Muhammad Shamim Khan

Introduction: Absence of residual cancer in radical cystectomy (RC) specimens is a well-known positive prognostic factor for non-muscle and muscle-invasive bladder cancer (NMIBC and MIBC) in patients with or without neoadjuvant chemotherapy (NAC). Understanding the clinical and pathological features associated with a final pT0 status can provide valuable prognostic insights, serve as a surrogate marker for survival outcomes, and help identify candidates suitable for bladder-sparing strategies. Methods: Temporal trends and clinical/demographic characteristics across clinically high-/very-high-risk NMIBC or MIBC RC patients from 2009 to 2024 were explored. Subsequently, RC pT0 patients were propensity score-matched (PSM, 1:1 ratio) with the >pT0 population based on age-adjusted CCI and preoperative clinical stage (cTis-T1 vs. cT2). Multivariable regression modelling was applied to explore predictors of pT0 status stratified according to clinical NMIBC or MIBC status. Results: A total of 655 RCs performed with curative intent were included (43% for MIBC, 57% for NMIBC). Of these, 117 were pT0 at final pathological assessment (68 NMIBC and 49 MIBC). Subsequently, 228 PSM patients (114 pT0 vs. 114 >pT0) were extracted from the original cohort and stratified according to preoperative clinical stage (MIBC vs. NMIBC). In multivariable analysis, male gender was associated with an increased likelihood of pT0 status in the NMIBC cohort (adjusted odds ratio [aOR] 2.89, 95% CI 1.13–7.90). Conversely, BCG failure and concomitant CIS independently reduced the chances of achieving pT0 status (aOR: 0.40, 95% CI 0.19–0.99; aOR: 0.16, 95% CI 0.03–0.97). For MIBC patients, as expected, NAC more than doubled the chances of achieving pT0 status (aOR: 2.20, 95% CI 1.01–6.82). On the other hand, the concomitant presence of CIS reduced the likelihood of pT0 achievement (aOR 0.22, 95% CI, 0.06–0.80). In both cohorts, the presence of variant histology (VH) demonstrated a negative association with pT0 achievement; however, the estimated effect did not reach statistical significance (p = 0.09 and p = 0.08). Conclusions: Our findings suggest potentially raising the threshold for RC consideration in high-risk or very-high-risk NMIBC patients with a favourable risk profile. MIBC patients without additional risk factors (CIS and VH) are more likely to achieve a tumour-free status, particularly when adequately receiving NAC.

Introduction: The role of urethrectomy at the time of Robotic-Assisted or Open Radical Cystectomy (RARC, ORC) is controversial. Whether urethrectomy should be performed at the time of RARC/ORC or delayed up to a 3–6 month interval is unclear. We performed a retrospective cohort analysis of perioperative and survival outcomes in patients with high-risk NMIBCs or non-metastatic MIBCs at our institution who underwent either concomitant or deferred urethrectomy after RC. Materials and Methods: cTis-T1 or cT2-T4, N0-1, M0 BC patients who underwent RARC or ORC from 2009 to 2024 were reviewed. Clinical, demographic, tumour, and patient characteristics and perioperative variables were assessed across concomitant and delayed urethrectomy groups. Multivariate logistic analysis was performed to estimate the impact of significant variables on intraoperative and postoperative outcomes. Univariable Kaplan–Meier and multivariable Cox regression modelling was implemented to explore the relative effect of time of urethrectomy on progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS). Results: A total of n = 58 patients (n = 47 delayed vs. n = 11 concomitant) with similar demographic characteristics were included. The concomitant urethrectomy group experienced longer operative time and greater blood loss (379 ± 65 min and 430 ± 101 mL vs. 342 ± 82 min and 422 ± 125 mL, with p = 0.049 and p = 0.028, respectively). Hospital readmission rates were higher in the concomitant urethrectomy group (36.4% vs. 8.5%, p = 0.016; OR: 17.9; 95% CI 1.2–265; p = 0.036). In Cox regression analysis, the timing of urethrectomy had no influence on PFS, CSS, or OS (all p > 0.05). Conclusions: Our study suggests that urethrectomy can be safely deferred unless urothelial disease is clearly present pre- or intraoperatively without compromising survival outcome and with the advantage of reducing surgical morbidity at the time of RC.

