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

To improve patient outcomes in robotic surgery, robotic training and education need to be modernised and augmented. The skills and performance levels of trainees need to be objectively assessed before they operate on real patients. The main goal of the first Orsi Consensus Meeting on European Robotic Training (OCERT) was to establish the opinions of experts from different scientific societies on standardised robotic training pathways and training methodology. After a 2-d consensus conference, 36 experts identified 23 key statements allotted to three themes: training standardisation pathways, validation metrics, and implementation prerequisites and certification. After two rounds of Delphi voting, consensus was obtained for 22 of 23 questions among these three categories. Participants agreed that societies should drive and support the implementation of benchmarked training using validated proficiency-based pathways. All courses should deliver an internationally agreed curriculum with performance standards, be accredited by universities/professional societies, and, trainees should receive a certificate approved by professional societies and/or universities after successful completion of the robotic training courses. This OCERT meeting established a basis for bringing surgical robotic training out of the operating room by seeking input and consensus across surgical specialties for an objective, validated, and standardised training programme with transparent, metric-based training outcomes. The Orsi Consensus Meeting on European Robotic Training (OCERT) is an international, multidisciplinary, Delphi-panel study of scientific societies and experts focused on training in robotic surgery. The panel achieved consensus that standardised international training pathways should be the basis for a structured, validated, replicable, and certified approach to implementation of robotic technology. The Orsi Consensus Meeting on European Robotic Training (OCERT) is an international, multidisciplinary, Delphi-panel study of scientific societies and experts focused on training in robotic surgery. It established a basis for bringing surgical robotic training out of the operating room by seeking input and consensus across surgical specialties for an objective, validated, and standardised training programme with transparent, metric-based training outcomes. [ABSTRACT FROM AUTHOR]

Over the years, several techniques for performing robot-assisted prostatectomy have been implemented in an effort to achieve optimal oncological and functional outcomes. To provide an evidence-based description and video-based illustration of currently available dissection techniques for robotic prostatectomy. A literature search was performed to retrieve articles describing different surgical approaches and techniques for robot-assisted radical prostatectomy (RARP) and to analyze data supporting their use. Video material was provided by experts in the field to illustrate these approaches and techniques. Multiple surgical approaches are available: extraperitoneal, transvesical, transperitoneal posterior, transperitoneal anterior, Retzius sparing, and transperineal. Surgical techniques for prostatic dissection sensu strictu are the following: omission of the endopelvic fascia dissection, bladder neck preservation, incremental nerve sparing by means of an antegrade or retrograde approach, and preservation of the puboprostatic ligaments and dorsal venous complex. Recently, techniques for total or partial prostatectomy have been described. Different surgical approaches and techniques for robotic prostatectomy have been analyzed. Two randomized controlled trials evaluating the extraperitoneal versus the transperitoneal approach have demonstrated similar results. Level I evidence on the Retzius-sparing approach demonstrated earlier return to continence than the traditional anterior approach. The question whether Retzius-sparing RARP is associated with a higher rate of positive surgical margins is still open due to the intrinsic bias in terms of surgical expertise in the available comparative studies. This technique also offers an advantage in patients who have received kidney transplantation. Retrospective evidence suggests that the more the anatomical dissection (eg., more periprostatic tissue is preserved), the better the functional outcome in terms of continence. Yet, two randomized controlled trials evaluating the different techniques of dissection have so far been produced. Partial prostatectomies should not be offered outside clinical trials. Several techniques and approaches are available for prostate dissection during RARP. While the Retzius-sparing approach seems to provide earlier return to continence than the traditional anterior transperitoneal approach, no technique has been proved to be superior to other(s) in terms of long-term outcomes in randomized studies. We have summarized available approaches for the surgical treatment of prostate cancer. Specifically, we described the different techniques that can be adopted for the surgical removal of the prostate using robotic technology. [ABSTRACT FROM AUTHOR]

