First-in-human real-time AI-assisted instrument deocclusion during augmented reality robotic surgery.

The integration of Augmented Reality (AR) into daily surgical practice is withheld by the correct registration of pre-operative data. This includes intelligent 3D model superposition whilst simultaneously handling real and virtual occlusions caused by the AR overlay. Occlusions can negatively impact surgical safety and as such deteriorate rather than improve surgical care. Robotic surgery is particularly suited to tackle these integration challenges in a stepwise approach as the robotic console allows for different inputs to be displayed in parallel to the surgeon. Nevertheless, real-time de-occlusion requires extensive computational resources which further complicates clinical integration. This work tackles the problem of instrument occlusion and presents, to the authors' best knowledge, the first-in-human on edge deployment of a real-time binary segmentation pipeline during three robot-assisted surgeries: partial nephrectomy, migrated endovascular stent removal, and liver metastasectomy. To this end, a state-of-the-art real-time segmentation and 3D model pipeline was implemented and presented to the surgeon during live surgery. The pipeline allows real-time binary segmentation of 37 non-organic surgical items, which are never occluded during AR. The application features real-time manual 3D model manipulation for correct soft tissue alignment. The proposed pipeline can contribute towards surgical safety, ergonomics, and acceptance of AR in minimally invasive surgery.

The ERUS course on robot-assisted kidney transplantation.

PURPOSE: Robot-assisted kidney transplantation (RAKT) is being increasingly performed at selected referral institutions worldwide. Yet, surgical training in RAKT is still unstructured and not grounded into formal credentialing courses including simulation, lab facilities, and modular training with animal models. As such, developing standardized, modular training programs is warranted to provide surgeons with the RAKT-specific skillset needed for a "safe" learning curve. METHODS: The 3-day course on RAKT developed at the EAU Skills Center in Orsi Academy was designed as a standardized, modular, step-by-step approach aiming to provide theoretical and practical skills. The course is held by expert proctors with extensive experience in RAKT. To maximize the course's usefulness, a solid knowledge of robotics and transplantation is desirable for participants. RESULTS: From January 2016 to July 2023, 87 surgeons from 23 countries (of which 36% from extra-European countries) participated in the RAKT course performed at the EAU Skills Center in Orsi Academy. Of these, 58/87 (67%) were urologists, while 27/87 (31%) were general surgeons and 2/87 (2%) were vascular surgeons. To date, 18 participants (20.6%) are actively involved in RAKT programs at institutions included in the European Association of Urology (EAU) Robotic Urology Section (ERUS)-RAKT network. CONCLUSION: Leveraging the potential of simulation, wet-lab training, live porcine models, and experienced proctors, the RAKT course performed at the EAU Skills Center in Orsi Academy represents the first structured teaching effort aiming to offer surgeons a full immersion in RAKT to train the core technical skills.

Proposal of a standardized training curriculum for open and robot-assisted kidney transplantation.

Standardized training programs for open (OKT) and robot-assisted kidney transplantation (RAKT) remain unmet clinical needs. To fill this gap, we designed a modified Delphi Consensus aiming to propose the first structured surgical curricula for both OKT and RAKT, involving a multispecialty international panel of experts. Two web-based surveys were built drafting two separate series of statements (for OKT and RAKT, respectively). The two surveys were delivered to a panel of 63 experts (for OKT) and 21 experts (for RAKT), selected considering their experience, academic profile and involvement in international associations. Consensus was defined as ≥75% agreement between the responders. Overall, 25/63 (40%) and 14/21 (67%) participated in the first round of the Delphi Consensus for the development of the structured curriculum for OKT and RAKT, respectively. During the second round, the experts reached consensus on all statements, as well as on the domains composing the structure of the training pathway: 1) eligibility criteria for trainees and host centres; 2) theoretical training; 3) simulation; 4) real case observation; and 5) modular training in the operating theatre. To the best of our knowledge, this is the first proposal of a dedicated curriculum for OKT and RAKT grounded on insights from international experts of different specialties. Our proposed curriculum provides the foundation to standardize the education and training in KT across Europe and beyond.

