Generative AI Platform for Automating Social Media Posts From Urology Journal Articles: A Cross-Sectional Study and Randomized Assessment.

PURPOSE: This cross-sectional study assessed a generative-AI platform to automate the creation of accurate, appropriate, and compelling social-media (SoMe) posts from urological journal articles. MATERIALS AND METHODS: One hundred SoMe-posts from the top 3 journals in urology X (Twitter) profiles were collected from Aug-2022 to Oct-2023 A freeware GPT-tool was developed to auto-generate SoMe posts, which included title-summarization, key findings, pertinent emojis, hashtags, and DOI links to the article. Three physicians independently evaluated GPT-generated posts for achieving tetrafecta of accuracy and appropriateness criteria. Fifteen scenarios were created from 5 randomly selected posts from each journal. Each scenario contained both the original and the GPT-generated post for the same article. Five questions were formulated to investigate the posts' likability, shareability, engagement, understandability, and comprehensiveness. The paired posts were then randomized and presented to blinded academic authors and general public through Amazon Mechanical Turk (AMT) responders for preference evaluation. RESULTS: Median (IQR) time for post auto-generation was 10.2 seconds (8.5-12.5). Of the 150 rated GPT-generated posts, 115 (76.6%) met the correctness tetrafecta: 144 (96%) accurately summarized the title, 147 (98%) accurately presented the articles' main findings, 131 (87.3%) appropriately used emojis and hashtags 138 (92%). A total of 258 academic urologists and 493 AMT responders answered the surveys, wherein the GPT-generated posts consistently outperformed the original journals' posts for both academicians and AMT responders (P < .05). CONCLUSIONS: Generative-AI can automate the creation of SoMe posts from urology journal abstracts that are both accurate and preferable by the academic community and general public.

Severity Grading Systems for Intraoperative Adverse Events. A Systematic Review of the Literature and Citation Analysis.

INTRODUCTION: The accurate assessment and grading of adverse events (AE) is essential to ensure comparisons between surgical procedures and outcomes. The current lack of a standardized severity grading system may limit our understanding of the true morbidity attributed to AEs in surgery. The aim of this study is to review the prevalence in which intraoperative adverse event (iAE) severity grading systems are used in the literature, evaluate the strengths and limitations of these systems, and appraise their applicability in clinical studies. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. PubMed, Web of Science, and Scopus were queried to yield all clinical studies reporting the proposal and/or the validation of iAE severity grading systems. Google Scholar, Web of Science, and Scopus were searched separately to identify the articles citing the systems to grade iAEs identified in the first search. RESULTS: Our search yielded 2957 studies, with 7 studies considered for the qualitative synthesis. Five studies considered only surgical/interventional iAEs, while 2 considered both surgical/interventional and anesthesiologic iAEs. Two included studies validated the iAE severity grading system prospectively. A total of 357 citations were retrieved, with an overall self/nonself-citation ratio of 0.17 (53/304). The majority of citing articles were clinical studies (44.1%). The average number of citations per year was 6.7 citations for each classification/severity system, with only 2.05 citations/year for clinical studies. Of the 158 clinical studies citing the severity grading systems, only 90 (56.9%) used them to grade the iAEs. The appraisal of applicability (mean%/median%) was below the 70% threshold in 3 domains: stakeholder involvement (46/47), clarity of presentation (65/67), and applicability (57/56). CONCLUSION: Seven severity grading systems for iAEs have been published in the last decade. Despite the importance of collecting and grading the iAEs, these systems are poorly adopted, with only a few studies per year using them. A uniform globally implemented severity grading system is needed to produce comparable data across studies and develop strategies to decrease iAEs, further improving patient safety.

Assessment and Reporting of Perioperative Adverse Events and Complications in Patients Undergoing Inguinal Lymphadenectomy for Melanoma, Vulvar Cancer, and Penile Cancer: A Systematic Review and Meta-analysis.

