Robot-Assisted Pyeloplasty with HUGO™ Robotic System: Initial Experience and Optimal Surgical Set-Up at a Tertiary Referral Robotic Center.

Background: In February 2021 Medtronic® (Minneapolis, MN) launched the HUGO™ Robot-Assisted Surgery (RAS) System in the global market. The aim of the current study is to describe the first case series and the optimal setup of robot-assisted pyeloplasty procedure, performed with HUGO RAS system in a tertiary referral robotic center. Methods: Data from consecutive patients who underwent robot-assisted pyeloplasty at Onze-Lieve-Vrouwziekenhuis Hospital (Aalst, Belgium) were recorded. Baseline characteristics, and perioperative and surgical outcomes were collected. Results: Overall, 10 robot-assisted pyeloplasties were performed (October 2022-September 2023). Based on our expertise, the following minor setting changes have been made, relative to the official setup guide: the endoscope port and, subsequently, the left and right-hand ports were positioned more laterally. Additionally, the reserve/4th port was placed more laterally and cranially, and adjusted the arm cart's tilt angle, reducing it from -30° to -15°. The median docking time was 8 (interquartile range [IQR]: 7.2-9.8) minutes, and the median active console time was 89.5 (80.0-95.8) minutes. No conversion to open/laparoscopic surgery or perioperative complications was encountered. A single technical problem was recorded in 1 (10%) procedure. Specifically, one arm was blocked, and the procedure was accomplished with three arms without compromising the procedure success. Conclusions: This study represents the first worldwide series of robot-assisted pyeloplasty performed with the HUGO RAS system and shows promising results. The procedure might be safely performed with this robotic platform achieving optimal perioperative outcomes.

Robot-assisted Radical Prostatectomy Performed with Different Robotic Platforms: First Comparative Evidence Between Da Vinci and HUGO Robot-assisted Surgery Robots.

BACKGROUND: In the field of robotic surgery, there is a lack of comparative evidence on surgical and functional outcomes of different robotic platforms. OBJECTIVE: To assess the outcomes of patients receiving robot-assisted radical prostatectomy (RARP) at a high-volume robotic center with daVinci and HUGO robot-assisted surgery (RAS) surgical systems. DESIGN, SETTING, AND PARTICIPANTS: We analyzed the data of 542 patients undergoing RARP ± extended pelvic lymph node dissection at OLV hospital (Aalst, Belgium) between 2021 and 2023. All procedures were performed by six surgeons using daVinci or HUGO RAS robots; the use of one platform rather than the other did not follow any specific preference and/or indication. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariable analyses investigated the association between robotic system (daVinci vs HUGO RAS) and surgical outcomes after adjustment for patient- and tumor-related factors. Urinary continence recovery was defined as the use of no/one safety pad. RESULTS AND LIMITATIONS: A total of 378 (70%) and 164 (30%) patients underwent RARP with daVinci and HUGO RAS surgical systems, respectively. Despite a higher rate of palpable disease in the HUGO RAS group (34% vs 25%), baseline characteristics did not differ between the groups (all p > 0.05). After adjusting for confounders, we did not find evidence of a difference between the groups with respect to operative time (estimate: 16.71; 95% confidence interval [CI]: -6.35, 39.78; p = 0.12), estimated blood loss (estimate: 3.12; 95% CI: -67.03, 73.27; p = 0.9), and postoperative Clavien-Dindo ≥2 complications (odds ratio [OR]: 1.66; 95% CI: 0.34, 8.15; p = 0.5). On final pathology, 55 (15%) and 20 (12%) men in, respectively, the daVinci and the HUGO RAS group had positive surgical margins (PSMs; p = 0.5). On multivariable analyses, we did not find evidence of an association between a robotic system and PSMs (OR: 1.08; 95% CI: 0.56, 2.07; p = 0.8). Similarly, the odds of recovering continence did not differ between daVinci and HUGO RAS cases after both 1 mo (OR: 0.78; 95% CI: 0.45, 1.38; p = 0.4) and 3 mo (OR: 1.17; 95% CI: 0.49, 2.79; p = 0.7). CONCLUSIONS: Among patients receiving RARP with daVinci or HUGO RAS surgical platforms, we did not find differences in surgical and functional outcomes between the robots. This may be a result of a standardized surgical technique that allowed surgeons to transfer their skills between robotic systems. Awaiting future investigations with longer follow-up, these results have important implications for patients, surgeons, and health care policymakers. PATIENT SUMMARY: We compared surgical and functional outcomes of patients receiving robot-assisted radical prostatectomy with daVinci versus HUGO robot-assisted surgery (RAS) robots. The two platforms were able to achieve similar outcomes, suggesting that the introduction of HUGO RAS is safe and allows for optimal outcomes after radical prostatectomy.

