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Objective: To compare the perioperative outcomes of intracorporeal (ICUD) vs extracorporeal urinary diversion (ECUD) after robot-assisted radical cystectomy (RARC)., Patients and Methods: We retrospectively reviewed the prospectively maintained International Robotic Cystectomy Consortium (IRCC) database. A total of 972 patients from 28 institutions who underwent RARC were included. Propensity score matching was used to match patients based on age, gender, body mass index (BMI), American Society of Anesthesiologists Score (ASA) score, Charlson Comorbidity Index (CCI) score, prior radiation and abdominal surgery, receipt of neoadjuvant chemotherapy, and clinical staging. Matched cohorts were compared. Multivariate stepwise logistic and linear regression models were fit to evaluate variables associated with receiving ICUD, operating time, 90-day high-grade complications (Clavien-Dindo Classification Grade ≥III), and 90-day readmissions after RARC., Results: Utilisation of ICUD increased from 0% in 2005 to 95% in 2018. The ICUD patients had more overall complications (66% vs 58%, P = 0.01) and readmissions (27% vs 17%, P = 0.01), but not high-grade complications (21% vs 24%, P = 0.22). A more recent RC era and ileal conduit diversion were associated with receiving an ICUD. Higher BMI, ASA score ≥3, and receiving a neobladder were associated with longer operating times. Shorter operating time was associated with male gender, older age, ICUD, and centres with a larger annual average RC volume. Longer intensive care unit stay was associated with 90-day high-grade complications. Higher CCI score, prior radiation therapy, neoadjuvant chemotherapy, and ICUD were associated with a higher risk of 90-day readmissions., Conclusions: Utilisation of ICUD has increased over the past decade. ICUD was associated with more overall complications and readmissions compared to ECUD, but not high-grade complications., (© 2020 The Authors BJU International © 2020 BJU International Published by John Wiley & Sons Ltd.)

Objectives: To design a methodology to predict operative times for robot-assisted radical cystectomy (RARC) based on variation in institutional, patient, and disease characteristics to help in operating room scheduling and quality control., Patients and Methods: The model included preoperative variables and therefore can be used for prediction of surgical times: institutional volume, age, gender, body mass index, American Society of Anesthesiologists score, history of prior surgery and radiation, clinical stage, neoadjuvant chemotherapy, type, technique of diversion, and the extent of lymph node dissection. A conditional inference tree method was used to fit a binary decision tree predicting operative time. Permutation tests were performed to determine the variables having the strongest association with surgical time. The data were split at the value of this variable resulting in the largest difference in means for the surgical time across the split. This process was repeated recursively on the resultant data sets until the permutation tests showed no significant association with operative time., Results: In all, 2 134 procedures were included. The variable most strongly associated with surgical time was type of diversion, with ileal conduits being 70 min shorter (P < 0.001). Amongst patients who received neobladders, the type of lymph node dissection was also strongly associated with surgical time. Amongst ileal conduit patients, institutional surgeon volume (>66 RARCs) was important, with those with a higher volume being 55 min shorter (P < 0.001). The regression tree output was in the form of box plots that show the median and ranges of surgical times according to the patient, disease, and institutional characteristics., Conclusion: We developed a method to estimate operative times for RARC based on patient, disease, and institutional metrics that can help operating room scheduling for RARC., (© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

Objective: To describe a detailed step-by-step approach of our technique for robot-assisted intracorporeal 'W'-configuration orthotopic ileal neobladder., Patients and Methods: Five patients underwent robot-assisted radical cystectomy (RARC), extended pelvic lymph node dissection and intracorporeal neobladder (ICNB). ICNB was divided into six key steps to facilitate and enable a detailed analysis and auditing of the technique. No conversion to open surgery was required. Timing for each step was noted. All patients had at least 3 months of follow-up., Results: The mean age was 57 years. The mean overall console and diversion times were 357 and 193 min, respectively. None of the patients had any evidence of residual disease after RARC. Four of the five patients had complications; three developed fevers due to urinary tract infections (one required readmission), and one developed myocardial infarction and required coronary angiography and stenting. Looking at the timing for the individual steps, bowel detubularisation and construction of the posterior plate were consistently the longest among the key steps (average 46 min, 13% of the overall operative time), followed by uretero-ileal anastomosis (37 min, 10%), neobladder-urethral anastomosis (23 min, 6%), and identification and fixation of the bowel (26 min, 7%)., Conclusion: We described our step-by-step technique and initial perioperative outcomes of our first five ICNBs with 'W' configuration., (© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

