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Background: Robot-assisted repair of benign ureteroenteric anastomotic strictures (UAS) provides an alternative to the open approach. We aimed to report short-, medium-, and long-term outcomes for robotic repair of benign UAS, and to provide a detailed video demonstration of critical operative techniques in performing this procedure robotically. Materials and Methods: Between January 2013 and September 2022, 31 patients from seven institutions who previously underwent radical cystectomy and subsequently developed UAS underwent robotic repair of UAS. Perioperative variables were prospectively collected, and postoperative outcomes were assessed. The surgery starts with a lysis of adhesions after previous surgery. Ureters are dissected, and the level of the stricture is identified. The ureter is then divided, and the stricture is resected. Finally, the ureter is spatulated and reimplanted with Nesbit technique after stenting with Double-J stents. In cases where both ureters show strictures, Wallace technique for reimplantation can be applied. Results: After robotic or open cystectomy, 31 patients had a total of 43 UAS at a median (interquartile range) follow-up of 21 (9-43) months. Median stricture length was 2.0 (1.0-3.25) cm, operative duration was 141 (121-232) minutes, estimated blood loss was 100 (50-150) mL, and length of hospital stay was 5 (3-9) days. One (3.2%) case was converted to open and one (3.2%) intraoperative complication occurred. Seven (22.6%) patients experienced postoperative complications, including four (12.9%) Clavien-Dindo grade 3 complications. No Clavien-Dindo grade 4 or 5 complications occurred. Stricture recurrence occurred in 2 (6.5%) patients. Conclusions: These results demonstrate that robotic repair of UAS is feasible and effective approach with outcomes in line with prior open series. Patient Consent Statement: Authors have received and archived patient consent for video recording and publication in advance of video recording of procedure.

Single-port (SP) robot-assisted laparoscopic partial nephrectomy (RAPN) is a promising new technique. The aim of this study was to compare surgical and oncological outcomes of SP-RAPN to the multi-port (MP) surgical platform. This is a retrospective, cohort-based study involving patients undergoing SP-RAPN between 2019 and 2020 at a single institution. Demographic, preoperative, surgical, and postoperative outcomes data were gathered and compared to a 1-to-1 matched MP cohort. A total of 50 SP and 50 matched MP cases were included. Length of surgery and ischemia time were not statistically significant between the two cohorts; however, estimated blood loss (EBL) was significantly lower in the SP group than in the MP (IQR 25-50 vs. IQR 50-100 mL, p = 0.002). No differences were seen in regard to the 30-day readmission rate, surgical margin status, pain scores, and complications between the two approaches. We found no statistically significant differences in positive margins, pain score, length of stay, or readmission rate between matched SP and MP patients. These data support the viability of the SP technique as an alternative to MP-RAPN when in the hands of experienced surgeons., (© 2023. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Objectives: To compare the safety and efficacy of oral apixaban with that of injectable enoxaparin after robot-assisted radical cystectomy (RARC) for venous thromboembolism (VTE) thromboprophylaxis., Materials and Methods: We conducted a retrospective review of prospectively collected data for all RARC patients treated at our tertiary care centre between 2018 and 2022. The study included two groups: patients who were subject to a prospectively implemented protocol from October 2021 to the present, comprising a 21-day postoperative course of apixaban 2.5 mg twice daily after discharge, and patients treated prior to October 2021 who received enoxaparin 40 mg daily. Baseline demographics and clinical characteristics, such as VTE (defined as deep vein thrombosis and pulmonary embolism), were analysed. The primary outcome was incidence of symptomatic VTE confirmed with definitive imaging within 90 days of RARC. Secondary outcomes included major bleeding, complications, readmission, and mortality within 30 days postoperatively. Descriptive statistics included baseline patient characteristics, operative information and complications. Differences in baseline characteristics and postoperative data were compared between groups. Multivariate logistic regression was used to determine associations between variables and the primary outcome., Results: A total of 124 patients received apixaban and 250 patients received enoxaparin prophylaxis. Ten patients (2.7%) experienced a VTE within 90 days postoperatively (two [1.6%] apixaban group vs eight [3.2%] enoxaparin group; P = 0.5). After patient stratification into European Association of Urology risk groups, no statistically significant difference in VTE rates was seen between groups in the apixaban (2.7% high- + intermediate-risk group vs 1.1% low-risk group; P = 0.5) and enoxaparin cohorts (4.3% high- + intermediate-risk group vs 2.5% low-risk group; P = 0.5). On multivariate logistic regression, no variables were associated with the development of the primary outcome., Conclusion: Prophylaxis with apixaban and enoxaparin showed no statistically significant differences in VTE rates among RARC patients. Apixaban appears to be safe and effective for VTE prophylaxis after RARC., (© 2023 BJU International.)

