Surgeons' dominant surgical modality: Impacts on wellbeing, burnout, and interventions for neuromusculoskeletal disorders.

BACKGROUND: This study investigated the impact of surgical modalities on surgeon wellbeing with a focus on burnout, job satisfaction, and interventions used to address neuromusculoskeletal disorders (NMSDs). METHODS: An electronic survey was sent to surgeons across an academic integrated multihospital system. The survey consisted of 47 questions investigating different aspects of surgeons' wellbeing. RESULTS: Out of 245 thoracic and abdominopelvic surgeons, 79 surgeons (32.2 â€‹%) responded, and 65 surgeons (82 â€‹%) were able to be categorized as having a dominant surgical modality. Compared to robotic surgeons, laparoscopic (p â€‹= â€‹0.042) and open (p â€‹= â€‹0.012) surgeons reported more frequent feelings of burnout. The number of surgeons who used any treatment/intervention to minimize the operative discomfort/pain was lower for robotic surgeons than the other three modalities (all p â€‹< â€‹0.05). CONCLUSIONS: NMSDs affect different aspects of surgeons' lives and occupations. Robotic surgery was associated with decreased feelings of burnout than the other modalities.

Management of the distal ureter and bladder cuff at the time of nephroureterectomy: an overview of open, laparoscopic, and robotic approaches.

Radical nephroureterectomy remains the gold standard treatment for high-risk upper tract urothelial carcinoma. The procedure is subdivided into six main steps: nephrectomy, ureterectomy, bladder cuff excision, cystorrhaphy, template-based lymph node dissection, and perioperative instillation of chemotherapy. Crucial in performing radical nephroureterectomy is successful management of the distal ureter and bladder cuff. Improper, inadequate, or incomplete bladder cuff excision can lead to worse oncologic outcomes and inferior cancer-specific survival. Throughout the years, open, laparoscopic, endoscopic, and robotic approaches have all been reported in performing bladder cuff excision during radical nephroureterectomy. The procedure can be accomplished via an extravesical, intravesical or transvesical manner. Each approach has distinct advantages and disadvantages. The robotic approach offers inherent advantages including improved dexterity, range of motion, and visualization. Critical to choosing an approach, however, is surgeon experience and comfort level. To date, no data suggests superiority of one approach over another. Sound oncologic principles must be adhered to when performing radical nephroureterectomy and include (I) adequate bladder cuff excision, (II) lymphadenectomy, (III) no complications and (IV) negative surgical margins, and (V) perioperative instillation of chemotherapeutic agent. Herein, we describe the various approaches in performing a bladder cuff excision and provide technical commentary supporting the advantages and disadvantages of each technique.

Oncological outcomes of visibly complete transurethral resection prior to neoadjuvant chemotherapy for bladder cancer

ABSTRACT Purpose: To evaluate the potential oncologic benefit of a visibly complete transurethral resection of a bladder tumor (TURBT) prior to neoadjuvant chemotherapy (NAC) and radical cystectomy (RC). Materials and Methods: We identified patients who received NAC and RC between 2011-2021. Records were reviewed to assess TURBT completeness. The primary outcome was pathologic downstaging (<ypT2N0), with complete pathologic response (ypT0N0) and survival as secondary endpoints. Logistic regression and Cox proportional hazards models were utilized. Results: We identified 153 patients, including 116 (76%) with a complete TURBT. Sixty-four (42%) achieved <ypT2N0 and 43 (28%) achieved ypT0N0. When comparing those with and without a complete TURBT, there was no significant difference in the proportion with <ypT2N0 (43% vs 38%, P=0.57) or ypT0N0 (28% vs 27%, P=0.87). After median follow-up of 3.6 years (IQR 1.5-5.1), 86 patients died, 37 died from bladder cancer, and 61 had recurrence. We did not observe a statistically significant association of complete TURBT with cancer-specific or recurrence-free survival (p≥0.20), although the hazard of death from any cause was significantly higher among those with incomplete TURBT even after adjusting for ECOG and pathologic T stage, HR 1.77 (95% CI 1.04-3.00, P=.034). Conclusions: A visibly complete TURBT was not associated with pathologic downstaging, cancer-specific or recurrence-free survival following NAC and RC. These data do not support the need for repeat TURBT to achieve a visibly complete resection if NAC and RC are planned.

