Advancements and Challenges in Robot-Assisted Bone Processing in Neurosurgical Procedures.

OBJECTIVE: Practical applications of nerve decompression using neurosurgical robots remain unexplored. Our ongoing research and development initiatives, utilizing industrial robots, aim to establish a secure and efficient neurosurgical robotic system. The principal objective of this study was to automate bone grinding, which is a pivotal component of neurosurgical procedures. METHODS: To achieve this goal, we integrated an endoscope system into a manipulator and conducted precision bone machining using a neurosurgical drill, recording the grinding resistance values across 3 axes. Our study encompassed 2 core tasks: linear grinding, such as laminectomy, and cylindrical grinding, such as foraminotomy, with each task yielding unique measurement data. RESULTS: In linear grinding, we observed a proportional increase in grinding resistance values in the machining direction with acceleration. This observation suggests that 3-axis resistance measurements are a valuable tool for gauging and predicting deep cortical penetration. However, problems occurred in cylindrical grinding, and a significant error of 10% was detected. The analysis revealed that multiple factors, including the tool tip efficiency, machining speed, teaching methods, and deflection in the robot arm and jig joints, contributed to this error. CONCLUSION: We successfully measured the resistance exerted on the tool tip during bone machining with a robotic arm across 3 axes. The resistance ranged from 3 to 8 Nm, with the measurement conducted at a processing speed approximately twice that of manual surgery performed by a surgeon. During the simulation of foraminotomy under endoscopic grinding conditions, we encountered a -10% error margin.

Assessment of Therapeutic Effects of Combined Treatment With Cisplatin and Anti-mouse Programmed Death (PD)-1 Antibody in a Mouse Urothelial Cancer Model.

BACKGROUND/AIM: The therapeutic impact of combination treatment with an immune checkpoint inhibitor (ICI) and chemotherapeutic agent on patients with urothelial cancer (UC) remains controversial. Therefore, the present study investigated differences in the therapeutic effects of combination therapy with cisplatin plus anti-mouse programmed death (PD)-1 antibody according to the dose of cisplatin using the mouse bladder tumor model MBT2. MATERIALS AND METHODS: The effects of treatment with two different doses cisplatin and/or anti-mouse PD-1 antibody on tumor growth after the subcutaneous injection of MBT2 cells were compared. Infiltrating patterns of lymphocytes into tumors after treatment were assessed using immunohistochemical staining. RESULTS: MBT2 tumor volumes were significantly larger in mice receiving high-dose cisplatin alone than in those receiving low-dose cisplatin alone. Combination treatment with cisplatin plus anti-mouse PD-1 antibody exerted significantly stronger growth inhibitory effects on MBT2 tumors than treatment with either agent alone, irrespective of cisplatin doses; however, no significant differences were observed in MBT2 tumor volumes between mice receiving anti-mouse PD-1 antibody plus high-dose cisplatin and those receiving anti-mouse PD-1 antibody plus low-dose cisplatin. Furthermore, CD8+ to CD3+ and CD8+ to CD11b+ T-lymphocyte ratios in MBT2 tumors were both significantly higher in the low-dose cisplatin alone group than in the high-dose cisplatin alone group, whereas no significant differences were noted in either ratio between the two different combination treatment regimens. CONCLUSION: When combined with ICI, a lower dose of cisplatin may achieve favorable antitumor effects in UC patients by preventing lymphocyte exhaustion.

Robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy using the novel surgical robot platform, hinotori: Initial experience with two cases.

Introduction: A newly developed surgical robot system, hinotori, with various unique advantages has been in clinical use in Japan; however, there have not been any studies of robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy using hinotori. Case presentation: We describe two male patients aged 67 and 76 years old with right renal cell carcinoma and a level II and I inferior vena cava tumor thrombus, respectively, undergoing robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy using hinotori. Both operations were successfully completed with a purely robotic procedure without any major perioperative complications, resulting in the following findings: time using robotic system, 158 and 156 min; total operative time, 228 and 214 min; estimated blood loss, 535 and 200 mL, respectively. Conclusion: Based on our first experience, robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy using hinotori may be an effective treatment for renal cell carcinoma with inferior vena cava tumor thrombus ≤level II.

Relationship Between Adverse Events and Progression-free Survival in Patients Receiving Cabozantinib for Previously Treated Metastatic Renal Cell Carcinoma.

