Three-dimensional virtual model for robot-assisted partial nephrectomy: a propensity-score matching analysis with a contemporary control group.

PURPOSE: To compare two cohorts of patients submitted to robot-assisted partial nephrectomy (RAPN) with vs without the use of three-dimensional virtual models (3DVMs). METHODS: We screened a prospective consecutive cohort of 152 patients submitted to RAPN with 3DVM and 1264 patients submitted to RAPN without 3DVM between 2019 and 2022. Propensity score matching analysis (PSMA) was applied. Primary endpoint was to evaluate whereas RAPNs with 3DVM were superior in terms of functional outcomes at 12-month. Secondary endopoints were to compare perioperative and oncological outcomes. Multivariable logistic regression analyses (MVA) tested the associations of clinically significant eGFR drop and 3DVMs. Subgroups analysis was performed for PAUDA-risk categories. RESULTS: 100 patients for each group were analyzed after PSMA. RAPN with 3DVM presented a higher rate of selective/no clamping procedure (32% vs 16%, p = 0.03) and a higher enucleation rate (40% vs 29%, p = 0.04). As concern to primary endopoint, 12-month functional preservation performed better within 3DVM group in terms of creatinine serum level (median 1.2 [IQR 1.1-1.4] vs 1.6 [IQR 1.1-1.8], p = 0.03) and eGFR (median 64.6 [IQR 56.2-74.1] vs 52.3 [IQR 49.2-74.1], p = 0.03). However, this result was confirmed only in the PADUA ≥ 10 renal masses. Regarding secondary endpoints, no significative difference emerged between the two cohorts. MVA confirmed 3DVM as a protective factor for clinically significant eGFR drop only in high-risk (PADUA ≥ 10) masses. CONCLUSIONS: RAPN performed with the use of 3DVM assistance resulted in lower incidence of global ischemia and higher rate of enucleations. The positive impact of such technology was found at 12-month only in high-risk renal masses.

Is it safe to defer prostate cancer treatment? Assessing the impact of surgical delay on the risk of pathological upstaging after robot-assisted radical prostatectomy.

INTRODUCTION: We sought to investigate whether surgical delay may be associated with pathological upstaging in patients treated with robot assisted radical prostatectomy (RARP) for localized and locally advanced prostate cancer (PCa). MATERIALS AND METHODS: Consecutive firstly-diagnosed PCa patients starting from March 2020 have been enrolled. All the patients were categorized according to EAU risk categories for PCa risk. Uni- and multivariate analysis were fitted to explore clinical and surgical predictors of pathological upstaging to locally advanced disease (pT3/pT4 - pN1 disease). RESULTS: Overall 2017 patients entered the study. Median age at surgery was 68 (IQR 63-73) years. Overall low risk, intermediate risk, localized high risk and locally advanced disease were recorded in 368 (18.2 %), 1071 (53.1 %), 388 (19.2 %) and 190 (9.4 %), respectively. Median time from to diagnosis to treatment was 51 (IQR 29-70) days. Time to surgery was 56 (IQR 32-75), 52 (IQR 30-70), 45 (IQR 24-60) and 41 (IQR 22-57) days for localized low, intermediate and high risk and locally advanced disease, respectively. Considering 1827 patients with localized PCa, at multivariate analysis ISUP grade group ≥4 on prostate biopsy (HR: 1.30; 95 % CI 1.07-1.86; p = 0.02) and surgical delay only in localized high-risk disease (HR: 1.02; 95 % CI 1.01-1.54; p = 0.02) were confirmed as independent predictors of pathological upstaging to pT3-T4/pN1 disease at final histopathological examination. CONCLUSIONS: In localized high-risk disease surgical delay could be associated with a higher risk of adverse pathologic findings.

3D virtual model for robot-assisted partial nephrectomy in highly-complex cases (PADUA ⩾ 10).

