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Robotic-Assisted Surgery (RAS) is beginning to unlock its potential. However, despite the latest advances in RAS, the steep learning curve of RAS devices remains a problem. A common teaching resource in surgery is the use of videos of previous procedures, which in RAS are almost always stereoscopic. It is important to be able to add virtual annotations onto these videos so that certain elements of the surgical process are tracked and highlighted during the teaching session. Including virtual annotations in stereoscopic videos turns them into Mixed Reality (MR) experiences, in which tissues, tools and procedures are better observed. However, an MR-based annotation of objects requires tracking and some kind of depth estimation. For this reason, this paper proposes a real-time hybrid tracking–matching method for performing virtual annotations on RAS videos. The proposed method is hybrid because it combines tracking and stereo matching, avoiding the need to calculate the real depth of the pixels. The method was tested with six different state-of-the-art trackers and assessed with videos of a sigmoidectomy of a sigma neoplasia, performed with a Da Vinci® X surgical system. Objective assessment metrics are proposed, presented and calculated for the different solutions. The results show that the method can successfully annotate RAS videos in real-time. Of all the trackers tested for the presented method, the CSRT (Channel and Spatial Reliability Tracking) tracker seems to be the most reliable and robust in terms of tracking capabilities. In addition, in the absence of an absolute ground truth, an assessment with a domain expert using a novel continuous-rating method with an Oculus Quest 2 Virtual Reality device was performed, showing that the depth perception of the virtual annotations is good, despite the fact that no absolute depth values are calculated.

Gastric cancer (GC) with peritoneal carcinomatosis (PC) is traditionally considered a terminal stage of the disease. The use of a multimodal treatment, including cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), can benefit these patients. Our goal was to evaluate the morbidity and survival outcomes of these patients. This is a retrospective, multicenter study from a prospective national database of patients diagnosed with PC secondary to GC treated with CRS and HIPEC from June 2006 to October 2017. Eighty-eight patients from seven specialized Spanish institutions were treated with CRS and HIPEC, with median age of 53 years; 51% were women. Median Peritoneal Cancer Index (PCI) was 6, and complete cytoreduction was achieved in 80 patients (90.9%). HIPEC was administered in 85 cases with 4 different regimens (Cisplatin + Doxorubicin, Mitomycin-C + Cisplatin, Mitomycin-C and Oxaliplatin). Twenty-seven cases (31%) had severe morbidity (grade III–IV) and 3 patients died in the postoperative period (3.4%). Median follow-up was 32 months. Median overall survival (OS) was 21.2 months, with 1-year OS of 79.9% and 3-year OS of 30.9%. Median disease-free survival (DFS) was 11.6 months, with 1-year DFS of 46.1% and 3-year DFS of 21.7%. After multivariate analysis, the extent of peritoneal disease (PCI ≥ 7) was identified as the only independent factor that influenced OS (hazard ratio [HR] 2.37, 95% confidence interval [CI] 1.26–4.46, p = 0.007). The multimodal treatment, including CRS and HIPEC, for GC with PC can improve the survival results in selected patients (PCI

The standardization of surgical outcomes throughout surgical procedures is mandatory. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) should provide proficient oncological and surgical outcomes.The aim of this study was to identify clinically relevant quality indicators and their quality standard, and to determine their acceptable quality limit. A systematic review on cytoreductive results from 2000 to 2018 was performed focusing on clinical guidelines, consensus conferences, and publications. After the selection of quality indicators, a systematic review of indexed references was performed in order to calculate the quality standard for each indicator.Unicentric/multicentric series, comparative studies, and clinical trials. Studies were to include outcomes after cytoreduction of colorectal origin and series with more than 50 patients. Quality indicators with at least 10 series were mandatory and objective measurements were also mandatory for inclusion.Quality indicators selected were 1- to 5-year survival, overall disease-free survival, 1- to 5-year disease-free survival, complete surgical resection, duration of surgery, length of stay, overall morbimortality, major morbidity, re-intervention, postoperative hemorrhage, intestinal fistula, anastomotic leakage, wound infection, postoperative medical complications, overall recurrence, and failure to rescue.The most relevant quality indicators and critical quality limits were overall disease-free survival and 5-year overall disease-free survival (14 months and10 months, and 14% and4%, respectively), completeness of surgical resection (89% and80%, respectively), overall mortality (3% and8%, respectively), overall morbidity (47% and63%, respectively), failure to rescue (12% and30%, respectively), reintervention (13 and22%, respectively), anastomotic leakage (6% and13%, respectively), and overall recurrence (60% and74%, respectively).This is the first study to assess quality standards in CRS + HIPEC for colorectal peritoneal metastases. The current data are of particular relevance for future studies to control the variability of this surgery.

