The use of Versius CMR for pelvic surgery: a multicentric analysis of surgical setup and early outcomes.

INTRODUCTION: Versius CMR is a novel robotic system characterized by an open surgical console and independent bedside units. The system has potentials of flexibility and versatility, and has been used in urological, gynecological, and general surgical procedure. The aim is to depict a comprehensive analysis of the Versius system for pelvic surgery. METHODS: This is a study involving two Institutions, ASST Santi Paolo and Carlo, Milan, and Apuane Hospital, Massa, Italy. All interventions performed in the pelvic area with the Versius were included. Data about indications, intra-, and post-operative course were prospectively collected and analyzed. RESULTS: A total of 171 interventions were performed with the Versius. Forty-two of them involved pelvic procedures. Twenty-two had an oncological indication (localized prostate cancer), the remaining had a non-oncological or functional purpose. The mostly performed pelvic procedure was radical prostatectomy (22) followed by annexectomy (9). No intra-operative complication nor conversion to other approaches occurred. A Clavien II complication and one Clavien IIIb were reported. Malfunctioning/alarms requiring a power cycle of the system occurred in 2 different cases. An adjustment in trocar placement according to patients' height was required in 2 patients undergoing prostatectomy, in which the trocar was moved caudally. In two cases, a pelvic prolapse was repaired concomitant with other gynecological procedures. CONCLUSIONS: Pelvic surgery with the Versius is feasible without major complications; either dissection and reconstructive steps could be accomplished, provided a proper OR setup and trocar placement are pursued. Versius can be easily adopted by surgeons of different disciplines and backgrounds; a further multi-specialty implementation is presumed and long-term oncological and functional outcomes are awaited.

Perceived usefulness of the nurse-patient therapeutic relationship in the rehabilitation journey of people with urinary incontinence: A mixed-method study.

INTRODUCTION: Despite various studies on the impact of incontinence on patients' lives, the existing literature has not investigated the contribution of nursing care during rehabilitation in terms of quality of life. Fewer data, therefore, exist on the characteristics and perceived impact of the therapeutic relationship as part of the rehabilitation program. AIMS: To investigate the characteristics of the nurse-patient therapeutic relationship and its impact throughout the rehabilitation program; to describe the levels of patient burden on everyday activities. MATERIALS AND METHODS: A monocentric, retrospective, multimethod descriptive study was conducted in the nurse-led continence clinic of a major teaching hospital in Northern Italy. A phenomenological approach with semistructured interviews was adopted after 6 weeks of rehabilitation, following the method of phenomenological enquiry by Giorgi. The short form 12 questionnaire was administered upon admission of patients to the clinic, after 6 weeks, and during the last consultation to investigate the impact of urinary incontinence (UI) on daily activities and physical and psychological quality of life. RESULTS: Ninety-one adult patients of both genders presenting for nonneurogenic nonpostpartum UI were consecutively enrolled. Physical scores (PCS-12) and MCS-12 scores significantly increased over time. Psychological scores showed great variability upon admission, which was reduced halfway through the rehabilitation program. The thematic analysis highlighted four categories based on data saturation: the impact of UI on daily activities, strategies to face the problem, feelings, and the role of nurses. CONCLUSIONS: This mixed-method investigation suggests the importance of therapeutic nursing relationships, clinical expertise, and rehabilitative skills. Quality of life is arguably related to the positive results of the rehabilitation program but also to the environment, patients perceive in terms of support, honesty, and trust.

Impacts on functional and oncological outcomes of Robotic-assisted Radical Prostatectomy 10 years after the US Preventive Service Taskforce recommendations against PSA screening.

OBJECTIVE: In the following years after the United States Preventive Service Task Force (USPSTF) recommendation against prostate cancer screening with PSA in 2012, several authors worldwide described an increase in higher grades and aggressive prostate tumors. In this scenario, we aim to evaluate the potential impacts of USPSTF recommendations on the functional and oncological outcomes in patients undergoing robotic-assisted radical prostatectomy (RARP) in a referral center. MATERIAL AND METHODS: We included 11396 patients who underwent RARP between 2008 and 2021. Each patient had at least a 12-month follow-up. The cohort was divided into two groups based on an inflection point in the outcomes at the end of 2012 and the beginning of 2013. The inflection point period was detected by Bayesian regression with multiple change points and regression with unknown breakpoints. We reported continuous variables as median and interquartile range (IQR) and categorical variables as absolute and relative percent frequencies. RESULTS: Group 1 had 4760 patients, and Group 2 had 6636 patients, with a median follow-up of 109 and 38 months, respectively. In the final pathology, Group 2 had 9.5% increase in tumor volume, 24% increase on Gleason ≥ 4+3 (ISUP 3) , and 18% increase on ≥ pT3. This translated to a 6% increase in positive surgical margins and 24% reduction in full nerve sparing in response to the worsening pathology. There was a significant decline in post-operative outcomes in Group 2, including a 12-month continence reduction of 9%, reduction in potency by 27%, and reduction of trifecta by 22%. CONCLUSIONS: The increasing number of high-risk patients has led to worse functional and oncologic outcomes. The initial rapid rise in PSM was leveled by the move towards more partial nerve sparing. Among some historical changes in prostate cancer diagnosis and management in the period of our study, the USPSTF recommendation coincided with worse outcomes of prostate cancer treatment in a population who could benefit from PSA screening at the appropriate time.

