Search

Treatment for bladder diverticula may become necessary in case of incomplete bladder emptying or recurrent urinary tract infections (UTI). When bladder outlet obstruction is present, a simultaneous desobstructive procedure can be performed. In this video, we present our technique for a transvesical approach in robot-assisted bladder diverticulectomy (RABD) and discuss its outcomes. We retrospectively analysed the outcomes of 23 patients who underwent a transvesical RABD between March 2015 and May 2020 at the OLV hospital of Aalst. After retrograde filling, a cystotomy is performed. The orifices are identified and the bladder diverticulum is visualized. The mucosa covering the diverticular neck is incised and the plane between the mucosa and the muscularis is identified. The mucosa is separated from the surrounding structures. The base of the diverticulum is transected using cautery. The defect is closed with a barbed suture. Median age was 66 years [Interquartile range (IQR) 60-69)]. The number of diverticula removed ranged from 1 to 3. 10 patients were treated with diverticulectomy alone, 12 underwent a simultaneous adenomectomy, 1 a radical prostatectomy. Median operative was 140 min (IQR 120-180), median estimated blood loss was 250 cc (IQR 28-438). Median catheterization time was 2 days (IQR 1-5), median hospitalization time 3 days (IQR 2-4). 1 patient developed urinary leakage after catheter removal, 1 patient developed a UTI. Median follow-up was 9 months (IQR 3,5-14). No late postoperative complications nor relapse were recorded. Average postvoid residual was 42 cc (IQR 0 to 111), with a median decline of 120cc (IQR -402 to -33). Transvesical approach for RABD is a safe and reliable technique which gives the advantage of a quick localization of the diverticulum and orifices, and direct access to the prostate when simultaneous desobstruction is necessary. Catheterisation time is short. No relapse has been observed.

Prediction of complications and surgical outcomes is of outmost importance even in patients with benign renal masses. The aim of our study is to test the PADUA, SPARE and R.E.N.A.L. scores to predict nephron sparing surgery (NSS) outcomes in patients presenting with renal angiomyolipoma (RAML).We retrospectively analyzed the clinical and pathological data of 93 patients with AML treated with robot-assisted partial nephrectomy (RAPN) at three tertiary care referral centers. Renal masses were classified according to the PADUA, SPARE and R.E.N.A.L. nephrometry scores. Surgical success was defined according to the novel Trifecta score. Logistic regression models (LRM) were fitted to predict the achievement of novel Trifecta and the risk of high-grade Clavien-Dindo (CD) complication. The receiver operating characteristics (ROC) curve analysis was used to estimate the accuracy of LRMs.Of 93 patients, 66 (69.9%) were females; median tumor size was 42 (36-48) mm. Novel Trifecta was achieved in 79 patients (84.9%) and post-operative complications classified as CD2 occurred in 7 (7.5%) patients. At univariate and multivariate LRMs all three nephrometry scores were significantly associated with novel Trifecta achievement. Similar findings were observed for the prediction of CD2 complications. The AUCs to predict optimal surgical outcomes and CD2 complications were 0.791 and 0.912 for PADUA, 0.767 and 0.836 for SPARE and 0.756 and 0.842 for RENAL score, respectively.RAPN appears to be a feasible and safe surgical technique for the treatment of RAML. PADUA, SPARE and RENAL scores can be safely adopted to predict surgical outcomes, with the first one showing a higher accuracy.

Background The use of a nephron-sparing surgery for the treatment of localized renal masses is being pushed to more challenging cases. However, this procedure is not devoid of risks, and the Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location (RENAL) and Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classifications are commonly employed in the prediction of complications. Recently, the Simplified PADUA REnal (SPARE) scoring system has been proposed with the aim to provide a more simple system, to improve its reproducibility to predict postoperative risks. Objective We aim to retrospectively validate and compare the proposed new SPARE system in a multi-institutional population. Design, setting, and participants The Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group collected data from 737 patients subjected to robot-assisted partial nephrectomy (RAPN) between 2010 and 2016 at three tertiary care referral centers. Of these patients, 536 presented complete demographic and clinical data. Outcome measurements and statistical analysis Renal masses were classified according to the SPARE, RENAL, and PADUA nephrometry scores, and surgical success was defined according to the margin, ischemia, and complication scores. Results and limitations Of 536 patients, 340 were male; the median age was 61 (53–69) yr and preoperative tumor size was 30 (22–43) mm. The margin, ischemia, and complication score was achieved in 399 of cases (74.4%). All three nephrometry scores were significant predictors of surgical outcomes both in univariate and in adjusted multivariate logistic regression model analysis. In accuracy analysis, the area under the curve (AUC) of the SPARE scoring system (0.73) was significantly higher than those of the PADUA (0.65) and RENAL (0.68) nephrometry scores in predicting surgical success. Conclusions The SPARE score appears to be a promising and reliable score for the prediction of surgical outcomes of RAPN, showing a higher accuracy relative to the traditional PADUA and RENAL nephrometry scores. Further, prospective studies are warranted before its introduction in clinical practice. Patient summary The Simplified PADUA REnal (SPARE) score is a reproducible and simple nephrometry score, offering better predictive capabilities of surgical success and complications.

Intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) has an incidence of approximately 20%-50%. Studies to date have been composed of mixed treatment cohorts-open, laparoscopic and robotic. The objective of this study is to assess clinicopathological risk factors for intravesical recurrence after RNU for UTUC in a completely minimally invasive cohort.We performed a multicenter, retrospective analysis of 485 patients with UTUC without prior or concurrent bladder cancer who underwent robotic or laparoscopic RNU. Patients were selected from an international cohort of 17 institutions across the United States, Europe and Asia. Univariate and multiple Cox regression models were used to identify risk factors for bladder recurrence.A total of 485 (396 robotic, 89 laparoscopic) patients were included in analysis. Overall, 110 (22.7%) of patients developed IVR. The average time to recurrence was 15.2 months (SD 15.5 months). Hypertension was a significant risk factor on multiple regression (HR 1.99, CI 1.06; 3.71, p=0.030). Diagnostic ureteroscopic biopsy incurred a 50% higher chance of developing IVR (HR 1.49, CI 1.00; 2.20, p=0.048). Treatment specific risk factors included positive surgical margins (HR 3.36, CI 1.36; 8.33, p=0.009) and transurethral resection for bladder cuff management (HR 2.73, CI 1.10; 6.76, p=0.031).IVR after minimally invasive RNU for UTUC is a relatively common event. Risk factors include a ureteroscopic biopsy, transurethral resection of the bladder cuff, and positive surgical margins. When possible, avoidance of transurethral resection of the bladder cuff and alternative strategies for obtaining biopsy tissue sample should be considered.

BACKGROUND: Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. Such delays can lead to disease progression. OBJECTIVE: We aimed to develop guidance on criteria for prioritization for surgery and reconfiguring management pathways for non-metastatic stage of prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve low likelihood of COVID-19 hazard if radical prostatectomy was to be carried out during the outbreak and whilst the disease is endemic. DESIGN, SETTING AND PARTICIPANTS: An accelerated consensus process and systematic review. We conducted a systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n=34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. OUTCOME MEASURES: Consensus opinion was defined as ≥80% agreement, which were used to reconfigure the prostate cancer pathways. RESULTS: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and develop measures to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritization criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as "COVID-19 cold sites". CONCLUSION: Re-configuring management pathways for prostate cancer patients is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing radical prostatectomy within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery.

Use of three-dimensional (3D) guidance for nephron-sparing surgery (NSS) has increased in popularity, especially for laparoscopic and robotic approaches. Different 3D visualization modalities have been developed as promising new tools for surgical planning and intraoperative navigation.To summarize and evaluate the impact of 3D models on minimally invasive NSS in terms of perioperative, functional, and oncological outcomes.A systematic literature search was conducted in December 2021 using the Medline (PubMed), Embase (Ovid), Scopus, and Web of Science databases. The protocol was registered on PROSPERO (CRD42022300948). The search strategy used the PICOS (Population, Intervention, Comparison, Outcome, Study design) criteria and article selection was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Meta-analysis was performed using the Mantel-Haenszel method for binary outcomes, with results summarized as the odds ratio (OR), and the inverse variance method for continuous data, with results reported as the mean difference (MD). All effect estimates are reported with the 95% confidence interval (CI) and p ≤ 0.05 was considered statistically significant. All analyses were performed using R software and the meta package.The initial electronic search identified 450 papers, of which 17 met the inclusion criteria and were included in the analysis. Use of 3D technology led to a significant reduction in the global ischemia rate (OR 0.22, 95% CI 0.07-0.76; p = 0.02) and facilitated more frequent enucleation (OR 2.54, 95% CI 1.36-4.74; p0.01) and less frequent opening of the collecting system (OR 0.36, 95% CI 0.15-0.89; p = 0.03) and was associated with less blood loss (MD 23.1 ml, 95% CI 31.8-14.4; p0.01). 3D guidance for NSS was associated with a significant reduction in the transfusion rate (OR 0.20, 95% CI 0.07-0.56; p0.01). There were no significant differences in rates of conversion to radical nephrectomy, minor and major complications, change in glomerular filtration rate, or surgical margins (all p0.05).3D guidance for NSS is associated with lower rates of detriment and surgical injury to the kidney. Specifically, a lower amount of nontumor renal parenchyma is exposed to ischemia or sacrificed during resection, and opening of the collecting system is less frequent. However, use of 3D technology does not lead to significant improvements in oncological or functional outcomes.We reviewed the use of three-dimensional tools for minimally invasive surgery for partial removal of the kidney in patients with kidney cancer. The evidence suggests that these tools have benefits during surgery, but do not lead to significant improvements in cancer control or functional outcomes for patients.

