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Robotic surgery has recently been used for treatment of renal cell carcinoma (RCC) and neoplastic thrombus located in the renal vein or inferior vena cava (IVC). Accurate identification of the thrombus location is crucial, and three-dimensional augmented reality (3D AR) may be valuable in achieving this. We enrolled patients with nonmetastatic RCC and level 0–I venous thrombus (Mayo Clinic classification) for robot-assisted radical nephrectomy and thrombectomy with 3D AR guidance. Five patients were prospectively enrolled; three had a level 0 thrombus and two had a level I thrombus. The mean operative time was 123 ± 15 min, mean IVC clamping time was 9.4 ± 6.8 min, and mean estimated blood loss was 750 ± 150 ml. The AR system allowed precise estimation of the thrombus location in all cases. No intraoperative complications or postoperative Clavien-Dindo grade >2 complications occurred. Use of 3D AR guidance allowed correct estimation of the limits of the thrombus and guided the surgeon in selecting an appropriate surgical strategy.

A new concept for minimally invasive treatment involves abdominal laparoscopic surgery performed while the patient breathes independently without losing consciousness. Here we report the first series of laparoscopic partial nephrectomy (LPN) performed under neuroaxial anesthesia (NA). From May 2021 to September 2022 we prospectively enrolled selected patients with an organ-confined single renal mass to undergo LPN under NA. Anesthesia was administered using an epidural catheter placed at the level of T7, with additional anesthesia at the level of T10. The rationale was to avoid use of a tracheal tube and the side effects of general anesthesia. Ten patients were enrolled in the study. Targeted sedation was achieved in all cases. In one case, a switch to general anesthesia was needed because of patient anxiety. Food intake started at 12 h after surgery in 9/10 cases; mobilization started from 3 h after surgery. The length of hospital stay was 3 d in 4/10 cases and 4 d in 3/10 cases. This first experience worldwide of LPN performed under NA demonstrates the feasibility and safety of the procedure.

Objective: To evaluate the accuracy of our new three-dimensional (3D) automatic augmented reality (AAR) system guided by artificial intelligence in the identification of tumour's location at the level of the preserved neurovascular bundle (NVB) at the end of the extirpative phase of nerve-sparing robot-assisted radical prostatectomy. Methods: In this prospective study, we enrolled patients with prostate cancer (clinical stages cT1c–3, cN0, and cM0) with a positive index lesion at target biopsy, suspicious for capsular contact or extracapsular extension at preoperative multiparametric magnetic resonance imaging. Patients underwent robot-assisted radical prostatectomy at San Luigi Gonzaga Hospital (Orbassano, Turin, Italy), from December 2020 to December 2021. At the end of extirpative phase, thanks to our new AAR artificial intelligence driven system, the virtual prostate 3D model allowed to identify the tumour's location at the level of the preserved NVB and to perform a selective excisional biopsy, sparing the remaining portion of the bundle. Perioperative and postoperative data were evaluated, especially focusing on the positive surgical margin (PSM) rates, potency, continence recovery, and biochemical recurrence. Results: Thirty-four patients were enrolled. In 15 (44.1%) cases, the target lesion was in contact with the prostatic capsule at multiparametric magnetic resonance imaging (Wheeler grade L2) while in 19 (55.9%) cases extracapsular extension was detected (Wheeler grade L3). 3D AAR guided biopsies were negative in all pathological tumour stage 2 (pT2) patients while they revealed the presence of cancer in 14 cases in the pT3 cohort (14/16; 87.5%). PSM rates were 0% and 7.1% in the pathological stages pT2 and pT3 (

