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Purpose: To investigate the relationship between a set of prostate-urethral complex (PUC) measurements and incontinence after robot-assisted radical prostatectomy (RARP)., Methods: The study included data from patients undergoing RARP performed by 2 expert surgeons between 2019 and 2022, with data about preoperative magnetic resonance imaging (MRI) and functional follow-up. Continence status was assessed according to a stringent definition (no PADS used). MRIs were evaluated to calculate prostatic urethral length, membranous urethral length, membranous urethral width, levator ani thickness, and prostate shape. The association of PUC measurements with continence after RARP was studied. Secondarily, we evaluated whether pre-determined cut-off values of PUC measurements could be associated with time to continence. Cumulative hazard incidence analysis was performed by the Nelson-Aalen hazard function. Cumulative incidence hazard curves were built; the Peto-Peto test was used to evaluate the difference among the curves., Results: 366 patients were included. At the 12-month follow-up, 333 patients (90.1%) were continent. Classification of PUC measurements overlapped between continent and noncontinent patients. However, a statistically significant difference was observed for levator ani thickness, greater in continent patients (12.8 mm vs. 11.7; p = 0.02). Multivariable models found BMI as independent predictor of incontinence (HR 1.04, 95% C.I 1.00-1.07, p = 0.04). None of PUC measurements associated with incontinence. Also, cumulative hazard incidence analysis at 3 / 6 / 12-months found no statistically significant difference in PUC measurements., Conclusion: No association was found between anatomical characteristics of PUC and continence or time to continence after RARP performed by proficient surgeons. Our data would suggest that once the surgeon has surpassed the learning curve, anatomical variations do not significantly affect the appropriate and proficient execution of the prostate apex dissection during RARP., Competing Interests: Declarations. Competing interests: The authors declare no competing interests. Ethical approval: The study was conducted in accordance with ethical standards and the principles of the Declaration of Helsinki. The local ethics committee (Comitato etico Territoriale Area Sud-Ovest Veneto - CET-ASOV) did not consider the application on the present clinical audit/evaluation of aggregate/anonymous data from the institutional routinely gathered record., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Objectives : We sought to investigate whether the 2012 Briganti nomogram may represent a potential prognostic factor of prostate cancer (PCa) progression after surgical treatment beyond European Association of Urology (EAU) risk categories. Materials and Methods : From January 2013 to December 2021, data on PCa patients treated with robot-assisted radical prostatectomy at a single tertiary referral center were extracted. The 2012 version of the Briganti nomogram assessing the risk of pelvic lymph node invasion was used. Here, the nomogram score was evaluated both as a continuous and a categorical variable. The association between variables and disease progression after surgery was evaluated through Cox regression models. Results : Overall, 1047 patients were identified. According to the EAU classification system, 297 (28.4%) patients were low-risk, 527 (50.3%) intermediate-risk, and 223 (21.3%) high-risk. The median (interquartile range) 2012 Briganti nomogram score within the investigated population was 3% (2-8%). Median (95% Confidence Interval [CI]) follow-up was 95 (91.9-112.4) months. Disease progression occurred in 237 (22.6%) patients, who were more likely to have an increasing 2012 Briganti nomogram score (Hazard Ratio [HR]: 1.03; 95%CI: 1.01-1.81; p = 0.015), independently of unfavorable issues at clinical presentation. Moreover, the nomogram score stratified according to tertiles (<3% vs. 3-8% vs. ≥8%) hold significance beyond EAU risk categories: accordingly, the risk of disease progression increased as the score increased from the first (reference) to the second (HR: 1.50; 95%CI: 1.67-3.72; p < 0.001) up to the third (HR: 3.26; 95%CI: 2.26-4.72; p < 0.001) tertile. Conclusions : Beyond EAU risk categories, the 2012 Briganti nomogram represented an independent predictor of PCa progression after surgery. Likewise, as the nomogram score increased so patients were more likely to experience disease progression. Accordingly, it may allow further stratification of patients within each risk category to modulate appropriate treatment paradigms.

Background: This study aims to prospectively compare the outcomes of robot-assisted radical prostatectomy (RARP) performed using the Hugo RAS and da Vinci Xi systems, focusing on the postoperative course, pathological findings, and health-related quality of life., Methods: The COMPAR-P trial, a prospective post-market study (clinical-trials.org NCT05766163), commenced in March 2023, enrolling patients for RARP performed with either da Vinci or Hugo RAS without selection criteria for up to 50 consecutive cases per system. Two experienced console surgeons performed the procedures according to a standardized technique. The study evaluated differences between da Vinci and Hugo RAS regarding the postoperative course, pathology findings, 30-day PSA value, functional metrics, and health-related quality of life using SF-36 and University of California Los Angeles Prostate Cancer Index questionnaires., Results: Fifty patients underwent DV-RARP and H-RARP each. Postoperative complications, pathological data, and quality of life metrics did not significantly differ between the groups. Noteworthy limitations include the comparison between the first 50 H-RARP and last 50 DV-RARP cases, as well as the potential influence of surgeons' specialized expertise on the generalizability of findings., Conclusions: This prospective study of 100 unselected patients undergoing RARP with either da Vinci or Hugo RAS systems reveals comparable outcomes in postoperative course, pathology, functional metrics, and health-related quality of life. However, further research with larger sample sizes, longer follow-up periods, and diverse surgical expertise is essential to validate these findings and better understand the implications for clinical practice.