Privacy-proof Live Surgery Streaming: Development and Validation of a low-cost, Real-time Robotic Surgery Anonymization Algorithm.

OBJECTIVE: Develop a pioneer surgical anonymization algorithm for reliable and accurate real-time removal of out-of-body images, validated across various robotic platforms. SUMMARY BACKGROUND DATA / BACKGROUND: The use of surgical video data has become common practice in enhancing research and training. Video sharing requires complete anonymization, which, in the case of endoscopic surgery, entails the removal of all nonsurgical video frames where the endoscope can record the patient or operating room staff. To date, no openly available algorithmic solution for surgical anonymization offers reliable real-time anonymization for video streaming, which is also robotic-platform- and procedure-independent. METHODS: A dataset of 63 surgical videos of 6 procedures performed on four robotic systems was annotated for out-of-body sequences. The resulting 496.828 images were used to develop a deep learning algorithm that automatically detected out-of-body frames. Our solution was subsequently benchmarked against existing anonymization methods. In addition, we offer a post-processing step to enhance the performance and test a low-cost setup for real-time anonymization during live surgery streaming. RESULTS: Framewise anonymization yielded an ROC AUC-score of 99.46% on unseen procedures, increasing to 99.89% after post-processing. Our Robotic Anonymization Network (ROBAN) outperforms previous state-of-the-art algorithms, even on unseen procedural types, despite the fact that alternative solutions are explicitly trained using these procedures. CONCLUSIONS: Our deep learning model ROBAN offers reliable, accurate, and safe real-time anonymization during complex and lengthy surgical procedures regardless of the robotic platform. The model can be used in real-time for surgical live streaming and is openly available.

Comparative study between the use of double J ureteric stents vs bander ureteric stents during robotic-assisted radical cystectomy with intra corporeal ileal conduit urinary diversion.

Robotic-assisted radical cystectomy (RARC) is fast becoming the standard of care with comparable oncological outcomes to open surgery for patients with muscle-invasive bladder cancer. Ileal conduit is by far the most popular means of urinary diversion following a cystectomy. Use of stents is common practice to reduce uretero-enteric anastomosis-related complications. In the current study, practice was changed from the use of Double J (DJ) stents to bander stent intraoperatively. The potential advantages of using bander stent are avoiding second surgery for stent removal and easier change under local anaesthetic in the interventional radiology department. To compare the incidence of blocked, slipped stents and rate of ureteroileal anastomotic stricture after RARC with intracorporeal ileal conduit between practices of using DJ stents and bander stents. Retrospective analysis of all the patients undergoing Robotic radical cystectomy and intracorporeal ileal conduit between June 2014 and August 2023 was done. Initially, all intracorporeal anastomosis were covered with DJ stents. The practice was changed to cover the anastomosis with bander stent in November 2020. Number of patients needing re-surgery for blocked, slipped stents and ureteroileal anastomotic stricture were analyzed and compared using Chi-square analysis and Fisher's exact test (P < 0.05). A total of 168 patients underwent RARC with intracorporeal ileal conduit between June 2014 and August 2023 of which 128 patents were diverted with DJ stents and 40 with bander stent. The mean age and the patient demographics between the two groups were comparable. Of the 128 patients who were diverted with DJ stents, 6 (4.7%) had blocked stents, 3 (2.3%) had slipped stents, and 3 (2.3%) developed ureteroileal stricture needing readmission and urgent invasive intervention to exchange the stent or nephrostomy tube, whereas only 1 (2.5%) of the 40 patients with bander stent had blocked stent which was changed under local anaesthetic in the interventional radiology suite with no slipped stents reported and 2 (5%) had ureteroileal stricture who needed nephrostomies. Intraoperative ureteric stenting using bander stent has the potential to reduce the incidence of stent-related complications, such as blockage, slippage, and ureteroileal anastomotic stricture, following RARC with intracorporeal ileal conduit urinary diversion. Additionally, managing bander stent-related complications is less invasive with lower rate of readmission postoperatively compared to managing DJ stent-related ones.

