Corrigendum to "RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned" [Eur. Urol. Open Sci. 54 (2023) 33-42].

[This corrects the article DOI: 10.1016/j.euros.2023.05.007.].

Quantitation of Aloe Vera Polysaccharides by O-Acetyl and UV-Vis Spectrophotometry: First Action 2018.14.

Background: Aloe vera polysaccharides are considered to be the primary active components that provide numerous anecdotal health benefits. Objective: Several analytical methods are currently being used to quantitate the acemannan content of aloe vera processed raw materials. Some involve the use of very expensive and intricate equipment that is not normally found in production facilities. This document describes a single-laboratory validation for a very simple and inexpensive method that will be supported by a future multi-laboratory validation determination. Methods: The acetyl groups on the acemannan are converted into a ferric-acetohydroxamic complex that is quantitated using a simple and inexpensive UV-Vis spectrophotometer at 540 nm. Results: The analytical range for this method is 0.03-100% acemannan in both liquid and powdered materials. The recovery rate were 98-105% for both liquid and powdered samples. The repeatability precision was <2% at a level close to the LOQ. Conclusions: The results met the Standard Method Performance Requirements set by the AOAC Stakeholder Panel on Dietary Supplements. Highlights: The AOAC Expert Review Panel approved the present method as AOAC Official First Action 2018.14.

Robot-assisted Level II-III Inferior Vena Cava Tumor Thrombectomy: Step-by-Step Technique and 1-Year Outcomes.

BACKGROUND: Level II-III inferior vena cava (IVC) tumor thrombectomy for renal cell carcinoma is among the most challenging urologic oncologic surgeries. In 2015, we reported the initial series of robot-assisted level III caval thrombectomy. OBJECTIVE: To describe our University of Southern California technique in a step-by-step fashion for robot-assisted IVC level II-III tumor thrombectomy. DESIGN, SETTING, AND PARTICIPANTS: Twenty-five selected patients with renal neoplasm and level II-III IVC tumor thrombus underwent robot-assisted surgery with a minimum 1-yr follow-up (July 2011 to March 2015). SURGICAL PROCEDURE: Our standardized anatomic-based "IVC-first, kidney-last" technique for robot-assisted IVC thrombectomy focuses on minimizing the chances of an intraoperative tumor thromboembolism and major hemorrhage. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Baseline demographics, pathology data, 90-d and 1-yr complications, and oncologic outcomes at last follow-up were assessed. RESULTS AND LIMITATIONS: Robot-assisted IVC thrombectomy was successful in 24 patients (96%) (level III: n=11; level II: n=13); one patient was electively converted to open surgery for failure to progress. Median data included operative time of 4.5h, estimated blood loss was 240ml, hospital stay 4 d; five patients (21%) received intraoperative blood transfusion. All surgical margins were negative. Complications occurred in four patients (17%): two were Clavien 2, one was Clavien 3a, and one was Clavien 3b. All patients were alive at a 16-mo median follow-up (range: 12-39 mo). CONCLUSIONS: Robotic IVC tumor thrombectomy is feasible for level II-III thrombi. To maximize intraoperative safety and chances of success, a thorough understanding of applied anatomy and altered vascular collateral flow channels, careful patient selection, meticulous cross-sectional imaging, and a highly experienced robotic team are essential. PATIENT SUMMARY: We present the detailed operative steps of a new minimally invasive robot-assisted surgical approach to treat patients with advanced kidney cancer. This type of surgery can be performed safely with low blood loss and excellent outcomes. Even patients with advanced kidney cancer could now benefit from robotic surgery with a quicker recovery.

Initial Series of Four-Arm Robotic Completely Intracorporeal Ileal Ureter.

Ileal ureter formation has been found to be a suitable treatment option for long, chronic ureteral strictures not amendable to less invasive forms of repair. Minimally invasive surgical techniques for this condition have been investigated. We report the first series of robotic completely intracorporeal ileal ureter using a four-arm robotic technique. Three patients underwent this procedure, including one patient with a solitary kidney. All procedures were performed effectively with a median operative time of 450 minutes (range: 420-540) and median estimated blood loss of 100 mL (range: 50-200). Postoperatively, one patient suffered volvulus and subsequent necrosis of small bowel and ileal ureter, which required re-operation and small bowel resection, including the ileal ureter. The other two patients report no surgical complications to date. This early series represents preliminary technical procedure feasibility. Further experience is necessary.

