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To report perioperative and postoperative outcomes in men who undergo salvage RASP (sRASP) following some other endoscopic outlet procedure for benign prostate enlargement (BPE) compared to those undergoing RASP for primary treatment (pRASP).A prospectively maintained database consisting of all RASP surgeries (December 2014-October 2019) performed at our institution by 3 different urologists was used. Patients who had received an endoscopic procedure for BPE prior to their RASP (sRASP) were compared to those who had not had a prior outlet procedure (pRASP).In total, 310 men underwent RASP during the study period. Of those, 30 (9.7%) had undergone an endoscopic procedure prior to surgery. There were no significant differences in age, race, ASA, BMI, prostate volume, PSA or rates of preoperative retention (P.05 for all). Men who were treatment-naive had significantly higher preoperative International Prostate Symptom Scores (IPSS) than men who had a prior procedure (18.3 ± 7.7 vs 13.6 ± 6.2, P = .008). However, there were no significant differences in functional or quality of life outcomes between the 2 groups (P.05 for all). There were no significant differences in perioperative or post-operative outcomes between the 2 groups. Furthermore, rates of post-operative complications and incontinence were similar between groups (11% vs 10%, P = .9 and 2% vs 0%, P = 1 respectively).Performing a RASP after prior endoscopic procedure for BPE was found to be safe and effective. Success and complication rates were similar to patients with no prior procedures.

Introduction: Ureteroscopy (URS) is associated with substantial patient-perceived morbidity. To improve the patient experience, we developed an enhanced recovery after surgery (ERAS) protocol for U...

Introduction: Irreversible electroporation (IRE) is a nonthermal ablative technology that applies high-voltage short-pulse electrical current to create cellular membrane nanopores and ultimately re...

We seek to understand if an automated algorithm can replace human scoring of surgical trainees performing the urethrovesical anastomosis in radical prostatectomy with synthetic tissue. Specifically, we investigate neural networks for predicting the surgical proficiency score (GEARS score) from video clips. We evaluate videos of surgeons performing the urethral anastomosis using synthetic tissue. The algorithm tracks surgical instrument locations from video, saving the positions of key points on the instruments over time. These positional features are used to train a multi-task convolutional network to infer each sub-category of the GEARS score to determine the proficiency level of trainees. Experimental results demonstrate that the proposed method achieves good performance with scores matching manual inspection in 86.1% of all GEARS sub-categories. Furthermore, the model can detect the difference between proficiency (novice to expert) in 83.3% of videos. Evaluation of GEARS sub-categories with artificial neural networks is possible for novice and intermediate surgeons, but additional research is needed to understand if expert surgeons can be evaluated with a similar automated system.

Intravesical gemcitabine and docetaxel (Gem/Doce) has been established as a safe and efficacious salvage treatment for recurrent NMIBC since 2015. Despite widespread adoption of this regimen, long-term outcomes have not been described. We report our experience with intravesical Gem/Doce following BCG failure in a large cohort of patients with extended follow-up.We retrospectively identified 97 patients at our institution treated with Gem/Doce for high-risk NMIBC after BCG failure between 2009 and 2017. Patients received six weekly intravesical Gem/Doce instillations. Monthly maintenance for 2 years was initiated if disease free at first follow-up. Outcomes included recurrence-free survival (RFS), high-grade recurrence-free survival (HG-RFS), progression-free survival (PFS), cystectomy-free survival (CFS), cancer-specific survival (CSS), and overall survival (OS). Survival probabilities were estimated using the Kaplan-Meier method.Median follow-up was 49 months. Median age was 73 years, and 71% of the cohort had CIS containing disease. Thirty five percent of the cohort had BCG-unresponsive disease. Complete response at 3-month surveillance was 74% and median duration of response was 25 months. At 1, 2, and 5 years, HG-RFS was 60%, 50%, and 30%, respectively. HG-RFS was similar among BCG-unresponsive patients and the overall cohort. During follow-up, 20 patients underwent cystectomy and 15 patients experienced disease progression. Five-year PFS, CFS, CSS, and OS were 82%, 75%, 91%, and 64%, respectively.In this long-term analysis, intravesical Gem/Doce for high-risk NMIBC after BCG failure yielded a 75% 5-year bladder preservation rate and a 91% 5-year cancer-specific survival rate. Further prospective trials are warranted.