Objectives The research's purpose is to develop a software that automatically integrates and overlay 3D virtual models of kidneys harboring renal masses into the Da Vinci robotic console, assisting surgeon during the intervention. Introduction Precision medicine, especially in the field of minimally-invasive partial nephrectomy, aims to use 3D virtual models as a guidance for augmented reality robotic procedures. However, the co-registration process of the virtual images over the real operative field is performed manually. Methods In this prospective study, two strategies for the automatic overlapping of the model over the real kidney were explored: the computer vision technology, leveraging the super-enhancement of the kidney allowed by the intraoperative injection of Indocyanine green for superimposition and the convolutional neural network technology, based on the processing of live images from the endoscope, after a training of the software on frames from prerecorded videos of the same surgery. The work-team, comprising a bioengineer, a software-developer and a surgeon, collaborated to create hyper-accuracy 3D models for automatic 3D-AR-guided RAPN. For each patient, demographic and clinical data were collected. Results Two groups (group A for the first technology with 12 patients and group B for the second technology with 8 patients) were defined. They showed comparable preoperative and post-operative characteristics. Concerning the first technology the average co-registration time was 7 (3–11) seconds while in the case of the second technology 11 (6–13) seconds. No major intraoperative or postoperative complications were recorded. There were no differences in terms of functional outcomes between the groups at every time-point considered. Conclusion The first technology allowed a successful anchoring of the 3D model to the kidney, despite minimal manual refinements. The second technology improved kidney automatic detection without relying on indocyanine injection, resulting in better organ boundaries identification during tests. Further studies are needed to confirm this preliminary evidence.

Selective clamping during robot-assisted partial nephrectomy (RAPN) may reduce ischemia-related functional impairment. The intraoperative use of 3D-virtual models (3DVMs) can improve surgical planning, resulting in a greater success rate for selective clamping. Our goal is to introduce a new generation of 3DVMs, which consider the perfusion volumes of the kidney. Patients listed for RAPN from 2021 to 2022 were recruited. A selective clamping strategy was designed and intraoperatively performed based on the specifically generated 3DVMs. The effectiveness of selective clamping was evaluated using near-infrared-fluorescence imaging (NIRF) and 3DVM. Perfusion areas extensions were compared, and relevant preoperative characteristics were analyzed. In 61 of 80 (76.25%) cases, selective clamping was performed. The concordance between the 3DVM areas and the NIRF-enhanced areas was verified (k = 0.91). According to the distribution of perfused areas crossing the tumor, there were one, two, three, four, and five crossing areas, with relative perfusion rates of 13.75%, 35%, 32.5%, 13.75%, and 5%, respectively. Lesion diameter and mesorenal location were the only factors related to a higher number (>3) of perfusion volumes crossing the lesion. The implementation of mathematical algorithms to 3DVMs allows for precise estimation of the perfusion zone of each arterial branch feeding the organ, leading to the performance of safe and effective pedicle management planning.

We performed a systematic literature review of the psychological impact on donors of living kidney donation. We conducted a literature review in PubMed/Medline according to PRISMA guidelines which included both qualitative (based on interviews) and quantitative studies (based on standardized questionnaire). There were 15 quantitative studies and 8 qualitative studies with 2,732 donors. Given that the methodologies of qualitative and quantitative studies are fundamentally different, we narratively synthetized results of studies according to four axes: quality of life, anxiety/depression, consequences of donation on the donor/recipient relationship, overall satisfaction and regret. The quantitative studies reported that donor quality of life remained unchanged or improved. Donor regret rates were very low and donor-recipient relationships also remained unchanged or improved. Qualitative studies reported more complex donation experiences: one can regret donation and still decide to recommend it as in a social desirability bias. In both study types, donor-recipient relationships were closer but qualitative studies reported that post-donation rebonding was required. The qualitative studies therefore highlighted the psychological complexity of donation for donors, showing that living donation impacts the donor’s life whether it is successful or not. A better understanding of the impact of donation on donors could provide better care for donors.