Personalized 3D printed model of kidney and tumor anatomy: a useful tool for patient education.

PURPOSE: To assess the impact of 3D printed models of renal tumor on patient's understanding of their conditions. Patient understanding of their medical condition and treatment satisfaction has gained increasing attention in medicine. Novel technologies such as additive manufacturing [also termed three-dimensional (3D) printing] may play a role in patient education. METHODS: A prospective pilot study was conducted, and seven patients with a primary diagnosis of kidney tumor who were being considered for partial nephrectomy were included after informed consent. All patients underwent four-phase multi-detector computerized tomography (MDCT) scanning from which renal volume data were extracted to create life-size patient-specific 3D printed models. Patient knowledge and understanding were evaluated before and after 3D model presentation. Patients' satisfaction with their specific 3D printed model was also assessed through a visual scale. RESULTS: After viewing their personal 3D kidney model, patients demonstrated an improvement in understanding of basic kidney physiology by 16.7 % (p = 0.018), kidney anatomy by 50 % (p = 0.026), tumor characteristics by 39.3 % (p = 0.068) and the planned surgical procedure by 44.6 % (p = 0.026). CONCLUSION: Presented herein is the initial clinical experience with 3D printing to facilitate patient's pre-surgical understanding of their kidney tumor and surgery.

Utility and significance of ureteric frozen section analysis during radical cystectomy.

OBJECTIVE: To assess the utility of routine frozen section analysis of ureters at the time of radical cystectomy (RC) for urothelial cancer (UC), and the long-term outcomes of adverse ureteric pathology. PATIENTS AND METHODS: Pathological data on 2 047 patients undergoing RC for UC with routine frozen section analysis of ureters (January 1971 to December 2009) were analysed. Univariate and multivariable logistic and Cox proportional hazards models were used to determine the risk of upper tract UC (UTUC) recurrence, local recurrence and overall survival in those identified as having adverse pathology (severe atypia/carcinoma in situ [CIS] or UC) at time of frozen section analysis. RESULTS: Adverse pathology was identified by frozen section analysis in 178 patients (8.6%). Frozen section analysis was found to have poor sensitivity in identifying adverse pathology (59.1%), which was improved in patients with preoperative CIS (68.0%). After a median (interquartile range) follow-up of 12.4 (1.9-10.1) years, 28 patients (1.4%) developed UTUC recurrence. There were no uretero-enteric anastomotic recurrences. Adverse pathology on frozen section analysis was associated with UTUC recurrence on univariate analysis (hazard ratio [HR] 6.2, 95% confidence interval [CI] 2.9-13.5), but 15/28 patients (54%) with UTUC recurrence had benign ureteric frozen section analysis on initial sectioning. Adverse pathology on frozen section analysis was not independently associated with the risk of local recurrence (HR 1.08, 95% CI 0.61-1.89) or overall survival (HR 1.12, 95% CI 0.94-1.35) in multivariate models. CONCLUSIONS: Ureteric frozen section analysis has poor sensitivity and may be marginally improved in pre-existing CIS. UTUC recurrence is rare and can occur despite negative frozen section analysis. Our data question the utility of routine frozen section analysis of the distal ureteric margin at the time of RC.

The Impact of Transtomal Rigid Endoscopy in Continent Cutaneous Urinary Diversions.

