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Importance: Robot-assisted radical cystectomy is being performed with increasing frequency, but it is unclear whether total intracorporeal surgery improves recovery compared with open radical cystectomy for bladder cancer.Objectives: To compare recovery and morbidity after robot-assisted radical cystectomy with intracorporeal reconstruction vs open radical cystectomy.Design, Setting, and Participants: Randomized clinical trial of patients with nonmetastatic bladder cancer recruited at 9 sites in the UK, from March 2017-March 2020. Follow-up was conducted at 90 days, 6 months, and 12 months, with final follow-up on September 23, 2021.Interventions: Participants were randomized to receive robot-assisted radical cystectomy with intracorporeal reconstruction (n = 169) or open radical cystectomy (n = 169).Main Outcomes and Measures: The primary outcome was the number of days alive and out of the hospital within 90 days of surgery. There were 20 secondary outcomes, including complications, quality of life, disability, stamina, activity levels, and survival. Analyses were adjusted for the type of diversion and center.Results: Among 338 randomized participants, 317 underwent radical cystectomy (mean age, 69 years; 67 women [21%]; 107 [34%] received neoadjuvant chemotherapy; 282 [89%] underwent ileal conduit reconstruction); the primary outcome was analyzed in 305 (96%). The median number of days alive and out of the hospital within 90 days of surgery was 82 (IQR, 76-84) for patients undergoing robotic surgery vs 80 (IQR, 72-83) for open surgery (adjusted difference, 2.2 days [95% CI, 0.50-3.85]; P = .01). Thromboembolic complications (1.9% vs 8.3%; difference, -6.5% [95% CI, -11.4% to -1.4%]) and wound complications (5.6% vs 16.0%; difference, -11.7% [95% CI, -18.6% to -4.6%]) were less common with robotic surgery than open surgery. Participants undergoing open surgery reported worse quality of life vs robotic surgery at 5 weeks (difference in mean European Quality of Life 5-Dimension, 5-Level instrument scores, -0.07 [95% CI, -0.11 to -0.03]; P = .003) and greater disability at 5 weeks (difference in World Health Organization Disability Assessment Schedule 2.0 scores, 0.48 [95% CI, 0.15-0.73]; P = .003) and at 12 weeks (difference in WHODAS 2.0 scores, 0.38 [95% CI, 0.09-0.68]; P = .01); the differences were not significant after 12 weeks. There were no statistically significant differences in cancer recurrence (29/161 [18%] vs 25/156 [16%] after robotic and open surgery, respectively) and overall mortality (23/161 [14.3%] vs 23/156 [14.7%]), respectively) at median follow-up of 18.4 months (IQR, 12.8-21.1).Conclusions and Relevance: Among patients with nonmetastatic bladder cancer undergoing radical cystectomy, treatment with robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy resulted in a statistically significant increase in days alive and out of the hospital over 90 days. However, the clinical importance of these findings remains uncertain.Trial Registration: ISRCTN Identifier: ISRCTN13680280; ClinicalTrials.gov Identifier: NCT03049410. [ABSTRACT FROM AUTHOR]

Objectives: To analyze the impact of neoadjuvant chemotherapy on survival and recurrence patterns in muscle‐invasive bladder cancer after robot‐assisted radical cystectomy. Materials and methods: The International Robotic Cystectomy Consortium database was reviewed to identify patients who underwent robot‐assisted radical cystectomy for muscle‐invasive bladder cancer between 2002 and 2019. Survival outcomes, response rates, and recurrence patterns were compared between patients who received neoadjuvant chemotherapy and those who did not. Survival distributions were estimated using Kaplan–Meier analyses and compared using the log‐rank test. Results: A total of 1370 patients with muscle‐invasive bladder cancer were identified, of whom 353 (26%) received neoadjuvant chemotherapy. After a median follow‐up of 27 months, neoadjuvant chemotherapy recipients had higher 3‐year overall survival (74% vs 57%; log‐rank P < 0.01), 3‐year cancer‐specific survival (83% vs 73%; log‐rank P = 0.03), and 3‐year relapse‐free survival (64% vs 48%; log‐rank P < 0.01). Neoadjuvant chemotherapy was a predictor of higher overall survival, cancer‐specific survival, and relapse‐free survival in univariate but not multivariate analysis. Pathological downstaging (46% vs 23%; P < 0.01), complete responses (24% vs 8%; P < 0.01), and margin negativity (95% vs 91%; P < 0.01) at robot‐assisted radical cystectomy were more common in the neoadjuvant chemotherapy group. Neoadjuvant chemotherapy recipients had lower distant (15% vs 22%; P < 0.01) but similar locoregional (12% vs 13%; P = 0.93) recurrence rates. Conclusions: In this analysis from a large international database, patients with muscle‐invasive bladder cancer who received neoadjuvant chemotherapy before robot‐assisted radical cystectomy had higher rates of survival, pathological downstaging, and margin‐negative resections. They also experienced fewer distant recurrences. [ABSTRACT FROM AUTHOR]