PURPOSE: To compare two cohorts of patients submitted to robot-assisted partial nephrectomy (RAPN) for highly-complex renal masses (PADUA ⩾ 10) with versus without the use of 3DVMs. MATERIALS AND METHODS: We screened a prospective consecutive cohort of 152 patients submitted to RAPN with 3DVM and 1264 patients submitted to RAPN without 3DVM between 2019 and 2022. Only PADUA ⩾ 10 cases were considered eligible for analysis. Propensity score matching (PSM) analysis was applied. Primary endpoint was to evaluate whereas RAPNs with 3DVM were superior in terms of functional outcomes at 12-month. Secondary outcomes were to compare perioperative and oncological outcomes. Multivariable logistic regression analyses (MVA) tested the associations of clinically significant eGFR drop and 3DVMs. Subgroups analysis was performed for PAUDA-risk categories. RESULTS: Thirty seven patients for each group were analyzed after PSM. RAPN with 3DVM presented a higher rate of selective/no clamping procedure (32.5% vs 16.2%, p = 0.03) and a higher enucleation rate (43.2% vs 29.8%, p = 0.04). Twelve-month functional preservation performed better within 3DVM group in terms of creatinine serum level (median 1.2 [IQR 1.1-1.4] vs 1.6 [IQR 1.1-1.8], p = 0.03) and eGFR (median 64.6 [IQR 56.2-74.1] vs 52.3 [IQR 49.2-74.1], p = 0.03). MVA confirmed 3DVM as a protective factor for clinically significant eGFR drop in this subgroup of patients. CONCLUSIONS: RAPN performed with the use of 3DVM assistance for PADUA ⩾ 10 cases resulted in lower incidence of global ischemia and higher rate of enucleations. The positive impact of such technology was found at 12-month follow-up.

Stentless florence robotic intracorporeal neobladder (FloRIN), a feasibility prospective randomized clinical trial.

INTRODUCTION: Aim of the study was to evaluate perioperative, postoperative and mid-term functional outcomes of Florence intracorporeal neobladder (FloRIN) configuration technique performed with stentless procedure. MATERIALS AND METHODS: This single institution randomized 1:1 prospective series included consecutive patients treated with Robot-Assisted Radical Cystectomy (RARC) and FloRIN reconfiguration from January 2021 to February 2022. Postoperative complications were graded according to Clavien Dindo classification and divided in early (<30 days from discharge) and delayed (>30 days). RESULTS: Overall, 63 patients were included in the analysis. Among these 32 (50.8 %) were treated with RARC + stentless FloRIN while 31 (49.2 %) underwent stent placement procedure. No differences were found in terms of baseline characteristics between the two groups. Stentless procedure was associated with significant shorter console time 328 vs 374 min (p = 0.04) and lower estimated blood loss (EBL) 330 vs 350 ml (p = 0.04) comparing to stent group. As regards perioperative features, no significant differences were recorded in terms of canalization (p = 0.58) and time to drainage removal (p = 0.11) while a shorter length of hospital stay was found in case of stentless procedure (p = 0.04). Early postoperative complications Clavien ≥ 3a occurred in 9.3 % and 12.9 % of patients while delayed major complications were recorded in the 3.1 % and 9.6 % of patients treated with stentless and stent FloRIN, respectively (p = 0.09). As regards the mid-term functional outcomes, no differences were found in terms of kidney function loss in both 3rd and 6th month assessment (p = 0.13 and p = 0.14, respectively). CONCLUSIONS: In conclusion, Stentless FloRIN is a feasible and safe IntraCorporeal Neobladder technique, as confirmed by the worthy functional and perioperative outcomes achieved in comparison with the standard FloRIN ureteral management strategy.

Computer-aided diagnosis in prostate cancer: a retrospective evaluation of the Watson Elementary® system for preoperative tumor characterization in patients treated with robot-assisted radical prostatectomy.

PURPOSE: Computer-aided diagnosis (CAD) may improve prostate cancer (PCa) detection and support multiparametric magnetic resonance imaging (mpMRI) readers for better characterization. We evaluated Watson Elementary® (WE®) CAD system results referring to definitive pathological examination in patients treated with robot-assisted radical prostatectomy (RARP) in a tertiary referral center. METHODS: Patients treated with RARP between 2020 and 2021 were selected. WE® calculates the Malignancy Attention Index (MAI), starting from the information contained in the mpMRI images. Outcome measures were the capability to predict the presence of PCa, to correctly locate the dominant lesion, to delimit the largest diameter of the dominant lesion, and to predict the extraprostatic extension (EPE). RESULTS: Overall, tumor presence was confirmed in 46 (92%) WE® highly suspicious areas, while it was confirmed in 43 (86%) mpMRI PI-RADS ≥ 4 lesions. The WE® showed a positive agreement with mpMRI of 92%. In 98% of cases, visible tumor at WE® showed that the highly suspicious areas were within the same prostate sector of the dominant tumor nodule at pathology. WE® showed a 2.5 mm median difference of diameter with pathology, compared with a 3.8 mm of mpMRI versus pathology (p = 0.019). In prediction of EPE, WE® and mpMRI showed sensitivity, specificity, positive and negative predictive value of 0.81 vs 0.71, 0.56 vs 0.60, 0.88 vs 0.85 and 0.42 vs 0.40, respectively. CONCLUSION: The WE® system resulted accurate in the PCa dominant lesion detection, localization and delimitation providing additional information concerning EPE prediction.