Robot-assisted adrenalectomy: Step-by-step technique and surgical outcomes at a high-volume robotic center.

Objective: In the last years, robotic surgery was introduced in several different settings with good perioperative results. However, its role in the management of adrenal masses is still debated. In order to provide a contribution to this field, we described our step-by-step technique for robotic adrenalectomy (RA) and related modifications according to the type of adrenal mass treated. Methods: We retrospectively analyzed 27 consecutive patients who underwent RA at Onze-Lieve-Vrouw hospital (Aalst, Belgium) between January 2009 and October 2022. Demographic, intra- and post-operative, and pathological data were retrieved from our prospectively maintained institutional database. Continuous variables are summarized as median and interquartile range (IQR). Categorical variables are reported as frequencies (percentages). Results: Twenty-seven patients underwent RA were included in the study. Median age, body mass index, and Charlson's comorbidity index were 61 (IQR: 49-71) years, 26 (IQR: 24-29) kg/m2, and 2 (IQR: 0-3), respectively, and 16 (59.3%) patients were male. Median tumor size at computed tomography scan was 6.0 (IQR: 3.5-8.0) cm. Median operative time and blood loss were 105 (IQR: 82-120) min and 175 (IQR: 94-250) mL, respectively. No intraoperative complications were recorded. Overall postoperative complications rate was 11.1%, with a postoperative transfusion rate of 3.7%. A total of 10 (37.0%) patients harbored malignant adrenal masses. Among them, 3 (11.1%) had adrenocortical carcinoma, 6 (22.2%) secondary metastasis, and 1 (3.7%) malignant pheochromocytoma on final pathological exam. Only 1 (10.0%) patient had positive surgical margins. Conclusion: We described our step-by-step technique for RA, which can be safely performed even in case of high challenging settings as malignant tumors, pheochromocytoma, and large masses. The standardization of perioperative protocol should be encouraged to maximize the outcomes of this complex surgical procedure.

Transitioning from Da Vinci Si to Xi: assessing surgical outcomes at a high-volume robotic center.

PURPOSE: In the emerging field of robotics, only few studies investigated the transition between different robotic platforms in terms of surgical outcomes. We aimed at assessing surgical outcomes of patients receiving robot-assisted radical prostatectomy (RARP) and robot-assisted partial nephrectomy (RAPN) at a high-volume robotic center during the transition from Si to Xi Da Vinci surgical systems. METHODS: We analyzed data of 1884 patients undergoing RARP (n = 1437, 76%) and RAPN (n = 447, 24%) at OLV hospital (Aalst, Belgium) between 2011 and 2021. For both procedures, we assessed operative time, estimated blood loss, length of stay, and positive surgical margins. For RARP, we investigated length of catheterization and PSA persistence after surgery, whereas warm ischemia time, clampless surgery, and acute kidney injury (AKI) were assessed for RAPN. Multivariable analyses (MVA) investigated the association between robotic platform (Si vs. Xi) and surgical outcomes after adjustment for patient- and tumor-related factors. RESULTS: A total of 975 (68%) and 462 (32%) patients underwent RARP performed with the Si vs. Xi surgical system, respectively. Baseline characteristics did not differ between the groups. On MVA, we did not find evidence of a difference between the groups with respect to operative time (estimate: 1.07) or estimated blood loss (estimate: 32.39; both p > 0.05). Median (interquartile range [IQR]) length of stay was 6 (3, 6) and 4 (3, 5) days in the Si vs. Xi group, respectively (p < 0.0001). On MVA, men treated with the Xi vs. Si robot had lower odds of PSM (Odds ratio [OR]: 0.58; p = 0.014). A total of 184 (41%) and 263 (59%) patients received RAPN with the Si and Xi robotic system, respectively. Baseline characteristics, including demographics, functional data, and tumor-related features did not differ between the groups. On MVA, operative time was longer in the Xi vs. Si group (estimate: 30.54; p = 0.006). Patients treated with the Xi vs. Si system had higher probability of undergoing a clampless procedure (OR: 2.56; p = 0.001), whereas the risk of AKI did not differ between the groups (OR: 1.25; p = 0.4). On MVA, patients operated with the Xi robot had shorter length of stay as compared to the Si group (estimate: - 0.86; p = 0.003), whereas we did not find evidence of an association between robotic system and PSM (OR: 1.55; p = 0.3). CONCLUSION: We found that the Xi robot allowed for improvements in peri-operative outcomes as compared to the Si platform, with lower rate of positive margins for RARP and higher rate of off-clamp procedures for RAPN. Hospital stay was also shorter for patients operated with the Xi vs. Si robot, especially after robot-assisted partial nephrectomy. Awaiting future investigations-in particular, cost analyses-these results have important implications for patients, surgeons, and healthcare policymakers.

