Current practice and unmet training needs in robotic-assisted radical prostatectomy: investigation from the Junior ERUS/YAU working group.

PURPOSE: To access the current scenario of robotic-assisted radical prostatectomy training in multiple centers worldwide. METHODS: We created a multiple-choice questionnaire assessing all details of robotic-assisted radical prostatectomy training with 41 questions divided into three different categories (responder demography, surgical steps, and responder experience). The questionnaire was created and disseminated using the "Google Docs" platform. All responders had an individual invitation by direct message or Email. We selected urologists who had recently finished a postgraduation urologic robotic surgery training (fellowship) in the last five years. We sent 624 invitations to urologists from 138 centers, from January 10th to April 10th, 2022. The answers were reported as percentages and illustrated in pie charts. RESULTS: The response rate was 58% among all centers invited (138/81), 20% among all individual invitations (122/624 answers). Globally, we gathered responses from 23 countries. Most surgeons were older than 34 years, 71% trained in an academic center, and 64% performed less than ten full RARP cases. Transperitoneal is the most common access, and 63% routinely opens the endopelvic fascia. Almost 90% perform the Rocco's stitch, and 94% perform the anastomosis with barbed sutures. Finally, only 31% of surgeons assisted more than 100 cases before moving to the console, and most surgeons (63.9%) performed less than ten full RARP cases during their training. CONCLUSION: By assessing the robotic-assisted radical prostatectomy training status in 23 countries and 81 centers worldwide, we assessed the trainees' demography, step-by-step surgical technique, training perspectives, and impressions of surgeons who trained in the last five years. This data is crucial for a better understanding the trainee's standpoint, addressing potential deficiencies, and implementing improvements needed in the training process. Our study clearly indicates elements of current training modalities that are prone to major improvement.

Label-Free SERS of Urine Components: A Powerful Tool for Discriminating Renal Cell Carcinoma through Multivariate Analysis and Machine Learning Techniques.

The advent of Surface-Enhanced Raman Scattering (SERS) has enabled the exploration and detection of small molecules, particularly in biological fluids such as serum, blood plasma, urine, saliva, and tears. SERS has been proposed as a simple diagnostic technique for various diseases, including cancer. Renal cell carcinoma (RCC) ranks as the sixth most commonly diagnosed cancer in men and is often asymptomatic, with detection occurring incidentally. The onset of symptoms typically aligns with advanced disease, aggressive histology, and unfavorable prognosis, and therefore new methods for an early diagnosis are needed. In this study, we investigated the utility of label-free SERS in urine, coupled with two multivariate analysis approaches: Principal Component Analysis combined with Linear Discriminant Analysis (PCA-LDA) and Support Vector Machine (SVM), to discriminate between 50 RCC patients and 44 healthy donors. Employing LDA-PCA, we achieved a discrimination accuracy of 100% using 13 principal components, and an 88% accuracy in discriminating between different RCC stages. The SVM approach yielded a training accuracy of 100%, a validation accuracy of 99% for discriminating between RCC and controls, and an 80% accuracy for discriminating between stages. The comparative analysis of raw and normalized SERS spectral data shows that while raw data disclose relative concentration variations in urine metabolites between the two classes, the normalization of spectral data significantly improves the accuracy of discrimination. Moreover, the selection of principal components with markedly distinct scores between the two classes serves to alleviate overfitting risks and reduces the number of components employed for discrimination. We obtained the accuracy of the discrimination between the RCC patients cases and healthy donors of 90% for three PCs and a linear discrimination function, and a 88% accuracy of discrimination between stages using six PCs, mitigating practically the risk of overfitting and increasing the robustness of our analysis. Our findings underscore the potential of label-free SERS of urine in conjunction with chemometrics for non-invasive and early RCC detection.

Kidney transplantation from elderly donors (> 70 years): a systematic review.

