Partial nephrectomy series using Versius robotic surgical system: technique and outcomes of an initial experience.

Partial nephrectomy (PN) represents a procedure where the use of a robot has further enabled successful completion of this complex surgery. The results of this procedure using Versius Robotic Surgical System (VRSS) still need to be evaluated. Our working group described the technique and reported the initial results of a series of PN using VRSS. We presented our setting, surgical technique and outcomes for PN, using VRSS. Between 2022 and 2023, 15 patients underwent PN performed by two surgeons in two different centers. Fifteen patients underwent PN. The median lesion size identified on preoperative imaging was 4 (IQR 2.3-5) cm. Median PADUA score was 8 (IQR 7-9). Two procedures were converted to radical nephrectomy for enhanced oncological disease control. Of the 13 nephrectomies that were completed as partial, 7 were performed clampless and 6 with warm ischemia clamping. Median clamping time was 10 (IQR 9-11) minutes. No procedure was converted to open. Median blood loss was 200 (IQR 100-250) mL. Median total operative time was 105 (IQR 100-110) minutes. Median console time was 75 (IQR 66-80) minutes. Median set-up time was 13 (IQR 12-14) minutes. No intraoperative complications were reported. The median hospitalization time was 4 (IQR 3.5-4) days. None of the patients were transfused and none of the patients required readmission. In a pathology report, one patient had a positive surgical margin. Our initial experience suggests that performing PN using VRSS is feasible with good short-term outcomes.

The use of Versius CMR for pelvic surgery: a multicentric analysis of surgical setup and early outcomes.

INTRODUCTION: Versius CMR is a novel robotic system characterized by an open surgical console and independent bedside units. The system has potentials of flexibility and versatility, and has been used in urological, gynecological, and general surgical procedure. The aim is to depict a comprehensive analysis of the Versius system for pelvic surgery. METHODS: This is a study involving two Institutions, ASST Santi Paolo and Carlo, Milan, and Apuane Hospital, Massa, Italy. All interventions performed in the pelvic area with the Versius were included. Data about indications, intra-, and post-operative course were prospectively collected and analyzed. RESULTS: A total of 171 interventions were performed with the Versius. Forty-two of them involved pelvic procedures. Twenty-two had an oncological indication (localized prostate cancer), the remaining had a non-oncological or functional purpose. The mostly performed pelvic procedure was radical prostatectomy (22) followed by annexectomy (9). No intra-operative complication nor conversion to other approaches occurred. A Clavien II complication and one Clavien IIIb were reported. Malfunctioning/alarms requiring a power cycle of the system occurred in 2 different cases. An adjustment in trocar placement according to patients' height was required in 2 patients undergoing prostatectomy, in which the trocar was moved caudally. In two cases, a pelvic prolapse was repaired concomitant with other gynecological procedures. CONCLUSIONS: Pelvic surgery with the Versius is feasible without major complications; either dissection and reconstructive steps could be accomplished, provided a proper OR setup and trocar placement are pursued. Versius can be easily adopted by surgeons of different disciplines and backgrounds; a further multi-specialty implementation is presumed and long-term oncological and functional outcomes are awaited.

Versius robotic surgical system: case series of 18 robot-assisted radical prostatectomies.

