24 results on '"Moschovas, M."'
Search Results
2. If not now, then when? The need for new evidence in the robotic management of upper tract urothelial carcinoma.
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DI Maida F, Bravi CA, DE Groote R, Piramide F, Turri F, Wenzel M, Sharma G, Würnschimmel C, Andras I, Lambert E, Dell'oglio P, Covas Moschovas M, Campi R, Liakos N, Grosso AA, Montorsi F, Briganti A, Mottrie A, Minervini A, and Larcher A
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- Humans, Ureteral Neoplasms surgery, Lymph Node Excision methods, Robotic Surgical Procedures methods, Carcinoma, Transitional Cell surgery, Carcinoma, Transitional Cell pathology, Kidney Neoplasms surgery, Kidney Neoplasms pathology, Nephroureterectomy methods
- Abstract
Current guidelines recommend radical nephroureterectomy with bladder cuff excision as the standard surgical treatment for high-risk upper tract urothelial carcinoma (UTUC). While large evidence is available regarding open and laparoscopic nephroureterectomy, data focusing on robotic nephroureterectomy (RNU) in UTUC are mostly limited with mixed results, especially in locally advanced disease. In light of the recent introduction of new robotic platforms, it is of utmost importance to further investigate oncologic outcomes associated with RNU. Moreover, stronger data exploring different operative settings (i.e. robotic arms and trocars placement) for the new robotic systems are eagerly warranted. To give an answer to such open clinical questions, the Junior ERUS/Young Academic Urologist Working Group on Robot-assisted Surgery designed a multicentric project involving different high-volume centers across the world. The aim of the study will be exploring surgical and oncologic outcomes of RNU, specifically focusing on several clinical unmet needs, such as best operative setting for new robotic platforms, lymph node dissection (LDN) template and robotic bladder cuff management.
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- 2024
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3. How to tailor renorrhaphy technique during robot-assisted partial nephrectomy.
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DI Maida F, Bravi CA, Piramide F, Dell'oglio P, DE Groote R, Andras I, Turri F, Covas Moschovas M, Paciotti M, Grosso AA, Minervini A, and Larcher A
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- Humans, Kidney Neoplasms surgery, Kidney surgery, Nephrectomy methods, Robotic Surgical Procedures methods, Suture Techniques
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- 2024
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4. Impact of human placental derivative allografts on functional and oncological outcomes after radical prostatectomy: a literature review.
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Noël J, Ahmed S, Mascarenhas A, Stirt D, Moschovas M, Patel E, Reddy S, Bhat S, Rogers T, and Patel V
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- Pregnancy, Male, Humans, Female, Prostate surgery, Quality of Life, Placenta, Prostatectomy, Allografts, Treatment Outcome, Robotic Surgical Procedures methods, Prostatic Neoplasms surgery, Erectile Dysfunction
- Abstract
Post radical prostatectomy (RP) erectile dysfunction and incontinence impacts quality of life for patients. In an objective to hasten the recovery of these functional outcomes, human placental derived allografts laid on neurovascular bundles (NVB) have been investigated. These grafts include amniotic membranes (AM) chorionic membranes (CM) or umbilical cord (UC) allografts. A literature review performed using the MeSH terms "AMNION" OR "CHORION" OR "AMNIOTIC MEMBRANE" OR "UMBILICAL CORD" AND "PROSTATE CANCER" from no specified start date, to April 2022. 163 articles were retrieved, with 149 articles excluded. 14 articles were eligible and analysed. 5 articles were included in this review for an analysis on comparative outcomes. The average return to potency was statistically significant in the intervention groups. Positive surgical margin (PSM) rates showed a higher rate in the control groups. BCR was observed at a lower rate in the interventional group. This review reveals a benefit from human placental allograft's ability to hasten post RP functional recovery, without impacting oncological control., (© 2022. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)
- Published
- 2023
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5. A systematic review and meta-analysis of robot-assisted vs. open radical cystectomy: where do we stand and future perspective.
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Fallara G, Di Maida F, Bravi CA, De Groote R, Piramide F, Turri F, Andras I, Moschovas M, Larcher A, Breda A, and Dell'oglio P
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- Humans, Cystectomy adverse effects, Prospective Studies, Quality of Life, Treatment Outcome, Postoperative Complications etiology, Robotics, Robotic Surgical Procedures adverse effects, Urinary Bladder Neoplasms pathology
- Abstract
Introduction: Radical cystectomy represents the standard of care for localized muscle invasive or high-grade non-muscle invasive BCG unresponsive bladder cancer. Several randomized control trials have been published comparing open (ORC) with robot-assisted radical cystectomy (RARC). We aimed to summarize evidence in this setting with a systematic review and meta-analysis., Evidence Acquisition: All published randomized prospective trials that compared ORC with RARC were retrieved through a systematic search according to PRISMA guidelines. Outcomes investigated were the risks of overall complications, high grade (Clavien-Dindo ≥3) complications, positive surgical margins, the number of lymph nodes removed, estimated blood loss, operative time, length of hospital stay, quality of life, overall survival (OS) and progression-free survival. A random effect model was applied. Subgroup analysis on the basis of the urinary diversion was also performed., Evidence Synthesis: Seven trials enrolling 974 patients were included. No differences in terms of major oncological and perioperative outcomes between RARC and ORC were observed. However, length of hospital stay was significantly shorter (MD -0.95; 95%CI -1.32, -0.58) and estimated blood loss lower (MD -296.66; 95%CI -462.59, -130.73) for RARC. Operative time was overall shorter for ORC (MD 89.52; 95%CI 55.88, 123.16), however no difference emerged between ORC and RARC with intracorporeal urinary diversion., Conclusions: Despite several limitations due to heterogeneity and possible unaddressed confounding in included trials, we concluded that ORC and RARC represent equally valid options for the surgical treatment of patients with advanced bladder cancer.
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- 2023
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6. Nerve spare robot assisted laparoscopic prostatectomy with amniotic membranes: medium term outcomes.
