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The objective was to describe our step-by-step technique for robot-assisted orthotopic "W" ileal neobladder (INB) for urinary diversion following radical cystectomy for oncological purpose, and to report the outcomes of this technique for the first six male patients treated at our center. Patients underwent robot-assisted radical cystoprostatectomy for bladder cancer and had a "W" ileal neaobladder as urinary diversion. Our surgical technique is described step by step and video illustrated. Patients and operative data were collected and reported. The Expanded Prostate Cancer Index Composite Short Form (EPIC-26) self-administered questionnaire was used to assess the urinary, sexual and bowel functions outcomes at 90 days postoperatively. The mean operative time was 475 min [420-525] and mean length of stay was 13 days [11-15]. No major complications occurred (Clavien grade ≥ 3). Regarding the continence four patients reported they leaked urine rarely or never and two patients having urine leak once a day. Two patients did not wear any pad, the four others reported using pad at night. Two patients reported urinary function as not a problem, one as a very small problem, two as a small problem and one as a moderate problem. These results from our six first cases using the technique described here are promising with interesting early functional outcomes. This has to be confirmed on larger cohort and with long-term follow-up.

Several studies have attempted to define the learning curve associated with robot-assisted laparoscopic prostatectomy (RALP). These studies have focused on the acquisition of skills by novice robotic surgeons. It is unclear, however, if basic proficiency can be equated with satisfactory patient outcomes. We surveyed experienced robotic surgeons with high surgical volume in an attempt to define an "advanced" learning curve, relating to proficiency and outcomes with the robotic procedure. A questionnaire was designed to evaluate the learning curve of the RALP from basic to advanced techniques. High-volume, experienced surgeons were asked to complete this questionnaire on the basis of their personal experience with the RALP procedure. Nine institutions participated in the study accounting for a total case volume of 6,276. Median surgeon experience was 460 cases (range 325-1,500); median total operative and robotic time were 165 and 105 min, respectively. Median time to "basic proficiency" with the robot was 40 cases; proficiency in more challenging cases was approached after a median of 50 cases. Surgical outcomes were deemed satisfactory to the surgeon for continence, potency, and surgical margins after a median of 100, 200, and 300 procedures, respectively. These data confirm previous studies that basic proficiency with the robotic system occurs relatively quickly, after 25-40 cases. Obtaining "satisfactory outcomes" took substantially longer, from 100 to 300 cases. Satisfactory outcomes regarding surgical margins and potency took longer to obtain than continence, likely reflecting the relative complexity of cancer control and nerve-sparing compared with the vesico-urethral anastomosis.

While cancer control is the primary objective of radical prostatectomy, maintenance of sexual function is a priority for the majority of men presenting with prostate cancer. Preservation of the neurovascular bundles is the challenging and critical step of radical prostatectomy with regards to maintenance of potency. The objective of this study is to describe the surgical steps of our hybrid technique: athermal early retrograde release of the neurovascular bundle during nerve-sparing robotic-assisted laparoscopic radical prostatectomy. This technique involves releasing the neurovascular bundle in a retrograde direction from the apex toward the base of the prostate, during an antegrade prostatectomy. It is a hybrid of the traditional open and the laparoscopic approaches to nerve sparing. With this approach we are able to clearly delineate the path of the bundle and avoid inadvertently injuring it when controlling the prostatic pedicle. Our hybrid nerve-sparing technique combines aspects of the traditional open anatomical approach with those of the laparoscopic antegrade approach. The benefits of robotic technology allow a retrograde neurovascular bundle dissection to be performed during an antegrade radical prostatectomy.

The seminal vesicles, particularly the lateral aspect and tips, are among the closest structures to the cavernous nerves and pelvic plexus. Given this proximity it is essential that the seminal vesicle dissection be performed in an athermal and atraumatic fashion during robot-assisted laparoscopic prostatectomy (RALP). Traditionally the seminal vesicle dissection during RALP is performed by dividing the vas deferens and following it proximally to locate the tip of the seminal vesicle. Here we describe a modification to the traditional anterior approach to seminal vesicle dissection. Our modification allows the dissection to be performed athermally and efficiently with use of minimal traction. The dissection proceeds medially between the two terminal vas deferens to identify the medial surface of one of the seminal vesicles. This medial surface is avascular and can be developed easily along the length of the vesicle using blunt dissection. Once its tip is identified it is elevated with the fourth arm medially between the two vas deferens. The ipsilateral vas can then be clipped and divided below the level of the elevated seminal vesicle. The vascular supply to the seminal vesicle is then simply identified entering the lateral aspect of its tip. A hemolock clip is placed directly beneath the tip of the seminal vesicle to control its vasculature. The remainder of the dissection can be performed with sharp dissection. Using this technique the seminal vesicle can be excised entirely with minimal traction and no thermal energy. By elevating the tip medially away from the location of the pelvic plexus and cavernous nerves, inadvertent damage to these neural structures is avoided when placing the hemolock clips.

Recently, we have introduced robotic-assisted laparoscopic radical prostatectomy (RALP) in Japan. This article describes the details of a training program to shorten the learning curve in the absence of an urologist with expertise in robotic surgery. Five months after a 2-day training course of robotic surgery, RALP was first performed in Japan, and a total of 15 cases were performed in the subsequent 4 months. Our training program consisted of: (1) image training using surgical operation videos, (2) dry lab training using a sham pelvic cavity model, and (3) intraoperative mentoring. The operative procedure was divided into five consecutive stages, and time required to complete each stage was recorded. Robotic radical prostatectomy was completed in all patients without conversion to open surgery, except for the first patient in whom a restriction to a 2-h operation had been imposed by the ethics committee. The mean console time and the mean intraoperative blood loss (including urine) reduced from 264.2 min and 459.4 ml, respectively, in the first 11 cases, to 151 min and 133.3 ml, respectively, in the last three cases. With direct intraoperative guidance by the mentor during cases 13 and 14, the operation time was reduced at all five stages of the operative procedure. Our training program proved remarkably effective in reducing the learning curve of RALP in Japan, where there is no person with expertise in robotic surgery.

Our aim was to examine the current status of minimally invasive approaches to ureteropelvic junction (UPJ) obstruction and compare it to the gold standard of open pyeloplasty. A review of the literature was conducted using PubMed and Medline databases for UPJ obstruction. Open pyeloplasty achieves good results, in the range of 90-100%. Laparoscopic pyeloplasty results are as good as those of open surgery. However, the goal of laparoscopic pyeloplasty as a means of providing minimally invasive surgery to a larger number of patients has not been achieved. The reason for this is the difficulty faced by most urologists in acquiring the technical skills to perform a laparoscopic pyeloplasty. In reports of robot-assisted pyeloplasty, results in the range of 88-97% appear to be achieved. Robotic technology has the potential to make minimally invasive pyeloplasty an easier skill to acquire for a larger number of urologists. Long-term data are still required to determine its efficacy.