Robot-assisted thrombectomy (RAT) for inferior vena cava (IVC) thrombus (RAT-IVCT) is being increasingly reported. However, the techniques and indications for robot-assisted cavectomy (RAC) for IVC thrombus are not well described. To develop a decision-making program and analyze multi-institutional outcomes of RAC-IVCT versus RAT-IVCT. Ninety patients with renal cell carcinoma (RCC) with level II IVCT were included from eight Chinese urological centers, and underwent RAC-IVCT (30 patients) or RAT-IVCT (60 patients) from June 2013 to January 2019. The surgical strategy was based on IVCT imaging characteristics. RAT-IVCT was performed with standardized cavotomy, thrombectomy, and IVC reconstruction. RAC-IVCT was mainly performed in patients with extensive IVC wall invasion when the collateral blood vessels were well-established. For right-sided RCC, the IVC from the infrarenal vein to the infrahepatic veins was stapled. For left-sided RCC, the IVC from the suprarenal vein to the infrahepatic veins was removed and caudal IVC reconstruction was performed to ensure the right renal vein returned through the IVC collaterals. Clinicopathological, operative, and survival outcomes were collected and analyzed. All procedures were successfully performed without open conversion. The median operation time (268 vs 190 min) and estimated blood loss (1500 vs 400 ml) were significantly greater for RAC-IVCT versus RAT-IVCT (both p < 0.001). IVC invasion was a risk factor for progression-free and overall survival at midterm follow-up. Large-volume and long-term follow-up studies are needed. RAC-IVCT or RAT-IVCT represents an alternative minimally invasive approach for selected RCC patients with level II IVCT. Selection of RAC-IVCT or RAT-IVCT is mainly based on preoperative IVCT imaging characteristics, including the presence of IVC wall invasion, the affected kidney, and establishment of the collateral circulation. In this study we found that robotic surgeries for level II inferior vena cava thrombus were feasible and safe. Preoperative imaging played an important role in establishing an appropriate surgical plan. Robot-assisted cavectomy (RAC) for inferior vena cava thrombus (IVCT) is safe and feasible in patients with extensive IVC wall invasion if the collateral blood vessels are well established. Selection of RAC or robot-assisted thrombectomy for IVCT can be based on preoperative IVCT imaging characteristics, including the presence of IVC wall invasion, the affected kidney, and establishment of the collateral circulation. IVC invasion and tumor grade were independent risk factors for progression-free survival, while body mass index, tumor type and grade, perirenal fat invasion, and lymph node metastasis were independent risk factors for overall survival. [ABSTRACT FROM AUTHOR]

Surgical repair of a vesicovaginal fistula (VVF) has been described extensively in the literature for several decades. Advances in robotic repair have been adopted since 2005. A consensus review of existing data based on published case series, expert opinion, and a survey monkey. This document summarizes the consensus group meeting and survey monkey results convened by the European Association of Urology Robotic Urology Section (ERUS) relating to the robotic management of VVF. Current data underline the successful robotic repair of supratrigonal nonobstetric VVF. The panel recommends preoperative marking of the fistula by a guidewire or ureteral catheter, and placement of a protective ureteral JJ stent. An extravesical robotic approach usually provides a good anatomic view for adequate and wide dissection of the vesicovaginal space, as well as bladder and vaginal mobilization. Careful sharp dissection of fistula edges should be performed. Tension-free closure of the bladder is of utmost importance. Tissue interposition seems to be beneficial. The success rate of published series often reaches near 100%. An indwelling bladder catheter should be placed for about 10 d postoperatively. When considering robotic repair for VVF, it is essential to establish the size, number, location, and etiology of the VVF. Robotic assistance facilitates dissection of the vesicovaginal space, harvesting of a well-vascularized tissue flap, and a tension-free closure of the bladder with low morbidity for the patient being operated in the deep pelvis with delicate anatomical structures. Robotic repair of a vesicovaginal fistula can be applied safely with an excellent success rate and very low morbidity. This confirms the use of robotic surgery for vesicovaginal fistula repair, which is recommended in a consensus by the European Association of Urology Robotic Section Scientific Working Group for reconstructive urology. Robotic repair of vesicovaginal fistula can be applied safely, with low morbidity for the patient. The excellent view allows precise preparation with a high success rate, which underlines the use of robotic surgery for vesicovaginal fistula repair. [ABSTRACT FROM AUTHOR]

