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Rectal perforations during pelvic surgery are rare but serious complications. The occurrence of rectal involvement is generally lower than that of the involvement of other portions of the bowel. The urologic field is responsible for the majority of iatrogenic rectal injuries from pelvic surgery; general and gynecologic surgeries are prone to the occurrence as well, the latter especially in the case of rectal shaving for deep infiltrating endometriosis. Attention should be posed to the prevention of rectal injuries, especially in case of challenging or salvage procedures; some tricks may be recommended to avoid thermal and mechanical damages and to realize a safe dissection. Intraoperative detection of rectal injuries is of paramount importance; once confirmed, immediate management with the closure of the defect is recommended. In general, rectal injuries diagnosed after surgery are liable to significantly worse outcomes than those detected and managed intraoperatively. Patient summary: Rectal perforation is a rare but possible complication of pelvic surgeries. The more challenging the procedure (ie, surgery for locally advanced tumors or after radiation therapy), the higher the risk of rectal lesion. Intraoperative management of the injury should be attempted, with direct repair of the defect with or without fecal diversion.

Despite the advent of robotics and the decreasing rate of complications after radical cystectomy, several factors are renowned to impair the early outcomes of this procedure. The aim of this paper is to provide a multivariate analysis (MVA) of patient and surgical procedure-related variables likely to affect postoperative course and 30-day complication rate. Fifty-five robotic-assisted radical cystectomies (RARCs) performed at a single center from July 2021 to March 2023 were enrolled. Baseline demographics, comorbidities, and intraoperative and postoperative data were collected. Uni- and multivariate analyses were performed to evaluate the relationship with Clavien ≥ II complications arising within 30 days of surgery. A postoperative Clavien ≥ II complication was evident in 15 patients (28%), whereas Clavien ≥ III occurred only in 5 (9%). At MVA, the only independent predictor of Clavien ≥ II complications was a prior neoadjuvant chemotherapy (OR 5.6; 95% CI 1.22-25.3, p = 0.026). Recognized the small sample size, patients who received a prior NAC should deserve special care within the postoperative course.

We compared the perioperative outcomes of open (ORC) vs. robot-assisted (RARC) radical cystectomy in the treatment of pT4a MIBC. In total, 212 patients underwent ORC (102 patients, Group A) vs. RARC (110 patients, Group B) for pT4a bladder cancer. Patients were prospectively followed and retrospectively reviewed. We assessed operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of stay, transfusion rate, and oncological outcomes. Preoperative features were comparable. The mean operative time was 232.8 vs. 189.2 min ( p = 0.04), and mean EBL was 832.8 vs. 523.7 mL in Group A vs. B ( p = 0.04). An intraoperative transfusion was performed in 32 (31.4%) vs. 11 (10.0%) cases during ORC vs. RARC ( p = 0.03). The intraoperative complications rate was comparable. The mean length of stay was shorter after RARC (12.6 vs. 7.2 days, p = 0.02). Postoperative transfusions were performed in 36 (35.3%) vs. 13 (11.8%) cases ( p = 0.03), and postoperative complications occurred in 37 (36.3%) vs. 29 (26.4%) patients in Groups A vs. B ( p = 0.05). The positive surgical margin (PSM) rate was lower after RARC. No differences were recorded according to the oncological outcomes. ORC and RARC are feasible treatments for the management of pT4a bladder tumors. Minimally invasive surgery provides shorter operative time, bleeding, transfusion rate, postoperative complications, length of stay, and PSM rate.

Despite the arising interest in three-dimensional (3D) reconstruction models from 2D imaging, their diffusion and perception among urologists have been scarcely explored. The aim of the study is to report the results of an international survey investigating the use of such tools among urologists of different backgrounds and origins. Beyond demographics, the survey explored the degree to which 3D models are perceived to improve surgical outcomes, the procedures mostly making use of them, the settings in which those tools are mostly applied, the surgical steps benefiting from 3D reconstructions and future perspectives of improvement. One hundred responders fully completed the survey. All levels of expertise were allowed; more than half (53%) were first surgeons, and 59% had already completed their training. Their main application was partial nephrectomy (85%), followed by radical nephrectomy and radical prostatectomy. Three-dimensional models are mostly used for preoperative planning (75%), intraoperative consultation and tailoring. More than half recognized that 3D models may highly improve surgical outcomes. Despite their recognized usefulness, 77% of responders use 3D models in less than 25% of their major operations due to costs or the extra time taken to perform the reconstruction. Technical improvements and a higher availability of the 3D models will further increase their role in surgical and clinical daily practice.

Background: Robot-assisted surgery ensures minimal invasiveness; since the expiry of the Da Vinci patent, new robotic systems have entered the market. Recently, the Hugo RAS received CE approval for several surgical procedures. However, more is needed to know about skill acquisition at the new simulator., Objective: This study aims to analyse the factors impacting basic surgical skills at the Hugo RAS simulator., Design Setting and Participants: We present a cross-sectional study involving 71 participants of different backgrounds invited to a hands-on session with the Hugo RAS simulator voluntarily. All of them had no prior expertise with the system. Participants were recruited among medical/nurse students, residents, and laparoscopic and robotic surgeons., Intervention: All participants underwent a hands-on "pick and place" exercise at the Hugo RAS simulator; the metrics of a second-round pick and place exercise were recorded., Outcome Measurements and Statistical Analysis: Metrics were analysed with regard to the following variables: demographics, videogame use, and prior surgical experience (no surgical expertise, experience with laparoscopy, and experience with robotic console)., Results and Limitations: All participants completed the test. Of them, 77.5% were naïve to surgery, 8.5% had prior laparoscopic expertise, and 14.1% had prior robotic console experience. The time to complete the pick and place exercise was significantly lower ( p  < 0.001) among prior robotic surgeons (38 s, interquartile range [IQR] 34-45) compared with both naïve participants (61 s, IQR 53-71) and laparoscopists (93 s, IQR 53-162). The overall score of the exercise decreased with age ( p  = 0.046); however, the overall scores were significantly and steadily higher among surgeons experienced in robotic consoles across all age groups ( p  = 0.006). Neither gender ( p  = 0.7) nor videogame use ( p  = 0.9) correlated significantly with the metrics., Conclusions: This is the first study analysing factors impacting basic skill acquisition at a new robotic simulator. Experience with robotic consoles may represent a major factor, raising the hypothesis of the transferability of basic robotic skills across different robotic systems. Further studies are required to explore this issue., Patient Summary: In the present study, we analysed which characteristics may affect the basic surgical skills at a novel robotic platform., (© 2023 The Authors.)

