offers perspective on noteworthy research in the peer-reviewed literature. Dr. Mian is professor of surgery in the division of urology at Albany Medical College, New York.

Despite a paucity of high-quality evidence, extended pelvic lymph node dissection (EPLND) at the time of radical prostatectomy (RP) has been being recommended with increasing frequency over the last few years. Several retrospective studies have reported increased lymph node yield as well as increased detection of positive lymph nodes. However, the true extent of any therapeutic benefits of EPLND remains debatable. In a recently reported randomized study comparing limited pelvic lymphadenectomy (LPLND) and EPLND, Lestingi et al demonstrated that although EPLND may improve pathological staging, the oncological benefits remain unclear.

The study enrolled 300 patients from May 2012 to December 2016, and randomly allocated 150 men to LPLND and 150 men to EPLND. The primary end point of interest was 5-year biochemical recurrence-free survival (BRFS). Secondary end points included metastasis-free survival (MFS), cancer-specific survival, and histopathological findings. The study was designed to detect a 15% improvement in 5-year BRFS in the EPLND group, assuming a 5-year BRFS rate of 65% for the LPLND group.

For the entire cohort, median age was 63 years and median prostate-specific antigen level was 10.5. Gleason grade group distribution showed 36% of patients were grade group (GG) 1, 40% GG 2, and 23% GG 3 to 5. Nearly 62% were classified as D’Amico intermediate-risk prostate cancer and 38% as high-risk prostate cancer. For the bilateral lymph node dissection, LPLND was confined to the obturator zone only while the EPLND included the obturator, external iliac, internal iliac, common iliac, and presacral regions.

After RP and pelvic lymphadenectomy, pathologic stage T3a or higher was noted in more than 60% of patients, and positive surgical margins were noted in 40%. The median number of nodes removed with LPLND and EPLND was 3 and 17, respectively (

<.001). Lymph node metastases were noted in 5 (3.4%) men in the LPLND group and in 25 (17%) men in the EPLND group (

<.001). In subgroup analysis of men with D’Amico intermediate-risk and high-risk prostate cancer, a higher lymph node metastases rate was noted with EPLND (11% and 26%, respectively) than with LPLND (0% and 11%). Of the 25 patients with lymph node metastases in the EPLND group, the most frequent sites included internal iliac (65%), external iliac (39%), and obturator (35%) lymph nodes.

The median follow-up for patients without biochemical recurrence was 53.9 months. No difference in BRFS was noted between EPLND and LPLND groups. The median BRFS was 61.4 months in the LPLND group, and it was not reached in the EPLND group (HR, 0.91; 95% CI, 0.63-1.32; 

=0.6). Further, the median MFS was not reached in either group, and there were no differences between the 2 groups in terms of distant metastases or death. Salvage radiation therapy utilization was similar in both groups (32% in LPLND, 25% in EPLND). Androgen deprivation therapy was required in 18% and 14% of men in the LPLND group and the EPLND group, respectively.

In the subgroup of men with biopsy GG 3 to 5 undergoing EPLND, the BRFS was superior to men undergoing LPLND using both the intention-to-treat (HR, 0.33) and per-protocol analyses (HR, 0.48). Using Kaplan-Meier estimates, intention-to-treat analysis showed median BRFS at 12.34 months in the LPLND group and not reached in the EPLND group (HR, 0.48; 

=0.02). However, in the per-protocol analysis, the median BRFS in the LPLND and EPLND groups was not statistically significant (19.9 months vs 32.7 months, respectively; HR, 0.79; 

One of the limitations of the study is the somewhat short follow-up to assess survival outcomes; however, this follow-up may be acceptable for the early oncological outcome such as biochemical recurrence. Further, the complications associated with PLND were not reported and will likely be revealed in a follow-up manuscript. Although findings suggest that a subset of patients, such as those with Gleason GG 3 to 5, may benefit from EPLND, the number of subjects in each group was too small (LPLND, 38 men; EPLND, 31 men) to draw firm conclusions. The oncological benefit of EPLND in men with high-grade prostate cancer would require validation in a separate larger study.