OBJECTIVE: To determine if transtomal rigid endoscopy damages the continence mechanism of continent cutaneous reservoirs. We report the largest and longest series to date from a single institution demonstrating the safety of transtomal rigid endoscopy. MATERIALS AND METHODS: We conducted an institutional review board-approved retrospective review of a prospectively accrued database of all patients with urinary diversions that underwent rigid endoscopic procedures for various reasons between 2000 and 2013. Pre- and postoperative continence, difficulty with catheterization, and need for surgical revision post procedure were evaluated. RESULTS: From 2000 to 2013, 71 patients with continent cutaneous diversions underwent 191 endoscopic procedures by a single surgeon. Mean follow-up was 603 days. Mean age was 58.4 years. The mean number of procedures per patient was 2.7 (1-7). All procedures were performed by gaining access through the stoma with an offset rigid nephroscope and a 28-30Fr access sheath. Two patients reported incontinence postoperatively; 1 patient was treated conservatively by way of indwelling catheter for 1 week and full continence returned. The second patient had small-volume incontinence preoperatively that worsened postoperatively. The procedure uncovered an existing efferent limb-cutaneous fistula. Patients undergoing repeated procedures were not at any higher risk of incontinence. There were no patients that had difficulty with catheterization postoperatively. No surgical revisions were required for worsened continence postoperatively. CONCLUSION: Transtomal rigid endoscopic procedures do not negatively affect the continence mechanism in continent cutaneous diversions. Transtomal rigid endoscopy allows for safe endoscopic access in these difficult to treat patients.

Robotic Transabdominal Control of the Suprahepatic, Infradiaphragmatic Vena Cava to Enable Level 3 Caval Tumor Thrombectomy: Pilot Study in a Perfused-Cadaver Model.

PURPOSE: To develop a robotic technique for exclusively transabdominal control of the suprahepatic, infradiaphragmatic inferior vena cava (IVC) to enable level 3 IVC tumor thrombectomy. MATERIALS AND METHODS: Robotic technique was developed in three fresh, perfused-model cadavers. Preoperatively, inflow (right jugular vein) and outflow (left femoral vein) cannulae were inserted and connected to a centrifugal pump to establish a 10 mmHg pressure in the IVC for the water-perfused cadaver model. Using a five-port transperitoneal robotic approach, the falciform ligament was detached from the anterior abdominal wall toward its junction with the diaphragm and tautly retracted caudally; this adequately retracted the liver caudally as well. Triangular and coronary ligaments were incised, allowing ready visualization of suprahepatic/infradiaphragmatic IVC and right/left main hepatic veins. Under direct robotic visualization, IVC was circumferentially mobilized, vessel-looped, and controlled. RESULTS: All three robotic procedures were successfully completed transabdominally. Average robotic time to control the suprahepatic IVC was 37 minutes; in each case, the suprahepatic IVC was circumferentially controlled with a vessel-loop. There were no intraoperative complications. Length of the mobilized suprahepatic IVC measured between 2 and 3 cm. Right and left suprahepatic veins were clearly visualized in each case. Necropsy revealed no intra-abdominal/intrathoracic visceral or vascular injuries to the suprahepatic IVC, bilateral hepatic veins, or tributaries. CONCLUSIONS: We developed a novel robotic technique for transabdominal control of the suprahepatic infradiaphragmatic IVC in a perfused human cadaver model. This approach may extend the application of advanced robotic techniques for the performance of major vena caval, hepatic, and level 3 IVC renal tumor thrombus surgery.

Robotic Level III Inferior Vena Cava Tumor Thrombectomy: Initial Series.

PURPOSE: Level III inferior vena cava tumor thrombectomy for renal cancer is one of the most challenging open urologic oncology surgeries. We present the initial series of completely intracorporeal robotic level III inferior vena cava tumor thrombectomy. MATERIALS AND METHODS: Nine patients underwent robotic level III inferior vena cava thrombectomy and 7 patients underwent level II thrombectomy. The entire operation (high intrahepatic inferior vena cava control, caval exclusion, tumor thrombectomy, inferior vena cava repair, radical nephrectomy, retroperitoneal lymphadenectomy) was performed exclusively robotically. To minimize the chances of intraoperative inferior vena cava thrombus embolization, an "inferior vena cava-first, kidney-last" robotic technique was developed. Data were accrued prospectively. RESULTS: All 16 robotic procedures were successful, without open conversion or mortality. For level III cases (9), median primary kidney (right 6, left 3) cancer size was 8.5 cm (range 5.3 to 10.8) and inferior vena cava thrombus length was 5.7 cm (range 4 to 7). Median operative time was 4.9 hours (range 4.5 to 6.3), estimated blood loss was 375 cc (range 200 to 7,000) and hospital stay was 4.5 days. All surgical margins were negative. There were no intraoperative complications and 1 postoperative complication (Clavien 3b). At a median 7 months of followup (range 1 to 18) all patients are alive. Compared to level II thrombi the level III cohort trended toward greater inferior vena cava thrombus length (3.3 vs 5.7 cm), operative time (4.5 vs 4.9 hours) and blood loss (290 vs 375 cc). CONCLUSIONS: With appropriate patient selection, surgical planning and robotic experience, completely intracorporeal robotic level III inferior vena cava thrombectomy is feasible and can be performed efficiently. Larger experience, longer followup and comparison with open surgery are needed to confirm these initial outcomes.