Objectives: To prospectively analyse robotically administered transperitoneal transversus abdominis plane (robot-assisted transversus abdominis plane [RTAP]) compared with both ultrasonography-guided transversus abdominis plane (UTAP) and local anaesthesia (LA) with regard to pain control and narcotic use in patients undergoing robot-assisted prostatectomy (RARP) or robot-assisted partial nephrectomy (RAPN)., Subjects/patients and Methods: Patients undergoing RARP or RAPN were randomized in a single-blind 2:2:1 fashion to RTAP:UTAP:LA, with the study powered to evaluate superiority of UTAP to LA and non-inferiority of RTAP to UTAP. We compared time to deliver the block, operating room time, postoperative pain scores using the visual analogue scale, and intra-operative and postoperative analgesia consumption., Results: A total of 143 patients were randomized and received treatment. There was no significant difference in patient baseline characteristics. UTAP did not demonstrate superiority to LA in terms of pain control. RTAP and LA were faster to administer than UTAP (time to perform block 2.5 vs 2.5 vs 6.25 min; P < 0.001). There was no difference in postoperative narcotic, acetaminophen, ketorolac or ondansetron requirements among the three groups (P > 0.05). The study was terminated early due to the unexpected efficacy of LA., Conclusion: This study showed that UTAP and RTAP do not provide superior pain control to LA. The efficiency, effectiveness, and ease of administration of LA make it an excellent option for first-line therapy for postoperative analgesia., (© 2022 BJU International.)

In the last two decades, surgical techniques for intracorporeal urinary diversion have been developed with the aim of reducing surgical morbidity. Although increasing constantly, the numbers of urologists offering intracorporeal neobladder reconstruction remain limited due to the complex nature of the procedure. In this article, we aim to provide a detailed description of the surgical technique we currently use at our institution. This technique was initially developed and perfected at the Karolinska Institutet in Sweden starting in 2003. It is a reproducible surgical approach with standardized and well-defined surgical steps. We give a detailed description of the surgical steps and provide tips and tricks to address specific situations and to increase efficiency. We also review the indications, the preoperative considerations, equipment necessary, postoperative considerations, and clinical outcomes for this procedure. Finally, we provide an accompanying didactic surgical video. We believe that this standardized approach can be learned and reproduced safely by motivated robotic surgeons.

Background: Radical nephroureterectomy (RNU) represents the standard of care for high grade upper tract urothelial carcinoma (UTUC). Open and laparoscopic approaches are well-established treatments, but evidence regarding robotic RNU is growing. The introduction of the Xi ® system facilitates the implementation of this multi-quadrant procedure. The aim of this video-article is to describe the surgical steps and the outcomes of Xi ® robotic RNU., Methods: Single stage Xi ® robotic RNU without patients repositioning and robot re-docking were done between 2015 and 2019 and collected in a large worldwide multi-institutional study, the ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST). Institutional review board approval and data share agreement were obtained at each center. Surgical technique is described in detail in the accompanying video. Descriptive statistics of baseline characteristics and surgical, pathological, and oncological outcomes were analyzed., Results: Overall, 148 patients were included in the analysis; 14% had an ECOG >1 and 68.2% ASA ≥3. Median tumor dimension was 3.0 (IQR:2.0-4.2) cm and 34.5% showed hydronephrosis at diagnosis. Forty-eight% were cT1 tumors. Bladder cuff excision and lymph node dissection were performed in 96% and 38.1% of the procedures, respectively. Median operative time and estimated blood loss were 215.5 (IQR:160.5-290.0) minutes and 100.0 (IQR: 50.0-150.0) mL, respectively. Approximately 56% of patients took opioids during hospital stay for a total morphine equivalent dose of 22.9 (IQR:16.0-60.0) milligrams equivalent. Post-operative complications were 26 (17.7%), with 4 major (2.7%). Seven patients underwent adjuvant chemotherapy, with median number of cycles of 4.0 (IQR:3.0-6.0)., Conclusions: Single stage Xi ® RNU is a reproducible and safe minimally invasive procedure for treatment of UTUC. Additional potential advantages of the robot might be a wider implementation of LND with a minimally invasive approach.