Robot-assisted sacro(hystero)colpopexy with anterior and posterior mesh placement: impact on lower bowel tract function and clinical outcomes at mid-term follow-up.

Background: Robotic sacrocolpopexy (RSCP) is an established option for the treatment of apical, anterior, and proximal posterior compartment pelvic organ prolapses (POP). However, there is lack of evidence investigating how lower bowel tract symptoms (LBTS) may change after RSCP. Methods: Data from consecutive patients treated with RSCP for stage 3 or higher POP from 2012 to 2019 at a single tertiary referral center with at least 1 year of follow-up were prospectively collected and retrospectively analyzed. RSCP was performed following a standardized technique which always employed both anterior and posterior hand-shaped meshes. Outcomes were collected at follow-up and analyzed. LBTS were evaluated through the Wexner questionnaire. Results: Overall, 114 women underwent RSCP. Eleven were excluded for missing data, whereas 12 had insufficient follow-up. Thus, 91 (79.8%) patients were included in this cohort. Median follow-up was 42 [interquartile range (IQR), 19-62] months. Mean age was 65 ± 10 years. In our series, RSCP was mainly performed for anterior and apical/medium stage 3 POP (in 95.6% of patients). Anatomic success rate of RSCP was 97.8%, with 89 patients with POP stage 0-1 at 12-month follow-up. Two patients (2.2%) experienced POP recurrence and were treated with redo-SCP. No patient experienced clinically significant posterior vaginal wall prolapse after RSCP. When analyzing LBTS, there was no significant change in postoperative total Wexner's score as compared to the preoperative value (p > 0.05). However, the manual assistance subscore was statistically significantly lower within the first-year follow-up (p = 0.04), but it spontaneously improved during the follow-up (p = 0.12). Conclusion: RSCP with simultaneous placement of both anterior and posterior mesh is safe and successful to treat high-stage POP in carefully selected patients. Of note, LBTS appear unaffected by posterior mesh placement, supporting its routine use to prevent posterior POP recurrence. Larger prospective studies are needed to confirm our results.

Robot assisted radical cystectomy with Florence Robotic Intracorporeal Neobladder (FloRIN): Functional and urodynamic features compared with a contemporary series of open Vescica Ileale Padovana (VIP).

INTRODUCTION: FloRIN reconfiguration technique was introduced in 2016 according to the IDEAL-Collaboration Guidelines, with the attempt to conjugate the advantages of both intracorporeal neobladder and robotic assistance. Herein we report functional outcomes of FloRIN reservoir, specifically focusing on urodynamic features. MATERIALS AND METHODS: Consecutive patients treated with RARC and FloRIN reconstruction were prospectively collected from February 2016 to June 2020. Only patients with a minimum 6-month follow up were analyzed to obtain a stable grade of neobladder maturation before performing the urodynamic study (UDS). The FACT-BL and the QLQ-C30 EORTC questionnaires were used to evaluate urinary function and health-related QoL. Results were compared with a contemporary series of patients treated at the same Institution with open radical cystectomy (ORC) and Vescica Ileale Padovana (VIP). RESULTS: One hundred patients entered the study and 69 patients had complete functional data. Overall, 52 (75.4%) patients reached the daytime continence. Among these, 28 (40.6%) were dry (no pads during daytime), while 24 (34.8%) used one pad/12 h. Night-time continence was achieved by 45 (65.2%) patients. Complete UDS findings were available for 28 patients. No statistically significant differences were found with the VIP-ORC group except for neobladder compliance, being higher in the FloRIN group (p = 0.03). When evaluating QoL scores, RARC with FloRIN reconfiguration showed a better continence recovery, as well as a higher improvement in urgency domain (p = 0.01), psychological status (0.02) and physical self-acceptance (p = 0.02), compared to the VIP-ORC group. CONCLUSIONS: The FloRIN technique showed excellent functional outcomes when compared to the referral VIP-ORC procedure.