El objetivo principal del estudio es la estimación de la incidencia de la enfermedad litiásica renoureteral candidata a un tratamiento activo en la Comunidad Valenciana y su comparación con otros datos epidemiológicos a nivel nacional. Medicina Ciencias de la Salud

El mayor conocimiento de la historia natural de la carcinomatosis peritoneal ha permitido su valoración como una progresión locorregional. Tras los trabajos publicados por Sugarbaker tanto a nivel quirúrgico, con la descripción de las técnicas de peritonectomía como a nivel farmacológico experimental para la aplicación de la quimioterapia intraperitoneal hipertérmica (HIPEC), se considera un tratamiento locorregional de la enfermedad confinada al abdomen. Así, una cirugía radical de citorreducción con extirpación de la enfermedad macroscópica y la aplicación posterior de HIPEC para control de la enfermedad microscópica residual, ha obtenido resultados muy superiores a la quimioterapia aislada. En todo tratamiento quirúrgico, y más en aquellos de mayor complejidad como la cirugía de citorreducción y HIPEC (CRS+HIPEC), se debe garantizar una atención sanitaria óptima que ofrezca una adecuada calidad en la asistencia y disminuya la variabilidad en los tratamientos y en los resultados. Esta gestión de la calidad viene determinada por una serie de indicadores y estándares, medibles, reproducibles y que garantizan los cambios y mejoras en la asistencia si fuera necesario. En los últimos años se han evaluado estándares de calidad en varios procesos asistenciales relacionados con el cáncer, sin embargo, Carecemos de estándares de ca en el ámbito del tratamiento multidisciplinar de la cirugía oncológica peritoneal. Hipótesis Mediante la aplicación de los métodos de análisis y la utilización de las gráficas de control de procesos, es posible determinar los estándares de calidad en los resultados de la cirugía de carcinomatosis peritoneal de origen colorrectal, a partir de datos objetivos y estadísticamente robustos publicados en la literatura. Objetivos 1. Determinar cuáles son los indicadores de calidad y su valor correspondiente, clínicamente relevantes 2. Establecer escalas o intervalos con los límites de variabilidad o límites de calidad aceptables para cada indicador, de fácil medición, que sirvan de herramienta a las unidades de cirugía oncológica peritoneal y permitan auditar los resultados de forma sencilla y objetiva Resultados y conclusiones 1. Se han determinado 20 indicadores de calidad: media de supervivencia global, media de supervivencia global a 1 año y a 5 años, media de supervivencia libre de enfermedad global, a 1 año y a 5 años, supervivencia libre de enfermedad global, a 1 año y a 5 años, tasa de resecciones completas, duración media de la cirugía, estancia media hospitalaria, tasa de mortalidad global, tasa de morbilidad global, tasa de morbilidad mayor, tasa de reintervenciones, tasa de hemorragias postoperatorias, tasa de fístulas intestinales, tasa de dehiscencia de anastomosis, tasa de infecciones de herida, tasa de complicaciones médicas, tasa de recurrencia global y tasa de fallo de rescate.

