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INTRODUCTION AND OBJECTIVE:Pelvic lymphadenectomy (PLN) during Retzius-Sparing Robotic-Assisted Radical Prostatectomy (RS-RARP) may be challenging because the medial umbilical ligaments are not rel...

PURPOSE: We explore and validate objective surgeon performance metrics using a novel recorder (“dVLogger”) to directly capture surgeon manipulations on the da Vinci Surgical System. We present the initial construct and concurrent validation study of objective metrics during preselected steps of robot-assisted radical prostatectomy. MATERIALS AND METHODS: Kinematic and events data were recorded for expert (100 or more cases) and novice (less than 100 cases) surgeons performing bladder mobilization, seminal vesicle dissection, anterior vesicourethral anastomosis and right pelvic lymphadenectomy. Expert/novice metrics were compared using mixed effect statistical modeling (construct validation). Expert reviewers blindly rated seminal vesicle dissection and anterior vesicourethral anastomosis using GEARS (Global Evaluative Assessment of Robotic Skills). Intraclass correlation measured inter-rater variability. Objective metrics were correlated to corresponding GEARS metrics using Spearman’s test (concurrent validation). RESULTS: The performance of 10 experts (mean 810 cases, range 100 to 2,000) and 10 novices (mean 35 cases, range 5 to 80) was evaluated in 100 robot-assisted radical prostatectomy cases. For construct validation the experts completed operative steps faster (p

INTRODUCTION AND OBJECTIVES: Body mass index (BMI) has been associated to outcomes in several solid malignancies. We aimed to evaluate the association between BMI and oncological outcomes in patients treated with radical cystectomy (RC) for muscleinvasive urothelial carcinoma of the bladder (UCB). METHODS: We retrospectively reviewed 701 consecutive patients treated with RC and pelvic lymphadenectomy for UCB at our institution between 1990 and 2012. Univariable and multivariable cox regression models investigated the association of BMI with disease recurrence, cancer-specific mortality and overall mortality. BMI was analyzed as both continuous and categorical variable (

INTRODUCTION AND OBJECTIVES: We describe the first retropubic suburethral autologous sling created and placed during robotic radical prostatectomy (RARP). Surgical technique and preliminary data regarding its effectiveness in improving early urinary continence (UC) recovery are presented. METHODS: Between November 2013 and February 2014 a cohort of 60 continents and neurologically healthy patients affected by localized prostate cancer and submitted to RARP at single highvolume center were prospectively randomized into sling and non-sling group. Sling technique was performed in the following steps: 1) at the beginning of right pelvic lymphadenectomy, vas deferens was isolated and removed 2) on scrub nurse table the vas deferens specimen was shaped in a 5-cm section and inserted at the middle of 14cm absorbable double end wire 3) the autologous sling obtained was positioned before the time of bladder-urethral anastomosis, immediately below the plane of the reconstructed recto-uretralis muscle and fixed to the periosteum of the pubic branch bilaterally 4) after completion of the vesico-urethral anastomosis, the sling was anchored definitively pulling further and fixing its wire ends in order to give the wanted urethral support. Early UC recovery was assessed at 5 (catheter removal), 10 and 30 days postoperatively through the record of the daily number of pads used and the collection of International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF). Chisquare test and Indipendent Sample T-test were used to investigate UC recovery between the two groups. RESULTS: Complete data collection was available for 60/60 (100%) patients. Mean SD age was 63 9.0 years. Mean SD number of pads daily used in non sling and sling group were at 5 days 1.9 1.2 vs 1.7 1.4 (p1⁄40.5); at 10 days 1.8 1.3 vs 1.3 1.3 (p1⁄40.1) and at 30 days 1.1 1.2 vs 0.4 0.8 (p1⁄40.01) respectively. At 1 month mean SD ICIQ-UI-SF score was 1.8 3.4 vs 4.8 4.6 (p1⁄40.01) in sling and nonsling group; moreover sling patients were found to be associated with a pad-free status ( 2: 4.7; p1⁄40.03). CONCLUSIONS: Our initial experience indicates that new designed suburethral autologous sling is technically feasible and may represent a reliable intraoperative solution in order to improve early UC recovery in patients undergoing RARP. Because the improvement in the percentage of UC recovery at one month post-operatively and the absence of surgical complications this technique has become standard in our department.