Previous publications (typically observational or case-control studies) have variably reported some oncological benefit associated with EPLND but also increased risk of complications such as lymphocele formation, bleeding and increased operative time. The current study may represent the only study providing a high level of evidence about the oncologic benefits of EPLND at the time of RP. In this randomized trial, EPLND significantly improved lymph node staging but failed to demonstrate any overall benefit compared to LPLND in terms of biochemical recurrence or metastases.

While we await results of other trials, especially those including a larger number of men with biopsy GG 3 to 5, or high-risk prostate cancer, it appears that EPLND is unnecessary in most patients undergoing RP, with the possible exception of men with high-risk disease.

1. Lestingi JFP, Guglielmetti GB, Trinh Q-D, et al. Extended versus limited pelvic lymph node dissection during radical prostatectomy for intermediate- and high-risk prostate cancer: early oncological outcomes from a randomized phase 3 trial. 

Published online December 5, 2020. doi:10.1016/j.eururo.2020.11.040

Articles

The technique fails to demonstrate benefits for prostate cancer recurrence and metastases.

Extended pelvic lymph node dissection during RP does not appear beneficial

Urologic cancer care is quickly changing with the widespread use of a growing number of immunotherapy drug options. The shifting treatment paradigm is impacting not only patients’ lives but also urology practices, as more practices look to incorporate immunotherapy treatment for prostate, bladder, and kidney cancers.

Urologists actually were among the pioneers in immunotherapy treatment, dating back to the 1980s.

“Urologists have been using [BCG] immunotherapy in bladder cancer for over 3 decades,” said Neal D. Shore, MD, director of the Carolina Urologic Research Center at Atlantic Urology Clinics in Myrtle Beach, South Carolina.

BCG offered one of the first options for cancer treatment in which the patient’s immune system could be stimulated to help fight the cancer, minimizing cytotoxic adverse effects of treatment.

“This new era of cancer therapy really focuses on optimally treating cancer while maximizing quality of life during treatment,” said Tom Jayram, MD, codirector of the Advanced Therapeutics Center for Urology Associates in Nashville, Tennessee.

Another immunotherapy used by urologists is sipuleucel-T (Provenge), which was FDA approved in 2010 for patients with asymptomatic or minimally symptomatic metastatic castrate-resistant prostate cancer.

Sipuleucel-T was a game changer for prostate cancer and the specialty of urology, said Rian Dickstein, MD, a urologist at Chesapeake Urology and chairman of urology at the University of Maryland Baltimore Washington Medical Center.

“Provenge was the first autologous cellular immunotherapy [for metastatic disease] and the first immunotherapy to prolong overall survival in the setting of advanced prostate cancer,” Dickstein said.

The FDA has since approved 5 checkpoint inhibitors: pembrolizumab (Keytruda) for bladder and kidney cancers, nivolumab (Opdivo) for bladder and kidney cancers, atezolizumab (Tecentriq) for bladder cancer, avelumab (Bavencio) for bladder cancer and in combination with a tyrosine kinase inhibitor for kidney cancer, and durvalumab (Imfinzi) for bladder cancer.

“Since 2015, we have witnessed a breakthrough pace of approvals of an additional class of immunotherapeutics called checkpoint inhibitors, [which] either directly block [PD-1] or block [PD-L1], which interacts with the [PD-1] receptor,” Shore said. “These 5 therapeutics have gained widespread global usage in patients with advanced bladder cancer.”

The thinking is that many tumors grow and spread by turning off the host’s immune system. Checkpoint inhibitors target this ability, essentially turning back on the body’s natural tendency to fight the cancer. This “natural” defense also spares patients of some of the adverse effects of older chemotherapy drugs, according to Jayram.

“Chemotherapy is still very effective,” Jayram said. “But what we’re seeing, especially in genitourinary cancers, is immunotherapy can work just as well while being easier to administer and safer for patients.”

