Definition of a Structured Training Curriculum for Robot-assisted Radical Cystectomy with Intracorporeal Ileal Conduit in Male Patients: A Delphi Consensus Study Led by the ERUS Educational Board.

Robot-assisted radical cystectomy (RARC) continues to expand, and several surgeons start training for this complex procedure. This calls for the development of a structured training program, with the aim to improve patient safety during RARC learning curve. A modified Delphi consensus process was started to develop the curriculum structure. An online survey based on the available evidence was delivered to a panel of 28 experts in the field of RARC, selected according to surgical and research experience, and expertise in running training courses. Consensus was defined as ≥80% agreement between the responders. Overall, 96.4% experts completed the survey. The structure of the RARC curriculum was defined as follows: (1) theoretical training; (2) preclinical simulation-based training: 5-d simulation-based activity, using models with increasing complexity (ie, virtual reality, and dry- and wet-laboratory exercises), and nontechnical skills training session; (3) clinical training: modular console activity of at least 6 mo at the host center (a RARC case was divided into 11 steps and steps of similar complexity were grouped into five modules); and (4) final evaluation: blind review of a video-recorded RARC case. This structured training pathway will guide a starting surgeon from the first steps of RARC toward independent completion of a full procedure. Clinical implementation is urgently needed. PATIENT SUMMARY: Robot-assisted radical cystectomy (RARC) is a complex procedure. The first structured training program for RARC was developed with the goal of aiding surgeons to overcome the learning curve of this procedure, improving patients' safety at the same time.

Robot-assisted vesicovaginal fistula repair - initial experience.

Purpose: To report our initial experience of robot-assisted vesicovaginal fistula (VVF) repair.Materials and methods: Data from all patients who underwent robot-assisted VVF repair from August 2015 to October 2018 were analyzed. Preoperative data included age, BMI, smoking status, alcohol consumption, etiology of fistula and location and size of fistula. Operative data was operation time and the use of tissue interposition. Postoperative data included time to follow up, complications and reoperations.Results: A total of 13 patients underwent robot-assisted VVF repair and 15 operations were performed as 2 patients required a repeated procedure. The mean age was 45.0 ± 14.5 years (±SD) and operative time was 138.3 ± 58.9 min (±SD). The mean time to follow up was 18.3 ± 16.1 weeks (±SD). Postoperative complications were reported by one patient and was Clavien-Dindo I. Relapse of fistula was found in two patients who had a successful reoperation with repeated robotic-assisted surgery. An interposition flap was used in a single patient. The overall success rate was 84.6% after primary surgery (11 out of 13) and 100% after repeated procedure (2 out of 2).Conclusions: In this initial small series, we found that robot-assisted VVF repair is a safe procedure with results comparable to transvaginal repair. This procedure has a high success rate and few complications without using interposed tissue.

A study of image-guided radiotherapy of bladder cancer based on lipiodol injection in the bladder wall.

PURPOSE: We have tested a procedure of focal injection of the contrast medium Lipiodol as a fiducial marker for image-guided boost of the tumor in bladder cancer radiotherapy (RT). In this study, we have evaluated the feasibility and the safety of the method as well as the inter- and intra-fraction shift of the bladder tumor. MATERIALS AND METHODS: Five patients with muscle invasive urinary bladder cancer were included in the study. Lipiodol was injected during flexible cystoscopy into the submucosa of the bladder wall at the periphery of the tumor or the post resection tumor-bed. Cone-beam CT (CBCT) scans were acquired daily throughout the course of RT. RESULTS: Lipiodol demarcation of the bladder tumor was feasible and safe with only a minimum of side effects related to the procedure. The Lipiodol spots were visible on CT and CBCT scans for the duration of the RT course. More than half of all the treatment fractions required a geometric shift of 5 mm or more to match on the Lipiodol spots. The mean intra-fraction shift (3D) of the tumor was 3 mm, largest in the anterior-posterior and cranial-caudal directions. CONCLUSION: This study demonstrates that Lipiodol can be injected into the bladder mucosa and subsequently visualized on CT and CBCT as a fiducial marker. The relatively large inter-fraction shifts in the positions of Lipiodol spots compared to the intra-fraction movement indicates that image-guided RT based on radio-opaque markers is important for RT of the bladder cancer tumor.