PURPOSE: The incidence of kidney transplants from elderly donors over 70 years of age has increased significantly over the past 10 years to reach 20% of available kidney graft in some European countries. However, there is little data available on the outcomes of transplants from these donors. We performed a systematic review to evaluate the outcomes of transplantation from donors over 70 years of age. METHODS: A systematic review was performed according to preferred reporting items for systematic reviews and meta-analyses. Medline, Embase, and Cochrane databases were searched to identify all studies reporting outcomes on kidney transplants from donors over 70 years. Due to the heterogeneity of the studies, a meta-analysis could not be performed. RESULTS: A total of 29,765 patients in 27 studies were included. The mean donors age was 74.79 years, and proportion of kidney graft from women was 53.54%. The estimated 1- and 5-year kidney death-censored graft survivals from donors > 70 years old were, respectively, 85.95 and 80.27%, and the patient survivals were 90.88 and 71.29%. The occurrence of delayed graft function was 41.75%, and primary non-function was 4.67%. Estimated graft function at 1 and 5 years was 36 and 38 mL/min/1.73 m2. Paucity data were available on post-operative complications. CONCLUSIONS: Elderly donors appear to be a reliable source of grafts. However, these transplants are associated with a high rate of delayed graft function without repercussion on long-term graft survival. Allocation strategy to elderly recipients is the main factor of decreased recipient survival.

Systematic review of techniques and devices used to avoid warm ischemia time injury during kidney transplantation.

PURPOSE: The lack of a reliable and reproducible technique to ensure a constantly low temperature of the graft during kidney transplantation (KT) may be a cause of renal nonfunction. The aim of this review was to assess all the methods and devices available to ensure hypothermia during vascular anastomosis in KT. METHODS: A literature search was conducted through May 2022 using PubMed/Medline, Cochrane Library, Embase and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The review protocol was registered on PROSPERO (CRD42022326550). RESULTS: A total of 20 studies reporting on four hypothermia techniques met our inclusion criteria. Simple instillation of cold serum is not sufficient, the graft reaching up to 33 ℃ at the end of warm ischemia time (WIT). Plastic bags filled with ice slush have questionable efficiency. The use of a gauze jacket filled with ice-slush was reported in 12/20 studies. It ensures a graft temperature up to 20.3 ℃ at the end of WIT. Some concerns have been linked to potentially inhomogeneous parenchymal cooling and secondary ileus. Novel devices with continuous flow of ice-cold solution around the graft might overcome these limitations, showing a renal temperature below 20 ℃ at all times during KT. CONCLUSION: The gauze filled with ice slush is the most common technique, but several aspects can be improved. Novel devices in the form of cold-ischemia jackets can ensure a lower and more stable temperature of the graft during KT, leading to higher efficiency and reproducibility.

Effectiveness of endourological management of ureteral stenosis in kidney transplant patients: EAU-YAU kidney transplantation working group collaboration.

PURPOSE: Ureteral stenosis (US) in kidney transplant (KT) recipients is associated with poorer long-term graft survival. Surgical repair is the standard of care, and endoscopic treatment represents an alternative for stenosis < 3 cm. We aimed to determine the effectiveness and safety of endourological management of US in KT patients and predictors of failure. METHODS: A retrospective multicenter study was conducted in four European referral centers, including all KT patients with US managed endoscopically between 2009 and 2021. Clinical success was defined as the absence of upper urinary tract catheterization, surgical repair or transplantectomy during follow-up. RESULTS: A total of 44 patients were included. The median time to US onset was 3.5 months (IQR 1.9-10.8), the median length of stricture was 10 mm (IQR 7-20). Management of US involved balloon dilation and laser incision in 34 (79.1%) and 6 (13.9%) cases, respectively, while 2 (4.7%) received both. Clavien-Dindo complications were infrequent (10%); only one Clavien ≥ III complication was reported. Clinical success was 61% at last follow-up visit (median = 44.6 months). In the bivariate analysis, duckbill-shaped stenosis (vs. flat/concave) was associated with treatment success (RR = 0.39, p = 0.04, 95% CI 0.12-0.76), while late-onset stenosis (> 3 months post KT) with treatment failure (RR = 2.00, p = 0.02, 95% CI 1.01-3.95). CONCLUSIONS: Considering the acceptable long-term results and the safety of these procedures, we believe that the endoscopic treatment should be offered as a first-line therapy for selected KT patients with US. Those with a short and duckbill-shaped stenosis diagnosed within 3 months of KT seem to be the best candidates.

Integration of Virtual Reality in the Control System of an Innovative Medical Robot for Single-Incision Laparoscopic Surgery.

