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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 ≥200 cc. Materials and Methods: Between 2009 and 2020 a total of 53 patients with a prostate volume of ≥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 ≥200 cc. These findings will require external validation at other high-volume centers.

Renal cell carcinoma is among major causes of death in patients with Von Hippel-Lindau (VHL) syndrome, and it usually presents with multiple and bilateral lesions that may require multiple renal surgeries. This, in turn, may compromise renal function, resulting in end-stage renal disease. To minimize renal function impairment in these patients, great importance is given to the preservation of functional parenchyma with the use of nephron-sparing techniques. Furthermore, new techniques such as off-clamp surgery, selective suturing or sutureless techniques may improve long-term functional outcomes. We described the case of a 27-year-old male patient with a family history of VHL disease affected by multiple, bilateral renal masses. He received bilateral, metachronous robot-assisted partial nephrectomies (RAPN) for a total of 15 renal lesions. No intra- or post-operative complications occurred, and the patient was discharged on the second postoperative day after both procedures. Serum creatinine after the second RAPN was 0.99 mg/dl (baseline value was 1.11 mg/dl). In patients with VHL syndrome and multiple renal lesions, robot-assisted partial nephrectomy, especially with the use of clampless and sutureless techniques, helps minimizing renal function impairment and should be performed when anatomically and technically feasible., (© 2023. The Author(s) under exclusive licence to The Japan Society of Nephrology.)

Introduction: We report on a case of congenital unilateral atresia of the vas deferens encountered during a robotic-assisted transabdominal preperitoneal (TAPP) inguinal hernia repair., Case Report: Our 65-years-old male patient was scheduled for a bilateral robotic-assisted TAPP inguinal hernia repair because of bilateral symptomatic groin hernia. Standard intraoperative dissection obtaining a critical view of the myopectineal orifice did not allow for an identification of the vas deferens (VD) on the left side. On the right side, a normal VD was identified. There was no suspicion of an intraoperative lesion or ligation of the VD. Both gonadal and inferior epigastric vessels were present on both sides. Upon clinical evaluation, no VD was palpable in the scrotum on the left side. The diagnosis of a congenital unilateral absence of the vas deferens was made. Additional abdominal computed tomography scan revealed a congenital agenesis of the left kidney, ureter, vesicula seminalis and vas deferens., Discussion: The accidental finding of a congenital absence of the vas deferens during inguinal hernia repair is rare. However, surgeons performing inguinal hernia repair should be aware of this condition and the clinical implications it poses, as this could prevent unnecessary exploration and missed diagnosis of associated underlying conditions.

Introduction: Bladder neck dissection is one of the most delicate surgical steps of robotic-assisted radical prostatectomy (RARP) [1, 2], and it may affect surgical margins rate and functional outcomes [3, 4]. Given the relationship between outcomes and surgical experience [5-7], it is crucial to implement a step-by-step approach for each surgical step of the procedure, especially in the most challenging part of the intervention. In this video compilation, we described the techniques for bladder neck dissection utilized at OLV Hospital (Aalst, Belgium)., Surgical Technique: We illustrated five different techniques for bladder neck dissection during RARP. The anterior technique tackles the bladder neck from above until the urethral catheter is visualized, and then the dissection is completed posteriorly. The lateral and postero-lateral approaches involve the identification of a weakness point at the prostate-vesical junction and aim to develop the posterior plane - virtually until the seminal vesicles - prior to the opening of the urethra anteriorly. Finally, we described our techniques for bladder neck dissection in more challenging cases such as in patients with bulky middle lobes and prior surgery for benign prostatic hyperplasia. All approaches follow anatomic landmarks to minimize positive surgical margins and aim to preserve the bladder neck in order to promote optimal functional recovery. All procedures were performed with DaVinci robotic platforms using a 3-instruments configuration (scissors, fenestrated bipolar, and needle driver). As standard protocol at our Institution, urinary catheter was removed on postoperative day two [8]., Conclusions: Five different approaches for bladder neck dissection during RARP were described in this video compilation. We believe that the technical details provided here might be of help for clinicians who are starting their practice with this surgical intervention., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Robot-assisted simple prostatectomy (RASP) has demonstrated better peri-operative outcomes as compared to open simple prostatectomy. However, RASP is still limited by platform availability and cost-effectiveness issues. The new surgical robots increasing competition may spread the robotic approach also in non-oncological fields. We reported the first RASP executed in Europe at OLV Hospital (Aalst, Belgium) performed with the novel HUGO™ Robot-Assisted Surgery (RAS) System. The platform consists of four independent carts, an open console, and a system tower equipped for both laparoscopic and robotic surgery. Our main goal was to demonstrate the technical feasibility of RASP with the novel HUGO™ RAS along with its safety in terms of perioperative outcomes and complications. We also aimed to describe our surgical setup. We collected patient's baseline characteristics, intraoperative and perioperative complications, postoperative outcomes, docking time, operative time, clashing of the instruments, or technical errors of the system. The procedure was performed in a 72-year-old male with a prostate volume of 155 g at preoperative imaging. No need for conversion to open/laparoscopic surgery and/or for additional port placement was required. No intraoperative complications, instrument clashes, or failure of the system that compromised the completion of the surgery were recorded. Docking, operative, and console times were 9, 150, and 120 minutes, respectively. The catheter was removed on the second postoperative day. No postoperative complications occurred. The postoperative uroflowmetry revealed a maximum flow of 26.2 mL/s, without postvoid residual volume. Robot-assisted simple prostatectomy with the HUGO™ RAS System is a feasible and safe procedure in terms of perioperative outcomes and complications. Our setup allowed for a rapid docking procedure and a smoothly completion of the surgery.