The habits of European urologists in the field of cryopreservation before the urological cancers treatment.

INTRODUCTION: Treatments against urogenital cancers frequently have fertility side-effects. The strategy to preserve fertility after oncologic treatments is still a matter of debate with a lack of evidence and international guidelines. The aim of this study is to investigate fertility preservation practices before urogenital cancer treatments and to compare national habits. MATERIAL AND METHODS: An online anonymous survey was submitted from January to June 2021 to six European urological societies. The 31-items questionnaire included questions about demography, habits of evaluation, and management of fertility preservation in case of urogenital cancer treatments. RESULTS: Two hundred twenty-eight urologists from six urological societies in five different countries (Belgium, The Netherlands, Luxembourg, France, Finland) filled out the survey. Three quarter (74%; n = 166) usually propose a cryopreservation before orchidectomy. In case of oligo/azoo-spermia, the technique performed for the sperm extraction during orchidectomy varies among the sample: 70.5% (n = 160) of the responders do not perform a Testicular Sperm Extraction (TESE) nor a Percutaneous Epididymal Sperm Aspiration (PESA). The cryopreservation for prostate cancer treatments is never proposed in 48.17% (n = 105) of responders but conversely it is always proposed in 5.05% (n = 11). The cryopreservation before bladder cancer treatments is not commonly proposed (67.5%, n = 154). CONCLUSION: Our study showed variable country specific tendencies in terms of fertility preservation in the period of treatment of urological cancers. These differences seem to be related to national guidelines recommendations. Standardization of international guidelines is urgently needed in the field of fertility for urological cancer patients.

Radical cystectomy or trimodality therapy for muscle-invasive bladder cancer: a qualitative study exploring patient priorities and counselling needs when making a treatment choice.

BACKGROUND: This study aims to explore the priorities and counselling needs of patients with muscle-invasive bladder cancer faced with a decision between radical cystectomy and trimodality therapy. METHODS: We performed a qualitative study according to the phenomenological approach. Sixteen muscle-invasive bladder cancer survivors who underwent radical cystectomy or trimodality therapy completed a semi-structured interview between May 2022 and February 2023. Patients were recruited via Ghent University Hospital and a patient organisation. Data were analysed with inductive thematic analysis by a multi-disciplinary team using an iterative approach and investigators' triangulation. RESULTS: Four main priorities determining the treatment decision were identified. (1) curing the disease; (2) health-related quality of life (physical, mental and social); (3) confidence in the treatment, which was mainly based on trust in the clinician; and (4) personal attributes. Trust in the clinician can be achieved by fulfilling the patient's information needs (accurate, complete, clear, impartial, personalised, realistic, and transparent information), ensuring accessibility of the clinician, and creating a clear and personalised treatment plan, involving patients to the extend they desire. Many patients considered a patient decision aid as a valuable asset in this process. CONCLUSION: Priorities vary between patients with muscle-invasive bladder cancer. Identifying individual priorities and offering personalised information about them is crucial for ensuring trust in the clinician and confidence in the treatment. Use of a patient decision aid can be beneficial in this process.

Surgical Phase Duration in Robot-Assisted Partial Nephrectomy: A Surgical Data Science Exploration for Clinical Relevance.

(1) Background: Surgical phases form the basic building blocks for surgical skill assessment, feedback, and teaching. The phase duration itself and its correlation with clinical parameters at diagnosis have not yet been investigated. Novel commercial platforms provide phase indications but have not been assessed for accuracy yet. (2) Methods: We assessed 100 robot-assisted partial nephrectomy videos for phase durations based on previously defined proficiency metrics. We developed an annotation framework and subsequently compared our annotations to an existing commercial solution (Touch Surgery, Medtronic™). We subsequently explored clinical correlations between phase durations and parameters derived from diagnosis and treatment. (3) Results: An objective and uniform phase assessment requires precise definitions derived from an iterative revision process. A comparison to a commercial solution shows large differences in definitions across phases. BMI and the duration of renal tumor identification are positively correlated, as are tumor complexity and both tumor excision and renorrhaphy duration. (4) Conclusions: The surgical phase duration can be correlated with certain clinical outcomes. Further research should investigate whether the retrieved correlations are also clinically meaningful. This requires an increase in dataset sizes and facilitation through intelligent computer vision algorithms. Commercial platforms can facilitate this dataset expansion and help unlock the full potential, provided that the phase annotation details are disclosed.