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Noël J, Mascarenhas A, Patel E, Reddy S, Sandri M, Bhat S, Moschovas M, Rogers T, Ahmed S, Stirt D, and Patel V
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- Amnion transplantation, Humans, Male, Middle Aged, Prostatectomy adverse effects, Treatment Outcome, Laparoscopy, Prostatic Neoplasms pathology, Robotic Surgical Procedures methods, Robotics
- Abstract
Introduction: dHACM is a source of factors including cytokines that allow anti-inflammatory and proliferative elements to be utilized for wound and ulcer management. We present our experience of using dHACM in a cohort of patients undergoing nerve-sparing (NS) robot-assisted laparoscopic prostatectomy (RALP). Our objective is to investigate the functional and oncological outcomes of NS after placing amniotic or dehydrated human amnion/chorion membrane (dHACM) on preserved neurovascular bundles (NVBs). From 2013 to 2019, our institution performed transperitoneal multi-port da Vinci robotic prostatectomy. The NVBs are spared by releasing their fascial planes posteriorly, followed by an anterior release of the plane at a similar level. Once the retrograde release of the NVB is performed then 599 patients underwent placement of dHACM graft (AmnioFix by MiMedx, Marietta, GA, USA). The graft was cut into two 4 × 1 cm pieces and laid over the NVB as a wrap. In order to inform the urological community of oncological and functional outcomes, we excluded patients with less than 12 months follow up (n = 64), benign prostatic hyperplasia (n = 5), and unilateral NS (n = 1). 529 (88%) patients were included in this study who underwent a partial or full bilateral NS with dHACM. 529 patients were followed-up for a median (IQR) of 42 months (25-89). Demographics include median (IQR) age 57 years (52-62), median preoperative SHIM score of 24 (21-15), and AUASS of 5 (2-11). Full NS was performed in 74% (391/529). Pathological staging was pT2 = 399 (75%), pT3a = 107 (20%), pT3b = 19 (4%) and pT4 = 4 (1%) with N1 = 3 (0.6%). The number of patients with PSM was 86 (16%), and the overall BCR in the entire cohort was 10%. Postoperatively, 434 (82%) were sexually active. Median time to potency was 119 (37-420) days and time to continence was 42 (23-91) days. Regarding full vs partial NS: median post op SHIM score 18 (13-20) vs 15 (6-20), median time to potency 92 (35-365) days vs 184 (42-560) days, and median time to continence 42 (23-91) days vs 44 (30-92) days. Age > 55 vs ≤ 55 years: median post op SHIM score 18 (12-20) vs 15 (10-20), median time to potency 167 days (42-549) vs 80 (35-288) days, and median time to continence 42 (25-116) days vs 42 (29-76) days. In our series the application of amniotic membrane/dHACM has led to acceptable post RALP outcomes. The BCR rate of 10% in addition to the recovery of potency at a median time of 3 months and continence at 6 weeks is an encouraging result of dHACM. Our findings indicate that dHACM allowed for an even faster period for continence recovery which was independent of grade of NS. Future comparative studies may further assess the impact of new amniotic membrane types on the functional and oncological outcomes after RALP., (© 2022. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)
- Published
- 2022
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7. Outcomes of Salvage Robot-assisted Radical Prostatectomy After Focal Ablation for Prostate Cancer in Comparison to Primary Robot-assisted Radical Prostatectomy: A Matched Analysis.
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Bhat KRS, Covas Moschovas M, Sandri M, Noel J, Reddy S, Perera R, Rogers T, Roof S, and Patel VR
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- Male, Humans, Prostate surgery, Prostate pathology, Prostate-Specific Antigen, Retrospective Studies, Prostatectomy methods, Robotics, Robotic Surgical Procedures methods, Prostatic Neoplasms surgery, Prostatic Neoplasms pathology
- Abstract
Background: Focal therapy (FT) for prostate cancer is less invasive than radical treatment but carries a risk of recurrence. Salvage robot-assisted radical prostatectomy (S-RARP) is a possible option after FT failure., Objective: To evaluate the impact of FT on functional and oncological outcomes following S-RARP., Design, Setting, and Participants: In a retrospective analysis of data from a prospectively collected institutional database, 53 patients who underwent S-RARP following failure of focal ablation were selected as group I; patients who had whole-gland ablation and external beam therapy were excluded. This group was matched to a control sample (matched at ratios of 1:1, 1:2, 1:3, 1:4) of men who had undergone primary RARP, using age, prostate-specific antigen (PSA), PSA density, body mass index, Sexual Health Inventory for Men score, American Urological Association symptom score, Charlson comorbidity index, prostate weight, preoperative Gleason score (GS), and history of smoking as variables., Surgical Procedure: S-RARP after FT was performed using a standardized technique developed at our institute with the da Vinci Xi Surgical System., Measurements: Oncological and functional outcomes were compared between the S-RARP and primary RARP groups., Results and Limitations: There was no difference in estimated blood loss (p = 0.8) between the 1:1 matched groups, but operating room time was significantly longer for S-RARP (p = 0.007). The primary RARP group had a higher proportion of patients who underwent a full nerve-sparing procedure. The S-RARP group had higher incidence of positive surgical margins (40% vs 15%; p = 0.008), GS ≥8 (25% vs 15%; p = 0.07), and positive lymph node status (9.4% vs 5.7%; p = 0.02). There was no significant difference in overall complications between the groups. The primary RARP group had a higher incidence of lymphocele drainage after surgery (15% vs 0%; p = 0.006). The main limitation of the study is its retrospective design., Conclusions: S-RALP after FT failure is feasible; however, surgery following FT leads to poorer oncological and functional outcomes. Despite the targeted nature of FT, significant nonfocal collateral damage is evident in tissues surrounding the prostate, which in turn translates to poorer functional outcomes after S-RARP., Patient Summary: We studied the surgical challenges during robot-assisted removal of the prostate after previous focal treatment (FT) for prostate cancer and compared the outcomes to those for robot-assisted prostate removal in patients who had no previous FT. We found that this technique is safe and effective with a limited risk of complications, but poor urinary and sexual functional outcomes., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)
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- 2022
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8. Same-Day Discharge Protocol for Robot-Assisted Radical Prostatectomy: Experience of a High-Volume Referral Center.