BACKGROUND/AIM: Although the adverse events (AEs) of drugs, such as sunitinib and axitinib, have been shown to predict treatment responses, evidence to support cabozantinib-induced AEs as predictors of responses to treatment for metastatic renal cell carcinoma (mRCC) is limited. Therefore, we herein investigated the relationship between AE profiles and progression-free survival (PFS) in patients receiving cabozantinib for previously treated mRCC. PATIENTS AND METHODS: The present study retrospectively analyzed 40 patients receiving cabozantinib for previously treated mRCC between July 2020 and August 2022. PFS was estimated using the Kaplan-Meier method and the impact of several parameters, including cabozantinib-induced AEs, on PFS was investigated by a Cox proportional regression analysis. RESULTS: The median observation period was 15 (2-29) months, during which time 31 patients (77.5%) progressed, with median PFS of 11 months. Thirty-nine patients (97.5%) developed at least one AE. Liver toxicity occurred in 16 patients (40.0%) and hand-foot syndrome, hypertension, and diarrhea in 14 each (17.5%). Only hypertension correlated with longer PFS. A multivariate analysis identified hypertension as an independent prognostic factor for PFS (p=0.049). CONCLUSION: These results suggest the potential of treatment-induced hypertension as a significant predictor of prolonged PFS in patients receiving cabozantinib for mRCC.

Robot-assisted radical nephrectomy using novel surgical robot platform, hinotori: Report of initial series of 13 cases.

OBJECTIVES: The aims of the present study were to describe the perioperative findings of the first series of patients undergoing robot-assisted radical nephrectomy (RARN) with a newly launched platform, the hinotori surgical robot system, and compare the findings with a similar set receiving RARN with the existing system, da Vinci. METHODS: This study included 34 patients, consisting of 13 and 21 undergoing RARN using the hinotori and da Vinci robotic systems, respectively. As a rule, RARN was performed via an intraperitoneal approach employing 3 robotic arms, irrespective of the robotic systems. RESULTS: In the hinotori group, the median age, body mass index and tumor diameter were 65 years, 23.3 kg/m2 and 50 mm, respectively. All surgical procedures with hinotori could be completed by a purely robotic approach. In the hinotori group, the median operative time, time using the robotic system, estimated blood loss and length of hospital stay were 157, 83 min, 11 mL and 6 days, respectively, and major perioperative complications did not occur. In this group, 3, 1 and 9 patients were pathologically diagnosed with pT1a, pT1b and pT3a tumors, respectively. No significant differences in baseline characteristics were noted between the hinotori and da Vinci groups, and there were also no significant differences in perioperative findings between them. CONCLUSIONS: Despite a case series with a small sample size, this is the first report evaluating RARN using the hinotori surgical robot system, which could be safely conducted and achieved perioperative outcomes similar to that using the da Vinci system.

Assessments of therapeutic effects according to timings for combined therapy with axitinib and immune check point inhibitor in a mouse renal cell carcinoma model.

Recently, several types of systemic therapy using tyrosine kinase inhibitor (TKI) and immune checkpoint inhibitor (ICI) have been performed for advanced renal cell carcinoma (aRCC) patients; however, the optimal strategy of sequential treatment with these agents has not been well established. The objective of this study was to determine the differences of therapeutic effects according to timing for the introduction of TKI and ICI using a mouse RCC, RenCa model. The effects of combined treatment of TKI and/or ICI with axitinib, anti-mouse programmed death (PD)-1, or PD-ligand 1 (PD-L1) antibody on tumor growth and survival after subcutaneous and intravenous injection of RenCa cells, respectively, were compared according to three different treatment schedules: simultaneous administration, initial axitinib administration, and initial ICI administration. Infiltrating patterns of lymphocytes into tumors after combined treatments were evaluated by immunohistochemical staining. In mice treated with anti-PD-1 and anti-PD-L1 antibodies, significantly marked inhibitory effects on subcutaneous growth of tumors were observed in the simultaneous and initial ICI treatment groups, but not the group with the initial axitinib administration, compared to controls without treatment. Survival intervals of mice after intravenous injection of RenCa cells were significantly longer in the simultaneous and initial ICI administration, but not the initial axitinib administration, compared to the control. Furthermore, both CD8+ to CD3+ and CD8+ to CD11b+ T-lymphocyte ratios in subcutaneous RenCa tumors were significantly higher in the simultaneous and initial ICI administration, but not the initial axitinib administration, compared to the control. Favorable control against aRCC progression may be achieved by administering TKI and ICI simultaneously or ICI followed by TKI.