Robot-assisted Partial Nephrectomy Using Intra-arterial Renal Hypothermia for Highly Complex Endophytic or Hilar Tumors: Case Series and Description of Surgical Technique.

Background: In partial nephrectomy for highly complex tumors with expected long ischemia time, renal hypothermia can be used to minimize ischemic parenchymal damage. Objective: To describe our case series, surgical technique, and early outcomes for robot-assisted partial nephrectomy (RAPN) using intra-arterial cold perfusion through arteriotomy. Design setting and participants: A retrospective analysis was conducted of ten patients with renal tumors (PADUA score 9-13) undergoing RAPN between March 2020 and March 2023 with intra-arterial cooling because of expected arterial clamping times longer than 25 min. Surgical procedure: Multiport transperitoneal RAPN with full renal mobilization and arterial, venous, and ureteral clamping was performed. After arteriotomy and venotomy, 4°C heparinized saline is administered intravascular through a Fogarty catheter to maintain renal hypothermia while performing RAPN. Measurements: Demographic data, renal function, console and ischemia times, surgical margin status, hospital stay, estimated blood loss, and complications were analyzed. Results and limitations: The median warm and cold ischemia times were 4 min (interquartile range [IQR] 3-7 min) and 60 min (IQR 33-75 min), respectively. The median rewarming ischemia time was 10.5 min (IQR 6.5-23.75 min). The median pre- and postoperative estimated glomerular filtration rate values at least 1 mo after surgery were 90 ml/min (IQR 78.35-90 ml/min) and 86.9 ml/min (IQR 62.08-90 ml/min), respectively. Limitations include small cohort size and short median follow-up (13 [IQR 9.1-32.4] mo). Conclusions: We demonstrate the feasibility and first case series for RAPN using intra-arterial renal hypothermia through arteriotomy. This approach broadens the scope for minimal invasive nephron-sparing surgery in highly complex renal masses. Patient summary: We demonstrate a minimally invasive surgical technique that reduces kidney infarction during complex kidney tumor removal where surrounding healthy kidney tissue is spared. The technique entails arterial cold fluid irrigation, which temporarily decreases renal metabolism and allows more kidneys to be salvaged.

Comparing different pneumoperitoneum (12 vs. 15 mmHg) pressures with cytokine analysis to evaluate clinical outcomes in patients undergoing robotic-assisted laparoscopic radical cystectomy and intracorporeal robotic urinary diversion.

