Unveiling the Hidden Perils: A Comprehensive Review of Fungal Infections in Inflatable Penile Prosthesis Surgery.

Inflatable penile prosthesis (IPP) surgery is an effective treatment for erectile dysfunction (ED), but infections pose a significant threat to its success. Current guidelines lack antifungal recommendations, despite rising fungal infection rates post-IPP surgery. This review examines epidemiology, risk factors (including diabetes mellitus, immunosuppression, and obesity), and pathogenesis, highlighting the role of biofilm formation in device contamination. Clinical manifestations vary from acute to delayed, with fungal biofilms presenting challenges in diagnosis. Prophylactic strategies, including broad-spectrum antibiotics and antifungals, are crucial, with evidence suggesting a 92% reduction in infections. With fungal infections showing lower salvage rates, management involves culture-guided treatment, irrigation, and oral antibiotics. Future research aims to understand biofilm mechanisms and develop biomaterials to reduce infection rates. Implementing antifungal therapy, along with standard practices like the no-touch technique and antibiotic dips, is crucial in preventing IPP infections.

Thulium fiber laser enucleation of the prostate: a systematic review of the current outcomes.

INTRODUCTION: One recent addition to different lasers used for endoscopic enucleation of the prostate is the thulium fiber laser (TFL). The purpose of this systematic review is to present the feasibility, safety and efficacy of TFL Enucleation of the Prostate (ThuFLEP). EVIDENCE ACQUISITION: PubMed®, Scopus® and Cochrane® primary databases were systematically screened. The search strategy used the PICO (Patients, Intervention, Comparison, Outcome) criteria. Patients should be adults with benign prostatic obstruction (BPO) undergoing ThuFLEP. While comparative studies reporting comparison of ThuFLEP to other BPO treatments were included, cohort studies with no comparison group were also accepted. Outcomes including enucleation time and complication rates were reported. EVIDENCE SYNTHESIS: Twelve studies met all the predefined criteria and were included in the final qualitative synthesis. Mean operative time and enucleation time ranged from 46.6±10.2 to 104.5±33.6 and from 38.8±17.9 to 66.0±24.9 minutes, respectively. Most of the complications were Grade I or Grade II ones. Although TFL was found to present some advantages over older BPO treatments, its outcomes were comparable with other endoscopic enucleation approaches. CONCLUSIONS: ThuFLEP seems to be a feasible, safe and efficient approach for BPO symptoms management. Limited evidence showed that although ThuFLEP was associated with a reduced total operative time, it was also associated with worse IPSS improvement at 1-year follow-up, when compared with MOSESTM Holmium Laser Enucleation of the Prostate (HoLEP). These findings confirm the well-established opinion that the enucleation technique itself is more important than the technology which is used.

Assessment of stone ablation rate using the Moses technology modes with different energy and pulse settings: An experimental study.

Objectives: To compare lithotripsy ablation rate with the Moses modes versus conventional pulse modes when using the Holmium:Yttrium-Aluminum-Garnet (Ho:YAG) laser. Methods: The Lumenis® Pulse P120H Holmium Laser System and a 365 µm Moses D/F/L fiber were used to assess stone ablation rate in conventional Short and Long Pulse as well as Moses Contact and Distance at 10 W (0.5Jx20Hz and 2Jx5Hz) and 60 W (1Jx60Hz and 2Jx30Hz). Hard and soft phantom stones were formed, and all tests were conducted in a custom experimental configuration installed in a saline-filled bath. The laser was delivered up to 3 kJ of total energy. The fragmentation pattern was assessed via photographs in each cohort. Results: The time to reach the target energy was 5 min and 50 s in all 10 W and 60 W trials, respectively. In both stone types, ablation was more effective when high-power, high-energy and Moses Distance was utilized. In soft stones, the lowest ablation rate was detected in the Long Pulse modality in all power, energy and frequency settings. Overall, when dusting settings (high-frequency, low-energy) were used, a deeper single cavitation was observed rather than small cavitations. Conclusions: The most effective pulse modality as evaluated via stone ablation rate depends on the stone hardness as well as energy and frequency settings. In both hard and soft stones, ablation is more effective when 60 W (2Jx30Hz) power settings and Moses Distance are used. Tailored laser settings in terms of energy and frequency could be set for each case scenario.

