Multimodular robotic systems (Hugo RAS and Versius CMR) for pelvic surgery: tasks and perspectives from the bed-side assistant.

The Hugo RAS and Versius are new robotic systems with a multimodular configuration, requiring a dedicated positioning of units, arms and trocars. While promising flexibility and multiquadrant opportunities-with an enhanced range of motion-the presence of multiple units around the patient should be effectively managed by the assistant and requires a new background of tasks. The article represents a practical guide while providing an overview on assistants' perspectives.

First case of robot-assisted radical cystectomy and intracorporeal neobladder reconstruction with the Hugo RAS system: step-by-step surgical setup and technique.

Robotic assisted radical cystectomy (RARC) is a standard option for the treatment of bladder cancer. Currently, novel platforms are entering the market and the Hugo RAS (Medtronic, Minneapolis, MN, USA) is a new system consisting of an open console with 3D-HD screen and a multi-modular fashion. Even if several series are already available for radical prostatectomy, to now a full description of RARC performed with Hugo RAS is still lacking. We report the first case of RARC with intracorporeal neobladder performed with the Hugo RAS-and another case of RARC with ureterostomy. Both patients were affected by MIBC. Case 1 was a 61-year-old patient without comorbidities (CCI 4), in which a Bordeaux ileal neobladder was scheduled after previous NAC. The second was the case of a 70-year-old one with CCI 7 and BMI 35; in this case, a ureterostomy was planned. Details of the robotic system: one 11 mm endoscope port was placed on the midline 2 cm above the umbilicus. Another two 8 mm robotic ports were symmetrically placed under vision on a transversal line-located 1 cm below the umbilicus. A third robotic port was positioned on the left side in a W configuration. All ports were located at least 9 cm between each other. Finally, two assistant ports were positioned in the right abdominal site. All arm-carts were parked 45-60 cm from the operative bed, before the docking process begins. Three arm-carts were parked on the left side, the assistant and the scrub nurse worked on the right side, while the energy tower stayed at the foot of the bed, according to the previous description of Hugo RAS robotic radical prostatectomy. The endoscope arm-cart is docked first, then the adjacent left carts are docked; finally, the surgeon's right-hand cart is docked from the right side of the bed. The docking angles and tilt we applied were: endoscope: 175°; minus 45°; surgeon left hand 140°; minus 30°; surgeon right hand 225°; minus 30°; fourth arm 125°; plus 15°. The instruments we used were those fitting our conventional four-instrument setup for RARC: monopolar shears, Maryland forceps, needle driver and Cadiere as the fourth arm. The procedures were completed without technical errors or technological failures-requiring a change in surgical strategy. Docking time was approximately 35 min; console time up to urethral dissection was 150 and 140 min in Case 1 and 2. The time for pelvic nodal dissection was approximately 37 min for both. The multi-modularity fashion of the Hugo RAS allowed an easy management of the bowel in Case 1; the absence of robotic staplers required the use of the laparoscopic ones, managed by an adjunctive assistant with room within the cart. In conclusion, RARC with the Hugo RAS is a feasible procedure able to reproduce all surgical steps without critical errors or complications requiring a change in surgical planning. Urinary diversion with intracorporeal reconstruction is feasible as well, with adequate preliminary outcomes.

Flower Pollen Extract in Association with Vitamins (Deprox 500®) Versus Serenoa repens in Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Comparative Analysis of Two Different Treatments.

OBJECTIVE: Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is reported in the literature ranging from 1 to 14.2%. The aim of the present study was to assess the impact on patient's quality of life and symptoms of Flower pollen extract in association with vitamins (Deprox 500®) in comparison with Serenoa repens 320 mg (Permixon 320 mg® by Pierre Fabre) in patients with CP/CPPS. METHODOLOGY: All consecutive patients, with a diagnosis of CP/CPPS, referred to our center from January to August 2016, were screened to be enrolled in this single-center, randomized, controlled trial. The main outcome measure was the evaluation of IPSS/NIHCPSI (International Prostatic Symptom Score/NIH-Chronic Prostatitis Symptom Index) score variation and the assessment of the quality of life and symptoms at the end of the therapy. The second outcome measure was the evaluation of the comorbidity role in the CP/CPPS therapy. 63 patients were analyzed; patients were randomized into two groups: 29 patients were treated with Deprox 500® 2 tablets/day for 6 weeks and 34 patients with Serenoa repens 320 mg, 1 tablet/day for 6 weeks. RESULTS: The mean score variation for IPSS was -12.7 ± 4.3 in the Deprox 500® group and -7.8 ± 4.7 in the Serenoa repens group (p=0.0005) while for NIH-CPSI was -17.3±3.1 in the Deprox 500® group and -13.6±4.8 in the Serenoa repens group (p=0.0016). By accounting only the symptoms part of NIH-CPSI questionnaire, the mean score variation reported was -11.5±2.5 in the Deprox 500® group and -9.02±4.0 in the Serenoa repens group (p=0.009321). Furthermore, analyzing the comorbidity subgroups, in patients with hypertension, the mean IPSS score variation was -14.3±3.2 in the Deprox 500® group and - 9.02±4.0 in the Serenoa repens group. CONCLUSION: In conclusion, in patients with CP/CPPS, Deprox 500® improves IPSS and NIH-CPSI scores up to 74.5% and 84.5% respectively. Furthermore, in patients with hypertension, the antioxidant effect of Deprox 500® reduces the mean IPSS score of 82.7%.