Background: To investigate the potential prognostic impact of Briganti's 2012 nomogram in EAU intermediate-risk patients presenting with an unfavorable tumor grade and treated with robot-assisted radical prostatectomy, eventually associated with extended pelvic lymph node dissection., Materials and Methods: From January 2013 to December 2021, the study included 179 EAU intermediate-risk patients presenting with an unfavorable tumor grade (ISUP 3), eventually associated with a PSA of 10-20 ng/ml and/or cT-2b. Briganti's 2012 nomogram was assessed as both a continuous and dichotomous variable, categorized according to the median (risk score ⩾7% vs <7%). Disease progression, defined as biochemical recurrence and/or metastatic progression, was evaluated using Cox proportional hazards in both univariate and multivariate analyses., Results: Disease progression occurred in 43 (24%) patients after a median (95% CI) follow-up of 78 (65.7-88.4) months. The nomogram risk score predicted disease progression, evaluated both as a continuous variable (hazard ratio, HR = 1.064; 95% CI: 1.035-1.093; p  < 0.0001) and as a categorical variable (HR = 3.399; 95% CI: 1.740-6.638; p  < 0.0001). This association was confirmed in multivariate analysis, where hazard ratios remained consistent even after adjusting for clinical and pathological factors., Conclusions: In EAU intermediate-risk PCa cases presenting with an unfavorable tumor grade and treated surgically, Briganti's 2012 nomogram was associated with disease progression after surgery. Consequently, as the nomogram risk score increased, patients were more likely to experience PCa progression, facilitating the stratification of the patient population into distinct prognostic subgroups., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: We assessed the prognostic impact of the 2012 Briganti nomogram on prostate cancer (PCa) progression in intermediate-risk (IR) patients presenting with PSA <10ng/mL, ISUP grade group 3, and clinical stage up to cT2b treated with robot assisted radical prostatectomy eventually associated with extended pelvic lymph node dissection., Materials and Methods: From January 2013 to December 2021, data of surgically treated IR PCa patients were retrospectively evaluated. Only patients presenting with the above-mentioned features were considered. The 2012 Briganti nomogram was assessed either as a continuous and a categorical variable (up to the median, which was detected as 6%, vs. above the median). The association with PCa progression, defined as biochemical recurrence, and/or metastatic progression, was evaluated by Cox proportional hazard regression models., Results: Overall, 147 patients were included. Compared to subjects with a nomogram score up to 6%, those presenting with a score above 6% were more likely to be younger, had larger/palpable tumors, presented with higher PSA, underwent tumor upgrading, harbored non-organ confined disease, and had positive surgical margins at final pathology. PCa progression, which occurred in 32 (21.7%) cases, was independently predicted by the 2012 Briganti nomogram both considered as a continuous (Hazard Ratio [HR]:1.04, 95% Confidence Interval [CI]:1.01-1.08;p=0.021), and a categorical variable (HR:2.32; 95%CI:1.11-4.87;p=0.026), even after adjustment for tumor upgrading., Conclusions: In IR PCa patients with PSA <10ng/mL, ISUP grade group 3, and clinical stage up to cT2b, the 2012 Briganti nomogram independently predicts PCa progression. In this challenging subset of patients, this tool can identify prognostic subgroups, independently by upgrading issues., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Objectives: To report the results of the first quantitative synthesis of literature data from studies comparing Single-Port Robot-Assisted Radical Prostatectomy performed using the novel SP surgical platform (SP-RARP) versus RARP performed by using multi-arms robotic systems., Methods: Studies comparing the use of da Vinci SP versus that of other available multi-arms da Vinci platforms were eligible for inclusion in the present review. From selected studies, data were extracted by using a standardized data extraction form. Patients baseline demographics and disease characteristics and perioperative variables of interest for the present review (operative time, blood losses, complications, length of stay and positive surgical margins rate) were noted whenever available. Weighted mean difference (WMD) was used as a summary measure for continuous outcomes, whereas the odds ratio with 95% confidence interval (CI) was calculated for binary variables. Pooled estimates were calculated by using the random-effect model to account for clinical heterogeneity. Statistical analysis was performed using Review manager 5.3 (Cochrane Collaboration, Oxford, UK)., Results: Four comparative studies were retrieved, analysing a total of 610 patients. Baseline characteristics of treatment groups were statistically similar. No significant differences were found when comparing SP-RARP versus multi-arms robotic systems in terms of operative time, blood losses, complications rate and positive surgical margins. Conversely, SP-RARP was found to allow for a shorter hospital stay (WMD = -0.79 days, 95% CI = -1.07; -0.52, P-value < .001)., Conclusion: The adoption of the SP platform for duplicating the technique of minimally-invasive RARP appears to be safe and feasible., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: To review the recent advances in terms of surgical technique and new robotic platforms applied to radical perineal prostatectomy (RPP)., Methods: A literature review was performed focusing on original articles on perineal prostatectomy searching via Medline/Pubmed and Embase. The entire spectrum was covered such as development of surgical technique including pelvic lymphadenectomy, adoption of novel surgical platforms, learning curve and future directions., Results: Surgical removal of the prostate plays a significant role on the treatment of localized prostate cancer (PCa). RPP was the first surgical approach described for radical prostatectomy. This technique declined in popularity secondary to the development of the retropubic approach. Recently, the appearance of novel robotic technology has generated renewed interest in the perineal approach., Conclusion: There has been a recent resurgence on the interest of radical perineal prostatectomy for the treatment of localized PCa driven by the advent of new robotic surgical technologies into the field. Future studies are needed to better determine the learning curve of the perineal approach and its current role in the treatment of prostate cancer.

