete response rates after alum (60%) and formalin administration (75%). Endoscopic conservative surgical treatments (fibrin glue or vaporization) also showed 75% complete response rates. In patients who did not respond to conservative treatments robotic cystectomy is feasible with overall complication rates of about 59.3% at 90 days.

Conclusions: Radiotherapy induced cystitis is an under-reported condition after pelvic radiotherapy. Several treatments have been proposed, but in up to 10% of cases salvage cystectomy is necessary. A stepwise approach, with progressive treatment aggressiveness is recommended.
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http://dx.doi.org/10.23736/S2724-6051.21.04539-0DOI Listing
October 2021

New Ultra-minimally Invasive Surgical Treatment for Benign Prostatic Hyperplasia: A Systematic Review and Analysis of Comparative Outcomes.

Eur Urol Open Sci 2021 Nov 22;33:28-41. Epub 2021 Sep 22.

Department of Oncology, Division of Urology, University of Turin, Turin, Italy.

Context: Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr.

Objective: To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezūm, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection.

Evidence Acquisition: A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses.

Evidence Synthesis: The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; -9.81 points, 95% confidence interval [CI] -11.37 to -8.25 at 1 mo; -13.13 points, 95% CI -14.98 to -11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8-4.5 to +4.14 ml/s, 95% CI 0.72-7.56 at 12 mo), and postvoid residual volume (-10.10 ml, 95% CI -27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34-2.42 at the start of follow-up; and 1.04, 95% CI 0.28-1.8 after 1 yr), or the IPSS-Quality of Life questionnaire.

Conclusions: Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezūm, UroLift, and PAE had a minimal impact on patients' sexual function with respect to baseline, especially regarding preservation of ejaculation.

Patient Summary: We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function.

Take Home  Message: Novel ultra-minimally invasive treatments can yield fast and effective relief of lower urinary tract symptoms without affecting a patient's quality of life.
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http://dx.doi.org/10.1016/j.euros.2021.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8473553PMC
November 2021

Renal tumors ablation.

Minerva Urol Nephrol 2021 Aug;73(4):549-551

Unit of Urological Robotic Surgery and Renal Transplantation, University of Florence, Careggi Hospital, Florence, Italy.

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http://dx.doi.org/10.23736/S2724-6051.21.04605-XDOI Listing
August 2021

Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review.

Patient Saf Surg 2021 Jul 12;15(1):24. Epub 2021 Jul 12.

Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA.

Background: A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management.

Methods: Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical "sharps," a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of "sharps". Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview.

Results: Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery.

Conclusion: The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.
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http://dx.doi.org/10.1186/s13037-021-00297-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276389PMC
July 2021

Risks and Benefits of Live Surgical Broadcast: A Systematic Review.

Eur Urol Focus 2021 Jun 17. Epub 2021 Jun 17.

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

Context: Live surgical broadcast (LSB), also known as live surgery, has become a popular format for many types of surgical education meetings. However, concerns have been raised in relation to patient safety, ethical issues, and the actual educational value of LSB.

Objective: To summarize current evidence on LSB with a focus on the risks of complications and the educational impact.

Evidence Acquisition: We performed a systematic review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies up to December 2020. We identified original articles reporting on patient outcomes, educational value, current use, and development of LSB. We also interrogated surgical society guidelines for position statements on LSB.

Evidence Synthesis: Our literature search identified 46 studies spanning six surgical specialties, with urology being the most frequent. Approximately half of the studies reported on outcomes of surgical procedures during LSB. In urology, the few comparative studies available did not suggest higher complication rates in LSB, whereas data for other surgical fields highlighted evidence of worse outcomes. Four studies assessed the educational value of LSB via survey administration, for which the evidence is limited and of low quality. Thirteen guidelines and position statements on live surgery were identified among major surgical societies, including the European Association of Urology (EAU). Some surgical societies have expressly prohibited the use of LSB at their major meetings. The perspective of surgeons performing and/or attending live surgical sessions was evaluated in six studies, and four studies looked at urologists' perception of LSB compared to semi-LSB. Limitations of this systematic review include the limited number of studies available, the low quality of the evidence, and data heterogeneity.