A comparative analysis of the HUGOTM robot-assisted surgery system and the Da Vinci® Xi surgical system for robot-assisted sacrocolpopexy for pelvic organ prolapse treatment.

BACKGROUND: We aimed to compare the outcomes of Robot-assisted sacrocolpopexy (RASC) performed using the novel HUGOTM Robot-Assisted Surgery (RAS) System with the Da Vinci® Xi surgical system. METHODS: Data from 38 women undergoing RASC for a ≥ 2-grade pelvic organ prolapse were collected (2021-2023). RESULTS: Overall, 23 (60.5%) and 15 (39.5%) procedures were performed using the DaVinci® Xi and the HUGOTM RAS system, respectively. The median total operative time was 123 (IQR:106.5-140.5) minutes for the DaVinci® Xi versus 120 (IQR:120-146) minutes for the HUGOTM RAS cases (p = 0.5). No conversion to open/laparoscopic surgery, perioperative complications, or system failures occurred. No differences were recorded according to day of catheter removal and length of stay. CONCLUSIONS: This study represents the first worldwide comparison of RASC executed using the HUGOTM RAS versus the Da Vinci® Xi System. Our data suggest that RASC might be performed with both robotic platforms with similar perioperative outcomes.

Transperineal vs. transrectal prostate biopsies under local anesthesia: A prospective cohort study on patient tolerability and complication rates.

OBJECTIVES: An increasing number of urologists is switching from transrectal (TR) to transperineal (TP) biopsy procedures for the diagnosis of prostate cancer. Local anesthesia (LA) might be advantageous in terms of patient management, risks and costs. We aimed to evaluate the tolerability and complication rates of TP prostate biopsy performed under LA. METHODS: This is a monocentric, prospective, comparative, observational cohort study. Between July 2020 and July 2021 we included 128 consecutive patients (TR, n = 61; TP, n = 67), with a suspicion of prostate cancer. Transrectal vs. transperineal prostate biopsies were both performed under LA. To evaluate the tolerability we administered a validated visual analog pain score (VAS) during the different steps of the biopsy procedure as well as at 12-, 24- and 48-hours post procedure. The International Prostate Symptom Score (IPSS) questionnaire was administered before the procedure and at the same time intervals. The presence of hematuria, hematospermia, rectal blood loss, acute retention and febrile urinary tract infection (UTI) were also monitored. RESULTS: There were no significant differences in pain or IPSS between groups, except for a significantly higher pain score during the LA of the prostate in the TP group. In general, complication rates were similar, only the prevalence of hematuria at 24 hours was significantly higher in the TP group, as was rectal blood loss at 12 hours postprocedure in the TR group. CONCLUSIONS: In conclusion, our study showed that transperineal prostate biopsy under local anesthesia could be performed with similar pain scores and complication rates, compared to the transrectal procedure.

Initial Experience of Robot-Assisted Simple Prostatectomy with Hugo Robot-Assisted Surgery System: Step-by-Step Description of Two Different Techniques.