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Reddy SS, Noël J, Covas Moschovas M, Bhat S, Perera R, Rogers T, Stirt D, Doss J, Jenson C, Andrich J, and Patel VR
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- Dizziness complications, Humans, Male, Nausea complications, Pain etiology, Patient Discharge, Postoperative Complications etiology, Prostatectomy methods, Referral and Consultation, COVID-19, Robotic Surgical Procedures methods, Robotics
- Abstract
Objective: As the coronavirus disease 2019 (COVID-19) global pandemic continues, there is increased value in performing same-day discharge (SDD) protocols to minimize viral exposure and maintain the appropriate surgical treatment for oncologic patients. In this scenario, we performed a prospective analysis of outcomes of our patients undergoing SDD protocol after robot-assisted radical prostatectomy (RARP). Materials and Methods: The SDD criteria included patients with no intraoperative complications, stable postoperative hemoglobin levels (compared with preoperative values), stable vital signs, normal urine output, ambulation with assistance and independently without dizziness, tolerance of clear liquids without nausea or vomiting, pain control with oral medication, and patient/family confidence with SDD. Patients older than 70 years, concomitant general surgery operations, multiple comorbidities, and complex procedures such as salvage surgery were excluded from our protocol. Results: Of the 101 patients who met the criteria for SDD, 73 (72%) had an effective SDD. All SDF (same day discharge failure) patients were discharged one day after surgery. Intraoperative characteristics were not statistically different with a median operative time of 92 (81-107) vs 103 (91-111) minutes for SDD and SDF, respectively. Of the 28 SDF patients, the most common reasons for staying were anesthesia-related factors of nausea (35%), drowsiness (7%), patient/caregiver preference (25%), pain (14%), labile blood pressure (7%), arrhythmia (7%), and dizziness (7%). There was no significant difference in readmission rates, complication rates, or postoperative pain scores between SDD and SDF patients. Conclusions: In our experience, SDD for patients undergoing RARP can be safely and feasibly incorporated into a clinical care pathway without increasing readmission rates. We were effective in 72% of cases because of coordinated care between anesthetics, nursing staff, and appropriate patient selection. We also believe that incorporating pre- and postoperative patient education and assurance is crucial to minimize their exposure to COVID-19 during the surgical treatment for prostate cancer.
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- 2022
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9. Implementing the da Vinci SP Without Increasing Positive Surgical Margins: Experience and Pathologic Outcomes of a Prostate Cancer Referral Center.
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Covas Moschovas M, Kind S, Bhat S, Noel J, Sandri M, Rogers T, Moser D, Brady I, and Patel V
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- Aged, Humans, Male, Margins of Excision, Middle Aged, Prostatectomy methods, Referral and Consultation, Retrospective Studies, Prostatic Neoplasms pathology, Prostatic Neoplasms surgery, Robotic Surgical Procedures methods
- Abstract
Background: Different consoles have been described for the da Vinci single-port (SP) surgery since it was cleared by the FDA in November 2018. However, the literature still lacks studies identifying factors related to the SP learning curve and how to overcome the technological limitations, especially in terms of maintaining acceptable positive surgical margins (PSMs). This study describes our perioperative experience implementing a safe SP approach to radical prostatectomy (RP) while minimizing PSM, especially during the initial learning period. Materials and Methods: We performed a retrospective analysis of 100 consecutive patients with prostate cancer who underwent RP with the SP robot from June 2019 to December 2020 (IRB 237998). We accessed the perioperative data, pathology report, and short-term oncologic outcomes. We also represented our PSM trends in 100 consecutive cases, discussing potential factors for minimizing the learning curve impact on positive margins and outcomes. Medians and interquartile ranges, as well as frequencies and proportions, were reported for continuous and categorical variables, respectively. Results and Limitations: The median follow-up is 14 months (8-17). The cohort has a median age of 62 years (56-68), median prostate-specific antigen of 5.5 (4.3-7.7), median preoperative Sexual Health Inventory for Men (SHIM) of 20, median American Urological Association (AUA) of 7 (3-11), and median body mass index of 25.4 (23.4-27.4). The median total operative time was 114 minutes (104-124), the median console time was 80 minutes (75-90). No intraoperative complications were reported. The overall rate of PSMs was 15% (5% were pT2 and 10% were pT3). Conclusions: The SP approach to RP is feasible, safe, and with acceptable intraoperative performance. In this study, we have described crucial factors for considering selection criteria in candidates for SP-robot-assisted RP. We believe that with an appropriate patient selection, this robot can be safely implemented without increasing positive margins and compromising the outcomes, especially during the learning curve period.
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- 2022
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10. Da Vinci SP platform updates and modifications: the first impression of new settings.
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Covas Moschovas M, Bhat S, Rogers T, Reddy S, Noel J, Corder C, and Patel V
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- Humans, Male, Prostatectomy, Prostatic Neoplasms surgery, Robotic Surgical Procedures methods
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- 2021
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11. Da Vinci Single-Port Robotic Radical Prostatectomy.
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Covas Moschovas M, Bhat S, Rogers T, Noel J, Reddy S, and Patel V
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- Humans, Lymph Node Excision, Male, Prostate surgery, Prostatectomy, Seminal Vesicles, Robotic Surgical Procedures
- Abstract
The field of robotic surgery continues to evolve and the advent of the single-port (SP) platform is another step toward the future. The SP platform is a new technology that has promising implications for urologic surgery. Since the Food and Drug Administration (FDA) cleared this platform in 2018, multiple urologic procedures have been described, with radical prostatectomy being the most common. This article aims to describe and illustrate the step-by-step technique of SP radical prostatectomy. We have described our technique from the patient positioning and trocar placement until the anastomosis. We included in the video compilation surgical steps such as bladder dropping and anterior bladder neck dissection, posterior bladder neck and seminal vesicles, posterior prostate dissection and nerve sparing, apical dissection and dorsal venous complex control, posterior reconstruction and anastomosis, and lymph node dissection.
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- 2021
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12. Minimally Invasive Lymphocele Drainage Using the Da Vinci Single-Port Platform: Step-By-Step Technique of a Prostate Cancer Referral Center.