Bacillus Calmette-Guérin (BCG) is currently recommended as adjuvant therapy following complete transurethral resection of bladder tumor for high-risk nonmuscle-invasive bladder cancer (NMIBC). In response to the BCG shortage, gemcitabine plus docetaxel (Gem/Doce) has been utilized at our institution in the BCG-naïve setting. We report the outcomes of patients with high-risk BCG-naïve NMIBC treated with Gem/Doce.We retrospectively reviewed patients with BCG-naïve high-risk NMIBC treated with Gem/Doce from May 2013 through April 2021. Patients received 6 weekly intravesical instillations of sequential 1 gm gemcitabine and 37.5 mg docetaxel after complete transurethral resection of bladder tumor. Monthly maintenance of 2 years was initiated if disease-free at first followup. The primary outcome was recurrence-free survival. Survival was assessed with the Kaplan-Meier method, indexed from the first Gem/Doce instillation. Adverse events were reported using CTCAE (Common Terminology Criteria for Adverse Events) v5 (National Cancer Institute, Bethesda, Maryland). Differences were assessed with the log-rank test.There were 107 patients with a median followup of 15 months included in the analysis. Patients had high-risk characteristics including 47 with any carcinomaGem/Doce is an effective and well-tolerated therapy for BCG-naïve NMIBC. Further investigation is warranted.

Intravesical gemcitabine-docetaxel has emerged as an efficacious and well-tolerated salvage therapy for non-muscle-invasive bladder cancer. However, further rescue therapies are needed for subsequent recurrences or intolerance, particularly when cystectomy is refused or precluded. Valrubicin is a U.S. Food and Drug Administration-approved agent for bacillus Calmette-Guérin unresponsive disease, yet as monotherapy has demonstrated poor efficacy. We report our experience with sequential intravesical valrubicin and docetaxel as a rescue therapy for non-muscle-invasive bladder cancer.We retrospectively identified all patients with recurrent non-muscle-invasive bladder cancer treated with valrubicin and docetaxel between April 2013 and June 2021. Patients received weekly sequential intravesical instillations of 800 mg valrubicin and 37.5 mg docetaxel for 6 weeks. If disease-free at first follow-up, monthly maintenance of 2 years was initiated. The primary outcome was recurrence-free survival, assessed using the Kaplan-Meier method.The analysis included 75 patients with median follow-up of 21 months (IQR: 13-37). Twelve patients with low-grade disease had a 73% recurrence-free survival at 2 years. Sixty-three patients with recurrent high-grade disease had a 38% 2-year high-grade recurrence-free survival. Forty-two (56%) patients had carcinoma in situ present; recurrence-free survival was similar for those with and without carcinoma in situ (In a heavily pretreated population, our results suggest valrubicin and docetaxel is an effective rescue treatment for patients with recurrent non-muscle-invasive bladder cancer. Further prospective evaluation is needed.