Conclusions: Evidence regarding outcomes of LSB is limited. Almost all the studies do not show a higher risk of complications or worse outcomes for patients undergoing a procedure during LSB. Only one study on gastrointestinal surgery reported that LSB outcomes were worse. Ongoing concerns have led to specific guidelines by several scientific societies, including the EAU, with the ultimate aim of minimizing surgical risks and maximizing patient safety.

Patient Summary: Live surgery events are often part of surgical conferences. Data in the literature show mixed outcomes for operations performed during live surgery events, but with no increase in complication rates. Safety and ethical concerns remain. Other educational tools, such as prerecorded videos and live surgery transmission from the home institution of the operating surgeon might become preferred options in the future. This review was prospectively registered on the PROSPERO website (www.crd.york.ac.uk/PROSPERO, registration number CRD42020194023).
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http://dx.doi.org/10.1016/j.euf.2021.06.003DOI Listing
June 2021

Robot-Assisted Ureteral Reimplantation: A Single-Center Comparative Study.

J Endourol 2021 Oct;35(10):1504-1511

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

Aim of this study was to report a single-center experience with robot-assisted ureteral reimplantation (RAUR) and to compare its outcomes with those of open ureteral reimplantation (OUR). Patients who underwent RAUR or OUR for ureteral disease between 2016 and 2020 were identified. Data collected included baseline, pathologic, perioperative, and postoperative features. The RAUR outcomes were compared with those of OUR. Overall, 21 (42.8%) patients underwent RAUR, and 28 (57.2%) underwent OUR. The two groups were similar in terms of baseline and pathologic characteristics. There was a statistically significant difference in favor of RAUR for median operative time (216 317 minutes,  = 0.01) and median blood loss (35 175 mL,  = 0.001). No difference was observed in overall complication rate (33.3% 46.4%,  = 0.9), as well as major complications (Clavien-Dindo≥III grade) rate between RAUR and OUR groups. Median length of stay was shorter for RAUR (2 6 days;  = 0.001), as well as median catheterization time (16 28 days;  = 0.005). RAUR is a safe and effective minimally invasive surgical procedure for the management of mid to distal ureteral strictures. It can recapitulate the success rate of the gold standard OUR while offering a benefit in terms of lower surgical morbidity and faster postoperative recovery.
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http://dx.doi.org/10.1089/end.2021.0083DOI Listing
October 2021

Retroperitoneal versus transepritoneal robot-assisted partial nephrectomy for postero-lateral renal masses: an international multicenter analysis.

World J Urol 2021 Nov 29;39(11):4175-4182. Epub 2021 May 29.

Division of Urology, VCU Health, Richmond, VA, 23298-0118, USA.

Purpose: To assess the outcomes of retroperitoneal robot-assisted partial nephrectomy (r-RAPN) in a large cohort of patients with postero-lateral renal masses comparing to those of transperitoneal RAPN (t-RAPN).

Methods: Patients with posterior (R.E.N.A.L. score grading P) or lateral (grading X) renal mass who underwent RAPN in six high-volume US and European centers were identified and stratified into two groups according to surgical approach: r-RAPN ("study group") and t-RAPN ("control group"). Baseline characteristics, intraoperative, and postoperative data were collected and compared.

Results: Overall, 447 patients were identified for the analysis. 231 (51.7%) and 216 (48.3%) patients underwent r-RAPN and t-RAPN, respectively. Baseline characteristics were not statistically significantly different between the groups. r-RAPN group reported lower median operative time (140 vs. 170 min, p < 0.001). No difference was found in ischemia time, estimated blood loss, and intraoperative complications. Overall, 47 and 54 postoperative complications were observed in r-RAPN and t-RAPN groups, respectively (20.3 vs. 25.1%, p = 0.9). 1 and 2 patients reported major complications (Clavien-Dindo ≥ III grade) in the retroperitoneal and transperitoneal groups (0.4 vs. 0.9%, p = 0.9). There was no difference in hospital re-admission rate, median length of stay, and PSM rate. Trifecta criteria were achieved in 90.3 and 89.2% of r-RAPN and t-RAPN, respectively (p = 0.7).