BACKGROUND: Inguinal lymph node dissection (ILND) plays a crucial role in the oncological management of patients with melanoma, penile, and vulvar cancer. This study aims to systematically evaluate perioperative adverse events (AEs) in patients undergoing ILND and its reporting. METHODS: A systematic review was conducted according to PRISMA. PubMed, MEDLINE, Scopus, and Embase were queried to identify studies discussing perioperative AEs in patients with melanoma, penile, and vulvar cancer following ILND. RESULTS: Our search generated 3.469 publications, with 296 studies meeting the inclusion criteria. Details of 14.421 patients were analyzed. Of these studies, 58 (19.5%) described intraoperative AEs (iAEs) as an outcome of interest. Overall, 68 (2.9%) patients reported at least one iAE. Postoperative AEs were reported in 278 studies, combining data on 10.898 patients. Overall, 5.748 (52.7%) patients documented ≥1 postoperative AEs. The most reported ILND-related AEs were lymphatic AEs, with a total of 4.055 (38.8%) events. The pooled meta-analysis confirmed that high BMI (RR 1.09; p = 0.006), ≥1 comorbidities (RR 1.79; p = 0.01), and diabetes (RR 1.81; p = < 0.00001) are independent predictors for any AEs after ILND. When assessing the quality of the AEs reporting, we found 25% of studies reported at least 50% of the required criteria. CONCLUSION: ILND performed in melanoma, penile, and vulvar cancer patients is a morbid procedure. The quality of the AEs reporting is suboptimal. A more standardized AEs reporting system is needed to produce comparable data across studies for furthering the development of strategies to decrease AEs.

Long-term oncological and surgical outcomes after Video Endoscopic Inguinal Lymphadenectomy (VEIL) in patients with penile cancer.

OBJECTIVE: To report outcomes from the largest multicenter series of penile cancer patients undergoing video endoscopic inguinal lymphadenectomy (VEIL). MATERIALS AND METHODS: Retrospective multicenter analysis. Authors of 21 centers from the Penile Cancer Collaborative Coalition-Latin America (PeC-LA) were included. All centers performed the procedure following the same previously described standardized technique. Inclusion criteria included penile cancer patients with no palpable lymph nodes and intermediate/high-risk disease and those with non-fixed palpable lymph nodes less than 4 cm in diameter. Categorical variables are shown as percentages and frequencies whereas continuous variables as mean and range. RESULTS: From 2006 to 2020, 210 VEIL procedures were performed in 105 patients. Mean age was 58 (45-68) years old. Mean operative time was 90 minutes (60-120). Mean lymph node yield was 10 nodes (6-16). Complication rate was 15.7%, including severe complications in 1.9% of procedures. Lymphatic and skin complications were noted in 8.6 and 4.8% of patients, respectively. Histopathological analysis revealed lymph node involvement in 26.7% of patients with non-palpable nodes. Inguinal recurrence was observed in 2.8% of patients. 10y- overall survival was 74.2% and 10-y cancer specific survival was 84.8%. CSS for pN0, pN1, pN2 and pN3 were 100%, 82.4%, 72.7% and 9.1%, respectively. CONCLUSION: VEIL seems to offer appropriate long term oncological control with minimal morbidity. In the absence of non-invasive stratification measures such as dynamic sentinel node biopsy, VEIL emerged as the alternative for the management of non-bulky lymph nodes in penile cancer.

Robotic-assisted vesicovaginal fistula repair using a vaginal cuff flap.

INTRODUCTION AND HYPOTHESIS: Vesicovaginal fistula (VVF) is an abnormal communication between the bladder and the vagina. Complex fistulae include those after failed repair attempts, radiotherapy, measuring ≥ 2 cm, located in the trigone, or with concomitant ureteric strictures or fistulae. We aimed to describe a technique for the robotic repair of a complex VVF using a vaginal cuff flap. METHODS: A 56-year-old woman with a history of ovarian debulking surgery and radiotherapy underwent repair for VVF and rectovaginal fistula. In lithotomy, cystoscopy was performed for fistulous tract cannulation. Port placement, extensive adhesiolysis, and robot docking followed. The vaginal apex was dissected, the VVF excised, and the bladder closed. The rectum was separated from the posterior vaginal wall, the rectovaginal fistula excised, and the rectum closed. A vaginal cuff flap was harvested and interposed between the bladder and the vagina. RESULTS: Operative time was 9 h, estimated blood loss was 300 cc, and no intraoperative complications occurred. The patient was discharged on postoperative day 8. Further management included 37 sessions in a hyperbaric chamber and a transvesical endoluminal bladder closure 10 months after the initial surgery. Follow-up at 30 months shows no fistula recurrence. CONCLUSIONS: Vaginal cuff flaps represent a feasible interposition tissue in patients with hysterectomy for managing complex VVF in the case of omentum unavailability.