In recent years, there has been an expansion in the development of simulators that use virtual reality (VR) as a learning tool. In surgery where robots are used, VR serves as a revolutionary technology to help medical doctors train in using these robotic systems and accumulate knowledge without risk. This article presents a study in which VR is used to create a simulator designed for robotically assisted single-uniport surgery. The control of the surgical robotic system is achieved using voice commands for laparoscopic camera positioning and via a user interface developed using the Visual Studio program that connects a wristband equipped with sensors attached to the user's hand for the manipulation of the active instruments. The software consists of the user interface and the VR application via the TCP/IP communication protocol. To study the evolution of the performance of this virtual system, 15 people were involved in the experimental evaluation of the VR simulator built for the robotic surgical system, having to complete a medically relevant task. The experimental data validated the initial solution, which will be further developed.

Outcomes of Salvage Robotic-assisted Radical Prostatectomy in the last decade: systematic review and perspectives of referral centers.

PURPOSE: Salvage robotic-assisted radical prostatectomy (S-RARP) has gained prominence in recent years for treating patients with cancer recurrence following non-surgical treatments of Prostate Cancer. We conducted a systematic literature review to evaluate the role and outcomes of S-RARP over the past decade. MATERIAL AND METHODS: A systematic review was conducted, encompassing articles published between January 1st, 2013, and June 1st, 2023, on S-RARP outcomes. Articles were screened according to PRISMA guidelines, resulting in 33 selected studies. Data were extracted, including patient demographics, operative times, complications, functional outcomes, and oncological outcomes. RESULTS: Among 1,630 patients from 33 studies, radiotherapy was the most common primary treatment (42%). Operative times ranged from 110 to 303 minutes, with estimated blood loss between 50 to 745 mL. Intraoperative complications occurred in 0 to 9% of cases, while postoperative complications ranged from 0 to 90% (Clavien 1-5). Continence rates varied (from 0 to 100%), and potency rates ranged from 0 to 66.7%. Positive surgical margins were reported up to 65.6%, and biochemical recurrence ranged from 0 to 57%. CONCLUSION: Salvage robotic-assisted radical prostatectomy in patients with cancer recurrence after previous prostate cancer treatment is safe and feasible. The literature is based on retrospective studies with inherent limitations describing low rates of intraoperative complications and small blood loss. However, potency and continence rates are largely reduced compared to the primary RARP series, despite the type of the primary treatment. Better-designed studies to assess the long-term outcomes and individually specify each primary therapy impact on the salvage treatment are still needed. Future articles should be more specific and provide more details regarding the previous therapies and S-RARP surgical techniques.

Robotic Radical Cystectomy with Intracorporeal Urinary Diversion - Tips and Tricks.

Radical cystectomy represents the standard surgical treatment in case of muscle invasive bladder cancer. During the last two decades a change in the surgical approach of the MIBC has been observed, from open surgery to minimal invasive surgery. Nowadays, in the majority of tertiary urologic centers, robotic radical cystectomy with intracorporeal urinary diversion represents the standard surgical approach. The aim of the current study is to describe in detail the surgical steps of the robotic radical cystectomy and the reconstruction of the urinary diversion and to present our experience. From the surgical point of view, the most important principles which should guide the surgeon when performing this procedure are: 1. Good working place and access both to the pelvis and abdomen and use of the "technique of spaces" 2. Respect the oncological principles of the surgery with attention to the margin resection and limitation of the risk of tumour spillage; 3. Attention to both the ureter and bowel manipulation in order to avoid grasping lesions; 4. High care in realisation of the uretero-ileal anastomosis so that good long term functional results are achieved. We analyzed our database of 213 patients diagnosed with muscle invasive bladder cancer who underwent minimally invasive radical cystectomy (laparoscopic and robotic approaches) between January 2010 and December 2022. We identified 25 patients for whom the robotic approach was used to perform the surgery. Despite being one of the most challenging urologic surgical procedures, with careful preparation and training, the surgeon is able to achieve the maximum oncological and functional results by performing robotic radical cystectomy with intracorporeal urinary.

Systematic review on oncologic outcomes on adjuvant endovesical treatment for non-muscle invasive bladder cancer in patients with solid organ transplant.

