Vulvar pagetoid urothelial intraepithelial neoplasia: a case report.

BACKGROUND: Pagetoid urothelial intraepithelial neoplasia (PUIN) is a form of secondary Extramammary Paget Disease (EMPD). It is a rare malignant condition seen on the female genitalia synchronous or metachronous with bladder cancer (BC). CASE PRESENTATION: A 66-year-old female presented with PUIN at the labia minora 2 years after an open anterior pelvic exenteration with ileal conduit urinary diversion for carcinoma in situ (CIS) of the bladder. PUIN of the vulva and vagina was confirmed by a punch biopsy and the patient underwent a radical vaginectomy with urethrectomy and inguinal sentinel node procedure. Immunohistochemically EMPD was identified by the expression tumor protein 63 (p63), cytokeratin 7, and cytokeratin 20 (CK20). CONCLUSIONS: PUIN is a rare but distinct clinical entity as a form of secondary EMPD which can be differentiated from primary EMPD based on medical history, histology, and immunohistochemistry.

POIROT trial: post-operative imaging after urethroplasty with peri-catheter retrograde urethrography or trial of voiding with voiding cysto-urethrography.

PURPOSE: This study directly compares peri-catheter retrograde urethrography (pcRUG) and voiding cysto-urethrography (VCUG) as early postoperative imaging after urethroplasty and aims to assess whether pcRUG is superior at avoiding catheter reinsertion. METHODS: This is a single-center, prospective, interventional study comparing pcRUG and VCUG after urethroplasty in a within-patient fashion. All participants were first evaluated with pcRUG and subsequently with VCUG, unless pcRUG revealed significant contrast extravasation warranting further catheter stay. The primary end-point was to assess whether pcRUG is superior at avoiding catheter reinsertion compared with VCUG. Secondary end-points included the amount of significant contrast extravasations missed on pcRUG and the differences in radiation exposure. RESULTS: 80 patients were included in this study. Median (IQR) interval between surgery and first postoperative imaging was 16 (9-16) days. In 14/80 (18%) patients, the pcRUG showed significant contrast extravasation and catheter reinsertion was avoided, while this percentage is 0 by default for VCUG (p < 0.001). In the other 66/80 (82%) patients, a VCUG was performed and 1/66 (1.5%) of these was considered as significant contrast extravasation. Notably, 9/66 (14%) of these patients could not void during the investigation. Median (IQR) dose of radiation exposure during pcRUG and VCUG was, respectively, 120 (84-161) mGy/cm2 and 241 (169-334) mGy/cm2 (p < 0.001). CONCLUSIONS: After urethroplasty, pcRUG is a valuable alternative for VCUG as early postoperative imaging. It has a comparable diagnostic yield, averts the risk of having to reinsert the catheter, avoids the problem of patients being unable to void during the examination and requires significantly less radiation.

Robot-assisted radical cystectomy with intracorporeal urinary diversion decreases postoperative complications only in highly comorbid patients: findings that rely on a standardized methodology recommended by the European Association of Urology Guidelines.

INTRODUCTION: The available studies comparing robot-assisted radical cystectomy (RARC) with intracorporeal (ICUD) vs. extracorporeal (ECUD) urinary diversion have not relied on a standardized methodology to report complications and did not assess the effect of different approaches on postoperative outcomes. MATERIALS: Two hundred and sixty seven patients treated with RARC at a single center were assessed. A retrospective analysis of data prospectively collected according to a standardized methodology was performed. Multivariable logistic regression models (MVA) assessed the impact of ICUD vs. ECUD on intraoperative complications, prolonged length of stay (LOS), 30-day Clavien Dindo (CD) ≥ 2 complications and readmission rate. Interaction terms tested the impact of the approach on different patient subgroups. Lowess graphically depicted the probability of CD ≥ 2 after ICUD or ECUD according to patient baseline characteristics. RESULTS: Overall, 162 ICUD vs 105 ECUD (61 vs. 39%) were performed. Intraoperative complications were recorded in 24 patients. The median LOS and readmission rate were 11 vs. 13 (p = 0.02) and 24 vs. 22% (p = 0.7) in ICUD vs. ECUD, respectively. Overall, 227 postoperative complications were recorded. The overall rate of CD ≥ 2 was 35 and 43% in patients with ICUD vs. ECUD, respectively (p = 0.2). At MVA, the approach type was not an independent predictor of any postoperative outcomes (all p ≥ 0.4). Age-adjusted Charlson Comorbidity Index (ACCI) was associated with an increased risk of CD ≥ 2 (OR: 1.2, p = 0.006). We identified a significant interaction term between ACCI and approach type (p = 0.04), where patients with ICUD had lower risk of CD ≥ 2 relative to those with ECUD with increasing ACCI. CONCLUSIONS: Relying on a standardized methodology to report complications, we observed that highly comorbid patients who undergo ICUD have lower risk of postoperative complications relative to those patients who received ECUD.