Objectives: To evaluate: (i) the neuro-regenerative potential of chitosan membrane (CS-Me) on acutely axotomised autonomic neurones in vitro; (ii) to exclude the possibility that a pro-regenerative biomaterial could interfere with the proliferation activity of prostate cancer cell lines; (iii) to provide an in vivo proof of the biocompatibility and regeneration promoting effect of CS-Me in a standardised rat model of peripheral nerve injury and repair; (iv) finally, to evaluate the tissue reaction induced by the degrading material; as previous studies have shown promising effects of CS-Me for protection of the neurovascular bundles for potency recovery in patients that undergo nerve-sparing radical prostatectomy (RP)., Materials and Methods: Addressing aim (i), the neuro-regenerative potential, organotypic cultures derived from primary sympathetic ganglia were cultured on CS-Me over 3 days and neurite extension and axonal sprouting were evaluated. Addressing aim (ii), effects of CS on cancer cells, different human prostate cancer cell lines (PC3, DU-145, LN-Cap) were seeded on CS-coated plates or cultured in the presence of CS-Me dissolution products. Addressing aims (iii) and (iv), functional recovery of peripheral nerve fibres and tissue reaction with the biomaterial, CS-Me and CS nerve guides were used to repair a median nerve injury in the rat. Functional recovery was evaluated during the post-recovery time by the behavioural grasping test., Results: CS-Me significantly stimulated axon elongation from autonomic ganglia in comparison to control conditions in organotypic three-dimensional cultures. CS coating, as well as the dissolution products of CS-Me, led to a significantly lower proliferation rate of prostate cancer cell lines in vitro. Tissue reaction towards CS-Me and standard CS nerve guides was similar in the rat median nerve model, as was the outcome of nerve fibre regeneration and functional recovery., Conclusion: The results of this study provide the first experimental evidence in support of the clinical safety of CS-Me and of their postulated effectiveness for improving functional recovery after RP. The presented results are coherent in demonstrating that acutely axotomised autonomic neurones show increased neurite outgrowth on CS-Me substrate, whilst the same substrate reduces prostate cancer cell line proliferation in vitro. Furthermore, CS-Me do not demonstrate any disadvantage for peripheral nerve repair in a standard animal model., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)

To describe the surgical management of patients who had radical prostatectomy previously attempted but aborted due to diverse causes. Patients who underwent an "aborted prostatectomy" were extracted from the institutional prostatectomy database. A description of the tailored robotic approach was reported for each case. Tips and tricks for the accomplishment of robotic prostatectomy after aborted prostatectomy were reported. Six clinical cases were analyzed. Three patients had aborted prostatectomy due to complicated dissection hindered by pelvic mesh and bowel adhesions; one prostatectomy was aborted due to anesthesiology/respiratory matters; one for narrow pelvis; one due to abnormal pelvic vascular anatomy. All patients successfully underwent robotic prostatectomy at our institution. In five patients, standard transperitoneal robotic approach was performed. In one patient, robotic transperineal approach was mandatory. Median operative time was 282 min (86-460). Median estimated blood loss was 325 mL (50-1000). Two patients had positive surgical margins. One patient was found with nodal metastasis at final pathology. Neither perioperative nor postoperative complications were reported. At last follow-up, PSA was undetectable in 5/6 patients. Even after previous aborted prostatectomy, robot-assisted prostatectomy is feasible, with acceptable results. The case-by-case tailoring of the technique is the key for a successful intervention.

Objective: To compare outcomes of laparoscopic radical prostatectomy (LRP) performed in live surgery versus daily routine LRP., Methods: From January 2014 to June 2017, data from LRP performed at our Institution in live broadcasting by 3 experienced laparoscopic surgeons during educational events were collected. A 1:2 matching (according to BMI, comorbidities, NCCN risk groups, and operating surgeon) was performed with the routine LRP patients collected in our prospectively-maintained database. Chosen procedures were performed within the same time span by the same surgeons. Data of interest were compared., Results: Twenty-three live surgery LRPs were analyzed (Group A). Forty-six matched patients were the controls (Group B). Groups were comparable at baseline. No differences were found in perioperative data (operative time, blood loss, and intraoperative complications, 4.3% in both Groups) and postoperative complications. Particularly, 10 (43.5%) and 22 patients (47.8%) did not report complications (Group A vs B, respectively, P = .54). The majority of complications were Clavien 1-2, with 2 patients per Group requiring blood transfusion. Overall positive surgical margins rate was 26.1%. It was significantly higher in Group A (43.5% vs 17.4%; P = .02), but no differences were found in the number of patients who relapsed, who needed radiotherapy or androgen deprivation therapy within a median follow-up of 25 months in both Groups. No differences were found regarding functional data. Limitations include a low sample size and limited follow-up., Conclusion: LRP has similar perioperative outcomes when performed in either live surgery or daily routine setting. We underline the higher positive surgical margins rate after live surgeries that should increase the awareness before embarking on it., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To report a step-by-step technique for robot-assisted transvesical simple prostatectomy (RASP) focusing on surgical hints to facilitate the procedure., Methods: From January 2014 to April 2018 the institutional database was queried for consecutive patients undergoing RASP performed by a single-surgeon. Procedures were performed according to standardized steps as reported in the accompanying video. Ports were placed in a 'W' configuration. Surgery started with the bladder detachment, then the endopelvic fascia was exposed. The bladder neck was incised in a longitudinal fashion. Exposure of the adenoma was aided by using Keith needles. The bladder mucosa was incised and the dissection of the adenoma was performed till complete adenomectomy. Hemostasis of the enucleation bed was performed with electrocauterization. A 2-0 Polysorb suture was used for accomplishing the trigonization. Bladder closure was performed in double layer. A Foley catheter was inserted, then a water-tightness test was performed. Specimen was retrieved via the incision for the optical port., Results: Twenty-eight patients were performed, according to the described technique. Median prostate volume was 180 cm 3 . Median blood losses were 200 mL. No intraoperative complications were recorded. Four patients had minor complications (14%). Median catheterization time was 8 days. Regarding functional outcomes, patients had significant improvement of Qmax, postvoided residual volume, and international prostate symptom score at postoperative control (P < .001)., Conclusion: RASP is feasible, safe and effective, and represents a viable approach to large adenomas. Prospective comparison with alternative minimally-invasive endoscopic techniques is warranted., (Copyright © 2018. Published by Elsevier Inc.)