OBJECTIVE: To present the results of the first series of patients treated with robot-assisted radical prostatectomy (RARP) with the use of the Versius® Surgical System (CMR Surgical Ltd., Cambridge, UK). RARP has demonstrated better perioperative outcomes compared to open RP. However, RARP remains limited by platform availability and cost-effectiveness issues. The increasing competition from new robotic surgical platforms may further drive utilisation of the robotic approach. PATIENTS AND METHODS: Data were collected prospectively for our first 18 consecutive patients with localised prostate cancer who underwent RARP at our centre over a 3-month period. We recorded parameters, including patient demographics and perioperative outcomes. We also report our optimised set-up with regard to trocar placement, bedside unit placement, and overall composition of the operating room for this procedure. Describing the incremental modifications carried out to achieve reductions in set-up and operating times to optimise utilisation of the Versius system. RESULTS: The median (interquartile range [IQR]) set-up time was 8.5 (7-10) min. The median (IQR) console time was 201 (170-242) min. The median (IQR) operative time was 213 (186-266) min. The median (IQR) total surgery time was 226 (201-277) min. Bilateral pelvic lymphadenectomy median (IQR) time was 19 (17-20) min. There were no complications and/or limitations related to the use of the Versius system including need for conversion. There were no relevant intra- or postoperative complications at the 1-month follow-up related to the use of the Versius system. Patients were discharged after a median (IQR) of 4 (3.75-5) days, and the transurethral catheter was removed after a mean (range) of 8 (7-14) days. Continence at 2 months was achieved in 72.2% of the patients. CONCLUSIONS: Performing RARP using the Versius system is feasible, safe, and easily reproducible. Our set-up enables a rapid docking approach and efficient completion of the surgery.

Treatment of a hemorrhage secondary to nephrostomy tube placement for derivation of monstrous hydronephrosis in upper tract urothelial carcinoma.

A 85-year-old female patient underwent nephrostomy tube insertion for a huge hydronephrosis due to a papillary mass involving the right ureteral ostium diagnosed by at computed tomography scan. As soon as the nephrostomy tube was inserted, a pulsatile bleeding was found and a renal angiography was done. A massive bleeding from the main and unique right renal artery was found such as to require prompt endovascular embolization. A transurethral resection of the bladder was performed and the pathology report confirmed high-grade pTa transitional cell carcinoma. An open drainage was then placed to empty the contents of the pyelocalyceal system of the kidney. Once obtained the volumetric reduction of the abdominal mass the patient underwent the right nephroureterectomy.

Optimizing decision-making process of benign uretero-enteric anastomotic stricture treatment after radical cystectomy.

PURPOSE: To identify preoperative predictors of endo-urological treatment (EUT) failure while promoting a new diagnostic and therapeutic pathway for benign uretero-enteric anastomosis stricture (UES) management after radical cystectomy (RC). MATERIALS AND METHODS: We relied on a prospectively maintained database including 96 individuals (122 renal units) who developed a benign UES at our institution between 1990 and 2018. UES was classified into two different types according to morphology: FP1 (i.e., sharp or duckbill) and FP2 (i.e., flat or concave). EUT feasibility, success rate, as well as intra and postoperative complications were recorded. Uni- and multivariable logistic regression analysis (MVA) assessed for predictors of EUT failure. RESULTS: Overall, 78 (63.9%) and 32 (26.3%) cases were defined as FP1 and FP2, respectively. EUT was not feasible in 33 (27.1%) cases. After a median follow-up of 50 (IQR 5-240) months, successful treatment was reached only in 15/122 (12.3%) cases. EUT success rates raised when considering short (< 1 cm) (16.8%), FP1 morphology (16.7%) strictures, or the combination of these characteristics (22.4%). Overall, 5 (5.2%) cases had CD ≥ III complications. FP2 (OR: 1.91, 95%CI 1.21-5.31, p = 0.03) and stricture length ≥ 1 cm (OR: 9.08, 95%CI 2.09-65.71, p = 0.009) were associated with treatment failure at MVA. CONCLUSIONS: Endoscopic treatment for benign UES after RC is feasible but harbors a low success rate. Stricture length and radiological morphology of the stricture are related to endoscopic treatment failure. Surgeons should be aware of the stricture features during the preoperative decision-making process to choose the optimal candidate for endoscopic treatment.

A single-operator experience using EchoLaser SoracteLiteTM for focal laser ablation of prostate cancer: One more arrow in the quiver for the conservative management of the disease.