Conclusion: r-RAPN and t-RAPN offer similar postoperative, functional, and oncological outcomes for patients with postero-lateral renal tumors. Our analysis suggests an advantage for r-RAPN in terms of shorter operative time, whereas it does not confirm a difference in terms of length of stay, as suggested by previous reports.
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http://dx.doi.org/10.1007/s00345-021-03741-2DOI Listing
November 2021

Mechanical and Ablative Minimally Invasive Techniques for Male LUTS due to Benign Prostatic Obstruction: A Systematic Review according to BPH-6 Evaluation.

Urol Int 2021 13;105(9-10):858-868. Epub 2021 Apr 13.

Department of Urology, University of Catania, Catania, Italy.

The treatment of male lower urinary tract symptoms (LUTS) due to benign prostatic obstruction represents one of the major interesting aspects in urological clinical practice. Although transurethral resection of the prostate is still considered the surgical gold standard for treatment of benign prostatic hyperplasia with prostate volume <80 mL, various minimally invasive surgical treatments (MITs) have been developed to overcome the limitations of the "conventional" surgery. To date, there are no validated tools to evaluate the surgical outcomes of MITs; however, in the past, BPH-6 has been used for this purpose. In this systematic review, we evaluated the efficacy and safety of MITs according to BPH-6 score system. We focused our attention on MITs based on mechanical devices (prostatic urethral lift and the temporary implantable nitinol device) and techniques for prostate ablation (image guided robotic waterjet ablation and convective water vapor energy ablation). Evidence shows that MITs are capable of leading to an improvement in LUTS without having an overwhelming impact on complications and are a valid alternative to other treatments in patients who wish to preserve their sexual function or in case of inapplicability of conventional surgery. However, comparative studies between these techniques are still missing.
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http://dx.doi.org/10.1159/000514438DOI Listing
January 2022

Robot-assisted radical prostatectomy versus standard laparoscopic radical prostatectomy: an evidence-based analysis of comparative outcomes.

World J Urol 2021 Oct 11;39(10):3721-3732. Epub 2021 Apr 11.

Division of Urology, VCU Health, Richmond, VA, 23298-0118, USA.

Purpose: To provide a systematic analysis of the comparative outcomes of robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) in the treatment of prostate cancer based on the best currently available evidence.

Methods: An independent systematic review of the literature was performed up to February 2021, using MEDLINE, EMBASE, and Web of Science databases. Preferred reporting items for systematic review and meta-analysis (PRISMA) recommendations were followed to design search strategies, selection criteria, and evidence reports. The quality of the included studies was determined using the Newcastle-Ottawa scale for non-randomized controlled trials. Demographics and clinical characteristics, surgical, pathological, and functional outcomes were collected.

Results: Twenty-six studies were identified. Only 16 "high-quality" (RCTs and Newcastle-Ottawa scale 8-9) studies were included in the meta-analysis. Among the 13,752 patients included, 6135 (44.6%) and 7617 (55.4%) were RARP and LRP, respectively. There was no difference between groups in terms of demographics and clinical characteristics. Overall and major complication (Clavien-Dindo ≥ III) rates were similar in LRP than RARP group. The biochemical recurrence (BCR) rate at 12months was significantly lower for RARP (OR: 0.52; 95% CI 0.43-0.63; p < 0.00001). RARP reported lower urinary incontinence rate at 12months (OR: 0.38; 95% CI 0.18-0.8; p = 0.01). The erectile function recovery rate at 12months was higher for RARP (OR: 2.16; 95% CI 1.23-3.78; p = 0.007).

Conclusion: Current evidence shows that RARP offers favorable outcomes compared with LRP, including higher potency and continence rates, and less likelihood of BCR. An assessment of longer-term outcomes is lacking, and higher cost remains a concern of robotic versus laparoscopic prostate cancer surgery.
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http://dx.doi.org/10.1007/s00345-021-03687-5DOI Listing
October 2021

Incidence and OR team awareness of "near-miss" and retained surgical sharps: a national survey on United States operating rooms.

Patient Saf Surg 2021 Apr 3;15(1):14. Epub 2021 Apr 3.

Division of Urology Denver Health Medical Center and University of Colorado Anschutz Medical Campus, Denver, USA.