Introduction: Preoperative treatment and adequate surgery increase local control in rectal cancer. However, modalities and indications for neoadjuvant treatment may be controversial. Aim of this study was to assess the trends of preoperative treatment and outcomes in patients with rectal cancer included in the Rectal Cancer Registry of the Spanish Associations of Surgeons. Method: This is a STROBE-compliant retrospective analysis of a prospective database. All patients operated on with curative intention included in the Rectal Cancer Registry were included. Analyses were performed to compare the use of neoadjuvant/adjuvant treatment in three timeframes: I)2006–2009; II)2010–2013; III)2014–2017. Survival analyses were run for 3-year survival in timeframes I-II. Results: Out of 14, 391 patients, 8871 (61.6%) received neoadjuvant treatment. Long-course chemo/radiotherapy was the most used approach (79.9%), followed by short-course radiotherapy ± chemotherapy (7.6%). The use of neoadjuvant treatment for cancer of the upper third (15-11 cm) increased over time (31.5%vs 34.5%vs 38.6%, p = 0.0018). The complete regression rate slightly increased over time (15.6% vs 16% vs 18.5%; p = 0.0093); the proportion of patients with involved circumferential resection margins (CRM) went down from 8.2% to 7.3%and 5.5% (p = 0.0004). Neoadjuvant treatment significantly decreased positive CRM in lower third tumors (OR 0.71, 0.59–0.87, Cochrane-Mantel-Haenszel P = 0.0008). Most ypN0 patients also received adjuvant therapy. In MR-defined stage III patients, preoperative treatment was associated with significantly longer local-recurrence-free survival (p < 0.0001), and cancer-specific survival (p < 0.0001). The survival benefit was smaller in upper third cancers. Conclusion: There was an increasing trend and a potential overuse of neoadjuvant treatment in cancer of the upper rectum. Most ypN0 patients received postoperative treatment. Involvement of CRM in lower third tumors was reduced after neoadjuvant treatment. Stage III and MRcN + benefited the most.

Introduction Radical Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC), has been proposed as the current standard of treatment for metastatic peritoneal disease by several tumors. Despite its widely utilization, there seems to be a great variability in their organization, clinical practice, and safety among centers. Aim of the study To obtain updated information on clinical practice in different perioperative areas of the CRS-HIPEC. Patients and methods All 25 members of the Spanish Surface Peritoneal Malignancy (GECOP), were invited to answer an online survey, to describe their usual practice in different perioperative areas of the CRS-HIPEC. Results Survey was responded by 100% of centers. This study represents more than 800 patients treated annually. Seventy per cent of respondents perform CRS-HIPEC for more than 5 years. The most frequent technique was Coliseum (88%). Routinely non-invasive monitoring of cardiac output is used by 92% of centers. More than 50% of centers administer oxaliplatin (74%), or mitomycin-C (65%) in colorectal cancer; cisplatin in gastric cancer (73%) and mesothelioma (74%). Ovarian cancer is treated with cisplatin and various combinations, in 64% or paclitaxel in 54.5%. Spillage protocol was available in 100% centers. Conclusions Data showed an important variability in volume of patients per center, selection of cytostatic agents, professional training and safety measures applied. The standardization of CRS/HIPEC procedures based on the best available evidence, the individualization of patients and the consensus among professionals, constitute an important part of the basis that will allow us to improve results of this complex procedure.

Aim Reports detailing the morbidity-mortality after left colectomy are sparse and do not allow definitive conclusions to be drawn. We aimed to identify risk factors for anastomotic leakage, perioperative mortality and complications following left colectomy for colonic malignancies. Method We undertook a STROBE-compliant analysis of left colectomies included in a national prospective online database. Forty-two variables were analysed as potential independent risk factors for anastomotic leakage, postoperative morbidity and mortality. Variables were selected using the 'least absolute shrinkage and selection operator' (LASSO) method. Results We analysed 1111 patients. Eight per cent of patients had a leakage and in 80% of them reoperation or surgical drainage was needed. A quarter of patients (24.9%) experienced at least one minor complication. Perioperative mortality was 2%, leakage being responsible for 47.6% of deaths. Obesity (OR 2.8, 95% CI 1.00-7.05, P = 0.04) and total parenteral nutrition (TPN) (OR 3.7, 95% CI 1.58-8.51, P = 0.002) were associated with increased risk of leakage, whereas female patients had a lower risk (OR 0.36, 95% CI 0.18-0.67, P = 0.002). Corticosteroids (P = 0.03) and oral anticoagulants (P = 0.01) doubled the risk of complications, which was lower with hyperlipidaemia (OR 0.3, P = 0.02). Patients on TPN had more complications (OR 4.02, 95% CI 2.03-8.07, P = 0.04) and higher mortality (OR 8.7, 95% CI 1.8-40.9, P = 0.006). Liver disease and advanced age impaired survival, corticosteroids being the strongest predictor of mortality (OR 21.5, P = 0.001). Conclusion Requirement for TPN was associated with more leaks, complications and mortality. Leakage was presumably responsible for almost half of deaths. Hyperlipidaemia and female gender were associated with lower rates of complications. These findings warrant a better understanding of metabolic status on perioperative outcome after left colectomy.