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Covas Moschovas M, Helman T, Reddy S, Bhat S, Rogers T, Sandri M, Noel J, and Patel V
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- Drainage, Humans, Lymph Node Excision, Male, Neoplasm Recurrence, Local, Prostatectomy, Referral and Consultation, Lymphocele surgery, Prostatic Neoplasms surgery, Robotic Surgical Procedures
- Abstract
Background: Some reports in the literature describe lymphocele formation in as much as half of patients after pelvic lymph node dissection (PLND) in robot-assisted radical prostatectomy (RARP), with 1%-2% requiring intervention. Several treatment modalities for symptomatic lymphoceles are available, including percutaneous drainage, sclerosing agents, and surgical marsupialization, typically performed by laparoscopy or with a multiport robotic platform. The advantage of surgical approach is permanent excision of the lymphocele capsule and fewer days with pelvic drains compared to percutaneous drainage. This study aims to describe and illustrate, for the first time, the step-by-step surgical management of symptomatic lymphoceles using a less invasive robotic platform, the da Vinci
® Single Port (SP). Materials and Methods: We describe the outcomes of three patients who underwent lymphocelectomy and marsupialization with the da Vinci SP for symptomatic lymphoceles after RARP and PLND with the da Vinci Xi. Results: Operative time for cases 1, 2, and 3 was 84, 80, and 79 minutes. The blood loss for each surgery was 25 mL. Patient 2 was discharged in 3 days, whereas patients 1 and 3 were discharged in 4 days. No intraoperative or postoperative complications were reported. All patients had their drain removed in under 24 hours after surgery. The mean follow-up period was 7.7 months (3.5-15.8). No patients were readmitted or had lymphocele recurrence. Conclusion: Da Vinci SP lymphocelectomy is safe and feasible with satisfactory outcomes. The SP enables definitive treatment of the lymphocele sac, reducing the number of days with abdominal drains, and allows further decrease in surgical invasiveness with fewer incisions and better cosmesis.- Published
- 2021
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13. Establishing a successful robotic surgery program and improving operating room efficiency: literature review and our experience report.
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Giedelman C, Covas Moschovas M, Bhat S, Brunelle L, Ogaya-Pinies G, Roof S, Corder C, Patel V, and Palmer KJ
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- Facility Design and Construction, Humans, Laparoscopy, Marketing of Health Services, Patient Care Team, Efficiency, Efficiency, Organizational, Operating Rooms, Quality Improvement, Quality of Health Care, Robotic Surgical Procedures economics, Robotic Surgical Procedures education, Robotic Surgical Procedures trends
- Abstract
The benefits and outcomes of robotic surgery are well established in the literature across multiple specialties. The increasing need for and dissemination of this technology associated with high costs, demand adequate planning during its implementation. Therefore, after years of training several robotic surgeons and establishing multiple robotic programs worldwide, the purpose of this article is to focus on the necessary elements in the initial phase of establishing a robotics program. We summarized in our article crucial factors when implementing a robotic program. Therefore, we explained in detail the critical aspects of the program design, implementation, marketing, research and outcomes, and ultimately improving efficiency. The creation of a robotics planning committee composed of several hospital individuals contributes in different lines of work such as cost evaluation, staff training, and OR modifications. A multidisciplinary approach and a robotic lead surgeon are also recommended to guarantee surgical volume and satisfactory outcomes. Furthermore, market analysis should evaluate the competition with other centres and potential surgical candidates in that area. Data collection should also be considered a vital element of the program organization, which assures quality control and helps to diagnose any program deficiency. We believe that the robotic program should be individualized according to the economy and reality of each centre. The success and duration of a robotic surgery program depend on long-term results. Therefore, careful planning with a robotic committee defining the types of procedures to be performed and appropriate multidisciplinary training to avoid surgery cancelations are crucial factors in establishing a successful program.
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- 2021
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14. Robot-assisted radical cystectomy with intracorporeal urinary diversion decreases postoperative complications only in highly comorbid patients: findings that rely on a standardized methodology recommended by the European Association of Urology Guidelines.
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Mazzone E, D'Hondt F, Beato S, Andras I, Lambert E, Vollemaere J, Covas Moschovas M, De Groote R, De Naeyer G, Schatteman P, Mottrie A, and Dell'Oglio P
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- Aged, Europe, Female, Humans, Male, Middle Aged, Retrospective Studies, Societies, Medical, Urology, Cystectomy methods, Cystectomy standards, Postoperative Complications epidemiology, Postoperative Complications prevention & control, Practice Guidelines as Topic, Robotic Surgical Procedures, Urinary Bladder Neoplasms complications, Urinary Bladder Neoplasms surgery, Urinary Diversion methods, Urinary Diversion standards
- Abstract
Introduction: The available studies comparing robot-assisted radical cystectomy (RARC) with intracorporeal (ICUD) vs. extracorporeal (ECUD) urinary diversion have not relied on a standardized methodology to report complications and did not assess the effect of different approaches on postoperative outcomes., Materials: Two hundred and sixty seven patients treated with RARC at a single center were assessed. A retrospective analysis of data prospectively collected according to a standardized methodology was performed. Multivariable logistic regression models (MVA) assessed the impact of ICUD vs. ECUD on intraoperative complications, prolonged length of stay (LOS), 30-day Clavien Dindo (CD) ≥ 2 complications and readmission rate. Interaction terms tested the impact of the approach on different patient subgroups. Lowess graphically depicted the probability of CD ≥ 2 after ICUD or ECUD according to patient baseline characteristics., Results: Overall, 162 ICUD vs 105 ECUD (61 vs. 39%) were performed. Intraoperative complications were recorded in 24 patients. The median LOS and readmission rate were 11 vs. 13 (p = 0.02) and 24 vs. 22% (p = 0.7) in ICUD vs. ECUD, respectively. Overall, 227 postoperative complications were recorded. The overall rate of CD ≥ 2 was 35 and 43% in patients with ICUD vs. ECUD, respectively (p = 0.2). At MVA, the approach type was not an independent predictor of any postoperative outcomes (all p ≥ 0.4). Age-adjusted Charlson Comorbidity Index (ACCI) was associated with an increased risk of CD ≥ 2 (OR: 1.2, p = 0.006). We identified a significant interaction term between ACCI and approach type (p = 0.04), where patients with ICUD had lower risk of CD ≥ 2 relative to those with ECUD with increasing ACCI., Conclusions: Relying on a standardized methodology to report complications, we observed that highly comorbid patients who undergo ICUD have lower risk of postoperative complications relative to those patients who received ECUD.
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- 2021
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15. Applications of the da Vinci single port (SP) robotic platform in urology: a systematic literature review.