Oncological outcomes of visibly complete transurethral resection prior to neoadjuvant chemotherapy for bladder cancer.

PURPOSE: To evaluate the potential oncologic benefit of a visibly complete transurethral resection of a bladder tumor (TURBT) prior to neoadjuvant chemotherapy (NAC) and radical cystectomy (RC). MATERIALS AND METHODS: We identified patients who received NAC and RC between 2011-2021. Records were reviewed to assess TURBT completeness. The primary outcome was pathologic downstaging (

Conversion to Disposable Cystoscopes Decreased Post-procedure Encounters and Infections Compared to Reusable Cystoscopes.

INTRODUCTION: We evaluated for differences in post-procedure 30-day encounters or infections following office cystoscopy using disposable vs reusable cystoscopes. METHODS: Cystoscopies performed from June to September 2020 and from February to May 2021 in our outpatient practice were retrospectively reviewed. The 2020 cystoscopies were performed with reusable cystoscopes, and the 2021 cystoscopies were performed with disposable cystoscopes. The primary outcome was the number of post-procedural 30-day encounters defined as phone calls, patient portal messages, emergency department visits, hospitalizations, or clinic appointments related to post-procedural complications such as dysuria, hematuria, or fever. Culture-proven urinary tract infection within 30 days of cystoscopy was evaluated as a secondary outcome. RESULTS: We identified 1,000 cystoscopies, including 494 with disposable cystoscopes and 506 with reusable cystoscopes. Demographics were similar between groups. The most common indication for cystoscopy in both groups was suspicion of bladder cancer (disposable: 153 [30.2%] and reusable: 143 [28.9%]). Reusable cystoscopes were associated with a higher number of 30-day encounters (35 [7.1%] vs 11 [2.2%], P < .001), urine cultures (73 [14.8%] vs 3 [0.6%], P = .005), and hospitalizations attributable to cystoscopy (1 [0.2%] vs 0 [0%], P < .001) than the disposable scope group. Positive urine cultures were also significantly more likely after cystoscopy with a reusable cystoscope (17 [3.4%] vs 1 [0.2%], P < .001). CONCLUSIONS: Disposable cystoscopes were associated with a lower number of post-procedure encounters and positive urine cultures compared to reusable cystoscopes.

Robot-Assisted Simple Prostatectomy: A Comparison of Primary Simple Prostatectomy vs Salvage Simple Prostatectomy in Treatment of Lower Urinary Tract Symptoms.

Purpose: Simple prostatectomy is indicated in patients with enlarged glands (>80 g) who present with lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia. Salvage robotic simple prostatectomy (SSP) is defined as simple prostatectomy after failed transurethral procedure. The aim of this study is to evaluate the efficacy of primary robotic simple prostatectomy (PSP) vs SSP in ameliorating LUTS. Materials and Methods: We retrospectively reviewed 124 patients who underwent RSP between 2013 and 2021. Indications for surgery were enlarged prostate, bothersome LUTS, or symptoms refractory to medical management and/or previous prostate surgery. PSP and SSP preoperative, perioperative, and postoperative variables were recorded. The severity of LUTS was assessed using the International Prostate Symptoms Score (IPSS). Two-tailed t-tests were performed to compare primary vs salvage RSP cohorts at a p-value of 0.05. Results: Of 124 patients who underwent RSP, 98 were primary and 26 were in the salvage setting with 19 patients undergoing prior transurethral resection of the prostate, 3 status post-transurethral microwave therapy, 1 status post-transurethral needle ablation of the prostate, and 3 status post-UroLIFT. Mean length of stay following RSP was 1.87 (days). At mean follow-up of ∼12 months, no patient required reoperation for LUTS. Preoperative IPSS for primary and salvage RSP was 18.56 and 16.25, respectively (p = 0.36), and postoperative IPSS for primary and salvage RSP was 5.33 and 8.00, respectively (p = 0.38). Conclusion: Regardless of primary or salvage indication, RSP remains a highly efficient and durable procedure for improvement in LUTS. RSP performed in the salvage setting greatly improved urinary function outcomes in patients after failure of previous transurethral procedures.

Robot-Assisted Laparoscopic Ureteral Reconstruction for Malignant Pathology: Single-Center Experience with Analysis of Perioperative, Functional, and Oncologic Outcomes.