Peripheral nerves are complex organs that spread throughout the entire human body. They are frequently affected by lesions not only as a result of trauma but also following radical tumor resection. In fact, despite the advancement in surgical techniques, such as nerve-sparing robot assisted radical prostatectomy, some degree of nerve injury may occur resulting in erectile dysfunction with significant impairment of the quality of life. The aim of this review was to provide an overview on the mechanisms of the regeneration of injured peripheral nerves and to describe the potential strategies to improve the regeneration process and the functional recovery. Yet, the recent advances in bio-engineering strategies to promote nerve regeneration in the urological field are outlined with a view on the possible future regenerative therapies which might ameliorate the functional outcome after radical prostatectomy.

Objectives: Literature regarding experience with three-dimensional (3D) laparoscopy in urology has remained scanty, and this might be also related to the parallel explosion of robot-assisted laparoscopic surgery. The study aim was to compare 3D vs two-dimensional (2D) laparoscopic approaches for urological procedures in perioperative outcomes in a subgroups analysis of studies reporting procedures requiring intracorporeal suturing., Materials and Methods: We searched EMBASE and Medline from database inception to September 22, 2017 for studies comparing patients undergoing 2D vs 3D laparoscopic approach for urological procedures. Two investigators independently selected studies for inclusion. Studies identification and selection was performed according to PRISMA criteria. Quality of the studies was assessed by the Newcastle-Ottawa and the Jadad scales for nonrandomized controlled trials (RCTs) and RCTs, respectively. For continuous variables, weighted mean difference was used for quantitative synthesis; for categorical variables, the odds ratio with confidence interval (95% CI) was used instead. A random-effect model was used for pooled estimates to account for heterogeneity. Statistical analyses were performed using RevMan 5.3 (Cochrane Collaboration, Oxford, United Kingdom)., Results: Eight comparative studies of interest published in English were found and considered for the quantitative synthesis. Among them, four were RCTs. Six studies regarded procedures requiring intracorporeal suturing and were considered for cumulative-analysis. Meta-analysis did not show any significant difference in operative time. Quantitative synthesis showed advantages for 3D laparoscopy in terms of operative time, blood losses, and length of stay. When limited to studies regarding radical prostatectomy, operative time significantly favored 3D approach (mean difference -35.00, 95% CI -41.34 to -28.67 minutes)., Conclusions: The present systematic review and cumulative-analysis indicated that 3D laparoscopy could offer some advantages in terms of operative time for more challenging procedures requiring intracorporeal suture.

Purpose: To provide latest evidence on the use of suprapubic catheter (SPC) versus urethral catheter (UC) after robot-assisted laparoscopic radical prostatectomy (RARP)., Materials and Methods: A systematic revision of literature was performed up to September 2017 using different search engines (Pubmed, Ovid, Scopus) to identified studies comparing the use of SPC versus standard UC after RARP. Identification and selection of the studies were conducted according to the preferred reporting items for systematic reviews and meta-analysis criteria. For continuous outcomes, the weighted mean difference (WMD) was used as a summary measure, whereas the odds ratio (OR) or risk ratio (RR) with 95% confidence interval (CI) was calculated for binary variables. RR was preferred in cases of a high number of events to avoid overestimation. Pooled estimates were calculated using the random-effect model to account for clinical heterogeneity. All statistical analyses were performed using Review manager 5 (Cochrane Collaboration, Oxford, UK)., Results: Eight studies were identified and included in this systematic review, namely 3 RCTs, 4 non-randomized prospective studies, and one retrospective study. A total of 966 RARP cases were collected for the cumulative analysis. Among them, 492 patients received standard UC and 474 SPC placement after RARP. UC patients had higher baseline PSA (WMD 0.44 ng/ml; p = 0.02). Visual Analog Scale (VAS) score was found to be significantly lower in patients with SPC at postoperative day 7 (WMD 0.53; 95% CI 0.13-0.93; p = 0.009). Regarding penile pain, a significant difference in favor of the SPC group was found at postoperative day 7 assessment (WMD 1.2; 95% CI 0.82-1.6; p < 0.001). More patients in the SPC group reported "not at all" or "minimal pain" at this time point (OR 0.17, 95% CI 0.06, 0.44; p < 0.001). No significant differences were found in terms of continence recovery rate at 6-12 weeks between the groups (UC 78.7%, 88.2%; RR 0.92, 95% CI 0.84, 1.01; p = 0.09). Similarly, no differences were found in terms of catheter-related issues (p = 0.17). However, UC patients had lower likelihood of overall complications (OR 0.44, 95% CI 0.21-0.89, p = 0.02)., Conclusions: Available evidence suggests that the use of SPC can be a viable option for postoperative urine drainage after RARP, as it can translate into decreased postoperative pain without carrying a significant higher risk of catheter-related complications. Further investigation seems to be warranted, ideally within the framework of a multicentre randomized study with standardized analysis of outcomes.