BACKGROUND: The aim of this study was to evaluate the outcomes of patients suffering prostate cancer (PCa) treated conservatively using 1064 nm laser energy for focal laser ablation (FLA). The patients included in the study were unsuitable for surgery or unwilling to receive external beam radiotherapy because they were afraid of the possible side effects of whole-gland therapies. METHODS: This study included patients with a diagnosis of nonmetastatic PCa who underwent FLA using SoracteLiteTM system. Tissue ablation was performed at a fixed power of 5 W by the diode multichannel laser system EchoLaser X4 that uses laser light transmitted through optical fibres causing the target tissue to undergo irreversible thermal damage. Functional outcomes were evaluated with the International Prostatic Symptoms Score (IPSS) and 5-item version of the International Index of Erectile Function (IIEF-5) before the treatment and one year later. RESULTS: Ten patients suffering non-metastatic PCa were included. Four decided upon a conservative treatment because of reduced performance status and for six patients the procedure was chosen electively. All patients underwent multiparametric magnetic resonance imaging at 3 and 12 months and eight out of ten patients underwent prostate biopsy at 6 months. Persistent disease was detected in 3 patients who underwent a second ablation. In these patients at the biopsy following the second ablation none harbored residual disease. At follow-up, no patient suffered urinary incontinence requiring the use of pads. No significant worsening in sexual potency measured with IIEF-5 (p = 0.356) or prostatic symptoms measured at IPSS (p = 0.462) were recorded comparing pre-treatment condition vs one-year follow-up. Compared with baseline, prostate-specific antigen was significantly reduced at one-year follow-up (3.7 ± 1.1 vs 7.9 ± 4.1 ng/mL; p = 0.008). CONCLUSIONS: Although whole gland therapies remain the gold standard treatment for PCa, our results indicate that the SoracteLiteTM system for focal laser ablation, as a very preliminary step, appears to offer a short-term oncologic control of PCa with negligible side effects.

Intravesical instillation with glycosaminoglycan replacement treatment in patients suffering radiation-induced haemorrhagic cystitis: When and which patients can benefit most from it?

INTRODUCTION & OBJECTIVES: Radiation-induced haemorrhagic cystitis (RHC) is a frightening complication occurring after pelvic radiotherapy (PRT) which may significantly affect patients' quality of life. Bladder instillation with glycosaminoglycan replacement therapy (GRT) including hyaluronic acid +/- chondroitin sulphate has been proposed as an emerging alternative to prevent relapses of haematuria. Strong points in favour of using GRT for RHC are the ease of administration, cost, almost absence of side effects and possibility of administration to outpatients. We investigated the effectiveness of GRT in a cohort, single-centre, of patients with past-medical history of PRT attending the outpatient clinic and/or the accident & emergency department (A&E) for RHC. MATERIALS & METHODS: Patients with diagnosis of RHC, either with toxicity grade of 2 or 3, were deemed candidate for GRT as long as no active bleeding was occurring; in the case of non-self-limiting haematuria and/or anaemia for active bleeding, admission in the urology department was prompted for bleeding control prior to GRT instillation. An induction course of 6 weekly instillations was scheduled; if tolerated, patients were given a maintenance course with at least 6 monthly instillations. The primary end-point consisted in assessing the rate of haematuria remission (either partial or complete) defined as no need to readmission in the A&E and/or in the hospital. Secondary end-points included factors related to GRT failure. Univariate and multivariate analysis were undertaken to identify clinical independent variables associated to the events. RESULTS: Fifty-one patients with at least 1-year follow-up from the first GRT were included in the analysis. 88.2, 9.8 and 2% of patients had undergone PRT because affected by prostate, uterus and colorectal cancer, respectively. Median time-to-RHC was 31 months (IQR 21-90). Access to A&E and hospital admission were needed in 47 (92.1%) and 35 (68.6%) of the patients, respectively. Twenty-two (n = 22/35, 62.9%) patients required transurethral fulguration of the bladder, while the remainders could be managed with bladder wash-out. Median number of GRT instillations was 6 (IQR 3-7). Twenty-three (45.1%) patients needed to be readmitted to hospital a second time, receiving bladder wash-out (n = 7/23, 30.4%), transurethral fulguration of the bladder (n = 10/23, 43.5%) and/or cystectomy (n = 6/23, 26.1%). Ten (19.6%) patients received a second induction course of GRT. At the last follow-up, 36 (70.6%) patients did not required further hospital admission. Type of PRT and number of hospital admissions pre-GRT were the only variables statistically associated to the events at both univariate (P = 0.032 and P = 0.045) and multivariate analysis (P = 0.048 and P = 0.049). CONCLUSIONS: GRT should be prompted as soon as possible after diagnosis of the haematuria and settling of active bleeding. Patients who had undergone adjuvant PRT after radical prostatectomy are those at higher risk of GRT failure.