To quantify the benefits and harms of post-procedural antibiotic use after common urologic procedures.This retrospective cohort study included patients who underwent an endoscopic urologic procedure (transurethral resection of bladder tumor, transurethral resection of prostate, or ureteroscopy) within the Veterans Health Administration between January 1, 2017 and June 30, 2021. A post-procedural antibiotic was any qualifying antibiotic prescribed for administration on the day after the procedure. Guidelines generally do not recommend post-procedural antibiotics for surgical prophylaxis. Outcomes included unplanned return visits and Clostridioides difficile infection within 30 days. Log-binomial models with risk-adjustment were used to measure the association between post-procedural antibiotic use and outcomes. Hospital-level observed-to-expected (O:E) ratios were constructed to compare post-procedural antibiotic use.There were 74,629 qualifying procedures across 105 hospitals; 27,422 (36.7%) received post-procedural antibiotics (median 3 days, IQR 3-6). An unplanned return visit occurred in 20.2% of patients who received post-procedural antibiotics vs 17.2% who did not (adjusted RR 1.032, 95% CI 0.999-1.066). C. difficile infection was diagnosed in 0.27% vs 0.10% in those who received and did not receive post-procedural antibiotics (adjusted RR 1.67, 95% CI 1.13-2.45). The O:E ratio for post-procedural antibiotic use ranged from 0.46 among hospitals in the lowest-use quartile to 1.93 in the highest-use quartile.Post-procedural antibiotics were frequently prescribed after urologic procedures with large inter-facility variability even after adjusting for case-mix differences. Post-procedural antibiotic use was associated with increased risk for C. difficile infection but not fewer unplanned return visits. Efforts to reduce guideline-discordant use of post-procedural antibiotics are needed.

Robotic-assisted simple prostatectomy (RASP) has proven to be an effective minimally invasive option for benign prostatic enlargement (BPE) in recent years. Single-site surgery is theorized to reduce post-operative pain beyond traditional minimally invasive approaches. We sought to assess whether use of a single-port robotic platform decreases post-operative opioid use in patients undergoing robotic-assisted simple prostatectomy (RASP). A retrospective review was performed of all patients undergoing RASP our institution from November 2017 to July 2019. Demographic, intraoperative, and post-operative data, including morphine equivalent (ME) use, were collected. Patients were stratified by robotic platform utilized. Propensity score matching using nearest neighbor method was performed using prostate volume, Charlson comorbidity index (CCI), and post-op ketorolac use in 4:1 fashion. Chi-squared analysis and Kruskal–Wallis analyses were utilized. Two-hundred-and-seven men underwent RASP. After matching, 80 patients (64 multi-port, 16 single-port) were included in the analysis. Groups were comparable for age, body mass index, CCI, prostate volume, prior opioid use, and use of scheduled ketorolac post op. The single-port approach was associated with a reduction in MEs once admitted to the floor (5 vs. 11 mg, p = 0.025) and an increase in the proportion of patients who did not require any narcotics post-operatively (44 vs. 19%, p = 0.036). In a propensity matched cohort of patients undergoing RASP at a single institution, use of the single-port robotic system conferred a significant decrease in post-operative narcotic use by approximately 50%.

To re-evaluate the treatment of T1HG bladder cancer by analyzing our experience over 18 years.An IRB-approved, single-institution retrospective review was performed of all patients with T1HG bladder cancer between August 1999 and July 2017. We assessed clinicopathologic characteristics, treatment history (including intravesical therapy, cystectomy, systemic chemotherapy, and radiation), and oncologic outcomes.We identified 191 patients with T1HG. Five patients underwent cystectomy at diagnosis. The five-year recurrence-free survival (RFS) for the 186 patients who initially underwent bladder sparing treatments was 50% (95% CI: 41%-58%). There were 83 patients (45%) with disease recurrence; median time to recurrence was 6.7 months (IQR: 4.9-17.5). Disease characteristics at initial recurrence was T2 or greater in 8 patients (10%), T1HG in 19 (23%), CIS in 30 (36%), TaHG in 10 (12%), T1 low-grade (LG) in 1 (1%), and TaLG in 15 (18%). For patients with no prior recurrences, neither re-resection (P = 0.12), receipt of induction therapy (P = 0.81), prostatic urethra positivity (P = 0.51), or age (P = 0.34) were significantly associated with risk of recurrence. Similarly, patients with a single recurrence also fared well without identifiable risk factors. In fact, baseline hazard function analysis demonstrated no differences in RFS comparing patients stratified by 0, 1, and 2+ prior recurrences (P = 0.46). The five-year overall survival (OS) was 76% (95% CI: 68%-82%), and median OS was 127 months. The five-year cancer-specific survival was 86% (95% CI: 78%-91%) for the overall cohort. Five-year cystectomy-free survival for patients with BCG responsive disease and unresponsive disease was 95% (95% CI: 85%-98%) and 72% (95% CI: 52%-84%), respectively.For patients who recurred after intravesical therapy, including those with recurrent T1 disease, additional induction courses of intravesical therapy did not negatively affect oncologic outcomes. Pathology of initial recurrence was not found to be a statistically significant risk factor for future recurrence. These findings suggest that BCG-unresponsive disease does not necessarily require immediate cystectomy. A multicenter, pragmatically designed evaluation in a contemporary cohort would more validly interrogate this important patient population.