State of the art of prostatic arterial embolization for benign prostatic hyperplasia.

Prostatectomy via open surgery or transurethral resection of the prostate (TURP) is the standard treatment for benign prostatic hyperplasia (BPH). Several patients present contraindication for standard approach, individuals older than 60 years with urinary tract infection, strictures, post-operative pain, incontinence or urinary retention, sexual dysfunction, and blood loss are not good candidates for surgery. Prostatic artery embolization (PAE) is emerging as a viable method for patients unsuitable for surgery. In this article, we report results about technical and clinical success and safety of the procedure to define the current status.

[Transrectal ultrasound assessment of anastomosis after videolaparoscopic radical prostatectomy: our experience]. / Il controllo ecografico transrettale dell'anastomosi dopo VLRP. La nostra esperienza.

BACKGROUND: Trans-Rectal UltraSound (TRUS) has proved to be an accurate procedure comparable to that of Fluoro-cystography (FC) to assess vesicourethral anastomosis after radical prostatectomy, with the advantages of lower costs, no radiation exposure and no dependence on the radiology department. METHODS: 60 Video Laparoscopic Radical Prostactomies (VLRP) were performed at our institution between September 2008 and January 2010. All patients underwent anatomosis assessment on postoperative day 6 with TRUS (Aloka A7 US machine with endorectal end-fire probe). 200 ml of sterile saline was manually instilled into the bladder by an assistant, while TRUS visualization of anastomosis was carried out by an urologist. The test was considered positive if any expanding anechoic shadow developed beside the anastomosis. In case of negative test the catheter was removed. In case of positive test the catheter was left in place and reassessment was performed every 5-7 days with both TRUS and FC, until negative result. RESULTS: At the initial TRUS assessment we had 4 positive and 56 negative tests. Three out of the four patients with a positive test had a second assessment on p.o. day 14, which gave a negative result. The 4th positive case had a positive second assessment on p.o. day 14 and a third negative one on p.o. day 21. In a total of 20 assessments both TRUS and FC were performed. The results of the two procedures were always in accordance. CONCLUSIONS: We have introduced TRUS assessment of vescicourethral anastomosis after laparoscopic radical prostatectomy as a routine procedure in our department. We are planning a comparative study, using FC as the gold standard, for validation purposes.

Preservation of cavernosal erectile function after soft penile prosthesis implant in Peyronie's disease: long-term followup.

The aim of this retrospective study is to evaluate the long-term followup of soft penile SSDA prosthesis, without plaque surgery in the treatment of Peyronie's disease. This study included 12 men with Peyronie's disease who underwent placement of a penile prosthesis. All patients were followed for at least 6 years. Prosthesis straightened the penile shaft in all cases, restoring patient sexual satisfaction. No operative or postoperative complications occurred, and no reoperations were needed. All patients have undergone further examination with basal and dynamic eco color Doppler. The findings are encouraging as the penis preserves the ability to enhance the tumescence and penile girth. We can conclude that SSDA penile prosthesis is safe and effective in Peyronie's disease.

Local treatment of penile squamous cell carcinoma.

Treatment of primary tumour represents one of the main issues in the management of squamous cell carcinoma of the penis. Radical surgery assures the best results in terms of oncological radicality but causes important anatomical and functional limitations and a significant quality of life compromise. It is possible to suggest a penile-sparing treatment in the presence of small size and low stage tumours. The local recurrence rates seem higher than radical surgery and the functional and aesthetic results are not excellent in all cases. Moreover, radiotherapy seems to have a negligible percentage of local complications.