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Covas Moschovas M, Bhat S, Rogers T, Thiel D, Onol F, Roof S, Sighinolfi MC, Rocco B, and Patel V
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- Female, Humans, Male, Prostatectomy methods, Robotic Surgical Procedures methods, Urologic Surgical Procedures methods
- Abstract
Introduction: Robotic surgical technology has evolved to include a new platform specifically designed for the single-port (SP) approach. Benefits of the da Vinci SP are still under investigation. This study aimed to review the urological literature since the first report of the use of the platform., Evidence Acquisition: We performed a systematic literature review of PubMed, Medline, and Web of Science databases on June 15, 2020 searching for all available articles of da Vinci SP use from December 2014 (date of the first clinical report of da Vinci SP in the urology) until June 1, 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines., Evidence Synthesis: A total of 43 articles were eligible for inclusion. Ten studies reported different surgeries and techniques on cadavers while the rest described the clinical experience of different groups. We divided our article and tables into preclinical experience with surgery on cadavers, radical prostatectomy (RP) approach, and multiple types of procedures described in the same study., Conclusions: The application of da Vinci SP in urologic procedures after five years of the first clinical investigation is feasible and safe. Radical prostatectomy is the most common intervention performed with this robot. Some groups described benefits in terms of less postoperative pain and early discharge, especially with the extraperitoneal approach. However, further studies with larger sample sizes and longer follow-up are awaited.
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- 2021
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16. Use of transversus abdominis plane block to decrease pain scores and narcotic use following robot-assisted laparoscopic prostatectomy.
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Rogers T, Bhat KRS, Moschovas M, Onol F, Jenson C, Roof S, Gallo N, Sandri M, Gallo B, and Patel V
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- Aged, Anesthetics, Local administration & dosage, Bupivacaine administration & dosage, Humans, Laparoscopy methods, Male, Middle Aged, Perioperative Care statistics & numerical data, Prostatectomy methods, Retrospective Studies, Robotic Surgical Procedures methods, Time Factors, Abdominal Muscles, Drug Utilization statistics & numerical data, Laparoscopy adverse effects, Narcotics administration & dosage, Nerve Block methods, Pain Management methods, Pain, Postoperative prevention & control, Pain, Postoperative therapy, Prostatectomy adverse effects, Robotic Surgical Procedures adverse effects
- Abstract
The aim of this study was to assess whether transversus abdominis plane (TAP) blocks can be utilized to decrease patient pain scores and narcotic use during the first 24 h following robot-assisted laparoscopic prostatectomy (RALP). 100 patients received a TAP block with a mixture of 1.3% liposomal bupivacaine, 0.5% Marcaine and 0.9% NaCl prior to RALP. This was in addition to an already established pain management regiment, which included preoperative PO acetaminophen (650 mg), celecoxib (200 mg), and tolterodine ER (4 mg). These patients were prospectively followed and then retrospectively compared to a 1:1 propensity matched group of 100 patients that did not receive a TAP but did receive the preoperative PO medications. Pain scores were assessed on a scale from 1-10 in the PACU, as well as the surgical floor at 8, 16, and 24-h post-surgery. Intra-/post-operative narcotic use and time to ambulation following arrival to the surgical floor were also analyzed. Patient receiving TAP blocks had immediate post-op pain scores of 2.23 vs 4.26 for those not receiving TAP blocks (p = 0.000). The pain scores at 8, 16, and 24 h for TAP patients were 2.68, 2.62, and 2.62 as compared to 2.89, 2.87, and 3.36 for non-TAP patients. The difference was statistically significant for immediate and 24-h pain scores (p = 0.000, 0.001, respectively). On average, TAP block patients ambulated faster than non-TAP patients, 2.68 vs 4.91 h (p = 0.000). Intra-operative narcotic use was decreased in the TAP group for each of the opioids that were used: fentanyl 177.5 vs 205mcg (p = 0.001), morphine 5.5 vs 10 mg (p = 0.000), and hydromorphone 0.75 vs 1.75 mg (p = 0.001). Narcotic usage in the PACU was limited to hydromorphone and TAP patients used 0.7 mg compared to 1.36 mg (p = 0.003) for non-TAP patients. Oral oxycodone/acetaminophen (5 mg/325 mg) was used for pain control on the surgical floor and on average TAP patients received less, 2.4 vs 5 tabs (p = 0.000). Average time to perform the TAP block was 3.5 min and total OR time for TAP vs non-TAP patients was 107.41 vs 106.58 min (p = 0.386). TAP blocks as part of a perioperative pain management protocol can be utilized during RALPs to decrease patient pain scores at two different time intervals, immediately post-operative and 24 h after surgery. Patients also ambulate sooner following surgery and require a decreased amount of narcotics during the intra-operative and post-operative periods. TAP blocks are quick, effective, and do not add a significant amount of OR time to RALPs.
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- 2021
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17. Early outcomes of single-port robot-assisted radical prostatectomy: lessons learned from the learning-curve experience.
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Covas Moschovas M, Bhat S, Onol F, Rogers T, and Patel V
- Subjects
- Adenocarcinoma pathology, Blood Loss, Surgical, Humans, Learning Curve, Male, Margins of Excision, Middle Aged, Neoplasm Grading, Neoplasm Staging, Neoplasm, Residual, Operative Time, Pain, Postoperative etiology, Penile Erection, Prostatectomy adverse effects, Prostatectomy instrumentation, Prostatic Neoplasms pathology, Robotic Surgical Procedures adverse effects, Robotic Surgical Procedures instrumentation, Urinary Incontinence etiology, Adenocarcinoma surgery, Prostatectomy methods, Prostatic Neoplasms surgery, Robotic Surgical Procedures methods
- Abstract
Objective: To describe the crucial factors related to the implementation of the da Vinci single-port (SP) system (Intuitive Surgical Inc., Sunnyvale, CA, USA), and the early outcomes after the introduction of this robot for robot-assisted radical prostatectomy (RARP)., Patients and Methods: We prospectively collected data from 50 consecutive patients with prostate adenocarcinoma who underwent RARP using this robot. The median follow-up was 53 days. We performed a transperitoneal technique. The robotic (multiport) trocar was placed on the supra-umbilical midline 20 cm from the pubis and an assistant trocar placed in the right lower quadrant. We report our initial experience describing the intra- and postoperative outcomes associated with this new robot. Also, we report the early functional and oncological outcomes in the follow-up period considered. Continuous variables were described as medians and interquartile ranges, while categorical variables as frequencies and proportions., Results: The median total operative time was 118 min, median console time was 80 min, and median estimated blood loss was 50 mL. There were no intraoperative complications or blood transfusions. The final pathology reported 18% Grade Group (GrGp)1, 58% GrGp2, 18% GrGp3, 2% GrGp4, and 4% GrGp5. In all, 40 patients (80%) were pT2 and 20% were ≥pT3a. The overall positive surgical margin rate was 14%. In all, 39 patients (78%) achieved full continence at median of 21 days after RARP. The median pain scale (0-10) score at 8, 12 and 16 h after RARP was 2, 2, and 0, respectively., Conclusion: The use of the da Vinci SP robot with an additional assistant port for RARP is technically safe and feasible, with acceptable short-term functional and oncological outcomes. However, there is a technical learning curve for this new platform due to the smaller scope of the operative field and the decreased flexibility and strength of the surgical instruments., (© 2020 The Authors BJU International © 2020 BJU International Published by John Wiley & Sons Ltd.)