Objective: Indocyanine green (ICG) and Three-dimensional virtual models (3DVMs) have been developed and introduced in surgical daily practice in the last years to improve preoperative planning and efficacy of selective clamping during nephron sparing surgery. Aim of the study is to evaluate ICG and 3DVMs usefulness in guiding the surgeon's strategy during robot-assisted partial nephrectomy (RAPN). Materials and methods: We retrospectively reviewed our institutional database and analysed all patients harboring organ-confined renal masses underwent RAPN from 2018 to 2023. Specifically, we included all the patients with a 3DVMs available for preoperative planning and intraoperative surgical navigation. In those cases in which a selective clamping was planned and intraoperatively preformed, ICG solution was injected allowing visualization of the kidney's perfusion regions during the surgery. All demographic, intraoperative, postoperative and functional data were extracted and evaluated, comparing the 3DVM-ICG selective clamping with the global clamping Group. Results: Overall, 212 patients were included. 111 (51%) patients underwent 3DVM-ICG selective clamping RAPNs. No differences were recorded in terms of preoperative or perioperative variables between the global and the selective clamping group, except for a lower operative time for the global clamping group (93.5 min vs. 100 min, p = 0.02). Focusing on the functional outcomes, the selective clamping group showed better postoperative outcomes in terms of ΔeGFR at every timepoint considered (postoperative: -10.4% vs. -16.7%, p = 0.003; 3rd month: -9% vs. -14%, p = 0.01; 6th month: -8.9% vs. -13.8%, p = 0.04). Conclusions: ICG and 3DVMs can be considered the most useful and advanced tools to plan an effective selective clamping strategy during RAPN. They can be used in different ways, matching the surgeon's needs from the planning phase to the time of the surgery, leading towards maximum safety and efficacy outcomes.

Partial nephrectomy (PN) is the primary surgical method for renal tumor treatment, typically involving clamping the renal artery during tumor removal, leading to warm ischemia and potential renal function impairment. Off-clamp approaches have been explored to mitigate organ damage, yet few results have emerged about the possible effects on hemoglobin loss. Most evidence comes from retrospective studies using propensity score matching, known to be sensitive to PS model misspecification. The energy balancing weights (EBW) method offers an alternative method to address bias by focusing on balancing all the characteristics of covariate distribution. We aimed to compare on- vs. off-clamp techniques in PN using EB-weighted retrospective patient data. Out of 333 consecutive PNs (275/58 on/off-clamp ratio), the EBW method achieved balanced variables, notably tumor anatomy and staging. No significant differences were observed in the operative endpoints between on- and off-clamp techniques, although off-clamp PNs showed slight reductions in hemoglobin loss and renal function decline, albeit with slightly higher perioperative blood loss. Our findings support previous evidence, indicating comparable surgical outcomes between standard and off-clamp procedures, with the EBW method proving effective in balancing baseline variables in observational studies comparing interventions.

Objective: The aim of the study was to evaluate three-dimensional virtual models (3DVMs) usefulness in the intraoperative assistance of minimally-invasive partial nephrectomy in highly complex renal tumors. Methods: At our institution cT1-2N0M0 all renal masses with Preoperative Aspects and Dimensions Used for an Anatomical classification score ≥10 treated with minimally-invasive partial nephrectomy were considered for the present study. For inclusion a baseline contrast-enhanced computed tomography in order to obtain 3DVMs, the baseline and postoperative serum creatinine as well as estimated glomerular filtration rate values were needed. These patients, in which 3DVMs were used to assist the surgeon in the planning and intraoperative guidance, were then compared with a control group of patients who underwent minimally-invasive partial nephrectomy with the same renal function assessments, but without 3DVMs. Multivariable logistic regression models were used to predict the margin, ischemia, and complication score achievement. Results: Overall, 79 patients met the inclusion criteria and were compared with 143 complex renal masses without 3DVM assistance. The 3DVM group showed better postoperative outcomes in terms of baseline-weighted differential estimated glomerular filtration rate (−17.7% vs. −22.2%, p=0.03), postoperative complications (16.5% vs. 23.1%, p=0.03), and major complications (Clavien Dindo >III, 2.5% vs. 5.6%, p=0.03). At multivariable logistic regression 3DVM assistance independently predicted higher rates of successful partial nephrectomy (odds ratio: 1.42, p=0.03). Conclusion: 3DVMs represent a useful tool to plan a tailored surgical approach in case of surgically complex masses. They can be used in different ways, matching the surgeon's needs from the planning phase to the demolitive and reconstructive phase, leading towards maximum safety and efficacy outcomes.

