Robotic surgery played a major role on the virtual stage of the AUA2021 meeting. As expected, a lot of interesting, stimulating and–in some cases–thought-provoking work was presented by national and international speakers alike. First and foremost, invited lectures and semi-live surgery transmissions enriched the plenary program over the 4-day event. On Friday, Dr. Joseph (University of Rochester) showed his technique for robotic single port extraperitoneal radical prostatectomy, and Dr. Badani (Mount Sinai) illustrated his tips and tricks for retroperitoneal robotic partial nephrectomy (106HO). On Saturday (Plenary: Prime Time, Saturday, Afternoon Session), as part of the “Crossfire: Controversies in Urology” debates, Dr. Bocciardi (Niguarda Hospital, Milan), who first conceived and reported in 2010 the Retzius-sparing approach for robotic prostatectomy, debated with Dr. Tewari (Mount Sinai), who presented the anatomical and surgical principles of his Hood technique. Immediately after this debate, Dr. Humphreys (Mayo Clinic Arizona) presented a State-of-the-Art Lecture on robotic ureteroscopy, and Dr. Kaouk (Cleveland Clinic) gave an update on the latest advances in the field of single port robotic surgery. Later, Dr. Hemal (Wake Forest) provided an overview of robotic procedures for the management of upper tract urothelial cancer. Moreover, on Sunday, the Society of Urologic Robotic Surgeons (SURS) session at AUA2021, led by Dr. Tewari, featured eminent speakers lecturing on different hot topics related to robotic assisted surgery.

Over 320 abstracts related to robotic surgery were accepted as podium presentations and moderated posters, as well as videos (103) distributed in different subject areas. Not surprisingly, most contributions were in oncology, above all for prostate and kidney cancer management (fig. 1). Here are some of the abstracts that deserve, in my opinion, to be mentioned.

Figure 1. Abstracts related to robotic surgery at AUA2021: distribution by therapeutic area.

Oncology: Kidney Cancer

Beksac et al reported a multi-institutional analysis of 72 patients who underwent robotic partial nephrectomy for recurrent renal tumor (PD64-06). Two cases (2.8%) were converted to open surgery. One patient underwent radical nephrectomy due to bleeding. Major complication rate was 8.3%. Estimated glomerular filtration rate preservation was 90.8% at 1-year followup. Positive surgical margin rate was 9.5%. Only 1 patient had local recurrence (1.4%). Yim et al presented a retrospective analysis utilizing the ROSULA registry comparing minimally invasive radical nephrectomy to robotic partial nephrectomy for cT3a renal tumors (PD64-11). A total of 441 patients were analyzed. Multivariate analysis demonstrated increasing American Society of Anesthesiologists® class, positive margins, and sarcomatoid histology to be independently associated with worsened all-cause mortality, while type of surgery was not. Increasing age, hypertension and radical nephrectomy were associated with de novo estimated glomerular filtration rate <60.

Oncology: Prostate Cancer

Nguyen et al reported the preliminary results of a phase I study in 24 high-risk prostate cancer patients undergoing robotic prostatectomy using a novel near-infrared prostate specific membrane antigen (PSMA) targeted fluorophore (IS-002) designed to enhance intraoperative cancer visualization (PD61-04). Among the 7 patients with complete histopathology data, IS-002 successfully achieved pathologically confirmed tumor fluorescence in 7/7 (100%). Surgeons using IS-002 reported excellent tumor discrimination (fig. 2). Nyarangi-Dix et al reported early continence outcomes of a prospective, randomized, single blinded trial comparing Retzius-sparing to conventional robotic assisted radical prostatectomy (MP15-14). At 3 months, Retzius-sparing patients had a faster recovery of continence. Checcucci et al investigated the use of “hyper accuracy” 3D prostate models during 160 robotic radical prostatectomy procedures in a cognitive or augmented reality setting (PD61-01). The use of 3D models was an independent predictor of lower rates of positive surgical margins. Gondoputro et al reported the interim results of a prospective, international, multi-institutional study (DETECT) evaluating radio-guided surgery for prostate cancer using ^99mTc-labelled PSMA targeting (MP50-05). Men with suspected or known lymph node metastasis who had undergone a preoperative PSMA positron emission tomography scan were consented to undergo a preoperative intravenous administration of ^99mTc-labelled PSMA (500 MBq). Patients then underwent a robot-assisted radical prostatectomy with extended lymph node dissection. A total of 10 patients were included in the study. The sensitivity, specificity, and negative and positive predictive values of the gamma probe in the intraoperative detection of extra-prostatic prostate cancer was 68.8%, 82.2%, 57.9%, and 88.1%, respectively.

