Robot-assisted surgical management of ureteral stricture is a relatively uncommon procedure with numerous techniques described. This literature review combined with expert opinion outlines the key surgical principles of ureteral reconstruction and proposes an algorithm for the robot-assisted treatment of ureteral strictures. A narrative literature review was conducted using PubMed and Cochrane databases with a predefined search strategy including terms related to ureteroplasty and upper urinary tract reconstruction. The search yielded approximately 900 results. After screening, 219 relevant studies were selected for analysis. Two authors independently reviewed all included articles, and whenever evidence was inconsistent or insufficient, consensus was reached through discussion within the full author group. Robotic ureteral reconstruction includes several techniques, with the choice of procedure guided by multiple factors. Key principles include the use of healthy tissue, creation of a tension-free anastomosis, and ensuring adequate drainage. Outcomes may be further optimized by preoperative ureteral rest, intraoperative ureteroscopy, and the use of intravenous indocyanine green (ICG). Buccal mucosa grafting has emerged as a breakthrough in minimally invasive reconstruction. The robotic approach is adept at managing standard techniques such as ureteroureterostomy, psoas hitch, Boari flap, ureteroneocystostomy, and more recently described methods such as non-transecting ureteral reimplantation and bladder flap ureteroplasty. Ileal ureter remains a good option in cases of challenging reconstructions and patients with prior radiation therapy or extensive defects. Robot- assisted ureteral reconstruction has shifted the paradigm in stricture management, allowing complex reconstructive operations to be performed with minimally invasive techniques. This expert review summarizes key surgical approaches and presents a practical algorithm to guide urologists in the management of ureteral strictures.

PURPOSE:To investigate the feasibility and safety of robot-assisted partial nephrectomy (RAPN) to treat large (T2) cystic renal-cell carcinoma. METHODS:A multinational study was conducted worldwide. Patients with renal tumors larger than 7cm who underwent partial nephrectomy between December 2007 and July 2017 were recruited retrospectively. The patients were divided into solid tumor group (143 cases) and cystic tumor group (28 cases). Baseline parameters, tumor characteristics, perioperative variables, and pathological outcomes were collected. RESULTS:Between cystic and solid tumors, no statistically significant differences were detected in age, gender, BMI, ASA score, clinical tumor size, laterality, or R.E.N.A.L nephrometry score. Operating time, warm ischemic time, estimated blood loss, complications, histology outcomes, and margin status were comparable. Pathology of 6 cystic tumors came back benign (21.4%). In solid tumors, 6 intraoperative bleeding require transfusion, 1 ureteral damage, and 3 postoperative urinary fistulas were observed. In cystic tumors, conversion to radical nephrectomy happened in one case, because of sticky fat and the risk of cyst rupture. In two cases, postoperative bleeding was treated with embolism. The longest follow-up was 113 months. In cystic group, 1 recurrence or metastasis was observed, while in solid group, 14 cases were observed. CONCLUSION:RAPN can be safely performed to treat large (T2) cystic renal-cell carcinoma. Patients with cystic renal-cell carcinoma exhibited favorable renal function recovery after robot-assisted partial nephrectomy (RAPN), which maximally preserved normal renal tissue and its function. Further studies are needed to better understand the role of RAPN for these challenging cases.

To assess the long-term urinary and sexual function outcomes for men undergoing robotic-assisted simple prostatectomy (RASP) with circumferential mucosal anastomosis performed at a single, high-volume robotics center. RASP cases performed by a single surgeon from June 2013 through June 2024 using the da Vinci® Xi robotic system were analyzed. Indications for surgery were bothersome lower urinary tract symptoms (LUTS) refractory to medical management and prostate volume ≥ 80 g. Urinary function and sexual function parameters were assessed by the American Urologic Association Symptoms Score (AUASS) and Sexual Health Inventory for Men (SHIM), respectively at routine 6-month postoperative visits. A uniform phone survey was conducted in September 2024, which assessed long-term functional outcomes by combining AUASS with questions on incontinence, erectile function, and orgasm. A Wilcoxon signed rank test was utilized to compare pre- and postoperative IPSS and SHIM scores with p < 0.05 considered significant. 292 patients underwent RASP during the query interval and were included in the perioperative analysis with a mean follow-up time of 22.6 months (SD ± 15.2). Mean preoperative AUASS was 17.9 (SD ± 7.9). Mean postoperative AUASS was 5.7 (SD ± 5.2); W-statistic 352.0 (p < 0.001). Bother scores preoperative mean was 4.3 (SD ± 1.5), with postoperative values of 1.1 ± 1.4; W-statistic 395.0 (p < 0.001). Sexual Health Inventory for Men (SHIM) scores demonstrated a preoperative mean of 12.8 (SD ± 8.1). Postoperatively, the SHIM mean was 12.6 (SD ± 8.5); W-statistic: 4462.0 (p = 0.57). No patients required reoperation for LUTS, although one patient underwent completion prostatectomy for malignancy identified on RASP pathology. No patients developed bladder neck contracture. Calls were placed to 288 patients (98.6