Perioperative intravesical chemotherapy (IVC) at or around the time of radical nephroureterectomy (RNU) reduces the risk of intravesical recurrence. Guidelines since 2013 have recommended its use. The objective of this study is to examine IVC utilization and determine predictors of its administration within a large international consortium.Data was collected from 17 academic centers on patients who underwent robotic/laparoscopic RNU between 2006 and 2020. Patients who underwent concomitant radical cystectomy and cases in which IVC administration details were unknown were excluded. Univariate and multivariate analyses were utilized to determine predictors of IVC administration. A Joinpoint regression was performed to evaluate utilization by year.Six hundred and fifty-nine patients were included. A total of 512 (78%) did not receive IVC while 147 (22%) did. Non-IVC patients were older (P0.001), had higher ECOG scores (P = 0.003), and had more multifocal disease (23% vs. 12%, P = 0.005). Those in the IVC group were more likely to have higher clinical T stage disease (P = 0.008), undergone laparoscopic RNU (83% vs. 68%, P0.001), undergone endoscopic management of the bladder cuff (20% vs. 4%, P = 0.008). Multivariable regression showed that decreased age (OR 0.940, P0.001), laparoscopic approach (OR 2.403, P = 0.008), and endoscopic management of the bladder cuff (OR 7.619, P0.001) were significant predictors favoring IVC administration. Treatment at a European center was associated with lower IVC use (OR 0.278, P = 0.018). Overall utilization of IVC after the 2013 European Association of Urology (EAU) guideline was 24% vs. 0% prior to 2013 (P0.001). Limitations include limited data regarding IVC timing/agent and inclusion of minimally invasive RNU patients only.While IVC use has increased since being added to the EAU UTUC guidelines, its use remains low at academic centers, particularly within Europe.

Background Robot-assisted partial nephrectomy (RAPN) is considered a feasible minimally invasive alternative to open partial nephrectomy (OPN) for the surgical treatment of renal tumors. Objective To provide further evidence supporting the effectiveness of RAPN in a contemporary patient population treated at one of three tertiary care centers for robotic surgery and to describe the evolution of RAPN-based technical improvements. Design, setting, and participants The Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group prospectively collected data from 635 patients subjected to RAPN for clinically localized kidney cancer between 2010 and 2016 at three high-volume tertiary care centers. Surgical procedure RAPN was performed using methods outlined in the supplementary video using either the da Vinci Si or Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Measurements Clinical data were collected within a prospectively maintained multi-institutional database. Intra- and postoperative data as well as surgical outcomes were assessed. Descriptive statistical analysis was performed and multivariable logistic regression models were fitted to determine the predictors of surgical outcomes. Results and limitations Mean patient age was 60.7yr and mean preoperative tumor size was 33mm. According to the PADUA score, 202 (31.8%) patients had a low-, 235 (37.0%) had an intermediate-, and 198 (31.2%) had a high-complexity tumor. In the majority of patients, a transperitoneal approach was used (n=447; 70.4%). Mean operative time was 156.3min and mean estimated blood loss was 171ml. Overall, 25 (3.9%) patients experienced a significant (Clavien-Dindo >2) complication after surgery. No statistically significant differences between pre- and postoperative creatinine values were observed (p≤0.823). Finally, optimal surgical outcomes defined according to the margin, ischemia, and complication score were achieved in 459 (72.3%) individuals. At a mean follow-up of 26mo, only two local and two distant recurrences of the disease were observed. Finally, in multivariable logistic regression models, tumor complexity was associated with the risk of not achieving optimal surgical outcomes. Conclusions RAPN represents an effective minimally invasive alternative to OPN in the treatment of clinically localized renal tumors. Patient summary We reported contemporary experience with RAPN for the treatment of kidney cancer. RAPN appears to be a safe and effective procedure, resulting in optimal outcomes in the majority of individuals despite tumor complexity.

CONTEXT: The optimal ischemia technique at partial nephrectomy (PN) for renal masses is yet to be determined. OBJECTIVE: To summarize and analyze the current evidence about surgical, oncological, and functional outcomes after different ischemia techniques (cold, warm, and zero ischemia) at PN. EVIDENCE ACQUISITION: A computerized systematic literature search was performed by using PubMed (MEDLINE) and Science Direct. Identification and selection of the studies were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria. Outcomes of interest were estimated blood loss (EBL), overall complications, positive surgical margins, local tumor recurrence, and renal function preservation. Meta-analysis and forest-plot diagrams were performed. Overall pooled estimates, together with 95% confidence intervals (CIs), of the incidence of all parameters were obtained using a random effect model (RE-Model) on the log transformed means (MLN), proportion, or standardized mean change, as deemed appropriate. EVIDENCE SYNTHESIS: One hundred and fifty-six studies were included. No clinically meaningful differences were found in terms of EBL after cold (mean: 215.5; 95% CI: 154.2-276.8m), warm (mean: 201.8; 95% CI: 175.0-228.7ml), or zero (mean: 261.2; 95% CI: 171.0-351.3ml) ischemia technique. Overall, postoperative complications were recorded in 14.1% (95% CI: 6.7-27.4), 11.1% (95% CI: 10.0-12.3), and 9.7% (95% CI: 7.7-12.2) of patients after cold, warm, and zero ischemia (p