Ongoing trials are investigating checkpoint inhibitors as maintenance therapy for patients with advanced bladder cancer. According to Shore, these agents are being well utilized for patients with advanced renal cancer, in addition to incorporating the CTLA4 antibody inhibitor ipilimumab (Yervoy) as a second immunotherapy.

Urologists are particularly interested in investigators studying these same checkpoint inhibitors in trials examining their activity in neoadjuvant therapy prior to cystectomy, in lieu of or in combination with platinum-based chemotherapy. Researchers are also investigating these checkpoint inhibitors in combination with chemo-radiation as part of the trimodal bladder-sparing approach to avoid cystectomy for patients who have T2 or greater disease, as well as to treat BCG-naive, high-risk non–muscle invasive bladder cancer patients with concomitant BCG, with or without a course of maintenance BCG, Shore said.

“Of note, in 2020, pembrolizumab received FDA approval for high-risk BCG-unresponsive patients with carcinoma in situ,” Shore said.

Incorporating immunotherapy into your practice

Given the tremendous advancements in urologic cancer care with immunotherapeutic and other drug options, Shore added that it is incumbent upon urologists to develop their expertise in the different therapy types and to consider launching advanced prostate, bladder, and possibly kidney cancer clinics in their practices.

Currently, providers administer immunotherapy intravenously, with the exception of BCG, which is administered intravesically.

“Trials are ongoing looking at subcutaneous administration of checkpoint inhibitors, which may be appealing to some urologic clinics that are not as comfortable with an intravenous administration,” Shore said.

But for now, the newer PD-1 and PD-L1 inhibitors are administered intravenously and carry risk for systemic toxicities. Medical oncologists typically administer these immunotherapies, but a number of urology practices have implemented or are looking at implementing immunotherapy options, especially in the setting of non–muscle invasive bladder cancer, according to Dickstein.

Collaborating with a medical oncologist is ideal for urology practices launching infusion or immunotherapy centers, but if that is not an option for a community urology practice, it is possible to offer immunotherapy treatment safely and successfully, Dickstein said.

Because immunotherapy is different than other drugs in respect to adverse events, monitoring, and disease progression, Jayram said that most urology practices are going to need an experienced cancer team, consisting of a centralized treating physician and nurses and nurse practitioners familiar with infusion therapies, as well as cancer navigation systems to appropriately identify patients.

Shore said that he believes the biggest barrier to entry for urologists in this space is their comfort level in understanding the etiology and management of immune-related adverse events from checkpoint inhibitors.

“These are immune-related inflammatory type syndromes,” Shore said. “The most common ones we see include dermatitis, pneumonitis, colitis, [and] transaminitis, but there are other very important adverse immune events that need to be recognized and can include thyroiditis, pancreatitis, and very uncommon observations of encephalitis or myocarditis. It is incumbent upon the health care provider to be absolutely familiar with the mechanism of action, the appropriate indications, and how to assuredly educate patients and their families on identification of adverse events as early as possible and to manage them as early as possible with appropriate interventions, which can oftentimes involve medical subspecialty consultation.”

Telemedicine has been a boon to urologists’ management of many patients with cancer, including those on immunotherapy. Urologists and staff members can talk more often with patients, asking important questions about how they are feeling and potential adverse effects. They can also use the time on telemedicine visits to review lab work and radiographic imaging. But telemedicine does not take the place of the physical exam, which must still be done, according to Shore.

To monitor for adverse events from immunotherapies, Jayram’s staff schedules telehealth appointments between the infusions.

“With checkpoint inhibitors, small things can become big things in terms of [adverse] effects. The treatment team needs to be proactive in monitoring response and prioritize patient-provider communication,” Jayram said. “Telehealth has proven to be a great tool for monitoring, especially during [coronavirus disease 2019], when patients do not want to be coming to the office very frequently.”

Regarding reimbursement for FDA-approved immunotherapies, it has not been a problem for Shore’s practice.