Objectives: To develop a wet laboratory training model for learning core laparoscopic surgical skills and evaluating learners' competency level outside the operating room. Methods: Participants completed three tasks (task 1: tissue dissection around the aorta; task 2: tissue dissection and division of the renal artery; task 3: renal parenchymal closure). Each performance was video recorded and subsequently evaluated by two experts, according to the Global Operative Assessment of Laparoscopic Skills and task‐specific metrics that we developed (Assessment Sheet of Laparoscopic Skills in Wet Lab score). Mean scores were used for analyses. The subjective mental workload was also assessed (NASA Task Load Index). Results: The 54 participants included 32 urologists, eight young trainees and 14 medical students. A total of 13 participants were categorized as experts (≥50 laparoscopic surgeries), eight as intermediates (10–49) and 33 as novices (0–9). There were significant differences in the Global Operative Assessment of Laparoscopic Skills and Assessment Sheet of Laparoscopic Skills in Wet Lab scores among the three groups in all three tasks. Higher NASA Task Load Index scores were observed in novices, and there were significant differences in tasks 1 (Kruskal–Wallis test, P = 0.0004) and 2 (P = 0.0002), and marginal differences in task 3 (P = 0.0745) among the three groups. Conclusions: Our training model has good construct validity, and differences in the NASA Task Load Index score reflect previous laparoscopic surgical experiences. Our findings show the ability to assess both laparoscopic surgical skills and mental workloads, which could help educators comprehend trainees' level outside the operating room. Given the decreasing opportunity to carry out pure laparoscopic surgeries because of the dissemination of robotic surgery, especially in urology, our model can offer practical training opportunities. [ABSTRACT FROM AUTHOR]

Background: The advent of Virtual Reality technologies presents new opportunities for enhancing current surgical practice. Studies suggest that current techniques in endoscopic surgery are prone to disturbance of a surgeon's visual-motor axis, influencing performance, ergonomics and iatrogenic injury rates. The Microsoft® HoloLens is a novel head-mounted display that has not been explored within surgical innovation research. This study aims to evaluate the HoloLens as a potential alternative to conventional monitors in endoscopic surgery.Materials and Methods: This prospective, observational and comparative study recruited 72 participants consisting of novices (n = 28), intermediate-level (n = 24) and experts (n = 20). Participants performed ureteroscopy, within an inflatable operating environment, using a validated training model and the HoloLens mixed-reality device as a monitor. Novices also completed the assigned task using conventional monitors; whilst the experienced groups did not, due to their extensive familiarity. Outcome measures were procedural completion time and performance evaluation (OSATS) score. A final evaluation survey was distributed amongst all participants.Results: The HoloLens facilitated improved outcomes for procedural times (absolute difference, - 73 s; 95% CI - 115 to - 30; P = 0.0011) and OSAT scores (absolute difference, 4.1 points; 95% CI 2.9-5.3; P < 0.0001) compared to conventional monitors. Feedback evaluation demonstrated 97% of participants agreed or strongly agreed that the HoloLens will have a role in surgical education (mean rating, 4.6 of 5; 95% CI 4.5-4.8). Furthermore, 95% of participants agreed or strongly agreed that the HoloLens is feasible to introduce clinically and will have a role within surgery (mean rating, 4.4 of 5; 95% CI 4.2-4.5).Conclusion: This study demonstrates that the device facilitated improved outcomes of performance in novices and was widely accepted as a surgical visual aid by all groups. The HoloLens represents a feasible alternative to the conventional setup, possibly by aligning the surgeon's visual-motor axis. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effect of suboptimal dosing on the outcomes of patients who received neoadjuvant chemotherapy ( NAC) and robot-assisted radical cystectomy ( RARC). Patients and Methods We retrospectively reviewed 336 consecutive patients with urothelial carcinoma of the bladder who were treated with NAC and RARC at three academic institutions. Outcomes were compared among three groups: patients who received optimal NAC; patients who received suboptimal NAC; and those who did not receive NAC. To adjust for potential baseline differences between the three groups, propensity-score-based matching was performed. The suboptimal dose group was defined as those who received <3 cycles of cisplatin-based chemotherapy, received a decreased dosage, or those not treated with cisplatin. Primary outcomes analysed were recurrence-free survival ( RFS) and overall survival ( OS). Secondary outcomes were peri-operative complications and readmissions after RARC. Results After propensity-score matching, 69 patients in the cohort received optimal-dose NAC, 41 received suboptimal NAC and 69 did not receive NAC. Complication rates and readmission rates did not differ significantly among the three groups. On multivariable analysis, suboptimal NAC and no NAC were independent predictors of worse RFS (hazard ratio [ HR] 2.5, 95% confidence interval [ CI] 1.2-5.7, P = 0.01 and HR 2.4, 95% CI 1.28-5.16, P = 0.01) and worse OS ( HR 4.5, 95% CI 1.6-15.0, P < 0.01 and HR 4.9, 95% CI 1.9-15.6, P < 0.01) in patients who received NAC and RARC. Failure to achieve pathological complete response (ypT0N0) was also an independent predictor of worse RFS ( HR 6.6, 95% CI 1.3-20.9; P = 0.02) and OS ( HR 4.9, 95% CI 1.8-15.3; P = 0.02). Conclusion Optimal NAC resulted in a better RFS and OS when compared with suboptimal or no NAC. Suboptimal and no NAC were associated with worse OS and RFS. These findings will facilitate improved patient counseling and treatment selection. [ABSTRACT FROM AUTHOR]