Validated uroflowmetry-based predictive model for the primary diagnosis of urethral stricture disease in men.

OBJECTIVES: To define a uroflowmetry-based non-invasive predictive tool for the primary diagnosis of urethral stricture disease. METHODS: A total of 300 male patients (150 with urethral stricture disease and 150 with benign prostatic obstruction), treated surgically between 2005 and 2015, and 75 healthy males were included in this study. Patients were randomly assigned to one of two groups (75 benign prostatic obstruction patients and 75 urethral stricture disease patients in each group). A model, able to objectively differentiate between benign prostatic obstruction and urethral stricture disease, was created by use of original and hybrid uroflowmetry variables in logistic regression in group A (test group). Receiver operating characteristics curve analysis was used for validation in group B (validation group) and to calculate cut-off values to distinguish healthy individuals from benign prostatic obstruction as a result of urethral stricture disease. RESULTS: Receiver operating characteristics area under the curve values of the created model were 0.841 (0.777-0.905) and 0.807 (0.735-0.879) in groups A and B, respectively. Optimal cut-off values were 2.2847 and 0.1182 to distinguish healthy individuals versus benign prostatic obstruction and benign prostatic obstruction versus urethral stricture disease. CONCLUSIONS: A triphasic uroflowmetry-based model is able to objectively distinguish voiding patterns of healthy individuals, benign prostatic obstruction and urethral stricture disease. The probability of urethral stricture disease can be objectively calculated for each individual patient based on a non-invasive uroflowmetry test. Uroflowmetry pattern interpretation by use of statistical models could become a new standard.

Nontransecting Anastomotic Repair in Urethral Reconstruction: Surgical and Functional Outcomes.

PURPOSE: We evaluated the surgical and functional outcomes, and the effect of the learning curve of nontransecting anastomotic repair for short bulbar and posterior urethral strictures. MATERIALS AND METHODS: A total of 75 patients were treated with nontransecting anastomotic repair for short bulbar strictures in 55 and for posterior strictures in 20. Surgical morbidity was scored using the Clavien-Dindo classification at 3 months. Sexual function was measured using SHIM (Sexual Health Inventory for Men) scoring preoperatively and postoperatively. Post-void dribbling before and after nontransecting anastomotic repair was also determined. To evaluate the learning curve outcomes were evaluated in patients 1 to 25, 26 to 50 and 51 to 75. RESULTS: Median followup was 30 months. Stricture recurred in 6 patients (8%), all diagnosed within 7 months after nontransecting anastomotic repair. Median operative time was 95 minutes and median hospital stay was 2 days. In 61 patients (81.3%) no surgical morbidity was recorded. Five (6.7%), 6 (8%) and 3 patients (4%) experienced a grade 1, 2 and 3b complication, respectively. Seven of 32 (21.9%) and 2 of 42 evaluable patients (4.7%) reported de novo erectile dysfunction and post-void dribbling, respectively, 3 months after nontransecting anastomotic repair. No difference in outcomes was observed among the 3 patient groups. CONCLUSIONS: Nontransecting anastomotic repair appears to be safe without a substantial learning curve effect. Patient counseling about possible surgical complications and transient erectile dysfunction is important.

Haemophilus influenzae biofilm formation in chronic otitis media with effusion.