Objective: To identify which high-risk patients with prostate cancer may harbour favourable pathological outcomes at radical prostatectomy (RP)., Patients and Methods: We evaluated 810 patients with high-risk prostate cancer, defined as having one or more of the following: PSA level of >20 ng/mL, Gleason score ≥8, clinical stage ≥T2c. Patients underwent robot-assisted RP (RARP) with pelvic lymph node dissection, between 2003 and 2012, in one centre. Only 1.6% (13/810) of patients received any adjuvant treatment. Favourable pathological outcome was defined as specimen-confined disease (SCD; pT2-T3a, node negative, and negative surgical margins) at RARP-specimen. Logistic regression models were used to test the relationship among all available predicators and harbouring SCD. A logistic regression coefficient-based nomogram was constructed and internally validated using 200 bootstrap resamples. Kaplan-Meier method estimated biochemical recurrence (BCR)-free and cancer-specific mortality (CSM)-free survival rates, after stratification according to pathological disease status., Results: Overall, 55.2% patients harboured SCD at RARP. At multivariable analysis, PSA level, clinical stage, primary/secondary Gleason scores, and maximum percentage tumour quartiles were all independent predictors of SCD (all P < 0.04). A nomogram based on these variables showed 76% discrimination accuracy in predicting SCD, and very favourable calibration characteristics. Patients with SCD had significantly higher 8-year BCR- (72.7% vs 31.7%, P < 0.001) and CSM-free survival rates (100% vs 86.9%, P < 0.001) than patients with non-SCD., Conclusions: We developed a novel nomogram predicting SCD at RARP. Patients with SCD achieved favourable long-term BCR- and CSM-free survival rates after RARP. The nomogram may be used to support clinical decision-making, and aid in selection of patients with high-risk prostate cancer most likely to benefit from RARP., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

Objective: To validate robot-assisted surgery skills acquisition using an augmented reality (AR)-based module for urethrovesical anastomosis (UVA)., Methods: Participants at three institutions were randomised to a Hands-on Surgical Training (HoST) technology group or a control group. The HoST group was given procedure-based training for UVA within the haptic-enabled AR-based HoST environment. The control group did not receive any training. After completing the task, the control group was offered to cross over to the HoST group (cross-over group). A questionnaire administered after HoST determined the feasibility and acceptability of the technology. Performance of UVA using an inanimate model on the daVinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) was assessed using a UVA evaluation score and a Global Evaluative Assessment of Robotic Skills (GEARS) score. Participants completed the National Aeronautics and Space Administration Task Load Index (NASA TLX) questionnaire for cognitive assessment, as outcome measures. A Wilcoxon rank-sum test was used to compare outcomes among the groups (HoST group vs control group and control group vs cross-over group)., Results: A total of 52 individuals participated in the study. UVA evaluation scores showed significant differences in needle driving (3.0 vs 2.3; P = 0.042), needle positioning (3.0 vs 2.4; P = 0.033) and suture placement (3.4 vs 2.6; P = 0.014) in the HoST vs the control group. The HoST group obtained significantly higher scores (14.4 vs 11.9; P 0.012) on the GEARS. The NASA TLX indicated lower temporal demand and effort in the HoST group (5.9 vs 9.3; P = 0.001 and 5.8 vs 11.9; P = 0.035, respectively). In all, 70% of participants found that HoST was similar to the real surgical procedure, and 75% believed that HoST could improve confidence for carrying out the real intervention., Conclusion: Training in UVA in an AR environment improves technical skill acquisition with minimal cognitive demand., (© 2014 The Authors. BJU International © 2014 BJU International.)