Port Placement and Docking for Robotic Surgery: The University of Southern California Approach.

PURPOSE: To describe our approach for port placement and robot docking for pelvic and kidney surgery (KS). PATIENTS AND METHODS: We use a four-arm robotic approach and a 5 to 6 port placement consisting of: One 12-mm camera port, three 8-mm robotic ports, and one to two assistant ports. For radical prostatectomy, the working robotic ports run parallel below the level of the umbilicus. Radical cystectomy ports are more cephalad and above the level of the umbilicus. For transperitoneal KS, two bariatric robotic ports are used, aiming for an equilateral triangle configuration. With retroperitoneal (RN) KS, a balloon dilator and balloon port create the RN space; bariatric ports comprise the most anterior and posterior ports. RESULTS: This technique has been used since 2010 on more than 2370 robotic urologic cases. To date, no procedure has needed patient or robot positioning while maintaining fourth arm functionality with minimal robotic arm clashing. CONCLUSIONS: Our approach of port placement and robot docking is reproducible and feasible for pelvic surgical procedures and KS.

Anatomic partial nephrectomy: technique evolution.

PURPOSE OF REVIEW: Partial nephrectomy provides equivalent long-term oncologic and superior functional outcomes as radical nephrectomy for T1a renal masses. Herein, we review the various vascular clamping techniques employed during minimally invasive partial nephrectomy, describe the evolution of our partial nephrectomy technique and provide an update on contemporary thinking about the impact of ischemia on renal function. RECENT FINDINGS: Recently, partial nephrectomy surgical technique has shifted away from main artery clamping and towards minimizing/eliminating global renal ischemia during partial nephrectomy. Supported by high-fidelity three-dimensional imaging, novel anatomic-based partial nephrectomy techniques have recently been developed, wherein partial nephrectomy can now be performed with segmental, minimal or zero global ischemia to the renal remnant. Sequential innovations have included early unclamping, segmental clamping, super-selective clamping and now culminating in anatomic zero-ischemia surgery. By eliminating 'under-the-gun' time pressure of ischemia for the surgeon, these techniques allow an unhurried, tightly contoured tumour excision with point-specific sutured haemostasis. Recent data indicate that zero-ischemia partial nephrectomy may provide better functional outcomes by minimizing/eliminating global ischemia and preserving greater vascularized kidney volume. SUMMARY: Contemporary partial nephrectomy includes a spectrum of surgical techniques ranging from conventional-clamped to novel zero-ischemia approaches. Technique selection should be tailored to each individual case on the basis of tumour characteristics, surgical feasibility, surgeon experience, patient demographics and baseline renal function.

A novel interface for the telementoring of robotic surgery.

