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Objective: To investigate and document the surgical, functional and oncological outcomes following surgery for high-risk prostate cancer patients. Patients and methods: Patients with pathological T3a, T3b and N1 disease were extracted from our prospectively updated institutional database. Data include demographics, preoperative cancer parameters, short and long-term complications and functional results. Details of biochemical recurrence, type and oncological outcome of salvage treatments, cancer-specific and overall survival were also obtained. Results: A total of 669 patients were included; 58.9% had T3a disease, 35.9% had pT3b and 11.4% N1 disease. With a median follow-up of 66 months (8–129), overall survival was 94.3%, cancer-specific survival was 98.7% and biochemical recurrence was 45.6%. Average inpatient stay was 1 day and the overall complication rate was 9.1%; 54.2% experienced a biochemical recurrence and 90.3% went on to have one or more salvage treatments, which were varied. Significant predictors of biochemical recurrence included pathological stage, any positive margin and patient age ( PConclusions: Surgery is associated with encouraging surgical and functional outcomes, cancer-specific survival and overall survival rates in these patients. Pathological stage is a significant predictor of biochemical recurrence. The present analysis shows that long-term observation for certain patients with biochemical recurrence is appropriate and questions the effectiveness of further local salvage treatments in patients with an immediate biochemical recurrence postoperatively. Level of evidence: II

Objectives In recent years, there has been rapid adoption of robotically-assisted surgery (RAS) for the treatment of pelvic urological cancers. This is particularly true for radical prostatectomy (RP) where robotically-assisted laparoscopic prostatectomy (RALP) has become the predominant surgical approach across England. Despite this, less than 15% of patients undergoing radical cystectomy (RC) in England in 2014 underwent a robotically-assisted radical cystectomy (RARC). However, as expertise in RAS spreads, an increasing number of cancer centres are now adopting this approach for patients undergoing RC. The current paper describes the implementation phase of a robotically-assisted radical cystectomy (RARC) programme including side-effect profiles and impact on length of stay (LOS). Patients and Methods 114 consecutive patients (82% male) underwent RARC and urinary diversion between April 2013 and December 2015 (ileal conduit (n= 97) and orthotopic neobladder (n=17)). Surgery was performed by two surgeons within a designated regional cancer centre. No exclusion criteria were applied. All patients were managed on the Exeter Enhanced Recovery Pathway (ERP) in a unit where embedded ER practice was already established. Data were collected prospectively on the national cystectomy registry - the British Association of Urological Surgeons (BAUS) Complex Operations Dataset. Results RARC was technically feasible in all but one case. Mean operative time period was 3-5 hours with an overall transfusion rate of 8.8%. Higher-grade complications (Clavien-Dindo grade III-IV) were seen in 18.4% of patients with a 30-day mortality of 0.9%. Median LOS following RARC was 7 days (range 3-68) with a re-admission rate of 18.4%. Conclusions The current series demonstrates that RARC can be safely implemented in a unit experienced in RAS. Case-selection in this setting is not deemed necessary. There are benefits in terms of lower transfusion rates and reduced LOS. The side-effect profile appears to differ from that of ORC and, despite the fact that complication rates are equivalent, ‘technical’ complications are over-represented in the RAS group. As such, they should improve with experience, recognition and modification of surgical technique. ERPs can be safely applied to all patients undergoing RARC to maximize the benefits of minimally-invasive surgery. This article is protected by copyright. All rights reserved.

Background\ud Research has demonstrated the benefits of robotic surgery for the patient; however, research examining the benefits of robotic technology for the surgeon is limited. This study aimed to adopt validated measures of workload, mental effort, and gaze control to assess the benefits of robotic surgery for the surgeon. We predicted that the performance of surgical training tasks on a surgical robot would require lower investments of workload and mental effort, and would be accompanied by superior gaze control and better performance, when compared to conventional laparoscopy.\ud Methods\ud Thirty-two surgeons performed two trials on a ball pick-and-drop task and a rope-threading task on both robotic and laparoscopic systems. Measures of workload (the surgery task load index), mental effort (subjective: rating scale for mental effort and objective: standard deviation of beat-to-beat intervals), gaze control (using a mobile eye movement recorder), and task performance (completion time and number of errors) were recorded.\ud Results\ud As expected, surgeons performed both tasks more quickly and accurately (with fewer errors) on the robotic system. Self-reported measures of workload and mental effort were significantly lower on the robotic system compared to the laparoscopic system. Similarly, an objective cardiovascular measure of mental effort revealed lower investment of mental effort when using the robotic platform relative to the laparoscopic platform. Gaze control distinguished the robotic from the laparoscopic systems, but not in the predicted fashion, with the robotic system associated with poorer (more novice like) gaze control.\ud Conclusions\ud The findings highlight the benefits of robotic technology for surgical operators. Specifically, they suggest that tasks can be performed more proficiently, at a lower workload, and with the investment of less mental effort, this may allow surgeons greater cognitive resources for dealing with other demands such as communication, decision-making, or periods of increased complexity in the operating room.