Distal ureter and bladder cuff excision using the "Keyhole Technique" during Robotic Radical Nephroureterectomy.

INTRODUCTION: Upper tract urothelial carcinoma (UTUC) accounts for 5-10% of all urothelial tumors (1). Radical nephroureterectomy (RNU) remains the standard treatment for high, and low-grade UTUC (2). Although the open approach has been considered the gold standard, robotic techniques have shown comparable oncological outcomes with potential advantages in terms of peri-operative morbidity (3). MATERIALS AND METHODS: We present a novel "Keyhole" technique for management of distal ureter and bladder cuff during robotic RNU. This technique allows the surgeon to directly visualize the ureteric orifices, delineate resection borders, and maintain oncologic principles of en-bloc excision without necessitating secondary cystotomy incision or concomitant endoscopic procedure. Descriptive demographic characteristics, surgical, pathological, and oncological outcomes were analyzed. Complications were reported using the Clavien-Dindo classification system. RESULTS: Between 2015 and 2020, ten patients underwent robotic RNU with bladder cuff excision using the Keyhole technique (single-dock, single-position). Median age was 75 years. Eight patients underwent surgery for right-sided tumors. Median operative time, estimated blood loss, and length of hospital stay were 287 min, 100 mL, and 3 days, respectively. No intraoperative complications occurred, and one grade II complication occurred during the 90-day postoperative period. All patients had high-grade UTUC, being 90% pure urothelial. Bladder recurrences occurred in 30% of patients with an overall median follow-up of 11.2 months. CONCLUSIONS: Keyhole technique for the management of distal ureter and bladder cuff during RNU represents a feasible approach with minimal 90-day complications and low bladder recurrence rate at centers of experience.

Stoma complications and quality of life in patients with Indiana pouch versus appendico/neo-appendico-umbilicostomy urinary diversions.

OBJECTIVES: To evaluate three subtypes of continent-cutaneous urinary diversion (CCUD); Indiana pouch (IP), right colon pouch with appendico-umbilicostomy (AU), and right colon pouch with neo-appendico-umbilicostomy (NAU), by investigating diversion-specific complications and quality-of-life outcomes. MATERIALS AND METHODS: A retrospective review of an IRB-approved database was conducted for perioperative and outcome data. The EORTC QLQ-C30 questionnaire was used to assess quality of life; all responses were obtained > 6 months after diversion. RESULTS: Fifty-eight patients who underwent a CCUD at our institution from 2010 to 2016 (33 IP by two surgeons, 15 AU and ten NAU by third surgeon) were identified for this study. Higher age and Charlson Comorbidity Index (CCI) ≥ 3 were seen in the AU cohort when compared to the IP cohort (P = 0.02 and 0.02, respectively). NAU group were also older when compared to the IP group (P = 0.02). After a median follow-up of 21 months (range: 0.8-81.0), more high-grade diversion-related complications were reported for AU and NAU patients comparing to the IP group (P < 0.01 and P = 0.02, respectively). More stoma complications were also reported for the NAU cohort than the IP cohort (70% vs 30%, P = 0.03). In all groups, > 60% of stoma complications occurred at the skin or fascia level. In the 90-day postoperative period, a higher continence rate was reported for the IP cohort, and this difference was significant when compared to the NAU cohort (P = 0.04). Length of stay after surgery and revision rates were not significantly different. For all groups, the majority of patients reported little-to-no disturbance of daily functions and rated overall quality of life as good-to-excellent. CONCLUSION: Urinary diversion using the Indiana pouch and right colon pouch with appendico/neo-appendico-umbilicostomy are all associated with high rates of continence and patient satisfaction. When compared to IP, AU and NAU patients had higher rates of high-grade diversion-related complications and NAU patients had a higher stoma complications with lower 90-day continence rate.