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- 2021
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18. Modified Apical Dissection and Lateral Prostatic Fascia Preservation Improves Early Postoperative Functional Recovery in Robotic-assisted Laparoscopic Radical Prostatectomy: Results from a Propensity Score-matched Analysis.
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Covas Moschovas M, Bhat S, Onol FF, Rogers T, Roof S, Mazzone E, Mottrie A, and Patel V
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- Aged, Fascia, Humans, Male, Middle Aged, Organ Sparing Treatments, Propensity Score, Retrospective Studies, Time Factors, Treatment Outcome, Laparoscopy, Prostatectomy methods, Prostatic Neoplasms surgery, Recovery of Function, Robotic Surgical Procedures
- Abstract
Background: Early recovery of continence and potency after robotic-assisted laparoscopic prostatectomy (RALP) still remains a challenge., Objective: To assess the effect of our modified apical dissection and lateral prostatic fascia preservation (mod-RALP) technique on early functional outcomes., Design, Setting, and Participants: Among 2168 patients who underwent RALP between 2017 and 2019, 104 received a mod-RALP, and for the purposes of this study they were propensity score (PS) matched with a control group of conventional RALP cases based on preoperative and histological characteristics., Surgical Procedure: In the mod-RALP technique, significant dissection of the apical complex was avoided with maximized preservation of periurethral tissue around the urethral stump. Nerve sparing was also modified with intrafascial dissection inside of the lateral fascia, leaving the lateral tissue including the neurovascular bundle (NVB) untouched and covered., Measurements: The mod-RALP and conventional RALP groups were compared for continence and potency recovery at 1 and 6 wk postoperatively, as well as at 3, 6, and 12 mo. Kaplan-Meier curves and multivariate Cox regression models were used to identify survival estimations and their predictors., Results and Limitations: The mod-RALP technique resulted in faster continence (mean 46 vs 70 d) and potency (mean 74 vs 118 d, p < 0.05 for both) recovery. Functional recovery rates at postoperative follow-up were significantly higher in the mod-RALP group at all time points within the first 6 mo following surgery. Multivariate analyses revealed age, baseline functional status, surgical technique, and lymph node dissection as independent predictors of early functional recovery. This study is limited by its retrospective design and small size of the study groups., Conclusions: Our results with a modified technique intended to better preserve the apical complex and NVBs suggest earlier recovery of urinary continence and sexual function. These results should be tested with future randomized studies., Patient Summary: We report a modified approach to apical dissection and lateral prostatic fascia preservation in robotic-assisted laparoscopic prostatectomy that resulted in earlier continence and potency recovery as compared with our conventional technique., (Copyright © 2020. Published by Elsevier B.V.)
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- 2020
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19. Technical Modifications Necessary to Implement the da Vinci Single-port Robotic System.
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Covas Moschovas M, Bhat S, Rogers T, Onol F, Roof S, Mazzone E, Mottrie A, and Patel V
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- Aged, Equipment Design, Humans, Male, Middle Aged, Prospective Studies, Treatment Outcome, Prostatectomy instrumentation, Prostatectomy methods, Prostatic Neoplasms surgery, Robotic Surgical Procedures instrumentation
- Abstract
Background: Since the implementation of robotic surgery, the platforms have been updating constantly in terms of arm configuration, tool design, scope settings, and the number of trocars placed. The introduction of new robotic technology is challenging and requires studies followed by technique adaptions., Objective: This study aims to report a logical and technologically safe approach to the learning curve using the da Vinci single-port (SP) console and describes our robotic-assisted radical prostatectomy (RARP) technique step by step., Design, Setting, and Participants: A prospective study from 26 consecutive patients who underwent RARP with the da Vinci SP console from June to August 2019., Surgical Procedure: All surgeries were performed with a transperitoneal technique; one robotic trocar was placed above the umbilicus and one additional 12 mm trocar was placed in the right lower quadrant., Measurements: We described the step-by-step technique and reported the perioperative and pathological data. In addition, we considered the hospital length of stay and pain scale following surgery. Continuous variables were reported as median and interquartile ranges. Categorical variables were reported as frequencies and proportions., Result and Limitations: The total median operative time was 121 min, console time was 85 min, and blood loss was 50 ml. No complications were reported. In the final pathology, four patients had Gleason 6, 20 had Gleason 7, one had Gleason 8, and one had Gleason 9.Of the patients, 70% were ≤pT2 and 30% were ≥pT3a. Only 11% had positive surgical margins. This study is limited by the small number of patients and a short period of follow-up to evaluate functional and oncological outcomes of this new technology., Conclusions: RARP with the da Vinci SP is feasible and safe. Therefore, the step-by-step technique described in this study could be considered an option to perform radical prostatectomies. However, we still need better-designed studies to compare the outcomes with those of the multiport platform., Patient Summary: We reported our step-by-step technique describing a safe approach to robotic-assisted radical prostatectomy during the transition from the Xi to the da Vinci single-port robot., (Copyright © 2020. Published by Elsevier B.V.)