Kidney transplantation is the best replacement treatment for the end-stage renal disease. Currently, the imbalance between the number of patients on a transplant list and the number of organs available constitutes the crucial limitation of this approach. To expand the pool of organs amenable for transplantation, kidneys coming from older patients have been employed; however, the combination of these organs in conjunction with the chronic use of immunosuppressive therapy increases the risk of incidence of graft small renal tumors. This narrative review aims to provide the state of the art on the clinical impact and management of incidentally diagnosed small renal tumors in either donors or recipients. According to the most updated evidence, the use of grafts with a small renal mass, after bench table tumor excision, may be considered a safe option for high-risk patients in hemodialysis. On the other hand, an early small renal mass finding on periodic ultrasound-evaluation in the graft should allow to perform a conservative treatment in order to preserve renal function. Finally, in case of a renal tumor in native kidney, a radical nephrectomy is usually recommended.

Objective: In the last years selective clamping strategies have been tested during partial nephrectomy (PN) to decrease the functional impairment linked to the ischemic damage. Recently, 3D virtual models (3DVM) have been reported to increase the accuracy of surgical strategy, leading to a higher rate of successful selective clamping. However, sometimes this empirical definition of vascular regions, based on arterial branches’ direction, fails intraoperatively and forcing towards a global clamping.Our aim is to present our new generation of 3DVM, built taking in consideration the different perfusion areas of the kidney instead of vascular regions empirically estimated, and to evaluate their accuracy intraoperatively and to assess if there are factors influencing the tumor location relative to these perfusion areas. Patients and surgical procedure: By using a mathematical tool, the Voronoi diagram, we calculate vascular perfusion regions of the organs and built the 3DVMs for all consecutive patients scheduled in our center for robot-assisted PN (RAPN) from 2019 to 2021. Based on the info given by the 3DVMs, a selective clamping strategy was planned end performed intraoperatively if feasible. To assess selective clamping success, near-infrared-fluorescence imaging (NIRF) was used. The concordance between virtual and real perfusion regions was automatically assessed by superimposition of 3DVMs over the real endoscopic view. The comparison between their extension was then assessed via k-Cohen test.At last, each lesion location was evaluated in relation to the number of its crossing perfused areas and a multivariate regression model (MLR) was fitted to assess potentially related preoperative factors. Results: 48 patients were enrolled. The renal pedicle management strategy was conducted as preoperatively planned in 100% of them. 68.7% of cases underwent selective clamping. The concordance between the NIRF enhanced areas and their corresponding 3DVM areas was confirmed (k = 0.94). Distribution of perfused areas crossing the tumor was as follows: 16.6%, 29.1%, 43.7%, 8.3%, 2.4% for 1, 2, 3, 4 and 5 crossing areas respectively. At MLR the clear cell histotype was the only factor related to a lower number (3) of perfusion areas. Conclusions: The implementation of mathematical algorithms to 3DVMs allows a precise estimation of the perfusion area of each arterial branch feeding the organ, leading to perform an effective pedicle management. Moreover, with this new technology it is possible to open new perspectives on the knowledge of renal tumors features, considering their growth in relation to their surrounding environment.

Objective: Nowadays we are facing a raising in adverse events related to robotic procedures due to lacking well-trained robotic surgeons. To cope with this issue, along with a standardized surgical training program, the advent of new technologies can come handy in helping beginner surgeons to avoid unwanted surgical events. In this study, a model based on Artificial Intelligence (AI) was developed to predict the occurrence of intraoperative bleeding and to warn the surgeon on bleeding risk. Patients and surgical procedure: A dedicated artificial Neural Network (NN) was created and trained to recognize active bleeding during robot-assisted radical prostatectomy (RARP). The created software scans the video recorded by the endoscope every 3 seconds, and returns the confidence rating, in percentage, that the bleeding event is recognized in that interval of time. Confident rates lower than 100% were used as a score to predict the possibility of the bleeding occurrence in the next frames, alerting the medical staff beforehand. All the videos recorded were reviewed by a human operator in order to evaluate the capability of the software to correctly identify the bleeding and the performances were analyzed in terms of true/false negative/positive. Results: 10 patients undergoing RARP were enrolled from October 2021 to April 2022. Our software demonstrated: (1) Correct identification of active bleeding (true positive 98%); (2) no false alert in case of absence of bleeding (false positive 3%); (3) Ability to anticipate, by gradually increasing the %, the possible occurrence of the event; (4) Beyond the 93-95% threshold, the event occurs in the next second. Conclusion: Our software, based on NN, reveales to be able to predict the intraoperative bleeding. The prediction of adverse events during robotic surgery with Artificial Intelligence will help the beginner surgeons during interventions, potentially improving patient's safety.