Insights from telesurgery expert conference on recent clinical experience and current status of remote surgery.

Remote surgery provides opportunity for enhanced surgical capabilities, wider healthcare reach, and potentially improved patient outcomes. The network reliability is the foundation of successful implementation of telesurgery. It relies on a robust, high-speed communication network, with ultra-low latency. Significant lag has been shown to endanger precision and safety. Furthermore, the full-fledged adoption of telerobotics demands careful consideration of ethical challenges too. A deep insight into these issues has been investigated during the first Telesurgery Consensus Conference that took place in Orlando, Florida, USA, on the 3rd and 4th of February, 2024. During the Conference, the state of the art of remote surgery has been reported from robotic systems displaying telesurgery potential. The Hinotori, a robotic-assisted surgery platform developed by Medicaroid, experienced remote surgery as pre-clinical testing only; the Edge Medical Company, Shenzen, China, reported more than one hundred animal and 30 live human surgeries; the KanGuo reported human telesurgical cases performed with distances more than 3000 km; the Microport, China, collected more than 100 human operations at a distance up to 5000 km. Though, several issues-cybersecurity, data privacy, technical malfunctions - are yet to be addressed before a successful telesurgery implementation. Expanding the discussion to encompass ethical, financial, regulatory, and legal considerations is essential too. The Telesurgery collaborative community is working together to address and establish the best practices in the field.

Partial nephrectomy series using Versius robotic surgical system: technique and outcomes of an initial experience.

Partial nephrectomy (PN) represents a procedure where the use of a robot has further enabled successful completion of this complex surgery. The results of this procedure using Versius Robotic Surgical System (VRSS) still need to be evaluated. Our working group described the technique and reported the initial results of a series of PN using VRSS. We presented our setting, surgical technique and outcomes for PN, using VRSS. Between 2022 and 2023, 15 patients underwent PN performed by two surgeons in two different centers. Fifteen patients underwent PN. The median lesion size identified on preoperative imaging was 4 (IQR 2.3-5) cm. Median PADUA score was 8 (IQR 7-9). Two procedures were converted to radical nephrectomy for enhanced oncological disease control. Of the 13 nephrectomies that were completed as partial, 7 were performed clampless and 6 with warm ischemia clamping. Median clamping time was 10 (IQR 9-11) minutes. No procedure was converted to open. Median blood loss was 200 (IQR 100-250) mL. Median total operative time was 105 (IQR 100-110) minutes. Median console time was 75 (IQR 66-80) minutes. Median set-up time was 13 (IQR 12-14) minutes. No intraoperative complications were reported. The median hospitalization time was 4 (IQR 3.5-4) days. None of the patients were transfused and none of the patients required readmission. In a pathology report, one patient had a positive surgical margin. Our initial experience suggests that performing PN using VRSS is feasible with good short-term outcomes.

Cost analysis of new robotic competitors: a comparison of direct costs for initial hospital stay between Da Vinci and Hugo RAS for radical prostatectomy.

Robotic surgery with Da Vinci has revolutionized the treatment of several diseases, including prostate cancer; nevertheless, costs remain the major drawback. Recently, new robotic platforms entered the market aiming to reduce costs and improve the access to robotic surgery. The aim of the study is to compare direct cost for initial hospital stay of radical prostatectomy performed with two different robotic systems, the Da Vinci and the new Hugo RAS system. This is a projection study that applies cost of robotic surgery, derived from a local tender, to the clinical course of robotic radical prostatectomy (RALP) performed with Da Vinci and Hugo RAS. The study was performed in a public referral center for robotic surgery equipped with both systems. The cost of robotic surgery from a local tender were considered and included rent, annual maintenance, and a per-procedure fee covering the setup of four robotic instruments. Those costs were applied to patients who underwent RALP with both systems since November 2022. The primary endpoint is to evaluate direct costs of initial hospital stay for Da Vinci and Hugo RAS, by considering equipment costs (as derived from the tender), and costs of theater and of hospitalization. The direct per-procedure cost is €2,246.31 for a Da Vinci procedure and €1995 for a Hugo RALP. In the local setting, Hugo RAS provides 11% of cost saving for RALP. By applying this per-procedure cost to our clinical data, the expenditure for the entire index hospitalization is € 6.7755,1 for Da Vinci and € 6.637,15 for Hugo RALP. The new Hugo RAS system is willing to reduce direct expenditures of robotic surgery for RALP; furthermore, it provides similar peri-operative outcomes compared to the Da Vinci. However, other drivers of costs should be taken into account, such as the duration of OR use-that is more than just console time and may depend on the facility's background and organization. Further variations in direct costs of robotic systems are related to caseload, local agreements and negotiations. Thus, cost comparison of new robotic platform still remains an ongoing issue.