PURPOSE: Urothelial carcinoma has a higher incidence in renal transplanted patients according to several registries (relative risk × 3), and the global prognosis is inferior to the general population. The potential impact of immunosuppressive therapy on the feasibility, efficacy, and complications of endovesical treatment, especially Bacillus Calmette-Guerin, has a low level of evidence. We performed a systematic review that aimed to assess the morbidity and oncological outcomes of adjuvant endovesical treatment in solid organ transplanted patients. METHODS: Medline was searched up to December 2021 for all relevant publications reporting oncologic outcomes of endovesical treatment in solid organ transplanted patients with NMIBC. Data were synthesized in light of methodological and clinical heterogeneity. RESULTS: Twenty-three retrospective studies enrolling 238 patients were included: 206 (96%) kidney transplants, 5 (2%) liver transplants, and 2 (1%) heart transplants. Concerning staging: 25% were pTa, 62% were pT1, and 22% were CIS. 140/238 (59%) patients did not receive adjuvant treatment, 50/238 (21%) received mitomycin C, 4/238 (2%) received epirubicin, and 46/238 (19%) received BCG. Disease-free survival reached 35% with TURBT only vs. 47% with endovesical treatment (Chi-square test p = 0.08 OR 1.2 [0.98-1.53]). The complication rate of endovesical treatment was 12% and was all minor (Clavien-Dindo I). CONCLUSION: In solid organ transplanted patients under immunosuppressive treatment, both endovesical chemotherapy and BCG are safe, but the level of evidence concerning efficacy in comparison with the general population is low. According to these results, adjuvant treatment should be proposed for NMIC in transplanted patients as in the general population.

Adrenal Gland Primary Neuroblastoma in an Adult Patient: A Case Report and Literature Review.

Neuroblastoma (NB) is an undifferentiated malignant tumor of the sympathetic ganglia, occurring in children under 5 years of age. However, it is a rare histology in adult patients, occurring once per every 10 million patients per year. We present the case of a 68-year-old male patient presented to our department for right lumbar pain, asthenia, loss of weight and altered general status. The contrast-enhanced abdominal computer tomography revealed bilateral adrenal tumoral masses of 149 mm and 82 mm on the right and left sides, respectively, with invasion of the surrounding organs. The patient underwent right 3D laparoscopic adrenalectomy and right radical nephrectomy. The pathological result concluded that the excised tumor was a neuroblastoma of the adrenal gland. The patient followed adjuvant oncological treatment; however, due to disease progression, he passed away 22 months after the surgery. To our knowledge, less than 100 cases of adrenal NB in adult patients have been published, the eldest case being diagnosed at 75 years of age; meanwhile, the largest reported tumor measured 200 mm, and was excised through open surgery. Minimally invasive techniques have been limited so far to smaller, organ-confined diseases, thus making the present case the largest adrenal NB removed entirely laparoscopically. Neuroblastoma in the adult population is a rare finding, with worse prognosis compared to pediatric patients. The available literature does not provide enough data for standardized, multimodal management, as the patients are treated following adapted pediatric protocols, thus reinforcing the need for international, multidisciplinary boards for rare tumors.

Robot-assisted Boari flap and psoas hitch ureteric reimplantation: technique insight and outcomes of a case series with ≥1 year of follow-up.

OBJECTIVE: To describe step-by-step surgical techniques and report outcomes of the largest single-centre series of patients with distal ureteric disease exclusively treated with robot-assisted ureteric reimplantation with Boari flap (RABFUR) and psoas hitch (RAPHUR), with a minimum follow-up of 1 year and complete postoperative data. PATIENTS AND METHODS: A total of 37 patients with distal ureteric disease were treated between 2010 and 2018. Of these, 81% and 19% underwent RAPHUR and RABFUR, respectively. Intra-, peri- and postoperative outcomes were assessed. The 90-day postoperative complications were reported according to the standardised methodology proposed by the European Association of Urology Ad Hoc Panel. Functional outcomes (creatinine, estimated glomerular filtration rate [eGFR]) and postoperative symptoms (visual analogue pain scale) were assessed. RESULTS: The median operating time and blood loss were 180 min and 100 mL, respectively. There were no conversions to open surgery and no intraoperative transfusions. The median length of stay, bladder catheter indwelling time and stent removal were 4, 7 and 30 days, respectively. The median follow-up was 24 months. Overall, 10 patients (27%) had postoperative complications and of these, eight (22%) and two (5.4%) were Clavien-Dindo Grade I-II and III, respectively. At the last follow-up, the median postoperative creatinine level and eGFR were 0.9 mg/dL and 73.5 mL/min/1.73 m2 , respectively. At the last follow-up, five (13.5%) and three (8%) patients had Grade 1 hydronephrosis and mild urinary symptoms, respectively. The study limitations include its retrospective nature. CONCLUSION: In the present study, we present our RABFUR and RAPHUR techniques. We confirm the feasibility and safety profile of both approaches in patients with distal ureteric disease relying on the largest single-centre series with ≥1 year of follow-up.