Introduction: Radical nephroureterectomy with bladder cuff excision (BCE) is the standard of care all high-risk upper tract urothelial carcinomas. With continued advancements, robot-assisted segmental ureteral resection can be employed for ureteral tumors for ipsilateral renal preservation. Herein, we are presenting our experience of different techniques classified by the affected ureteral segment, along with perioperative and intermediate to long-term functional and oncologic outcomes. Methods: From January 2008 to June 2021, a total of 17 patients underwent robot-assisted renal preserving excisional procedures for ureteral tumors. We collected and analyzed baseline, perioperative and follow-up outcomes parameters from our prospectively maintained institutional database. Eleven patients underwent segmental ureterectomy (SU) with BCE and ureteroneocystostomy with psoas hitch, five patients underwent SU with ureteroureteral anastomosis with/without psoas hitch, and one patient underwent ileal patch interposition after segmental ureteral excision. Results: Although majority of the patients had inconclusive or low-grade pathology on initial ureteroscopic biopsies, 73.33% of the patients were found to have high-grade tumors on final pathology report. Median tumor size was 2.7 cm (1-5.5 cm), and the median operative duration was 193 minutes (142-400 minutes). None of the procedures required conversion to open. Overall, only one patient (5.9%) had Clavien-Dindo grade ≥ III complication (pelvic abscess). At median follow-up of 41 months (7-156 months), four patients (26.67%) developed urothelial recurrences out of which only one patient required nephroureterectomy. Overall survival and nephroureterectomy-free survival were 86.67% and 92.31%, respectively. Conclusions: Our study provides a comprehensive review of various surgical approaches of robot-assisted renal sparing management for ureteral tumors. These procedures are surgically safe, feasible, and effective with satisfactory oncologic outcomes at intermediate to long-term follow-up. These procedures may be safely employed in select patients with a localized ureteral tumor to salvage the ipsilateral kidney and estimated glomerular filtration rate.

An analysis of diversity within academic urology leadership.

INTRODUCTION: Women, underrepresented minorities, and international medical graduates are underrepresented in urology. We sought to compare demographics of leaders in academic urology to urology faculty and academic medical faculty. MATERIALS AND METHODS: The Association of American Medical Colleges provided academic medical faculty demographics. Women, underrepresented minorities, and international medical graduates in leadership roles (department/division chair or full professor) were identified. Fisher's exact tests were performed to compare proportions of those groups in urology leadership to academic urology, academic medicine leadership, and academic medicine. RESULTS: In 2019, there were 179,105 faculty in academic medicine with 41,766 in leadership and 1,614 faculty in urology with 567 in leadership. Significantly fewer women were in urology leadership compared to academic urology (7.4% vs. 22.0%, p < 0.0001), academic medical leadership (7.4% vs. 25.0%, p < 0.0001), and academic medicine (7.4% vs. 42.0%, p < 0.0001). Significantly fewer underrepresented minorities were in urology leadership compared to academic medicine (6.9% vs. 9.4%, p = 0.04) with no significant difference when compared to urology faculty (6.9% vs. 8.1%, p = 0.4) or medical faculty leadership (6.9% vs. 6.4%, p = 0.6). Significantly more international medical graduates were in urology leadership compared to across academic urology, (32% vs. 24%, p = 0.0006), but significantly fewer than those in leadership across all medical specialties (32% vs. 40%, p = 0.0001). CONCLUSIONS: Women and underrepresented minorities are significantly underrepresented in academic urologic leadership while international medical graduates are statistically overrepresented. Considering calls for diversity, equity, and inclusion, these data highlight a need for increased representation in leadership positions in academic urology.

Prophylactic Ureteral Localization Stent with Guidewire Assistance Decreases Urologic-Induced Complication Rates: Quality Improvement Initiative and Review of Literature.