Rescue intravesical therapies for patients with bacillus Calmette-Guérin failure nonmuscle invasive bladder cancer remain a critical focus of ongoing research. Sequential intravesical gemcitabine and docetaxel therapy has shown safety and efficacy in 2 retrospective, single institution cohorts. This doublet has since been adopted as an intravesical salvage option at multiple institutions. We report the results of a multi-institutional evaluation of gemcitabine and docetaxel.Each institution retrospectively reviewed all records of patients treated with intravesical gemcitabine and docetaxel for nonmuscle invasive bladder cancer between June 2009 and May 2018. Only patients with recurrent nonmuscle invasive bladder cancer and a history of bacillus Calmette-Guérin treatment were included in the analysis. If patients were disease-free after induction, maintenance was instituted at the treating physician's discretion. Posttreatment surveillance followed American Urological Association guidelines. Survival analysis was performed using the Kaplan-Meier method and risk factors for treatment failure were assessed with Cox regression models.Overall 276 patients (median age 73 years, median followup 22.9 months) received treatment. Nine patients were unable to tolerate a full induction course. One and 2-year recurrence-free survival rates were 60% and 46%, and high grade recurrence-free survival rates were 65% and 52%, respectively. Ten patients (3.6%) had disease progression on transurethral resection. Forty-three patients (15.6%) went on to cystectomy (median 11.3 months from induction), of whom 11 (4.0%) had progression to muscle invasion. Analysis identified no patient, disease or prior treatment related factors associated with gemcitabine and docetaxel failure.Intravesical gemcitabine and docetaxel therapy is well tolerated and effective, providing a durable response in patients with recurrent nonmuscle invasive bladder cancer after bacillus Calmette-Guérin therapy. Further prospective study is warranted.

Summary Introduction Patients with neurogenic bladder (NGB) require periodic urodynamics (UDS) to evaluate bladder function, which in turn helps guide management. At times, bladder decompensation or hydronephrosis may develop in patients between urodynamic testing intervals. Increased surveillance has improved outcomes in other chronic conditions (e.g., diabetes). Two novel devices, the cystomanometer (CM) and cystoelastometer (CEM), have been developed at the authors' institution to allow for home bladder pressure monitoring. The handheld CM can be attached to the end of any catheter and records the opening bladder pressure along with a time stamp. In addition, the CEM actively evacuates urine via a pump and records the urine volume evacuated. For safety, the pump slows and stops as it detects increasing resistance. Data are stored and transmitted wirelessly from both devices to a smartphone. A novel phone application stores, displays, and transmits data to a secure hospital server. Objective This aim of this study was to validate the function of the CM and CEM and their accuracy relative to UDS. Study design Institutional review board approval was obtained. All patients with NGB managed with intermittent catheterization undergoing routine UDS were eligible for study inclusion. At the completion of UDS, the instillation port of the 6-French dual-lumen UDS catheter was connected to the CM or CEM. Bladder parameters were simultaneously recorded using the device and UDS during bladder emptying. Correlative statistics were calculated. Results A total of 36 patients (30 children/6 adults; age range from 1.2 to 38 years [median: 7.5 years]) underwent CM testing. Strong pressure correlation with UDS was identified (R2 = 0.89). A total of 42 patients (30 children/12 adults; age range of 2.9–85.2 years [median: 12.2 years]) underwent CEM testing. Again, strong pressure correlation was found (R2 = 0.77). Cystoelastometer volume measurements were highly correlated with measured volumes (Fig. 4, R2 = 0.98). Discussion Both the CM and CEM functioned well and transmitted the data wirelessly to a smartphone. The data from these devices were strongly correlated with simultaneous data from the UDS. A limitation is that these devices were used by healthcare providers, and therefore, use by patients or their parents/caregivers at home has not been demonstrated. Conclusion The CM and CEM devices provide accurate bladder pressure and volume measurements. The potential for improved patient monitoring and care is promising. Reliability testing and the effects of such monitoring on patient outcomes remain to be determined. Download : Download high-res image (352KB) Download : Download full-size image Summary Figure .