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.

Combined Systematic and MRI-US Fusion Prostate Biopsy Has the Highest Grading Accuracy When Compared to Final Pathology.

Background and objectives: Systematic prostate biopsy (SB) has a low Gleason group (GG) accuracy when compared to final pathology. This may negatively impact the inclusion of patients into specific risk groups and treatment choice. The aim of our study was to assess the GG accuracy of magnetic resonance imaging-ultrasound (MRI-US) fusion prostate biopsy. Materials and Methods: Of a cohort of minimally invasive radical prostatectomy (RP), we selected all patients who were diagnosed with prostate cancer (PCa) via MRI-US fusion biopsy (n = 115). Results: Combined biopsy had the highest rate for GG concordance (61.7% vs. 60.4% for SB vs. 45.3% for MRI-US fusion biopsy) and the lowest for upgrading (20.9% vs. 24.5% for SB vs. 34.9% for MRI-US fusion biopsy), p < 0.0001. No clinical data were predictive for upgrading or downgrading at final pathology. Locally advanced PCa was associated with a high Prostate Imaging-Reporting and Data System (PIRADS) score (p = 0.0014) and higher percentages of positive biopsy cores (PBC)/targeted (p = 0.0002) and PBC/total (p = 0.01). Positive surgical margins were correlated with higher percentages of PBC/systematic (p = 0.003) and PBC/total (p = 0.009). Conclusions: Pre-biopsy prostate MRI improves GG concordance between biopsy and RP. Combined biopsy provides the highest grading accuracy when compared to final pathology. Targeted and systematic biopsy data are predictive for adverse pathologic outcomes.

Artificial intelligence and robotics: a combination that is changing the operating room.

PURPOSE: The aim of the current narrative review was to summarize the available evidence in the literature on artificial intelligence (AI) methods that have been applied during robotic surgery. METHODS: A narrative review of the literature was performed on MEDLINE/Pubmed and Scopus database on the topics of artificial intelligence, autonomous surgery, machine learning, robotic surgery, and surgical navigation, focusing on articles published between January 2015 and June 2019. All available evidences were analyzed and summarized herein after an interactive peer-review process of the panel. LITERATURE REVIEW: The preliminary results of the implementation of AI in clinical setting are encouraging. By providing a readout of the full telemetry and a sophisticated viewing console, robot-assisted surgery can be used to study and refine the application of AI in surgical practice. Machine learning approaches strengthen the feedback regarding surgical skills acquisition, efficiency of the surgical process, surgical guidance and prediction of postoperative outcomes. Tension-sensors on the robotic arms and the integration of augmented reality methods can help enhance the surgical experience and monitor organ movements. CONCLUSIONS: The use of AI in robotic surgery is expected to have a significant impact on future surgical training as well as enhance the surgical experience during a procedure. Both aim to realize precision surgery and thus to increase the quality of the surgical care. Implementation of AI in master-slave robotic surgery may allow for the careful, step-by-step consideration of autonomous robotic surgery.

The impact of minimal invasive surgery on early complications and mortality after radical cystectomy for muscle-invasive urothelial bladder cancer.