Background: We previously reported a 2% Clavien IIIb urologic-induced complication rate associated with blind (no guidewire, no fluoroscopy) prophylactic ureteral localization stent (PULSe) placement. As part of a quality improvement initiative, mandatory guidewire placement before PULSe was performed and urologic-induced Clavien IIIb or greater complication rates were evaluated. A systematic review was performed to elicit the overall urologic-induced complication rate in the literature. Materials and Methods: A retrospective review of all patients who underwent guidewire-assisted PULSe placement before colorectal surgery was performed. The contemporary cohort was compared with those in the prior cohort using age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, preoperative creatinine, postoperative creatinine, pre-/postoperative creatinine difference, and Clavien IIIb urologic-induced complication rates. A review of literature from 1982 to 2019 was performed using 14 unique search terms. Of 38 studies reviewed, 18 met predetermined inclusion criteria. Results: One hundred thirty-two patients underwent bilateral PULSe placement with mandatory guidewire utilization. Mean age and BMI were 55.78 (18-89) and 27.02, respectively, with zero Clavien IIIb complications, compared with a rate of 2% (P < .001) in our prior study. Our contemporary cohort yielded a more favorable postoperative creatinine (P < .022) and pre-/postoperative creatinine difference (P < .003). A review of literature identified a mean Clavien IIIb complication rate of 0.38%. Conclusions: Mandatory guidewire utilization before PULSe placement reduced the Clavien IIIb complication rate to zero, compared with a rate of 2% from our prior cohort. Guidewire utilization can decrease Clavien IIIb urologic-induced complication rates. A review of the literature shows a lack of uniformity concerning the technique of PULSe placement.

Influence of Preoperative and Postoperative Factors on Prolonged Length of Stay and Readmission After Minimally Invasive Radical Prostatectomy.

Background: The mean length of stay (LOS) after minimally invasive radical prostatectomy (MI-RP) is <2 days. Our main objective was to utilize the National Surgical Quality Improvement Program (NSQIP) database to evaluate preoperative factors that may contribute to prolonged hospital stay and readmission. Materials and Methods: Utilizing the NSQIP database, records for surgery with the Current Procedural Terminology code 55866 (prostatectomy) between 2007 and 2017 were evaluated. Chi-square and t-tests were used to assess the effects of preoperative factors on prolonged LOS and rates of hospital readmission within 30 days. Odds ratios (ORs), p-values, and confidence intervals were determined using multivariable logistic regression. Results: A total of 40,764 patients underwent MI-RP between 2007 and 2017. Of these, 11.7% reported an LOS of >2 days, whereas 3.9% of patients were readmitted to the hospital within 30 days. Preoperative congestive heart failure within 30 days of surgery was shown to be strongly associated with both prolonged LOS (OR = 6.16) and readmission (OR = 3.28). Bleeding requiring transfusion was demonstrated to be the most significant postoperative factor for prolonged LOS (OR = 23.9), whereas unplanned intubation was shown to be the most significant postoperative factor for readmission (OR = 57.1). Body mass index (BMI) >30 was associated with both prolonged LOS and increase in readmission. Conclusions: Upon NSQIP database analysis, cardiopulmonary factors and BMI were demonstrated to have negative impacts on postoperative quality indicators. Patients with comorbidities should be counseled preoperatively concerning their individual risk factors. Mitigation of these factors is important in ensuring optimal outcomes.

Histologic Analysis of Urethral Stricture in 9 Patients Following Dorsal Vaginal Graft Urethroplasty.

OBJECTIVE: To present the pathologic analysis of female urethral strictures obtained during reconstructive urethroplasty. METHODS: Nine separate female urethral tissue specimens were obtained during dorsal vaginal graft urethroplasty by a single surgeon (S.P.P.). Samples were serially sectioned and fixed in 10% formalin 6 to 12 hours before routine processing in paraffin blocks. Serial 5-µm sections were subjected to H&E, Masson trichrome, and elastin staining. End point analysis included evaluation for epithelial hyperplasia and cell type, mucosal edema, degree of fibroblast/inflammatory cell infiltrate, and elastin fiber density and distribution. RESULTS: Nine specimens were examined. Six specimens had epithelial linings of stratified squamous epithelium overlying fibrosis (67%), 1 had mixed squamous and urothelial epithelium, and 2 had only urothelial epithelium. Two specimens (29%) showed acute injury with prominent squamous papillary hyperplasia, focal erosion, and patchy mucosal hemorrhage. Areas of urethral stricture were variably thickened, with increased, densely packed collagen fibers and associated mucosal lymphocytic inflammation ranging from mild and patchy to focally dense with lymphoid aggregates. The highest elastin fiber density appeared to be associated with vessels and overlying muscle bundles in the submucosa. CONCLUSIONS: Further elucidation of histopathologic characteristics may illuminate more appropriate therapeutic pathways for female urethral stricture disease management.

Early return to continence and potency with use of dehydrated human umbilical cord graft at the time of robot-assisted radical prostatectomy: A case study and analysis of relevant literature.