Prospective comparative study of postoperative systemic inflammatory syndrome in robot-assisted vs. open kidney transplantation.

PURPOSE: Robot-assisted kidney transplant (RAKT) recently proved to provide functional results similar to the preferred open kidney transplant (OKT), but with inferior wound morbidity. In a comparative prospective study, we explored the systemic inflammatory response syndrome (SIRS) after KT and compared OKT with RAKT. METHODS: Forty-nine patients underwent pre-emptive ABO-compatible kidney transplantations (KT) between January 2017 and December 2018 in 2 centers: 25 RAKT, 24 OKT. Postoperative SIRS was biologically assessed by serum markers (NGAL, CRP and IL-6) measured at: T0 (preoperative/baseline), T1(H1), T2(H6), T3(H12), T4(H24), T5(D2), T6(D3) and T7(D5) after KT. RESULTS: Inflammatory markers + eGFR were assessed in OKT vs. RAKT. IL-6 peak value occurred at H6 and reached ×9 from baseline. CRP peak occurred at H24 and reached ×28 from baseline (All P < 0.05). NGAL decreased after surgery with a plateau (divided by 2 from baseline) from H12 to D5. There was no significant difference in IL-6, CRP and NGAL kinetics and peak values between RAKT and OKT (All P > 0.05). Serum creatinine and eGFR on postoperative days 1, 3 and 7 were similar in RAKT and OKT (All P > 0.05). Delayed graft function was not observed. CONCLUSION: In this exploratory study, the biological evaluation of postoperative SIRS after living-donor kidney transplant revealed no significant difference between OKT and RAKT and similar functional outcomes in the short term. These results highlight the safety of RAKT as an alternative to OKT in this setting.

Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma: Oncologic Outcomes and Prognostic Factors in a Contemporary Cohort.

Introduction: Appropriate risk stratification and complete tumor ablation are the key factors to optimize the oncologic outcomes of patients undertaking endoscopic management for upper urinary tract urothelial carcinoma (UTUC). We aimed to identify risk factors associated to tumor recurrence and progression in a contemporary cohort of patients diagnosed and treated with the latest endourologic technologies. Patients and Methods: Forty-seven patients were selected between January-2015 and March-2019 for an endoscopic management of UTUC. Last generation of digital ureteroscopes with image-enhancing technologies were used for the detection of the lesions. The retrograde approach was the most frequent access (n = 45/47). The confocal laser endomicroscopy and multiple biopsy devices were variably used according to site and tumor presentation for their characterization. Holmium and Thulium lasers were variably used, with their combination being the preferred approach in case of larger lesions. Primary endpoints included the identification of factors associated with UTUC recurrence and progression, and bladder tumor recurrence. Results: Median follow-up (FU) was 24 months (interquartile range 17-44). On multivariate analysis, bladder cancer (BC) recurrence was associated to previous contralateral UTUC (hazard ratios: 5.08 confidence interval [95% CI: 1.35-18.94], p < 0.05) and tumor size (hazard ratios: 1.07 [95% CI: 1.00-1.14], p < 0.05). UTUC recurrence was associated to incomplete clearance after primary treatment (hazard ratios: 4.99 [95% CI: 1.15-21.62], p < 0.05), while UTUC progression was significantly related to the number of UTUC recurrences (hazard ratios: 3.10 [95% CI: 1.27-7.53], p < 0.05). No significant survival differences in BC/UTUC recurrence, as well as in UTUC progression, were detected between risk groups. No Clavien-Dindo grade >2 were detected; one patient developed ureteric stricture at 7-month FU. Limitations involve retrospective nature of the study and relatively small number of patients. Conclusions: The appropriate use of latest technology may enhance the oncologic outcomes of the endoscopic management of UTUC without compromising the safety of the approach. Among the prognostic factors identified in our series, UTUC recurrence seems to be associated to disease progression.

