On-clamp partial nephrectomy for the surgical treatment of renal masses poses the risk of ischemia and greater post-operative renal function loss. Conversely, the off-clamp technique might enhance renal function preservation by avoiding any ischemia time. Nevertheless, the debate persists regarding the efficacy of the on- versus off-clamp partial nephrectomy in achieving better surgical, functional, and oncological outcomes. We retrospectively assessed the data from patients undergoing Robot-Assisted Partial Nephrectomy (RAPN) from 2016 and 2023 in a tertiary robotic center. Inverse probability of treatment weighting (IPTW) was used to account for selection bias in treatment allocation. The main objective of the study was assessing the achievement rates of a modified trifecta within the two groups. Multivariable logistic regression analysis (MLRA) was employed to assess the predictors of trifecta achievement. 532 patients were included in the analysis, of whom 74.1

Objective: To present the surgical technique and outcomes of robotic ureteral reimplantation in ileal conduit (IC) and neobladder (NB) in patients with prior minimally-invasive radical cystectomy and intracorporeal urinary diversion, who developed benign uretero-ileal anastomotic strictures. Patients and surgical procedure: We report on a multiinstitutional cohort of 10 patients (7 IC, 3 NB) who had 12 uretero-ileal strictures (8 unilateral, 2 bilateral) causing hydronephrosis and renal function deterioration, who underwent robotic uretero-ileal reimplantation in referral centers for robotic surgery between 2016 and 2022. Median age was 67.5 years (Interquartile range [IQR]: 66–69). The stricture was diagnosed at a median of 6 months (IQR 5–10) from the initial surgery. All unilateral strictures were on the left side. Two patients received unsuccessful endoscopic dilatation before the reconstructive surgery. All patients underwent nephrostomy placement prior to the reconstructive procedure. Robotic uretero-ileal reanastomosis started with adhesiolysis, followed by the identification of the ureters and urinary diversion, facilitated by the use of intracavitary saline or ICG. When dissecting the ureters, a „no touch” technique was used, in order to minimize devascularization and ischemia. Localization of the ureteral stricture was critical. The excision of the entire ischemic segment was performed until signs indicative of adequate tissue trophism were found. At the same time, consideration was given to spare sufficient length of the ureteral stumps to allow for a tension-free anastomosis. Direct anastomosis using monofilament resorbable suture, with insertion of mono J or double J stent was performed with both ileal conduit and neobladder. Bricker technique was used in case of unilateral stricture. Results: The median operative time for robotic uretero-ileal reanastomosis was 152 min (IQR 120–180) and the median blood loss was 50 ml (IQR 40–70). No intraoperative complications occurred according to the ICARUS criteria. Median length of hospital stay was 4.5 days (IQR 3–6). Two Clavien-DIndo II (20 %) postoperative complications were registered (urinary tract infection and acute kidney injury). No patients required readmission or reoperation. The mean length of ureteral catheterization for reimplantation in IC was 20.7 days (± 4.29). For patients with NB, the mean ureteral and urethral catheterization times were 54.3 days (± 22.8) and 19.3 days (± 11.08), respectively. The ureteral stents were removed in all patients. At a median of 16 months follow-up (range 6–36 months), 2 patients (one IC and one NB, respectively) had persistent hydronephrosis. Conclusion: In patients requiring surgery for benign ureteral strictures following cystectomy, robotic surgery allows for safe and efficient ureteral reimplantation in urinary diversion.

Introduction Robot-assisted partial nephrectomy (RAPN) is currently the gold standard approach for the treatment of renal masses (T1-2N0M0). Many techniques have been developed to perform this procedure maximizing oncological and functional outcomes. In this setting, the clampless approach (enucleation without clamping the renal artery or its branches) together with the sutureless technique are considered to reduce the impact of ischemia on renal parenchyma and thus the impairment of renal function. Objective To demonstrate the feasibility and safety of performing clampless and sutureless RAPN in several clinical scenarios of increasing complexity. Methods Three RAPN cases, all done with clampless and sutureless techniques by a single experienced surgeon are considered. The first case was a two centimeters upper polar mass of the right kidney, with a RENAL score of 4. The second was a hilar mass of three centimeters of the right kidney with a RENAL score of 9. In the last case the technique was applied in a patient with Von Hippel Lindau syndrome and eight masses in the right kidney. Results In all the procedures ischemia time was zero. Mean blood loss was 300 (50-650) milliliters, and the mean operative time was 125 minutes (80-205). All the patients were discharged on the second post operative day. Mean value of post operative serum creatinine was 0,9mg/dl. No peri- and post-operative complications were recorded. All three cases were R0 at final pathology. Conclusion Clampless and sutureless RAPN has proven to be a safe and effective approach to reduce the loss of renal function in nephron sparing surgery, without compromising surgical and oncological outcomes.

