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.

Management of ureteric duplications identified during robotic cystectomy and intracorporeal urinary diversion.

Ureteral duplication is rarely seen malformation that could be diagnosed during radiological imaging. Herein, we present 5 patients with ureteral duplication who underwent robotic radical cystectomy with intracorporeal urinary diversion for bladder cancer. Preoperative computerized tomography did not show presence of a ureteral duplication in any patient and all were identified intraoperatively. A Wallace type uretero-ureteral anastomosis was performed in all patients. During the follow-up period, we did not detect any ureterointestinal anastomotic strictures or complication related to the presence of a ureteral duplication following robotic cystectomy. We conclude that ureteral duplication might be missed during preoperative radiological imaging, might be a surprising and challenging issue for the robotic surgeon that could be safely managed intraoperatively.

Development of a patient and institutional-based model for estimation of operative times for robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

OBJECTIVES: To design a methodology to predict operative times for robot-assisted radical cystectomy (RARC) based on variation in institutional, patient, and disease characteristics to help in operating room scheduling and quality control. PATIENTS AND METHODS: The model included preoperative variables and therefore can be used for prediction of surgical times: institutional volume, age, gender, body mass index, American Society of Anesthesiologists score, history of prior surgery and radiation, clinical stage, neoadjuvant chemotherapy, type, technique of diversion, and the extent of lymph node dissection. A conditional inference tree method was used to fit a binary decision tree predicting operative time. Permutation tests were performed to determine the variables having the strongest association with surgical time. The data were split at the value of this variable resulting in the largest difference in means for the surgical time across the split. This process was repeated recursively on the resultant data sets until the permutation tests showed no significant association with operative time. RESULTS: In all, 2 134 procedures were included. The variable most strongly associated with surgical time was type of diversion, with ileal conduits being 70 min shorter (P < 0.001). Amongst patients who received neobladders, the type of lymph node dissection was also strongly associated with surgical time. Amongst ileal conduit patients, institutional surgeon volume (>66 RARCs) was important, with those with a higher volume being 55 min shorter (P < 0.001). The regression tree output was in the form of box plots that show the median and ranges of surgical times according to the patient, disease, and institutional characteristics. CONCLUSION: We developed a method to estimate operative times for RARC based on patient, disease, and institutional metrics that can help operating room scheduling for RARC.

Early Recurrence Patterns Following Totally Intracorporeal Robot-assisted Radical Cystectomy: Results from the EAU Robotic Urology Section (ERUS) Scientific Working Group.

Recurrence following radical cystectomy often occurs early, with >80% of recurrences occurring within the first 2 yr. Debate remains as to whether robot-assisted radical cystectomy (RARC) negatively impacts early recurrence patterns because of inadequate resection or pneumoperitoneum. We report early recurrence patterns among 717 patients who underwent RARC with intracorporeal urinary diversion at nine different institutions with a minimum follow-up of 12 mo. Clinical, pathologic, radiologic, and survival data at the latest follow-up were collected. Recurrence-free survival (RFS) estimates were generated using the Kaplan-Meier method, and Cox regression models were built to assess variables associated with recurrence. RFS at 3, 12, and 24 mo was 95.9%, 80.2%, and 74.6% respectively. Distant recurrences most frequently occurred in the bones, lungs, and liver, and pelvic lymph nodes were the commonest site of local recurrence. We identified five patients (0.7%) with peritoneal carcinomatosis and two patients (0.3%) with metastasis at the port site (wound site). We conclude that unusual recurrence patterns were not identified in this multi-institutional series and that recurrence patterns appear similar to those in open radical cystectomy series. PATIENT SUMMARY: In this multi-institutional study, bladder cancer recurrences following robotic surgery are described. Early recurrence rates and locations appear to be similar to those for open radical cystectomy series.

Robotic and Open Radical Prostatectomy: The First Prospective Randomised Controlled Trial Fuels Debate Rather than Closing the Question.

Despite the finally acquired level 1 evidence, the urologic debate on open versus robotic prostatectomy still persists. This trial from Brisbane will encourage future studies that will better inform this debate and define what robotic surgery offers.

Robotic intracorporeal urinary diversion: practical review of current surgical techniques.