Otitis media with effusion (OME) is a highly prevalent disease in children, but the exact pathogenesis and role of bacteria are still not well understood. This study aimed to investigate the presence of otopathogenic bacteria in the middle ear effusion (MEE) and adenoid of children with chronic OME (COME), and to investigate in vivo whether these bacteria, especially Haemophilus influenzae, are organized as a biofilm in the middle ear fluid. MEE and adenoid samples were collected from 21 patients with COME. Extensive bacterial culturing and genotyping was performed on all middle ear and adenoid samples. Fluorescence in situ hybridization (FISH) and confocal laser scanning microscopy (CLSM) was used to visualize possible biofilm structures for a selection of middle ear effusion samples. 34 MEE samples were collected from 21 patients of which 64.7 % were culture positive for bacteria and 47.0 % were culture positive for Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus and/or Streptococcus pneumoniae. All 21 adenoid samples were culture positive for one or more of these four otopathogens. H. influenzae (35.3 %) and S. pneumoniae (76.2 %) were the most frequently cultured bacteria in the MEE and adenoid samples, respectively. The same bacterial species was found in MEE and adenoid for 84.6 % of the patients and in 81.2 % of the cases where the same species was found in more than one site it involved the same bacterial genotype. FISH and CLSM demonstrated the presence of H. influenzae specific biofilm structures in five of the eight culture positive MEEs that were tested, but in none of the two culture negative MEEs. The findings in this study indicate that the adenoid acts as a reservoir for bacteria in MEE and confirms that biofilms, in at least half of the cases consisting of H. influenzae, are indeed present in the MEE of children with COME. Biofilms may thus play a crucial role in the pathogenesis of COME, which is important in the understanding of this disease and the development of potential future treatment options.

Robot-assisted Periprostatic Artificial Urinary Sphincter Implantation in Men with Neurogenic Stress Urinary Incontinence: Description of the Surgical Technique and Comparison of Long-term Functional Outcomes with the Open Approach.

BACKGROUND: Periprostatic artificial urinary sphincter implantation (pAUSi) is a rare yet relevant indication for male neurogenic stress urinary incontinence (SUI). OBJECTIVE: To describe the surgical technique of robot-assisted pAUSi (RApAUSi) and compare the long-term functional results with the open pAUSi (OpAUSi). DESIGN, SETTING, AND PARTICIPANTS: Data of 65 consecutive men with neurogenic SUI undergoing pAUSi between 2000 and 2022 in a tertiary centre were collected retrospectively. SURGICAL PROCEDURE: Thirty-three patients underwent OpAUSi and 32 underwent RApAUSi. OpAUSi cases were performed by a single surgeon, experienced in functional urology and prosthetic surgery. RApAUSi cases were performed by the same surgeon together with a second surgeon, experienced in robotic surgery. MEASUREMENTS: Outcome measures were achievement of complete urinary continence, intra- and postoperative complications, and surgical revision-free survival (SRFS). RESULTS AND LIMITATIONS: RApAUSi showed superior results to OpAUSi in terms of median (interquartile range) operative time (RApAUSi: 170 [150-210] min vs OpAUSi: 245 [228-300] min; p < 0.001), estimated blood loss (RApAUSi: 20 [0-50] ml vs OpAUSi: 500 [350-700] ml; p < 0.001), and median length of hospital stay (LOS; RApAUSi: 5 [4-6] d vs OpAUSi: 11 [10-14] d; p < 0.001). Clavien-Dindo grade ≥3a complications occurred more frequently after OpAUSi (RApAUSi: 1/32 [3%] vs OpAUSi: 10/33 [30%]; p = 0.014). Achievement of complete urinary continence (zero pads) was comparable between the groups (RApAUSi: 24/32 [75%] vs OpAUSi: 24/33 [73%]; p = 0.500). The median follow-up periods were 118 (50-183) and 56 (25-84) mo for OpAUSi and RApAUSi, respectively (p < 0.001). A tendency towards longer SRFS was observed in the RApAUSi group (p = 0.076). The main study limitation was its retrospective nature. CONCLUSIONS: RApAUSi is an efficient alternative to OpAUSi, resulting in shorter operative times, less blood loss, fewer severe complications, and a shorter LOS with similar functional results and need for revision surgery. PATIENT SUMMARY: Compared with open periprostatic artificial urinary sphincter implantation (pAUSi), robot-assisted pAUSi leads to faster recovery and similar functional results, with fewer postoperative complications.

If not now, then when? The need for new evidence in the robotic management of upper tract urothelial carcinoma.

Current guidelines recommend radical nephroureterectomy with bladder cuff excision as the standard surgical treatment for high-risk upper tract urothelial carcinoma (UTUC). While large evidence is available regarding open and laparoscopic nephroureterectomy, data focusing on robotic nephroureterectomy (RNU) in UTUC are mostly limited with mixed results, especially in locally advanced disease. In light of the recent introduction of new robotic platforms, it is of utmost importance to further investigate oncologic outcomes associated with RNU. Moreover, stronger data exploring different operative settings (i.e. robotic arms and trocars placement) for the new robotic systems are eagerly warranted. To give an answer to such open clinical questions, the Junior ERUS/Young Academic Urologist Working Group on Robot-assisted Surgery designed a multicentric project involving different high-volume centers across the world. The aim of the study will be exploring surgical and oncologic outcomes of RNU, specifically focusing on several clinical unmet needs, such as best operative setting for new robotic platforms, lymph node dissection (LDN) template and robotic bladder cuff management.