Perioperative outcomes of robot-assisted partial nephrectomy using hinotori versus da Vinci surgical robot system: a propensity score-matched analysis.

The purpose of this study was to evaluate perioperative outcomes of robot-assisted partial nephrectomy (RAPN) using hinotori, a recently developed robot-assisted surgical platform, by comparing them with those using da Vinci. This study included 303 and 40 consecutive patients who underwent RAPN using da Vinci and hinotori, respectively. To adjust potential baseline parameters between da Vinci and hinotori groups, 1:2 propensity score-matching was performed, and perioperative outcomes in these two groups were comprehensively evaluated. Propensity score-matched analysis generated two groups, consisting of 74 and 37 patients undergoing RAPN using da Vinci and hinotori, respectively, and no significant differences in major baseline parameters were noted between the two groups. RAPN could be completed without conversion to nephrectomy or open surgery in all patients. There were no significant differences in major perioperative outcomes between da Vinci and hinotori groups, including the operative time, time using the robotic system and warm ischemia time. No patient in either group was diagnosed with a positive surgical margin or experienced perioperative complications, corresponding to Clavien-Dindo 3 ≤ . There were no significant differences in the achievements of trifecta and margin, ischemia and complications outcomes between the two groups, and changes in the estimated glomerular filtration rate 1 and 28 days after RAPN were also similar between them. In conclusion, these findings showed that the hinotori platform could facilitate similar perioperative outcomes in patients undergoing RAPN in comparison with the existing robotic system, da Vinci.

Robot-assisted adrenalectomy using a hinotori surgical robot system: Report of first series of six cases.

AIM: The hinotori surgical robot system, a newly launched platform, has already been utilized in several urological robotic surgeries; however, limited information is available in terms of its feasibility and safety in each type of surgery. The objectives of this study were to describe the perioperative outcomes of the first series of six patients who underwent robot-assisted adrenalectomy (RAA) using hinotori, and compare the outcomes with a similar set of five patients undergoing RAA with the existing system, da Vinci. METHODS: This study included a total of 11 consecutive patients with adrenal tumors undergoing RAA between July 2020 and November 2022 at our institution. Comprehensive perioperative outcomes in these patients were retrospectively analyzed. RESULTS: Median age, body mass index (BMI), and tumor diameter in the hinotori group were 48 years, 27.5 kg/m2 , and 36 mm, respectively, and four patients were diagnosed with a functioning tumor, consisting of three and one with hypersecretion of cortisol and catecholamine, respectively. All procedures using hinotori were performed via the transperitoneal approach, and could be completed without conversion to open surgery. Median operative time, time using robotic system, the estimated blood loss, and length of hospital stay in this group were 119 min, 58 min, 8 mL, and 7 days, respectively, and no patient experienced major perioperative complications. There were no significant differences in clinical characteristics between the hinotori and da Vinci groups, and no significant differences in the perioperative outcomes were noted between these two groups. CONCLUSION: Despite being a small case series, this is the first study focusing on RAA using the hinotori surgical robot system, which could be efficaciously performed, resulting in the achievement of perioperative findings comparable with those of the da Vinci system.

Initial Experience of Robot-Assisted Partial Nephrectomy Using Hinotori Surgical Robot System: Single Institutional Prospective Assessment of Perioperative Outcomes in 30 Cases.

Introduction: Innovation of robotic surgery is still actively growing, and various novel robotic systems are in the process of development. The objective of this study was to assess the perioperative outcomes of robot-assisted partial nephrectomy (RAPN) using the hinotori surgical robot system, a recently developed robot-assisted surgical platform, for patients with small renal tumors. Methods: This study prospectively included a total of 30 consecutive patients who were found to have small renal tumors and subsequently underwent RAPN using hinotori between April and November 2022. Major perioperative outcomes in these 30 patients were comprehensively analyzed. Results: The median tumor size and R.E.N.A.L. nephrometry score in the 30 patients were 28 and 8 mm, respectively. Of these 30, 25 and 5 received RAPN by intra- and retroperitoneal approaches, respectively. RAPN could be completed in all 30 patients without conversion to nephrectomy or open surgery. The median operative time, time using hinotori, and warm ischemia time were 179, 106, and 13 minutes, respectively. No patient was found to have a positive surgical margin or experienced major perioperative complications, corresponding to Clavien-Dindo 3≤. Achievements of trifecta and margin, ischemia, and complications (MIC) outcomes in this series were 100% and 96.7%, respectively, and median changes in the estimated glomerular filtration rate 1 day and 1 month after RAPN were -20.9% and -11.7%, respectively. Conclusions: This is the first study focusing on RAPN using hinotori, which showed favorable perioperative outcomes, considering the findings of trifecta and MIC. Although it will be necessary to investigate the long-term effects of RAPN using hinotori on oncologic and functional outcomes, the present findings strongly suggest that the hinotori surgical robot system could be safely applied to RAPN for patients with small renal tumors.