INTRODUCTION AND OBJECTIVES: Despite optimal imaging, occult lymph node (LN) metastases are found in 25% of patients with muscle invasive bladder cancer (MIBC) undergoing radical cystectomy (RC). These patients are at high risk for subsequent disease recurrence and death. Better prediction of LN metastases is warranted to improve patient management. METHODS: Transcriptome expression profiles of 199 RC samples were generated using a 1.4 million feature Human Exon microarray. All patients underwent RC and extended pelvic LN dissection (1998-2004) at the University of Southern California. The patient cohort was divided into a discovery set (n1⁄4133) and a validation set (n1⁄466). In the discovery set, features were identified using a Wilcoxon test and modeled into a K-nearest neighbor (KNN) classifier for LN metastases prediction. Two additional gene signatures, the 15 gene cancer recurrence signature (Mitra2014) and 20 gene LN signature (Smith2011) were also modeled in the discovery set for comparison. Area under the curve (AUC) and odds ratios (OR) were used to compare the performance of these signatures in the validation set. RESULTS: The KNN51 model was developed from 133 radical cystectomy patients to predict LN metastases. In the validation set, this model achieved an AUC of 0.82 [0.71 e 0.93] for predicting LN positive patients, significantly outperforming Mitra2014 and Smith2011 which had AUCs of 0.62 [0.47 e 0.76] and 0.46 [0.32 e 0.60], respectively. Only KNN51hadsignificantodds for predictingLNmetastasiswith anORof2.65 [1.68 4.67] for every 10% increase in score (p1⁄4 0.0002). Both Mitra2011 and Smith2011 were not found to have significant odds ratios of 1.21 [0.97 e 1.54, p 1⁄4 0.09] and 1.39 [0.52 e 3.77, p 1⁄4 0.5], respectively. CONCLUSIONS: The integrated expression of 51 genes in primary MIBC was successfully used to predict LN metastases and was superior to previously described gene signatures. If validated in TURBT samples, KNN51 could be used to guide the extent of pelvic LN dissection and to direct high risk patients towards treatment intensification, for example with neoadjuvant chemotherapy.

Purpose: We postulate that the number of lymph nodes examined in cystectomy specimens can have an impact on the outcome of patients with bladder cancer. Materials and Methods: We analyzed data on 322 patients with muscle invasive bladder cancer who underwent radical cystectomy and bilateral pelvic lymphadenectomy. We evaluated the associations of the number of lymph nodes identified by the pathologist in the surgical specimen with the local recurrence rate and survival outcome. Results: Patients were divided into groups by lymph node status and the distribution of the number of lymph nodes examined. In stages pN 0 and pN + cases improved survival was associated with a greater number of lymph nodes examined. We determined that at least nine lymph nodes should be studied to define lymph node status accurately. Conclusions: These results indicate that surgical resection and pathological assessment of an adequate number of lymph nodes in cystectomy specimens increases the likelihood of proper staging and impacts patient outcome. Such information is important not only for the therapy and prognosis of individuals, but also for identifying those who may benefit from adjuvant chemotherapy.

patients with non-metastatic muscle invasive urothelial carcinoma (UC) of the bladder treated with radical cystectomy (RC). METHODS: We retrospectively analyzed data of 1400 patients collected in two prospectively-maintained institutional databases between 2001 and 2010. Standard PLND (s-PLND) had the upper boundary at the iliac bifurcation while extended PLND (e-PLND) included the presacral and the common iliac nodes. Patients who met inclusion criteria (non-metastatic high-grade UC, not undergone neoadjuvant treatments, patients receiving e-PLND or s-PLND) were included in analysis. Univariable and multivariable Cox regression analyses was performed to identify independent predictors of DFS and CSS and, subsequently, the effect of e-PLND on DFS and CSS after stratifying according to pathological Tumor (pT) and Nodal (pN) stage was determined with a multivariable Cox analysis. RESULTS: In 971 patients who met inclusion criteria, significant predictors of DFS and CSS (p 0.05) were age, pT, pN, number of nodes removed and extent of PLND at univariable analysis and pT, pN and extent of PLND at multivariable analysis (all p 0.001). At multivariable analysis, the benefit of an e-PLND on DFS and CSS was significant across all pT stages (all p 0.05) and across all pN stages (pN 0: p 0.011 and p 0.034 for DFS and CSS, respectively; pN1 and pN2: both p 0.001). Table 1. CONCLUSIONS: The staging accuracy and the survival benefit provided by e-PLND suggest to consider this template as the standard procedure for muscle-invasive UC treated with RC.