Objective: To investigate the utility of cognitive assessment during robot-assisted surgery (RAS) to define skills in terms of cognitive engagement, mental workload, and mental state; while objectively differentiating between novice and expert surgeons., Subjects and Methods: In all, 10 surgeons with varying operative experience were assigned to beginner (BG), combined competent and proficient (CPG), and expert (EG) groups based on the Dreyfus model. The participants performed tasks for basic, intermediate and advanced skills on the da Vinci Surgical System. Participant performance was assessed using both tool-based and cognitive metrics., Results: Tool-based metrics showed significant differences between the BG vs CPG and the BG vs EG, in basic skills. While performing intermediate skills, there were significant differences only on the instrument-to-instrument collisions between the BG vs CPG (2.0 vs 0.2, P = 0.028), and the BG vs EG (2.0 vs 0.1, P = 0.018). There were no significant differences between the CPG and EG for both basic and intermediate skills. However, using cognitive metrics, there were significant differences between all groups for the basic and intermediate skills. In advanced skills, there were no significant differences between the CPG and the EG except time (1116 vs 599.6 s), using tool-based metrics. However, cognitive metrics revealed significant differences between both groups., Conclusion: Cognitive assessment of surgeons may aid in defining levels of expertise performing complex surgical tasks once competence is achieved. Cognitive assessment may be used as an adjunct to the traditional methods for skill assessment during RAS., (© 2014 The Authors. BJU International © 2014 BJU International.)

Objective: To describe a novel method of achieving pelvic hypothermia during robot-assisted radical prostatectomy (RARP) and a modification of technique allowing immediate organ retrieval for intraoperative examination and targeted frozen-section biopsies., Patients and Methods: Intracorporeal cooling and extraction (ICE) consists of a modification of the standard RARP technique with the use of the GelPOINT™ (Applied Medical, Rancho Santa Margarita, CA, USA), a hand access platform, which allows for delivery of ice-slush and rapid specimen extraction without compromising pneumoperitoneum., Results: The ICE technique reproducibly achieves a temperature of 15 °C in the pelvic cavity with no obvious body temperature change. Adopting this technique during RARP, there was an absolute risk reduction by 26.6% in positive surgical margin rate in patients with pT3a disease when compared with similar patients undergoing conventional RARP (P = 0.04)., Conclusions: The ICE technique eliminates the potential handicap of decreased tactile sensation for oncological margins, especially in the high-risk patients. This technique allows the surgeon to immediately examine the surgical specimen after resection, and with the aid of frozen-section pathology determine if further resection is required. A prospective trial is underway in our centre to evaluate the effects of this novel technique on postoperative outcomes., (© 2013 The Authors. BJU International © 2013 BJU International.)

Objective: To evaluate oncological outcomes in patients undergoing robot-assisted radical prostatectomy (RARP) at a high-volume tertiary centre with focus on biochemical recurrence (BCR); previous studies on oncological outcomes for patients undergoing RARP for prostate cancer are limited to small series., Patients and Methods: In all, 5152 consecutive patients underwent RARP from 2001 to 2010; 4803 patients comprised the study cohort after exclusions. BCR was defined as a serum prostate-specific antigen (PSA) level of ≥0.2 ng/mL with a confirmatory value. BCR-free survival (BCRFS), metastasis-free survival (MFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method and Cox hazards regression models were generated., Results: The mean preoperative PSA level was 6.1 ng/mL, pathological Gleason grade and stage were ≥7 in 68% and ≥pT3 in 34% of patients. There was BCR in 470 patients (9.8%), 31 patients developed metastatic disease (0.7%) and 13 patients died from prostate cancer (0.3%) during a mean (range) follow-up of 34.6 (1-116.7) months. Actuarial 8-year BCRFS, MFS and CSS were 81%, 98.5% and 99.1%, respectively. In patients with node-positive disease, actuarial 5-year BCRFS, MFS, and CSS were 26%, 82%, and 97%. For organ-confined disease, predictors of BCR included pathology Gleason grade (primary Gleason 5 vs 3, hazard ratio [HR] 5.52, P = 0.018; Gleason 4 vs 3, HR 1.97, P = 0.001), preoperative PSA level (10-20 vs ≤10 ng/mL, HR 2.38, P = 0.001), and surgical margin status (positive vs negative, HR 3.84, P < 0.001) CONCLUSIONS: RARP appears to confer effective long-term biochemical control. To our knowledge, this is the largest report of oncological outcomes in a RARP series to date., (© 2013 The Authors. BJU International © 2013 BJU International.)