Radical cystectomy pentafecta: a proposal for standardisation of outcomes reporting following robot-assisted radical cystectomy.

OBJECTIVE: To propose a standardisable composite method for reporting outcomes of radical cystectomy (RC) that incorporates both perioperative morbidity and oncological adequacy. PATIENTS AND METHODS: From July 2010 to December 2017, 277 consecutive patients who underwent robot-assisted RC with intracorporeal urinary diversion (UD) for bladder cancer at our Institution were prospectively analysed. Patients who simultaneously demonstrated negative soft tissue surgical margins (STSMs), ≥16 lymph node (LN) yield, absence of major (grade III-IV) complications at 90 days, absence of UD-related long-term sequelae and absence of clinical recurrence at ≤12 months, were considered as having achieved the RC-pentafecta. A multivariable logistic regression model was assessed to measure predictors for achieving RC-pentafecta. RESULTS AND LIMITATIONS: Since 2010, 270 of 277 patients that had completed at least 12 months of follow-up were included. Over a mean follow-up of 22.3 months, ≥16 LN yield, negative STSMs, absence of major complications at 90 days, and absence of UD-related surgical sequelae and clinical recurrence at ≤12 months were observed in 93.0%, 98.9%, 76.7%, 81.5% and 92.2%, patients, respectively, resulting in a RC-pentafecta rate of 53.3%. Multivariable logistic regression analysis revealed age (odds ratio [OR] 0.95; P = 0.002), type of UD (OR 2.19; P = 0.01) and pN stage (OR 0.48; P = 0.03) as independent predictors for achieving RC-pentafecta. CONCLUSIONS: We present a RC-pentafecta as a standardisable composite endpoint that incorporates perioperative morbidity and oncological adequacy as a potential tool to assess quality of RC. This tool may be useful for assessing the learning curve and calculating cost-effectiveness amongst others but needs to be externally validated in future studies.

One-Stop MRI and MRI/transrectal ultrasound fusion-guided biopsy: an expedited pathway for prostate cancer diagnosis.

PURPOSE: To assess the feasibility, safety, and outcomes of an expedited One-Stop prostate cancer (PCa) diagnostic pathway. PATIENTS AND METHODS: We identified 370 consecutive patients who underwent multiparametric magnetic resonance imaging (mpMRI) and transrectal ultrasound fusion prostate biopsy (MRI/TRUS-PBx) from our institutional review board-approved database. Patients were divided according to diagnostic pathway: One-Stop (n = 74), with mpMRI and same-day PBx, or Standard (n = 296), with mpMRI followed by a second visit for PBx. mpMRIs were performed and interpreted according to Prostate Imaging-Reporting and Data System (PI-RADS v2). Grade group ≥ 2 PCa defined clinically significant PCa (csPCa). Statistical significance was considered when p < 0.05. RESULTS: Age (66 vs 66 years, p = 0.59) and PSA density (0.1 vs 0.1 ng/mL2, p = 0.26) were not different between One-Stop vs Standard pathway, respectively. One-Stop patients lived further away from the hospital than Standard patients (163 vs 31 km; p < 0.01), and experienced shorter time from mpMRI to PBx (0 vs 7 days; p < 0.01). The number (p = 0.56) and distribution of PI-RADS lesions (p = 0.67) were not different between the groups. All procedures were completed successfully with similar perioperative complications rate (p = 0.24). For patients with PI-RADS 3-5 lesions, the csPCa detection rate (49% vs 41%, p = 0.55) was similar for One-Stop vs Standard, respectively. The negative predictive value of mpMRI (PI-RADS 1-2) for csPCa was 78% for One-Stop vs 83% for Standard (p = 0.99). On multivariate analysis, age, prostate volume and PI-RADS score (p < 0.01), but not diagnostic pathway, predicted csPCa detection. CONCLUSION: A One-Stop PCa diagnostic pathway is feasible, safe, and provides similar outcomes in a shorter time compared to the Standard two-visit diagnostic pathway.