PURPOSE: to evaluate the 30-day death rate and the factors associated with short-term complications after radical cystectomy for muscle-invasive urothelial bladder cancer. METHODS: The study included 123 patients (age 64.1±7.9 years; 111 (90.2%) males and 12 (9.8%) females) previously diagnosed with urothelial bladder cancer, admitted for radical cystectomy in a tertiary center. The following data were noted: age, gender, perioperative chemotherapy and radiotherapy, pre- and postoperative hemoglobin and creatinine levels, tumor stage, type of surgery, type of diversion and Clavien classification. Patients were followed for 30 days and several complications were noted: cardiovascular, gastrointestinal, local, or infectious complications, anemia. Death rate was also recorded. RESULTS: Open cystectomy was performed in 81 (65.9%) patients, and laparoscopic approach was used in 43 (34.1%) patients. An ileal neobladder was created for 11 (8.9%) patients and noncontinent diversion for 112 (91.1%). There were 2 (1.6%) deaths following surgery. The following complication rates were noted: 27 local (22%), 16 infectious (13%), 54 cases of postoperative anemia (43.9%). Postoperative anemia was independently associated with open cystectomy (OR, 5.7; p=0.001), ileal neobladder (Odds ratio/OR, 14.6, p=0.002) and male gender (OR, 0.15, p=0.01). The Clavien classification did not differ between open and laparoscopic cystectomy (p=0.3), even though the complication grade was higher in the former. CONCLUSIONS: The 30-day death rate after radical cystectomy for muscle-invasive urothelial bladder cancer was low. Open cystectomy was associated with more severe short-term complications as compared with the laparoscopic approach. Postoperative anemia was associated with the type of surgery, diversion type and male gender.

Serum metabolomics can predict the outcome of first systematic transrectal prostate biopsy in patients with PSA <10 ng/ml.

AIM: To assess the predictive value of metabolomic analysis for the presence of prostate cancer (PCa) at first systematic biopsy. PATIENTS & METHODS: Ninety serum samples from patients with suspicion for PCa were included. Targeted and nontargeted metabolomic analysis was performed. RESULTS: Six metabolites were combined into a predictive score. A cutoff value of 0.528 for the metabolomic score showed a good accuracy for the prediction of PCa at biopsy (Area under the curve (AUC): 0.779; p < 0.001). These results were validated in a subgroup of patients, showing similar accuracy (p = 0.1). For patients with prostate specific antigen (PSA) less than 10 ng/ml, the score showed a Se 80.95%, Sp 64.52% for the detection of PCa at biopsy. CONCLUSION: Metabolomic analysis can predict the outcome of the first systematic biopsy.

The emerging role of obesity, diet and lipid metabolism in prostate cancer.

Obesity is associated with an increased risk of a number of serious medical conditions, including cancer. As far as prostate cancer is concerned, obesity is associated with an increased risk of high-grade tumors, which is possibly related to lower androgen levels. Diet may also affect prostate cancer risk since countries with a higher dietary fat intake also present higher prostate cancer mortality rates. Interestingly, prostate cancer is associated with a number of metabolic alterations that may provide valuable diagnostic and therapeutic targets. This review explores the available clinical as well as biological evidence supporting the relationship between obesity, diet, alteration in metabolic pathways and prostate cancer.

Every setback is a setup for a comeback: 3D laparoscopic radical prostatectomy after robotic radical prostatectomy.

PURPOSE: To assess whether previous experience in robotic surgery has a role in the transition to 3D laparoscopy and influences the perioperative results and short term oncological and functional outcomes of the first patients that undergo laparoscopic radical prostatectomy (LRP). METHODS: We analyzed 248 patients that underwent robotic radical prostatectomy (RALP) between 2009-2015 and 98 patients that underwent 3D HD LRP from 2015-present in our department. The procedures were performed by the same two surgeons, who crossed from open to robotic surgery, and afterwards to 3D laparoscopy. RESULTS: The patients in the study groups were comparable in terms of age, pre-operative PSA levels, clinical staging and D'Amico risk groups. The operative time was significantly shorter in favor of the laparoscopic approach (a difference of 110 min, p<0.0001). The overall rate of positive surgical margins was similar, with the biggest difference from 40.8% to 25% in pT3 patients in favor of the laparoscopic approach. The mean time to catheter removal was 7 days for RALP and 8 days for LRP. We did not identify any significant difference between the two groups in terms of biochemical recurrence, continence or potency at 3 and 6 months after the procedure. CONCLUSIONS: Previous experience in robotic surgery ensured a fast transition to 3D laparoscopic approach for radical prostatectomy, with comparable oncologic and functional outcomes, but with a shorter operative time and reduced costs.

Robotic-assisted radical prostatectomy - the 5-year Romanian experience.