Since the implementation of robotic surgery, the platforms have been updating constantly in terms of arm configuration, tool design, scope settings, and the number of trocars placed. The introduction of new robotic technology is challenging and requires studies followed by technique adaptions. This study aims to report a logical and technologically safe approach to the learning curve using the da Vinci single-port (SP) console and describes our robotic-assisted radical prostatectomy (RARP) technique step by step. A prospective study from 26 consecutive patients who underwent RARP with the da Vinci SP console from June to August 2019. All surgeries were performed with a transperitoneal technique; one robotic trocar was placed above the umbilicus and one additional 12 mm trocar was placed in the right lower quadrant. We described the step-by-step technique and reported the perioperative and pathological data. In addition, we considered the hospital length of stay and pain scale following surgery. Continuous variables were reported as median and interquartile ranges. Categorical variables were reported as frequencies and proportions. The total median operative time was 121 min, console time was 85 min, and blood loss was 50 ml. No complications were reported. In the final pathology, four patients had Gleason 6, 20 had Gleason 7, one had Gleason 8, and one had Gleason 9.Of the patients, 70% were ≤pT2 and 30% were ≥pT3a. Only 11% had positive surgical margins. This study is limited by the small number of patients and a short period of follow-up to evaluate functional and oncological outcomes of this new technology. RARP with the da Vinci SP is feasible and safe. Therefore, the step-by-step technique described in this study could be considered an option to perform radical prostatectomies. However, we still need better-designed studies to compare the outcomes with those of the multiport platform. We reported our step-by-step technique describing a safe approach to robotic-assisted radical prostatectomy during the transition from the Xi to the da Vinci single-port robot. This article describes the step-by-step technique and surgical outcomes during the transition from da Vinci Xi to single-port system. Currently, to the best of our knowledge, the literature lacks studies describing the challenges of this new technology on radical prostatectomies. [ABSTRACT FROM AUTHOR]

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). 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). 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. 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. 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. 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. 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. 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. Three-dimensional augmented reality robot-assisted partial nephrectomy allows identification of the intraparenchymal structures that are difficult to visualise with ultrasound only. This translates to a potential improvement of the quality of the resection phase and a reduction of postoperative complications, with better functional recovery. [ABSTRACT FROM AUTHOR]

Renal artery aneurysm (RAA) is a rare condition, traditionally managed with endovascular or open surgical techniques. To report our experience with robotic RAA repair. Nine consecutive patients underwent intracorporeal robotic surgery for 10 RAAs. Two patients underwent concomitant robotic partial nephrectomy. One patient had RAA in a solitary kidney. Median RAA diameter was 2.2 (1.8–3) cm. Intracorporeal transarterial hypothermic renal perfusion was performed in five patients. Robotic techniques included tailored aneurysmectomy and repair (n = 5), excision with end-to-end anastomosis (n = 2), aneurysmectomy with branch reimplantation (n = 1), prosthetic interposition graft repair (n = 1), and simple nephrectomy (n = 1; this patient's data were excluded from analysis). Demographics, RAA characteristics, intraoperative techniques, perioperative outcomes, and follow up data were analyzed. Aneurysms were diagnosed by computed tomography, angiography, or incidentally during the performance of a partial nephrectomy. All cases were performed robotically, without conversion to open surgery. Median (range) operative time was 3.8 (3–6) h, warm ischemia time 26 (19–32) min, hypothermic renal perfusion time 34 (29–69) min, and estimated blood loss 100 (25–400) ml. No intraoperative blood transfusion was required. Median hospital stay was 3 (2–6) d. One patient had a Clavien-Dindo grade II complication. At median follow-up of 16 (2–67) mo, all patients had preserved renal function. Follow-up imaging confirmed normal caliber reconstructed renal arteries with globally perfused kidneys, except for two kidneys with small segmental infarcts due to an intentionally ligated small polar vessel. Limitations include the small number of patients and the retrospective nature of the study. Robotic repair of complex RAAs is feasible. Surgical expertise, patient selection, and RAA-specific vascular reconstruction are critical for success. Greater experience is needed to evaluate the proper place of robotic repair of RAAs. We report intracorporeal robotic repair for complex renal artery aneurysms. This robotic operation is feasible and safe, and replicates open principles. However, it requires considerable experience and expertise. We report our experience with nine consecutive patients who underwent robotic aneurysm repair. Techniques after the excision included tailored repair, end-to-end anastomosis, branch reimplantation, and graft interposition. This technique is feasible. However, surgical expertise and proper patient selection are critical. [ABSTRACT FROM AUTHOR]