Introduction: There are only a few clinical data on nononcologic procedures performed with the new Hugo™ robot-assisted surgery (RAS) system. Robot-assisted simple prostatectomy (RASP) is a minimally invasive treatment option for benign prostatic hyperplasia, and it demonstrated equal early functional and better perioperative outcomes as compared with open simple prostatectomy. In this article, we reported the first large series of RASP performed with Hugo RAS system. Methods: This Supplementary Video S1 is a step-by-step description of two different techniques for RASP. We analyzed the data of 20 consecutive patients who underwent RASP at OLV Hospital (Belgium) between February 2022 and March 2023. Patients baseline characteristics, perioperative and pathologic, and 1-month postoperative outcomes were reported, using the median (interquartile range [IQR]) and frequencies, as appropriate. Results: Median age (IQR) and preoperative prostate specific antigen (PSA) were 72 (67-76) years, and 7.7 (5.0-13.4) ng/mL, respectively. A total of 11 patients experienced an episode of preoperative acute urinary retention, and 8 men had an indwelling bladder catheter at the time of the surgery. No intraoperative complication occurred, and there was no need for conversion to open surgery. Median operative and console time were 165 (121-180) and 125 (101-148) minutes. On the first postoperative day the urethral catheter was removed in 80% of the patients. Median length of stay was 3 (3-4) days. Three patients had minor postoperative complications. On final pathology report, median prostate volume was 120 (101-154) g. On postoperative uroflowmetry, median Qmax and postvoid residual were 16 (13-26) mL/s and 15 (0-34) mL, respectively. Conclusions: This series represents the first report of surgical outcomes of RASP executed with Hugo RAS system. Awaiting study with longer follow-up, our study suggests that Hugo RAS has multiple applications, and it can ensure optimal outcomes in nononcologic procedures.

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.

Different approaches for bladder neck dissection during robot-assisted radical prostatectomy: the Aalst technique.

INTRODUCTION: Bladder neck dissection is one of the most delicate surgical steps of robotic-assisted radical prostatectomy (RARP) [1, 2], and it may affect surgical margins rate and functional outcomes [3, 4]. Given the relationship between outcomes and surgical experience [5-7], it is crucial to implement a step-by-step approach for each surgical step of the procedure, especially in the most challenging part of the intervention. In this video compilation, we described the techniques for bladder neck dissection utilized at OLV Hospital (Aalst, Belgium). SURGICAL TECHNIQUE: We illustrated five different techniques for bladder neck dissection during RARP. The anterior technique tackles the bladder neck from above until the urethral catheter is visualized, and then the dissection is completed posteriorly. The lateral and postero-lateral approaches involve the identification of a weakness point at the prostate-vesical junction and aim to develop the posterior plane - virtually until the seminal vesicles - prior to the opening of the urethra anteriorly. Finally, we described our techniques for bladder neck dissection in more challenging cases such as in patients with bulky middle lobes and prior surgery for benign prostatic hyperplasia. All approaches follow anatomic landmarks to minimize positive surgical margins and aim to preserve the bladder neck in order to promote optimal functional recovery. All procedures were performed with DaVinci robotic platforms using a 3-instruments configuration (scissors, fenestrated bipolar, and needle driver). As standard protocol at our Institution, urinary catheter was removed on postoperative day two [8]. CONCLUSIONS: Five different approaches for bladder neck dissection during RARP were described in this video compilation. We believe that the technical details provided here might be of help for clinicians who are starting their practice with this surgical intervention.

The IRON Study: Investigation of Robot-assisted Versus Open Nephron-sparing Surgery.