Nutcracker phenomenon of the left renal vein is a rare anatomic anomaly that can present with chronic flank/pelvic pain, pelvic congestion, and hematuria. Conventional treatment options (superior mesenteric artery transposition, endovascular stent placement, auto-transplantation) involve substantial risk, morbidity, or the need for chronic anti-coagulation. We now report our institution's robotic experience with extravascular left renal vein stent placement. A retrospective, single surgeon series from December 2016 to May 2019 was reviewed. After positioning and port placement (three robotic ports, one assistant), the left renal vein was exposed and dissected free circumferentially down to the inferior vena cava insertion. The distance between the renal vein ostium and adrenal vein was measured and a 1 cm-diameter ringed polytetrafluoroethylene vascular stent of this length placed. The stent edges were secured to itself with 3-0 polyglactin sutures. Demographics, surgical, and functional outcomes were collected. Six patients with mean age of 45 ± 6 years and body mass index of 20.3 ± 3.3 g underwent the procedure. Mean operative time was 143 ± 20 min. Estimated blood loss was minimal. Mean graft length utilized was 2.25 ± 0.3 cm. Median day of discharge was 1.5 days (range 1-3). No high-grade complications occurred. All patients received immediate pain relief and 50% also saw other symptomatic improvements. Robotic assisted extravascular left renal vein stent placement appears safe and effective in a small cohort with short follow-up. Further long-term follow-up for pain relief and graft-related complications are needed.

Urologists must balance multiple roles as part of their work. In doing so, many will identify a need for new technology or areas of improvement for existing technology. In considering the ways to address the problem, the idea for a novel device may take shape. If the physician is interested, creation of a novel device or redesigning existing technology can be intellectually stimulating, collaborative and may aid the medical community at large. During development of any device, documenting project details and progress is critical to protect one’s ideas. Prototyping is now faster and less costly than in years prior as a result of new software and fabrication technologies. In this chapter, we detail the steps to inventorship and important considerations that must be undertaken along the way.

