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To compare perioperative, oncological and functional outcomes of robotic partial nephrectomy (RPN) versus cryoablation in elderly patients (75 years old), accounting for patient's and tumor's related factors.Retrospective institutional review of 312 consecutive elderly patients (75 years old) who underwent RPN or cryoablation for renal mass (June 2006-December 2016). Demographic, perioperative, functional, and oncological data were evaluated. Sixty-five patients who underwent RPN were propensity-score matched 1:1 to 65 who underwent cryoablation (matching was based on demographics, renal function, comorbidities and tumor characteristics). Perioperative outcomes were compared. Survival analysis was performed to estimate overall (OS), recurrence-free (RFS) and cancer-specific survival (CSS) by Kaplan-Meier method. A linear mixed effect model (LME) estimated the effect of follow-up on estimated glomerular filtration rate (eGFR).After matching, the variables were well balanced with no differences at baseline between groups. Shorter operative time and lower blood losses favored cryoablation (140 vs. 200 min, P0.0001 and 100 vs. 195 ml, P = 0.0002, respectively). Overall complications rate was higher for RPN (31% vs. 9%; P = 0.007), but no difference was found in major (Clavien III-IV) complications (6% vs. 1.5%, P = 0.2). At a median follow-up of 37 (29-44) and 46 (38-53) months for RPN and cryoablation, no significant differences were found in CSS (100% vs. 95%, P = 0.3) and OS (80% vs. 75%, P = 0.2) but RFS was higher for RPN (100% vs. 83%, RPN vs. cryoablation, respectively, P = 0.02). eGFR was comparable between the groups at every time point analyzed.Although with a higher rate of recurrences, our data confirm cryoablation as a lower morbidity profile treatment option for small renal masses in the elderly population, with cancer-specific survival comparable to surgery.

Objective To compare outcomes of laparoscopic radical prostatectomy (LRP) performed in live surgery versus daily routine LRP. Methods From January 2014 to June 2017, data from LRP performed at our Institution in live broadcasting by 3 experienced laparoscopic surgeons during educational events were collected. A 1:2 matching (according to BMI, comorbidities, NCCN risk groups, and operating surgeon) was performed with the routine LRP patients collected in our prospectively-maintained database. Chosen procedures were performed within the same time span by the same surgeons. Data of interest were compared. Results Twenty-three live surgery LRPs were analyzed (Group A). Forty-six matched patients were the controls (Group B). Groups were comparable at baseline. No differences were found in perioperative data (operative time, blood loss, and intraoperative complications, 4.3% in both Groups) and postoperative complications. Particularly, 10 (43.5%) and 22 patients (47.8%) did not report complications (Group A vs B, respectively, P = .54). The majority of complications were Clavien 1-2, with 2 patients per Group requiring blood transfusion. Overall positive surgical margins rate was 26.1%. It was significantly higher in Group A (43.5% vs 17.4%; P = .02), but no differences were found in the number of patients who relapsed, who needed radiotherapy or androgen deprivation therapy within a median follow-up of 25 months in both Groups. No differences were found regarding functional data. Limitations include a low sample size and limited follow-up. Conclusion LRP has similar perioperative outcomes when performed in either live surgery or daily routine setting. We underline the higher positive surgical margins rate after live surgeries that should increase the awareness before embarking on it.

Objective To compare perioperative and oncological outcomes of intracorporeal (ICUD) vs extracorporeal urinary diversion (ECUD) after robot-assisted radical cystectomy (RARC). Methods From January 2014 to December 2017, data of consecutive patients who underwent RARC performed by 2 institutional surgeons were prospectively collected in a dedicated database (IRB: 251647). Patients were divided in 2 groups according to the operating surgeon, one performing ECUD, the other ICUD. Groups were compared in perioperative outcomes and Clavien complications (during admission, within 30- and 90-days postoperatively). Univariable and multivariable analyses tested the impact of variables of interest on the occurrence of complications at the different time points. Kaplan-Meier method was used to estimate recurrence and metastasis-free survivals. Results Sixty to 66 patients underwent RARC with ileal conduit ICUD and ECUD, respectively. ICUD patients were younger (69 vs 73 years old, P = .009). No differences were found in other baseline characteristics and final pathology. Regarding perioperative outcomes, shorter operative time favored ECUD (7 vs 6 hours, P = .0004). Specifically, no differences were found in postoperative complications while admitted, either overall (ICUD: 16 [26.7%] vs ECUD: 23 [34.8%] patients, P = .3) or major (ICUD: 10 [16.7%] vs ECUD: 14 [21.2%], P = .6); same was for reassessment within 30- and 90-days postoperatively. At multivariable analysis, Charlson's Comorbidity Index ≥3 and blood losses >600 mL predicted complications during the admission (P = .02). Male gender, higher body mass index, and ureteral involvement predicted 30-days complications (P = .04). No differences in oncological outcomes. Conclusion At head-to-head comparison of 2 expert surgeons, ICUD and ECUD for ileal conduit had comparable perioperative outcomes.