High-power Holmium:Yag lithotripsy in bladder urolithiasis: Is it safe and effective? A combined clinical and experimental study.

Objective: To evaluate the efficacy and safety of Holmium: Yttrium-Aluminum-Garnet (Ho:YAG) laser in bladder lithotripsy using high-power settings > 100 W. Materials and Methods: A combined experimental and clinical study was conducted. The Quanta Cyber: Ho 150 with a 550 µm Quanta optical fiber was utilized in all set-ups. Ablation rates for soft and hard artificial stones were tested in vitro using 100 W and 20 W power settings. In the experiment, a porcine bladder was used. The optical fiber was inserted through a rigid cystoscope, whilst a K-type thermocouple was inserted in the bladder dome. The tested high-power settings were 152 W, 120 W and 105 W. In every trial, the lasing time was over 60 s. In the clinical study, 35 patients underwent transurethral high-power bladder lithotripsy. Laser settings were set between 100 W and 150 W. Results: Stone mass (stone weight) was significantly lower after stone ablation independently of the stone type or the laser settings. Significantly higher mass decrease and ablation rate were detected in high-power compared to low-power settings. In the experiment, the highest temperature recorded was 32°C at 152 W. At 120 W and 105 W, the peak temperatures didn't reach 30°C. In the clinical study, a stone-free rate of 100% and a mean operative time of 43 ± 18 min were reported. All patients stayed in the hospital for one day except for one who presented minor hematuria. Additional complications did not occur. Conclusion: Ho:YAG laser lithotripsy > 100 W is an effective, fast and safe modality for the treatment of bladder calculi.

Fluid dynamics within renal cavities during endoscopic stone surgery: does the position of the flexible ureteroscope and ureteral access sheath affect the outflow rate?

PURPOSE: To evaluate the impact of ureteroscope position within renal cavities as well as different locations of the tip of the ureteral access sheath (UAS) on fluid dynamics during retrograde intrarenal surgery (RIRS). MATERIALS AND METHODS: A prospective observational clinical study was performed. Measurements with a flexible ureteroscope placed in the upper, middle and lower calyces were obtained with the tip of the UAS placed either 2 cm below the pyelo-ureteric junction (PUJ), or at the level of the iliac crest. RESULTS: 74 patients were included. The outflow rates from the middle and upper calyxes were statistically significantly higher compared to the lower calyx, both with the UAS close to the pyelo-ureteric junction and at the iliac crest. When the UAS was withdrawn and positioned at the level of the iliac crest, a significant decrease in outflow rates from the upper (40.1 ± 4.3 ml/min vs 35.8 ± 4.1 ml/min) and middle calyces (40.6 ± 4.0 ml/min vs 36.8 ± 4.6 ml/min) and an increase in the outflow from the lower calyx (28.5 ± 3.3 ml/min vs 33.7 ± 5.7 ml/min) were noted. CONCLUSIONS: Our study showed that higher fluid outflow rates are observed from upper and middle calyces compared to lower calyx. This was true when the UAS was positioned 2 cm below the PUJ and at the iliac crest. Significant worsening of fluid dynamics from upper and middle calyces was observed when the UAS was placed distally at the level of the iliac crest. While the difference was statistically significant, the absolute change was not significant. In contrast, for lower calyces, a statistically significant improvement was documented.

Cellular senescence in testicular cancer. Is there a correlation with the preoperative markers and the extent of the tumor? An experimental study.

PURPOSE: The aim of this experimental study is to investigate the correlation between the presence of senescent cells and the tumor size, the lymphovascular invasion (LVI), the invasion of rete testis (RTI), the preoperative tumor markers or pathological stage in patients who underwent orchiectomy for malignant purposes. METHODS: This experimental study included patients with a history of radical orchiectomy performed from January 2011 to January 2019. The testicular tissue specimens underwent an immunohistopathological process for the detection of the presence of cellular senescence. Besides, the tumor size, the histopathological type, the pathological stage of the tumor and the presence of Lymphovascular (LVI) or rete testis (RTI) invasions were also recorded. Additionally, the preoperative serum levels of alpha-fetoprotein, beta-human chorionic gonadotropin and lactate dehydrogenase were recorded. After the completion of immunohistochemical analysis, the rate of senescent cells in each specimen was also recorded. RESULTS: The mean senescent cell rate was estimated to be 14.11±11.32% and 15.46±10.58% in patients with presence of LVI or absence of LVI, respectively (p=0.46). The mean senescent cell rate was calculated at 18.13±12.26% and 12.56±9.38% (p=0.096) in patients with presence of RTI or absence of RTI, respectively. The mean senescent cell rate in the pT1 group was calculated at 14.58 ± 9.82%, while in T2 and T3 groups the mean senescent cell rate was estimated to be 15.22 ± 12.03% and 15.35 ± 14.21%, respectively (p=0.98). A statistically significant correlation was detected between the senescence rate and the tumor size (Pearson score 0.40, p=0.027) and between the rate of senescent cells and the preoperative level of lactate dehydrogenase (LDH) (Pearson score -0.53, p=0.002). CONCLUSIONS: The presence of cellular senescence was correlated with the extent of the testicular tumor in terms of tumor size as well as the preoperative level of the LDH serum marker.