Predictive factors of de novo overactive bladder in clinically localized prostate cancer patients after robot-assisted radical prostatectomy.

OBJECTIVES: To assess the postoperative status of clinically localized prostate cancer patients who underwent robot-assisted radical prostatectomy (RARP) with a focus on de novo overactive bladder (OAB). METHODS: The present study included 156 patients who did not have preoperative OAB and underwent RARP between December 2015 and April 2020 at our institution. Patients were divided into the de novo OAB group and non-OAB group based on the findings of overactive bladder symptoms score (OABSS) 6 months after RARP, and comparative assessments were performed between the two groups. RESULTS: Six months after RARP, de novo OAB was detected in 38 (24.4%) out of 156 patients. Body mass index (BMI) and the proportion of patients with hypertension were significantly higher in the de novo OAB group than in the non-OAB group. No significant differences were observed in the other characteristics examined. Furthermore, the preoperative findings of uroflowmetry and a urodynamic study did not significantly differ between the two groups. Despite the lack of significant differences in preoperative OABSS, total international prostate symptom score, the voiding symptom score, storage symptom score, and quality of life score between the two groups, all of these findings 6 months after RARP were significantly worse in the de novo OAB group than in the non-OAB group. Among the several factors examined, only BMI was independently associated with the development of de novo OAB 6 months after RARP. CONCLUSIONS: Patients with a high BMI may develop de novo OAB after RARP, resulting in the significant deterioration of lower urinary tract symptoms.

Significance of second progression-free survival in patients with advanced urothelial cancer who received platinum-based combination chemotherapy followed by pembrolizumab.

OBJECTIVES: The present study comprehensively investigated the significance of several factors reflecting the therapeutic effects of anticancer treatment on overall survival (OS) in advanced urothelial cancer (UC) patients receiving sequential systemic therapy. METHODS: This study included 101 consecutive advanced UC patients who received first-line platinum-based combination chemotherapy followed by second-line pembrolizumab. The impacts of the following factors on OS in these patients were analyzed: responses to chemotherapy, responses to pembrolizumab, progression-free survival (PFS) with chemotherapy, PFS with pembrolizumab, and second PFS (PFS2). RESULTS: The median age of patients was 71 years, and 35 and 66 had UC in the upper urinary tract and bladder, respectively. objective response rate to first-line chemotherapy and second-line pembrolizumab were 37.6% and 19.8%, respectively. Median PFS with chemotherapy, pembrolizumab, and PFS2 were 5, 4, and 9 months, respectively. Uni- and multivariate analyses of the five factors examined identified PFS with pembrolizumab and PFS2 as independent surrogates for OS, with PFS2 (hazard ratio [HR] = 0.23) being more closely associated with OS than PFS with pembrolizumab (HR = 0.31). Furthermore, uni- and multivariate analyses of various prognostic parameters showed the independent impacts of baseline performance status (PS) and neutrophil-to-lymphocyte ratio (NLR) on PFS2. CONCLUSIONS: The present results suggest the potential of PFS2 as an optimal surrogate for OS in advanced UC patients receiving standard sequential systemic therapy and indicate that intensive treatment needs to be considered for those with poor PS and/or high NLR prior to the introduction of first-line chemotherapy.

Robot-assisted radical nephroureterectomy for upper urinary tract tumor: initial experience with the use of novel surgical robot system, hinotori.