Level III-IV robot-assisted inferior vena cava (IVC) thrombectomy (RA-IVCT) has been reported in limited series. To report our initial series of level III-IV RA-IVCT with step-by-step procedures and 1-yr outcomes. From November 2014 to January 2018, 13 patients with level III-IV IVC tumor thrombi underwent RA-IVCT with a minimum of 1-yr follow-up. Level III RA-IVCT requires liver mobilization and clamping of first porta hepatis (FPH), and suprahepatic and infradiaphragmatic IVC. Level IV RA-IVCT requires establishment of cardiopulmonary bypass (CPB). Thoracoscopy-assisted thrombectomy was performed for the intra-atrium part of the thrombus under CPB. Infradiaphragmatic RA-IVCT was completed in a manner similar to that of level III RA-IVCT. Detailed techniques were described for various scenarios. Baseline and perioperative outcomes were reported, and descriptive statistical analysis was performed. Median operative time was 465 (interquartile range [IQR]: 338–567) min. Median estimated intraoperative blood loss was 2000 (IQR: 1000–3000) ml. The rates of intraoperative blood transfusion and postoperative transformation to the intensive care unit ward were 92.3% and 100%, respectively. Median FPH blocking time was 40 (IQR: 25–60) min and the CPB time was 72 (IQR: 51–87) min. Three cases had grade IV complications, including two vascular injuries that were treated with intraoperative endoscopic sutures and one perioperative death. The perioperative mortality rate was 7.7%. During an 18-mo follow-up, two patients died and one patient progressed. Although the risks involved are high, level III-IV RA-IVCT is feasible and serves as an alternative minimally invasive method for selected patients. It also requires more complex techniques and multidisciplinary cooperation. We studied the treatment of patients with level III-IV inferior vena cava (IVC) tumor thrombi using a robotic approach. This technique was feasible for well-selected patients. However, level III-IV robot-assisted IVC thrombectomy requires more complex techniques and multidisciplinary cooperation. Although the risks involved are high, level III and IV robot-assisted inferior vena cava thrombectomy (RA-IVCT) is feasible. It provides an alternative minimally invasive method for well-selected patients. Level III and IV RA-IVCT required more complex techniques and multi-disciplinary cooperation. [ABSTRACT FROM AUTHOR]

Single-port (SP) robot-assisted laparoscopic prostatectomy (RALP) appears to be a safe and feasible approach for radical prostatectomy, but no prior studies have compared SP-RALP to a multiport (MP) platform. Using retrospective data from a single-center tertiary institution we compare 50 consecutive SP-RALP patients (da Vinci SP) to a contemporary cohort of 113 patients who underwent MP-RALP (da Vinci Xi). We found no significant differences in surgical or total operating room time. Pain scores were measured on a scale from 0 to 10. There were more pain-free patients on postoperative day 1 (18% difference, 95% confidence interval [CI] 9.9–27%) and there were shorter hospital stays (−1 d, 95% CI −1.0 to 0) in favor of SP. There were no significant differences in inpatient total morphine equivalents used, complication rates, or stress incontinence determined at a minimum of 90 d. These findings show that the learning curve for SP-RALP is relatively short for an experienced robotic surgeon and may favor better pain control and shorter hospitalization. We analyzed the differences in robotic surgery for localized prostate cancer using a single-port robotic platform compared to the traditional multiport robotic platform. We did not find significant differences in operative times, but significantly more patients were pain-free on the first postoperative day and had shorter hospital stays. [ABSTRACT FROM AUTHOR]