Open versus Robot-Assisted Radical Cystectomy for the Treatment of pT4a Bladder Cancer: Comparison of Perioperative Outcomes.

We compared the perioperative outcomes of open (ORC) vs. robot-assisted (RARC) radical cystectomy in the treatment of pT4a MIBC. In total, 212 patients underwent ORC (102 patients, Group A) vs. RARC (110 patients, Group B) for pT4a bladder cancer. Patients were prospectively followed and retrospectively reviewed. We assessed operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of stay, transfusion rate, and oncological outcomes. Preoperative features were comparable. The mean operative time was 232.8 vs. 189.2 min (p = 0.04), and mean EBL was 832.8 vs. 523.7 mL in Group A vs. B (p = 0.04). An intraoperative transfusion was performed in 32 (31.4%) vs. 11 (10.0%) cases during ORC vs. RARC (p = 0.03). The intraoperative complications rate was comparable. The mean length of stay was shorter after RARC (12.6 vs. 7.2 days, p = 0.02). Postoperative transfusions were performed in 36 (35.3%) vs. 13 (11.8%) cases (p = 0.03), and postoperative complications occurred in 37 (36.3%) vs. 29 (26.4%) patients in Groups A vs. B (p = 0.05). The positive surgical margin (PSM) rate was lower after RARC. No differences were recorded according to the oncological outcomes. ORC and RARC are feasible treatments for the management of pT4a bladder tumors. Minimally invasive surgery provides shorter operative time, bleeding, transfusion rate, postoperative complications, length of stay, and PSM rate.

Impacts on functional and oncological outcomes of Robotic-assisted Radical Prostatectomy 10 years after the US Preventive Service Taskforce recommendations against PSA screening

ABSTRACT Objective: In the following years after the United States Preventive Service Task Force (USPSTF) recommendation against prostate cancer screening with PSA in 2012, several authors worldwide described an increase in higher grades and aggressive prostate tumors. In this scenario, we aim to evaluate the potential impacts of USPSTF recommendations on the functional and oncological outcomes in patients undergoing robotic-assisted radical prostatectomy (RARP) in a referral center. Material and Methods: We included 11396 patients who underwent RARP between 2008 and 2021. Each patient had at least a 12-month follow-up. The cohort was divided into two groups based on an inflection point in the outcomes at the end of 2012 and the beginning of 2013. The inflection point period was detected by Bayesian regression with multiple change points and regression with unknown breakpoints. We reported continuous variables as median and interquartile range (IQR) and categorical variables as absolute and relative percent frequencies. Results: Group 1 had 4760 patients, and Group 2 had 6636 patients, with a median follow-up of 109 and 38 months, respectively. In the final pathology, Group 2 had 9.5% increase in tumor volume, 24% increase on Gleason ≥ 4+3 (ISUP 3), and 18% increase on ≥ pT3. This translated to a 6% increase in positive surgical margins and 24% reduction in full nerve sparing in response to the worsening pathology. There was a significant decline in post-operative outcomes in Group 2, including a 12-month continence reduction of 9%, reduction in potency by 27%, and reduction of trifecta by 22%. Conclusions: The increasing number of high-risk patients has led to worse functional and oncologic outcomes. The initial rapid rise in PSM was leveled by the move towards more partial nerve sparing. Among some historical changes in prostate cancer diagnosis and management in the period of our study, the USPSTF recommendation coincided with worse outcomes of prostate cancer treatment in a population who could benefit from PSA screening at the appropriate time.

Reproducibility of a modified posterior reconstruction during robotic intracorporeal neobladder reconfiguration

ABSTRACT Objective: Robotic intracorporeal neobladder reconstruction is a complex procedure in which the approximation of the reservoir to the urethral stump can be a demanding step. The aim of the study is to evaluate the reproducibility of a modified posterior reconstruction (PR) during the reconfiguration of intracorporeal neobladder after robot assisted radical cystectomy (RARC). Materials and Methods: From July 2021 to July 2022, 35 RARC were performed, and 17 patients underwent intracorporeal neobladder reconstruction. A PR was planned in males (14). Intra- and peri-operative data were collected. Surgical technique: RARC and node dissection are performed. Afterwards, 40-cm ileal segment is isolated; the portion with the more adequate mesenteric length is brought down to the pelvis. A modified PR is performed with a double-armed barbed suture: a first layer connects the Denonvillier's fascia to the rhabdosphincter in a running fashion; the second layer is created with the other arm and approximates the posterior side of the ileal segment towards the urethral stump. In the anterior caudal part of the ileum, a 1.5-cm incision is made to realize the neobladder neck; the neovesical-urethral anastomosis is performed with a second bidirectional suture. Results: Anastomotic and PR time were 14 (range 7-20) and 5 minutes (4-8), respectively. A single Clavien IIIa complication was recorded in a patient who underwent NAC and had a C. albicans superinfection in the post-operative course. All patients were discharged with complete or acceptable bladder voiding. Twelve patients with follow-up >90-days reported a satisfying daytime continence. Conclusions: PR represents a simple technical refinement that improves neobladder-urethral anastomosis by favoring ileal approximation to the urethral stump and decreasing anastomotic tension.