Introduction: A retained surgical sharp (RSS) is a never event and defined as a lost sharp (needle, blade, instrument, guidewire, metal fragment) that is not recovered prior to the patient leaving the operating room. A "near-miss" sharp (NMS) is an intraoperative event where there is a lost surgical sharp that is recovered prior to the patient leaving the operating room. With underreporting of such incidents, it is unrealistic to expect aggressive development of new prevention and detection strategies. Moreover, awareness about the issue of "near-miss" or retained surgical sharps remains limited. The aim of this large-scale national survey-based study was to estimate the incidence of these events and to identify the challenges surrounding the use of surgical sharps in daily practice.

Methods: We hypothesized that there was a larger number of RSS and NMS events than what was being reported. We survived the different OR team members to determine if there would be discordance in reported incidence between groups and to also evaluate for user bias. An electronic survey was distributed to OR staff between December 2019 and April 2020. Respondents included those practicing within the United States from both private and academic institutions. Participants were initially obtained by designating three points of contact who identified participants at their respective academic institutions and while attending specialty specific medical conferences. Together, these efforts totaled 197 responses. To increase the number of respondents, additional emails were sent to online member registries. Approximately 2650 emails were sent resulting in an additional 250 responses (9.4% response rate). No follow up reminders were sent. In total, there were 447 survey responses, in which 411 were used for further analysis. Thirty-six responses were removed due to incomplete respondent data. Those who did not meet the definition of one of the three categories of respondents were also excluded. The 411 were then categorized by group to include 94 (22.9%) from anesthesiologist, 132 (32.1%) from resident/fellow/attending surgeon and 185 (45%) from surgical nurse and technologist.

Survey: The survey was anonymous. Participants were asked to answer three demographic questions as well as eight questions related to their personal perception of NMS and RSS (Fig. 1). Demographic questions were asked with care to ensure no identifiable information was obtained and therefore unable to be traced back to a specific respondent or institution. Perception questions 4-6 and 11 were designed to understand the incidence of various sharp events (e.g. lost, retained, miscounted). Questions 7 and 10 were dedicated to understanding time spent managing sharps and questions 8 and 9 were dedicated to understanding the use x-ray and its effectiveness.

Results: Overall, most of each respondent group reported 1-5 lost sharp events over the last year. Roughly 20% of surgeons believed they never had a miscounted sharp over the last year, where only 5.3% of anesthesiologist reported the same (p = 0.002). Each group agreed that roughly 4 lost events occur every 1000 surgeries, but a significant difference was found between the three groups regarding the number of lost sharps not recovered per 10,000 surgeries with anesthesiologist, surgeon and nurse/technologist groups estimating 2.37, 2.56 and 2.94 respectively (p = 0.001). All groups noted x-ray to offer poor effectiveness at 26-50% with 31-40 min added for each time x-ray was used. More than half (56.8%) of surgeons reported using x-ray 100% of the time when managing a lost sharp whereas anesthesiologists and nurses/technologists believe it is closer to 1/3 of the time. An average of 21-30 min is spent managing each NMS, making a lost sharp event result in up to 70 min of added OR time.

Conclusions: "Near-miss" and RSS are more prevalent than what is reported in current literature. Surgeons perceive a higher rate of success in retrieving the RSS when compared to anesthesiologists and OR nurses/technologists. We recognize several challenges surrounding "near-miss" and never events as contributing factors to their underreported nature and the higher degree of surgeon recall bias associated with these events. Additionally, we highlight that current methods for prevention are costly in time and resources without improvement in patient safety. As NMS and RSS have significant health system implications, a strong understanding of these implications is important as we strive to improve patient safety.
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http://dx.doi.org/10.1186/s13037-021-00287-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019169PMC
April 2021

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.

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

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

Nomogram predicting 30-day mortality after nephrectomy in the contemporary era: Results from the SEER database.

Int J Urol 2021 Mar 14;28(3):309-314. Epub 2020 Dec 14.

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

Objectives: To assess contemporary 30-day mortality rates after partial and radical nephrectomy in USA, and to develop a predictive model of 30-day mortality.

Methods: We relied on the National Cancer Institute Surveillance, Epidemiology and End Results database. A multivariable logistic regression analysis was fitted to predict 30-day mortality. A nomogram was built based on the coefficients of the logit function. Internal validation was carried out using the leave-one-out cross-validation. Calibration was graphically investigated.