Background: Robotic cystectomy is the mainstay surgical intervention for treatment-refractory nonmuscle-invasive and muscle-invasive bladder cancer. However, paralytic ileus may complicate the postoperative recovery and may be a consequence of an inflammatory response associated with transient gut ischaemia. We have therefore investigated clinical, operative and inflammatory biomarker associations between paralytic ileus in the context of robotic cystectomy and intracorporeal ileal conduit urinary diversion. Methods: Prospective consective patients referred for robotic cystectomy were consented and included in the study, while patients >75 years old and converted to open procedure were excluded. The pneumoperitoneum pressure (PP) for carbon dioxide insufflation required to perform the procedure efficiently and safely was recorded (12 or 15 mmHg). We also recorded the postoperative days patients passed flatus and stools, whether they developed ileus, as well as other standard clinical and demographic data. The expression of select proinflammatory and anti-inflammatory cytokines was determined by multiplex analysis using a cytometric bead array with changes in profiles correlated with the pressures applied and with the existence of an ileus. Results: Twenty-seven patients were recruited, but only 20 were used in the study with 10 patients in each PP group. Seven patients were excluded all of whom had an extracorporeal ileal conduit formation. There were differences in the 40-min shorter operative time and 1 day shorter length of stay, as well as passing flatus 1 day and stools 1.5 days earlier in the 12 mmHg compared with the 15 mmHg group. More patients had ileus in the 15 mmHg group vs 12 mmHg group (30% vs. 10.0%). These were not statistically significant. Similarly, there were no statistical differences in the expression of proinflammatory cytokines at the two different pressures or between patient groups, but there were outliers, with the median indicating nonsymmetrical distribution. By comparison, anti-inflammatory cytokines showed some significant differences between groups, with IL-6 and IL-10 showing elevated levels postsurgery. No statistical difference was observed between pressures or the existence of an ileus, but the maximum levels of IL-6 and IL-10 detected in some patients reflect a pressure difference. Conclusions: The initial findings of this novel scientific study indicated a higher risk of paralytic ileus postrobotic cystectomy and robotic intracorporeal urinary diversion when a higher pressure of 15 mmHg is used compared with 12 mmHg. Although further studies are required to establish the linkage between cytokine profile expression, pressure and ileus, our initial data reinforces the advantages of lower pressure robotic cystectomy and intracorporeal urinary diversion in patient outcomes.

Extensive profiling of histidine-containing dipeptides reveals species- and tissue-specific distribution and metabolism in mice, rats, and humans.

AIM: Histidine-containing dipeptides (HCDs) are pleiotropic homeostatic molecules with potent antioxidative and carbonyl quenching properties linked to various inflammatory, metabolic, and neurological diseases, as well as exercise performance. However, the distribution and metabolism of HCDs across tissues and species are still unclear. METHODS: Using a sensitive UHPLC-MS/MS approach and an optimized quantification method, we performed a systematic and extensive profiling of HCDs in the mouse, rat, and human body (in n = 26, n = 25, and n = 19 tissues, respectively). RESULTS: Our data show that tissue HCD levels are uniquely produced by carnosine synthase (CARNS1), an enzyme that was preferentially expressed by fast-twitch skeletal muscle fibres and brain oligodendrocytes. Cardiac HCD levels are remarkably low compared to other excitable tissues. Carnosine is unstable in human plasma, but is preferentially transported within red blood cells in humans but not rodents. The low abundant carnosine analogue N-acetylcarnosine is the most stable plasma HCD, and is enriched in human skeletal muscles. Here, N-acetylcarnosine is continuously secreted into the circulation, which is further induced by acute exercise in a myokine-like fashion. CONCLUSION: Collectively, we provide a novel basis to unravel tissue-specific, paracrine, and endocrine roles of HCDs in human health and disease.

The First Entirely 3D-Printed Training Model for Robot-assisted Kidney Transplantation: The RAKT Box.

Background: Robot-assisted kidney transplantation (RAKT) is increasingly performed at selected referral institutions worldwide. However, simulation and proficiency-based progression training frameworks for RAKT are still lacking, making acquisition of the RAKT-specific skill set a critical unmet need for future RAKT surgeons. Objective: To develop and test the RAKT Box, the first entirely 3D-printed, perfused, hyperaccuracy simulator for vascular anastomoses during RAKT. Design setting and participants: The project was developed in a stepwise fashion by a multidisciplinary team including urologists and bioengineers via an iterative process over a 3-yr period (November 2019-November 2022) using an established methodology. The essential and time-sensitive steps of RAKT were selected by a team of RAKT experts and simulated using the RAKT Box according to the principles of the Vattituki-Medanta technique. The RAKT Box was tested in the operating theatre by an expert RAKT surgeon and independently by four trainees with heterogeneous expertise in robotic surgery and kidney transplantation. Surgical procedure: Simulation of RAKT. Measurements: Video recordings of the trainees' performance of vascular anastomoses using the RAKT Box were evaluated blind by a senior surgeon according to the Global Evaluative Assessment of Robotic Skills (GEARS) and Assessment of Robotic Console Skills (ARCS) tools. Results and limitations: All participants successfully completed the training session, confirming the technical reliability of the RAKT Box simulator. Tangible differences were observed among the trainees in both anastomosis time and performance metrics. Key limitations of the RAKT Box include lack of simulation of the ureterovesical anastomosis and the need for a robotic platform, specific training instruments, and disposable 3D-printed vessels. Conclusions: The RAKT Box is a reliable educational tool to train novice surgeons in the key steps of RAKT and may represent the first step toward the definition of a structured surgical curriculum in RAKT. Patient summary: We describe the first entirely 3D-printed simulator that allows surgeons to test the key steps of robot-assisted kidney transplantation (RAKT) in a training environment before performing the procedure in patients. The simulator, called the RAKT Box, has been successfully tested by an expert surgeon and four trainees. The results confirm its reliability and potential as an educational tool for training of future RAKT surgeons.

