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Background: Retroperitoneal lymph node dissection (RPLND) is a treatment option for men with stage 1 or 2 testis cancer and the standard of care for men with postchemotherapy retroperitoneal residual disease. Given the morbidity of RPLND, four important surgical modifications have been proposed: minimally invasive access, nerve-sparing resection, template resection, and en-bloc resection. Objective: To describe the surgical steps and perioperative outcomes of robotic nerve-sparing unilateral template RPLND with en-bloc resection (roboRPLND-NS+). Design, setting, and participants: From 2017 to 2019, five patients with suspicion of retroperitoneal metastatic testicular cancer on abdominopelvic computed tomography underwent roboRPLND-NS+ at a single referral center. All surgeries were carried out by a single surgeon who has performed more than 500 extended and more than 50 super-extended robot-assisted lymph node dissections. Surgical procedure: A lateral transperitoneal robotic approach with a da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in six-arm configuration was used. The sympathetic chains, postganglionic sympathetic fibers, and hypogastric plexus were preserved as much as possible to ensure a nerve-sparing procedure. The template borders consisted of the renal vein cranially, the ureter laterally, the interaortocaval space medially, the common iliac artery caudally, and the psoas muscle dorsally for the right and left modified RPLND templates. Lymph nodes and the surrounding fatty tissue were progressively resected from the common iliac vessels and the abdominal aorta using the split-and-roll technique, and all of the template tissue was resected as a single specimen. Intraoperative and postoperative complications were recorded. Measurements: Lymph node yield and perioperative and postoperative oncological and functional outcomes were measured. Results and limitations: The median patient age was 38 yr (interquartile range [IQR] 32–41) and the median operative time was 274 min (IQR 238–280). Node metastases were pathologically confirmed in three patients. The median number of lymph nodes removed was 19 (IQR 18–21), and the median number of positive lymph nodes was 2 (IQR 1–3). No patient experienced intraoperative or postoperative complications. The postoperative hospital stay was either 3 or 4 d. Maintenance of antegrade ejaculation was achieved in all patients. After median follow-up of 15 mo (IQR 14–30), all patients were alive and no recurrence was observed. Limitations include the low number of patients and the single surgeon experience. Conclusions: RoboRPLND-NS+ is a safe and feasible technique that allows removal of a high number of lymph nodes with good functional outcomes. Short-term survival outcomes were excellent, with no recurrences or deaths recorded. Patient summary: We describe a feasible and safe robot-assisted surgical procedure for removal of lymph nodes in patients with testicular cancer. Our technique has potential to decrease the medical problems arising as side effects of the surgery while achieving good cancer control.

Objective: Laparoscopic total mesorectal excision (L-TME) is difficult to perform because of its technical shortcomings in cases of difficult anatomical condition. In such situations, robotic TME (R-TME) tends to be the procedure of choice. This study aimed to compare R-TME and L-TME treatments for mid-low rectal cancer in patients with difficult anatomical conditions., Methods: This retrospective single-center study examined data from 01/2019 to 02/2021 of mid-low rectal cancer patients with difficult anatomical conditions. Perioperative data, short-term outcomes, and 2-year oncologic outcomes were compared between groups., Results: The 106 patients were divided into R-TME (n = 56) and L-TME (n = 50). R-TME was associated with a lower diverting ileostomy rate (28.6% vs 50.0%, P = 0.005). R-TME involved a longer operation time (180 min vs 147.5 min, P < 0.001) but a similar procedure time (147.5 min vs 143.5 min, P = 0.110). More patients treated with R-TME experienced mild postoperative pain (33.9% vs 12.0%, P = 0.015) at a much higher cost ([$13740.8 ± 2038.13] vs [$9579.97 ± 2404.22], P < 0.001). The 2-year overall survival and disease-free survival rates were similar between the groups., Conclusion: R-TME, when performed by an experienced surgeon, can reduce the diverting ileostomy rate and relieve postoperative pain without a longer procedure time but at a higher cost. Larger trials of difficult patients with extended follow-up times are expected., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest or financial ties., (Copyright © 2022 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Introduction: With the advent of robot-assisted laparoscopic