ImportanceDue to the ongoing bacillus Calmette-Guérin (BCG) shortage, sequential intravesical gemcitabine and docetaxel has been increasingly used as first-line therapy for high-risk non–muscle-invasive bladder cancer (NMIBC). However, data directly comparing these 2 therapies are lacking.ObjectiveTo compare the outcomes of patients with high-risk NMIBC treated with gemcitabine and docetaxel vs BCG.Design, Setting, and ParticipantsThis retrospective cohort study was conducted from January 1, 2011, to December 31, 2021. The median (IQR) duration of follow-up was 23 (12-33) months for patients receiving gemcitabine and docetaxel and 49 (27-79) months for patients receiving BCG. All patients were treated at the University of Iowa tertiary care center. A total of 312 patients with high-risk treatment-naive NMIBC were included; 174 patients were treated with BCG therapy and 138 were treated with gemcitabine and docetaxel therapy.ExposuresAfter undergoing complete transurethral resection of bladder tumor, patients received either sequential intravesical gemcitabine, 1 g, and docetaxel, 37.5 mg, or 1 vial of BCG. Induction treatments were administered once per week for 6 weeks. Maintenance regimens were initiated if the patient was disease free at the first follow-up visit.Main Outcomes and MeasuresThe primary outcome was high-grade recurrence-free survival (RFS). Survival probabilities were estimated using the Kaplan-Meier method. Cox regression models were used to evaluate the association of covariates with outcomes. Adverse events were reported using the Common Terminology Criteria for Adverse Events, version 5.ResultsAmong 312 patients, the median (IQR) age was 73 (66-79) years; 255 patients (81.7%) were male and 292 (93.6%) were White. Baseline clinicopathological characteristics such as sex, smoking status, and pretreatment tumor pathology were similar between treatment groups. High-grade RFS estimates were 76% (95% CI, 69%-82%) at 6 months, 71% (95% CI, 64%-78%) at 12 months, and 69% (95% CI, 62%-76%) at 24 months in the BCG group and 92% (95% CI, 86%-95%) at 6 months, 85% (95% CI, 78%-91%) at 12 months, and 81% (95% CI, 72%-87%) at 24 months in the gemcitabine and docetaxel group. Multivariable Cox regression analyses controlled for age, sex, treatment year, and presence of carcinoma in situ revealed that treatment with gemcitabine and docetaxel was associated with better high-grade RFS (hazard ratio, 0.57; 95% CI, 0.33-0.97; P = .04) and RFS (hazard ratio, 0.56; 95% CI, 0.34-0.92; P = .02) than treatment with BCG. Induction therapy for BCG was associated with greater treatment discontinuation than induction therapy for gemcitabine and docetaxel (9.2% vs 2.9%; P = .02).Conclusions and RelevanceIn this cohort study, gemcitabine and docetaxel therapy was associated with less high-grade disease recurrence and treatment discontinuation than BCG therapy. These findings suggest that, while awaiting results from an ongoing randomized clinical trial during the current BCG shortage, use of gemcitabine and docetaxel can be considered for recommendation in updated practice guidelines.

497 Background: Due to ongoing bacillus Calmette-Guerin (BCG) shortages, sequential intravesical gemcitabine and docetaxel (Gem/Doce) has been increasingly utilized as first-line adjuvant treatment for patients with high-risk non-muscle invasive bladder cancer. Herein, we compared oncologic outcomes and tolerance of Gem/Doce versus BCG. Methods: We retrospectively identified 312 patients with high-risk, treatment-naïve, NMIBC treated at our institution between January 2011 and December 2021; 174 treated with BCG and 138 treated with Gem/Doce. After complete TURBT, patients received a 6 weekly intravesical induction regimen of Gem/Doce or BCG, followed by maintenance if disease free at first follow-up. The primary outcome was high-grade (HG) recurrence-free survival (RFS). Cox multivariable regression analyses were performed. Adverse events were reported using CTCAE v5. Results: Median follow-up for patients receiving Gem/Doce and BCG was 23 and 49 months, respectively. Baseline clinicopathologic characteristics were similar between groups, including presence of CIS (41% vs 44%, p=0.6) and T1 (37% vs 41%, p=0.5) disease for patients receiving Gem/Doce and BCG, respectively. HG-RFS estimates at 6, 12, and 24-months were 92%, 85%, and 81% for Gem/Doce and 76%, 71%, and 69% for BCG, respectively. On multivariable Cox regression analyses controlling for age, gender, treatment year, and presence of CIS, Gem/Doce treatment was associated with superior HG-RFS (HR 0.57, p=0.04) and RFS (HR 0.56, p=0.02) versus BCG (Table). Progression-free, cystectomy-free, cancer-specific, and overall survival were similar between groups. Induction BCG was associated with greater treatment discontinuation (9.2% vs 2.9%, p=0.02), dysuria (p=0.03), and arthralgias (p=0.02), but less bladder spasms (p