Objective: To evaluate the feasibility of a single-port transvesical robotic approach for anterior partial prostatectomy in a cadaver model., Materials and Methods: The cadavers were placed in a lithotomy position and secured to the operating table. A 3-cm midline incision was made in the suprapubic skin fold. After opening the Retzius space, a single-port mini device (GelPOINT, Rancho Margarita, CA) was introduced percutaneously directly into the bladder. The da Vinci Si robotic platform (Intuitive Surgical, Sunnyvale, CA) was docked to the GelPOINT by inserting 2 8-mm (robotic arms) and 1 12-mm (camera) trocar through the GelSeal Cap. The surgical steps for en bloc anterior prostatectomy were performed in the following order: (1) retrograde dissection of transition zone at the bladder neck, (2) lateral excision of the peripheral zone, and (3) urethrovesical anastomosis. Primary outcomes such as intraoperative complications, rate of conversion to standard techniques, and operative times were recorded., Results: Single-port transvesical robotic approach for anterior partial prostatectomy was technically completed in 2 male cadavers. Both cases were completed successfully using the da Vinci Si surgical system without conversion or the need for additional ports. There were no intraoperative complications. The total operative time was 124.1 and 81.3 minutes. Step-specific times are listed in Table 1., Conclusion: Transvesical robotic partial prostatectomy is technically feasible using a single-port approach in a preclinical model. Further studies are needed for evaluation on patients with anterior localized prostate cancer. Prospective comparison with standard surgical techniques and focal therapy are warranted. Refinement of this technique may potentially expand the role of single-site surgery in the clinical practice., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To present our preliminary experience with augmented reality robot-assisted radical prostatectomy (AR-RARP)., Materials: From June to August 2017, patients candidate to RARP were enrolled and underwent high-resolution multi-parametric magnetic resonance imaging (1-mm slices) according to dedicated protocol. The obtained three-dimensional (3D) reconstruction was integrated in the robotic console to perform AR-RARP. According to the staging at magnetic resonance imaging or reconstruction, in case of cT2 prostate cancer, intrafascial nerve sparing (NS) was performed: a mark was placed on the prostate capsule to indicate the virtual underlying intraprostatic lesion; in case of cT3, standard NS AR-RARP was scheduled with AR-guided biopsy at the level of suspected extracapsular extension (ECE). Prostate specimens were scanned to assess the 3D model concordance., Results: Sixteen patients underwent intrafascial NS technique (cT2), whereas 14 underwent standard NS+ selective biopsy of suspected ECE (cT3). Final pathology confirmed clinical staging. Positive surgical margins' rate was 30% (no positive surgical margins in pT2). In patients whose intraprostatic lesions were marked, final pathology confirmed lesion location. In patients with suspected ECE, AR-guided selective biopsies confirmed the ECE location, with 11 of 14 biopsies (78%) positive for prostate cancer. Prostate specimens were scanned with finding of a good overlap. The mismatch between 3D reconstruction and scanning ranged from 1 to 5 mm. In 85% of the entire surface, the mismatch was <3 mm., Conclusion: In our preliminary experience, AR-RARP seems to be safe and effective. The accuracy of 3D reconstruction seemed to be promising. This technology has still limitations: the virtual models are manually oriented and rigid. Future collaborations with bioengineers will allow overcoming these limitations., (Copyright © 2018 Elsevier Inc. All rights reserved.)

3D reconstruction of the standard two-dimension cross-sectional imaging has known increasing diffusion. It may represent one of the key points for a tailored treatment planning. Along these lines, we used a novel software for augmented-reality robot-assisted radical prostatectomy (AR-RARP) at our Institution. 3D virtual models of the prostate and the prostate cancer were reconstructed from high resolution (1-mm slices) multi-parametric Magnetic Resonance Imaging (mp-MRI) by M3dics (Turin, Italy). The innovation in the study is represented by the software-based integration of the virtual model inside the Da Vinci (Intuitive, Sunnyvale, CA, USA) robotic console during robotic prostatectomy. In January 2018, the above-described AR-RARP technique has been used during the live surgery sessions of the 6th Techno-Urology Meeting held at San Luigi Gonzaga Hospital (Orbassano, Turin, Italy). During this meeting, 6 experienced robotic surgeons (who have already performed more than 1000 RARP) used the software during nerve-sparing prostatectomy. The use of the technology was standardized to four key steps during the procedure: 1) bladder neck dissection; 2) nerve-sparing technique; 3) apex dissection; and 4) tailoring of eventual selective biopsies of prostatic lodge after prostatectomy). A Face Validity questionnaire was purpose-built aimed to collect the expert surgeons' insights about the eventual help of the technology in guiding the surgeon during the above-described AR-RARP steps. It was administered at the end of the surgeries to the respective surgeons. The questionnaire was made of open-ended questions of ordinal ten-point rating Likert Scale (where 1 corresponded to a strongly negative opinion and 10 to a strongly positive opinion). The median value of Likert scale from the evaluation of each of the aforementioned steps of AR-RARP was 9, (IQR 9-10). These findings are a confirmation of the increasing interest for a new-generation of image-guided surgery. Particularly, AR-RARP seems to be a step in the direction of "precision" surgery.

Objective: To evaluate the feasibility and the safety of applying chitosan membrane (ChiMe) on the neurovascular bundles (NVBs) after nerve-sparing robot-assisted radical prostatectomy (NS-RARP). The secondary aim of the study was to report preliminary data and in particular potency recovery data., Patients and Methods: This was a single-centre, single-arm prospective study, enrolling all patients with localised prostate cancer scheduled for RARP with five-item version of the International Index of Erectile Function scores of >17, from July 2015 to September 2016. All patients underwent NS-RARP with ChiMe applied on the NVBs. The demographics, perioperative, postoperative and complications data were evaluated. Potency recovery data were evaluated in particular and any sign/symptom of local allergy/intolerance to the ChiMe was recorded and evaluated., Results: In all, 140 patients underwent NS-RARP with ChiMe applied on the NVBs. Applying the ChiMe was easy in almost all the cases, and did not compromise the safety of the procedure. None of the patients reported signs of intolerance/allergy attributable to the ChiMe and potency recovery data were encouraging., Conclusion: In our experience, ChiMe applied on the NVBs after NS-RARP was feasible and safe, without compromising the duration, difficulty or complication rate of the 'standard' procedure. No patients had signs of intolerance/allergy attributable to the ChiMe and potency recovery data were encouraging. A comparative cohort would have added value to the study. The present paper was performed before Conformité Européene (CE)-mark achievement., (© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