Laparoscopic pelvic lymph node dissection is currently an accepted procedure for staging adenocarcinoma of the prostate. To assess the feasibility and efficacy of performing laparoscopic pelvic lymph node dissection and radical perineal prostatectomy during the same anesthesia, we retrospectively analyzed 98 patients with clinically localized adenocarcinoma of the prostate who were candidates for radical prostatectomy. Of the patients 12 (12%) underwent laparoscopic pelvic lymph node dissection only since they had metastatic disease to the pelvic lymph nodes on frozen section evaluation (the Gleason pathological grade was 2 to 4 in 2 patients, 5 to 7 in 8 and 8 in 2). Of the remaining 86 patients who underwent radical perineal prostatectomy for definitive management 76 (88%) underwent 1-stage radical perineal prostatectomy immediately after laparoscopic pelvic lymph node dissection, while 10 (12%) in the initial stages of our series underwent delayed perineal prostatectomy following laparoscopic p...

We attempt to clarify the impact of the learning curve on the first 30 laparoscopic pelvic lymphadenectomies performed at our institute. Open surgical revision of the area of laparoscopic dissection was performed at radical retropubic prostatectomy. The mean number of obturator and iliac lymph nodes removed laparoscopically was 8.7 and 8.8 from the right and left sides, respectively. The mean number of residual obturator and iliac lymph nodes removed at open operation was 3.2 and 3 from the right and left sides, respectively. The amount of residual lymph node tissue after laparoscopic lymphadenectomy progressively decreased with time, especially after the first 20 cases. A microscopic pelvic lymph node metastasis was found at open operation in patients 6, 14 and 15, who had false-negative results at laparoscopy. Due to the learning curve effect, the first 30 patients who undergo laparoscopic pelvic lymphadenectomy should be assessed again by an open operation at radical retropubic prostatectomy.

We compared the nodal yield and volume of target tissue removed in 3 groups of patients undergoing laparoscopic pelvic lymphadenectomy as a staging procedure for carcinoma of the prostate. With the exception of the type of peritoneotomy used to expose the obturator fossa, surgical management of all patients was identical. Results were evaluated in patients undergoing linear peritoneotomy (40), inverted V peritoneotomy (14) or both procedures (28, 1 approach on each side). Significantly more tissue was removed from patients in the inverted V group (16.3 +/- 8.3 cm.3) compared to the linear peritoneotomy group (7.2 +/- 5.7 cm.3, p = 0.004). This resulted in a significant increase in nodal yield in patients in the inverted V group (11.0 +/- 4.1) relative to the linear peritoneotomy group (6.8 +/- 5.2, p = 0.003). In terms of the volume of tissue removed and the number of nodes obtained, combination patients had values intermediate to those in the other groups (11.6 +/- 10.5 cm.3 and 8.8 +/- 5.6 nodes, respectively). The right-to-left ratio of nodes and tissue volume was reversed in the combination group relative to the other 2 groups. Operative time was significantly decreased for the inverted V technique compared to the linear peritoneotomy approach (p = 0.01). No difference in operative blood loss of complications was identified. The improved exposure obtained with this technique appears to result in a more complete lymphadenectomy without increased risk of complications.

From 1966 to 1979, 360 patients with clinical stages A2, B and C1 prostate cancer underwent staging pelvic lymphadenectomy, and completed a course of combined interstitial radioactive gold seeds and external beam radiotherapy. All patients had a normal serum prostatic acid phosphatase level and a bone scan negative for metastases. All patients were followed until death or for a mean of 7.3 years (range 1.2 to 18.25 years) for those alive at analysis. To determine the risk of dying of prostate cancer we reviewed the records of the 142 patients (39%) who died. At analysis 21% of the patients had died of prostate cancer and 17% of other known causes. The cause of death could not be determined in 4 patients (1%). Cardiovascular disease accounted for a fifth of all deaths. The actuarial risk of death of prostate cancer for all patients was 8 +/- 3% (+/- 2 standard errors) at 5 years and 30 +/- 7% at 10 years. The risk of death of all causes was 16 +/- 4% at 5 years and 46 +/- 7% at 10 years. An increased risk of cancer death was associated with established risk factors, including advanced local disease, poorly differentiated histology, pelvic nodal metastases and distant recurrence. We also noted a substantial risk of cancer death in patients who had local tumor recurrence. While previous studies have reported a relatively low incidence of cancer deaths (4 to 17%) in patients initially diagnosed with localized disease, our data suggest that prostate cancer is the major cause of mortality in such patients. Aggressive curative therapy, regardless of treatment modality, should be considered for localized prostate cancer in men with a life expectancy of 10 or more years.