Background: Current literature does not provide large-scale data regarding clinical outcomes of robot-assisted (RAPN) versus open (OPN) partial nephrectomy. Moreover, data assessing predictors of long-term oncologic outcomes after RAPN are scarce. Objective: To compare perioperative, functional, and oncologic outcomes of RAPN versus OPN, and to investigate the predictors of oncologic outcomes after RAPN. Design setting and participants: This study included 3467 patients treated with OPN (n = 1063) or RAPN (n = 2404) for a single cT1-2N0M0 renal mass from 2004 to 2018 at nine high-volume European, North American, and Asian institutions. Outcome measurements and statistical analysis: The study outcomes were short-term postoperative, functional, and oncologic outcomes. Regression models investigated the effect of surgical approach (open vs Robot assisted) on study outcomes, and interaction tests were used for subgroup analyses. Propensity score matching for demographic and tumor characteristics was used in sensitivity analyses. Multivariable Cox-regression analyses identified predictors of oncologic outcomes after RAPN. Results and limitations: Baseline characteristics were similar between patients receiving RAPN and OPN, with only few differences. After adjusting for confounding, RAPN was associated with lower odds of intraoperative (odds ratio [OR]: 0.39, 95% confidence interval [CI]: 0.22, 0.68) and Clavien-Dindo ≥2 postoperative (OR: 0.29, 95% CI: 0.16, 0.50) complications (both p < 0.05). This association was not affected by comorbidities, tumor dimension, PADUA score, or preoperative renal function (all p > 0.05 on interaction tests). On multivariable analyses, we found no differences between the two techniques with respect to functional and oncologic outcomes (all p > 0.05). Overall, there were 63 and 92 local recurrences and systemic progressions, respectively, with a median follow-up after surgery of 32 mo (interquartile range: 18, 60). Among patients receiving RAPN, we assessed predictors of local recurrence and systemic progression with discrimination accuracy (ie, C-index) that ranged from 0.73 to 0.81. Conclusions: While cancer control and long-term renal function did not differ between RAPN and OPN, we found that the intra- and postoperative morbidity-especially in terms of complications-was lower after RAPN than after OPN. Our predictive models allow surgeons to estimate the risk of adverse oncologic outcomes after RAPN, with relevant implications for preoperative counseling and follow-up after surgery. Patient summary: In this comparative study on robotic versus open partial nephrectomy, functional and oncologic outcomes were similar between the two techniques, with lower morbidity-especially in terms of complications-for robot-assisted surgery. The assessment of prognosticators for patients receiving robot-assisted partial nephrectomy may help in preoperative counseling and provides relevant data to tailor postoperative follow-up.

Improving Augmented Reality Through Deep Learning: Real-time Instrument Delineation in Robotic Renal Surgery.

Several barriers prevent the integration and adoption of augmented reality (AR) in robotic renal surgery despite the increased availability of virtual three-dimensional (3D) models. Apart from correct model alignment and deformation, not all instruments are clearly visible in AR. Superimposition of a 3D model on top of the surgical stream, including the instruments, can result in a potentially hazardous surgical situation. We demonstrate real-time instrument detection during AR-guided robot-assisted partial nephrectomy and show the generalization of our algorithm to AR-guided robot-assisted kidney transplantation. We developed an algorithm using deep learning networks to detect all nonorganic items. This algorithm learned to extract this information for 65 927 manually labeled instruments on 15 100 frames. Our setup, which runs on a standalone laptop, was deployed in three different hospitals and used by four different surgeons. Instrument detection is a simple and feasible way to enhance the safety of AR-guided surgery. Future investigations should strive to optimize efficient video processing to minimize the 0.5-s delay currently experienced. General AR applications also need further optimization, including detection and tracking of organ deformation, for full clinical implementation.

Impact of previous malignancy at diagnosis on oncological outcomes of upper tract urothelial carcinoma.

BACKGROUND: The evidence of prognostic factors and individualized surveillance strategies for upper tract urothelial carcinoma are still weak. OBJECTIVES: To evaluate whether the history of previous malignancy (HPM) affects the oncological outcomes of upper tract urothelial carcinoma (UTUC). METHODS: The CROES-UTUC registry is an international, observational, multicenter cohort study on patients diagnosed with UTUC. Patient and disease characteristics from 2380 patients with UTUC were collected. The primary outcome of this study was recurrence-free survival. Kaplan-Meier and multivariate Cox regression analyses were performed by stratifying patients according to their HPM. RESULTS: A total of 996 patients were included in this study. With a median recurrence-free survival time of 7.2 months and a median follow-up time of 9.2 months, 19.5% of patients had disease recurrence. The recurrence-free survival rate in the HPM group was 75.7%, which was significantly lower than non-HPM group (82.7%, P = 0.012). Kaplan-Meier analyses also showed that HPM could increase the risk of upper tract recurrence (P = 0.048). Furthermore, patients with a history of non-urothelial cancers had a higher risk of intravesical recurrence (P = 0.003), and patients with a history of urothelial cancers had a higher risk of upper tract recurrence (P = 0.015). Upon multivariate Cox regression analysis, the history of non-urothelial cancer was a risk factor for intravesical recurrence (P = 0.004), and the history of urothelial cancer was a risk factor for upper tract recurrence (P = 0.006). CONCLUSION: Both previous non-urothelial and urothelial malignancy could increase the risk of tumor recurrence. But different cancer types may increase different sites' risk of tumor recurrence for patients with UTUC. According to present study, more personalized follow-up plans and active treatment strategies should be considered for UTUC patients.