Current guidelines recommend radical nephroureterectomy with bladder cuff excision as the standard surgical treatment for high-risk upper tract urothelial carcinoma (UTUC). While large evidence is available regarding open and laparoscopic nephroureterectomy, data focusing on robotic nephroureterectomy (rNU) in UTUC are mostly limited with mixed re-sults, especially in locally advanced disease. in light of the recent introduction of new robotic platforms, it is of utmost importance to further investigate oncologic outcomes associated with rNU. Moreover, stronger data exploring different operative settings (i.e. robotic arms and trocars placement) for the new robotic systems are eagerly warranted. To give an answer to such open clinical questions, the Junior erUS/young academic Urologist Working group on robot-assisted Surgery designed a multicentric project involving different high-volume centers across the world. The aim of the study will be exploring surgical and oncologic outcomes of RNU, specifically focusing on several clinical unmet needs, such as best operative setting for new robotic platforms, lymph node dissection (ldN) template and robotic bladder cuff management.

Background and Objectives Enhanced Recovery After Surgery (ERAS) guidelines for Radical Cystectomy (RC) were published over ten years ago. Aim of this systematic review is to update ERAS recommendations for patients undergoing RC and to give an expert opinion on the relevance of each single ERAS item. Methods A systematic review was performed to identify the impact of each single ERAS item on RC outcomes. Embase and Medline (through Pubmed) were searched systematically. Relevant articles were selected and graded. For each ERAS item, a level of evidence was determined. An e-Delphi consensus was then performed amongst an international panel with renowned experience in RC to provide recommendations based on expert opinion. Key Findings and Limitations Preoperative medical optimization and avoiding bowel preparation are highly recommended. Robotic-assisted RC with intracorporeal urinary diversion is moderately recommended and can help in applying other ERAS items, such as early mobilization. Medical thromboprophylaxis should be administered and nasogastric tube should be removed at the end of surgery. Perioperative fluid restriction as well as opioid-sparing anesthesia protocols should be implemented. Generally, consensus was reached on most ERAS items, with the exception of epidural anesthesia (no consensus), resection site drainage (consensus against), and type of urinary drainage. Limitations include the lack of a multidisciplinary approach to the present consensus, giving however a highly specialized surgical opinion on ERAS. Conclusions and clinical implications: The current study updates ERAS recommendations for patients undergoing RC and suggests application of ERAS by a panel of experts in the field.

The number of available hospital beds is decreasing in many countries. Reducing the length of hospital stay (LOS) and increasing bed turnover could improve patient flow. We evaluated whether robot-assisted surgery (RAS) had a beneficial impact on the LOS in a French hospital trust with a long-established robotic program (Assistance Publique–Hôpitaux de Paris, AP-HP). We extracted data from “Programme de Médicalisation des Systèmes d’Information” to determine the median LOS for adults in our trust after RAS versus laparoscopy and open surgery in 2021–2022 for eight target procedures, and compared data nationally and at similar academic centres (same database). We also calculated the number of hospitalisation days ‘saved’ using RAS. Overall, 9326 target procedures were performed at AP-HP: 3864 (41.4

Objective: Artificial urinary sphincter (AUS) implantation is indicated for women with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) affecting their quality of life. The goal of this study was to give a step-by-step description of the surgical procedure of robot-assisted AUS implantation in women. Patients and surgical procedure: A 72 years-old woman with recurrent SUI was referred to our tertiary center. Clinical and urodynamic investigation revealed an ISD for which a minimally invasive robot-assisted AUS implantation was indicated. The AUS was implanted through a transperitoneal posterior robot-assisted approach. A detailed description of the different surgical steps is provided. The plane between the posterior bladder wall and anterior vaginal wall is dissected. The lateral sides of the bladder are detached from the pelvic wall. A cuff sizer is passed around the bladder neck under vision. An adequate cuff size is chosen and the cuff is placed around the bladder neck. The balloon is placed in the preperitoneal space and the tubing of the cuff and the balloon are pulled through the abdominal wall. The AUS pump is placed in the labia majora at the side of the patient's dominant hand and all tube connections are made. Results: The total operating time was 177 min. No intra- or postoperative complications occurred. The patient was discharged on postoperative day 2 with catheter in place. Spontaneous micturition recovered after removal of the bladder catheter on day 5. The AUS system was activated in the outpatient clinic after 6 weeks. The patient reported no more SUI. Conclusion: Robot-assisted AUS implantation in women is a feasible and effective surgical treatment for selected women with SUI due to ISD.