Radical cystectomy represents one of the most challenging surgical procedures, exhibiting a high morbidity rate. The transition to minimally invasive surgery in the field has been steep, due to either the technical complexity and prior concerns of atypical recurrences and/or peritoneal spread. More recently, a larger series of RCTs has proven the oncological safety of robot-assisted radical cystectomy (RARC). Beyond survival outcomes, the comparison between RARC and open surgery in terms of peri-operative morbidity is still ongoing. We present a single-center experience of RARC with intracorporeal urinary diversion. Overall, 50% of patients had an intracorporeal neobladder reconstruction. The series confirms a low rate of complications (Clavien Dindo ≥ IIIa 7.5%) and wound infections (2.5%) and the absence of thromboembolic events. No atypical recurrences were found. To discuss these outcomes, we reviewed the literature related to RARC including level-1 evidence. PubMed and Web of Science searches were performed using the medical subject terms "robotic radical cystectomy" and "randomized controlled trial (RCT)". Six unique RCTs comparing robot and open surgery were found. Two clinical trials dealt with RARC with an intracorporeal reconstruction of UD. Pertinent clinical outcomes are summarized and discussed. In conclusion, RARC is a complex but feasible procedure. The transition from extracorporeal urinary diversion (UD) to a complete intracorporeal reconstruction could be the key to improving peri-operative outcomes and reducing the whole morbidity of the procedure.

Context: Erectile dysfunction (ED) following radical prostatectomy is a concern for patients and their partners. Low-intensity extracorporeal shockwave therapy (LI-ESWT) can potentially enhance tissue repair and regeneration. The aim of the current study was to systematically review the literature to assess the role of LI-ESWT in the management of patients with postprostatectomy ED., Evidence Acquisition: Two authors independently performed a systematic search of the PubMed and Web of Science databases to identify all relevant articles. Non-English reports, case reports, reviews, letters, and editorials were excluded. Risk of bias was assessed according to the GRADE guidelines., Evidence Synthesis: Nine articles met the inclusion criteria and were included in the qualitative analysis. All the studies included were published between 2015 and 2022 and the majority of them compared phosphodiesterase type 5 inhibitors (PDE5Is) alone versus a combination of LI-ESWT and PDE5Is. Only three studies were randomized controlled trials (RCTs). In general, there is no standardized protocol for LI-ESWT for postprostatectomy ED. In comparisons of LI-ESWT + PDE5Is versus PDE5Is alone, some authors found a statistically significant improvement in erectile function with LI-ESWT + PDE5Is. The starting time for LI-ESWT differed among the studies, ranging from 3 d to 6 mo after surgery. The main limitations of the review are the scarcity of studies, small sample sizes, high risk of bias, and high heterogeneity among studies., Conclusions: There is currently limited evidence on the use of LI-ESWT either alone or in combination with PDE5Is in penile rehabilitation protocols after prostatectomy. However, small clinical trials with short follow-up show that LI-ESWT could potentially play a role in the management of postprostatectomy ED in the future. Further RCTs with larger sample sizes are needed., Patient Summary: Despite limited reports in the literature, low-intensity shockwave therapy after removal of the prostate is a promising noninvasive treatment for dealing with erectile dysfunction after surgery., (© 2022 The Authors.)

Objective: Robotic intracorporeal neobladder reconstruction is a complex procedure in which the approximation of the reservoir to the urethral stump can be a demanding step. The aim of the study is to evaluate the reproducibility of a modified posterior reconstruction (PR) during the reconfiguration of intracorporeal neobladder after robot assisted radical cystectomy (RARC)., Materials and Methods: From July 2021 to July 2022, 35 RARC were performed, and 17 patients underwent intracorporeal neobladder reconstruction. A PR was planned in males (14). Intra- and peri-operative data were collected., Surgical Technique: RARC and node dissection are performed. Afterwards, 40-cm ileal segment is isolated; the portion with the more adequate mesenteric length is brought down to the pelvis. A modified PR is performed with a double-armed barbed suture: a first layer connects the Denonvillier's fascia to the rhabdosphincter in a running fashion; the second layer is created with the other arm and approximates the posterior side of the ileal segment towards the urethral stump. In the anterior caudal part of the ileum, a 1.5-cm incision is made to realize the neobladder neck; the neovesical-urethral anastomosis is performed with a second bidirectional suture., Results: Anastomotic and PR time were 14 (range 7-20) and 5 minutes (4-8), respectively. A single Clavien IIIa complication was recorded in a patient who underwent NAC and had a C. albicans superinfection in the post-operative course. All patients were discharged with complete or acceptable bladder voiding. Twelve patients with follow-up >90-days reported a satisfying daytime continence., Conclusions: PR represents a simple technical refinement that improves neobladder-urethral anastomosis by favoring ileal approximation to the urethral stump and decreasing anastomotic tension., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)