Atlas of Intracorporeal Orthotopic Neobladder Techniques After Robot-assisted Radical Cystectomy and Systematic Review of Clinical Outcomes.

BACKGROUND: Multiple and heterogeneous techniques have been described for orthotopic neobladder (ONB) reconstruction after robot-assisted radical cystectomy. Nonetheless, a systematic assessment of all the available options is lacking. OBJECTIVE: To provide the first comprehensive step-by-step description of all the available techniques for robotic intracorporeal ONB together with individual intraoperative, perioperative and functional outcomes based on a systematic review of the literature. DESIGN, SETTING, AND PARTICIPANTS: We performed a systematic review of the literature, and MEDLINE/PubMed, Embase, Scopus, and Web of Science databases were searched to identify original articles describing different robotic intracorporeal ONB techniques and reporting intra- and perioperative outcomes. Studies were categorized according to ONB type, providing a synthesis of the current evidence. Video material was provided by experts in the field to illustrate the surgical technique of each intracorporeal ONB. SURGICAL PROCEDURE: Nine different ONB types were identified: Studer, Hautmann, Y shape, U shape, Bordeaux, Pyramid, Shell, Florence Robotic Intracorporeal Neobladder, and Padua Ileal Neobladder. MEASUREMENTS: Continuous and categorical variables are presented as mean ± standard deviation and as frequencies and proportions, respectively. RESULTS AND LIMITATIONS: Of 2587 studies identified, 19 met our inclusion criteria. No cohort studies or randomized control trials comparing different neobladder types are available. Available techniques for intracorporeal robotic ONB reconstruction have similar operative time, estimated blood loss, intraoperative complications, and length of stay. Major variability exists concerning postoperative complications and functional outcomes, likely related to reporting bias. CONCLUSIONS: Several techniques are described for intracorporeal ONB during robot-assisted radical cystectomy with comparable perioperative outcomes. We provide the first step-by-step surgical atlas for robot-assisted ONB reconstruction. Further comparative studies are needed to assess any advantage of one technique over others. PATIENT SUMMARY: Patients elected for radical cystectomy should be aware that multiple techniques for robotic orthotopic neobladder are available, but that current evidence does not favor one type over the others.

The Changing Landscape of Systemic Therapy in the Treatment of Synchronous Metastatic Hormone-sensitive Prostate Cancer.

INTRODUCTION: To describe the changes in systemic treatments (ST) of synchronous metastatic hormone-sensitive prostate cancer (mHSPC) patients in a "real-world" setting and to explore reasons why contemporary standard of care (SOC) was not administrated to the patient. PATIENTS AND METHODS: Since 2014, we prospectively register mHSPCpatients. Patients were grouped in 4 time periods: group 1 (Time period 1, January 2014-July 2015), group 2 after introduction of docetaxel (Time period 2, August 2015-July 2017), group 3 after introduction of abiraterone acetate (Time period 3, August 2017-February 2018) and group 4 after introduction of apalutamide (Time period 4, March 2018-October 2021). For every time period, we evaluated the initiated additional ST. In case patients received treatment that differed from contemporary SOC according to guidelines, reasons for this difference were explored. RESULTS: In total, 243 patients were included. A progressive decline in ADT monotherapy from 85% to 29% over time was observed. The proportion of patients receiving additional STs increased from 34% to 59%. Forty percent of patients were not treated according to contemporary SOC, but this percentage varied strongly per time period (10%, 67%, 53%, and 32% from time period 1 to time period 4 respectively). Reasons for these variations were heterogenous and varied across the 4 time periods. Patients being unfit for treatment and treating physicians failing to consider additional STs were the most prevalent reasons. The proportion of patients unfit for additional ST decreased from 18% to 4% over time. CONCLUSION: Use of ADT monotherapy declined gradually after the introduction of additional systemic treatments. The proportion of patients unfit for additional ST declined as more treatments became available. Although compliance to SOC increased over time, these real-world data show that adherence to clinical practice guidelines remains suboptimal. Efforts should be made by clinicians to increase the adherence to practice guidelines.