Robot-assisted radical nephrectomy for Wilms' tumor in children.

INTRODUCTION: Surgical removal of the tumor is a key step in the management of nephroblastoma. Less invasive surgical approaches such as robot-assisted radical nephrectomy (RARN) has gained momentum over the past few years. This video presents a comprehensive step-by-step video for two cases: one uncomplicated left RARN and one more challenging right RARN. MATERIALS & METHODS: Following the UMBRELLA/SIOP protocol, both patients received neoadjuvant chemotherapy. Under general anesthesia, in a lateral decubitus position, four robotic and one assistant port are placed. After mobilization of the colon, the ureter and gonadal vessels are subsequently identified. The renal hilum is dissected, and the renal artery and vein are divided. The kidney is dissected with sparing of the adrenal gland. The ureter and gonadal vessels are divided, and the specimen is removed through a Pfannenstiel incision. Lymph node sampling is performed. RESULTS: Patients were 4 and 5 years old. The total surgical time was 95 and 200 min, with an estimated blood loss of 5 and 10 cc. The hospital stay was limited to 3 and 4 days. Both pathological reports confirmed the diagnosis of nephroblastoma, with tumour-free resection margins. No complications were observed 2 months postoperatively. CONCLUSION: RARN is feasible in children.

Robot-assisted Radical Cystectomy with Orthotopic Neobladder Reconstruction: Techniques and Functional Outcomes in Males.

BACKGROUND: Little is known regarding functional outcomes after robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction. OBJECTIVE: To report on urinary continence (UC) and erectile function (EF) at 12 mo after RARC and ICNB reconstruction and investigate predictors of these outcomes. DESIGN, SETTING, AND PARTICIPANTS: We used data from a multi-institutional database of patients who underwent RARC and ICNB reconstruction for bladder cancer. SURGICAL PROCEDURE: The cystoprostatectomy sensu stricto followed the conventional steps. ICNB reconstruction was performed at the physician's discretion according to the Studer/Wiklund, S pouch, Gaston, vescica ileale Padovana, or Hautmann technique. The techniques are detailed in the video accompanying the article. MEASUREMENTS: The outcomes measured were UC and EF at 12 mo. RESULTS AND LIMITATIONS: A total of 732 male patients were identified with a median age at diagnosis of 64 yr (interquartile range 58-70). The ICNB reconstruction technique was Studer/Wiklund in 74%, S pouch in 1.5%, Gaston in 19%, vescica ileale Padovana in 1.5%, and Hautmann in 4% of cases. The 12-mo UC rate was 86% for daytime and 66% for nighttime continence, including patients who reported the use of a safety pad (20% and 32%, respectively). The 12-mo EF rate was 55%, including men who reported potency with the aid of phosphodiesterase type 5 inhibitors (24%). After adjusting for potential confounders, neobladder type was not associated with UC. Unilateral nerve-sparing (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.88-7.85; p < 0.001) and bilateral nerve-sparing (OR 6.25, 95% CI 3.55-11.0; p < 0.001), were positively associated with EF, whereas age (OR 0.93, 95% CI 0.91-0.95; p < 0.001) and an American Society of Anesthesiologists score of 3 (OR 0.46, 95% CI 0.25-0.89; p < 0.02) were inversely associated with EF. CONCLUSIONS: RARC and ICNB reconstruction are generally associated with good functional outcomes in terms of UC. EF is highly affected by the degree of nerve preservation, age, and comorbidities. PATIENT SUMMARY: We investigated functional outcomes after robot-assisted removal of the bladder in terms of urinary continence and erectile function. We found that, in general, patients have relatively good functional outcomes at 12 months after surgery.