Objective: To characterise the surgical feasibility and outcomes of robot-assisted radical cystectomy (RARC) for pathological T4 bladder cancer., Patients and Methods: Retrospective evaluation of a prospectively maintained International Radical Cystectomy Consortium database was conducted for 1118 patients who underwent RARC between 2003 and 2012. We dichotomised patients based on pathological stage (≤pT3 vs pT4) and evaluated demographic, operative and pathological variables in relation to morbidity and mortality., Results: In all, 1000 ≤pT3 and 118 pT4 patients were evaluated. The pT4 patients were older than the ≤pT3 patients (P = 0.001). The median operating time and blood loss were 386 min and 350 mL vs 396 min and 350 mL for p T4 and ≤pT3, respectively. The complication rate was similar (54% vs 58%; P = 0.64) among ≤pT3 and pT4 patients, respectively. The overall 30- and 90-day mortality rate was 0.4% and 1.8% vs 4.2% and 8.5% for ≤pT3 vs pT4 patients (P < 0.001), respectively. The body mass index (BMI), American Society of Anesthesiology score, length of hospital stay (LOS) >10 days, and 90-day readmission were significantly associated with complications in pT4 patients. Meanwhile, BMI, LOS >10 days, grade 3-5 complications, 90-day readmission, smoking, previous abdominal surgery and neoadjuvant chemotherapy were significantly associated with mortality in pT4 patients. On multivariate analysis, BMI was an independent predictor of complications in pT4 patients, but not for mortality., Conclusions: RARC for pT4 bladder cancer is surgically feasible but entails significant morbidity and mortality. BMI was independent predictor of complications in pT4 patients., (© 2013 The Authors. BJU International © 2013 BJU International.)

Objective: To describe our technique of maintaining bladder drainage after robot-assisted radical prostatectomy (RARP) using a percutaneous suprapubic tube (PST) in place of a urethral catheter., Methods: A watertight anastomosis permits placement of the PST. Contraindications include morbid obesity, concomitant inguinal hernia mesh repair, anticoagulation therapy, limited hand dexterity in the patient, bladder neck reconstruction and extensive adhesiolysis at RARP. The necessary equipment includes a 14-F PST balloon catheter set, a three-way connector, a connecting tube, a suture passer, 1/0 polypropylene sutures on a CT1 needle, a sterile plastic button, adhesive and steri-strips., Results: The important steps for PST placement are: Step 1: robot-assisted placement of a bladder wall anchor suture; Step 2: transferring the bladder wall suture to anterior abdominal skin; Step 3: guided placement of the PST under robotic vision; Step 4: securing the PST within the bladder and abdominal wall; Step 5. postoperative care: clamping the PST on postoperative day 5, recording each void and post-void residual urine volumes in a patient diary, removal of the PST on postoperative day 7 after 48 h of voiding with residual urine <100 mL per void., Conclusion: We provide a concise step-by-step guide for placement of a PST during RARP as well as important management aspects for the successful adoption of this technique., (© 2013 The Authors. BJU International © 2013 BJU International.)

Objective: To determine trends in demographics and treatment for inpatient upper urinary tract calculi in the USA using a population-based cohort., Patients and Methods: All patients with a primary or secondary diagnosis of kidney or ureteric calculus between 1999 and 2009 in the US Nationwide Inpatient Sample were extracted and weighted. Temporal trend analyses were used to determine trends in gender, race and age presentation, as well as utilization rates of interventions. Temporal trends were quantified using the estimated annual percent change (EAPC) using least squares linear regression analysis., Results: Overall, 2 109 455 patients were hospitalized with upper urinary tract calculi over the 11-year period. The majority of admissions were for ureteric calculi (63.4%). Admissions for renal calculus increased by 12.1% during the study period (EAPC + 0.92%, P = 0.039, 95% CI: 0.17-1.66), whilst discharges for ureteric calculus remained stable. A significant increase (25.4%) in hospitalizations for women was found (EAPC + 2.21%, P < 0.001, 95% CI: 1.40-3.03); by 2006, more women than men were admitted to hospital (95 953 vs. 94 556, respectively). There were significant increases in hospitalization for black, Hispanic and older patients. Significant changes in the use of all studied interventions were found except for ureteroscopy, extracorporeal shockwave lithotripsy and nephrectomy., Conclusions: In this nationally representative sample of inpatient discharges, significant increases were found in admissions for renal compared with ureteric calculi, and for black, Hispanic and older patients. With regard to surgical intervention, the largest increase was found in the use of procedures for kidney calculi. Women now comprise the majority in the inpatient management of stone disease., (© 2013 BJU International.)