Is It Safe to Switch from a Standard Anterior to Retzius-Sparing Approach in Robot-Assisted Radical Prostatectomy?

BACKGROUND: Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has been shown to lead to better outcomes regarding early continence compared to standard anterior RARP (SA-RARP). The goal of this study was to assess the feasibility and safety of implementing RS-RARP in a tertiary center with experience in SA-RARP. METHODS: From February 2020, all newly diagnosed non-metastatic prostate cancer patients for whom RARP was indicated were evaluated for RS-RARP. Data from the first 100 RS-RARP patients were prospectively collected and compared with data from the last 100 SA-RARP patients. Patients were evaluated for Clavien Dindo grade ≥3a complications, urinary continence after 2 and 6 weeks, 3, 6 and 12 months, erectile function, positive surgical margins (PSMs) and biochemical recurrence (BCR). RESULTS: There was no significant difference in postoperative complications at Clavien-Dindo grade ≥3a (SA-RARP: 6, RS-RARP: 4; p = 0.292). At all time points, significantly higher proportions of RS-RARP patients were continent (p < 0.001). No significant differences in postoperative potency were observed (52% vs. 59%, respectively, p = 0.608). PSMs were more frequent in the RS-RARP group (43% vs. 29%, p = 0.034), especially in locally advanced tumors (pT3: 64.6% vs. 43.8%, p = 0.041-pT2: 23.5% vs. 15.4%, p = 0.329). The one-year BCR-free survival was 82.6% vs. 81.6% in the SA-RARP and RS-RARP groups, respectively (p = 0.567). The median follow-up was 22 [18-27] vs. 24.5 [17-35] months in the RS-RARP and SA-RARP groups, respectively (p = 0.008). CONCLUSIONS: The transition from SA-RARP to RS-RARP can be safely performed by surgeons proficient in SA-RARP. Continence results after RS-RARP were significantly better at any time point. A higher proportion of PSMs was observed, although it did not result in a worse BCR-free survival.

A Novel Three-dimensional Planning Tool for Selective Clamping During Partial Nephrectomy: Validation of a Perfusion Zone Algorithm.

BACKGROUND: Selective clamping during robot-assisted partial nephrectomy (RAPN) requires extensive knowledge on patient-specific renal vasculature, obtained through imaging. OBJECTIVE: To validate an in-house developed perfusion zone algorithm that provides patient-specific three-dimensional (3D) renal perfusion information. DESIGN, SETTING, AND PARTICIPANTS: Between October 2020 and June 2022, 25 patients undergoing RAPN at Ghent University Hospital were included. Three-dimensional models, based on preoperative computed tomography (CT) scans, showed the clamped artery's ischemic zone, as calculated by the algorithm. SURGICAL PROCEDURE: All patients underwent selective clamping during RAPN. Indocyanine green (ICG) was administered to visualize the true ischemic zone perioperatively. Surgery was recorded for a postoperative analysis. MEASUREMENTS: The true ischemic zone of the clamped artery was compared with the ischemic zone predicted by the algorithm through two metrics: (1) total ischemic zone overlap and (2) tumor ischemic zone overlap. Six urologists assessed metric 1; metric 2 was assessed objectively by the authors. RESULTS AND LIMITATIONS: In 92% of the cases, the algorithm was sufficiently accurate to plan a selective clamping strategy. Metric 1 showed an average score of 4.28 out of 5. Metric 2 showed an average score of 4.14 out of 5. A first limitation is that ICG can be evaluated only at the kidney surface. A second limitation is that mainly patients with impaired renal function are expected to benefit from this technology, but contrast-enhanced CT is required at present. CONCLUSIONS: The proposed new tool demonstrated high accuracy when planning selective clamping for RAPN. A follow-up prospective study is needed to determine the tool's clinical added value. PATIENT SUMMARY: In partial nephrectomy, the surgeon has no information on which specific arterial branches perfuse the kidney tumor. We developed a surgeon support system that visualizes the perfusion zones of all arteries on a three-dimensional model and indicates the correct arteries to clamp. In this study, we validate this tool.

Holmium Laser Enucleation of the Prostate vs Robot-Assisted Simple Prostatectomy for Lower Urinary Tract Symptoms in Patients with Extremely Large Prostates ≥200 cc: A Comparative Analysis.