PURPOSE: Radical prostatectomy is the standard therapeutic approach for localized prostate cancer. After the implementation of robotic surgery in Romania, the indication extended progressively to locally advanced prostate cancer. Our objective was to evaluate the oncological and functional outcomes in patients undergoing robotic-assisted radical prostatectomy (RARP), 5 years after the first intervention in Romania. METHODS: Between November 2009 and July 2014, 207 RARPs were performed using the da Vinci SI Surgical System. Perioperative data were prospectively collected. The oncological and functional follow-up was up to 55 months (range 3-55). RESULTS: Patient stratification according to D'Amico risk categories was 16% low risk, 56.7% intermediate risk and 27.3% high risk. Median console time was 210 min (range 160-360). Median blood loss was 300 ml (range 50-1300), transfusion being required in 2.9% of the cases. Histopathological examinations showed pT3 in 40.8% of the cases, with a positive surgical margin rate of 21.1%, 13.6% for pT2, and 32.1% for pT3. Continence rate (0-1 daily safety pad) at 6, 12, 24 and 55 months was 88.3, 88.8, 90.1, and 93.7% respectively. Overall sexual function restoration rate at 6, 12, 24 and 55 months was 41.1, 44.4, 47.4 and 53%, respectively. Biochemical recurrence rate during follow-up was 6.9%. CONCLUSIONS: RARP is a minimally invasive therapeutic approach for prostate cancer, with acceptable outcomes, even in countries such as Romania, where the detection rate for localized prostate cancer is lower compared to other European countries due to lack of national screening programs.

Right Radical Nephrectomy With Level IV Thrombus by Combined 3D Laparoscopic and Mini-thoracotomy Approach.

OBJECTIVE: To report our step-by-step technique for 3D laparoscopic radical nephrectomy and thrombectomy for a right renal tumor with level IV venous thrombus. Worldwide experience in minimally-invasive approach for such complex cases is limited. MATERIALS AND METHODS: A 66-year-old male was incidentally diagnosed with a right renal tumor. He had a medical history of hypertension and benign prostatic hyperplasia. Blood test analysis showed a hemoglobin of 11.2 g/dL and creatinine of 0.92 mg/dL. Liver function and bilirubin were within normal limits. Contrast-enhanced abdominal CT scan showed an 90/77/85 mm right renal mass with a level IV inferior vena cava (IVC) tumor thrombus. Cardiac MRI showed that the tumor thrombus was extending into the right atrium, through the tricuspid valve and into the right ventricle. There was no evidence of distant metastases. After a multidisciplinary team reviewed the case, the patient was scheduled for 3D laparoscopic radical nephrectomy and thrombectomy by mini-thoracotomy approach RESULTS: Retroperitoneal laparoscopic approach was used to ensure rapid access on the renal artery, with minimal mobilization of the renal vein, and to better isolate the posterior wall of the IVC. Surgery continued with the transperitoneal approach and the isolation of the infrarenal and infrahepatic IVC and left renal vein. Meanwhile the right femoral artery and vein and right jugular vein were cannulated. Mini-thoracotomy was performed and cardiopulmonary by-pass was started. Blood flow through the IVC and left renal vein was stopped, and the right atrium was opened to control the thrombus. Cavotomy was performed at the level of right renal hilum and the tumor thrombus was identified and sectioned. There were no signs of thrombus adherence to the IVC wall. The thoracic segment of the thrombus was completely extracted by the cardiovascular surgeons. Pringle maneuver was not necessary, as there was no retrograde bleeding. No intraoperative adverse events occurred, according to the Intraoperative Complications Assessment and Reporting with Universal Standards Criteria. The operative time was 7 hours. Blood loss was minimal, with no need of intra- or postoperative transfusions. Hospital length of stay was 8 days. Pathology revealed renal cell carcinoma, International Society of Urological Pathology 3, with negative surgical margins. At 9-months follow-up, the patient is doing well, without signs of local or distant recurrence. CONCLUSION: 3D laparoscopy is a feasible alternative to open surgery for the most complex cases, enabling very precise dissection and suturing. We have shown a case of successful 3D laparoscopic radical nephrectomy with IVC thrombectomy combined with mini-thoracotomy achieving complete intracardiac thrombus removal.