Robotic simple prostatectomy plus panniculectomy and Giant umbilical hernia repair.

INTRODUCTION: Simple prostatectomy is the gold standard for prostates >80 grams, robotic system has proven to help into speed the recovery of the patient and in morbid obesity the advantages of the robotic system can help to perform a successful surgery. CASE: 80 years old male with morbid obesity (BMI 45) and several other comorbidities, with history of an umbilical hernia and obstructive lower urinary tract symptoms in acute urinary retention. PSA was 7 ng/dl, DRE demonstrates a >100gr prostate gland. A robotic simple prostatectomy, urethropexy, umbilical hernia repair and panniculectomy in Fleur-de-Lis was performed. RESULTS: Operative time (OT) and estimated blood loss (EBL) were 438 min and 160 ml respectively. A JP drain was placed in the pelvis and 2 additional were left in the abdominal cavity with several Penrose drains. No immediate or intraoperative complications were observed. The length of stay (LOS) was 6 days without complications. Pathology report showed prostate of 304gr and benign prostatic tissue. DISCUSSION: In patients with multiple comorbidities robot-assisted surgery provides advantages of shorter LOS, EBL, less transfusion and lower rate of complications. In patients with morbid obesity where the increased girth makes difficult the open approach, robotic surgery is an ideal way to provide definitive treatment; concomitant, Fleur-de-Lis panniculectomy can correct the abdominal contour in both vertical and horizontal orientation at the same time that provides a better plane for trocar insertion, an accurate location of the needle tip and a proper position of the remote center decreasing the possible complication of port placement.

Impact of Surgical Factors on Robotic Partial Nephrectomy Outcomes: Comprehensive Systematic Review and Meta-Analysis.

PURPOSE: Utilization of robotic partial nephrectomy has increased significantly. We report a literature wide systematic review and cumulative meta-analysis to critically evaluate the impact of surgical factors on the operative, perioperative, functional, oncologic and survival outcomes in patients undergoing robotic partial nephrectomy. MATERIALS AND METHODS: All English language publications on robotic partial nephrectomy comparing various surgical approaches were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement and AHRQ (Agency for Healthcare Research and Quality) guidelines to evaluate PubMed®, Scopus® and Web of Science™ databases (January 1, 2000 to October 31, 2016, updated June 2017). Weighted mean difference and odds ratio were used to compare continuous and dichotomous variables, respectively. Sensitivity analyses were performed as needed. To condense the sheer volume of analyses, for the first time data are presented using novel summary forest plots. The study was registered at PROSPERO (https://www.crd.york.ac.uk/prospero/, ID CRD42017062712). RESULTS: Our meta-analysis included 20,282 patients. When open partial nephrectomy was compared to robotic partial nephrectomy, the latter was superior for blood loss (weighted mean difference 85.01, p  <0.00001), transfusions (OR 1.81, p <0.001), complications (OR 1.87, p <0.00001), hospital stay (weighted mean difference 2.26, p = 0.001), readmissions (OR 2.58, p = 0.005), percentage reduction of latest estimated glomerular filtration rate (weighted mean difference 0.37, p = 0.04), overall mortality (OR 4.45, p <0.0001) and recurrence rate (OR 5.14, p <0.00001). Sensitivity analyses adjusting for baseline disparities revealed similar findings. When robotic partial nephrectomy was compared to laparoscopic partial nephrectomy, the former was superior for ischemia time (weighted mean difference 4.21, p <0.0001), conversion rate (OR 2.61, p = 0.002), intraoperative (OR 2.05, p >0.0001) and postoperative complications (OR 1.27, p = 0.0003), positive margins (OR 2.01, p <0.0001), percentage decrease of latest estimated glomerular filtration rate (weighted mean difference -1.97, p = 0.02) and overall mortality (OR 2.98, p = 0.04). Hilar control techniques, selective and unclamped, are effective alternatives to clamped robotic partial nephrectomy. An important limitation is the overall suboptimal level of evidence of publications in the field of robotic partial nephrectomy. No level I prospective randomized data are available. Oxford level of evidence was level II, III and IV in 5%, 74% and 21% of publications, respectively. No study has indexed functional outcomes against volume of parenchyma preserved. CONCLUSIONS: Based on the contemporary literature, our comprehensive meta-analysis indicates that robotic partial nephrectomy delivers mostly superior, and at a minimum equivalent, outcomes compared to open and laparoscopic partial nephrectomy. Robotics has now matured into an excellent approach for performing partial nephrectomy for renal masses.