OBJECTIVE: To prospectively evaluate the feasibility and safety of a novel, second-generation telementoring interface (Connect(™) ; Intuitive Surgical Inc., Sunnyvale, CA, USA) for the da Vinci robot. MATERIALS AND METHODS: Robotic surgery trainees were mentored during portions of robot-assisted prostatectomy and renal surgery cases. Cases were assigned as traditional in-room mentoring or remote mentoring using Connect. While viewing two-dimensional, real-time video of the surgical field, remote mentors delivered verbal and visual counsel, using two-way audio and telestration (drawing) capabilities. Perioperative and technical data were recorded. Trainee robotic performance was rated using a validated assessment tool by both mentors and trainees. The mentoring interface was rated using a multi-factorial Likert-based survey. The Mann-Whitney and t-tests were used to determine statistical differences. RESULTS: We enrolled 55 mentored surgical cases (29 in-room, 26 remote). Perioperative variables of operative time and blood loss were similar between in-room and remote mentored cases. Robotic skills assessment showed no significant difference (P > 0.05). Mentors preferred remote over in-room telestration (P = 0.05); otherwise no significant difference existed in evaluation of the interfaces. Remote cases using wired (vs wireless) connections had lower latency and better data transfer (P = 0.005). Three of 18 (17%) wireless sessions were disrupted; one was converted to wired, one continued after restarting Connect, and the third was aborted. A bipolar injury to the colon occurred during one (3%) in-room mentored case; no intraoperative injuries were reported during remote sessions. CONCLUSION: In a tightly controlled environment, the Connect interface allows trainee robotic surgeons to be telementored in a safe and effective manner while performing basic surgical techniques. Significant steps remain prior to widespread use of this technology.

Three primary testicular tumours: Trials and tribulations of testicular preservation.

Balancing recurrence risk, side effects and patient preference in the treatment of multiple metachronous testicular tumours can be challenging. We present the case of a young male patient who developed 3 different primary testicular neoplasms over an 8-year period, each associated with retroperitoneal lymphadenopathy requiring chemotherapy. The first tumour at age 19 was managed with radical orchiectomy. Four years later, a partial orchiectomy was performed to remove 2 small lesions. Another 4 years later, a complete orchiectomy was required for an additional tumour. This case highlights the caveats of testis-sparing surgery for testis cancer and the need for careful surveillance in these patients.

Reliability assessment of international grading system for vesicoureteral reflux.

PURPOSE: The International Reflux Committee proposed a grading system for vesicoureteral reflux in 1985 which has been used extensively in everyday practice and research studies. Despite widespread use, based mainly on face validity, the interrater and intrarater reliability of this tool are not known. A tool cannot be considered valid unless it is reliable. Therefore, we estimated the interrater and intrarater reliability of the international grading system for vesicoureteral reflux. MATERIALS AND METHODS: A series of 28 voiding cystourethrogram studies were selected. The images were assembled in an electronic presentation in random fashion. Four pediatric radiologists, 5 pediatric urologists and 4 senior urology residents graded the studies. The images were then shuffled in a random fashion and re-rated after 7 days (total 728 observations). Cohen weighted kappa statistics were used to determine interrater and intrarater reliability. Subgroup analysis was then performed comparing the variability among the 3 groups of raters and different grades. RESULTS: The average interrater reliability was 0.53 (95% CI 0.52-0.55, p <0.0001). Agreement in subgroups was 0.61 for urologists, 0.59 for residents and 0.56 for radiologists. The lowest agreement was shown in grade III (0.36) and the highest in grade I (0.98). The intrarater reliability was 0.86 (95% CI 0.77-0.95, p <0.001). CONCLUSIONS: The international grading system for vesicoureteral reflux shows low interrater reliability for moderate degrees of vesicoureteral reflux whereas the intrarater reliability is high. Modification of this system may improve its reproducibility.

Positive surgical margins are a risk factor for significant biochemical recurrence only in intermediate-risk disease.