Unlabelled: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Lymph node dissection and it's extend during robot-assisted radical cystectomy varies based on surgeon related factors. This study reports outcomes of robot-assisted extended lymphadenectomy based on surgeon experience in both academic and private practice settings., Objective: To evaluate the incidence of, and predictors for, extended lymph node dissection (LND) in patients undergoing robot-assisted radical cystectomy (RARC) for bladder cancer, as extended LND is critical for the treatment of bladder cancer but the role of minimally invasive surgery for extended LND has not been well-defined in a multi-institutional setting., Patients and Methods: Used the International Robotic Cystectomy Consortium (IRCC) database. In all, 765 patients who underwent RARC at 17 institutions from 2003 to 2010 were evaluated for receipt of extended LND. Patients were stratified by age, sex, clinical stage, institutional volume, sequential case number, and surgeon volume. Logistic regression analyses were used to correlate variables to the likelihood of undergoing extended LND., Results: In all, 445 (58%) patients underwent extended LND. Among all patients, a median (range) of 18 (0-74) LNs were examined. High-volume institutions (≥100 cases) had a higher mean LN yield (23 vs 15, P < 0.001). On univariable analysis, surgeon volume, institutional volume, and sequential case number were associated with likelihood of undergoing extended LND. On multivariable analysis, surgeon volume [odds ratio (OR) 3.46, 95% confidence interval (CI) 2.37-5.06, P < 0.001] and institution volume [OR 2.65, 95% CI 1.47-4.78, P = 0.001) were associated with undergoing extended LND., Conclusions: Robot-assisted LND can achieve similar LN yields to those of open LND after RC. High-volume surgeons are more likely to perform extended LND, reflecting a correlation between their growing experience and increased comfort with advanced vascular dissection., (© 2013 BJU International.)

Unlabelled: Study Type - Prognosis (cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Married individuals have lower morbidity and mortality rates for all major causes of death. Cancer-specific survival is better in married patients with testis cancer, prostate cancer, breast cancer, cervical cancer, as well as head and neck cancers. We have found the effect of marital status on outcomes after radical cystectomy to be variable, depending on gender and the outcome addressed. Being married is predictive of lower all-cause mortality for both men and women relative to their separated, divorced or widowed (SDW) or never-married counterparts. It is also predictive of lower bladder-cancer-specific mortality relative to SDW individuals. Marriage also exerts a protective effect on men regarding non-organ-confined disease, with those never having married having significantly higher rates., Objectives: • To examine the effect of marital status (MS) on the rate of non-organ-confined disease (NOCD) at radical cystectomy (RC) • To assess the effect of MS on the rate of bladder-cancer-specific mortality (BCSM) and all-cause mortality (ACM) after RC for urothelial carcinoma of the urinary bladder (UCUB)., Materials and Methods: • A total of 14 859 patients, who underwent RC for UCUB, were captured within the Surveillance, Epidemiology, and End Results database, between 1988 and 2006. • Logistic regression analysis was used to assess the rate of NOCD (T(3-4) /N(I-3) /M(0) ) at RC and Cox regression analyses were used to assess BCSM and ACM. • Analyses were stratified according to gender; covariates included socio-economic status, tumour stage, age, race, tumour grade and year of surgery., Results: • Never-married males had a higher rate of NOCD at RC (odds ratio = 1.22, P= 0.004), an effect not found in never-married females. • Separated, divorced or widowed (SDW) males (hazard ratio [HR]= 1.18, P= 0.005) and females (HR = 1.16, P= 0.002) had higher rates of BCSM than their married counterparts. • SDW and never-married males had higher rates of ACM than their married counterparts (HR = 1.22, P < 0.001 and HR = 1.26, P < 0.001, respectively). • SDW and never-married females also had higher rates of ACM than married females (HR = 1.24, P < 0.001 and HR = 1.22, P= 0.01, respectively)., Conclusions: • For both men and women, being SDW conveyed an increased risk of BCSM after RC. • SDW and never marrying had a deleterious effect on ACM. • Unfavourable stage at RC was also seen more commonly in never-married males., (© 2012 BJU INTERNATIONAL.)