“For appropriate FDA-approved indications, I have had no difficulty getting reimbursement for all 5 of the checkpoint inhibitors that have come onto the market since 2015. I have used all of them [including] ipilimumab,” Shore said.

Although reimbursement is not usually a major concern, private groups outside a hospital setting still have some operational considerations. Margins tend to be small, and there is some risk because groups generally buy the drugs first and bill the patient’s insurance later, according to Jayram.

Nevertheless, given the trend in urologic cancer therapy to include immunotherapy when appropriate in patients’ treatment, broadening treatment offerings is something that all urology practices should consider.

“Instead of just offering a select-few treatment options, ideally you would like to be able to offer patients a whole menu of treatments and have an educated conversation regarding the risks and benefits for each of these treatment options,” Dickstein said.

Undoubtedly, it is an exciting time in uro-oncology and urology.

“Systemic therapies for cancer historically were utilized the most at the end stages of cancer. Now, because these treatments have fared so well, we are seeing novel new applications being brought into the localized setting,” Jayram said.

Immunotherapy will begin to replace some, but not all, therapeutic regimens used to treat urologic cancers.

“There seems to be less of a role in prostate cancer for checkpoint inhibitors than in bladder or kidney [cancers], but there is still a lot of ongoing work to try and figure that out,” Jayram said. “The bigger trend is [that] we are bringing these agents earlier into cancer pathways and combining them with other established local and systemic treatments. This approach is allowing more patients to receive and potentially benefit from these life-altering therapies.”

“Instead of just offering a select-few treatment options, ideally you would like to be able to offer patients a whole menu of treatments and have an educated conversation regarding the risks and benefits for each of these treatment options," says Rian Dickstein, MD.

How urology groups can incorporate immunotherapy treatments into their practice

Urology Times® reached out to 3 urologists (selected randomly) and asked them each the following question: What do you hope to see happening in urology in 2021?

“I’m just praying for it to go back to the way it was in 2019, honestly. This year has been an exhausting, trying, difficult-to-navigate year. It would be lovely to just be the way it was a year ago. I’m not looking for anything exciting; I’m only looking to be able to practice medicine where I’m seeing patients in my office and having lunch with my staff again.

We are doing a ton of telemedicine here in Philadelphia. We’re not doing a ton of operating, but we’re doing a ton of telemedicine, which is not as fulfilling as seeing patients in the office.

I’m not hearing about a lot of advances going on in urology right now. That doesn’t mean it’s not happening; I’m just not aware of it.

At least [coronavirus disease 2019 (COVID-19)] doesn’t seem to be affecting the urologic system that we’re of aware of right now. I’m just hopeful the vaccines can get us back to normal.

This is probably about the first year we haven’t really been looking forward to some decent advancements in urology. There may be some coming, but this has been such a bizarre year [that] I think most everybody’s just looking to survive and get through this year as best we can. Our practices are changing. Patients aren’t coming in. We certainly don’t have our staff. It’s hard to look to the future when you can barely function in the present.”

“I’m certainly hoping, obviously, that we can return to practicing safely and helping patients with their urologic conditions in a timely manner.

We’ve had a lot of stress [around] delivering care because of COVID-19. There [have] been delays for men with prostate cancer [and for] people suffering with prolapse or other issues who are having trouble getting into, or are afraid of seeing, urologists. I really hope that doctors and their staffs can serve those people safely this year.

When they talk about elective procedures being postponed or unavailable because hospitals are dealing with COVID-19, we’re talking about the lady who has prolapse or the man with the catheter. Those are elective, but they’re definitely critical to quality of life. I’m hoping we can get back to taking care of patients who need us.

As far as anything new coming out of research, it’s actually been difficult, at least in California. We’ve had trouble because [of the] stay-at-home order. Campuses were closed; research staffs weren’t allowed on campus. In the spring, we shut down a lot of our labs.

I do health services research, so we can work remotely more easily, but it sometimes involves encountering patients. That’s a problem. I have COVID-19 right now. I’m recovering, but I was pretty sick.

Research was getting back to normal, but now we have another surge so we’re having another lockdown.

