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With the advancement of early detection tools for prostate cancer and ability to better localize disease, there has been increased interest in focal or targeted therapies that carry less morbidity than traditional whole-gland treatments. The Sonablate® high-intensity focused ultrasound (HIFU) device has Food and Drug Administration (FDA) 510(K) clearance in the United States for ablation of prostate tissue. HIFU utilizes an ultrasound (US) transducer that focuses US beams on a preset point as much as 4 cm from the energy source without injuring intervening tissue. The Sonablate system guides the surgeon step-by-step to perform effective ablation of a target lesion. The surgeon can assess treatment effect with tissue change monitoring, and care is taken to prevent rectal wall injury. We believe hemiablation is the most favorable focal HIFU treatment to optimize cancer control and minimize the side effects associated with whole gland therapy. We recommend considering HIFU ablation as an extension of active surveillance rather than definitive treatment. Further research on long-term oncologic and functional outcomes is warranted. [ABSTRACT FROM AUTHOR]

Introduction: We sought to update our experience of oncologic and functional outcomes of robot-assisted radical prostatectomy (RARP) for prostate cancer in patients with history of holmium laser enucleation of the prostate (HoLEP). Patients and Methods: Twenty-seven patients with previous HoLEP who underwent RARP were matched 1:1 with RARP patients with no history of transurethral surgery. Demographic, operative, oncologic, continence, and erectile function outcomes were analyzed. Results: Median time between HoLEP and RARP was 31 months with a mean prostate-specific antigen doubling time of 4.28 ng/mL/year. Operative times were significantly longer with higher bladder neck reconstruction rates and similarly low complication rates. Biochemical recurrence was relatively low (7%) in the HoLEP group, identical to the comparative group. Continence at last follow-up was not statistically significant between groups, although time to continence favored the non-HoLEP cohort. Erectile function recovery was generally poor in the post-HoLEP cohort (11%), although bilateral nerve sparing was rarely performed (11%). Compared with our initial experience, there were significant improvements in time to continence (16 vs 36 weeks). No T2 post-HoLEP RARP since 2010 has had a positive surgical margin. Conclusions: Post-HoLEP prostatectomy remains feasible with similar perioperative and oncologic outcomes compared with matched cohorts. Functional recovery remains slowed yet may continue to improve with technical familiarity. [ABSTRACT FROM AUTHOR]