Robotic uterine-sparing vesicovaginal fistula repair.

INTRODUCTION AND HYPOTHESIS: The objective was to describe a technique for the robotic repair of complex vesicovaginal fistula (VVF) with uterine preservation. METHODS: From 2015 to 2017, two patients underwent the procedure. Following placement of the patient in the lithotomy position, catheterization of the fistulous tract and laparoscopic omental harvesting is performed. Then, the robotic system is docked. A transverse incision was made in the peritoneum above the uterus was made to provide access to the bladder, the uterus is mobilized, and a cystotomy is performed to identify the structures. Subsequently, the cystotomy is extended toward the fistulous tract, the plane between the organs is dissected to proceed with the vaginal closure, the vagina is closed, the omental flap is interposed, and the bladder is closed. RESULTS: Mean operative time (OT) was 219 min. Mean estimated blood loss (EBL) was 75 ml. One of the patients had an intraoperative cervix canal injury that was identified and repaired. The postoperative course was uneventful, and the mean length of hospital stay (LOS) was 1 day. A mean follow-up of 17 (±9.89) months showed no recurrence at cystoscopy or imaging evaluation. CONCLUSIONS: Uterine-sparing VVF repair is feasible and safe. More studies are needed to assess equivalence compared with other procedures.

Robotic Management of Complex Vesicourethral Anastomosis Stenosis With Transperineal Urethral Advancement: A Step-by-Step Technique.

BACKGROUND: Vesicourethral anastomosis stenosis (VUAS) refers to the diameter narrowing of a vesicourethral anastomosis (VUA). It is a known complication after radical prostatectomy that nowadays presents in less than 1% of these cases. When the lumen narrows sufficiently to impede urine flow, obstructive symptoms arise. While the incidence of VUAS used to be notably higher prior to the widespread use of the robotic approach, traditional procedures still fail in up to 42% of cases. Initial management typically involves endoscopic procedures, such as dilation, incision, or resection. If these approaches prove ineffective, VUA reconstruction is warranted. Following the resection of the unhealthy urethra, a potential drawback is the insufficient length of the healthy proximal urethral to reach the bladder without tension. In such cases, urinary diversion with an ileal conduit is an option. However, when the patient prefers to maintain an orthotopic urinary tract configuration, there is limited guidance in the literature regarding surgical techniques. OBJECTIVE: To outline the indications, describe the step-by-step technique, and evaluate the outcomes of transperineal urethral advancement to facilitate a tension-free VUA. MATERIALS: We first discuss the indications to identify which patients are candidates for this procedure. Then, a step-by-step description of the robotic VUA revision assisted by transperineal urethral mobilization is presented. Detailed steps and helpful hints are included. Finally, we outline the postoperative pathway and expected outcomes. RESULTS: This technique allows patients with VUAS to preserve the orthotopic configuration of the urinary tract when a tension-free anastomosis proves challenging. Although urinary incontinence is expected, an artificial urinary sphincter could be placed in the following months. CONCLUSION: The robotic management of complex vesicourethral anastomosis stenosis with transperineal urethral advancement is a feasible and safe procedure that requires the interdisciplinary management of robotic and reconstructive urologists.

Robotic management of urinary fistula.