The Standardization in Surgical Education (SISE) program is a collaborative venture of European Association of Urology (EAU) Section of Uro-Technology (ESUT) and Urolithiasis (EULIS) along with the educational office, the European School of Urology (ESU). It is a reference framework in which a hands-on-training (HOT) program offers the development and practice of individual skills for trainees and trainers.

Background: Kidney transplantation (KT) is the best renal replacement treatment. The rewarming time is associated with ischemia/reperfusion damage. In both the open (open KT [OKT]) and the robotic (robotic-assisted KT [RAKT]) approaches, ice slush is used to maintain graft temperature (T degrees) below 20 degrees C. This may result in nonhomogeneous graft T degrees maintenance and, particularly during RAKT where the graft is completely inside the abdominal cavity, rises concerns regarding systemic hypothermia. Objective: To design a cold ischemia device (CID) to maintain a constant and homogeneous low graft T degrees during surgery. Design, setting, and participants: In IDEAL phase 0, a CID was developed and tested to determine its cooling effect on the kidney inside a closed system at 37.5 degrees C, by comparing it with kidney alone versus a gauze-jacket filled with ice slush. The CID was evaluated in pigs undergoing OKT and RAKT, assessing feasibility and adverse reactions. In IDEAL phase 1, the CID was tested in human OKT and RAKT. Surgical procedure: OKT and RAKT. Measurements: In all phases, T degrees was evaluated at scheduled time points. Results and limitations: In the preliminary tests of IDEAL phase 0, the CID was able to maintain a low graft T degrees and superiority to other groups (p = 0.002). In the in vivo animal model, the CID maintained a low and constant graft T degrees in OKT (n = 3) and RAKT (n = 3), with a mean T degrees at 50 min of 10.8 degrees C and 14.9 degrees C, respectively. IDEAL phase 1 demonstrated feasibility of both approaches (OKT, n = 2 and RAKT, n = 3) using the CID, and graft T degrees never exceeded 20 degrees C (mean T degrees: OKT 15.7 degrees C vs RAKT 18.3 degrees C). No complications were recorded. The main limitation consists in the low number of participants. Conclusions: The CID assured a constant low graft T degrees during rewarming time, in both OKT and RAKT. Patient summary: A cold ischemia device (CID) is the first step toward a feasible, safe, and reproducible method to maintain a low graft temperature during surgery. The employment of a CID may optimize the functional outcomes. (c) 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.

OBJECTIVE To conduct a multi-institutional validation of a high-fidelity, perfused, inanimate, simulation platform for robot-assisted partial nephrectomy (RAPN) using incorporated clinically relevant objective metrics of simulation (CROMS), applying modern validity standards. MATERIALS AND METHODS Using a combination of three-dimensional (3D) printing and hydrogel casting, a RAPN model was developed from the computed tomography scan of a patient with a 4.2-cm, upper-pole renal tumour (RENAL nephrometry score 7×). 3D-printed casts designed from the patient's imaging were used to fabricate and register hydrogel (polyvinyl alcohol) components of the kidney, including the vascular and pelvicalyceal systems. After mechanical and anatomical verification of the kidney phantom, it was surrounded by other relevant hydrogel organs and placed in a laparoscopic trainer. Twenty-seven novice and 16 expert urologists, categorized according to caseload, from five academic institutions completed the simulation. RESULTS Clinically relevant objective metrics of simulators, operative complications, and objective performance ratings (Global Evaluative Assessment of Robotic Skills [GEARS]) were compared between groups using Wilcoxon rank-sum (continuous variables) and parametric chi-squared (categorical variables) tests. Pearson and point-biserial correlation coefficients were used to correlate GEARS scores to each CROMS variable. Post-simulation questionnaires were used to obtain subjective supplementation of realism ratings and training effectiveness. RESULTS Expert ratings demonstrated the model's superiority to other procedural simulations in replicating procedural steps, bleeding, tissue texture and appearance. A significant difference between groups was demonstrated in CROMS [console time (P < 0.001), warm ischaemia time (P < 0.001), estimated blood loss (P < 0.001)] and GEARS (P < 0.001). Six major intra-operative complications occurred only in novice simulations. GEARS scores highly correlated with the CROMS. CONCLUSIONS This perfused, procedural model offers an unprecedented realistic simulation platform, which incorporates objective, clinically relevant and procedure-specific performance metrics.