Purpose: To test the face and content validity of 3D virtual-rendered printed models used before robot-assisted prostate cancer and nephron-sparing surgery., Methods: Patients who underwent live surgery during an international urological meeting organized in January 2017 were enrolled. Those with organ-confined prostate cancer underwent robot-assisted radical prostatectomy. Patients with a single renal tumor underwent minimally invasive nephron-sparing surgery. High-resolution (HR) imaging was obtained for all patients. Those with kidney tumors received contrast-enhanced CT scan with angiography; those with prostate cancer underwent mp-MRI. Images in DICOM format were processed by dedicated software. The first step was the rendering of a 3D virtual model. The models were then printed. They were presented during the live surgery of the urological meeting. All the participants and the operated patients were asked to fill a questionnaire about their opinion expressed in Likert scale (1-10) about the use and application of the 3D printed models., Results: 18 patients were enrolled, including 8 undergoing robot-assisted radical prostatectomy and 10 undergoing minimally invasive partial nephrectomy. For each patient, a virtual 3D printed model was created. The attendants rated the utility of printed models in surgical planning, anatomical representation and the role of technology in surgical training as 8/10, 10/10 and 9/10, respectively. All patients reported favorable feedbacks (from 9 to 10/10) about the use of the technology during the case discussion with the surgeon., Conclusions: In our experience, 3D printing technology has been perceived as a useful tool for the purpose of surgical planning, physician education/training and patient counseling. Further researches are expected to increase the level of evidence.

Background: The literature is lacking randomised controlled trials comparing robot-assisted (RARP) and laparoscopic (LRP) radical prostatectomy, especially for follow-up >1 yr., Objective: To report 5-yr outcomes for our previously published prospective randomised study comparing RARP and LRP., Design, Setting, and Participants: From January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned to RARP or LRP., Intervention: A single surgeon performed all interventions using the same transperitoneal anterograde technique., Outcome Measurements and Statistical Analysis: Continence, potency, and serum prostate-specific antigen were assessed postoperatively at 1, 3, 6, and 12 mo, and then every 6 mo until 60 mo. At the end of the follow-up period, patients were administered questions 1 and 46 of the Expanded Prostate Cancer Index Composite questionnaire to assess their satisfaction with the intervention and general health status. A generalised estimating equations model was used to compare time series data for functional results, and Kaplan-Meier and Cox models were used to analyse oncologic outcomes., Results and Limitations: The probability of achieving continence (odds ratio [OR] 2.47, p<0.021) and potency (OR 2.35, p<0.028) over time was more than doubled for the RARP compared to the LRP group. There was no difference between the two approaches in terms of patient survival. Pathologic Gleason score, positive surgical margins, and pT stage were associated with significantly higher biochemical recurrence in Cox multivariate models. Patient satisfaction with the intervention and their general health status was significantly higher in the RARP group., Conclusions: Throughout the 5-yr follow-up, RARP yielded better functional results compared to LRP, without compromising oncologic outcomes., Patient Summary: In this report we looked at 5-yr outcomes for a study comparing robot-assisted radical prostatectomy (RARP) and laparascopic radical prostatectomy for the treatment of prostate cancer. We found that continence and potency are better among patients treated with RARP, while oncologic results are comparable., (Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: The introduction of robotics revolutionized prostate cancer surgery because the magnified three-dimensional vision system and wristed instruments allow microsurgery to be performed. The advantages of robotic surgery could lead to improved continence outcomes in terms of early recovery compared with the traditional surgical methods., Objective: To describe the total anatomical reconstruction (TAR) technique during robot-assisted radical prostatectomy (RARP)., Primary Endpoint: evaluation of the continence rate at different time points. Secondary endpoint: evaluation of urine leakage and anastomosis stenosis rates related to the technique., Design, Setting, and Participants: June, 2013 to November, 2014; prospective consecutive series of patients with localized prostate cancer (cT1-3, cN0, cM0)., Surgical Procedure: RARP with TAR was performed in all cases. Lymph node dissection was performed if the risk of lymph nodal metastasis was over 5%, according to the Briganti updated nomogram., Measurements: Preoperative, intraoperative, postoperative, and pathological variables were analyzed. Enrolled patients were arbitrarily divided into three groups according to a time criterion. The relationships between the learning curve and the trend of the above-mentioned variables were analyzed using LOESS analysis. Continence was rigorously analyzed preoperatively and at 24h, 1 wk, 4 wk, 12 wk, and 24 wk after catheter removal., Results and Limitations: In total, 252 patients were analyzed. The continence rates immediately after catheter removal and at 1 wk, 4 wk, 12 wk, and 24 wk after RARP were 71.8%, 77.8%, 89.3%, 94.4%, and 98.0%, respectively. Multivariate analysis revealed that the nerve sparing technique, D'Amico risk groups, lymph node dissection, and prostate volume were involved in the early recovery of urinary continence. One ileal perforation requiring reoperation was recorded. The transfusion rate was 0.8%. Thirty-one (12.3%) postoperative complications were recorded up to 6 mo after surgery. Among these, eight acute urinary retentions (3.2%) and three urine leakages (1.2%) were recorded. There was a lack of randomization and comparison with other techniques. Both anatomical dissection of the prostatic apex and TAR were used. The results may not be generalized to low-volume centers., Conclusions: The TAR technique showed promising results in the early recovery of urinary continence, as well as watertight anastomosis and a low rate of urine leakage. The oncologic results were not affected. Comparative studies are needed to support the quality of reported results., Patient Summary: On the basis of our findings, it seems that the risk of urinary incontinence following radical prostatectomy can be lowered via meticulous anatomical reconstruction using a robotic system. Comparative studies are required to support the reported results., (Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: Extended pelvic lymph nodes dissection (EPLND) allows the removal of a higher number of lymph nodes than limited PLND. The aims of this study were to describe our robot-assisted EPLND (RAEPLND) technique with related complications, and to report the number of lymph nodes removed and the rate of lymph nodal metastasis., Materials and Methods: 153 patients underwent RAEPLND prior to robot-assisted radical prostatectomy (RARP). Indications were defined according to Briganti nomogram, to predict risk of lymph-nodal metastasis. Lymphatic packages covering the distal tract of the common iliac artery, the medial portion of the external iliac artery, the external iliac vein and the internal iliac vessels, together with the obturator and the presacral lymphatic packages were removed on both sides., Results: Median preoperative PSA was 7.5 ng/mL (IQR 5.5-11.5). Median operative time was 150 min (135-170). Median RAEPLND alone operative time was 38 min (32.75-41.25); for right and left side, 18 (15-29) and 20 min (15.75-30) (p=0.567). Median number of lymph nodes retrieved per patient was 25 (19.25-30); 13 (11-16) and 11 (8-15) for right and left side. In 19 patients (12.41%) metastasis was found at the level of pelvic lymph nodes. Median number of positive lymph nodes was 1 (1-4.6) per patient. Complications occurred in 11 patients (7.3%)., Conclusions: the number of lymph nodes removed was comparable to published data about open series, allowing the increase of detection rate of lymph nodal metastasis for minimally invasive approach without compromising complications' rate if performing the procedure following reported technique.