Objectives: To highlight critical preoperative and intraoperative considerations in approaching fistula repair robotically. Methods: A search of the literature was conducted to identify relevant articles pertaining to robotic management of urinary fistulae. Results: Fistulae of the genitourinary tract can be a challenging dilemma for urologists, as definitive management may require surgical intervention. Pathogenesis of both enteric and non-enteric fistulae are multifactorial, and successful repair hinges on the meticulous perioperative evaluation, planning, and execution. Traditional open techniques can subject patients to increased morbidity and prolonged hospitalizations. Since its introduction, the robotic surgical platform has continued to expand its indications. Its three-dimensional visualization and tremor free wristed instrument movements have made the robotic platform an attractive option for genitourinary fistula reconstruction. Conclusion: Robotic management of complex urinary fistulae is feasible in expert hands; more studies are needed to define its role in the treatment algorithm of this devastating conditions.

Complications and adverse events in lymphadenectomy of the inguinal area: worldwide expert consensus.

BACKGROUND: Inguinal lymph node dissection plays an important role in the management of melanoma, penile and vulval cancer. Inguinal lymph node dissection is associated with various intraoperative and postoperative complications with significant heterogeneity in classification and reporting. This lack of standardization challenges efforts to study and report inguinal lymph node dissection outcomes. The aim of this study was to devise a system to standardize the classification and reporting of inguinal lymph node dissection perioperative complications by creating a worldwide collaborative, the complications and adverse events in lymphadenectomy of the inguinal area (CALI) group. METHODS: A modified 3-round Delphi consensus approach surveyed a worldwide group of experts in inguinal lymph node dissection for melanoma, penile and vulval cancer. The group of experts included general surgeons, urologists and oncologists (gynaecological and surgical). The survey assessed expert agreement on inguinal lymph node dissection perioperative complications. Panel interrater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α. RESULTS: Forty-seven experienced consultants were enrolled: 26 (55.3%) urologists, 11 (23.4%) surgical oncologists, 6 (12.8%) general surgeons and 4 (8.5%) gynaecology oncologists. Based on their expertise, 31 (66%), 10 (21.3%) and 22 (46.8%) of the participants treat penile cancer, vulval cancer and melanoma using inguinal lymph node dissection respectively; 89.4% (42 of 47) agreed with the definitions and inclusion as part of the inguinal lymph node dissection intraoperative complication group, while 93.6% (44 of 47) agreed that postoperative complications should be subclassified into five macrocategories. Unanimous agreement (100%, 37 of 37) was achieved with the final standardized classification system for reporting inguinal lymph node dissection complications in melanoma, vulval cancer and penile cancer. CONCLUSION: The complications and adverse events in lymphadenectomy of the inguinal area classification system has been developed as a tool to standardize the assessment and reporting of complications during inguinal lymph node dissection for the treatment of melanoma, vulval and penile cancer.

Robotic-assisted Simple Prostatectomy: An Intrafascial Approach for a Prostate of 470 g.

BACKGROUND: Simple prostatectomy has been established as a management option for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with glands larger than 80 cc.1 Robotic-assisted simple prostatectomy (RASP) has been established as a safe and effective management option. This has been reported in multiple studies comparing it with the open approach where no statistically significant differences in complication rates have been found.2 The intrafascial approach is intended to add multiple benefits, such as not requiring continuous bladder irrigation and resection of a larger percentage of the adenoma, potentially leading to a lower reoperation rate and diagnosis of prostate cancer in patients in which this was missed preoperatively.3 OBJECTIVE: To present the resection of a very large prostate can lead to significant intraoperative challenges. Therefore, we demosntrate our intrafascial robotic management of a 470g prostate. MATERIALS AND METHODS: A 56-year-old with LUTS (IPSS: 34) for over 6 years, complicated with multiple episodes of urinary retention. PSA: 20.6 ng/mL. MRI reported a 463 cc prostate volume without focal lesions. First, the retropubic space was developed. Cystotomy was performed at the anterior bladder neck. A plane between the prostatic capsule and the surrounding fascia was dissected while carefully preserving the neurovascular bundles. Due to its large size, the prostate was divided into segments to facilitate its extraction. Hemostatic control and vesicourethral anastomosis were performed. RESULTS: Discharged on postoperative day 1 with a Jackson-Pratt drain and Foley catheter removed on days 6 and 9, respectively. Pathology was negative for malignancy. Patient-reported improvement of LUTS (IPSS: 3) and preservation of erectile function (SHIM: 23) at the 3-month follow-up. CONCLUSION: The intrafascial technique can be useful in cases where a large-sized prostate hinders a transvesical approach. Additionally, it allows for an easier piecemeal of the gland. A larger series is needed to determine its potential benefits.