Contains fulltext : 220648.pdf (Publisher’s version ) (Closed access) The coronavirus disease 2019 (COVID-19) pandemic is unlike anything seen before by modern science-based medicine. Health systems across the world are struggling to manage it. Added to this struggle are the effects of social confinement and isolation. This brings into question whether the latest guidelines are relevant in this crisis. We aim to support urologists in this difficult situation by providing tools that can facilitate decision making, and to minimise the impact and risks for both patients and health professionals delivering urological care, whenever possible. We hope that the revised recommendations will assist urologist surgeons across the globe to guide the management of urological conditions during the current COVID-19 pandemic.

Background Robot-assisted partial nephrectomy (RAPN) represents a widely accepted minimally invasive alternative to open and laparoscopic surgery for the treatment of clinically localized renal tumors. Objective To assess the feasibility of RAPN in a contemporary series of patients with highly complex tumors (PADUA score ≥10) treated at four high-volume robotic surgery institutions. Design, setting, and participants Data from a prospectively maintained multi-institutional database on patients subjected to RAPN between 2010 and 2017 were reviewed. For the scope of this analysis, only patients with highly complex renal tumors, defined as a PADUA score between 10 and 14, were included. Surgical procedure RAPN was performed with the da Vinci Si or Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) using novel technologies such as TilePro and near-infrared fluorescence imaging. Measurements Intraoperative, postoperative, surgical, and oncological outcomes were collected. Predictors of optimal surgical outcomes defined according to the Margin Ischemia and Complications binary system (absence of Clavien-Dindo >2 complications, warm ischemia time [WIT] Results and limitations Overall, 255 patients with complex renal tumors were included. The mean operative time was 165min and mean WIT was 18.6min. Overall, WIT was longer than 20min in 86 (33.7%) individuals, while a Clavien-Dindo >2 complication and positive surgical margins were observed in 13 (5.1%) and four (out of 211 patients with malignant histotypes; 1.9%) individuals, respectively. Optimal surgical outcomes were achieved in 158 (62.0%) patients. At a median follow-up of 28mo, one (0.4%) local and two (0.8%) distant recurrences of the disease were observed. In multivariable LRMs, extremely complex tumors (PADUA score 12–13) were associated with an increased likelihood of not achieving optimal outcomes (odds ratio: 2.31; p=0.024). Besides tumor complexity, male gender was also associated with a two-fold higher risk of not achieving optimal surgical outcomes (p=0.029). Conclusions In experienced hands, RAPN can be considered as an effective treatment option even in cases of complex renal lesions. However, increasing tumor complexity may affect the surgical outcomes in this highly selected patient population. Patient summary We reported our multicentric experience with robot-assisted partial nephrectomy (RAPN) in patients with complex renal tumors. We demonstrated that, in experienced hands, RAPN is a feasible and safe treatment option even in such patients. Novel technologies applied to RAPN may further extend the indications without compromising the outcomes.

Background Despite technical improvements introduced with robotic surgery, management of complex tumours (PADUA score ≥10) is still a matter of debate within the field of transperitoneal robot-assisted partial nephrectomy (RAPN). Objective To evaluate the accuracy of our three-dimensional (3D) static and elastic augmented reality (AR) systems based on hyperaccuracy models (HA3D) in identifying tumours and intrarenal structures during transperitoneal RAPN (AR-RAPN), compared with standard ultrasound (US). Design, setting, and participants A retrospective study was conducted, including 91 patients who underwent RAPN for complex renal tumours, 48 with 3D AR guidance and 43 with 2D US guidance, from July 2017 to May 2019. Surgical procedure In patients who underwent 3D AR-RAPN, virtual image overlapping guided the surgeon during resection and suture phases. In the 2D US group, interventions were driven by US only. Measurements Patient characteristics were tested using the Fisher's exact test for categorical variables and the Mann-Whitney test for continuous ones. Intraoperative, postoperative, and surgical outcomes were collected. All results for continuous variables were expressed as medians (range), and frequencies and proportions were reported as percentages. Results and limitations The use of 3D AR guidance makes it possible to correctly identify the lesion and intraparenchymal structures with a more accurate 3D perception of the location and the nature of the different structures relative to the standard 2D US guidance. This translates to a lower rate of global ischaemia (45.8% in the 3D group vs 69.7% in the US group; p = 0.03), higher rate of enucleation (62.5% vs 37.5% in the 3D and US groups, respectively; p = 0.02), and lower rate of collecting system violation (10.4% vs 45.5%; p = 0.003). Postoperatively, 3D AR guidance use correlates to a low risk of surgery-related complications in 3D AR groups and a lower drop in estimated renal plasma flow at renal scan at 3 mo of follow-up (–12.38 in the 3D group vs –18.14 in the US group; p = 0.01). The main limitations of this study are short follow-up time and small sample size. Conclusions HA3D models that overlap in vivo anatomy during AR-RAPN for complex tumours can be useful for identifying the lesion and intraparenchymal structures that are difficult to visualise with US only. This translates to a potential improvement in the quality of the resection phase and a reduction in postoperative complications, with better functional recovery. Patient summary Based on our findings, three-dimensional augmented reality robot-assisted partial nephrectomy seems to help surgeons in the management of complex renal tumours, with potential early postoperative benefits.