Background: Some renal tumors have an imperative indication for nephron-sparing surgery (NSS), such as in cases of chronic kidney disease and bilateral complex tumors. Objective: To demonstrate the degree to which three-dimensional virtual model (3DVM) assistance can be helpful in planning the surgical strategy for high-complexity renal masses with an imperative indication for NSS. Design, setting, and participants: Three patients with high-complexity renal masses with unusual anatomy and an imperative indication for NSS were prospectively selected across 2020 and 2021 at our institution. All patients underwent contrast-enhanced computed tomography from which a 3DVM was obtained. Surgical procedure: Robot-assisted partial nephrectomy with 3DVM augmented reality guidance. Measurements: Demographics and tumor-related features were recorded. Data for intraoperative, pathological, and functional assessments were collected for all three patients. Results and limitations: Two of the three patients harbored bilateral renal tumors. The third patient presented with a renal mass in the left kidney and contralateral renal hypoplasia (right-split renal function of 25%). All of the patients demonstrated similar anatomical and tumor features on 3DVMs, with potentially independent vascularization and drainage for the lower pole. In one patient the upper pole of the kidney was spared, exiting in a functionally excluded hydrocalyx, while in the other two cases the upper pole was removed together with the lesion. The spared portion of the kidney retained vascularization, as demonstrated by intraoperative ultrasound and indocyanine green injection. The small sample size and short follow-up are the main limitations of the study. Conclusions: 3DVMs, especially for complex renal masses with an imperative indication for NSS, allow planning of the surgical strategy on the basis of the anatomical characteristics of the organ in which the tumor is growing. Patient summary: Three-dimensional models help in defining the best surgical strategy for kidney tumors, especially for complex tumors that require surgery to spare as much of the kidney as possible.

More than ever, precision surgery is making its way into modern surgery for functional organ preservation. This is possible mainly due to the increasing number of technologies available, including 3D models, virtual reality, augmented reality, and artificial intelligence. Intraoperative surgical navigation represents an interesting application of these technologies, allowing to understand in detail the surgical anatomy, planning a patient-tailored approach. Automatic superimposition comes into this context to optimally perform surgery as accurately as possible. Through a dedicated software (the first version) called iKidney, it is possible to superimpose the images using 3D models and live endoscopic images during partial nephrectomy, targeting the renal mass only. The patient is 31 years old with a 28 mm totally endophytic right-sided renal mass, with a PADUA score of 9. Thanks to the automatic superimposition and selective clamping, an enucleoresection of the renal mass alone was performed with no major postoperative complication (i.e., Clavien–Dindo < 2). iKidney-guided partial nephrectomy is safe, feasible, and yields excellent results in terms of organ preservation and functional outcomes. Further validation studies are needed to improve the prototype software, particularly to improve the rotational axes and avoid human help. Furthermore, it is important to reduce the costs associated with these technologies to increase its use in smaller hospitals.

Context: Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr. Objective: To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezūm, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection. Evidence acquisition: A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses. Evidence synthesis: The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; −9.81 points, 95% confidence interval [CI] −11.37 to −8.25 at 1 mo; −13.13 points, 95% CI −14.98 to −11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8–4.5 to +4.14 ml/s, 95% CI 0.72–7.56 at 12 mo), and postvoid residual volume (−10.10 ml, 95% CI −27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34–2.42 at the start of follow-up; and 1.04, 95% CI 0.28–1.8 after 1 yr), or the IPSS-Quality of Life questionnaire. Conclusions: Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezūm, UroLift, and PAE had a minimal impact on patients’ sexual function with respect to baseline, especially regarding preservation of ejaculation. Patient summary: We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function. Take Home Message: Novel ultra-minimally invasive treatments can yield fast and effective relief of lower urinary tract symptoms without affecting a patient’s quality of life.