Introduction: To describe a step-by-step technique for single-port transperineal intracorporeal ileal conduit urinary diversion using a purpose-built robotic platform.Technical Considerations: In one male cadaver, the da Vinci SP1098 surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used to perform intracorporeal ileal conduit urinary diversion by a transperineal approach after radical cystoprostatectomy and bilateral pelvic lymph node dissection. The surgery was completed through a 2.5-cm perineal incision through which a GelPOINT Mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) and a dedicated 25-mm multichannel port accommodating a 12-mm × 10-mm oval articulating robotic camera, three 6-mm double-jointed articulating robotic instruments, and a 6-mm accessory laparoscopic instrument were placed. Moreover, at the planned level of the cutaneostomy, a 12-mm port to accommodate the Endo-GIA was placed. The primary outcomes were the technical feasibility, the operative time, and the record of eventual procedural complications. The intervention was successfully completed without any conversion or need for additional ports. The total operative time was 200 minutes. Operative time for urinary diversion was 90 minutes.Conclusion: We demonstrated the feasibility of single-port transperineal intracorporeal ileal conduit urinary diversion using the SP1098 purpose-built robotic platform. Limitations include the preclinical setting. The applicability in the clinical model is awaited to be tested after the platform will be commercially available. [ABSTRACT FROM AUTHOR]

Objectives: To describe step-by-step the port placement and the robot docking of the new purpose-built robotic platform for R-LESS. The feasibility of different approaches to the pelvic fossa and the retroperitoneum was reported in cadaver models.Methods: This was a preclinical study on human cadavers to assess the feasibility of the da Vinci SP1098 surgical system for R-LESS pelvic fossa and retroperitoneal urological surgeries. We used the SP1098 to perform R-LESS prostatectomies and cystoprostatectomies with transperineal and transvesical approaches, and nephrectomies (radical or partial) with retroperitoneal approach. The primary outcome was to report the port placement and docking. The technical feasibility of the procedures was then demonstrated as measured by the need for adjunctive ports or the occurrence of intraoperative complications. Operative times were recorded.Results: A total of 14 procedures were performed on 12 human cadavers. Namely 4 prostatectomies and 2 cystoprostatectomies with transperineal approach, 3 transvesical prostatectomies, 1 retroperitoneal radical, and 4 retroperitoneal partial nephrectomies. Operative times were in line with those of standard multiport robotic surgery. Neither additional ports nor percutaneous instruments were required. No intraoperative complications occurred. Limitations include the preclinical model, the small sample size, and the lack of a control group.Conclusion: In this preclinical model, the port placement and robot docking using the SP1098 robotic platform is reproducible and feasible for pelvic fossa and retroperitoneal urological surgeries. [ABSTRACT FROM AUTHOR]

With the aim of minimising the patient’s postoperative pain, expediting recovery and improving cosmesis, the idea of performing a laparoscopic procedure through a single abdominal incision was introduced. In the present report, we describe five different access routes to the prostate that may be at the surgeon’s disposal with the potential of decreasing patient’s perioperative morbidity. Robotic radical prostatectomy has been refined and became a standard of care in surgery for localised prostate cancer. The advent of single-port robotic surgery has prompted the re-discovery of different access routes to the prostate and ideally all of them are feasible. The potential for avoiding the abdominal cavity will decrease the surgical morbidity and minimise the surgical dissection. In the near future, each of the described approaches could be chosen on the basis of the patient’s preoperative comorbidities, body habitus, anatomy, and disease characteristics and location. [ABSTRACT FROM AUTHOR]