Unlabelled: Nodal metastases, even in the absence of distant metastases, portend a bad prognosis. The percentage of positive nodes (PPN) represents an important predictor of cancer-specific mortality (CSM) in patients in the group T(any) N(1) M(0) . In consequence, universal inclusion of PPN should be considered in prospective and retrospective CSM analyses., Objectives: To examine the outcomes of patients with node-positive renal cell carcinoma (RCC) in the absence of distant metastases in a large population-based cohort of patients To examine the ability of standard risk factors to predict cancer-specific mortality (CSM)., Patients and Methods: Using the Surveillance, Epidemiology, and End Results database, a total of 799 patients with RCC nodal metastases and absence of distant metastases undergoing nephrectomy were identified. Univariable and multivariable analyses was performed with the aim of identifying independent predictors of CSM in this cohort of patients. Specifically, we examined the effect of the number of removed nodes (NRN), the number of positive nodes (NPN) and the percentage of positive nodes (PPN) on CSM., Results: Actuarial survival estimates showed that 53.2, 37.8 and 25.7% of patients survived at 24, 60 and 120 months after nephrectomy. In Kaplan-Meier analyses, NRN failed to clearly discriminate between recorded CSM rates (log rank P = 0.07). Discrimination was noted when CSM was stratified according to NPN (log rank P = 0.02) and PPN (log rank P = 0.001). In multivariable analyses, age, Fuhrman grade, histological subtype, T stage and PPN were independent predictors of CSM., Conclusions: Our data indicate that CSM of patients with exclusive nodal metastases differs according to PPN. Consequently, PPN warrants consideration in future prognostic schemes., (© 2011 BJU INTERNATIONAL.)

Unlabelled: Study Type--Therapy (case series). Level of Evidence 4. What's known on the subject? And what does the study add? Adverse outcomes after radical prostatectomy are more often recorded in the elderly. In the USA, elderly patients undergoing radical prostatectomy are treated at institutions where suboptimal outcomes are recorded., Objective: • To assess the rate of adverse outcomes after open radical prostatectomy (ORP) in the elderly and to examine the effect of annual hospital caseload (AHC) and academic institutional status on adverse outcomes in these of patients., Patients and Methods: • Within the Health Care Utilization Project Nationwide Inpatient Sample, we focused on ORPs performed between 1998 and 2007. Subsequently, we restricted to patients aged ≥75 years. • In both datasets, we examined transfusion rates, intra-operative and postoperative complication rates, and in-hospital mortality rates. • Stratification was performed according to AHC tertiles and academic status. • Multivariable logistic regression analyses were fitted., Results: • Of 115,554 ORP patients, 2109 (1.8%) were aged ≥75 years. • In multivariable analyses performed in the entire cohort, elderly age increased homologous blood transfusion rates (P < 0.001), intra-operative (P= 0.001) and postoperative (P < 0.001) complication rates, and the mortality rate (P= 0.007). • Most elderly were treated at low or intermediate AHC (68.5%) and non-academic centres (56.2%). • Within the elderly cohort, intra-operative (2.9%) and postoperative (22.2%) complications tended to be highest at low AHC institutions compared to institutions of intermediate (2.7% and 17.4%) and high AHC (1.7% and 14.5%). Similarly, intra-operative (2.7% vs 2.1%) and postoperative complications (19.1% vs 13.9%) tended to be higher at non-academic than academic centres. • In multivariable analyses performed in the elderly subgroup, low AHC predicted higher intra-operative complications and higher homologous transfusions, whereas non-academic status predicted higher postoperative complications., Conclusions: • Adverse outcomes are more often recorded in the elderly. • Most elderly are treated at institutions where suboptimal outcomes are recorded., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Objective: • To assess the content validity of an early prototype robotic simulator. Minimally invasive surgery poses challenges for training future surgeons. The Robotic Surgical Simulator (RoSS) is a novel virtual reality simulator for the da Vinci Surgical System., Patients and Methods: • Participants attending the 2010 International Robotic Urology Symposium were invited to experience RoSS. Afterwards, participants completed a survey regarding the appropriateness of the simulator as a teaching tool., Results: • Forty-two subjects including surgeons experienced with robotics (n= 31) and novices (n= 11) participated in this study. • Eighty per cent of the entire cohort had an average of 4 years of experience with robot-assisted surgery. • Eleven (26%) novices lacked independent robot-assisted experience. The expert group comprised 17 (41%) surgeons averaging 881 (160-2200) robot-assisted cases. Experts rated the 'clutch control' virtual simulation task as a good (71%) or excellent (29%) teaching tool. • Seventy-eight per cent rated the 'ball place' task as good or excellent but 22% rated it as poor. • Twenty-seven per cent rated the 'needle removal' task as an excellent teaching tool, 60% rated it good and 13% rated it poor. • Ninety-one per cent rated the 'fourth arm tissue removal' task as good or excellent. • Ninety-four per cent responded that RoSS would be useful for training purposes. • Eighty-eight per cent felt that RoSS would be an appropriate training and testing format before operating room experience for residents. • Seventy-nine per cent indicated that RoSS could be used for privileging or certifying in robotic surgery., Conclusion: • Results based on expert evaluation of RoSS as a teaching modality illustrate that RoSS has appropriate content validity., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Objective: To evaluate the oncological outcomes of patients with specimen Gleason 8 and 9 prostate cancers and to determine factors that predict biochemical recurrence-free survival (BCRFS) after robot-assisted radical prostatectomy (RARP)., Patients and Methods: Of 4156 patients who underwent RARP from January 2001 to 2009, we identified 368 men with Gleason 8 or 9 tumours who met the inclusion criteria. BCR was defined as a PSA level of ≥0.2 ng/mL with a second rising value. The Kaplan-Meier method and log-rank test were used to compare BCRFS while factors that predict BCRFS were determined by Cox proportional hazards modelling., Results: The median age and PSA level were 62 years and 6.4 ng/mL for men with Gleason 8, and 63 years and 6.7 ng/mL for Gleason 9 cancers. The median (interquartile range, IQR) overall follow-up was 23 (10-46) months and 19 (7-37) months for Gleason 8 and 9 tumours, respectively. At 60 months the mean (se) overall BCRFS was 36 (5)% and for Gleason 8 it was 47 (6)% and for Gleason 9 it was 21 (7)% (P < 0.001). At 5 years, extraprostatic extension (pT3a) resulted in BCRFS of 52 (9)% for Gleason 8 tumours and 21 (11)% for Gleason 9 (P= 0.012). On multivariable analysis, lymph node invasion, specimen Gleason score, pathological stage and tumour volume predicted BCRFS., Conclusions: Early results suggest RARP monotherapy performs comparably to RP for BCRFS in men with high-grade prostate cancer. There are significant oncological differences between Gleason 8 and 9 tumours., (© 2010 HENRY FORD HOSPITAL HEALTH SYSTEM. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL.)