Purpose: We aimed to assess failure rates of salvage interventions and changes in split kidney function (SKF) following failed primary repair of ureteropelvic junction obstruction (UPJO). Materials and Methods: A retrospective review of adult patients at an academic medical center who underwent salvage intervention following primary treatment for UPJO was performed. Symptomatic failure was defined as significant flank pain. Radiographic failure was defined as no improvement in drainage or a decrease in SKF by ≥7%. Overall failure, the primary outcome, was defined as symptomatic failure, radiographic failure, or both. Results: Between 2008-2017, 34 patients (median age 38 years, 50% men) met study criteria. UPJO management was primary pyeloplasty/secondary endopyelotomy for 21/34 (62%), primary pyeloplasty/secondary pyeloplasty for 6/34 (18%), and primary endopyelotomy/secondary pyeloplasty for 7/34 (21%). Median follow-up was 3.3 years following secondary intervention. Patients undergoing primary pyeloplasty/secondary endopyelotomy had significantly higher overall failure than those undergoing primary pyeloplasty/secondary pyeloplasty (16/21 [76%] vs. 1/6 [17%], p=0.015). Among patients undergoing secondary endopyelotomy, presence of a stricture on retrograde pyelogram, stricture length, and SKF were not associated with symptomatic, radiographic, or overall failure. Serial renography was performed for 28/34 (82%) patients and 2/28 (7%) had a significant decline in SKF. Conclusions: Following failed primary pyeloplasty, secondary endopyelotomy had a greater overall failure rate than secondary pyeloplasty. No radiographic features assessed were associated with secondary endopyelotomy failure. Secondary intervention overall failure rates were higher than reported in the literature. Unique to this study, serial renography demonstrated that significant functional loss was overall infrequent.

INTRODUCTION AND OBJECTIVE:A robotic approach to renal surgery has been shown to be safe and effective and is typically performed in a transperitoneal fashion. Retroperitoneal surgery avoids entry ...

Background: As medical technology continues to advance, especially visualization and miniaturization, surgical intervention continues to become less invasive. Although initially seen with laparoscopy and multiport robotics, single-site surgery has been the focus for the past decade. Recently, a dedicated single-port operative robotic surgical system, DaVinci SP system, was approved by the Food and Drug Administration. We now report the results of our initial series of ureteral reconstructive procedures using this platform. Case Presentation: Three patients underwent robotic ureteral reconstructive procedures using the new single-port robotic system. A 62-year-old man with obstructive uropathy related to benign prostatic hypertrophy, relieved by a transurethral resection of the prostate, underwent bilateral ureteral reimplantation for functional ureteral obstruction. A 37-year-old woman with a history of hysterectomy had right flank pain and was found to have right hydroureteronephrosis down to the level of the right ovarian vein consistent with right ovarian vein syndrome. She underwent right ovarian vein clipping and ureterolysis. A 69-year-old woman with 1 year of right flank pain was found to have a ureteropelvic junction obstruction caused by a short atretic ureteral segment and underwent right pyeloplasty with stent placement. A flexible surgeon controlled suction system was used in the latter two cases. All procedures were completed without conversion to a multiport robotic system, laparoscopy, or open. No major complication or transfusions were required. All patients were discharged to home by postoperative day 2. Conclusion: Ureteral reconstructive procedures can be safely and effectively completed using the SP robotic surgical system. Flexible suction allows for near complete surgeon autonomy.

We sought to develop and validate a low-cost, high-fidelity robotic surgical model for the urethrovesical anastomosis component of the robot-assisted laparoscopic radical prostatectomy.A novel simulation model was constructed using a 3D-printed model of the male bony pelvis from CT scan data and silicone molds to recreate the soft tissue aspects. Using a da Vinci Si surgical robot, urology faculty and trainees performed simulated urethrovesical anastomosis. Each participant was given 12 minutes to complete the simulation. A survey established face validity, content validity, and acceptability. Simulation runs were evaluated by three blinded reviewers. The anastomosis was graded by two reviewers for suture placement accuracy and anastomosis quality. These factors were compared with robotic experience to establish construct validity.Twenty participants took part in the initial validation of this model. Groups were defined as experts (surgical faculty), intermediate (fellows and chief residents), and novices (junior residents). Likert scores (1-5 scale, top score 5) examining face validity, content validity, and acceptability were 3.49 ± 0.43, 4.15 ± 0.23, and 4.02 ± 0.19, respectively. Construct validity was excellent based on the model's ability to stratify groups. All evaluated metrics were statistically different between the three levels of training. Total material cost was $2.50 per model.We developed a novel low-cost robotic simulation of the urethrovesical anastomosis for robot-assisted radical prostatectomy. The model discerns robotic skill level across all levels of training and was found favorable by participants showing excellent face, content, and construct validities.