Introduction and Objectives: Robot-assisted simple prostatectomy (RASP) and holmium laser enucleation of the prostate (HoLEP) are both well-established, minimally invasive surgical treatment options for lower urinary tract symptoms caused by benign prostatic enlargement. We have reported the first comparative analysis of both techniques in patients with prostates of ≥200 cc. Materials and Methods: Between 2009 and 2020 a total of 53 patients with a prostate volume of ≥200 cc were surgically treated at OLV Hospital Aalst (Belgium): 31 underwent RASP and 22 underwent HoLEP. Preoperative and postoperative assessments included uroflowmetry with maximum urinary flow rate (Qmax) and postvoid residual volume (PVR), as well as the International Prostate Symptom Score (IPSS) and quality of life (IPSS-QoL). The complication rates were evaluated according to the Clavien-Dindo Classification. Results: Patients treated with RASP had significantly larger prostate volumes compared with HoLEP (median 226 cc vs 204.5 cc, p = 0.004). After a median follow-up of 14 months, both groups showed a significant improvement in the maximum flow rate (+10.60 mL/s vs +10.70 mL/s, p = 0.724) and a reduction of the IPSS score (-12.50 vs -9, p = 0.246) as well as improvement of the QoL (-3 vs -3, p = 0.880). Median operative time was similar in both groups (150 minutes vs 132.5 minutes, p = 0.665). The amount of resected tissue was lower in the RASP group (134.5 g vs 180 g, p = 0.029) and there was no significant difference in postoperative prostate-specific antigen (1.2 ng/mL vs 0.8 ng/mL, p = 0.112). Despite a similar median catheterization time (3 days vs 2 days, p = 0.748), the median hospitalization time was shorter in the HoLEP group (4 days vs 3 days, p = 0.052). Complication rates were similar in both groups (32% vs 36%, p = 0.987). Conclusion: Our results suggest similar outcomes for RASP and HoLEP in patients with very large prostates ≥200 cc. These findings will require external validation at other high-volume centers.

Discrimination, Reliability, Sensitivity, and Specificity of Robotic Surgical Proficiency Assessment With Global Evaluative Assessment of Robotic Skills and Binary Scoring Metrics: Results From a Randomized Controlled Trial.

Objective: To compare binary metrics and Global Evaluative Assessment of Robotic Skills (GEARS) evaluations of training outcome assessments for reliability, sensitivity, and specificity. Background: GEARS-Likert-scale skills assessment are a widely accepted tool for robotic surgical training outcome evaluations. Proficiency-based progression (PBP) training is another methodology but uses binary performance metrics for evaluations. Methods: In a prospective, randomized, and blinded study, we compared conventional with PBP training for a robotic suturing, knot-tying anastomosis task. Thirty-six surgical residents from 16 Belgium residency programs were randomized. In the skills laboratory, the PBP group trained until they demonstrated a quantitatively defined proficiency benchmark. The conventional group were yoked to the same training time but without the proficiency requirement. The final trial was video recorded and assessed with binary metrics and GEARS by robotic surgeons blinded to individual, group, and residency program. Sensitivity and specificity of the two assessment methods were evaluated with area under the curve (AUC) and receiver operating characteristics (ROC) curves. Results: The PBP group made 42% fewer objectively assessed performance errors than the conventional group (P < 0.001) and scored 15% better on the GEARS assessment (P = 0.033). The mean interrater reliability for binary metrics and GEARS was 0.87 and 0.38, respectively. Binary total error metrics AUC was 97% and for GEARS 85%. With a sensitivity threshold of 0.8, false positives rates were 3% and 25% for, respectively, the binary and GEARS assessments. Conclusions: Binary metrics for scoring a robotic VUA task demonstrated better psychometric properties than the GEARS assessment.

Epidemiology of Pediatric Tuberculosis and Factors Associated with Unsuccessful Treatment Outcomes in the Centre Region of Cameroon: A Three-Year Retrospective Cohort Study.