Introduction: The surgical treatment of ureteral strictures in adults represents a challenging procedure for the variability of location, extension, and etiology of the disease. Open ureteral reimplantation (OUR) offered high success rates even when considering complex ureteral disease. The debate for defining the role of robotic in the treatment of adult ureteral disease is still ongoing. The aim of the current systematic review is to provide an updated analysis of the comparative outcomes of robot-assisted UR (RAUR) versus OUR based on the available literature., Evidence Acquisition: An independent systematic review of the literature was performed from 2010 to 2021. Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) recommendations were followed to design search strategies, selection criteria, and evidence reports. The quality of the included studies was determined using the Newcastle-Ottawa scale for non-randomized controlled trials. Pooled analysis of demographics and clinical characteristics, as well as surgical and postoperative outcomes, was performed., Evidence Synthesis: After an initial screening and full-text review, five studies published between 2002 and 2021 were identified and included in the analysis. All the studies were observational retrospective case-control studies. Among the 225 patients included in the pooled analysis, 94 (41.8%) and 131 (58.2%) were RAUR and OUR, respectively. There was no difference between groups in terms of baseline characteristics. No differences in surgical approach and operative time were reported among the groups. Estimated blood loss was lower for robotic approach (WMD: -121.71 mL; P=0.0006). There were no significant differences between groups in overall (OR: 0.85; P=0.69) and major (OR: 0.69; P=0.52) complication. RAUR group reported shorter length of stay (WMD: -2.39 days; P<0.00001), catheter (WMD: -5.26 days; P=0.004) and stent (WMD: -11.9 days; P=0.001) time., Conclusions: Available evidence shows that RAUR offers similar surgical outcomes if compared to OUR, and potential advantages in terms of lower blood loss, shorter hospital stay, catheter, and stent time. The adoption of one approach over the other is likely to be mainly dictated by the surgeon's preference and expertise.