In this practical review, we discuss current surgical techniques reported in the literature to perform intracorporeal urinary diversion (ICUD) after robotic radical cystectomy (RARC), emphasizing criticisms of single approaches and making comparisons with extracorporeal urinary diversion (ECUD). Although almost 97% of all RARCs use an ECUD, ICUD is gaining in popularity, in view of its potential benefits (i.e., decreased bowel exposure, etc.), although there are a few studies comparing ICUD and ECUD. Analyzing single experiences and the data from recent metanalyses, we emphasize the current critiques to ICUD, stressing particular technical details which could reduce operative time, lowering the postoperative complications rate, and improving functional outcomes. Only analysis of long-term follow-up data from large-scale homogeneous series can ascertain whether robotic intracorporeal urinary diversion is superior to other approaches.

Enhanced Recovery After Robot-assisted Radical Cystectomy: EAU Robotic Urology Section Scientific Working Group Consensus View.

CONTEXT: Radical cystectomy (RC) is associated with frequent morbidity and prolonged length of stay (LOS) irrespective of surgical approach. Increasing evidence from colorectal surgery indicates that minimally invasive surgery and enhanced recovery programmes (ERPs) can reduce surgical morbidity and LOS. ERPs are now recognised as an important component of surgical management for RC. However, there is comparatively little evidence for ERPs after robot-assisted radical cystectomy (RARC). Due to the multimodal nature of ERPs, they are not easily validated through randomised controlled trials. OBJECTIVE: To provide a European Association of Urology (EAU) Robotic Urology Section (ERUS) policy on ERPs to guide standardised perioperative management of RARC patients. EVIDENCE ACQUISITION: The guidance was formulated in four phases: (1) systematic literature review of evidence for ERPs in robotic, laparoscopic, and open RC; (2) an online questionnaire survey formulated and sent to ERUS Scientific Working Group members; (3) achievement of consensus from an expert panel using the Delphi process; and (4) a standardised reporting template to audit compliance and outcome designed and approved by the committee. EVIDENCE SYNTHESIS: Consensus was reached in multiple areas of an ERP for RARC. The key principles include patient education, optimisation of nutrition, RARC approach, standardised anaesthetic, analgesic, and antiemetic regimens, and early mobilisation. CONCLUSIONS: This consensus represents the views of an expert panel established to advise ERUS on ERPs for RARC. The ERUS Scientific Working Group recognises the role of ERPs and endorses them as standardised perioperative care for patients undergoing RARC. ERPs in robotic surgery will continue to evolve with technological and pharmaceutical advances and increasing understanding of the role of surgery-specific ERPs. PATIENT SUMMARY: There is currently a lack of high-level evidence exploring the benefits of enhanced recovery programmes (ERPs) in patients undergoing robot-assisted radical cystectomy (RARC). We reported a consensus view on a standardised ERP specific to patients undergoing RARC. It was formulated by experts from high-volume RARC hospitals in Europe, combining current evidence for ERPs with experts' knowledge of perioperative care for robotic surgery.

Robot-assisted nerve-sparing radical cystectomy with bilateral extended pelvic lymph node dissection (PLND) and intracorporeal urinary diversion for bladder cancer: initial experience in 27 cases.

OBJECTIVE: • To report the outcomes of 27 patients whom we performed robot-assisted radical cystoprostatectomy and cystectomy (RARC) with intracorporeal urinary diversion (Studer pouch and ileal conduit) for bladder cancer. PATIENTS AND METHODS: • Between December 2009 and December 2010, we performed RARC in 25 men (intrafascial bilateral [22], unilateral [one], non-neurovascular bundle [NVB] sparing [two]), NVB-sparing RARC with anterior pelvic exenteration in two women, bilateral extended robot-assisted pelvic lymph node dissection (RAPLND) (25), intracorporeal Studer pouch (23), ileal conduit (two), and extracorporeal Studer pouch (two) construction. • Patient demographics, operative and postoperative variables, pathological variables, complications (according to modified Clavien system) and functional outcomes were evaluated. RESULTS: • The mean (sd, range) operative duration, intraoperative estimated blood loss and mean lymph node (LN) yield were 9.9 (1.4, 7.1-12.4) h, 429 (257, 100-1200) mL and 24.8 (9.2, 8-46), respectively. • The mean (sd, range) hospital stay was 10.5 (6.8, 7-36) days, there was one perioperative death (3.7%), lodge drains were removed at a mean of 11.3 (5.6, 9-35) days and surgical margins were negative in all but one patient who had pT4b disease. • The postoperative pathological stages were: pT0 (five), pTis (one), pT1 (one), pT2a (five), pT2b (three), pT3a (six), pT3b (two), pT4a (three) and pT4b (one). • Positive LNs and incidental prostate cancer were detected in six and nine patients, respectively and at a mean follow-up of 6.3 (2.9, 1.8-11.3) months, three patients died from metastatic disease and one from cardiac disease. • According to the modified Clavien system, there were nine minor (Grade 1 and 2) and four major (Grade 3-5) complications in the perioperative (0-30 days) period; four minor and three major complications in the postoperative (31-90 days) period. Of the available 18 patients, 11 were fully continent, four had mild and two had severe day-time incontinence. CONCLUSIONS: • Bilateral NVB-sparing RARC with RAPLND and intracorporeal Studer pouch or ileal conduit reconstruction are complex procedures with acceptable morbidity, excellent short-term surgical and pathological outcomes and satisfactory functional results. • Studies with more patients and longer follow-ups are required to evaluate the feasibility of these RA totally intracorporeal complex procedures.