Introduction: Radical cystectomy (RC) is the gold standard for urothelial cT2-4a, N0, M0 muscle-invasive bladder cancer (MIBC). However, bladder-sparing strategies (BSS) such as Trimodality Therapy (TMT) have emerged as alternative treatments for a select group of localized muscle-confined (cT2) urothelial bladder cancers. Accordingly, reliable preoperative staging and a reliable risk factor assessment linked to pathological upstaging play a key role in adequate counselling and patient selection for BSS. Patients and Methods: cT2 MIBC patients undergoing RC at our institution from 2014 to 2024 were reviewed. Preoperative staging modalities, demographics, and tumour and patient characteristics were assessed. Multivariable logistic regression was applied to explore the relative effect of confounders on any pathological upstaging from robot-assisted or open RC specimens. Subgroup analysis according to the local upstaging (>pT2) or nodal dissemination (pN+) was also performed. Results: N = 275 RCs were included (73.5% males, 26.5% females). Upstaging was documented in n = 141 (51%) cases. Of these, n = 125 (45.5%) were upstaged locally (>pT2) and n = 35 (23%) yielded pN+ disease. Preoperative parameters like gender, the number of TURBTs, previous BCG exposure, and concomitant CIS did not significantly influence the risk of any kind of upstaging (p > 0.05). At multivariable analysis, neoadjuvant chemotherapy (NAC) and multi-disciplinary team (MDT) discussion were found protective (odds ratio [OR]: 0.4, 95%CI 0.2–0.7, p = 0.001 and OR: 0.51, 95%CI 0.2–0.9, p = 0.01). Preoperative FDG-PET assessment yielded higher risk for later pN upstaging (OR: 1.8, 95%CI 1–3, p = 0.05). HG/G3 features at TURBT along with mixed/pure histology variants in RC specimens were the most relevant independent predictors for both any and pT upstaging (OR: 4.3, 95%CI 1–34, p = 0.04 and OR: 2.3, 95%CI 1.1–4.6, p = 0.02 for any upstaging and OR: 5.6, 95%CI 1.3–36, p = 0.02 and OR: 2.5, 95%CI 1.3–5, p = 0.01 for pT upstaging, respectively). Conclusions: In this study, over half of the patients undergoing RC for cT2 were upstaged at the final pathology. Therefore, adequate counselling and examining the non-conventional criteria for prognosis is mandatory in the contemporary era of bladder-preservation strategies.

Background/Objectives: Robot-assisted radical prostatectomy (RARP) for the treatment of prostate cancer (PCa) has been standardized over the last 20 years. At our institution, only n = 3 rob arms are used for RARP. In addition, n = 2, 12 mm lap trocars are placed for the bedside assistant symmetrically at the midclavicular lines, which allows for direct pelvic triangulation and greater involvement of the assisting surgeon. The aim of our study was to compare surgical and perioperative outcomes of RARP performed using our alternative trocar placement with no fourth robotic arm in the subgroups of experienced attending surgeons and post-graduate residents as bedside assistants. Residents’ satisfaction was also explored. Methods: RARPs performed within the urology residency program between 2019 and 2024 were retrospectively analyzed. Only rob procedures performed using our 3+2 trocars configuration were included. Intra- and postoperative outcomes, as well as long-term functional outcomes including continence recovery and potency, were assessed, stratified by the level of expertise of the bedside assistant, i.e., an experienced attending or post-graduate Year I–III resident. Satisfaction of residents assigned to the two groups during their robotic rotation was evaluated considering three domains with a score from 1 to 10: insight into surgical procedure, confidence level, and gratification level. Results: Out of n = 281 RARP procedures, the bedside assistant was an attending in 104 cases and a resident in 177. Operative time was found to be slightly longer in cases where the second operator was a resident (attendings vs. residents: 134 ± 40 vs. 152 ± 24; p < 0.001). Postoperative hospitalization time was longer in patients in the resident group (attendings vs. residents: 3.9 ± 1.6 vs. 4.3 ± 1 days; p = 0.025). However, cases where the second operator was a resident had a lower rate of positive surgical margins, with rates of 19.7% in the resident and 43.3% in the attending surgeon cohorts (OR = 0.32; 95% CI 0.18–0.55). This difference remained significant in multivariate analysis. There was no significant difference in postoperative blood transfusion rates (attendings vs. residents: 1.9% vs. 1.2%; p = 0.6). Similarly, long-term functional outcomes in terms of erectile dysfunction and urinary incontinence rates mostly overlapped between groups. The mean score in all three domains evaluating residents’ satisfaction was significantly higher when residents actively participated in the surgical procedure as bedside assistants (p = 0.02, p = 0.004, and p < 0.001, respectively, for insights into surgical procedure, confidence level, and gratification level). Conclusions: These findings provide insight into how an alternative port positioning during RARP could improve the involvement of the bedside assistant, particularly residents, without compromising perioperative outcomes or surgical safety.