Objective: To evaluate the initial results of salvage robotic-assisted radical prostatectomy (SRARP) after recurrence following primary radiotherapy (RT) for localized prostate cancer., Patients and Methods: Between December 2002 and January 2008, 11 patients had SRARP with pelvic lymph node dissection by one surgeon from one institution. Six patients had brachytherapy, three had external beam RT (EBRT), one intensity-modulated RT, and one received brachytherapy with an EBRT boost. All patients had prostate cancer on biopsy after RT, with negative computed tomography and bone scan. The mean (range) follow-up was 20.5 (1-77) months., Results: The mean interval from RT to SRARP was 53.2 months; the mean preoperative prostate-specific antigen (PSA) level was 5.2 ng/mL, the operative duration 183 min and the estimated blood loss 113 mL. One patient had prolonged lymphatic drainage, one had an anastomotic leak, and one had an anastomotic stricture requiring direct vision internal urethrotomy at 3 months. The mean duration of catheterization was 10.4 days and the hospital stay 1.4 days. Three patients had a biochemical recurrence, at 1, 2 and 43 months. In one of two patients with node-positive carcinoma of the prostate the PSA level failed to reach a nadir of zero after surgery. In patients with a minimum follow-up of 2 months, eight of 10 are continent (defined as zero to one pad per day) and two have erections adequate for intercourse with the use of phosphodiesterase-5 inhibitors., Conclusion: SRARP after RT-resistant disease recurrence is feasible with minimal perioperative morbidity. Early functional outcomes appear to be at least equivalent with historical salvage RP series. Robotic extended pelvic lymph node dissection is safe and can improve the accuracy of surgical staging. A longer follow-up is necessary to better assess the functional and oncological outcomes.