Recently, 3D models (3DM) gained popularity in urology, especially in nephron-sparing interventions (NSI). Up to now, the application of artificial intelligence (AI) techniques alone does not allow us to obtain a 3DM adequate to plan a robot-assisted partial nephrectomy (RAPN). Integration of AI with computer vision algorithms seems promising as it allows to speed up the process. Herein, we present a 3DM realized with the integration of AI and a computer vision approach (CVA), displaying the utility of AI-based Hyper Accuracy Three-dimensional (HA3D®) models in preoperative planning and intraoperative decision-making process of challenging robotic NSI. A 54-year-old Caucasian female with no past medical history was referred to the urologist for incidental detection of the right renal mass. Preoperative contrast-enhanced abdominal CT confirmed a 35 × 25 mm lesion on the anterior surface of the upper pole (PADUA 7), with no signs of distant metastasis. CT images in DICOM format were processed to obtain a HA3D® model. RAPN was performed using Da Vinci Xi surgical system in a three-arm configuration. The enucleation strategy was achieved after selective clamping of the tumor-feeding artery. Overall operative time was 85 min (14 min of warm ischemia time). No intra-, peri- and post-operative complications were recorded. Histopathological examination revealed a ccRCC (stage pT1aNxMx). AI is breaking new ground in medical image analysis panorama, with enormous potential in organ/tissue classification and segmentation, thus obtaining 3DM automatically and repetitively. Realized with the integration of AI and CVA, the results of our 3DM were accurate as demonstrated during NSI, proving the potentialities of this approach for HA3D® models’ reconstruction.

Objective: Nowadays the development of new technologies in urological field allows to perform surgical approaches tailored on the characteristics of each single case. Three-dimensional virtual models (3DVMs) have been developed in the last years to overcome the “building in mind” process that the surgeon should do to perceive the features of the organs in a real human body from CT scan images. Aim of the study is to report our experience regarding the use of 3DVMs in the planning and intraoperative navigation during minimally-invasive nephron sparing surgery (mi-NSS) in highly complex renal tumors. Patients and surgical procedure: We prospectively recorded preoperative, perioperative and functional data of high complex renal tumor who underwent miNSS from August 2017 to August 2021. All patients performed contrast-enhanced CT from which a 3DVM was obtained. Using such technological tools, it was possible to identify three different application field from the planning to the end of the surgery to optimize the success of the procedure. Results: Overall, 79 patients harboring PADUA> 10 unilateral renal masses were prospectively selected from our Institutional database. At CT scan the median clinical size was 50 mm, IQR: [43.5–60]. Concerning intraoperative characteristics, 34.1 and 24.1% of patients underwent selective or clampless NSS. The rate of positive surgical margin (PSM) was 2.5%. and the rate of postoperative complications was 16.5%. The difference between preoperative and postoperative eGFR was not meaningful (21% IQR: [1.8–32.7]). The MIC score was achieved in 87.3% of patients. The major complications rate (Clavien-Dindo> 2) was 2.5%. Conclusions: 3D models represent a useful tool to plan a tailored surgical approach in cases of surgically complex masses. They can be used in different ways, matching the surgeon's needs from the planning phase to the demolitive and reconstructive phase.