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- 2020
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20. The ongoing dilemma in pelvic lymph node dissection during radical prostatectomy: who should decide and in which patients?
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Onol FF, Bhat S, Moschovas M, Rogers T, Albala D, and Patel V
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- Aged, Aged, 80 and over, Device Removal methods, Humans, Male, Middle Aged, Organ Sparing Treatments methods, Treatment Outcome, Adenocarcinoma surgery, Lymph Node Excision methods, Lymph Nodes surgery, Pelvis, Prostatectomy methods, Prostatic Hyperplasia surgery, Prostatic Neoplasms surgery, Robotic Surgical Procedures methods
- Abstract
Pelvic lymph node dissection (pLND) is considered the most reliable method for the detection of lymph node metastases in prostate cancer. Current clinical guidelines recommend performing pLND in intermediate- and high-risk patients that are defined using different clinical nomograms and different cut-off values. Although the detection of lymph node metastatic disease can identify patients who could benefit from adjuvant therapies and potentially improve prostate cancer-related survival outcomes, so far there has been no level 1 evidence to support this survival benefit. Available retrospective data that suggest oncological benefits are subject to various forms of bias. Furthermore, pLND is not feasible or may be risky in some patient-related conditions, such as morbid obesity and previous history of intraabdominal surgery including organ transplants. In this review, we discuss the current controversies surrounding pLND during robotic-assisted prostatectomy in prostate cancer, specifically the pitfalls in interpretation of restricted evidence suggesting its oncological benefits, and examine the potential influence of patient- and surgeon-related factors that may determine the decision to perform pLND.
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- 2020
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21. Can we predict who will need lymphocele drainage following robot assisted laparoscopic prostatectomy (RALP)?
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Seetharam Bhat KR, Onol F, Rogers T, Ganapathi HP, Moschovas M, Roof S, and Patel VR
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- Body Mass Index, Forecasting, Humans, Lymph Nodes pathology, Lymphocele diagnostic imaging, Lymphocele pathology, Male, Pelvis, Postoperative Complications pathology, Retrospective Studies, Ultrasonography, Drainage methods, Laparoscopy methods, Lymph Node Excision methods, Lymphocele etiology, Lymphocele therapy, Postoperative Complications etiology, Postoperative Complications therapy, Prostatectomy methods, Prostatic Neoplasms surgery, Robotic Surgical Procedures methods
- Abstract
Pelvic lymph node dissection (PLND) can cause lymphoceles. Lymphocele formation following PLND can reach up to 60% and are symptomatic in 0.4 to 16% of patients. The aim of the study was to identify factors that are significantly associated with lymphocele drainage. We retrospectively analysed all men that underwent RALP between April 2010 and November 2018 from our prospectively collected IRB approved database. All patients who developed lymphoceles were grouped into two groups, the ones who were drained and those not drained. Chi-square test was used to perform univariate analysis for categorical variables and student's t test for continuous variables. Odds ratio was calculated using logistic multiple regression analysis. A P value of less than 0.05 was considered significant. The size of the lymphocele, the number of nodes retrieved, and BMI were significant factors that led to the drainage of lymphocele. The patients with lymphoceles larger than 10 cm had an odds ratio of 47.5 and those between 5 and 10 had an odds ratio of 10.7. The odds ratio of drainage in patients with BMI above 30 was 2.1. The odds of drainage were 8.8 when more than 10 nodes were taken. After PLND ultrasound could be effective in early identification of patients who could potentially need drainage. Early elective drainage should be offered to patients who have more than 10 lymph nodes removed with a lymphocele size more than 10 cm in size and BMI above 30.
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- 2020
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22. Comparison of outcomes of salvage robot-assisted laparoscopic prostatectomy for post-primary radiation vs focal therapy.
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Onol FF, Bhat S, Moschovas M, Rogers T, Ganapathi H, Roof S, Rocco B, and Patel V
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- Ablation Techniques, Aged, Humans, Male, Middle Aged, Retrospective Studies, Salvage Therapy, Treatment Outcome, Laparoscopy, Prostatectomy methods, Prostatic Neoplasms radiotherapy, Prostatic Neoplasms surgery, Robotic Surgical Procedures
- Abstract
Objectives: To compare salvage robot-assisted laparoscopic prostatectomy (RALP) outcomes in patients who underwent radiation and those who underwent focal ablation as primary therapies., Patients and Methods: We evaluated 126 patients who underwent salvage RALPbetween 2008 and 2018. Of these, 94 (74.6%) received radiation and 32 focal ablation (25.4%) as primary therapy. These groups were compared with regard to clinical, oncological and functional outcomes. Kaplan-Meier curves and regression models were used to identify survival estimations and their predictors., Results: Before surgery, more patients were potent in the focal ablation group compared to the radiation group (46.9% vs 22.6%; P = 0.013). Peri-operative characteristics and complication rates were not significantly different between the two groups. Postoperative catheterization duration was shorter in the focal ablation group (mean 10 vs 16 days; P = 0.018). At final pathology, the focal ablation group had higher non-organ-confined disease (71% vs 50%; P = 0.042) and positive surgical margin (PSM) rates (43.8% vs 17%; P = 0.004) as compared to the radiation group; however, 5-year biochemical recurrence (BCR)-free survival rates were similar (59% vs 56%; P = 0.761). Postoperative 1-year full (no pads/day) and social (0-1 pad/day) continence rates were significantly higher in the focal ablation as compared to the radiation group (77.3% vs 39.2%, P = 0.002, and 87.5% vs 51.3%, P = 0.002, respectively). Multivariate analyses showed primary focal ablation and nerve-sparing to be predictors of postoperative continence. Erectile function was preserved in 13% and 27% of preoperatively potent patients in the radiation and focal ablation groups, respectively (P = 0.435). No predictors were identified for postoperative potency., Conclusions: Radiation was associated with inferior functional outcomes after salvage RALP. Focal therapies were associated with higher non-organ-confined disease and PSMrates, with no significant difference in short-term BCR-free survival., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)
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- 2020
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23. Trends in clinical and oncological outcomes of robot-assisted radical prostatectomy before and after the 2012 US Preventive Services Task Force recommendation against PSA screening: a decade of experience
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Seetharam Bhat, K. R., Moschovas, M. C., Onol, F. F., Sandri, M., Rogers, T., Roof, S., Rocco, B., and Patel, V. R.