Purpose: Laparoscopic simple prostatectomy has been proposed to treat large glands. To date groups have investigated the feasibility and perioperative results of laparoscopic simple prostatectomy but to our knowledge no study has focused on its complications and functional results at longer followup. We investigated complications and functional results in patients with a large prostate who were treated with laparoscopic simple prostatectomy and had at least 1 year of followup. Material and Methods: From our prospectively maintained database we extracted data on 78 patients treated with laparoscopic simple prostatectomy at our institution who had at least 1 year of reported followup. Demographics, perioperative results, early and late complications, and functional results were evaluated. Followup was planned at 1, 3, 6 and 12 months, and every 6 months thereafter. Results: Mean followup was 30 months. Grade III complications were recorded in 2 cases and late complications were reported in 4 (5%). Statistically significant differences were observed in the International Prostate Symptom Score, the International Prostate Symptom Score quality of life index and maximum urine flow when comparing preoperative and postoperative results. No significant differences were recorded in maximum urine flow or the International Prostate Symptom Score quality of life index during followup. Conclusions: Results suggest that laparoscopic simple prostatectomy is safe and effective even after a significant period, as indicated by the low complication rate and positive, stable functional results found during followup. In our opinion laparoscopic simple prostatectomy can be offered to patients as a valid treatment option for a large prostate at advanced laparoscopic centers. [ABSTRACT FROM AUTHOR]

Objectives: To describe the first clinical experience with the novel purpose-built single-port robotic platform after Food Drug Administration approval.Methods: Two male patients diagnosed with prostate cancer amenable of radical prostatectomy underwent single-port robot-assisted radical prostatectomy with bilateral pelvic lymph-nodes dissection performed by using the da Vinci SP Surgical System (Intuitive Surgical, Sunnyvale, CA). The surgeries were completed through a 2.5-cm periumbilical incision through which a GelPOINT Mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA) and the dedicated 25-mm multichannel port accommodating a 12 × 10 mm oval articulating robotic camera, three 6-mm double-jointed articulating robotic instruments and a 6-mm accessory laparoscopic instrument were placed. One port for the assistant was placed at the level of the para-rectal line, at the planned final site for the drainage. The primary aim was to report, for the first time in the United States after Food Drug Administration approval of the system, the technical feasibility in the living human. The secondary aim was to report the perioperative outcomes.Results: The surgeries were successfully completed without conversion. In both cases, the total operative time was 140 minutes. Blood loss was negligible. No complications were recorded. Patients were discharged within 24 hours postoperation.Conclusions: Herein, we documented the first clinical application of the SP surgical platform for single-port transumbilical robot-assisted radical prostatectomy in the United States. This approach will be further investigated regarding the surgical morbidity and the outcomes. [ABSTRACT FROM AUTHOR]

Abstract We report the first clinical investigation for surgical procedures performed using the da Vinci SP robotic surgical platform (Intuitive Surgical, Sunnyvale, CA, USA) during the first 10 days (September 28–October 12, 2018) after the system was installed at our institution. The aim of the study was to determine the feasibility and safety of major urologic procedures, measured as the rate of conversions and the incidence of perioperative complications. Secondary aims of the study consisted of key perioperative surgical outcomes, including operative time, blood loss, and length of stay. Pathology data were reported. Data collection was performed under institutional review board approval (IRB 13-780). A total of nine patients were treated (3 robot-assisted radical prostatectomies, 3 transperitoneal robot-assisted partial nephrectomies, 1 simple cystectomy with intracorporeal ileal conduit urinary diversion, 2 ureteral reimplantations). No intraoperative complications occurred. In six cases the surgeries were performed according to a pure single-site approach. The mean operative time was slightly longer than that reported for the corresponding multiarm robotic procedures in the literature, which can easily be explained by the expected learning curve. One minor and one major complication occurred. A learning curve exists when embarking with this surgery. Further investigations are awaited. [ABSTRACT FROM AUTHOR]

Radical perineal prostatectomy (RPP) has been revived with the advent of single-port (SP) robotic surgery. However, its interest and precise role need to be evaluated and better defined. To describe in detail the technique of SP-RPP and compare initial perioperative outcomes with those of multiport robot-assisted transperitoneal radical prostatectomy (MP-RARP). From October 2018 to June 2020, perioperative data of 26 consecutive patients who underwent SP-RPP for localized prostate cancer (PCa) in a single institution were prospectively entered into an institutional review board–approved database. Data of 86 consecutive patients treated from September 2017 to September 2018 with MP-RARP by the same surgeon, before the beginning of the SP experience, were used as comparators. SP-RPP was performed using the SP robotic platform (Intuitive Surgical, Sunnyvale, CA, USA) according to the technique described in the supplementary video. Demographics, and intra- and postoperative data were analyzed in a matched-paired design with a 1:1 ratio on the following factors: age at surgery, prostate-specific antigen level, preoperative Gleason score, and history of abdominal surgery. After matching, baseline characteristics were comparable except for the rate of prior laparotomy, which was higher in the SP-RPP group (52% vs 8%, p < 0.001). In the SP-RPP group, 84% of the patients had a high risk and an unfavorable intermediate risk of positive surgical margins (PSMs) versus 57% in the MP-RARP group (p = 0.03). While the rate of nonlimited PSMs (ie, >3 mm) was higher in the SP-RPP group (38.5% vs 7.7%, p < 0.01), the number of patients with biochemical recurrence at 1 yr was comparable between SP-RPP and MP-RARP (1 vs 3, p = 0.3). SP-RPP is a complex procedure for patients with a complex surgical history and high-risk localized PCa with limited alternative therapeutic options. Our study suggests that patients with high-risk localized prostate cancer and limited treatment options due to a complex abdominal surgical history (ie, frozen pelvis) may be suitable candidates for single-port radical perineal prostatectomy. Single-port radical perineal prostatectomy is a feasible but challenging procedure for patients with complex surgical history (ie, frozen pelvis) and high-risk localized prostate cancer who have limited alternative therapeutic options. [ABSTRACT FROM AUTHOR]