INTRODUCTION:Single-port (SP) robotic surgical system performs well in small anatomical spaces, which makes it suitable for retroperitoneal robotic partial nephrectomy (RPN). However, there is limited evidence comparing the safety and feasibility of SP RPN to multiport (MP) RPN. To address this gap in evidence, we sought to analyze and compare the safety of retroperitoneal RPN between SP and MP approaches. METHODS:This is a retrospective cohort study using data from the Single Port Advanced Research Consortium (SPARC) and a multicenter database of patients who underwent retroperitoneal RPN using either SP or MP between 2017 and 2023. Baseline, perioperative, and postoperative data were compared using t-tests, Mann-Whitney U test, χ2 test, and Fisher exact test. Multivariable analyses were conducted using robust and Poisson regressions. RESULTS:A total of 286 patients (SP RPN, n = 86 [30%]; MP RPN, n = 200 [70%]) underwent retroperitoneal RPN. R.E.N.A.L nephrometry score and tumor location were significantly different between the 2 groups. Notably, the ischemia time was significantly shorter in the MP group (16 vs. SP, 22 minutes, P < 0.001). Adjusting for baseline characteristics, the ischemia time was approximately 7.89 minutes longer for patients in the SP group compared to the MP group, on average (95% CI: 5.87, 9.92; P < 0.001). No significant differences were observed in operative time, EBL, blood transfusion, conversion rates, LOS, PSM, and overall 30-day postoperative complications between the 2 groups. CONCLUSION:Our study shows that retroperitoneal SP and MP RPN have comparable perioperative and postoperative outcomes, except for the longer ischemia time in the SP platform. SP RPN is a safe and viable alternative; however, further research is needed to explore its potential benefits, cost-effectiveness, and long-term oncologic outcomes.

BACKGROUND:To determine the utility of creatinine-to-hemoglobin (Cr:Hgb) ratio, as a predictor of survival outcomes in upper tract urothelial carcinoma (UTUC). METHODS:We performed a multi-institutional retrospective analysis of UTUC-patients who underwent robotic radical nephrouretectomy utilizing the ROBUUST (ROBotic surgery for Upper Tract Urothelial Cancer Study) registry. Patients were divided into elevated Cr:Hgb ratio (>0.15, based on upper-limit of normal for creatinine and lower-limit of normal for hemoglobin) vs. non-elevated Cr:Hgb ratio (≤0.15). Primary outcome was all cause mortality (ACM)/overall survival (OS). Secondary outcomes were cancer-specific mortality (CSM) / survival (CSS) and recurrence-free survival (RFS). Cox proportional hazards (MVA) was used to elucidate predictive factors for ACM, CSM, and RFS. Kaplan-Meier analysis (KMA) was performed to analyze 5-year OS, CSS, and RFS. RESULTS:Overall, 829 patients were analyzed (744 non-elevated / 85 elevated Cr:Hgb). Elevated Cr:Hgb patients had more frequently advanced-stage (P=0.016) and high-grade tumors (P<0.001) at time of surgery. MVA demonstrated increasing-age (HR=1.04, P=0.002), elevated Cr:Hgb (HR=2.49, P=0.003), lympho-vascular invasion (HR=4.61, P<0.001), and higher-stage (HR=3.82, P<0.001) to be associated with worsened ACM. Increasing-age (HR=1.04, P=0.030), elevated Cr:Hgb (HR=3.64, P<0.001), and lympho-vascular invasion (HR=4.52, P<0.001) were independently associated with worsened CSM. Elevated Cr:Hgb (HR=1.27, P=0.001) was independently associated with worsened recurrence. For elevated vs. non-elevated Cr:Hgb patients, KMA revealed significantly worse 5-year OS (78% vs. 65%, P=0.002), CSS (86% vs. 74%, P<0.001), and RFS (53% vs. 22%, P=0.004). CONCLUSIONS:Baseline elevated Cr:Hgb predicted worsened survival outcomes in UTUC patients and may serve a pre-operative marker to stratify oncologic risk and guide counseling and management.

Open ureteroenteric reimplantation (OUER) of ureteroenteric strictures (UESs) is related to important morbidity. Robot-assisted ureteroenteric reimplantation (RUER) has been proposed to provide similar outcomes with lower morbidity. We aimed to compare perioperative and functional outcomes between RUER and OUER. A retrospective multicenter study of 80 patients, who underwent 82 ureteroenteric reimplantations (17 OUER vs 65 RUER) at 8 institutions between 2009–2021 for benign UESs after radical cystectomy. All the open procedures were performed by the same center in order to compare the robotic approach with a standardized technique. Data were reviewed for demographics, stricture characteristics, and perioperative outcomes. Complication and stricture recurrence rates were compared between both groups. Among 82 reimplantations, 44 were left sided (54