Robotic Simultaneous Repair of Rectovesical Fistula With Vesicourethral Anastomotic Stricture after Radical Prostatectomy: Step-by-Step Technique and Outcomes.

OBJECTIVE: To report our experience and outcomes using a novel robotic technique for the simultaneous repair of rectovesical fistula (RVF) with vesicourethral anastomotic stricture (VUAS) after radical prostatectomy (RP). METHODS: Between 2019 and 2021, four consecutive patients who underwent robotic-assisted simultaneous repair of RVF with concurrent VUAS after RP were retrospectively reviewed. Baseline characteristics and perioperative outcomes were examined and reported. Complications were graded using the modified Clavien-Dindo classification system and the European Association of Urology Complications Panel Assessment and Recommendations. RESULTS: Four cases with a median age of 68.5 (63.3-72.3) years were treated. Interposition omentum flaps were used in all our cases. One case had perineal urethral mobilization to reach healthy urethral margins and tension-free vesicourethral anastomosis. Surgeries were uneventful, with no intraoperative complications reported. Median operative time, estimated blood loss, and length of hospital stay were 370 (291.3-453) minutes, 255 (175-262.5) mL, and 2.5 (2-3) days, respectively. Median Jackson-Pratt drains, Double-J stents and Foley catheter removal days were 6 (6-10), 38 (32-43), and 30 (27-41) days, respectively. No postoperative complications were reported. The median follow-up time was 16.25 (12-26) months, and no fistula recurrence was shown. CONCLUSION: Robotic-assisted laparoscopic repair could represent an effective approach for the simultaneous repair of RVF with concomitant VUAS. More studies and management standardization are needed to assess the role of the robotic platform in the simultaneous repair of RVF with VUAS after radical prostatectomy.

Obturator Nerve Injury in Robotic Pelvic Surgery: Scenarios and Management Strategies.

BACKGROUND: Obturator nerve injury (ONI) is an uncommon complication of pelvic surgery, usually reported in 0.2-5.7% of cases undergoing surgical treatment of urological and gynecological malignancies involving pelvic lymph node dissection (PLND). OBJECTIVE: To describe how an ONI may occur during robotic pelvic surgery and the corresponding management strategies. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively analyzed video content on intraoperative ONI provided by robotic surgeons from high-volume centers. SURGICAL PROCEDURE: ONI was identified during PLND and managed according to the type of nerve injury. RESULTS AND LIMITATIONS: The management approach varies with the type of injury. Crush injury frequently occurs at an advanced stage of PLND. For a crush injury to the obturator nerve caused by a clip, management only requires its safe removal. Three situations can occur if the nerve is transected: (1) transection with feasible approximation and tension-free nerve anastomosis; (2) transection with challenging approximation requiring certain strategies for proper nerve anastomosis; and (3) transection with a hidden proximal nerve ending that may initially appear intact, but is clearly injured when revealed by further dissection. Each case has different management strategies with a common aim of prompt repair of the anatomic disruption to restore proper nerve conduction. CONCLUSIONS: ONI is a preventable complication that requires proper identification of the anatomy and high-risk areas when performing pelvic lymph node dissection. Prompt intraoperative recognition and repair using the management strategies described offer patients the best chance of recovery without sequelae. PATIENT SUMMARY: We describe the different ways in which the obturator nerve in the pelvic area can be damaged during urological or gynecological surgeries. This is a preventable complication and we describe how it can be avoided and different management options, depending on the type of nerve injury.