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Male ,Prostatectomy ,clinical trends ,PSA screening ,RALP outcomes ,USPSTF recommendation ,Prostate ,Prostatic Neoplasms ,Middle Aged ,Prostate-Specific Antigen ,Robotic Surgical Procedures ,Practice Guidelines as Topic ,Humans ,Neoplasm Recurrence, Local ,Aged ,Retrospective Studies - Abstract
To assess the influence of the 2012 US Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen (PSA)-based screening on oncological and functional outcomes following robot-assisted laparoscopic prostatectomy (RALP).We retrospectively analysed patients who underwent RALP between 2008 and 2018 with a minimum of 12-month follow-up from a prospectively collected institutional review board-approved database. The impact of the USPSTF recommendation against PSA screening on our surgical outcomes was assessed using a logistic regression model using two groups comprising patients treated before/after the USPSTF statement and indicating time trends for each successive year.The mean preoperative PSA increased from 6.0 to 7.4 ng/mL after the USPSTF recommendation. We detected statistically significant time-trend changes after 2012, including an increase in the positive slope of Gleason ≥3 + 4 or ≥pT3 disease. We detected a fall in bilateral full nerve-sparing and an increase in partial nerve-sparing. The total positive surgical margin (PSM) rate increased after the USPSTF recommendation; however, PSM rates pertinent to each pathological stage did not change significantly after 2012. There was a significant negative trend change in the postoperative 12-month continence and potency rates, indicating a breakpoint in functional outcomes after 2012. We detected a 1.7-fold increase in 12-month biochemical recurrence (BCR) rates. The 12-month BCR, potency and continence rates were maintained in young (55 years) patients with a Sexual Health Inventory for Men score22 and low-volume disease.Since the USPSTF's recommendation in 2012, we have seen a significant increase in the incidence of high-risk disease that has forced us to modify our approach to the procedure and the grade of nerve-sparing used, leading to a wider resection, in order to reduce PSMs. This has led to a decrease in postoperative functional recovery. Patients with favourable characteristics had good outcomes before and after the USPSTF's recommendation, implying that the quality of surgery did not change over time.
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- 2020
24. Contemporary Techniques of Prostate Dissection for Robot-assisted Prostatectomy
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Francesco Porpiglia, Alexandre Mottrie, Xiaochen Zhou, Aldo Massimo Bocciardi, Paolo Dell'Oglio, Carlo Andrea Bravi, N. Peter Wiklund, Alberto Briganti, Francesco Montorsi, Ashok K. Hemal, Ugo Falagario, Riccardo Autorino, Guilherme Sawczyn, Ashutosh K. Tewari, Mani Menon, Jihad H. Kaouk, Maurizio Buscarini, Arnauld Villers, Alberto Martini, Silvia Secco, Marcio Covas Moschovas, Elio Mazzone, R. Gaston, Gongxian Wang, Vipul R. Patel, Martini, A., Falagario, U. G., Villers, A., Dell'Oglio, P., Mazzone, E., Autorino, R., Moschovas, M. C., Buscarini, M., Bravi, C. A., Briganti, A., Sawczyn, G., Kaouk, J., Menon, M., Secco, S., Bocciardi, A. M., Wang, G., Zhou, X., Porpiglia, F., Mottrie, A., Patel, V., Tewari, A. K., Montorsi, F., Gaston, R., Wiklund, N. P., and Hemal, A. K.
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Male ,medicine.medical_specialty ,Urology ,medicine.medical_treatment ,030232 urology & nephrology ,law.invention ,03 medical and health sciences ,Prostate cancer ,0302 clinical medicine ,Robotic Surgical Procedures ,Randomized controlled trial ,Prostate ,law ,medicine ,Humans ,Prostatectomy ,business.industry ,Prostatic Neoplasms ,Robotics ,medicine.disease ,Surgery ,Clinical trial ,Dissection ,Neck of urinary bladder ,medicine.anatomical_structure ,030220 oncology & carcinogenesis ,Technique ,Positive Surgical Margin ,business - Abstract
Background Over the years, several techniques for performing robot-assisted prostatectomy have been implemented in an effort to achieve optimal oncological and functional outcomes. Objective To provide an evidence-based description and video-based illustration of currently available dissection techniques for robotic prostatectomy. Design, setting, and participants A literature search was performed to retrieve articles describing different surgical approaches and techniques for robot-assisted radical prostatectomy (RARP) and to analyze data supporting their use. Video material was provided by experts in the field to illustrate these approaches and techniques. Surgical procedure Multiple surgical approaches are available: extraperitoneal, transvesical, transperitoneal posterior, transperitoneal anterior, Retzius sparing, and transperineal. Surgical techniques for prostatic dissection sensu strictu are the following: omission of the endopelvic fascia dissection, bladder neck preservation, incremental nerve sparing by means of an antegrade or retrograde approach, and preservation of the puboprostatic ligaments and dorsal venous complex. Recently, techniques for total or partial prostatectomy have been described. Measurements Different surgical approaches and techniques for robotic prostatectomy have been analyzed. Results and limitations Two randomized controlled trials evaluating the extraperitoneal versus the transperitoneal approach have demonstrated similar results. Level I evidence on the Retzius-sparing approach demonstrated earlier return to continence than the traditional anterior approach. The question whether Retzius-sparing RARP is associated with a higher rate of positive surgical margins is still open due to the intrinsic bias in terms of surgical expertise in the available comparative studies. This technique also offers an advantage in patients who have received kidney transplantation. Retrospective evidence suggests that the more the anatomical dissection (eg., more periprostatic tissue is preserved), the better the functional outcome in terms of continence. Yet, two randomized controlled trials evaluating the different techniques of dissection have so far been produced. Partial prostatectomies should not be offered outside clinical trials. Conclusions Several techniques and approaches are available for prostate dissection during RARP. While the Retzius-sparing approach seems to provide earlier return to continence than the traditional anterior transperitoneal approach, no technique has been proved to be superior to other(s) in terms of long-term outcomes in randomized studies. Patient summary We have summarized available approaches for the surgical treatment of prostate cancer. Specifically, we described the different techniques that can be adopted for the surgical removal of the prostate using robotic technology.
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- 2020
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