As laparoscopic techniques develop, endoscopic lymph node dissection is becoming preferred as the minimally invasive technique for lymph node staging of pelvic malignancies. We developed an extraperitoneal laparoscopic approach to staging pelvic lymphadenectomy, and describe our technique, results and experience in our initial 9 patients.

The operative morbidity and convalescence of our initial 30 patients who underwent laparoscopic pelvic lymph node dissections were compared to those of 16 patients who underwent open surgical pelvic lymph node dissections performed at our institution for staging purposes between 1990 and 1992. The average time for laparoscopic pelvic lymph node dissection (199.4 minutes) was nearly twice that of surgical pelvic lymph node dissection (102.4 minutes). However, the blood loss in the former group was significantly less. Oral intake occurred after a mean of 0.63 days in the laparoscopic pelvic lymph node dissection group compared to 2.87 days in the surgical group. Also, laparoscopic pelvic lymph node dissection was superior to surgical pelvic lymph node dissection in terms of average postoperative analgesic use (1.55 versus 47 mg. morphine sulfate), average hospital stay (1.7 versus 5.37 days), average return to normal daily activities (4.94 versus 42.9 days) and interval to full recovery (10.8 versus 65.5 days). However, the incidence of significant complications in the laparoscopic pelvic lymph node dissection group was 13%, with no complications seen in the surgical group. Interestingly, all significant problems in the bilateral laparoscopic pelvic lymph node dissection patients were confined to our initial 12 patients, indicating the steepness of the laparoscopic learning curve.

When performing a laparoscopic pelvic lymph node dissection, the tissue specimen may be too large to remove intact through the laparoscopic trocar. An organ entrapment system has been developed that allows en bloc retrieval of nodal tissue via an 11mm. trocar site. This system facilitates tissue removal, and minimizes the risk of tissue loss and possible peritoneal or wound contamination.

The relationship of grade and local tumor extent to pelvic nodal involvement was assessed surgically in 469 patients who underwent pelvic lymphadenectomy and radical retropubic prostatectomy for adenocarcinoma of the prostate. Grade and local stage alone and combined score were associated in a linear fashion with nodal involvement. Gleason sum and Mayo grade alone were not predictive of nodal metastases. Some patients with a Gleason score of 4 had positive nodes and some with a score of 8 to 10 had negative nodes. Mayo sum (grade plus stage) consistently was related to negative nodal involvement.

The operative, postoperative and late complications experienced by 300 consecutive patients who underwent 125iodine implantation and pelvic lymphadenectomy for localized prostatic cancer were analyzed. Of the patients reviewed 68 per cent had clinical stage B lesions, while 32 per cent had clinical stage C lesions. The incidence of intraoperative complications was 6 per cent. There were 2 postoperative deaths and 23 per cent of the patients had postoperative complications. Of 177 patients followed postoperatively for 6 months or more (mean 29.3 months) late morbidity was experienced by 49 (28 per cent). The incidence of impotence in 109 patients who were potent preoperatively and who were followed for a minimum of 15 months was 7 per cent.

Interstitial implantation with the 125iodine isotope has been used as definitive treatment in 115 patients with localized carcinoma of the prostate. The disease was staged surgically by bilateral pelvic lymphadenectomy in all of the patients. Followup has been for a minimum of 1 year and 64 patients have been followed for a minimum of 5 years. There has been no operative mortality in this series. Mean patient age at implantation was 63 years. Potency has been maintained in 31 of 46 patients (78 per cent) followed for a minimum of 5 years and 15 of 26 (58 per cent) followed for a minimum of 7 years. At 5 years the actuarial survival free of disease by surgical stage was 100, 81, 49 and 41 per cent for patients with stages A2, B, C and D1 disease, respectively. All 7 patients with stage B1 nodules followed to 5 years are free of disease. The actuarial survival free of disease by grade at 5 years was 95 per cent for patients with well, 65 per cent with moderately and 34 per cent with poorly differentiated tumors. Local failure was defined as palpable evidence of prostatic enlargement or irregularity with biopsy confirmation of neoplasm. Patients with positive biopsy plus normal or stable prostatic examinations were not considered local failures, although such patients are at high risk for failure in the future. The actuarial probability of local failure at 5 years was 0, 13, 27 and 44 per cent for patients with surgical stages A2, B, C and D1 disease, respectively, and 5, 23 and 43 per cent for those with well, moderately and poorly differentiated tumors, respectively. Based on our experience, interstitial implantation with 125iodine isotope is reserved for patients with well or moderately differentiated stage B lesions. The ultimate success of this treatment modality awaits 10 and 15 years of followup.