Introduction: Nutcracker syndrome (NCS) is a rare syndrome, where symptoms can be debilitating, severely affecting quality of life. Patients who fail conservative management can be offered...

Robotic-assisted simple prostatectomy (RASP) has proven to be an effective minimally invasive option for benign prostatic enlargement (BPE) in recent years. Single-site surgery is theorized to reduce post-operative pain beyond traditional minimally invasive approaches. We sought to assess whether use of a single-port robotic platform decreases post-operative opioid use in patients undergoing robotic-assisted simple prostatectomy (RASP). A retrospective review was performed of all patients undergoing RASP our institution from November 2017 to July 2019. Demographic, intraoperative, and post-operative data, including morphine equivalent (ME) use, were collected. Patients were stratified by robotic platform utilized. Propensity score matching using nearest neighbor method was performed using prostate volume, Charlson comorbidity index (CCI), and post-op ketorolac use in 4:1 fashion. Chi-squared analysis and Kruskal-Wallis analyses were utilized. Two-hundred-and-seven men underwent RASP. After matching, 80 patients (64 multi-port, 16 single-port) were included in the analysis. Groups were comparable for age, body mass index, CCI, prostate volume, prior opioid use, and use of scheduled ketorolac post op. The single-port approach was associated with a reduction in MEs once admitted to the floor (5 vs. 11 mg, p = 0.025) and an increase in the proportion of patients who did not require any narcotics post-operatively (44 vs. 19%, p = 0.036). In a propensity matched cohort of patients undergoing RASP at a single institution, use of the single-port robotic system conferred a significant decrease in post-operative narcotic use by approximately 50%.

Solid renal masses have unknown malignant potential with commonly utilized imaging. Biopsy can offer a diagnosis of cancer but has a high non-diagnostic rate and complications. Reported use of multiparametric magnetic resonance imaging (mpMRI) to diagnose aggressive histology (i.e., clear cell renal cell carcinoma (ccRCC)) via a clear cell likelihood score (ccLS) was based on retrospective review of cT1a tumors. We aim to retrospectively assess the diagnostic performance of ccLS prospectively assigned to renal masses of all stages evaluated with mpMRI prior to histopathologic evaluation. In this retrospective cohort study from June 2016 to November 2019, 434 patients with 454 renal masses from 2 institutions with heterogenous patient populations underwent mpMRI with prospective ccLS assignment and had pathologic diagnosis. ccLS performance was assessed by contingency table analysis. The association between ccLS and ccRCC was assessed with logistic regression. Mean age and tumor size were 60 ± 13 years and 5.4 ± 3.8 cm. Characteristics were similar between institutions except for patient age and race (both p

Introduction: Despite proven effectiveness of medications in preventing stone recurrence, compliance with pharmacotherapy (PT) is often poor because of cost, side effects, and impact on lifestyle. ...

INTRODUCTION AND OBJECTIVE:Surgical skill evaluation relies on either direct observation or video review by humans. Both are time consuming, costly and difficult to perform at a large scale. Machin...

INTRODUCTION AND OBJECTIVE:Ureteroscopy (URS) and aggressive stone basketing for upper tract stones yields stone free rates (SFR) of only ∼50% by computed tomography (CT). We used a prospective coh...

INTRODUCTION AND OBJECTIVE:After the recurrence of NMIBC following BCG therapy, risk stratified management directs patients toward radical cystectomy, clinical trial enrollment, and off-label use o...

INTRODUCTION AND OBJECTIVE:Follow-up of patients with residual fragments (RFs) after ureteroscopy (URS) for upper tract stones has shown that the occurrence of stone-related events is common. Short...