Background: The hinotori surgical robot system is a promising robotic platform that has been recently introduced into routine clinical practice. The aim of this study was to report our initial experience of robot-assisted radical nephroureterectomy (RANU) using hinotori. Methods: This study included a total of eight patients with upper urinary tract tumor (UUTT) who underwent RANU using hinotori via the transperitoneal approach. In this series, nephrectomy was initially performed at the kidney direction stage followed by distal ureterectomy and bladder cuff excision at the bladder direction stage without repositioning of patient or port. Lymphadenectomy was performed at either stage. Results: Median age, body mass index, and tumor diameter were 76 years, 21.7 kg/m2, and 13 mm, respectively. Of eight patients, three were diagnosed with renal pelvic tumors and five with lower ureteral tumors. They underwent lymphadenectomy targeting the renal hilum plus para-aorta and the pelvis, respectively. All procedures in this series were completed without conversion to open surgery. Median operative time, time using the robotic system, estimated blood loss, and length of hospital stay were 230 minutes, 138 minutes, 23 mL, and 8 days, respectively. No major perioperative complication occurred. Pathological examinations of the tumors revealed seven urothelial carcinomas and one papilloma, the median number of resected lymph nodes was 13, and one patient was positive for both cancer margin and lymph node metastases. Conclusions: Despite being a small case series, this is the first study characterizing RANU using the hinotori surgical robot system. RANU was efficaciously and safely performed, resulting in the achievement of favorable perioperative findings.

Effects of Changes in Erectile Function After Holmium Laser Enucleation of the Prostate on Postoperative Outcomes in Patients With Benign Prostatic Hyperplasia.

BACKGROUND/AIM: Sexual function in patients with benign prostatic hyperplasia (BPH) could be affected by surgical intervention, such as holmium laser enucleation of the prostate (HoLEP). The objective of the present study was to investigate whether changes in erectile function (EF) after HoLEP affect postoperative outcomes in patients with BPH. PATIENTS AND METHODS: We retrospectively reviewed 54 consecutive Japanese patients with BPH undergoing HoLEP at our institution between August 2017 and December 2020, and analyzed data obtained before and 6 months after HoLEP, including the Erection Hardness Score (EHS), International Prostate Symptom Score (IPSS), IPSS-Quality of Life (IPSS-QOL), Overactive Bladder Symptom Score (OABSS), and the Medical Outcomes Study 8-Item Short-Form Health Survey consisting of a mental health component summary (MCS) and physical health component summary (PCS). RESULTS: Although no significant differences were observed between preoperative and postoperative EHS, postoperative EHS deteriorated in 19 out of 54 patients. Total IPSS, IPSS-QOL, and OABSS significantly improved after HoLEP, irrespective of the deterioration of EHS; however, despite the lack of significant changes in MCS and PCS in 19 patients with deteriorated EHS, significant improvements in MCS, but not PCS, were postoperatively observed in the remaining 35. A multivariable analysis of several factors identified a preoperative estimated prostate volume >100 cm3 as an independent risk factor associated with the postoperative deterioration of EHS. CONCLUSION: HoLEP had limited impact on postoperative EF in BPH patients; however, favorable QOL may be expected in patients without the postoperative deterioration of EF. Accordingly, it may be important to consider the prostate volume and its effect on postoperative EF when selecting indications for HoLEP.

Comparison of perioperative outcomes among patients with exophytic, mesophytic, and endophytic renal tumors undergoing robot-assisted partial nephrectomy.

OBJECTIVES: It has been well documented that partial nephrectomy for completely endophytic renal tumors is a highly challenging procedure accompanied by several technical difficulties even with the assistance of a robotic surgical system. This study aimed to compare perioperative variables among patients with exophytic, mesophytic, and endophytic renal tumors undergoing robot-assisted partial nephrectomy. METHODS: This study retrospectively included 265 consecutive patients with localized small renal masses undergoing robot-assisted partial nephrectomy at our institution. In this study, completely endophytic tumor was defined as the mass totally covered by renal healthy parenchyma, and according to the points for the 'E' domain of RENAL nephrometry score based on preoperative computed tomography, subjects were classified into three groups as follows: exophytic, mesophytic, and endophytic tumor groups, and perioperative outcomes among these groups were compared. RESULTS: Of 265 patients, 127, 112, and 26 were classified into the exophytic, mesophytic, and endophytic tumor groups, respectively. A significantly smaller tumor diameter was observed in the endophytic group than in the other groups (P < 0.001), whereas the RENAL nephrometry score was significantly higher (P < 0.001). In addition, the warm ischemia time in the endophytic tumor group was significantly longer than that in other groups (P = 0.009); however, no significant difference in the trifecta achievement was noted among the three groups. CONCLUSIONS: This study suggests that robot-assisted partial nephrectomy for patients with completely endophytic tumors can be regarded as a feasible approach without marked impairment of perioperative outcomes; however, further investigation of the long-term functional and oncological outcomes in these patients is required.

Robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy: Initial experience in Japan.

Introduction: Open surgical approach remains the standard treatment for renal cell carcinoma with an inferior vena cava tumor thrombus. In recent years, however, robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy have emerged as minimally invasive alternatives to conventional open surgery. Case presentation: Here, we describe a 76-year-old female patient with right renal cell carcinoma with a level I inferior vena cava thrombus undergoing robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy, which was successfully completed with a purely robotic procedure, resulting in the following outcomes: console time,167 min; total operative time, 211 min; and estimated blood loss, 150 mL. To our knowledge, this is the first case managed by robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy in Japan. Conclusion: Based on our experience, it might be worthwhile to consider purely robotic surgery for the treatment of renal cell carcinoma with an inferior vena cava thrombus.

Significant impact of a history of prior or concomitant upper urinary tract cancer on the recurrence and progression of non-muscle invasive bladder cancer.

BACKGROUND: The objective of the present study was to evaluate the prognostic impact of the upper urinary tract cancer status on recurrence-free survival and progression-free survival, and to develop risk stratification systems that include the upper urinary tract cancer status for patients with non-muscle invasive bladder cancer. PATIENTS AND METHODS: The present study included 40 (upper urinary tract cancer-non-muscle invasive bladder cancer group) and 285 (non-muscle invasive bladder cancer alone group) patients with and without a history of prior or concomitant upper urinary tract cancer, respectively. Nine clinicopathological findings between the two groups were compared, and risk stratification systems for the recurrence and progression of non-muscle invasive bladder cancer were developed. RESULTS: Recurrence-free survival and progression-free survival in the upper urinary tract cancer-non-muscle invasive bladder cancer group were significantly inferior to those in the NMIBC alone group (P < 0.001 and P = 0.006, respectively). Multivariate analyses identified the following independent prognosticators: multiplicity and upper urinary tract cancer status for recurrence-free survival, and pT category and upper urinary tract cancer status for progression-free survival. Significant differences were noted by the risk stratification systems based on the positive number of independent predictors of recurrence-free survival and progression-free survival (P < 0.001 and P = 0.007, respectively). The concordance indices of recurrence-free survival were 0.627, 0.588 and 0.499 in this study stratification, EORTC risk table and CUETO model, respectively. Those of progression-free survival were 0.752, 0.740 and 0.714, respectively. CONCLUSION: The present results suggest the significant impact of a history of prior or concomitant UUTC on recurrence-free survival and progression-free survival in non-muscle invasive bladder cancer patients, and risk stratification systems that include the upper urinary tract cancer status for the recurrence and progression of non-muscle invasive bladder cancer are promising tools for predicting the outcomes of these patients.

Limited impact of erectile function on health-related quality of life in Japanese men undergoing robot-assisted radical prostatectomy.

OBJECTIVE: To investigate the impact of erectile function on health-related quality of life in Japanese prostate cancer patients following robot-assisted radical prostatectomy. METHODS: Time-dependent changes in erectile function and health-related quality of life were assessed using the erection hardness score and Medical Outcomes Study 8-Item Short Form Health Survey, respectively, in 229 consecutive Japanese patients undergoing robot-assisted radical prostatectomy. In this series, patients with erection hardness score ≥2 were considered to those having a certain erectile function. RESULTS: Among the 229 patients examined, erection hardness score ≥2 was observed in 134 (58.5%) and 34 (14.9%) before and 12 months after robot-assisted radical prostatectomy, respectively. Prior to robot-assisted radical prostatectomy, all eight scale scores of 8-Item Short Form Health Survey were significantly superior in patients with erection hardness score ≥2 than in those with erection hardness score = 0 or 1. However, significant differences were observed in two scale scores between patients with erection hardness score ≥2 and those with erection hardness score = 0 or 1 at 12 months after robot-assisted radical prostatectomy. Furthermore, among patients with erection hardness score ≥2 before robot-assisted radical prostatectomy, no significant differences were noted in any of the eight scale scores between patients with erection hardness score ≥2 and erection hardness score = 0 or 1 at 12 months after robot-assisted radical prostatectomy. CONCLUSION: These findings suggest the limited impact of erectile function on postoperative health-related quality of life in Japanese patients undergoing robot-assisted radical prostatectomy.