Use of artificial stones in training and laboratory studies, have we found the right material? Outcomes of a systematic review from the European School of Urology.

Objective: In this review, we investigated the current literature to find out which artificial stones (AS) are available in endourology, and in which experimental and training schemes they are used. Materials and Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Twenty-one out of 346 studies met our inclusion criteria and are presented in the current review. The inclusion criteria were the existence of AS and their use for laboratory and training studies. Results: There is a wide variety of materials used for the creation of AS. BegoStone powder (BEGO USA, Lincoln, Rhode Island) and plaster of Paris™ were used in most of the studies. In addition, Ultracal-30 (U. S. Gypsum, Chicago, IL) was also used. Other materials that were used as phantoms were AS created from plaster (Limbs and Things, UK), standardized artificial polygonal stone material (Chaton 1028, PP13, Jet 280; Swarovski), model stones consisting of spheres of activated aluminum (BASF SE, Ludwigshafen am Rhein, Deutschland), Orthoprint (Zhermack, Badia Polesine, Italy), and a combination of plaster of Paris, Portland cement, and Velmix (calcium sulfate powder). Many experimental settings have been conducted with the use of AS. Our research demonstrated nine studies regarding testing and comparison of holmium: yttrium-aluminum-garnet laser devices, techniques, and settings. Six studies were about extracorporeal shock wave lithotripsy testing and settings. Three experiments looked into treatment with percutaneous nephrolithotomy. Additionally, one study each investigated imaging perioperatively for endourological interventions, stone bacterial burden, and obstructive uropathy. Conclusion: AS have been used in a plethora of laboratory experimental studies. Independent of their similarity to real urinary tract stones, they present a tremendous potential for testing and training for endourological interventions.

Percutaneous antegrade management of large proximal ureteral stones using non-papillary puncture.

Objective: To evaluate the feasibility and the safety of medial non-papillary percutaneous nephrolithotomy (npPCNL) for the management of large proximal ureteral stones. Methods: We evaluated prospectively collected data of 37 patients with large proximal ureteral stones more than 1.5 cm in diameter treated by prone npPCNL. Depending on stone size, in-toto stone removal or lithotripsy using the Lithoclast® Trilogy (EMS Medical, Nyon, Switzerland) was performed. Perioperative parameters including operative time (from start of puncture to the skin suturing), stone extraction time (from the first insertion of the nephroscope to the extraction of all stone fragments), and the stone-free rate were evaluated. Results: Twenty-one males and 16 females underwent npPCNL for the management of large upper ureteral calculi. The median age and stone size of treated patients were 58 (interquartile range [IQR]: 51-69) years and 19.3 (IQR: 18.0-22.0) mm, respectively. The median operative time and stone extraction time were 25 (IQR: 21-29) min and 8 (IQR: 7-10) min, respectively. One case (2.7%) of postoperative bleeding and two cases (5.4%) of prolonged fever were managed conservatively. The stone-free rate at a 1-month follow-up was 94.6%. Conclusion: The npPCNL provides a straight route to the ureteropelvic junction and proximal ureter. Approaching from a dilated portion of the ureter under low irrigation pressure with larger diameter instruments results in effective and safe stone extraction within a few minutes.

Transurethral resection of bladder tumor: A systematic review of simulator-based training courses and curricula.