Results: A total of 102 146 patients who underwent partial nephrectomy (n = 36 425; 35.7%) or radical nephrectomy (n = 65 721; 64.3%) between 2005 and 2015 were included in the analysis. The median age at diagnosis was 62 years. A total of 11 921 (11.7%) patients were African American. The clinical stage was T1-T2 in 79 452 (77.8%), T3 in 16 141 (15.8%) and T4/T1-4-M1 in 6553 (6.4%) patients. Overall, 497 deaths occurred during the initial 30 days after nephrectomy (0.49% 30-day mortality rate). Stratified by type of surgery, the 30-day mortality rate was 0.16% for partial nephrectomy and 0.67% for radical nephrectomy. At univariate analyses, age, tumor size, stage and surgical procedure emerged as predictors of 30-day mortality (all P < 0.001). All of these covariates were included in the multivariable logistic regression model. The area under the curve after leave-one-out cross-validation was 0.808 (95% confidence interval 0.788-0.828), and the model showed good calibration in the range of predicted probability <10%.

Conclusions: Contemporary rates of 30-day mortality in patients undergoing radical or partial nephrectomy are very low. Age and tumor stage are key determinants of 30-day mortality. We present a predictive model that provides individual probabilities of 30-day mortality after nephrectomy, and it can be used for patient counseling prior surgery.
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http://dx.doi.org/10.1111/iju.14461DOI Listing
March 2021

New robotic surgical systems in urology: an update.

Curr Opin Urol 2021 01;31(1):37-42

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

Purpose Of Review: The landscape of robotic surgical systems in urology is changing. Several new instruments have been introduced internationally into clinical practice, and others are in development. In this review, we provide an update and summary of recent surgical systems and their clinical applications in urology.

Recent Findings: Robotic-assisted laparoscopic surgery is increasingly becoming a standard skillset in the urologist's technical armamentarium. The current state of the robotic surgery market is monopolized because of a number of regulatory and technical factors but there are several robotic surgical systems approved for clinical use across the world and numerous others in development. Next-generation surgical systems commonly include a modular design, open access consoles, haptic feedback, smaller instruments, and machine learning.

Summary: Numerous robotic surgical systems are in development, and several have recently been introduced into clinical practice. These new technologies are changing the landscape of robotic surgery in urology and will likely transform the marketplace of robotic surgery across surgical subspecialties within the next 10--20 years.
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http://dx.doi.org/10.1097/MOU.0000000000000833DOI Listing
January 2021

Robotic radical perineal prostatectomy: tradition and evolution in the robotic era.

Curr Opin Urol 2021 01;31(1):11-17

Department of Emergency and Organ Transplantation -Urology, Andrology, and Kidney Transplantation Unit, University of Bari 'Aldo Moro', Bari, Italy.

Purpose Of Review: To provide an updated review of robotic radical perineal prostatectomy (r-RPP) with emphasis on the recent advances in terms of surgical technique, outcomes, and new robotic platforms.

Recent Finding: The technological innovations in the urological field have been applied to radical prostatectomy with the aim of preserving important anatomical structures and reduce patients' morbidity and mortality. In recent years, robotic surgery contributed to resurge radical perineal prostatectomy. In 2014, the Cleveland Clinic group was the first to demonstrate the utility of a robotic approach in RPP. To date, the majority of the reported studies showed that r-RPP has noninferior perioperative, short-term oncological, and functional outcomes compared with the traditional robot-assisted radical prostatectomy (RARP). Given these benefits, r-RPP is a promising approach in selected patients, such as obese ones. Moreover, robotic perineal pelvic lymph node dissection performed through the same incision of r-RPP and the new Single-Port (SP) Robotic System represent further steps towards the overcoming of some intrinsic limitation of this surgical approach making this technique suitable for a larger number of patients with prostatic cancer.

Summary: Overall, r-RPP represents a reliable and effective novel surgical technique. However, more studies with long-term follow-up are needed to clarify the advantages over RARP.
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http://dx.doi.org/10.1097/MOU.0000000000000830DOI Listing
January 2021

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

Eur Urol 2021 10 18;80(4):428-439. Epub 2020 Nov 18.

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
October 2021

Robot-assisted partial nephrectomy: 7-year outcomes.