While the benefits of robotic surgery for the patient have been relatively well established, little is known about the benefits for the surgeon. This study examined whether the advantages of robotically assisted laparoscopy (improved dexterity, a 3-dimensional view, reduction in tremors, etc.) enable the surgeon to better deal with stressful tasks. Subjective and objective (i.e. cardiovascular) responses to stress were assessed while surgeons performed on either a robotic or conventional laparoscopic system. Thirty-two surgeons were assigned to perform a surgical task on either a robotic system or a laparoscopic system, under three stress conditions. The surgeons completed self-report measures of stress before each condition. Furthermore, the surgeons' cardiovascular responses to stress were recorded prior to each condition. Finally, task performance was recorded throughout each condition. While both groups reported experiencing similar levels of stress, compared to the laparoscopic group, the robotic group displayed a more adaptive cardiovascular response to the stress conditions, reflecting a challenge state (i.e. higher blood flow and lower vascular resistance). Furthermore, despite no differences in completion time, the robotic group performed the tasks more accurately than the laparoscopic group across the stress conditions. These results highlight the benefits of using robotic technology during stressful situations. Specifically, the results show that stressful tasks can be performed more accurately with a robotic platform, and that surgeons' car-diovascular responses to stress are more favourable. Importantly, the 'challenge' cardiovascular response to stress displayed when using the robotic system has been associated with more positive long-term health outcomes in domains where stress is commonly experienced (e.g. lower cardiovascular disease risk).

Objective: To evaluate resection and re-resection practice in the South West region of England in patients with newly diagnosed T1 bladder cancer. Patients and methods: All patients diagnosed with T1 disease between 2005 and 2008 were identified. Patients with incomplete primary resections were excluded. Results: Of 344 patients identified, the primary resection specimen did not contain deep muscle in 110 (32%). In total, 76 patients (22%) underwent a planned re-resection within 8 weeks of their primary resection. In 225 patients, a routine check cystoscopy was performed at an interval of 3 months or greater. The remainder had no further cystoscopy. Residual disease was present in 38 (50%) patients undergoing early re-resection and 89 (40%) patients in the routine check cystoscopy group. Upstaging of tumours from T1 to T2 was demonstrated in 7% and 5% of patients within these respective groups. Grade of operating surgeon was not a predictor of adequacy of resection or tumour persistence/recurrence. Conclusions: Primary transurethral resection remains an area for improvement in contemporary practice. Early re-resection should be performed in patients with newly diagnosed T1 bladder cancer unless precluded by co-morbidity to ensure complete resection, accurate staging and facilitate risk stratification. Selective approaches to re-resection risk delayed treatment of significant residual disease.

Technical surgical skills are said to be acquired quicker on a robotic rather than laparoscopic platform. However, research examining this proposition is scarce. Thus, this study aimed to compare the performance and learning curves of novices acquiring skills using a robotic or laparoscopic system, and to examine if any learning advantages were maintained over time and transferred to more difficult and stressful tasks. Forty novice participants were randomly assigned to either a robotic- or laparoscopic-trained group. Following one baseline trial on a ball pick-and-drop task, participants performed 50 learning trials. Participants then completed an immediate retention trial and a transfer trial on a two-instrument rope-threading task. One month later, participants performed a delayed retention trial and a stressful multi-tasking trial. The results revealed that the robotic-trained group completed the ball pick-and-drop task more quickly and accurately than the laparoscopic-trained group across baseline, immediate retention, and delayed retention trials. Furthermore, the robotic-trained group displayed a shorter learning curve for accuracy. The robotic-trained group also performed the more complex rope-threading and stressful multi-tasking transfer trials better. Finally, in the multi-tasking trial, the robotic-trained group made fewer tone counting errors. The results highlight the benefits of using robotic technology for the acquisition of technical surgical skills.

Growth of new blood vessels (angiogenesis), required for all tumor growth, is stimulated by the expression of vascular endothelial growth factor (VEGF). VEGF is up-regulated in all known solid tumors but also in atherosclerosis, diabetic retinopathy, arthritis, and many other conditions. Conventional VEGF isoforms have been universally described as proangiogenic cytokines. Here, we show that an endogenous splice variant, VEGF165b, is expressed as protein in normal cells and tissues and is circulating in human plasma. We also present evidence for a sister family of presumably inhibitory splice variants. Moreover, these isoforms are down-regulated in prostate cancer. We also show that VEGF165b binds VEGF receptor 2 with the same affinity as VEGF165 but does not activate it or stimulate downstream signaling pathways. Moreover, it prevents VEGF165-mediated VEGF receptor 2 phosphorylation and signaling in cultured cells. Furthermore, we show, with two different in vivo angiogenesis models, that VEGF165b is not angiogenic and that it inhibits VEGF165-mediated angiogenesis in rabbit cornea and rat mesentery. Finally, we show that VEGF165b expressing tumors grow significantly more slowly than VEGF165-expressing tumors, indicating that a switch in splicing from VEGF165 to VEGF165b can inhibit tumor growth. These results suggest that regulation of VEGF splicing may be a critical switch from an antiangiogenic to a proangiogenic phenotype.

BACKGROUND AND PURPOSE Because of the increased use of robot-assisted laparoscopic prostatectomy (RALP) for the management of localized prostate cancer, surgeons in training face the issues of developing skills in both open surgery and the robotic console. This study compares prospectively the safety and efficacy of the first 50 open radical retropubic prostatectomy (RRP) procedures and the first 50 RALP procedures, performed by the same surgeon in the same institution. PATIENTS AND METHODS The patients' baseline demographic, clinical, and oncologic parameters were prospectively recorded. The study end points included oncologic outcome, functional outcomes (at 3 months), and perioperative parameters. Complications were classified according to the modified Clavien system. RESULTS No statistically significant differences were noted between the two groups in terms of preoperative patient characteristics and oncologic parameters. The operative time and mean estimated blood loss were lower in the RALP group (P