Objective: In 3% of cases renal cell carcinoma (RCC) is diagnosed with synchronous bilateral renal masses. However, until today, the optimal treatment strategies for these patients remain unknown.In clinical practice bilateral partial nephrectomies (PNs) are the treatment of choice because of the functional advantage relative to radical nephrectomy. Aim of the study is to show how the availability of such three-dimensional virtual model (3DVM) can be helpful in planning the surgical strategy in a challenging clinical case of bilateral highly complex renal masses.Patients and surgical procedure: one patient with high complexity bilateral renal masses (PADUA 13) was selected from our Institutional database. The patient underwent contrast-enhanced CT from which a 3DVM was obtained. Using such technological tool, it was possible to set the surgical strategy considering the anatomical details of the organ, leading the surgeon to plan synchronous right robot-assisted radical nephrectomy (RARN) and the sacrifice of the upper portion of the left kidney in light of its irrelevant contribution to the postoperative global renal function even if spared. Results: Operative time were 80 min and 148 min, for robot assisted partial nephrectomy and RARN, respectively. Total estimated blood loss was 350 ml with an ischemia time of 23.4 min. No intraoperative or postoperative complications have been recorded. At final pathological examination both kidneys presented a pT3a clear cell RCC. No positive surgical margins were recorded. DJ stent was removed 45 days after surgery. The patient was treated with dialysis for 6 months after surgery. One year later, serum creatinine level was 2.2 mg/dl, with an eGFR of 33%. No further dialytic sessions were needed. Conclusions: The use of 3DVMs, even if in case of extreme surgeries such as a synchronous radical and partial nephrectomy, allows to plan the most effective surgical strategy, well balancing the risk of complications with the postoperative recovery of the renal remnant.

Objective: In the last years three dimensional virtual models (3DVMs) had a widespread diffusion in the renal surgery field thanks to their more precise representation of anatomical details. Among the different ways to use the 3DVMs, Augmented reality seems one of the most promising thanks to the possibility of its application during both preoperative planning and intraoperative surgical navigation. In this study we show how to create hyper-accuracy 3DVMs and our specifically developed platform to perform Augmented reality Robot-assisted partial nephrectomy Patients and surgical procedure: From our prospectively maintained database we extracted all patients with localized renal mass underwent Augmented reality (AR) RAPN. Preoperatively all patients underwent a multiphase contrast enhanced CT-scan. From that DICOM images hyper-accuracy 3DVMs were built. Then to perform AR, the 3DVMs are overlayed on the endoscopic video of the Da-Vinci remote surgical console, thanks to a dedicated software, named Rviewer. Results: 65 patients were finally included in this analysis. The median tumor size was 50 mm with a PADUA score of 9. Concerning intraoperative variables, a higher rate of selective clamping and enucleation technique were recorded. The positive surgical margin (PSM) rate and the major complications rate (Clavien-Dindo>2) were 2.5 and 2.1%, respectively. The difference between preoperative and postoperative eGFR was not meaningful. The MIC score was gained in 87.3% of patients. Conclusions: In conclusion AR is still constantly evolving but it has already showed to represent a safe and effective application of 3DVMs. Moreover, in this era in which we are pushing through the limits of NSS and surgeons have to manage more large and complex renal mass than before, AR could represent a valid tool to maximize the probability of success and the perioperative outcome of partial nephrectomy.

Backgound and objectives: In recent years, the adoption of 3D models for surgical planning and intraoperative guidance has gained a wide diffusion. The aim of this study was to evaluate the surgeons’ perception and usability of ICON3DTM platform for robotic and laparoscopic urological surgical procedures. Materials and Methods: During the 10th edition of the Techno-Urology Meeting, surgeons and attendees had the opportunity to test the new ICON3DTM platform. The capability of the user to manipulate the model with hands/mouse, the software usability, the quality of the 3D model’s reproduction, and the quality of its use during the surgery were evaluated with the Health Information Technology Usability Evaluation Scale (Health-ITUES) and the User-Experience Questionnaire (UEQ). Results: Fifty-three participants responded to the questionnaires. Based on the answers to the Health-ITUES questionnaire, ICON3DTM resulted to have a positive additional value in presurgical/surgical planning with 43.4% and 39.6% of responders that rated 4 (agree) and 5 (strongly agree), respectively. Regarding the UEQ questionnaire, both mouse and infrared hand-tracking system resulted to be easy to use for 99% of the responders, while the software resulted to be easy to use for 93.4% of the responders. Conclusions: In conclusion, ICON3DTM has been widely appreciated by urologists thanks to its various applications, from preoperative planning to its support for intraoperative decision-making in both robot-assisted and laparoscopic settings.