Minerva Urol Nephrol 2021 08 17;73(4):540-543. 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 years, 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-year 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 88 months. Median clinical tumor size was 3 cm, with mostly (74.1%) clinical stage T1a, and median RENAL score 6. Final histopathologic analysis revealed clear cell RCC in 76.5% of cases. PSM was present in seven 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 84 months, 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/S2724-6051.20.04151-XDOI Listing
August 2021

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 2021 Sep 3;7(5):1115-1120. 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
September 2021

Robot-assisted simple prostatectomy for giant benign prostatic hyperplasia.

Cent European J Urol 2020 24;73(3):383-384. Epub 2020 Jul 24.

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

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http://dx.doi.org/10.5173/ceju.2020.0207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7587478PMC
July 2020

Detection Rate of Prostate Specific Membrane Antigen Tracers for Positron Emission Tomography/Computerized Tomography in Prostate Cancer Biochemical Recurrence: A Systematic Review and Network Meta-Analysis.

J Urol 2021 02 16;205(2):356-369. Epub 2020 Sep 16.

Department of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy.

Purpose: Restaging of prostate cancer in patients with biochemical recurrence after radical treatment remains a challenging clinical scenario as current imaging modalities are suboptimal. To date, prostate specific membrane antigen positron emission tomography/computerized tomography seems to represent a very promising diagnostic tool in this setting. Therefore, we evaluated the detection rate of several positron emission tomography/computerized tomography prostate specific membrane antigen based tracers in the restaging of prostate cancer in patients with biochemical recurrence.

Materials And Methods: According to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, a systematic search was performed across MEDLINE®, Embase® and Web of Science™. PICOS (Patient, Intervention, Comparator, Outcome, Study Type), criteria consisted of P: patients with biochemical recurrence after radical prostatectomy and/or radiation therapy as primary treatment; I: studies using gallium-68-prostate specific membrane antigen-11, gallium-68-prostate specific membrane antigen inhibitor for imaging and therapy, gallium-68-trishydroxypyridinone-prostate specific membrane antigen, copper-64-prostate specific membrane antigen-617, fluorine-18-DCFPyL or fluorine-18-prostate specific membrane antigen-1007; C: no control group or positron emission tomography/computerized tomography comparative studies; O: patient specific overall detection rate; and S: retrospective/prospective studies. A meta-analysis of proportions and a network meta-analysis were performed. Heterogeneity was assessed using Cochran Q and I statistics. Quality was assessed by QUADAS-2 (University of Bristol, Bristol, United Kingdom). Funnel plots and Egger test were used for publication biases.

Results: A total of 43 studies including 5,832 patients were identified and included in the analysis. An overall detection rate of 74.1% (95% CI 69.2%-78.5%) was found, with no differences between tracers. The overall detection rates were 33.7%, 50.0%, 62.8%, 73.1% and 91.7% % in prostate specific antigen subgroups of less than 0.2 ng/ml, 0.2 to 0.49 ng/ml, 0.50 to 0.99 ng/ml, 1.0 to 1.99 ng/ml, and 2.0 ng/ml or greater, respectively. No difference between tracers was found according to prostate specific antigen doubling time or prostate specific antigen velocity. No tracer proved superior to the others through network meta-analysis. High heterogeneity and inconsistency were found across all analyses. Included studies showed a low risk of bias.

Conclusions: Prostate specific membrane antigen positron emission tomography/computerized tomography for prostate cancer restaging in patients with biochemical recurrence achieves best detection rates (over 70%) if prostate specific antigen is below 1 ng/ml. At lower prostate specific antigen levels the detection rate of prostate specific membrane antigen positron emission tomography/computerized tomography is lower (33.7% for levels below 0.2 ng/ml and 50% for levels 0.2 to 0.49 ng/ml), despite being better than "older" tracers such as choline based positron emission tomography or computerized tomography/bone scintigraphy. Furthermore, no prostate specific membrane antigen tracer can be currently considered superior to others. Further studies are needed to better define the diagnostic performance and role of these imaging techniques.
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http://dx.doi.org/10.1097/JU.0000000000001369DOI Listing
February 2021

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

Eur J Surg Oncol 2021 05 16;47(5):1179-1186. 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
May 2021
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