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.

Experiences of Men With Prostate Cancer Participating in a Clinical Pathway With a Supervised Group-based Exercise Program to Combat Androgen Deprivation-Induced Side Effects: A Qualitative Focus Group Study.

OBJECTIVES: A clinical pathway in daily practice improved implementation of evidence-based strategies for the management of androgen deprivation-induced side effects in men with prostate cancer. This study aimed to explore patients' expectations and reasons to start with the clinical pathway; explore patients' experiences and attitudes toward the pathway; and identify key pathway ingredients and examine patients' attitudes about a possible transition toward the home environment after a hospital-based pathway participation. DATA SOURCES: Focus group interviews were conducted through purposeful sampling, consisting of former and current participants of the clinical pathway at Ghent University Hospital. Data was audiotaped and transcribed verbatim, coded in NVivo12, and thematically and inductively analyzed through constant comparisons. CONCLUSION: Men with prostate cancer have positive experiences toward the use of a holistic multidisciplinary approach (ie, clinical pathway) to combat androgen deprivation therapy-induced side effects in practice. Patients identified several key ingredients of the pathway, such as peer support, physiotherapist involvement, and availability of a multidisciplinary team. Patients were, however, reluctant to continue the exercise component at home because of negative attitudes toward a public gym, practical issues, absence of known facilitators, and other priorities. IMPLICATIONS FOR NURSING PRACTICE: Referral by a health care provider remains an important motivator for pathway participation. Peer support, physiotherapist involvement, and availability of a multidisciplinary team are crucial components of the clinical pathway and should be taken into account when developing and implementing similar pathways to increase program uptake in daily practice.

A Novel Three-dimensional Planning Tool for Selective Clamping During Partial Nephrectomy: Validation of a Perfusion Zone Algorithm.

BACKGROUND: Selective clamping during robot-assisted partial nephrectomy (RAPN) requires extensive knowledge on patient-specific renal vasculature, obtained through imaging. OBJECTIVE: To validate an in-house developed perfusion zone algorithm that provides patient-specific three-dimensional (3D) renal perfusion information. DESIGN, SETTING, AND PARTICIPANTS: Between October 2020 and June 2022, 25 patients undergoing RAPN at Ghent University Hospital were included. Three-dimensional models, based on preoperative computed tomography (CT) scans, showed the clamped artery's ischemic zone, as calculated by the algorithm. SURGICAL PROCEDURE: All patients underwent selective clamping during RAPN. Indocyanine green (ICG) was administered to visualize the true ischemic zone perioperatively. Surgery was recorded for a postoperative analysis. MEASUREMENTS: The true ischemic zone of the clamped artery was compared with the ischemic zone predicted by the algorithm through two metrics: (1) total ischemic zone overlap and (2) tumor ischemic zone overlap. Six urologists assessed metric 1; metric 2 was assessed objectively by the authors. RESULTS AND LIMITATIONS: In 92% of the cases, the algorithm was sufficiently accurate to plan a selective clamping strategy. Metric 1 showed an average score of 4.28 out of 5. Metric 2 showed an average score of 4.14 out of 5. A first limitation is that ICG can be evaluated only at the kidney surface. A second limitation is that mainly patients with impaired renal function are expected to benefit from this technology, but contrast-enhanced CT is required at present. CONCLUSIONS: The proposed new tool demonstrated high accuracy when planning selective clamping for RAPN. A follow-up prospective study is needed to determine the tool's clinical added value. PATIENT SUMMARY: In partial nephrectomy, the surgeon has no information on which specific arterial branches perfuse the kidney tumor. We developed a surgeon support system that visualizes the perfusion zones of all arteries on a three-dimensional model and indicates the correct arteries to clamp. In this study, we validate this tool.