New strategies for the treatment of cancer in the rectum should be directed towards the improvement of micrometastatic disease and the reduction of long-term sequelae, without prejudice to good local control. To achieve this, in the last decade, new strategies have been postulated. Treatment with preoperative chemotherapy (CT) alone or induction CT followed by chemoradiation CRT/short course radiation (CRT/SCPRT) or CRT/SCPRT and consolidative CT is being planned. We currently have data from phase II studies with results of stimulating efficacy and/or compliance. New single-arm and randomized trial is underway and will allow us to know the impact on survival outcomes and long-term sequelae of these strategies.

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are currently the most accepted treatment for peritoneal metastases from colorectal cancer. Restrictive selection criteria are essential to obtain the best survival benefits for this complex procedure. The most widespread score for patient selection, the peritoneal surface disease severity score (PSDSS), does not include current biological factors that are known to influence on prognosis. We investigated the impact of including RAS mutational status in the selection criteria for these patients. Methods: We studied the risk factors for survival by multivariate analysis using a prospective database of consecutive patients with carcinomatosis from colorectal origin treated by CRS and HIPEC in our unit from 2009 to 2017. The risk factors obtained were validated in a multicentre, international cohort, including a total of 520 patients from 15 different reference units. Results: A total of 77 patients were selected for local análisis. Only RAS mutational status (HR: 2.024; p = 0.045) and PSDSS stage (HR: 2.90; p = 0.009) were shown to be independent factors for overall survival. Early PSDSS stages I and II associated to RAS mutations impaired their overall survival with no significant differences with PSDSS stage III overall survival (p > 0.05). These results were supported by the international multicentre validation. Conclusions: By including RAS mutational status, we propose an updated RAS-PSDSS score that outperforms PSDSS alone providing a quick and feasible preoperative assessment of the expected overall survival for patients with carcinomatosis from colorectal origin undergone to CRS + HIPEC.

Objective: To analyze if there are urodynamic differences in patients with neurogenic detrusor overactivity (NDO) secondary to spinal cord injury (SCI) depending on whether the SCI is complete or incomplete according to the American Spinal Injury Association (ASIA) classification. Methods: A retrospective and comparative study was carried out, including 194 patients with suprasacral SCI and NDO. Maximum cystometric capacity (MCC), volume at first involuntary contraction (VIC), compliance, maximum pressure of the detrusor during filling cystometry (MaxDetP), detrusor leak point pressure (LeakDetP) and postvoid residual urine volume (PVR) were analysed. Means were compared with Student t test for independent samples, with statistical significance p < 0.05. Results: SCI was complete (ASIA A) in 51 patients (26.3%) and incomplete (ASIA B–E) in 143 (73.7%). The comparison of means showed significant differences regarding MCC (278.5 ± 102.6 mL in ASIA A vs. 321.6 ± 127.1 mL in ASIA B–E; p = 0. 018) and VIC (161 ± 85.1 and 210 ± 114.4 mL ­respectively; p = 0.006). There were no differences regarding MaxDetP (58.8 ± 26.9 vs. 49.3 ± 35.6 cm H2O), LeakDetP (44.6 ± 25.3 vs. 48.3 ± 26.7 cm H2O), PVR (155.3 ± 94.2 vs. 118.5 ± 129.8) or compliance (29.9 ± 25.3 vs. 48.3 ± 26.7 cm H2O). Conclusions: In our serie incomplete SCI (ASIA B–E) showed differences from complete ones (ASIA A) regarding MCC and VIC, but not regarding LeakDetP, MaxDetP, PVR or compliance.