Outcomes of Robot-assisted Radical Prostatectomy with the Hugo RAS Surgical System: Initial Experience at a High-volume Robotic Center.

Clinical data on robot-assisted radical prostatectomy (RARP) performed with the new Hugo robot-assisted surgery (RAS) system are scarce. We described surgical outcomes of 112 consecutive patients who underwent RARP ± extended pelvic lymph-node dissection (ePLND) at OLV Hospital (Aalst, Belgium) between February and November 2022. The median age was 65 yr (interquartile range [IQR] 60-70) and median preoperative prostate-specific antigen (PSA) was 7.9 ng/ml (5.8-10.7). Thirty-eight patients (34%) had International Society of Urological Pathology grade group ≥3 tumor on prostate biopsy. On preoperative magnetic resonance imaging, 26 (23%) patients had a suspicion of extraprostatic disease. The median operative time was 180 min (IQR 145-200) and 27 men (24%) underwent ePLND. On final pathology, 34 patients (31%) had extraprostatic disease and ten (9%) had positive surgical margins. The median number of nodes removed was 15 (IQR 9-19). Among men with data available on the first PSA after surgery, 88% (60/68) had undetectable PSA (<0.1 ng/ml). The probability of urinary continence (UC) recovery was 36% (95% confidence interval [CI] 28-47%) at 1 mo and 81% (95% CI 72-89%) at 3 mo. The median time to UC recovery was 36 d (95% CI 34-44). This is the first report of data on UC recovery and surgical pathology for patients undergoing RARP for prostate cancer performed with the Hugo RAS robotic system. Future investigations with longer follow-up are awaited. PATIENT SUMMARY: We describe surgical outcomes of patients undergoing robot-assisted surgical removal of the prostate for cancer performed with the Hugo RAS robotic system at our institution. In our experience this platform provided adequate results in terms of surgical results and early recovery of urinary continence. Studies with longer follow-up are awaited.

Robot-assisted sutureless partial nephrectomy for the treatment of fifteen bilateral renal masses in a patient with Von Hippel-Lindau syndrome: a case report from a high-volume robotic center.

Renal cell carcinoma is among major causes of death in patients with Von Hippel-Lindau (VHL) syndrome, and it usually presents with multiple and bilateral lesions that may require multiple renal surgeries. This, in turn, may compromise renal function, resulting in end-stage renal disease. To minimize renal function impairment in these patients, great importance is given to the preservation of functional parenchyma with the use of nephron-sparing techniques. Furthermore, new techniques such as off-clamp surgery, selective suturing or sutureless techniques may improve long-term functional outcomes. We described the case of a 27-year-old male patient with a family history of VHL disease affected by multiple, bilateral renal masses. He received bilateral, metachronous robot-assisted partial nephrectomies (RAPN) for a total of 15 renal lesions. No intra- or post-operative complications occurred, and the patient was discharged on the second postoperative day after both procedures. Serum creatinine after the second RAPN was 0.99 mg/dl (baseline value was 1.11 mg/dl). In patients with VHL syndrome and multiple renal lesions, robot-assisted partial nephrectomy, especially with the use of clampless and sutureless techniques, helps minimizing renal function impairment and should be performed when anatomically and technically feasible.

Long-term oncologic outcomes of robot-assisted radical cystectomy: update series from a high-volume robotic center beyond 10 years of follow-up.