Background: Urology has been at the forefront of adopting laparoscopic and robot-assisted techniques to improve patient outcomes. This systematic review aimed to examine the literature relating to the learning curves of major urological robotic and laparoscopic procedures. Methods: In accordance with PRISMA guidelines, a systematic literature search strategy was employed across PubMed, EMBASE, and the Cochrane Library from inception to December 2021 alongside a search of the grey literature. Two independent reviewers completed the article screening and data extraction stages, using the Newcastle-Ottawa Scale as a quality assessment tool. The review was reported in accordance with AMSTAR guidelines. Results: Of 3702 records identified, 97 eligible studies were included for narrative synthesis. Learning curves are mapped using an array of measurements including operative time, estimated blood loss, complication rates as well as procedure-specific outcomes, with operative time being the most commonly used metric by eligible studies. The learning curve for operative time was identified as 10-250 cases for robot-assisted laparoscopic prostatectomy (RALP), and 40-250 for laparoscopic radical prostatectomy (LRP).The robot-assisted partial nephrectomy (RAPN) learning curve for warm ischaemia time is 4-150 cases. No high-quality studies evaluating the learning curve for laparoscopic radical cystectomy and for robotic and laparoscopic retroperitoneal lymph node dissection were identified. Conclusion: There was considerable variation in the definitions of outcome measures and performance thresholds, with poor reporting of potential confounders. Future studies should use multiple surgeons and large sample sizes of cases to identify the currently undefined learning curves for robotic and laparoscopic urological procedures.

Background: Bladder cancer (BC) is the 9th most common cancer worldwide, but little progress has been made in improving patient outcomes over the last 25 years. The King’s Health Partners (KHP) BC biobank was established to study unanswered, clinically relevant BC research questions. Donors are recruited from the Urology or Oncology departments of Guy’s Hospital (UK) and can be approached for consent at any point during their treatment pathway. At present, patients with bladder cancer are approached to provide their consent to provide blood, urine and bladder tissue. They also give access to medical records and linkage of relevant clinical and pathological data across the course of their disease. Between June 2017 and June 2019, 531 out of 997 BC patients (53.3%) gave consent to donate samples and data to the Biobank. During this period, the Biobank collected fresh frozen tumour samples from 90/178 surgical procedures (of which 73 were biopsies) and had access to fixed, paraffin embedded samples from all patients who gave consent. Blood and urine samples have been collected from 38 patients, all of which were processed into component derivatives within 1 to 2 h of collection. This equates to 193 peripheral blood mononuclear cell vials; 238 plasma vials, 224 serum vials, 414 urine supernatant vials and 104 urine cell pellets. This biobank population is demographically and clinically representative of the KHP catchment area. Conclusion: The King’s Health Partners BC Biobank has assembled a rich data and tissue repository which is clinically and demographically representative of the local South East London BC population, making it a valuable resource for future BC research.

Background: Unsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH. Methods: Novices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants. Results: Forty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n = 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P = 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P = 0.0004). No significance differences were achieved in the circle cutting (P = 0.18) or needle guidance tasks (P = 0.32). The RCH group experienced significantly lower workload (P = 0.014) due to lower levels of distraction (P = 0.047). Conclusions: Remote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice. Trial registration: ISRCTN 83733979

To investigate whether a totally intracorporeally radical cystectomy (RC) can be considered the new 'gold standard' in bladder cancer, as open RC (ORC) is the current 'gold standard' for surgical treatment of muscle-invasive and high-grade non-muscle-invasive bladder cancer. However, robot-assisted radical cystectomy (RARC) is becoming the preferred surgical approach in many centres as it seems to maintain the oncological control of open surgery whilst offering improved perioperative benefits. A review of the literature was conducted using the Pubmed/MEDLINE, ISI Web of Knowledge and Cochrane Databases to identify studies that included both ORC and RARC with intracorporeal and extracorporeal urinary diversion (UD) published up to July 2017. Evidence from four single-centre randomised controlled trials and now the multicentre Randomized Trial of Open versus Robotic Cystectomy (RAZOR) trial demonstrate the oncological equivalence of RARC to ORC. The only convincing evidence for the superiority of RARC is in the area of blood loss and transfusion rates. However, the UD procedure in these trials was performed extracorporeally and, to realise the full benefits of RARC, a totally intracorporeal approach is needed. Intracorporeal UDs (ICUDs) have been shown to be technically feasible by a few expert centres and have demonstrated some improved short-term perioperative outcomes compared to extracorporeal UDs. Although initial outcomes appear promising, RARC with ICUD is far from gaining 'gold standard' status. Further studies are needed to confirm that outcomes are reproducible widely. Furthermore, the benefits of a totally intracorporeal approach must be confirmed in randomised controlled trials.