ureteral reimplantation (RALUR) for primary vesicoureteral reflux (VUR), understanding and minimizing its complications continues to be critical. Incidence of de novo hydronephrosis after RALUR could be indicative of an outcome that needs further study or could be a benign transient finding., Objective: In the present study, we hypothesized that the incidence of de novo hydronephrosis after RALUR is low and resolves spontaneously., Methods: An IRB-approved prospective single-institutional registry was utilized to identify all patients undergoing RALUR via an extravesical approach from 2012 to 2020. Patients with primary VUR and minimal (Grade I SFU) or no hydronephrosis prior to surgery were included. Patients who had other associated pathology or underwent concomitant procedures were excluded. Preoperative characteristics including VUR and hydronephrosis grades as well as post-operative clinical details and hydronephrosis grades were aggregated and analyzed., Results: 86/172 (50%) patients (133 ureters), with median reflux grade of 3 (IQR: G2, G3) met the inclusion criteria. Patients underwent RALUR at a median age of 5.7 years (IQR: 3.4, 8.7) with median 36.2 months (IQR: 19.6, 63.6) follow-up. Renal ultrasound at 4-6 weeks post-op showed de novo hydronephrosis in 18 (13.5%) ureters; the complete resolution was seen in 13 ureters (72%) at a median of 4.5 months from surgery. Among the 5 with non-resolved hydronephrosis (SFU G2:4, G3:1), 2 patients (3 ureters) underwent subsequent interventions., Discussion: The present study evaluating the natural history of de novo hydronephrosis after RALUR-EV performed for primary VUR, is to our knowledge the largest cohort of patients undergoing RALUR that this has been studied in. In our cohort, the incidence of de novo hydronephrosis after RALUR was 13.5%, similar to rates reported in two OUR cohorts, and significantly lower than reported incidence rates of 22-26% in several OUR cohorts, and 30% in a RALUR cohort. In the present cohort, hydronephrosis resolved spontaneously in more than 72% of cases. The median time from surgery until resolution of hydronephrosis was 4.5 (1.6, 10.5) months, which is shorter in comparison to the average time to resolution of 7.6 months, reported by Kim et al. in an earlier study., Conclusions: De novo hydronephrosis after RALUR can be followed with serial renal ultrasounds. The majority of de novo hydronephrosis post-RALUR is transient and resolves spontaneously within a year of surgery with a very low re-intervention rate., Competing Interests: Conflicts of interest None., (Copyright © 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Patients unfit for open repair after development a postdissection aortic arch and thoraco-abdominal aneurysm after open ascending aortic replacement for type A dissection would have no other treatment options. We report the case of a 75-year-old man with a type A aortic dissection treated by ascending aortic replacement. The patient presented an enlargement of the downstream aorta and thoraco-abdominal aneurysm 6-months after. This patient underwent a three-stage surgical sessions, open surgery for extraanatomical supra-aortic trunks reconstruction, endovascular branched treatment of ascending, arch and descending aorta and another one to perform an endovascular fenestrated reconstruction of thoraco-abdominal and infrarenal aorta., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To describe robotic-assisted laparoscopic artificial urinary sphincter (RAL-AUS) placement and a Malone antegrade continent enema (MACE) procedure on a 6-year-old girl., Patients and Results: Our patient is a 6-year-old girl with myelomeningocele. She was totally incontinent of urine and chronic constipated despite aggressive bowel regimen. Preoperative workup included renal and bladder ultrasound showing normal findings. Video-urodynamics was also obtained showing low leak point pressure (25 cm H 2 O) with no reflux. RAL-AUS was performed totally intra-corporally with no complications. The total operative time was 5 h 42 min. Estimated blood loss was minimal. The patient was discharged on postoperative day 4 with the AUS deactivated. Follow-up cystoscopy and activation of the AUS was done 6 weeks later. At 3-month follow-up, the patient was fully recovered and remained completely dry between voids. Also her bowel movements improved significantly with the MACE. Both patient and family appeared comfortable in using the AUS., Conclusion: To our knowledge, this is the first case described of RAL-AUS placement in the pediatric population. We believe this can be safely accomplished with good outcomes. The robotic approach provides an advantage in performing deep pelvic surgeries and facilitates concomitant intra-abdominal procedures., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)