INTRODUCTION: Robot-assisted radical prostatectomy often causes damage to the neurovascular bundle which results in erectile dysfunction and urinary incontinence. Recovery may take months; however, dehydrated umbilical cord allografts appear to offer an advantage in terms of a faster return to continence and potency. CASE PRESENTATION: A 67-year-old male, who presented with intermediate-risk prostate cancer, underwent a bilateral nerve-sparing radical prostatectomy and placement of dehydrated human umbilical cord graft. Four weeks post-prostatectomy, the patient reported minimal stress urinary incontinence and erections with 75% rigidity. Three months post-prostatectomy, the patient noted improved continence and erections with 100% rigidity. CONCLUSION: To our knowledge, this is the second experience reported in the literature evaluating the use of umbilical cord allograft during robot-assisted radical prostatectomy, with promising results, and it is the first reported case to analyze potency as an outcome.

The role of body mass index on quality indicators following minimally-invasive radical prostatectomy.

PURPOSE: We sought to determine the role of body mass index (BMI) on quality indicators, such as length of stay and readmission. The National Surgical Quality Improvement Program (NSQIP) database was queried to examine the effect of obesity, defined as BMI >30, on outcomes after Minimally Invasive Radical Retropubic Prostatectomy (MI-RRP). MATERIALS AND METHODS: Utilizing the NSQIP database, patient records were identified using the Current Procedural Terminology (CPT) code 55866 (laparoscopy, surgical prostatectomy, radical retropubic) during a 10-year period (2007-2017). Obesity was classified according to the CDC classification. Chi-square tests were utilized to evaluate BMI distribution by surgery year. Logistic regression was used to evaluate the relationship of BMI with length of stay (LOS) and hospital readmission within 30 days, after controlling for preoperative variables. RESULTS: Records of 49,238 patients who have undergone MI-RRP during 2007-2017 were evaluated. Mean yearly BMI rose from 28.5 to 29.2, while the percentage of surgical patients with BMI >30 rose by 5% (33% to 38%; p<0.0001) over the study period. Obese patients demonstrated higher morbidity, prolonged LOS, and increased readmission rates after MI-RRP. Obesity severity correlated negatively with quality indicators in a graded fashion. CONCLUSIONS: Obesity rates in patients undergoing MI-RRP increased from 2007-2017. Obese patients are at increased risk of morbidity, prolonged LOS, and readmission within 30 days, following MI-RRP. These patients should not be excluded from MI-RRP; rather, physicians should discuss these increased risks with their patients. Proper weight loss strategies should be instituted preoperatively to mitigate these risks.

Revision Surgery for Inflatable Penile Prosthesis (IPP): A Single-Center Experience and Pictorial Representation.

OBJECTIVE: To elucidate factors influencing Inflatable Penile Prosthesis (IPP) revision and describe outcomes associated with revision surgery. METHODS: A single surgeon, retrospective review of all patients who underwent IPP revision between 2008-2016, was performed. Patient age, BMI, operative duration, blood loss, hospital duration, time from most recent penile implant to revision surgery, etiology of revision, and whether the patient had a prior failed revision surgery were all collected and analyzed. RESULTS: A total of 57 patients, who had undergone IPP revision between the years 2008-2016, with at least 3 years of follow-up, were included in the investigation. Mean patient age and BMI were 68 and 29.2 kg/m2, respectively. The mean time between the most recent implant operation to revision was 8.4 years. Four patients (7%) reported IPP revision failure within a 3-year follow-up period. CONCLUSION: IPP revision demonstrates a relatively high success rate, in the short term, and should be offered to patients as a safe and effective option.

A rare case of emphysematous pyelonephritis caused by Candida parapsilosis and Finegoldia magna complicated by medical care avoidance.

Emphysematous pyelonephritis (EPN) is a necrotizing gas producing infection of the renal parenchyma that commonly occurs in patients with diabetes. EPN requires early diagnosis and treatment due to the possible life-threatening septic complications. We report a rare case of EPN caused by an unfavorable mixed infection of Candida parapsilosis and Finegoldia magna. To our knowledge, this is the first reported case of EPN caused by Finegoldia magna. A 62-year-old male with diabetes mellitus (DM) presented with abdominal pain, shortness of breath, and nausea in which a diagnosis of septic shock was made due to EPN. Our patient first noticed abdominal pain 3 weeks prior to hospital presentation; however, he avoided getting treatment due to a fear of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This patient exhibited deterioration and expired after surgical intervention despite uneventful nephrectomy. This case suggests that medical care avoidance behaviors among patients could potentially complicate their clinical course.

