Robert Abouassaly

Purpose: Unplanned conversion from minimally invasive surgery (MIS) to open surgery is a significant challenge, though the frequency of conversion for robotic and laparoscopic kidney surgery is not well described. We aimed to compare rates of conversion for robotic versus laparoscopic kidney surgery. Methods: The National Cancer Database was used to identify patients who underwent robotic or laparoscopic partial nephrectomy (PN), radical nephrectomy (RN), or nephroureterectomy (NU) from 2010–2014. Multivariate logistic regression was used to identify factors associated with conversion to open. Length of stay and 30-day mortality were compared between groups using Kruskal-Wallis and Fisher Exact tests. Propensity score matching was performed to confirm study results. Results: A total of 61,191 patients underwent MIS PN, RN, or NU. Conversion rates were lower for robotics than for laparoscopy (PN: 2.1% vs 6.4%; RN: 4.9% vs 6.0%; NU: 3.8% vs 9.2%; p<0.001). Median length of stay was longer for patients who underwent conversion than for those who did not (PN: 4.0 vs 2.0 days; RN: 4.0 vs 3.0; NU: 5.0 vs 4.0; p<0.0001). 30-day mortality was higher for patients who underwent conversion (PN: 0.24% vs 1.42%; RN: 0.73% vs 2.71%; NU: 1.0% vs 3.0%, p<0.001). Results were confirmed in propensity score matched cohorts. Conclusions: Among patients undergoing minimally invasive kidney surgery, robotics is associated with a lower rate of unplanned open conversion than laparoscopy. This relative advantage has implications on length of stay and short-term mortality, and should be considered when weighing the costs and benefits of robotic kidney surgery.

Purpose This report presents our early experience at Cleveland Clinic replacing conventional ultrasound with a novel 29 MHz high-resolution micro-ultrasound system for both systematic sampling and real-time targeting of suspicious regions during prostate biopsy. The added value of micro-ultrasound and MRI over systematic biopsy is presented. Methods Sixty-seven consecutive subjects (January–August 2018) from our prospective database who underwent prostate biopsy using the micro-ultrasound system were included. 19/67 had prostate MRI imaging available. MRI targets were sampled using the UroNav fusion system. Patients had a median PSA of 5.37 ng/mL (IQR 4.13–8.74). Results 38/67 (56.7%) subjects were positive for prostate cancer. In six of these cases, systematic biopsy was negative with only micro-ultrasound targeted samples detecting cancer. In two other cases, patients were upgraded from Grade Group 1 to Grade Groups 4 and 2 based on micro-ultrasound targets. Micro-ultrasound targets detected cancer in two subjects where MRI was negative (Grade Groups 3 and 2). MRI targets alone did not change the overall diagnosis of any subjects. Switching biopsy guidance to real-time micro-ultrasound increased detection rate on prostate biopsy from 44.8% (30/67) to 56.7% (38/67), a relative increase of 26.7%. Conclusion High-resolution micro-ultrasound identified clinically significant cancer that would have, otherwise, been missed by both MRI fusion and systematic biopsy and was useful in both biopsy naïve and repeat negative patients. Early results from this small, single-center cohort are promising, particularly given the ease with which micro-ultrasound can replace the conventional ultrasound in standard prostate biopsy procedures.