Background: Salvage treatment for local recurrence after prior partial nephrectomy (PN) or local tumor ablation (LTA) for kidney cancer is, as of yet, poorly investigated., Objective: To classify the treatments and standardize the nomenclature of salvage robot-assisted renal surgery, to describe the surgical technique for each scenario, and to investigate complications, renal function, and oncologic outcomes., Design, Setting, and Participants: Sixty-seven patients underwent salvage robot-assisted renal surgery from October 2010 to December 2020 at nine tertiary referral centers., Surgical Procedure: Salvage robot-assisted renal surgery classified according to treatment type as salvage robot-assisted partial or radical nephrectomy (sRAPN or sRARN) and according to previous primary treatment (PN or LTA)., Measurements: Postoperative complications, renal function, and oncologic outcomes were assessed., Results and Limitations: A total of 32 and 35 patients underwent salvage robotic surgery following PN and LTA, respectively. After prior PN, two patients underwent sRAPN, while ten underwent sRARN for a metachronous recurrence in the same kidney. No intra- or perioperative complication occurred. For local recurrence in the resection bed, six patients underwent sRAPN, while 14 underwent sRARN. For sRAPN, the intraoperative complication rate was 33%; there was no postoperative complication. For sRARN, there was no intraoperative complication and the postoperative complication rate was 7%. At 3 yr, the local recurrence-free rates were 64% and 82% for sRAPN and sRARN, respectively, while the 3-yr metastasis-free rates were 80% and 79%, respectively. At 33 mo, the median estimated glomerular filtration rates (eGFRs) were 57 and 45 ml/min/1.73 m 2 for sRAPN and sRARN, respectively. After prior LTA, 35 patients underwent sRAPN and no patient underwent sRARN. There was no intraoperative complication; the overall postoperative complications rate was 20%. No local recurrence occurred. The 3-yr metastasis-free rate was 90%. At 43 mo, the median eGFR was 38 ml/min/1.73 m 2 . The main limitations are the relatively small population and the noncomparative design of the study., Conclusions: Salvage robot-assisted surgery has a safe complication profile in the hands of experienced surgeons at high-volume institutions, but the risk of local recurrence in this setting is non-negligible., Patient Summary: Patients with local recurrence after partial nephrectomy or local tumor ablation should be aware that further treatment with robot-assisted surgery is not associated with a worrisome complication profile, but also that they are at risk of further recurrence., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Use of partial nephrectomy (PN) in T3 renal cell carcinoma (RCC) is controversial., Objective: To evaluate quality outcomes of robot-assisted PN (RAPN) for clinical T3a renal masses (cT3aRM)., Design, Setting, and Participants: This was a retrospective multicenter analysis of patients with cT3aN0M0 RCC who underwent RAPN., Intervention: RAPN., Outcome Measurements and Statistical Analysis: The primary endpoint was a trifecta composite outcome of negative surgical margins, warm ischemia time (WIT) ≤25 min, and no perioperative complications. The optimal outcome was defined as achieving this trifecta and ≥90% preservation of the estimated glomerular filtration rate (eGFR) and no stage upgrading of chronic kidney disease. Multivariable analysis (MVA) identified risk factors associated with lack of the optimal outcome. Kaplan-Meier analysis was conducted for survival outcomes., Results and Limitations: Analysis was conducted for 157 patients (median follow-up 26 mo). The median tumor size was 7.0 cm (interquartile range [IQR] 5.0-7.8) and the median RENAL score was 9 (IQR 8-10). Median estimated blood loss (EBL) was 242 ml (IQR 121-354) and the median WIT was 19 min (IQR 15-25). A total of 150 patients (95.5%) had negative margins. Complications were noted in 25 patients (15.9%), with 4.5% having Clavien grade 3-5 complications. The median change in eGFR was 7 ml/min/1.72 m 2 , with ≥90% eGFR preservation in 55.4%. The trifecta outcome was achieved for 64.3% and the optimal outcome for 37.6% of the patients. MVA revealed that greater age (odds ratio [OR] 1.06; p = 0.002), increasing RENAL score (OR 1.30; p = 0.035), and EBL >300 ml (OR 5.96, p = 0.006) were predictive of failure to achieve optimal outcome. The 5-yr recurrence-free survival, cancer-specific survival, and overall survival, were 82.1%, 93.3%, and 91.3%, respectively. Limitations include the retrospective design., Conclusions: RAPN for select cT3a renal masses is feasible and safe, with acceptable quality outcomes. Further investigation is requisite to delineate the role of RAPN in cT3a RCC., Patient Summary: Robot-assisted partial nephrectomy in patients with stage 3a kidney cancer provided acceptable survival, functional, and morbidity outcomes in the hands of experienced surgeons, and may be considered as an option when clinically indicated., (Copyright © 2020 European Association of Urology. All rights reserved.)

Objective: To assess the association between nephrometry score (NS) and prolonged warm ischemia time (WIT) in patients undergoing robotic partial nephrectomy (RPN) for clinically localized renal masses., Methods: We queried our prospectively maintained kidney cancer database to identify all patients undergoing RPN for localized tumors from 2007-2012. Patient and tumor characteristics were compared between complexity groups using analysis of variance and chi square tests. Multivariate logistic regression models were used to examine the relationship between NS complexity and warm ischemia >30 minutes., Results: Three hundred seventy-five patients (mean age, 59 ± 11 years; mean Charlson comorbidity index, 1.0 ± 1.3) undergoing RPN under warm ischemia for clinically localized renal tumors (mean tumor size, 3.1 ± 1.5 cm; mean NS, 6.8 ± 1.8) met inclusion criteria and had NS available. Stratified by complexity, groups differed with respect to age at surgery, tumor size, proximity to the hilum, collecting system entry, estimated blood loss, and operative time (all P values ≤.05). Significant differences in mean WIT were observed when comparing low (19.4 ± 12.1 minutes), intermediate (28.6 ± 12.8 minutes), and high (36.1 ± 13.7 minutes) NS complexity groups (P <.0001). Adjusting for confounders, patients with intermediate (odds ratio, 2.1; confidence interval, 1.2-3.9) and high (odds ratio, 3.7; confidence interval, 1.1-11.8) NS complexity were more likely to require prolonged WIT when compared with patients with low complexity tumors., Conclusion: In our large institutional cohort, quantification of anatomic complexity using the NS is associated with WIT >30 minutes in patients undergoing RPN for localized renal tumors. This provides further evidence that standardized reporting of tumor anatomic complexity affords meaningful outcome comparisons., (Copyright © 2014 Elsevier Inc. All rights reserved.)