Objective:. To compare binary metrics and Global Evaluative Assessment of Robotic Skills (GEARS) evaluations of training outcome assessments for reliability, sensitivity, and specificity. Background:. GEARS–Likert-scale skills assessment are a widely accepted tool for robotic surgical training outcome evaluations. Proficiency-based progression (PBP) training is another methodology but uses binary performance metrics for evaluations. Methods:. In a prospective, randomized, and blinded study, we compared conventional with PBP training for a robotic suturing, knot-tying anastomosis task. Thirty-six surgical residents from 16 Belgium residency programs were randomized. In the skills laboratory, the PBP group trained until they demonstrated a quantitatively defined proficiency benchmark. The conventional group were yoked to the same training time but without the proficiency requirement. The final trial was video recorded and assessed with binary metrics and GEARS by robotic surgeons blinded to individual, group, and residency program. Sensitivity and specificity of the two assessment methods were evaluated with area under the curve (AUC) and receiver operating characteristics (ROC) curves. Results:. The PBP group made 42% fewer objectively assessed performance errors than the conventional group (P < 0.001) and scored 15% better on the GEARS assessment (P = 0.033). The mean interrater reliability for binary metrics and GEARS was 0.87 and 0.38, respectively. Binary total error metrics AUC was 97% and for GEARS 85%. With a sensitivity threshold of 0.8, false positives rates were 3% and 25% for, respectively, the binary and GEARS assessments. Conclusions:. Binary metrics for scoring a robotic VUA task demonstrated better psychometric properties than the GEARS assessment.

BACKGROUND:Multiple and heterogeneous techniques have been described for orthotopic neobladder (ONB) reconstruction after robot-assisted radical cystectomy. Nonetheless, a systematic assessment of all the available options is lacking. OBJECTIVE:To provide the first comprehensive step-by-step description of all the available techniques for robotic intracorporeal ONB together with individual intraoperative, perioperative and functional outcomes based on a systematic review of the literature. DESIGN, SETTING, AND PARTICIPANTS:We performed a systematic review of the literature, and MEDLINE/PubMed, Embase, Scopus, and Web of Science databases were searched to identify original articles describing different robotic intracorporeal ONB techniques and reporting intra- and perioperative outcomes. Studies were categorized according to ONB type, providing a synthesis of the current evidence. Video material was provided by experts in the field to illustrate the surgical technique of each intracorporeal ONB. SURGICAL PROCEDURE:Nine different ONB types were identified: Studer, Hautmann, Y shape, U shape, Bordeaux, Pyramid, Shell, Florence Robotic Intracorporeal Neobladder, and Padua Ileal Neobladder. MEASUREMENTS:Continuous and categorical variables are presented as mean ± standard deviation and as frequencies and proportions, respectively. RESULTS AND LIMITATIONS:Of 2587 studies identified, 19 met our inclusion criteria. No cohort studies or randomized control trials comparing different neobladder types are available. Available techniques for intracorporeal robotic ONB reconstruction have similar operative time, estimated blood loss, intraoperative complications, and length of stay. Major variability exists concerning postoperative complications and functional outcomes, likely related to reporting bias. CONCLUSIONS:Several techniques are described for intracorporeal ONB during robot-assisted radical cystectomy with comparable perioperative outcomes. We provide the first step-by-step surgical atlas for robot-assisted ONB reconstruction. Further comparative studies are needed to assess any advantage of one technique over others. PATIENT SUMMARY:Patients elected for radical cystectomy should be aware that multiple techniques for robotic orthotopic neobladder are available, but that current evidence does not favor one type over the others.

Introduction and Objectives: Robot-assisted simple prostatectomy (RASP) and holmium laser enucleation of the prostate (HoLEP) are both well-established, minimally invasive surgical treatment options for lower urinary tract symptoms caused by benign prostatic enlargement. We have reported the first comparative analysis of both techniques in patients with prostates of & GE;200 cc.Materials and Methods: Between 2009 and 2020 a total of 53 patients with a prostate volume of & GE;200 cc were surgically treated at OLV Hospital Aalst (Belgium): 31 underwent RASP and 22 underwent HoLEP. Preoperative and postoperative assessments included uroflowmetry with maximum urinary flow rate (Qmax) and postvoid residual volume (PVR), as well as the International Prostate Symptom Score (IPSS) and quality of life (IPSS-QoL). The complication rates were evaluated according to the Clavien-Dindo Classification.Results: Patients treated with RASP had significantly larger prostate volumes compared with HoLEP (median 226 cc vs 204.5 cc, p = 0.004). After a median follow-up of 14 months, both groups showed a significant improvement in the maximum flow rate (+10.60 mL/s vs +10.70 mL/s, p = 0.724) and a reduction of the IPSS score (-12.50 vs -9, p = 0.246) as well as improvement of the QoL (-3 vs -3, p = 0.880). Median operative time was similar in both groups (150 minutes vs 132.5 minutes, p = 0.665). The amount of resected tissue was lower in the RASP group (134.5 g vs 180 g, p = 0.029) and there was no significant difference in postoperative prostate-specific antigen (1.2 ng/mL vs 0.8 ng/mL, p = 0.112). Despite a similar median catheterization time (3 days vs 2 days, p = 0.748), the median hospitalization time was shorter in the HoLEP group (4 days vs 3 days, p = 0.052). Complication rates were similar in both groups (32% vs 36%, p = 0.987).Conclusion: Our results suggest similar outcomes for RASP and HoLEP in patients with very large prostates & GE;200 cc. These findings will require external validation at other high-volume centers.