Objective: Transurethral resection of bladder tumor is one of the most common everyday urological procedures. This kind of surgery demands a set of skills that need training and experience. In this review, we aimed to investigate the current literature to find out if simulators, phantoms, and other training models could be used as a tool for teaching urologists. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement and the recommendations of the European Association of Urology guidelines for conducting systematic reviews. Fifteen out of 932 studies met our inclusion criteria and are presented in the current review. Results: The UroTrainer (Karl Storz GmbH, Tuttlingen, Germany), a virtual reality training simulator, achieved positive feedback and an excellent face and construct validity by the participants. The inspection of bladder mucosa, blood loss, tumor resection, and procedural time was improved after the training, especially for inexperienced urologists and medical students. The construct validity of UroSim® (VirtaMed, Zurich, Switzerland) was established. SIMBLA simulator (Samed GmbH, Dresden, Germany) was found to be a realistic and useful tool by experts and urologists with intermediate experience. The test objective competency model based on SIMBLA simulator could be used for evaluating urologists. The porcine model of the Asian Urological Surgery Training and Education Group also received positive feedback by the participants that tried it. The Simulation and Technology Enhanced Learning Initiative Project had an extraordinary face and content validity, and 60% of participants would like to use the simulators in the future. The 5-day multimodal training curriculum "Boot Camp" in the United Kingdom achieved an increase of the level of confidence of the participants that lasted months after the project. Conclusion: Simulators and courses or curricula based on a simulator training could be a valuable learning tool for any surgeon, and there is no doubt that they should be a part of every urologist's technical education.

Endoscopic enucleation of the prostate with Thulium Fiber Laser (ThuFLEP). A retrospective single-center study.

PURPOSE: The aim of the present, retrospective study was to describe our initial experience and early outcomes of Thulium Fiber Laser enucleation of the prostate (ThuFLEP) with the use of the FiberDust™ (Quanta System, Samarate, Italy) in patients with benign prostate hyperplasia. METHODS: From June 2022 to April 2023, all patients who underwent endoscopic enucleation of the prostate at Urology Department of the University Hospital of Patras were included. A single surgeon utilizing the same standardized operative technique performed all the surgeries. The primary endpoints included the uneventful completion of the operation, the surgical time and any minor or major complication observed intra- or post-operatively. RESULTS: Twenty patients with benign prostate hyperplasia were treated with ThuFLEP. All the surgeries were completed successfully and uneventfully. The enucleation phase of the operation was completed in a mean time of 45±9.1 min, while the average time needed for the morcellation was 17.65±3.42 min. No significant complications were observed intra- or post-operatively. The average hemoglobin drop was calculated to be 0.94±0.71 g/dL. CONCLUSIONS: All the operations were successfully and efficiently completed with the use of the FiberDust™ (Quanta System, Samarate, Italy) in ThuFLEP. Significant blood loss or major complications were not observed.

Minimal invasive treatment of urethral strictures: An experimental study of the effect of paclitaxel coated balloons in the wall of strictured rabbit's urethra.

PURPOSE: The aim of this study is the evaluation of the distribution of paclitaxel (PTX) released by a coated balloon in the layers of rabbit's urethra. METHODS: 18 rabbits were included. A laser device was used for the stricture formation. After two weeks, dilation of the strictured urethra was performed by using Advance 35LP PTA balloons and Advance 18 PTX PTA balloons. The experimental models were divided into 3 groups. The group Α included two rabbits without any intervention except for the stenosis procedure. Group B compromised six rabbits that underwent dilation with Advance 35LP PTA balloons. Group C consisted of 10 rabbits to which dilation with both Advance 35LP PTA balloons and Advance 18 PTX PTA balloons was applied. Histological evaluation and Immunohistochemistry were performed on all specimens. RESULTS: Inflammation, fibrosis and ruptures were detected in the specimens of the study. In specimens of Group C the decrease of inflammation and fibrosis rate was greater. Anti-PTX antibody was detected in the epithelium, lamina propria and smooth muscle layer of all specimens of urethras that have been harvested immediately and 1 day after the dilation with Advance 18 PTX PTA balloon and it was not observed in any layer of the urethral wall of the rest of the examined specimens of Group C. CONCLUSIONS: PTX's enrichment was detected in the smooth muscle layer of all specimens that have been harvested immediately and 24h after the dilation with Advance 18 PTX PTA balloons. PTX may play an inhibitive role in the recurrence of the stenosis.

Grafts in Peyronie's surgery without the use of prostheses: a systematic review and meta-analysis.