Background: In Cameroon, there are limited data on treatment outcomes of pediatric tuberculosis (TB). We sought to identify the factors associated with unsuccessful treatment outcomes and the risk factors for mortality among children receiving TB treatment in the Centre Region of Cameroon. Methods: This was a multicentre facility-based retrospective cohort study using routinely collected programmatic data. All children <15 years old treated for TB between 2018 and 2020 in 21 health facilities were included. We assessed risk factors for experiencing an unsuccessful treatment outcome and mortality through multivariable logistic regression analysis. Results: Of the 610 children with TB, 307 (50.3%) were females and the median age was 6 years (IQR = 2-12). One hundred and fifty-three (25.1%) of the children were TB/HIV co-infected patients. TB treatment success (cases categorized as cured and completed treatment) was observed in 488 (80.0%) of the patients. Unsuccessful treatment outcomes were experienced by 122 (20.0%) children. Of these, 73 (12.0%) died, 4 (0.6%) had treatment failure, 25 (4.1%) were lost to follow-up, and the outcomes of 20 (3.3%) children were not evaluated. In multivariable analysis, HIV-positive status (adjusted odds ratio [AOR] = 2.43; 95% CI, 1.55-3.80, p < 0.001) and clinical method of TB diagnosis (AOR = 2.46; 95% CI, 1.55-3.91, p < 0.001] were associated with unsuccessful treatment outcomes. HIV-positive status (AOR = 4.23; 95% CI, 2.44-7.33, p < 0.001) and clinical method of TB diagnosis (AOR = 2.22; 95% CI, 1.25-3.91, p=0.006) were the risk factors for mortality among children on TB treatment. Conclusion: The study found that HIV-TB co-infected children and those clinically diagnosed with TB were significantly more likely to have had unsuccessful TB treatment outcomes and mortality. Our findings underscore the need for healthcare workers to closely monitor and support HIV-TB co-infected children on TB treatment. TB/HIV collaborative activities should be strengthened by implementing TB preventive interventions among HIV-infected children.

Knowledge, Attitude, and Practice on Pediatric Tuberculosis Management among Healthcare Workers in the Centre Region of Cameroon: A Cross-Sectional Study.

Background: This study was designed to assess the level of knowledge, attitude, and practice (KAP) of healthcare workers (HCWs) on pediatric TB management and its associated factors in the Centre Region of Cameroon. Methods: A cross-sectional study was conducted between January and March 2022. HCWs, selected through a multistage sampling technique in 21 health facilities, were interviewed using a KAP questionnaire on pediatric TB management. Logistic regression analyses were used to test associations between HCWs' characteristics and knowledge, attitudes, and practice levels at a 0.05 level of significance. Results: The median age of the participants was 35 years (IQR = 30-42), and the majority (73.2%) were females. About half (50.9%) of the participants (173/340) had good knowledge, 55.6% (189/340) had a good attitude, and 57.1% (194/340) had good practice scores on pediatric TB management. Having a bachelor's degree and above, working in the TB unit, and having received training on pediatric TB in the last five years were significantly associated with good knowledge of pediatric TB management. Similarly, having a bachelor's degree or higher and more than five years of experience providing TB services were significantly associated with a good attitude towards pediatric TB management. Being a general practitioner, nurse, and lab technician was significantly associated with good practice in pediatric TB management. Conclusion: The level of knowledge, attitude, and practice on pediatric TB management among HCWs was suboptimal, as substantial gaps were identified. The Ministry of Health and other international organizations need to prioritize training, coaching, and mentoring support to help HCWs improve their knowledge, attitude, and practice to detect, diagnose, and treat pediatric TB.

Retzius-Sparing Robot-Assisted Radical Prostatectomy.

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The technique is described step-by-step and further illustrated by a video to enhance reproducibility. Early oncological and functional results were evaluated. In total, 77 patients were included with a median follow-up of 11 months (range: 3-21 months). Fifty-one percent of patients had local high-risk or locally advanced prostate cancer. There were no intra-operative complications, and all high-grade complications (2.6%) were related to pelvic lymph node dissection performed concomitant with RS-RARP. Median operation time was 160 min (range: 122-265 min) and median hospital stay was 3 (range: 3-8) days. A positive surgical margin was reported in 42.9%. One-year biochemical recurrence-free survival was 90.1%. After 6 months, all patients were socially continent and after 1 year, 94.3% were fully continent. Of sexually active patients who underwent at least unilateral nerve-sparing, 43.3% were able to have sexual intercourse. This series underlines the surgical safety of performing RS-RARP by a standardized technique and confirms the beneficial effect on the early return of continence. The patient needs to be informed about the risk of a positive surgical margin.

Intracorporeal Versus Extracorporeal Robot-assisted Kidney Autotransplantation: Experience of the ERUS RAKT Working Group.