Background Laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) are increasingly popular, but high-level evidence for these techniques remains lacking. Objective To compare the outcomes of patients undergoing open radical cystectomy (ORC), RARC, and LRC. Design, setting, and participants From March 2009 to July 2012, 164 patients requiring radical cystectomy for muscle-invasive bladder cancer or high-risk non–muscle-invasive bladder cancer were invited to participate, with an aim of recruiting 47 patients into each arm. Overall, 93 were suitable for trial inclusion; 60 (65%) agreed and 33 (35%) declined. Intervention ORC, RARC, or LRC with extracorporeal urinary diversion. Outcome measurements and statistical analysis Primary end points were 30- and 90-d complication rates. Secondary end points were perioperative clinical, pathologic, and oncologic outcomes, and quality of life (QoL). The Fisher exact test and analysis of variance were used for statistical analyses. Results and limitations The 30-d complication rates (classified by the Clavien-Dindo system) varied significantly between the three arms (ORC: 70%; RARC: 55%; LRC: 26%; p = 0.024). ORC complication rates were significantly higher than LRC ( p < 0.01). The 90-d complication rates did not differ significantly between the three arms (ORC: 70%; RARC: 55%; LRC 32%; p = 0.068). Mean operative time was significantly longer in RARC compared with ORC or LRC. ORC resulted in a slower return to oral solids than RARC or LRC. There were no significant differences in QoL measures. Major limitations are the small sample size and potential surgeon bias. Conclusions The 30-d complication rates varied by type of surgery and were significantly higher in the ORC arm than the LRC arm. There was no significant difference in 90-d Clavien-graded complication rates between the three arms. Patient summary We compared patients having open, robotic, or laparoscopic bladder removal surgery for bladder cancer and found no difference in Clavien-graded complication rates at 90 d. [ABSTRACT FROM AUTHOR]

Objectives To identify and review the currently available simulators for prostate surgery and to explore the evidence supporting their validity for training purposes. Materials and Methods A review of the literature between 1999 and 2014 was performed. The search terms included a combination of urology, prostate surgery, robotic prostatectomy, laparoscopic prostatectomy, transurethral resection of the prostate ( TURP), simulation, virtual reality, animal model, human cadavers, training, assessment, technical skills, validation and learning curves. Furthermore, relevant abstracts from the American Urological Association, European Association of Urology, British Association of Urological Surgeons and World Congress of Endourology meetings, between 1999 and 2013, were included. Only studies related to prostate surgery simulators were included; studies regarding other urological simulators were excluded. Results A total of 22 studies that carried out a validation study were identified. Five validated models and/or simulators were identified for TURP, one for photoselective vaporisation of the prostate, two for holmium enucleation of the prostate, three for laparoscopic radical prostatectomy ( LRP) and four for robot-assisted surgery. Of the TURP simulators, all five have demonstrated content validity, three face validity and four construct validity. The Green Light laser simulator has demonstrated face, content and construct validities. The Kansai HoLEP Simulator has demonstrated face and content validity whilst the UroSim HoLEP Simulator has demonstrated face, content and construct validity. All three animal models for LRP have been shown to have construct validity whilst the chicken skin model was also content valid. Only two robotic simulators were identified with relevance to robot-assisted laparoscopic prostatectomy, both of which demonstrated construct validity. Conclusions A wide range of different simulators are available for prostate surgery, including synthetic bench models, virtual-reality platforms, animal models, human cadavers, distributed simulation and advanced training programmes and modules. The currently validated simulators can be used by healthcare organisations to provide supplementary training sessions for trainee surgeons. Further research should be conducted to validate simulated environments, to determine which simulators have greater efficacy than others and to assess the cost-effectiveness of the simulators and the transferability of skills learnt. With surgeons investigating new possibilities for easily reproducible and valid methods of training, simulation offers great scope for implementation alongside traditional methods of training. [ABSTRACT FROM AUTHOR]