BCG sepsis following inadvertent intravenous BCG administration for the treatment of bladder cancer can be effectively cured with anti-tuberculosis medications.

AIM: To the best of our knowledge we are presenting the very first case of inadvertent intravascular administration of BCG and its successful treatment with anti-tuberculosis medications on a patient with superficial bladder cancer. METHODS: A search of the English literature (PubMed/Medline) was performed concerning inadvertent BCG administration for bladder cancer by using the key words. RESULTS: The patient was admitted to our hospital with high fever and chills a few hours after intravascular BCG administration. Chest CT showed bilateral infiltration of the lungs. Patient was placed on anti-tuberculosis treatment including isoniazid, rifampycin, ethambutol and methylprednisolone initially; and this treatment was adjusted according to his clinical course and liver function tests. By the end of the 4th week of hospitalisation patient was responded well with normalisation of his clinical status, liver function tests and a normal chest X-ray. Thereafter, he was discharged home on isoniazid, ethambutol for 6 months, streptomycin, cycloserine-C and ofloxacin for 2 months, methylprednisolone which was stopped eventually after dose reduction. On follow-up at 6th month after discharge from the hospital, he was fully recovered with normal chest X-ray and blood tests. CONCLUSIONS: Development of severe sepsis is inevitable following inadvertent intravascular BCG administration. Therefore, urologists should warn and inform not only their patients and families but also healthcare workers such as nurses regarding the route of administration of the BCG treatment for bladder cancer. Our experience also proved that such a serious complication can be successfully treated if promptly acted.

Role of Rho-kinase in contractions of ureters from rabbits with unilateral ureteric obstruction.

OBJECTIVE: To investigate the expression of two isoforms of Rho-kinase (ROCK) and its functional role in the pathophysiological control of smooth muscle contraction in rabbits with unilateral ureteric obstruction (UUO). MATERIAL AND METHODS: Left UUO was created in 14 rabbits and eight other rabbits (controls) had sham operations. After 2 weeks all the rabbits were killed. Ureteric strips suspended in an organ bath were used for functional studies and the effects of Y-27632, a specific inhibitor of Rho-kinase, on spontaneous contractions and electrical field stimulation (EFS; 50 V, 1 ms, 16 Hz, for 20 s), carbachol- (10(-7)-10(-4)m), phenylephrine- (10(-7)-10(-4)m) and KCl- (50 mm) induced contractions were analysed. Western blotting was used to determine expression levels of Rho-kinase protein in the ureters of UUO and control rabbits. RESULTS: In the functional analysis, the contractions induced by EFS, KCl, phenylephrine and carbachol in the ureteric strips from rabbits with UUO were significantly greater than those from the control rabbits. Y-27632 considerably suppressed the ureter contractile responses in both UUO and control rabbits. Western blot analysis showed that both ROCK-1 and ROCK-2 proteins were expressed in the rabbit ureter. In accordance with the functional studies, the expression levels of both ROCK-1 and ROCK-2 were significantly greater in the ureters of UUO rabbits than in the controls. CONCLUSIONS: Y-27632 suppressed ureteric contractions in the rabbits with UUO. Western blot analysis also confirmed greater expression levels of ROCK-1 and ROCK-2 in the ureters of UUO rabbits. It is important to elucidate by which mechanisms the Rho-kinase pathway affects ureteric function after obstruction.