Long-term oncologic data on patients undergoing robot-assisted radical cystectomy (RARC) for non-metastatic bladder cancer (BCa) are limited. The purpose of this study is to describe long-term oncologic outcomes of patients receiving robotic radical cystectomy at a high-volume European Institution. We analyzed data of 107 patients treated with RARC between 2003 and 2012 at a high-volume robotic center. Clinical, pathologic, and survival data at the latest follow-up were collected. Clinical recurrence (CR)-free survival, cancer-specific mortality (CSM)-free survival, and overall survival (OS) were plotted using Kaplan-Meier survival curves. Cox proportional hazard models investigated predictors of CR and CSM. Competing-risk regressions were utilized to depict cumulative incidences of death from BCa and death from other causes after RARC at long term. Pathologic nonorgan-confined BCa was found in 40% of patients, and 7 (7%) patients had positive soft tissue surgical margins. Median (interquartile range [IQR]) number of nodes removed was 11 (6, 14), and 26% of patients had pN + disease. Median (IQR) follow-up for survivors was 123 (117, 149) months. The 12-year CR-free, CSM-free and overall survival were 55% (95% confidence interval [CI] 44%, 65%), 62% (95% CI 50%, 72%), and 34% (95% CI 24%, 44%), respectively. Nodal involvement on final pathology was associated with poor prognosis on multivariable competing risk analysis. The cumulative incidence of non-cancer death exceeded that of death from BCa after approximately ten years after RARC. We provided relevant data on oncologic outcomes of RARC at a high-volume robotic center, with acceptable rates of clinical recurrence and cancer-specific survival at long-term. In patients treated with RARC, the cumulative incidence of death from causes other than BCa is non-negligible, and should be taken into consideration for post-operative follow-up.

External validation of yonsei nomogram predicting chronic kidney disease development after partial nephrectomy: An international, multicenter study.

OBJECTIVE: To externally validate Yonsei nomogram. METHODS: From 2000 through 2018, 3526 consecutive patients underwent on-clamp PN for cT1 renal masses at 23 centers were included. All patients had two kidneys, preoperative eGFR ≥60 ml/min/1.73 m2, and a minimum follow-up of 12 months. New-onset CKD was defined as upgrading from CKD stage I or II into CKD stage ≥III. We obtained the CKD-free progression probabilities at 1, 3, 5, and 10 years for all patients by applying the nomogram found at https://eservices.ksmc.med.sa/ckd/. Thereafter, external validation of Yonsei nomogram for estimating new-onset CKD stage ≥III was assessed by calibration and discrimination analysis. RESULTS AND LIMITATION: Median values of patients' age, tumor size, eGFR and follow-up period were 47 years (IQR: 47-62), 3.3 cm (IQR: 2.5-4.2), 90.5 ml/min/1.73 m2 (IQR: 82.8-98), and 47 months (IQR: 27-65), respectively. A total of 683 patients (19.4%) developed new-onset CKD. The 5-year CKD-free progression rate was 77.9%. Yonsei nomogram demonstrated an AUC of 0.69, 0.72, 0.77, and 0.78 for the prediction of CKD stage ≥III at 1, 3, 5, and 10 years, respectively. The calibration plots at 1, 3, 5, and 10 years showed that the model was well calibrated with calibration slope values of 0.77, 0.83, 0.76, and 0.75, respectively. Retrospective database collection is a limitation of our study. CONCLUSIONS: The largest external validation of Yonsei nomogram showed good calibration properties. The nomogram can provide an accurate estimate of the individual risk of CKD-free progression on long-term follow-up.

Will Renorrhaphy Become Obsolete? Evaluation of a New Hemostatic Sealant.

Background: In robot-assisted partial nephrectomy (RAPN) renorrhaphy is used to achieve hemostatic control of the tumoral resection bed, with detrimental impact on renal function. Hemostatic agents are used to achieve rapid and optimal hemostasis. GATT-Patch is a new hemostatic sealant that has already demonstrated promising results. Objective: Compare GATT-Patch and standard renorrhaphy in terms of hemostatic capacity, ischemia time, and prevention of urinary leakage after RAPN in a porcine model. Design, Setting, and Participants: In this preclinical randomized controlled trial, four pigs underwent 32 RAPNs. After resection, GATT-Patch application and performance of classic renorrhaphy were randomized. After the procedure, the resection bed was reinspected. A necropsy study evaluated the adhesiveness of the patch, and retrograde pyelography was performed to determine the leakage burst pressure. Intervention: Application of GATT-Patch and performance of classic renorrhaphy were randomized and surgeons blinded to the hemostatic technique to be performed. Outcome Measurements and Statistical Analysis: Warm ischemia, hemostatic control, active bleeding during hemostatic control, total procedure time, bleeding at reinspection, and presence of urinary leakage on retrograde pyelography were recorded. Continuous variables were compared using the Student t-test. Categorical variables were compared using the Chi-square or Fisher's exact test. Results and Limitations: GATT-Patch reduced warm ischemia time (WIT), time to achieve hemostatic control, active bleeding time, and total procedure time, achieving hemostasis in 100% of the cases. Rebleeding at reinspection occurred in 0% of the GATT-Patch group. Renal parenchyma damage was observed in 100% of renorrhaphy cases and in 0% of GATT-Patch cases. Conclusions: GATT-Patch guaranteed optimal hemostasis and urine sealant effect after RAPN in porcine models. Compared to renorrhaphy, we observed a reduction in WIT, total procedure time, and potential reduction in healthy parenchyma loss. Patient Summary: GATT-Patch stops bleeding and provides hemostasis faster than suturing after resection of portions of the kidney in pigs. It might be tested in patients undergoing partial nephrectomy for kidney cancer.