ABSTRACT: Peyronie's disease (PD) is characterized by abnormal penile curvature, and various surgical methods have been developed using different graft materials. However, there is currently no universal agreement on which type of graft is the best. The objective of this review was to evaluate the available literature and identify the most effective graft material for penile curvature correction in PD. A literature search was conducted using electronic databases, including PubMed, Scopus, and the Cochrane Library. The patients, intervention, comparison, and outcome (PICO) approach was used to define the eligibility of studies. Two authors independently selected studies, evaluated them, and extracted data. Random-effect models using the DerSimonian-Laird method were used. Most studies were single-arm studies and had a high risk of bias. Buccal mucosa grafts (BMG) were found to result in the highest penile straightening rates and were associated with the least de novo erectile dysfunction. TachoSil grafts demonstrated a high success rate in straightening despite a higher mean preoperative curvature, while Tutoplast grafts had a higher incidence of postoperative erectile dysfunction. BMG had the highest percentage of postoperative penile straightening. Overall, the TachoSil graft showed the best performance when preoperative curvature is taken into account. Based on the available literature, BMG appear to be the most effective for penile curvature correction in PD, but this is offset by the requirement for low preoperative curvature. The TachoSil graft shows the best overall performance when preoperative curvature is considered. Comparative randomized clinical trials are still needed to determine graft superiority.

How long do we need to reach sufficient expertise with the avatera® robotic system?

PURPOSE: To investigate the learning curve in four basic surgical skills in laparoscopic and robotic surgeries, and evaluate the approximate time needed to reach sufficient expertise in performing these tasks with the avatera® system. METHODS: Twenty urology residents with no previous experience in dry-lab and robotic surgery were asked to complete four basic laparoscopic tasks (peg transfer, circle cutting, needle guidance, and suturing) laparoscopically and robotically. All participants were asked to complete the tasks first after watching the Uroweb educational material and, second, after undertaking a 2-hour training in robotic and laparoscopic dry-lab. Thereafter, all trainees continued to undertake 2-hour training programs until being able to complete the tasks with the avatera® robot at the desired time. Paired t test and one-way ANOVA test were used to analyze time differences between the groups. RESULTS: Time needed to complete all tasks either robotically or laparoscopically was significantly less in the second compared to the first attempt for all Groups in each Task. In the robotic dry-lab, time needed to complete the tasks was significantly less than in the laparoscopic dry-lab. A significant effect of previous laparoscopic experience of the participants on the training time needed to achieve most of the goal times was detected. CONCLUSION: The results of the study highlight the role of previous laparoscopic experience in the training time needed to achieve the performance time goals and demonstrate that the learning curve of basic surgical skills using the avatera® system is steeper than the laparoscopic one.

Salvage holmium laser enucleation of the prostate after previous interventions: a systematic review.

OBJECTIVE: To investigate the feasibility, safety and efficacy of holmium laser enucleation of the prostate (HoLEP) in the re-treatment setting (salvage HoLEP) and compare it to the primary HoLEP procedure that is commonly used for the treatment of benign prostate hyperplasia (BPH). MATERIALS AND METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, PubMed, Scopus, and Cochrane databases were systematically screened, from inception to 8 August 2022. Other potentially eligible studies were retrieved using the reference lists of the included studies. Retrospective and prospective studies, both comparative and non-comparative, were included. RESULTS: A total of 12 studies met the inclusion criteria and were included in the final qualitative synthesis. One study was prospective comparative (non-randomised), seven studies were retrospective comparative, and four studies were retrospective non-comparative or case series. In total, 831 patients were treated with salvage HoLEP in the above studies. Previous intervention before salvage HoLEP ranged among studies. The most commonly performed was transurethral resection of the prostate. Intraoperative parameters of salvage HoLEP were comparable with those reported during primary HoLEP, while all postoperative outcomes were significantly improved after salvage HoLEP and were similar with those observed after primary HoLEP. No major complications were noted after salvage HoLEP according to Clavien-Dindo classification. CONCLUSIONS: Salvage HoLEP after previous interventions for treating recurrent or residual BPH is a feasible, safe, and efficient procedure. Data presented in selected studies, along with the holmium laser's physical properties to resect more tissue and to dissect along the true anatomical plane of BPH, render HoLEP an ideal salvage treatment modality for recurrent or residual BPH symptoms.

Robot-assisted radical prostatectomy using the avatera system™: a prospective pilot study.