Feasibility of interaortocaval clamping for renal artery during robot-assisted right partial nephrectomy: A propensity score-matching analysis.

AIM: To evaluate the impact of the interaortocaval clamping technique for the right renal artery on perioperative outcomes of patients who underwent robot-assisted partial nephrectomy (RAPN). METHODS: This study included 111 consecutive patients with right renal masses undergoing RAPN via the transperitoneal approach. In this series, standard and interaortocaval clamping techniques were defined as those for the right renal artery at the renal hilus and interaortocaval space, respectively. Based on the 3D images reconstructed from CT, interaortocaval clamping was preoperatively selected for patients in whom standard clamping of the main renal artery at the right hilum was judged to be technically difficult due to complicated vascular distribution, such as multiple branches of right renal arteries and veins and/or intertwining of these vessels. RESULTS: Of 111 patients, 95 and 16 were classified into the standard and interaortocaval clamping groups, respectively, and interaortocaval clamping was uneventfully performed as planned in all 16. After adjusting patient variables by 1:3 propensity score-matching, 33 and 11 patients were included in the respective groups, and there were no significant differences in major clinical characteristics between them, while the incidences of multiple branches of right renal vessels as well as their intertwining beside the right renal hilus were significantly higher in the interaortocaval clamping group. However, no significant difference was noted in any of the perioperative outcomes, including operative time or intraoperative blood loss, between the two groups. CONCLUSIONS: The interaortocaval clamping technique during RAPN is a feasible procedure with acceptable perioperative outcomes compared with standard hilar clamping, making it possible to more accurately resect renal tumors under clear visualization without unnecessary arterial bleeding from the tumor bed in patients with complex vascular distribution at the right renal hilus; however, special attention should be paid to the considerable individual variability of the interaortocaval anatomy.

Initial experience of robot-assisted radical nephrectomy in Japan: Single institutional study of 12 cases.

INTRODUCTION: To evaluate the initial experience of robot-assisted radical nephrectomy (RARN) in a single institution in Japan. METHODS: This study included a total of 12 patients with renal tumors who were not preoperatively regarded as optimal candidates for robot-assisted partial nephrectomy (RAPN) and subsequently treated with RARN between April 2019 and June 2021 at our institution. Comprehensive perioperative outcomes in these patients were retrospectively analyzed. RESULTS: Of the 12 included patients, 10 and two were male and female, respectively, and the median age was 66 years. The median tumor diameter was 44 mm, and four, four and four patients were classified into cT1a, cT1b and cT3a, respectively. There was no patient requiring open conversion, and the median operative and console times were 167 and 79 minutes, respectively. The median estimated blood loss was 42 cc, and no patient required blood transfusion. During the perioperative period, no major complication corresponding to Clavien-Dindo grade ≥3 occurred. Nine, two and one patient were pathologically diagnosed with clear cell carcinoma (CCC), non-CCC and benign cyst, respectively, and there was no patient who developed recurrent diseases. CONCLUSIONS: Considering complicated tumor characteristics not amenable to RAPN in this series, such as an intravenous tumor thrombus or previous history of open partial nephrectomy, perioperative outcomes of initial experience with RARN in Japan could be considered favorable. Collectively, these findings suggest that RARN may be a promising alternative to laparoscopic radical nephrectomy for patients with complicated renal tumors, contraindicated for RAPN.

Prognostic assessments in patients with upper tract urothelial carcinoma undergoing radical nephroureterectomy and systematic regional lymph node dissection.

OBJECTIVES: Systematic regional lymph node dissection (LND) combined with radical nephroureterectomy (RNU) has been reported to improve the outcomes of upper tract urothelial carcinoma (UTUC) patients. The objective of the present study was to assess the prognostic outcomes of UTUC patients undergoing systematic regional LND combined with RNU. PATIENTS AND METHODS: We conducted a retrospective evaluation of prognostic outcomes of 68 consecutive UTUC patients treated with RUN and systematic regional LND. RESULTS: The median durations of recurrence-free survival (RFS) and overall survival (OS) were 45 and 166 months, respectively. Univariate analyses of several parameters showed that despite the lack of a significant predictor for RFS, the presence of lymph node metastasis correlated with poor OS. CONCLUSION: These results suggest that comparatively favorable outcomes are achievable in UTUC patients by RNU and systematic regional LND; however, special attention is needed for patients with nodal involvement even after systematic regional LND due to the adverse impact of this factor on OS.