OBJECTIVE To describe the step-by-step technique for robotic intracorporeal ileal conduit urinary diversion (ICUD) following radical cystectomy performed by using the novel da Vinci SP surgical system (Intuitive Surgical, Sunnyvale, CA). METHODS Four consecutive patients (2 males and 2 females) were initially counseled for robotic cystectomy with ICUD performed by using the da Vinci SP surgical system. Surgeries were performed by duplicating the steps of the institutional approach for intracorporeal ICUD performed with the multiarms robotic platform. Perioperative outcomes were analyzed. Data were collected under institutional review board approval (IRB 13-780). RESULTS Single-port robot-assisted radical cystectomy with ICUD was successfully completed in 3 patients (2 males and 1 female). Mean robotic operative time for ICUD was 75 minutes (range 67-90). There was no conversion to standard multiarms robotic approach. One patient needed to be converted to extracorporeal urinary diversion due to severe adhesions of small bowels. No additional ports were placed. Neither transfusions nor intraoperative complications occurred. All patients were discharged on postoperative day 5. One patient reported self-limited nausea and vomiting after discharge (Clavien grade I). CONCLUSION In our preliminary experience, ICUD after robot-assisted radical cystectomy is feasible using the da Vinci SP surgical system. Further comparative studies with open and multiarms robotic approaches are warranted.

Objectives To describe step-by-step the port placement and the robot docking of the new purpose-built robotic platform for R-LESS. The feasibility of different approaches to the pelvic fossa and the retroperitoneum was reported in cadaver models. Methods This was a preclinical study on human cadavers to assess the feasibility of the da Vinci SP1098 surgical system for R-LESS pelvic fossa and retroperitoneal urological surgeries. We used the SP1098 to perform R-LESS prostatectomies and cystoprostatectomies with transperineal and transvesical approaches, and nephrectomies (radical or partial) with retroperitoneal approach. The primary outcome was to report the port placement and docking. The technical feasibility of the procedures was then demonstrated as measured by the need for adjunctive ports or the occurrence of intraoperative complications. Operative times were recorded. Results A total of 14 procedures were performed on 12 human cadavers. Namely 4 prostatectomies and 2 cystoprostatectomies with transperineal approach, 3 transvesical prostatectomies, 1 retroperitoneal radical, and 4 retroperitoneal partial nephrectomies. Operative times were in line with those of standard multiport robotic surgery. Neither additional ports nor percutaneous instruments were required. No intraoperative complications occurred. Limitations include the preclinical model, the small sample size, and the lack of a control group. Conclusion In this preclinical model, the port placement and robot docking using the SP1098 robotic platform is reproducible and feasible for pelvic fossa and retroperitoneal urological surgeries.

A standardized histologic definition and classification of the patterns of renal tumor pseudocapsular invasion (RTPI) in renal cell carcinoma (RCC) is not available. We classified RTPI into 2 main histologic patterns: expansive and infiltrative RTPI. Patients with organ-confined RCC and infiltrative RTPI had a greater risk of cancer-specific death and might require stricter postoperative surveillance strategies.A standardized histologic definition and classification of patterns of renal tumor pseudocapsular invasion (RTPI) in renal cell carcinoma (RCC) is not available. The aim of the present study was to propose a classification of RTPI patterns and assess their correlation with other pathologic features and prognosis.The renal tumor pseudocapsule was assessed by 2 expert genitourinary pathologists on the histologic slides of 190 specimens from radical nephrectomy performed for organ-confined (pT1-pT2) RCC. The histologic patterns of RTPI were classified and described. The association between the RTPI patterns and other pathologic features was assessed. The Kaplan-Meier method was used to calculate the survival functions, and Cox regression models were used to assess the predictors of cancer-specific survival.RTPI was classified into 2 main histologic patterns (expansive and infiltrative). Expansive and infiltrative RTPI was observed in 39.5% and 51.6% of cases, respectively. A significant association between the RTPI pattern and Fuhrman grade (P = .006) and RCC histologic subtype (P = .034) was detected. Patients with infiltrative pseudocapsular invasion had significantly poorer 5- and 10-year cancer-specific survival rates than patients with expansive invasion or no invasion (93.6% vs. 98.9% and 84.9% vs. 93%, respectively; P = .039). The presence of infiltrative pseudocapsular invasion was a significant predictor of cancer-specific survival (hazard ratio 4.38, 95% confidence interval 1.04-20.27).An expansive and an infiltrative RTPI pattern can be described. In our study, patients with organ-confined RCC and an infiltrative RTPI pattern had a greater risk of cancer-specific death and might require stricter postoperative surveillance strategies.

BACKGROUND: The purpose of this study was to evaluate the predictors of positive margins in one of the largest available prospective multi-institutional studies. PATIENTS AND METHODS: We evaluated all patients who underwent NSS for radiologically diagnosed kidney tumors between January 2009 and December 2012 at 19 urological Italian centers (Registry of Conservative Renal Surgery [RECORd] project). Preoperative and anthropometric data, comorbidities, intraoperative and postoperative outcomes, and histological findings were analyzed. The negative and PSMs were compared according to the clinical and surgical variables. Multivariable logistic regression models were applied to analyze predictors of PSMs. RESULTS: Eight hundred consecutive patients were evaluated. Seven hundred sixty-one (95.1%) and 39 patients (4.9%) achieved negative and PSMs, respectively. Patients with PSMs were significantly older compared with those with negative margins (median age: 66.6 vs. 61.8 years, respectively; P = .001). A higher incidence of PSMs was observed when NSS was performed for renal masses located in the upper pole (P = .001). A lower rate of PSMs was found in patients treated with simple enucleation rather than standard PN (1.6% vs. 7.4%, respectively; P < .0001). A greater incidence of PSMs was found in Fuhrman 3/4 tumors (11.3%; P < .0001). At multivariable analysis, age (odds ratio [OR], 1.04; P = .01), upper pole tumor location (OR, 2.85; P = .005), standard PN (OR, 3.45; P = .004), and Fuhrman 3-4 nuclear grade (OR, 4.81; P = .001) were found to be independent predictors of PSMs. CONCLUSION: In our multi-institutional report, young age, simple enucleation, middle or lower tumor location, and low-grade tumor were demonstrated to be independent predictors of negative SMs.