BACKGROUND: Robot-assisted radical prostatectomy is a minimally invasive, safe procedure preferred in the management of localized prostate cancer. In this study, we present our initial experience with the avatera™ system (avateramedical GmbH, Jena, Germany) in robot-assisted radical prostatectomy. METHODS: A total of fourteen patients underwent robot-assisted radical prostatectomy using this newly introduced system in our department from June 2022 to October 2022. The primary endpoints of the study were the time and the successful completion of the operation, the hemoglobin drop and the presence of complications. The pathologic tumor stage and the presence of positive surgical margins were also recorded. Follow-up of the patients for the functional outcomes over a period of 3 months took place. RESULTS: The completion of all the surgeries was successful. The median draping and docking times were 9.5 minutes (7-13) and 10 minutes (5-40), respectively. The median console time was 103.5 minutes (90-121). No conversion to laparoscopic or open prostatectomy was necessary. The median hemoglobin drop was 1.95 g/dL (0.3-2.7), while positive surgical margins were present in two patients postoperatively. No major complications or need for transfusion were noticed. Six months after the procedure, 78.6% of the participants were continent while 77.7% of the nerve-sparing patients reported erections adequate for intercourse. CONCLUSIONS: All the operations were completed successfully without major complications or significant blood loss. The functional outcomes were acceptable according to the literature. Based on the early outcomes, robot-assisted radical prostatectomy with the avatera™ system (avateramedical GmbH) could be considered feasible, safe, and efficient.

Radiological Density, Atomic Numbers, and Stone Fragmentation of Bego Stones Used for Research in Endourology: Comparison to Real Urinary Stones.

Objective: The aim of the study was to characterize artificial stones used for research in endourology in terms of radiological properties and hardness, based on stone fragmentation, and to compare them with real stones. Materials and Methods: We built artificial stones using BegoStone Plus™ powder (BEGO, Lincoln, RI), with powder (g)-water (mL) ratios ranging from 15:03 to 15:12. The CT Gemstone Spectral Imaging Software® (GE Medical Systems, LLC, Waukesha, WI) was used to evaluate the radiological density in HU and spectral properties. Stone fragmentation was assessed in an in vitro experimental setting. These properties of artificial stones were compared with real urinary calculi. Results: Regarding radiological density in terms of HUs, 15:03 artificial calculi showed similar results when compared with real stones comprising calcium oxalate and calcium phosphate. The 15:03 and 15:04 artificial stones showed similar spectral property results to calcium pyrophosphate stones. The 15:11 artificial stones showed similar stone fragmentation results to real stones comprising uric acid, and 15:03 artificial calculi showed similar results to apatite and cystine stones. Conclusions: Artificial stones are useful for research in endourology. Stones with a powder (g)-water (mL) ratio of 15:03 proved to mimic real hard stones in terms of HUs, atomic number, and stone fragmentation in our study and could be used as artificial hard stones, and 15:11 stones showed similar stone fragmentation to uric acid stones. Our study might suggest that standard Bego stones are useful to investigate different areas in endourology, but not radiological properties because radiological homogeneity is not ensured unless more sophisticated mixing methods are used.

Replicating Florence Intracorporeal Neobladder Technique in Laparoscopic Radical Cystectomy: A Retrospective Study.

OBJECTIVE: To evaluate retrospectively the feasibility of Florence robotic intracorporeal neobladder technique in laparoscopic radical cystectomy. METHODS: Fourteen patients with muscle-invasive bladder cancer underwent laparoscopic radical cystectomy and Florence robotic intracorporeal neobladder between September 2021 and February 2023. Patients' characteristics, pathology data, perioperative outcomes, postoperative complications, and follow-up data were collected. RESULTS: All operations were successfully completed laparoscopically. The median total operative time was 343 minutes, and the median estimated blood loss was 169.5 mL. No intraoperative complications were observed. The median hospitalization time was 7days, while the median time to regular diet was 3days. Clavien Dindo Grade < III complications appeared in five patients within 30days postoperation. No other complications were noted over the 90days follow-up. Organ-confined disease was confirmed in 11 patients and locally advanced disease in three patients. At 3months follow-up, eight and four patients were daytime and night-time continent, respectively. CONCLUSION: Replicating Florence robotic intracorporeal neobladder in laparoscopic radical cystectomy is safe, feasible, and repeatable, based on the encouraging perioperative, oncological, and functional outcomes of our study. However, further prospective studies on a larger scale are required to prove its long-term results.