Robot-assisted simple prostatectomy with the novel HUGO™ RAS System: feasibility, setting, and perioperative outcomes.

Robot-assisted simple prostatectomy (RASP) has demonstrated better peri-operative outcomes as compared to open simple prostatectomy. However, RASP is still limited by platform availability and cost-effectiveness issues. The new surgical robots increasing competition may spread the robotic approach also in non-oncological fields. We reported the first RASP executed in Europe at OLV Hospital (Aalst, Belgium) performed with the novel HUGO™ Robot-Assisted Surgery (RAS) System. The platform consists of four independent carts, an open console, and a system tower equipped for both laparoscopic and robotic surgery. Our main goal was to demonstrate the technical feasibility of RASP with the novel HUGO™ RAS along with its safety in terms of perioperative outcomes and complications. We also aimed to describe our surgical setup. We collected patient's baseline characteristics, intraoperative and perioperative complications, postoperative outcomes, docking time, operative time, clashing of the instruments, or technical errors of the system. The procedure was performed in a 72-year-old male with a prostate volume of 155 g at preoperative imaging. No need for conversion to open/laparoscopic surgery and/or for additional port placement was required. No intraoperative complications, instrument clashes, or failure of the system that compromised the completion of the surgery were recorded. Docking, operative, and console times were 9, 150, and 120 minutes, respectively. The catheter was removed on the second postoperative day. No postoperative complications occurred. The postoperative uroflowmetry revealed a maximum flow of 26.2 mL/s, without postvoid residual volume. Robot-assisted simple prostatectomy with the HUGO™ RAS System is a feasible and safe procedure in terms of perioperative outcomes and complications. Our setup allowed for a rapid docking procedure and a smoothly completion of the surgery.

Robot-Assisted Sacropexy with the Novel HUGO Robot-Assisted Surgery System: Initial Experience and Surgical Setup at a Tertiary Referral Robotic Center.

Introduction and Hypothesis: Robotic sacropexy (RSC) emerged in the last years as a valid alternative to the laparoscopic technique. However, the robotic approach is still limited by platform availability and concerns about cost-effectiveness. Recently, new robotic platforms joined the market, lowering the costs and offering the possibility to expand the robotic approach. The aim of our study was to demonstrate the technical feasibility and safety of the procedure with this new platform along with the description of our surgical setting. Materials and Methods: We reported data on the first five consecutive patients who underwent RSC at Onze Lieve Vrouw Hospital (Aalst, Belgium), performed with the novel HUGO™ Robot-Assisted Surgery (RAS) System. The platform consists of four fully independent carts, an open console, and a system tower equipped for both laparoscopic and robotic surgery. We collected patients' characteristics, intraoperative data, intraoperative complications, and clashes of instruments. Results: All procedures were completed according to the same surgical setting and technique. No need for conversion to open/laparoscopic surgery and/or for additional port placement was required. No intraoperative complications, instrument clashes, or system failure that compromised the surgery's completion were recorded. Median interquartile range docking, operative, and console time were 8 (6-9), 130 (115-165), and 80 (80-115) minutes, respectively. Conclusion: This series represents the first worldwide report of a robot-assisted sacropexy executed with the novel HUGO RAS System. Awaiting future investigation, this preliminary experience provides relevant data in terms of operative room settings and perioperative outcomes that might be helpful for future adopters of this platform.