There’s been less travel and more online conferences and meetings. That’s been a big change. There’s been more time, but there have been resource constraints around doing research at many facilities where campuses are not open.

Some interesting proposals are coming up [for] managing bladder cancer; some proposals are being developed around molecular subtyping of bladder cancer. There are also proposals around handling small renal masses—how to manage them without overtreating or undertreating them and the role of biopsy in those plans.”

“I’m excited for potential FDA approval of 2 intravascular therapies for high-risk, non–muscle invasive bladder cancer [that is] unresponsive to BCG. These include nadofaragene firadenovec, an investigational gene therapy by FerGene, and oportuzumab monatox, a recombinant fusion protein by Sesen Bio. These 2 therapies will join pembrolizumab [Keytruda], the first drug for patients unresponsive to BCG that was just approved this year that could allow these patients to avoid a cystectomy.

In prostate cancer, we should have the announcement of the phase 3 VISION trial results of the novel therapeutic drug Lu-PSMA-617, a prostate-specific membrane antigen–targeting agent used to deliver radionuclide therapy for the treatment of advanced prostate cancer patients with [metastatic castration-resistant prostate cancer]. This would add another new therapeutic with a distinct mechanism of action.

But I’m most excited about the FDA approval of the first and only oral [gonadotropin-releasing hormone] antagonist, relugolix (Orgovyx, Myovant Sciences), for androgen deprivation for patients with advanced prostate cancer. It offers enhanced cardiovascular safety and an enhanced mechanism of action as an antagonist. It has faster, more profound testosterone suppression and a shorter course of therapy.

Fortunately, our research program has not been deterred by the pandemic, and we’ve not experienced any setbacks in monitoring our patients or in accruing new subjects.

Our clinic, both outpatient and inpatient schedules, has been very busy. But personally, I haven’t been traveling anywhere near the degree I was, so it has allowed me to be more productive regarding my educational endeavors and
my research.”

"I’m just praying for it to go back to the way it was in 2019, honestly," says 1 urologist.

What do you hope to see happening in urology in 2021?

Are there any significant tax changes for 2021?

Each year, the Internal Revenue Service (IRS) announces adjustments to 

the tax code for the upcoming year. The IRS has not made any significant changes so far, but the agency did make some notable adjustments. Also keep in mind that with a new president-elect and a potential change in the makeup of Congress, the current tax code could be altered again. However, until that time, it is important to stay familiar with the current rules.

In this article, I will discuss some of the important adjustments made by the IRS for 2021.

The standard deduction increased from $24,800 to $25,100 for married couples who file jointly and increased by $150 to $12,550 for single filers and those married but filing separately. Head of households also get a $150 increase to $18,800 in their standard deduction.

Tax rates remained the same, but the brackets increased slightly (

). Likewise, the capital gains rates remained the same, but the income bracket that determines the rate paid increased. Single filers and married filing separately earning $40,400 per year or less will pay a 0% capital gains rate; married filing jointly earning $80,800 or less and head of households earning $54,100 or less will also pay a 0% taxable gains rate. The 15% rate will apply to adjusted net capital gains up to $501,600 for joint returns, $250,800 for married individuals’ separate returns, $473,750 for head-of-household returns, and $445,850 for single individual returns. For any earnings above these amounts, the applicable capital gains rate is set at 20%.

The maximum contribution amounts into employer-provided retirement plans, such as 401(k)s, 403(b)s, and 457 plans, and the federal government’s Thrift Savings Plan did not change. The limit remains at $19,500, and the catch-up contribution for employees 50 years and older continues to be $6500. For SIMPLE (Savings Incentive Match Plan for Employees) retirement accounts, the contribution limit remains $13,500 and the catchup remains $3,000.