Diagnostic ureteroscopy for upper tract urothelial carcinoma: friend or foe?

INTRODUCTION: The European Association of Urology guidelines recommend offering kidney-sparing surgery (KSS) as a primary treatment option to patients with low-risk tumours. Cystoscopy, urinary cytology, and computed tomography urography (CTU) do not always allow correct disease staging and grading, and sometimes there is even a lack of certainty regarding the diagnosis of UTUC. Diagnostic ureteroscopy (d-URS) may therefore be of crucial importance within the diagnostic framework and fundamental in establishing the appropriate therapeutic approach. EVIDENCE ACQUISITION AND SYNTHESIS: A systematic review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Risk of bias was assessed using Risk of Bias in Non-randomized Studies of interventions (ROBINS-I). Overall, from 3791 identified records, 186 full-text articles were assessed for eligibility. Finally, after a quantitative review of the selected literature, with the full agreement of all authors, 62 studies were considered relevant for this review. RESULTS: CTU has a sensitivity and specificity for UTUC of 92% and 95% respectively, but is not able to detect small or flat lesions with adequate accuracy. The sensitivity of voided urinary cytology for UTUC is around 67-76% and ranges from 43% to 78% for selective ureteric urine collection. As no technique offers a diagnosis of certainty, d-URS can allow an increase in diagnostic accuracy. In the present review the pros and cons of d-URS were analysed. This technique may provide additional information in the selection of patients suitable for neoadjuvant chemotherapy or KSS, distinguishing between normal tissue and low- and high-grade UTUC thanks to the emerging technologies. CONCLUSIONS: Information obtainable from d-URS and ureteroscopic-guided biopsy can prove extremely valuable when the diagnosis of UTUC is doubtful or KSS is being considered. Notwithstanding concerns remain regarding the potential risk of bladder recurrence, cancer dissemination, and/or delay in radical treatment.Abbreviations: CLE: confocal laser endomicroscopy; CSS: cancer-specific survival; CTU: CT urography; d-URS: diagnostic ureteroscopy; EAU: European Association of Urology; HR: hazard ratio; IMAGE1S: Storz professional imaging enhancement system; IVR: intravesical recurrence; KSS: kidney-sparing surgery; MFS: Metastasis-free survival; NAC: neoadjuvant chemotherapy; NBI: narrow-band imaging; OCT: optical coherence tomography; RFS: Recurrence-free survival; RNU: radical nephroureterectomy; ROBINS-I: Risk of Bias in Non-randomized Studies of interventions; URS(-GB): Ureteroscopy(-guided biopsy); UTUC: upper tract urothelial carcinoma; UUT: upper urinary tract.

En bloc resection of bladder tumors: indications, techniques, and future directions.

PURPOSE OF REVIEW: En bloc resection of bladder tumor (ERBT) is an innovative new surgical technique, the use of which is becoming increasingly widespread. In this review, we analyze the recent literature and explore new developments, which may impact the future role of en bloc bladder surgery. RECENT FINDINGS: ERBT increases the frequency with which detrusor muscle is present in the specimen (to 95%) and offers a significant improvement in the quality of the resection specimen, thereby helping with T1 substaging. Furthermore, the laser treatment reduces the rate of obturator nerve-related bladder perforation. SUMMARY: ERBT represents a considerable advancement in the surgical management of nonmuscle-invasive bladder cancer. It delivers excellent oncological results and is a well tolerated procedure. VIDEO: In the accompanying video, we shortly report the different modalities and energy sources used for bladder cancer resection. The three strategies are currently employed at the Fundació Puigvert (Barcelona). VIDEO ABSTRACT:.