BACKGROUND: Kidney autotransplantation is a useful technique to be reserved for cases in which kidney function is compromised by a complex anatomical configuration, such as long ureteral strictures and renal vascular anomalies not suitable for in situ reconstruction. Robot-assisted kidney autotransplantation (RAKAT) presents a novel, minimally invasive, and highly accurate approach. OBJECTIVE: The aim of this study is to present the largest cohort of patients who underwent either extracorporeal (eRAKAT) or intracorporeal (iRAKAT) RAKAT, to confirm safety and feasibility and to compare the two approaches. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively analyzed prospectively followed patients undergoing eRAKAT and totally intracorporeal RAKAT in a total of three institutions. SURGICAL PROCEDURE: Extracorporeal RAKAT and iRAKAT. MEASUREMENTS: Surgical and functional outcomes of patients subjected to eRAKAT and iRAKAT were measured. RESULTS AND LIMITATIONS: Between January 2017 and February 2021, 29 patients underwent RAKAT: 15 eRAKAT and 14 iRAKAT. No statistical difference in the preoperative data was recorded. The analysis of intraoperative variables showed a statistically significant difference between eRAKAT and iRAKAT in cold ischemia time (median [interquartile range {IQR}]: 151 [125-199] vs 27.5 [20-55]; p <  0.001) and total ischemia time (median [IQR]: 196.2 [182-241] vs 81.5 [73-88]; p <  0.001). However, faster renal function recovery in favor of eRAKAT was observed during the first 90 d, with comparable renal function at 1 yr. The 90-d Clavien-Dindo >2 complications were 13.8%. It is important to stress that RAKAT, and above all iRAKAT, should be performed by surgeons with experience in robotic renal, vascular, and transplant surgery. CONCLUSIONS: Both eRAKAT and iRAKAT represent promising minimally invasive techniques in selected cases with acceptable ischemia time and comparable long-term operative outcomes. PATIENT SUMMARY: In selected patients, both extra- and intracorporeal robot-assisted kidney autotransplantation represent valid alternatives in case of long ureteral strictures and renal vascular anomalies not suitable for in situ reconstruction.

How I do it: Buttonholing the preputial hood in hypospadias repair-related ventral skin shortage.

Gaining an esthetical skin coverage can be challenging in some hypospadias repair cases, especially in those with significant ventral skin paucity. A local institutional technique used to correct ventral skin paucity in hypospadias is described. It consists of a redistribution of the abundant dorsal skin and its hooded prepuce to the ventral side of the penis where skin shortage is observed. Reallocation of the skin is performed by buttonholing the dorsal skin to the ventral side. This versatile technique can be adapted to most penile surgeries where some ventral skin paucity is observed.

The Effect of Surgical Experience on Perioperative and Oncological Outcomes After Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Evidence from a Referral Centre with Extensive Experience in Robotic Surgery.

BACKGROUND: Evidence on the learning curve for robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is limited. OBJECTIVE: To assess the effect of surgical experience (SE) on perioperative and intermediate-term oncological outcomes in a large contemporary cohort of RARC patients after accounting for the impact of intersurgeon variability. DESIGN, SETTING, AND PARTICIPANTS: The study cohort included 164 patients treated with RARC and ICUD by two surgeons between 2004 and 2017 at a single European referral centre. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: For each patient, SE was defined as the total number of RARCs performed by each surgeon before the patient's operation. The relationship between SE and operative time (OT), lymph node yield (LNY), positive surgical margins (PSMs), Clavien-Dindo grade ≥2 30-d postoperative complication (CD≥2), and oncological outcomes (18-mo recurrence rate) was evaluated in multivariable linear and logistic regression models, clustering at a single-surgeon level. RESULTS AND LIMITATIONS: After adjusting for case mix, SE was associated with shorter OT (p= 0.003), lower probability of postoperative CD≥2 rates (p= 0.01), and lower 18-mo recurrence rates (p= 0.002). Conversely, SE did not predict lower PSM rates (p= 0.3) and higher LNY (p= 0.4). The relationship between SE and OT was nonlinear, with a plateau observed after 50 cases. Conversely, the relationship between SE and CD≥2 and 18-mo recurrence was linear without reaching a plateau after 88 procedures. CONCLUSIONS: SE affects perioperative and oncological outcomes after RARC with ICUD in a linear fashion, and its beneficial effect does not reach a plateau. Conversely, after 50 cases, no further improvement was observed for OT. PATIENT SUMMARY: Robot-assisted radical cystectomy with intracorporeal urinary diversion is a complex surgical procedure with a relatively long learning curve.