The limit on annual contributions into an individual retirement account (IRA) for pretax, Roth, or a combination remains at $6000 for 2021. The catch-up contribution limit remains at $1000. The deduction for taxpayers making contributions to a traditional IRA is phased out for singles and heads of household who are covered by a workplace retirement plan and have modified adjusted gross incomes (AGI) between $66,000 and $76,000, up from $65,000 and $75,000 in 2020. For married couples filing jointly, in which the spouse who makes the IRA contribution is covered by a workplace retirement plan, the income phase-out range is from $105,000 to $125,000 for 2021, up from $104,000 to $124,000. For an IRA contributor who is not covered by a workplace retirement plan but is married to someone who is covered, the deduction is phased out if the couple’s income is between $198,000 and $208,000 in 2021, up from $196,000 to $206,000 in 2020.

The Roth IRA AGI phase-out range increased to $198,000 to $208,000 for married couples filing jointly, up from $196,000 to $206,000 in 2020. For singles and heads of household, the income phase-out range is from $125,000 to $140,000, up from $124,000 to $139,000 in 2020. If your income exceeds these amounts, you can open a nondeductible IRA and convert it to a Roth IRA.

The income limit for the saver’s credit is $66,000 for married couples filing jointly, $49,500 for heads of household, and $33,000 for singles and married filing separately, up from $32,500.

The IRS made additional changes to the individual tax credit, alternative minimum tax, and allowances for fringe benefits, medical savings accounts, and estates.

Also remember that the special tax provisions enacted as part of the coronavirus relief bill expired at the end of 2020 (unless reenacted by new legislation). These rules offered more flexibility for certain distributions and loans from retirement plans and waived required minimum distributions.

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The information contained in this report is for informational purposes only. Any calculations have been made using techniques we consider reliable but are not guaranteed. Please contact your tax advisor to review this information and to consult with them regarding any questions you may have with respect to this communication.

Among the changes are increases in phase-out ranges for traditional and Roth IRAs.

Tax code in 2021: Take note of these changes

A new study investigating ethnic disparities in prostate cancer cases found no evidence that Hispanic White men had worse outcomes after undergoing radical prostatectomy (RP) compared to non-Hispanic White men.

 However, because of the limitations of the research, the findings need to be considered with caution, said Lourdes Guerrios-Rivera, MD, MSc.

“Our study was conducted utilizing the Shared Equal Access Regional Cancer Hospital (SEARCH), a robust multicenter and multiethnic database derived from the VA health system that was chosen to minimize potential confounding from differences in access to care. Besides, we focused on men with early-stage disease treated aggressively to minimize differences in practice patterns,” said Guerrios-Rivera, assistant professor of surgery, University of Puerto Rico School of Medicine, and urology staff, VA Caribbean Healthcare System, San Juan.

“However, SEARCH lacks granular data on country of origin, and that is a key limitation of our study because Hispanic individuals comprise a highly diverse population with subgroups in the United States differing culturally, socially, and possibly genetically. Therefore, it is important to state that our findings may not apply to all Hispanic subgroups and may miss important differences.”

Guerrios-Rivera is lead author of an article reporting the research. After excluding men who received neoadjuvant treatment, as well as those missing information on baseline disease-related characteristics and follow-up, it analyzed data from 3789 White men who underwent RP between 1988 and 2017. Of the included population, 236 (6%) were Hispanic.

Baseline disease-related characteristics between the Hispanic and non-Hispanic White men were similar except mean prostate-specific antigen (PSA), which was higher in the Hispanic group. Multivariable analysis adjusting for age, PSA, clinical stage, biopsy grade group, surgery year, and surgical center found no ethnicity-related differences in pathological features, including extracapsular extension, seminal vesicle invasion, positive margins, positive lymph nodes, or high-grade disease.

During a median follow-up of 7.9 years, biochemical recurrence occurred in 1168 men, 182 men developed metastasis, and 132 men developed castration-resistant prostate cancer. Findings from multivariable analysis showed that none of the oncologic outcomes were significantly associated with Hispanic ethnicity.

“In fact, the results for all 3 outcomes showed a numerical difference favoring the Hispanic men. However, none of the differences achieved statistical significance,” Guerrios-Rivera said.