Robot-Assisted Laparoscopic Bladder Diverticulectomy: Adaptation of Techniques for a Variety of Clinical Presentations.

OBJECTIVE: To report our experience in robot-assisted laparoscopic bladder diverticulectomy (RALBD) with a focus on technical modifications aimed at accommodating for differences in anatomy and pathologies. MATERIALS AND METHODS: A prospective database was maintained for 20 patients who had RALBD at our institution. Clinicopathological and follow-up details including concomitant procedure performed were reviewed for each case. Two patients had intra-diverticular urothelial carcinoma refractory to endoscopic and intravesical management. The dissection of the diverticular neck was performed utilising one of the 3 approaches: extravesical (8 of 20 patients), transvesical (11), and trans-diverticular (1). Pre and postoperative postvoid residual and International Prostate Symptom Score were compared using paired-sample t test. In addition, 6 patients underwent open bladder diverticulectomy during the period and their perioperative parameters were compared with the RALBD group. RESULTS: The median age was 66 and the average BMI was 27.2. Thirteen patients underwent major concomitant urologic procedures. Mean operative duration was 184 minutes with average length of hospital stay at 2.1 days. One Clavien 3 complication was encountered. There were significant improvements in pre & postoperative postvoid residual (425-49 ml, P = .000) and International Prostate Symptom Score (19-6, P = .033). When compared to open bladder diverticulectomy, RALBD is associated with reductions in blood loss (100 ml vs 283 ml, P = 0.003). CONCLUSION: Despite the wide variability in clinical presentations, RALBD is associated with minimal surgical morbidity and good perioperative outcomes. It can be safely performed in conjunction with other major urologic procedures in the pelvis.

Fate of residual ureteral stump in patients undergoing robot-assisted radical nephroureterectomy for high-risk upper tract urothelial carcinoma.

BACKGROUND: Management of the distal ureter in radical nephroureterectomy and bladder cuff excision (RNUBCE) is paramount, directly influencing oncologic outcomes. Herein, we analyze the natural history of patients who have undergone robotic radical nephroureterectomy without formal bladder cuff excision and retained ureteral stump and compare this cohort with patients undergoing formal RNUBCE for high-risk upper tract urothelial carcinoma (UTUC). METHODS: From February 2008 to October 2018, all patients who underwent robotic RNUBCE by multiple surgeons in a single institution for high-risk UTUC were reviewed. Preoperative, perioperative, and postoperative variables were investigated. Overall survival, cancer specific survival, local recurrence-free survival, distant recurrence-free survival, and bladder recurrence-free survival were compared between the two cohorts. Further management treatments were explored for patients with retained ureteral stump. Follow-up consisted of abdominopelvic/chest imaging and cystoscopy at regular intervals. RESULTS: A total of 105 patients underwent robotic RNU during the above time period. Of patients with documented 6-month follow-up, approximately 6.6% of patients had retained ureteral stump. Median follow-up for the entire cohort was 31.5 months with a range of 6 to 114.2 months. Factors that precluded formal BCE were densely, fibrotic reaction near the ureterovesical junction due to prior vascular or pelvic surgery in 5 patients, severe pyonephrosis and continued anesthetic risk in one patient, and surgeon choice (patient co-morbidities) in another patient. Three patients died with metastatic disease and one patient succumbed to cardiovascular compromise. Two additional patients developed local recurrence only at the level of the ureteral stump, with one patient undergoing eventual distal excision, contralateral RNUBCE and radical cystectomy. CONCLUSIONS: In these cases, responsibilities assumed by the surgeon demand the utmost in judgement and skill; however, at times, circumstances prevail such as patient factors and nature/biology of the disease. These factors may prevent adequate excision the complete ureter, ureterovesical junction, and bladder cuff at the time of RNU. In this robotic cohort of patients undergoing RNUBCE for UTUC, not excising the most distal part of the ureter directly translates to inferior oncologic outcomes. Complete ureteral excision with bladder cuff should be performed where possible as this is an integral part of the radical nephroureterectomy. Also, if feasible, adjunctive chemotherapy/immunotherapy treatments should be considered.