Vulvar pagetoid urothelial intraepithelial neoplasia: a case report.

BACKGROUND: Pagetoid urothelial intraepithelial neoplasia (PUIN) is a form of secondary Extramammary Paget Disease (EMPD). It is a rare malignant condition seen on the female genitalia synchronous or metachronous with bladder cancer (BC). CASE PRESENTATION: A 66-year-old female presented with PUIN at the labia minora 2 years after an open anterior pelvic exenteration with ileal conduit urinary diversion for carcinoma in situ (CIS) of the bladder. PUIN of the vulva and vagina was confirmed by a punch biopsy and the patient underwent a radical vaginectomy with urethrectomy and inguinal sentinel node procedure. Immunohistochemically EMPD was identified by the expression tumor protein 63 (p63), cytokeratin 7, and cytokeratin 20 (CK20). CONCLUSIONS: PUIN is a rare but distinct clinical entity as a form of secondary EMPD which can be differentiated from primary EMPD based on medical history, histology, and immunohistochemistry.

Peritoneal tuberculosis caused by intravesical instillation with Bacillus Calmette-Guérin (BCG) following nephroureterectomy in a patient with bladder and upper tract urothelial cancer: a case report.

BACKGROUND: The standard treatment for high-risk non-muscle-invasive bladder cancer (NMIBC) is trans-urethral resection of the bladder (TURB) followed by instillation of Bacillus Calmette-Guérin (BCG). The occurrence of peritoneal tuberculosis after intravesical BCG instillation is extremely rare and difficult to diagnose. METHODS: We report the case of a 79-year-old man with urothelial cell carcinoma (UCC) of the kidney and bladder who developed peritoneal tuberculosis after consecutive TURB and nephroureterectomy followed by intravesical BCG instillation. Further investigation revealed an undiagnosed bladder leak. CONCLUSION: This case serves as a reminder for urologists to be suspicious for urothelium discontinuity when administering BCG shortly after bladder surgery.

A systematic review and meta-analysis on delaying surgery for urothelial carcinoma of bladder and upper tract urothelial carcinoma: Implications for the COVID19 pandemic and beyond.

Purpose: The COVID-19 pandemic has led to competing strains on hospital resources and healthcare personnel. Patients with newly diagnosed invasive urothelial carcinomas of bladder (UCB) upper tract (UTUC) may experience delays to definitive radical cystectomy (RC) or radical nephro-ureterectomy (RNU) respectively. We evaluate the impact of delaying definitive surgery on survival outcomes for invasive UCB and UTUC. Methods: We searched for all studies investigating delayed urologic cancer surgery in Medline and Embase up to June 2020. A systematic review and meta-analysis was performed. Results: We identified a total of 30 studies with 32,591 patients. Across 13 studies (n = 12,201), a delay from diagnosis of bladder cancer/TURBT to RC was associated with poorer overall survival (HR 1.25, 95% CI: 1.09-1.45, p = 0.002). For patients who underwent neoadjuvant chemotherapy before RC, across the 5 studies (n = 4,316 patients), a delay between neoadjuvant chemotherapy and radical cystectomy was not found to be significantly associated with overall survival (pooled HR 1.37, 95% CI: 0.96-1.94, p = 0.08). For UTUC, 6 studies (n = 4,629) found that delay between diagnosis of UTUC to RNU was associated with poorer overall survival (pooled HR 1.55, 95% CI: 1.19-2.02, p = 0.001) and cancer-specific survival (pooled HR of 2.56, 95% CI: 1.50-4.37, p = 0.001). Limitations included between-study heterogeneity, particularly in the definitions of delay cut-off periods between diagnosis to surgery. Conclusions: A delay from diagnosis of UCB or UTUC to definitive RC or RNU was associated with poorer survival outcomes. This was not the case for patients who received neoadjuvant chemotherapy.