In addition to the inability to subgroup Hispanic men by country of origin, the study’s focus on men undergoing RP is another issue that limits the generalization of its findings.

“Treatment selection differences may exist among White Hispanic men, because race may influence the patient’s opinion for treatment selection,” Guerrios-Rivera said.

“Further studies are needed to investigate ethnicity-related differences in outcomes after other treatments for prostate cancer.”

There have been relatively few studies investigating associations between Hispanic ethnicity and outcomes after definitive treatment for prostate cancer, but the available research has generated conflicting results. Two small, single-institution studies of men undergoing RP found no differences among Hispanic men.

 However, results of a more recent population-based study showed higher rates of prostate cancer-specific mortality after RP for Puerto Rican men than for both non-Hispanic White men and non-Hispanic Black men.

“The latter findings are interesting in that in Puerto Rico, most men labeled as Hispanic White have some African ancestry due to extensive genetic admixture. As such, whether the findings of worse outcomes among men from Puerto Rico is due to African ancestry, which is known to impact poor outcomes, a unique mix of genetics, or environmental factors specific to Puerto Rico is not known,” Guerrios-Rivera said.

Overall, the available evidence indicates that a better understanding of the diversity within the Hispanic population may shed important light on health disparities and prostate cancer biology.

“It is our interest to develop future studies addressing prostate cancer disparities, particularly in Puerto Rican men, by evaluating the genomic and the immune biologic signatures of those populations at risk of progression,” Guerrios-Rivera told 

1. Guerrios-Rivera L, Howard LE, Klaassen Z, et al. Do Hispanic men have worse outcomes after radical prostatectomy? Results from SEARCH. 

Published online November 12, 2020. doi:10.1016/j.urology.2020.10.043

2. Lam JS, Sclar JD, Desai M, Mansukhani MM, Benson MC, Goluboff ET. Is Hispanic race an important predictor of treatment failure following radical prostatectomy for prostate cancer?


2004;172(5)(suppl 1):1856-1859. doi:10.1097/01.ju.0000141783.67470.55

3. Gomez P, Manoharan M, Sved P, Kim SS, Soloway MS. Radical retropubic prostatectomy in Hispanic patients. 

2004;100(8):1628-1632. doi:10.1002/cncr.20127

4. Velasquez MC, Chinea FM, Kwon D, et al. The influence of ethnic heterogeneity on prostate cancer mortality after radical prostatectomy in Hispanic or Latino men: a population-based analysis. 

2018;117:108-114. doi:10.1016/j.urology.2018.03.036

Because of the limitations of the research, the findings need to be considered with caution, said Lourdes Guerrios-Rivera, MD, MSc.

Study: No differences in oncologic outcomes after RP among Hispanic vs non-Hispanic White men

The majority of the literature on urologic robotic surgery centers around the transperitoneal approach. However, the robotic retroperitoneal approach is gaining momentum. The minimally invasive retroperitoneal approach to renal surgery was initially developed in the 1990s by urologists performing laparoscopic nephrectomies for benign conditions.

 They found that patients undergoing retroperitoneal laparoscopic nephrectomy resumed normal oral intake faster and had a trend toward lower postoperative narcotic requirements compared to their transperitoneal counterparts. Other groups adopted this technique and demonstrated shorter operative time,

 However, the challenge of laparoscopic suturing in the retroperitoneal space may have prevented the widespread adoption of this approach. In the 2000s, urologists quickly embraced the robotic platform and now routinely perform robotic renal surgery employing the benefits of instrument articulation and 3D view.

These improvements in robotic technology have reinvigorated interest in retroperitoneal access for renal surgery. The robotic retroperitoneal approach again has been shown to decrease the length of hospital stay,

 It offers direct access to the kidney without the need to mobilize the bowel and provides an avenue for urologists to avoid the hostile abdomen of a patient with prior abdominal surgery.

 Barriers to learning this technique may include the different perspective of hilar and renal anatomy, the smaller working space, and unfamiliarity with positioning, access, and docking the robot. However, once these are overcome, the benefits of retroperitoneal surgery are readily apparent.