Location of ureteral access sheath in the ureter. Does it affect the fluid flow in different calyces?

Introduction: The aim of this study was to evaluate outflow variation in different locations of the pyelocaliceal system with the use of different ureteral access sheath (UAS) sizes and different UAS positioning. Material and methods: The experimental setup included an anaesthetised porcine model, a 7.5-Fr ureteroscope with a 200-µm laser fibre inserted in the working channel, a hand-held pumping irrigating system, and UAS of different sizes, namely: 9.5/11.5 Fr, 12/14 Fr, and 14/16 Fr. Each UAS was placed just below the ureteropelvic junction (UPJ) or in the mid-ureter. The ureteroscope was placed in the renal pelvis, upper and lower calyces, and outflow measurements were obtained with 3-second interval pumping for one minute in every experimental setup. Results: The UAS positioning in the mid-ureter was associated with significantly higher outflow rates in the lower calyx (p = 0.041). While the UAS was below the UPJ, we observed a trend of lower outflow rate in the lower calyx, which was completely inverted when the UAS was in the mid-ureter. Increasing the UAS size from 9.5/11.5 Fr to 12/14 Fr led to a significant increase in outflow in the renal pelvis and upper calyx (p = 0.007), but not in the lower calyx. A further increase to 14/16 Fr did not produce increased flow. Conclusions: Different locations of the pyelocaliceal system have different fluid mechanics during fURS. In the renal pelvis and upper calyx increasing the diameter of the UAS improved the outflow, whereas in the lower calyx the position of the UAS seems to be the most relevant factor. These variables should be considered when performing fURS, especially with high-power laser lithotripsy.

Feasibility study of a novel robotic system for transperitoneal partial nephrectomy: An in vivo experimental animal study.

PURPOSE: To evaluate the safety and feasibility of partial nephrectomy with the use of the novel robotic system in an in vivo animal model. METHODS: Right partial nephrectomy was performed in female pigs by a surgical team consisting of one surgeon and one bedside assistant. Both were experienced in laparoscopic surgery and trained in the use of the novel robotic system. The partial nephrectomies were performed using four trocars (three trocars for the robotic arms and one as an assistant trocar). The completion of the operations, set-up time, operation time, warm ischemia time (WIT) and complication events were recorded. The decrease in all variables between the first and last operation was calculated. RESULTS: In total, eight partial nephrectomies were performed in eight female pigs. All operations were successfully completed. The median set-up time was 19.5 (range, 15-30) minutes, while the estimated median operative time was 80.5 minutes (range, 59-114). The median WIT was 23.5 minutes (range, 17-32) and intra- or postoperative complications were not observed. All variables decreased in consecutive operations. More precisely, the decrease in the set-up time was calculated to 15 minutes between the first and third attempts. The operative time was reduced by 55 minutes between the first and last operation, while the WIT was decreased by 15 minutes during the consecutive attempts. No complications were noticed in any operation. CONCLUSIONS: Using the newly introduced robotic system, all the advantages of robotic surgery are optimized and incorporated, and partial nephrectomies can be performed in a safe and effective manner.

How Safe Are the Laparoscopic and Robotic Graspers? Evaluation of the Novel Avatera Robotic Surgical System: An Acute In Vivo Study on a Porcine Model.

OBJECTIVE: To evaluate the tissue injury caused by the force applied by the roboticassisted graspers of avatera robotic surgical system on bowel tissue. METHODS: An experimental in vivo porcine model with 1 pig was conducted. After a standard transperitoneal setup of the avatera robotic surgical system, different laparoscopic and robotic graspers were used on the bowel with maximum force applied each time. Robotic atraumatic grasper, laparoscopic right angle grasper, laparoscopic curved grasper, and laparoscopic atraumatic grasper were used. After using all graspers, the pig was sacrificed. The bowel segments were resected and sent for histological analysis. RESULTS: The pathologist reported that all the graspers caused signs of acute inflammation without any irreversible damage or signs compatible with ischemia of the tissue. No significant difference in histology was observed between the graspers. CONCLUSION: No permanent damage was caused by graspers, except for acute, reversible inflammation. Concluding, the avatera grasper could be safe to use on bowel segments, independent of the applied pressure.