Introduction: Partial nephrectomy (PN) reduces the risk of postoperative chronic renal insufficiency (CRI). However, some patients still develop CRI after PN, and may eventually require dialysis. Being able to predict renal function before PN helps in counseling patients and managing expectations. We aimed to construct nomograms that predict estimated glomerular filtration rates (eGFRs), defined by the modification of diet in renal disease (MDRD) and the chronic kidney disease epidemiology collaboration (CKD-EPI) formulae, at 1 year after PN, using only preoperative covariates as predictors. Patients and Methods: We identified patients who underwent PN in our institution between 2004 and 2016, with known postoperative serum creatinine levels at 1 year. The preoperative covariates included patients' demographics, chronic comorbid conditions, tumor characteristics, and preoperative renal status. The endpoints were eGFRs at 1 year after PN, calculated using the MDRD and the CKD-EPI formulae. We first identified preoperative covariates with significant associations with the endpoints by Pearson correlation and independent samples t-test. Suitable covariates were then included in two multivariate linear regression models, for constructing and internally validating two nomograms. Results: 461 patients were eligible for analysis. The percentage of patients with eGFR below 60 mL/min/1.73 m2 increased from 25% before PN to 35% at 1 year after PN. We included age, gender, African American race, body mass index, preoperative creatinine level, ipsilateral renal volume, solitary kidney status, tumor diameter, hypertension, diabetes, ischemic heart disease, and previous stroke in the multivariate linear regression models for nomogram construction. Internal validation showed bootstrap-corrected coefficients of determination of 0.61 and 0.70, for predicting eGFRs defined by the MDRD and CKD-EPI formulae, respectively. Conclusions: We constructed and internally validated two nomograms to predict eGFRs at 1 year after PN, using only preoperative covariates as predictors. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the impact of obesity on patients developing wound complications within 30 days of open and robotic radical prostatectomy using the National Surgical Quality Improvement Program (NSQIP). Methods: Patients undergoing radical prostatectomy in 2011 to 2012 were identified from NSQIP, which is a multi-institutional database of comprehensive 30-day postoperative outcomes. Wound complication included superficial surgical site infections (SSIs), deep SSI, organ space infections, and dehiscence. Descriptive statistics and multiple logistic regression examined the relationship between obesity and wound complications in open and robotic radical prostatectomy. Results: Of the 12,454 radical prostatectomy cases reported in the study period, 9248 were robotic (74%), 2244 (18%) patients were normal weight (body mass index [BMI] <25), 5836 (47%) were overweight (BMI 25-30), and 4374 (35%) were obese (BMI >30). Wound complications occurred in 134 (4%) of open and 114 (1%) of robotic radical prostatectomies. After adjusting for age, history of smoking, history of diabetes, history of chronic steroid use, and operative time, it was determined that obese patients were at 71% increased odds of developing a wound complication after open prostatectomy (p = 0.034), while there was no difference in the odds of a wound complication after robotic radical prostatectomy (odds ratio 1.14, p = 0.665). Conclusions: Obese patients are at increased risk of developing wound complications when undergoing open vs robotic radical prostatectomy. Obese patients likely benefit from robotic radical prostatectomy whenever feasible. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate outcomes of post-holmium laser enucleation of the prostate (HoLEP) robot-assisted radical prostatectomy (RARP). Patients and Methods: Using an institutional database, we identified 11 HoLEP patients who subsequently underwent RARP. These were matched 1:2 to RARP patients without a previous transurethral surgical procedure. Variables matched were age, pre-RARP prostate-specific antigen level, and biopsy Gleason score. Urinary continence and sexual function were evaluated by physician questioning, American Urological Association symptom score, and Sexual Health in Men (SHIM) scores. Descriptive statistics were used to compare cohorts. Results: RARP pathologic outcomes were similar between cases and controls. Twenty-seven percent of previous HoLEP patients reached strict urinary continence (leak free, pad free) at last follow-up compared with 64% of matched controls ( P=0.071). The average (range) SHIM score at last follow-up was 2.6 (1-5) for previous HoLEP patients compared with 13.9 (5-20) ( P<0.001). The posterior bladder neck and apical dissections were significantly more challenging in the setting of previous HoLEP and necessitated a low threshold for wider resection to minimize positive surgical margins. Conclusions: Post-HoLEP RARP is challenging but preliminarily appears safe and feasible when performed by an experienced robotic surgeon. Patients should be counseled regarding expectations of urinary continence and sexual function in this setting. [ABSTRACT FROM AUTHOR]

Objective: To explore the relationship between operative time, approach, and length of stay (LOS) in partial nephrectomy (PN), radical prostatectomy (RP), and adrenalectomy (AD). Materials and Methods: Using the National Surgical Quality Improvement Program database, we identified all PN, RP, and AD from 2010 to 2012. Non-prostate cancer RP were excluded. The primary outcome was LOS. Descriptive comparisons were drawn between open and minimally invasive surgery (MIS) for each surgery. Multiple linear regression assessed the impact of open versus MIS and operative time on LOS when controlling for confounders. Results: We identified 3760 PN (60% MIS), 12,081 RP (82% MIS), and 1684 AD (76% MIS) cases for inclusion. Differences in operative time were identified. In PN and RP, MIS mean operative time was 10 to 23 minutes longer ( p<0.001 each); while for AD, open was 35 minutes longer ( p<0.001). Open procedures had consistently longer median LOS ( p<0.001 all). Results of the linear regression are given next. Conclusions: Operative time and surgical approach are directly associated with LOS, independent of complications and patient comorbidities. [ABSTRACT FROM AUTHOR]

Pelvic lymphadenectomy for prostate cancer is an important tool in the prognostication of the disease in selected patients who are at risk of occult lymph node metastases. This procedure, usually performed in conjunction with radical prostatectomy, had progressed successfully from an open approach to the current robot-assisted approach. The following article and accompanying video describe the surgical technique of robot-assisted pelvic lymphadenectomy for prostate cancer. We also discuss the indications, patient selection, preparation, complications, and tips to avoid the major pitfalls in the procedure. [ABSTRACT FROM AUTHOR]