Background Use of robot-assisted radical prostatectomy (RARP) for prostate cancer is increasing. Structured surgical training and objective assessment are critical for outcomes. Objective To develop and validate a modular training and assessment pathway via Healthcare Failure Mode and Effect Analysis (HFMEA) for trainees undertaking RARP and evaluate learning curves (LCs) for procedural steps. Design, setting, and participants This multi-institutional (Europe, Australia, and United States) observational prospective study used HFMEA to identify the high-risk steps of RARP. A specialist focus group enabled validation. Fifteen trainees who underwent European Association of Urology robotic surgery curriculum training performed RARP and were assessed by mentors using the tool developed. Results produced LCs for each step. A plateau above score 4 indicated competence. Outcome measurements and statistical analysis We used a modular training and assessment tool (RARP Assessment Score) to evaluate technical skills. LCs were constructed. Multivariable Kruskal-Wallis, Mann-Whitney U , and κ coefficient analyses were used. Results and limitations Five surgeons were observed for 42 console hours to map steps of RARP. HFMEA identified 84 failure modes and 46 potential causes with a hazard score ≥8. Content validation created the RARP Assessment Score: 17 stages and 41 steps. The RARP Assessment Score was acceptable (56.67%), feasible (96.67%), and had educational impact (100%). Fifteen robotic surgery trainees were assessed for 8 mo. In 426 RARP cases (range: 4–79), all procedural steps were attempted by trainees. Trainees were assessed with the RARP Assessment Score by their expert mentors, and LCs for individual steps were plotted. LCs demonstrated plateaus for anterior bladder neck transection (16 cases), posterior bladder neck transection (18 cases), posterior dissection (9 cases), dissection of prostatic pedicle and seminal vesicles (15 cases), and anastomosis (17 cases). Other steps did not plateau during data collection. Conclusions The RARP Assessment Score based on HFMEA methodology identified critical steps for focused RARP training and assessed surgeons. LCs demonstrate the experience necessary to reach a level of competence in technical skills to protect patients. Patient summary We developed a safety and assessment tool to gauge the technical skills of surgeons performing robot-assisted radical prostatectomy. Improvement was monitored, and measures of progress can be used in future to guide mentors when training surgeons to operate safely.

Background In recent years, novel technologies have been implemented in order to improve the surgical outcomes of robot-assisted partial nephrectomy (RAPN). Intraoperative administration of indocyanine green (ICG) has been proposed to assess kidney perfusion intraoperatively. Objective To confirm, on a large scale, the effectiveness of near-infrared fluorescence ICG–guided RAPN in leading the surgeon strategy and to provide hints to the use of this tool. Design, setting, and participants The Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group collected data from 737 patients subjected to RAPN between 2010 and 2016 at three tertiary care referral centers. Of them, 318 had complete demographic and clinical data, and underwent ICG-guided RAPN for clinically localized kidney cancer. Surgical procedure Patients were subjected to RAPN with intraoperative intravenous ICG injection. Measurements Optimal surgical outcomes, defined according to both the margin, ischemia, and complication (MIC), and the trifecta score, were assessed. Results and limitations A total of 194 (61%) patients were male and 124 (39%) were female. The median patient age was 61 yr and median preoperative tumor size was 30 mm. Median operative time, estimated blood loss, and warm ischemia time were, respectively, 162 min, 100 ml, and 17 min. In total, 228 (71.7%) and 254 (79.9%) individuals, respectively, were selected as optimal surgical patients defined according to MIC and trifecta. The univariate and multivariable logistic regression models showed that tumor complexity nephrometry scores were independent predictors of both trifecta and MIC. The main limitation of this study is the lack of a control group. Conclusions We report the largest population of patients who underwent ICG-guided RAPN. Intraprocedural ICG administration represents a useful tool where the vascular anatomy is challenging, and it could be implemented to maximize the adoption of RAPN. Patient summary We demonstrated that indocyanine green (ICG) is a reliable tool for guiding the surgeon strategy during robot-assisted partial nephrectomy. ICG may help in procedure tailoring, especially in cases with challenging vascularization or impaired renal function.