UNLABELLED: What's known on the subject? and What does the study add? Positive surgical margins (PSMs) after radical prostatectomy are common, although their impact on the risk of disease recurrence is unknown. We examined the impact of PSMs on the risk of 'significant' biochemical recurrence stratified by their risk of occult metastatic disease. We find that only in intermediate-risk disease does the presence of a PSM have a significant impact on the risk of recurrence, and this represents a failure of technique. By contrast, for high- and low-risk disease, the risk of recurrence is driven by intrinsic tumour biology, and the presence of a PSM has little impact on outcome. OBJECTIVE: To determine the impact of surgical margin status on the risk of significant biochemical recurrence (prostate-specific antigen [PSA] doubling time <3, <6 or <9 months) after prostatectomy. MATERIALS AND METHODS: Patients undergoing radical prostatectomy with complete clinical and pathological data and detailed PSA follow-up were identified from two prospectively recorded databases. Patients were stratified according to their risk of occult systemic disease (low risk: PSA < 10 ng/dL, pT2 stage and Gleason score ≤6; intermediate risk: PSA 10-20 ng/dL, pT2 stage and/or Gleason score 7; high: PSA > 20 ng/dL or pT3-4 stage or Gleason score 8-10) and the impact of a positive surgical margin (PSM) within each stratum determined by univariable and multivariable analysis. RESULTS: Of 1514 patients identified, 276 (18.2%), 761 (50.3%) and 477 (31.5%) were classified as having low-, intermediate- and high-risk disease respectively. A total of 370 (24.4%) patients had a PSM and with a median follow-up of 22.2 months, and 165 (7%) patients had a biochemical recurrence. Sufficient PSA data was available to calculate PSA doubling times in 151/165 patients (91.5%). The PSM rate rose significantly, from 11% in low-risk to 43% in high-risk disease (P < 0.001), with similar positive associations noted with tumour grade, stage and serum PSA (P < 0.001). Patients with low-risk disease had essentially identical risks of significant biochemical recurrence over the study period, regardless of surgical margin status. By contrast, in patients with both intermediate- and high-risk disease, a PSM was a strong predictor of significant biochemical recurrence on univariable analysis. On multivariable analysis, howver, PSM predicted significant disease recurrence in intermediate-risk disease only. CONCLUSIONS: PSM is a risk factor for significant biochemical recurrence only in intermediate risk disease.

Long-term results of surgical techniques and procedures in men with benign prostatic hyperplasia.

Benign prostatic hyperplasia (BPH) is one of the most common conditions associated with the aging male. Surgical management of lower urinary tract symptoms attributed to BPH has progressed over time as urologic surgeons search for more innovative and less invasive forms of treatment. Transurethral resection of the prostate (TURP) has long been the "gold standard" to which all other forms of treatment are compared. There are several different methods of surgical treatment of BPH, including whole gland enucleation/intact removal, vaporization, and induction of necrosis with delayed reabsorption as well as hybrid techniques. As with any form of surgical intervention, long-term results define success. Long-term follow-up consists of examining overall efficacy with attention to associated adverse events. TURP has the luxury of the longest follow-up, while less invasive forms of treatment starting to acquire long-term data. There are several surgical options for BPH; newer methods do show promise, while the "gold standard" continues to demonstrate excellent surgical results.

Antegrade balloon occlusion of inferior vena cava during thrombectomy for renal cell carcinoma.

Nephrectomy with inferior vena cava (IVC) thrombectomy for advanced renal cell carcinoma (RCC) is a challenging and morbid surgical case. We describe the use of a simple endoluminal technique to occlude the suprahepatic IVC during thrombectomy. A 60-year-old male presented with a large right-sided RCC and IVC tumour thrombus. The tip of the thrombus, which was non-adherent to the caval wall, extended to the level of the hepatic veins. After complete dissection of the kidney, we obtained suprahepatic control of the IVC by a large compliant balloon, introduced through the right internal jugular vein and inflated just below the level of the diaphragm. The IVC thrombectomy was performed in a bloodless field. Mean blood pressure remained stable during IVC balloon inflation with a total occlusion time of 10 minutes. Intraprocedural completion cavogram and postoperative Doppler ultrasonography showed no residual IVC clot. Blood loss during the thrombectomy portion of the case was scant. The patient's postoperative course was uncomplicated and, at the last follow-up, he had stable metastatic disease on sunitinib therapy. For the surgical treatment of RCC with retrohepatic IVC tumour extension, transjugular balloon occlusion of the suprahepatic IVC offers an alternative to extensive hepatic mobilization to obtain suprahepatic thrombus control. Advantages over traditional surgical methods may include decreased surgical time, lower risk of liver injury and tumour embolism. We suggest this method for further evaluation.