In the last decade, a shift has occurred in the treatment of patients with newly diagnosed metastatic prostate cancer (ndMPC) from ADT monotherapy to early combination therapies of ADT with docetaxel or ARTAs. Although the introduction of novel systemic therapies has made more patients eligible for additional treatments, adherence to clinical practice guidelines remains suboptimal.Introduction : To describe the changes in systemic treatments (ST) of synchronous metastatic hormone-sensitive prostate cancer (mHSPC) patients in a "real-world" setting and to explore reasons why contemporary standard of care (SOC) was not administrated to the patient. Patients and methods : Since 2014, we prospectively register mHSPCpatients. Patients were grouped in 4 time periods: group 1 (Time period 1, January 2014-July 2015), group 2 after introduction of docetaxel (Time period 2, August 2015-July 2017), group 3 after introduction of abiraterone acetate (Time period 3, August 2017-February 2018) and group 4 after introduction of apalutamide (Time period 4, March 2018-October 2021). For every time period, we evaluated the initiated additional ST. In case patients received treatment that differed from contemporary SOC according to guidelines, reasons for this difference were explored.Results : In total, 243 patients were included. A progressive decline in ADT monotherapy from 85% to 29% over time was observed. The proportion of patients receiving additional STs increased from 34% to 59%. Forty percent of patients were not treated according to contemporary SOC, but this percentage varied strongly per time period (10%, 67%, 53%, and 32% from time period 1 to time period 4 respectively). Reasons for these variations were heterogenous and varied across the 4 time periods. Patients being unfit for treatment and treating physicians failing to consider additional STs were the most prevalent reasons. The proportion of patients unfit for additional ST decreased from 18% to 4% over time.Conclusion : Use of ADT monotherapy declined gradually after the introduction of additional systemic treatments. The proportion of patients unfit for additional ST declined as more treatments became available. Although compliance to SOC increased over time, these real-world data show that adherence to clinical practice guidelines remains suboptimal. Efforts should be made by clinicians to increase the adherence to practice guidelines.

Background: Selective clamping during robot-assisted partial nephrectomy (RAPN) requires extensive knowledge on patient-specific renal vasculature, obtained through imaging.Objective: To validate an in-house developed perfusion zone algorithm that provides patient-specific three-dimensional (3D) renal perfusion information.Design, setting, and participants: Between October 2020 and June 2022, 25 patients undergoing RAPN at Ghent University Hospital were included. Three-dimensional mod-els, based on preoperative computed tomography (CT) scans, showed the clamped artery's ischemic zone, as calculated by the algorithm.Surgical procedure: All patients underwent selective clamping during RAPN. Indocyanine green (ICG) was administered to visualize the true ischemic zone perioperatively. Surgery was recorded for a postoperative analysis.Measurements: The true ischemic zone of the clamped artery was compared with the ischemic zone predicted by the algorithm through two metrics: (1) total ischemic zone overlap and (2) tumor ischemic zone overlap. Six urologists assessed metric 1; metric 2 was assessed objectively by the authors.Results and limitations: In 92% of the cases, the algorithm was sufficiently accurate to plan a selective clamping strategy. Metric 1 showed an average score of 4.28 out of 5. Metric 2 showed an average score of 4.14 out of 5. A first limitation is that ICG can be evaluated only at the kidney surface. A second limitation is that mainly patients with impaired renal function are expected to benefit from this technology, but contrast -enhanced CT is required at present.Conclusions: The proposed new tool demonstrated high accuracy when planning selec-tive clamping for RAPN. A follow-up prospective study is needed to determine the tool's clinical added value.Patient summary: In partial nephrectomy, the surgeon has no information on which specific arterial branches perfuse the kidney tumor. We developed a surgeon support system that visualizes the perfusion zones of all arteries on a three-dimensional model and indicates the correct arteries to clamp. In this study, we validate this tool.(c) 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.