OBJECTIVES: To assess the predictive accuracy and the clinical value of a recent nomogram predicting cancer-specific mortality-free survival after surgery in pN1 prostate cancer patients through an external validation. METHODS: We evaluated 518 prostate cancer patients treated with radical prostatectomy and pelvic lymph node dissection with evidence of nodal metastases at final pathology, at 10 tertiary centers. External validation was carried out using regression coefficients of the previously published nomogram. The performance characteristics of the model were assessed by quantifying predictive accuracy, according to the area under the curve in the receiver operating characteristic curve and model calibration. Furthermore, we systematically analyzed the specificity, sensitivity, positive predictive value and negative predictive value for each nomogram-derived probability cut-off. Finally, we implemented decision curve analysis, in order to quantify the nomogram's clinical value in routine practice. RESULTS: External validation showed inferior predictive accuracy as referred to in the internal validation (65.8% vs 83.3%, respectively). The discrimination (area under the curve) of the multivariable model was 66.7% (95% CI 60.1-73.0%) by testing with receiver operating characteristic curve analysis. The calibration plot showed an overestimation throughout the range of predicted cancer-specific mortality-free survival rates probabilities. However, in decision curve analysis, the nomogram's use showed a net benefit when compared with the scenarios of treating all patients or none. CONCLUSIONS: In an external setting, the nomogram showed inferior predictive accuracy and suboptimal calibration characteristics as compared to that reported in the original population. However, decision curve analysis showed a clinical net benefit, suggesting a clinical implication to correctly manage pN1 prostate cancer patients after surgery.

Introduction : Robotic surgery is a rapidly expanding field. Thus far training for robotic techniques has been unstructured and the requirements are variable across various regions. Several projects are currently underway to develop a robotic surgery curriculum and are in various stages of validation. We aimed to outline the structures of available curricula, their process of development, validation status and current utilization. Methods : We undertook a literature review of papers including the MeSH terms "Robotics" and "Education". When we had an overview of curricula in development, we searched recent conference abstracts to gain up to date information. Results : The main curricula are the FRS, the FSRS, the Canadian BSTC and the ERUS initiative. They are in various stages of validation and offer a mixture of theoretical and practical training, using both physical and simulated models. Discussion : Whilst the FSRS is based on tasks on the RoSS virtual reality simulator, FRS and BSTC are designed for use on simulators and the robot itself. The ERUS curricula benefits from a combination of dry lab, wet lab and virtual reality components, which may allow skills to be more transferable to the OR as tasks are completed in several formats. Finally, the ERUS curricula includes the OR modular training programme as table assistant and console surgeon. Conclusion : Curricula are a crucial step in global standardisation of training and certification of surgeons for robotic surgical procedures. Many curricula are in early stages of development and more work is needed in development and validation of these programmes before training can be standardised.

Objectives To provide a comprehensive overview of the current status of the field of robotic systems for urological surgery and discuss future perspectives. Materials and Methods A non-systematic literature review was performed using PubMed/Medline search electronic engines. Existing patents for robotic devices were researched using the Google search engine. Findings were also critically analysed taking into account the personal experience of the authors. Results The relevant patents for the first generation of the da Vinci platform will expire in 2019. New robotic systems are coming onto the stage. These can be classified according to type of console, arrangement of robotic arms, handles and instruments, and other specific features (haptic feedback, eye-tracking). The Telelap ALF-X robot uses an open console with eye-tracking, laparoscopy-like handles with haptic feedback, and arms mounted on separate carts; first clinical trials with this system were reported in 2016. The Medtronic robot provides an open console using three-dimensional high-definition video technology and three arms. The Avatera robot features a closed console with microscope-like oculars, four arms arranged on one cart, and 5-mm instruments with six degrees of freedom. The REVO-I consists of an open console and a four-arm arrangement on one cart; the first experiments with this system were published in 2016. Medicaroid uses a semi-open console and three robot arms attached to the operating table. Clinical trials of the SP 1098-platform using the da Vinci Xi for console-based single-port surgery were reported in 2015. The SPORT robot has been tested in animal experiments for single-port surgery. The SurgiBot represents a bedside solution for single-port surgery providing flexible tube-guided instruments. The Avicenna Roboflex has been developed for robotic flexible ureteroscopy, with promising early clinical results. Conclusions Several console-based robots for laparoscopic multi- and single-port surgery are expected to come to market within the next 5 years. Future developments in the field of robotic surgery are likely to focus on the specific features of robotic arms, instruments, console, and video technology. The high technical standards of four da Vinci generations have set a high bar for upcoming devices. Ultimately, the implementation of these upcoming systems will depend on their clinical applicability and costs. How these technical developments will facilitate surgery and whether their use will translate into better outcomes for our patients remains to be determined.