Abstract: Background: Long-term oncologic and functional outcomes after robot-assisted radical cystectomy (RARC) for bladder cancer (BCa) are lacking. Objective: To report oncologic and functional outcomes in a cohort of patients who have completed a minimum of 5 yr and a maximum of 8 yr of follow-up after RARC and extracorporeal urinary diversion. Design, setting, and participants: In this paper, we report on the experience from one of the first European urology centres to introduce RARC. Only patients between 2004 and 2006 were included to ensure follow-up of ≥5 yr. We report on an analysis of oncologic outcomes in 14 patients (11 males and 3 females) with muscle-invasive/high-grade non–muscle-invasive or bacillus Calmette-Guérin–refractory carcinoma in situ who opted to have RARC. Intervention: RARC with pelvic lymphadenectomy was performed using the three-arm standard da Vinci Surgical System (Intuitive Surgical, CA, USA). Urinary diversion, either ileal conduit (n =12) or orthotopic neobladder (n =2), was constructed extracorporeally. Outcome measurements: Parameters were recorded in a prospectively maintained database including assessment of renal function, overall survival, disease-specific survival, development of metastases, and functional outcomes. Statistical analysis: Results were analysed using descriptive statistical analysis. Survival data were analysed and presented using the Kaplan-Meier survival curve. Results and limitations: Five of the 14 patients have died. Three patients died of metastatic disease, and two died of unrelated causes. Two other patients are alive with metastases, and another has developed primary lung cancer. Six patients are alive and disease-free. These results show overall survival of 64%, disease-specific survival of 75%, and disease-free survival of 50%. None of the patients had deterioration of renal function necessitating renal replacement therapy. Three of four previously potent patients having nerve-sparing RARC recovered erectile function. The study is limited by the relatively small number of highly selected patients undergoing RARC, which was a novel technique 8 yr ago. The standard da Vinci Surgical System made extended lymphadenectomy difficult. Conclusions: Within limitations, in our experience RARC achieved excellent control of local disease, but the outcomes in patients with metastatic disease seem to be equivalent to the outcomes of open radical cystectomy. [Copyright &y& Elsevier]

Robot-assisted radical cystectomy is associated with less blood loss, fewer transfusions, longer operative times, shorter hospital length of stay, and better physical/role functioning compared with open radical cystectomy (ORC). ORC had higher rates of thromboembolic events. Limitations may include a lack of generalization given that trial patients and design may not reflect real-world evidence. Differences in recovery, oncological, and quality of life (QoL) outcomes between open radical cystectomy (ORC) and robot-assisted radical cystectomy (RARC) for patients with bladder cancer are unclear. This review aims to compare these outcomes within randomized trials of ORC and RARC in this context. The primary outcome was the rate of 90-d perioperative events. The secondary outcomes included operative, pathological, survival, and health-related QoL (HRQoL) measures. Systematic literature searches of MEDLINE, Embase, Web of Science, and clinicaltrials.gov were performed up to May 31, 2022. Eight trials, reporting 1024 participants, were included. RARC was associated with a shorter hospital length of stay (LOS; mean difference [MD] 0.21, 95% confidence interval [CI] 0.03–0.39, p = 0.02) than and similar complication rates to ORC. ORC was associated with higher thromboembolic events (odds ratio [OR] 1.84, 95% CI 1.02–3.31, p = 0.04). ORC was associated with more blood loss (MD 322 ml, 95% CI 193–450, p < 0.001) and transfusions (OR 2.35, 95% CI 1.65–3.36, p < 0.001), but shorter operative time (MD 76 min, 95% CI 39–112, p < 0.001) than RARC. No differences in lymph node yield (MD 1.07, 95% CI –1.73 to 3.86, p = 0.5) or positive surgical margin rates (OR 0.95, 95% CI 0.54–1.67, p = 0.9) were present. RARC was associated with better physical functioning or well-being (standardized MD 0.47, 95% CI 0.29–0.65, p < 0.001) and role functioning (MD 8.8, 95% CI 2.4–15.1, p = 0.007), but no improvement in overall HRQoL. No differences in progression-free survival or overall survival were seen. Limitations may include a lack of generalization given trial patients. RARC offers various perioperative benefits over ORC. It may be more suitable in patients wishing to avoid blood transfusion, those wanting a shorter LOS, or those at a high risk of thromboembolic events. This study compares robot-assisted keyhole surgery with open surgery for bladder cancer. The robot-assisted approach offered less blood loss, shorter hospital stays, and fewer blood clots. No other differences were seen. [ABSTRACT FROM AUTHOR]