Figure 2. a–h, images from abstract PD61-04 reporting on preliminary results from phase I dose-escalation study using novel near-infrared PSMA targeted fluorophore (IS-002) designed to enhance intraoperative cancer visualization during robotic radical prostatectomy. Reprinted with permission of the American Urological Association. NVB, neurovascular bundle. PSM, positive surgical margin.

Oncology: Bladder and Testis

Mastroianni et al reported the 2-year oncologic outcomes from a randomized controlled trial comparing open to robotic radical cystectomy with totally intracorporeal urinary diversion (NCT03434132; PD55-07). Overall, 116 patients were enrolled. The 2 study arms displayed comparable overall, cancer specific, disease-free and metastasis-free survival. Ghoreifi et al evaluated post-chemotherapy robotic retroperitoneal lymph node dissection in a retrospective study including 43 cases done at 5 U.S. academic centers (PD53-06). Median estimated blood loss, operative time, and length of hospital stay were 100 mL, 5.7 hours, and 2 days, respectively; 90-day complication rate was 25%, most of which were low grade. At a median followup of 9 months, 1 patient had disease recurrence.

Benign Prostatic Hyperplasia

French et al analyzed data on 799 patients from the 2016 HCUP State Databases from Florida and New York to look at a cost comparison between robotic assisted simple prostatectomy and holmium laser enucleation of the prostate for large gland benign prostatic hyperplasia (PD25-07). Interestingly, robotic assisted simple prostatectomy was significantly cheaper (average difference $1,149, p <0.001). Zorn et al reported the 3-year outcomes of the robotic-assisted Aquablation procedure for the treatment of benign prostatic hyperplasia due to large-volume prostates (80–150 cc) in an international multicenter prospective trial (NCT03123250; PD18-06). Improvements in International Prostate Symptom Score, International Prostate Symptom Score-Quality of Life, maximum flow rate, and post-void residual were immediate and sustained throughout followup. Only 3 subjects required surgical retreatment over the course of 3 years.

Transplantation

Zeinab et al presented the outcomes of the initial 7 patients who underwent robotic single port kidney transplantation (MP37-01) at their center. All cases were completed successfully. Median total operative and vascular anastomosis times were 372 and 53 minutes, respectively. None of the patients had delayed graft function requiring dialysis. All patients up to 1-year followup had no acute rejection.

Reconstruction

Chao et al reported the outcomes of 26 cases of robotic nontransecting ureteral reimplantation from a multi-institutional ureteral reconstruction database (CORRUS; PD35-07). There were no intraoperative or immediate postoperative complications. Over a median followup of 21 months, 2 patients (7.7%) developed recurrent stenosis. Ten patients (38.5%) reported symptoms suggestive of de novo vesicoureteral reflux, and they were mostly managed conservatively. Shakir et al presented a multi-institutional group experience with robotic-assisted vesicourethral anastomotic stenosis reconstruction (MP03-14). A total of 32 patients from 6 institutions met study criteria. At a median followup of 12 months, 25 patients (78%) had patent repairs and 26 (81%) were voiding per urethra.

Pediatrics

Grant et al compared the outcomes of stented (196) and stentless (114) robotic pyeloplasty (MP44-12). Stentless procedure had shorter operative time and similar overall complication rate allowing avoidance of a second procedure for stent removal.