Context Novel surgical techniques demand that surgical training adapts to the need for technical and nontechnical skills. Objective To identify training methods available for robot-assisted surgical (RAS) training in urology, evaluate their effectiveness in terms of validation, educational impact, acceptability, and cost effectiveness, and assess their effect on learning curves (LCs). Evidence acquisition A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines searched Ovid Medline, Embase, PsycINFO, and the Cochrane Library. Results were screened to include appropriate studies. Quality was evaluated. Each method was evaluated, and conclusions were drawn regarding LCs. Evidence synthesis Of 359 records, 24 were included (521 participants). Training methods included dry-lab training ( n =7), wet-lab training ( n =7), mentored training ( n =7), and nonstructured pathways ( n =5). Dry-lab training demonstrated educational impact by reducing console time and was acceptable in a study; 100% of participants confirmed face validity. Wet-lab training principally uses human cadaveric material; effectiveness is well rated, although dry-lab training and observation were rated as equally useful. Mentored programmes combine lectures, tutorials, observation, simulation, and proctoring. Minifellowships were linked to greater practice of RAS 1 yr later. LCs vary according to experience. One study found that surgeons from robot-related fellowships demonstrated fewer positive surgical margins than surgeons from laparoscopic-related fellowships (24% vs 34.6%; p =0.05) and reduced time (132 vs 152min; p =0.0003). Five studies examined nonstructured training pathways (clinical practice). Experience correlated with fewer complications ( p =0.007), improved continence ( p =0.049), and reduced time ( p =0.002). Conclusions RAS training methods include dry and wet lab, mentored training, and nonstructured pathways. Limited available evidence suggests that they affect LCs differently and are rarely used alone. The different methods of training appear effective when combined. Their benefits must be explored to facilitate validated acceptable training with educational impact. Patient summary Robot-assisted training encompasses several methods used in combination, but more evidence is required to gain the greatest benefit and formulate future training pathways.

OBJECTIVE: Effective training is paramount for patient safety. Modular training entails advancing through surgical steps of increasing difficulty. This study aimed to construct a modular training pathway for use in robot-assisted radical prostatectomy (RARP). It aims to identify the sequence of procedural steps that are learnt before surgeons are able to perform a full procedure without an intervention from mentor.DESIGN: This is a multi-institutional, prospective, observational, longitudinal study. We used a validated training tool (RARP Score). Data regarding surgeons' stage of training and progress were collected for analysis. A modular training pathway was constructed with consensus on the level of difficulty and evaluation of individual steps. We identified and recorded the sequence of steps performed by fellows during their learning curves.SETTING AND PARTICIPANTS: We included 15 urology fellows from UK, Europe, and Australia.RESULTS: A total of 15 surgeons were assessed by mentors in 425 RARP cases over 8 months (range: 7-79) across 15 international centers. There were substantial differences in the sequence of RARP steps according to the chronology of the procedure, difficulty level, and the order in which surgeons actually learned steps. Steps were not attempted in chronological order. The greater the difficulty, the later the cohort first undertook the step (p = 0.021). The cohort undertook steps of difficulty level I at median case number 1. Steps of difficulty levels II, III, and IV showed more variation in median case number of the first attempt. We recommend that, in the operating theater, steps be learned in order of increasing difficulty. A new modular training route has been designed. This incorporates the steps of RARP with the following order of priority: difficulty level > median case number of first attempt > most frequently undertaken in surgical training.CONCLUSIONS: An evidence-based modular training pathway has been developed that facilitates a safe introduction to RARP for novice surgeons.

To determine the current state of robotic urological practice, to establish how robotic training has been delivered and to ascertain whether this training was felt to be adequate. A questionnaire was emailed to members of the European Association of Urology robotic urology section mailing list. Outcomes were subdivided into three groups: demographics, exposure and barriers to training, and delivery of training. A comparative analysis of trainees and independently practising robotic surgeons was performed. 239 surgeons completed the survey, of these 117 (48.9 %) were practising robotic surgeons with the remainder either trainees or surgeons who had had received training in robotic surgery. The majority of robotic surgeons performed robotic-assisted laparoscopic prostatectomy (90.6 %) and were undertaking >50 robotic cases per annum (55.6 %). Overall, only 66.3 % of respondents felt their robotic training needs had been met. Trainee satisfaction was significantly lower than that of independently practising surgeons (51.6 versus 71.6 %, p = 0.01). When a subgroup analysis of trainees was performed examining the relationship between regular simulator access and satisfaction, simulator access was a positive predictor of satisfaction, with 87.5 % of those with regular access versus 36.8 % of those without access being satisfied (p

Background With the development of novel augmented reality operating platforms the way surgeons utilise imaging as a real-time adjunct to surgical technique is changing. Methods A questionnaire was distributed via the European Robotic Urological Society mailing list. The questionnaire had three themes: surgeon demographics, current use of imaging and potential uses of an augmented reality operating environment in robotic urological surgery. Results 117 of the 239 respondents (48.9%) were independently practising robotic surgeons. 74% of surgeons reported having imaging available in theatre for prostatectomy 97% for robotic partial nephrectomy and 95% cystectomy. 87% felt there was a role for augmented reality as a navigation tool in robotic surgery. Conclusions This survey has revealed the contemporary robotic surgeon to be comfortable in the use of imaging for intraoperative planning it also suggests that there is a desire for augmented reality platforms within the urological community. Copyright © 2014 John Wiley & Sons, Ltd.