The robotic retroperitoneal approach has been primarily implemented in partial nephrectomy cases but has also been used to perform radical nephrectomies,

 In the domain of partial nephrectomy, the retroperitoneal approach is thought to be especially useful for posterior and lateral tumors,

 but Arora et al showed that surgeons can take a retroperitoneal approach to anterior tumors without any difference in operative time, estimated blood loss, intra-operative complications, or postoperative complications.

In retroperitoneal renal surgery, the kidney is quickly encountered after a brief dissection of the retroperitoneal space. Unlike transperitoneal surgery, there is no need to mobilize the bowel. The surgeon never encounters nor has to retract the liver or spleen. There is no need to kocherize the duodenum for right-sided cases, and the tail of the pancreas is never encountered on the left. The hilum, and particularly the renal artery, is readily accessible for clamping within minutes of docking without navigating the renal vein. This direct approach to the kidney and rapid hilar access with minimal dissection allows for a much shorter operative time compared with the transperitoneal approach.

 Any postoperative bleed or urine leak is contained in the retroperitoneum, which may prevent the development of an ileus and other morbidities.

 These benefits can be especially useful in patients with intra-abdominal adhesions, ventral hernias, or colostomies, or those who are on peritoneal dialysis, but can also be applied to routine renal or adrenal surgery. The proximal ureter, renal pelvis, adrenal gland, and regional lymph nodes have all been accessed using the retroperitoneal approach.

Patients should be placed in a full lateral decubitus position with the table slightly flexed to increase space between the ribs and iliac crest (

). An axillary roll is utilized, and the patient is secured and padded using a beanbag, foam, and tape. The camera port incision is made 2 fingerbreadths above the iliac crest in the midaxillary line. Blunt finger dissection is carried down to the thoracolumbar fascia, which is divided sharply with scissors. Development of the retroperitoneal space can be performed either using a finger or small balloon dissector. At this point, pneumo-retroperitoneum is established. Landmarks are identified, including the psoas muscle as the “floor” and transversus abdominus muscle as the “ceiling,” with the peritoneal reflection draping medially. A posterior 8-mm robotic port is placed under direct vision 8 cm from the camera port, and through this a Kittner laparoscopic dissector is used to medialize the peritoneal reflection. A second 8-mm robotic port is placed after the peritoneum has been mobilized. It is critical to place the anterior port after mobilizing the peritoneum to prevent the port from being placed transperitoneally. A 12-mm assistant port is subsequently placed just inferior and medial to the camera port in a similar fashion. Robotic port placement can be varied to optimize access to the lower versus upper pole of the kidney or retroperitoneal space. The robot is docked over the 12-mm camera port with a slight anterior rotation (

). Once the robot is docked, the kidney is elevated off the psoas muscle and the hilum is identified by the pulsation of the renal artery. When approaching the hilum, the renal artery is usually the first vessel encountered. If needed, the renal vein can be skeletonized. We do not routinely close the fascia of the port sites.

Robotic retroperitoneal surgery is a valuable technique in the surgeon’s toolbox. With more familiarity, surgeons can employ the benefits offered by this approach. We anticipate further advancements in this field in an effort to minimize postoperative morbidity and the use of health care resources. We also imagine the retroperitoneal approach in novel applications such as ureteroplasty and ureterolithotomy. The continued miniaturization and refinement of the robotic platform combined with improved surgeon comfort will facilitate future innovation and refinement of urologic surgery in the retroperitoneal space.

is a 5th-year urology resident at Loyola University Medical Center, Maywood, Illinois. 

completed a robotics/endourology fellowship at Loyola University Medical Center in June 2020 and is now in community practice in Green Bay, Wisconsin. 

 is associate professor of urology, radiology, and surgery at Loyola University Medical Center.

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Improvements in technology have renewed interest in the technique.

Vol 49 No 01

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Going “retro”: A perspective on robotic retroperitoneal renal surgery