The long-term oncological outcomes of laparoscopic (LRC) and robotic-assisted radical cystectomy (RARC) are still maturing compared with open radical cystectomy (ORC). To evaluate the 5-yr oncological outcomes of patients recruited into the randomised trial of Open, Laparoscopic and Robot Assisted Cystectomy (CORAL) and extracorporeal urinary diversion. A review of prospectively maintained database of 60 patients with muscle-invasive bladder cancer (MIBC) or high-risk nonmuscle-invasive bladder cancer (HRNMIBC) who were previously randomised in the CORAL trial to receive ORC, RARC, or LRC. This trial was designed to compare the perioperative and early oncological outcomes of these techniques. The outcomes of interest included 5-yr recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS). Kaplan–Meier curves were used to plot the recurrence and survival data. The curves between RFS, CSS, and OS were compared using the log-rank test. A two-sided p value <0.05 was considered significant. Results were analysed on the basis of intention to treat. A total of 60 patients with either MIBC (n = 38) or HRNMIBC (n = 21) were randomised in the CORAL trial to receive ORC, RARC, or LRC. The 5-yr RFS was 60%, 58%, and 71%; 5-yr CSS was 64%, 68%, and 69%; and 5-yr OS was 55%, 65%, and 61% for ORC, RARC, and LRC, respectively. There was no significant difference in RFS, CSS, and OS between the three surgical arms. The principal limitation is the small sample size. There was no difference in 5-yr RFS, CSS, and OS rates of patients who underwent ORC, RARC, and LRC for management of bladder cancer. Minimally invasive techniques achieved equivalent oncological outcomes to the gold standard of ORC. However, the study was based at a single institution with a small sample size. Patients who agreed to participate in the randomised trial of either open, laparoscopic, or robotic-assisted radical cystectomy for bladder cancer did not have different cancer outcomes at 5 yr. Patients who agreed to participate in the randomised trial of either open, laparoscopic, or robot-assisted radical cystectomy for bladder cancer had equivalent cancer outcomes at 5 yr. [ABSTRACT FROM AUTHOR]

In prostate cancer (PCa) surgical procedures, in order to maximize potency recovery, a nerve-sparing (NS) procedure is preferred. However, cancer abutting or focally extending beyond the prostate capsule increases the risk of a positive surgical margin. To evaluate the accuracy of our new three-dimensional (3D) elastic augmented-reality (AR) system in identifying capsular involvement (CI) location of PCa during the NS phase of robot-assisted radical prostatectomy (RARP). Secondarily, the accuracy of this technology was compared with two-dimensional (2D)-based cognitive procedures. A prospective study, enrolling 40 patients with PCa undergoing RARP at our center, from May to October 2018. Patients underwent 3D AR RARP or, in case of unavailability of this technology, 2D cognitive RARP. In all patients, total anatomical reconstruction was used. Clinical data were collected. In order to compare the two groups, nonparametric Mann-Whitney and chi-square tests were performed. A metallic clip was placed at the level of suspicious CI on the basis of images given by the 3D AR or magnetic resonance imaging (MRI) report. The pathological analysis evaluated the presence of tumor at the level of the clip. Twenty patients were enrolled in each group. Focusing on the 3D AR group at macroscopic evaluation, the metallic clip was placed at the tumor and capsular bulging in all cases. At microscopic assessment, cancer presence was confirmed in the suspicious area in 95.4% of the cases. Moreover, CI was correctly identified in 100.0% of the cases, thanks to the 3D image overlap. These results were compared with the 2D MRI cognitive group, showing, at microscopic analysis, statistically significant superiority of the 3D AR group in CI detection during the NS phase (100% vs 47.0%; p < 0.05). The main limitation of this technique is that the segmentation and overlapping of the images are performed manually. Our findings suggest that, with the introduction of the elastic 3D virtual models, prostate deformation is correctly simulated during surgery and lesion location is correctly identified, even in dynamic reality with a subsequent potential reduction of positive surgical margin rate and, in the meantime, maximization of functional outcomes. On the basis of our findings, the three-dimensional elastic augmented-reality technology seems to help the surgeon in lesion location identification even in a dynamic phase of the intervention, optimizing the oncological outcomes. With the elastic three-dimensional augmented-reality robot-assisted radical prostatectomy, prostate deformation is correctly simulated during surgery and the lesion is correctly identified, allowing optimization of the nerve-sparing tailoring with a potential reduction of positive surgical margin rate and possible maximization of the functional outcomes. [ABSTRACT FROM AUTHOR]