Multicentre International Study for the Prevention with iAluRil of Radio-induced Cystitis (MISTIC): A Randomised Controlled Study.

BACKGROUND: Radiation-induced cystitis is a common side effect of radiotherapy (RT) to the pelvic area. Hyaluronic acid (HA) and chondroitin sulfate (CS) are components of the urothelial mucosa and positive results have been obtained for intravesical HA/CS instillations for the treatment of urinary tract infections and bladder pain syndrome. HA/CS may also have a protective effect against RT bladder toxicity. OBJECTIVE: To investigate whether HA and CS protect the urothelium during RT, alleviate lower urinary tract symptoms, and improve quality of life. DESIGN SETTING AND PARTICIPANTS: This multicentre randomised controlled trial was conducted across seven centres in four countries. Male patients aged ≥18 yr scheduled to undergo primary intensity-modulated radiotherapy for localised prostate cancer were enrolled. INTERVENTION: Patients were randomised to intravesical HA/CS plus an oral formulation of curcumin, quercetin, HA, and CS (group A) or no treatment (group B). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was absolute changes from baseline to follow-up in urinary domain scores for the Expanded Prostate Cancer Index Composite (EPIC), the International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms (ICIQ-MLUTS), and the EuroQol Group EQ-5D-5L questionnaire. Data analysis for efficacy and safety outcomes was performed using an intention-to-treat (ITT) approach; the ITT population was defined as all randomised patients. RESULTS AND LIMITATIONS: Of 57 patients screened, 49 were enrolled and randomly assigned to either active treatment (group A, n = 25) or the control (group B, n = 24). Three patients in the control group withdrew after randomisation. Changes from baseline to 12 mo were worse in the control group for subtotal scores for urinary symptoms and impact of symptoms on quality of life and for the total score (p = 0.05, p = 0.003, and p = 0.008, respectively). There was a significant time × group interaction in favour of active treatment for the incontinence symptom score (p = 0.011) and bother score (p = 0.017). The absence of a sham procedure and/or placebo is the main limitation. CONCLUSIONS: Our results suggest that intravesical HA/CS in combination with an oral formulation may reduce urinary symptoms and improve QoL at short-term (1 yr) follow-up. PATIENT SUMMARY: We investigated whether hyaluronic acid (HA) and chondroitin sulfate (CS) have a protective effect against the bladder toxicity of radiotherapy for prostate cancer. HA/CS used for weekly bladder irrigation for 6 wk and given orally with curcumin and quercetin for 12 wk reduced urinary incontinence symptoms and bother measured at 1-year follow-up. This may hold promise as a preventive treatment if the results are confirmed in further trials.

Robot assisted radical cystectomy with Florence robotic intracorporeal neobladder (FloRIN): Analysis of survival and functional outcomes after first 100 consecutive patients upon accomplishment of phase 3 IDEAL framework.

INTRODUCTION: Aim of the study was to evaluate the Florence intracorporeal neobladder (FloRIN) oncological and functional outcomes at the end of assessment phase (phase 3) IDEAL-Guidelines. MATERIALS AND METHODS: This single-institution prospective series included consecutive patients treated with robot-assisted radical cystectomy (RARC) and FloRIN reconfiguration technique from February 2016 to June 2020. Functional features were evaluated six months after surgery. Patients were grouped into four quartiles according to time of radical cystectomy and impact of learning curve improvement was evaluated. RESULTS: One-hundred FloRIN were completed with a median console time of 373 (IQR: 312-415) minutes. Two cases were converted to open surgery. No intraoperative complications occurred. At pathological examination, 30% of patients were staged as pT ≤ 1 and 47% as pT ≥ 3. Transitional cell carcinoma was present in 87% of cases. Carcinoma in situ (CIS) and nodal involvement were observed in 38% and 29% of patients, respectively. At a median follow-up time of 17 (IQR: 7-28) months, 20 clinically relevant events (Clavien-Dindo≥3) occurred. Operative time significantly decreased throughout the series (median minutes 435; 395; 365 and 330 in the four quartiles, respectively; p < 0.001). Similarly, early Clavien-Dindo≥3 postoperative complications rate significantly decreased across the series (number of events: 1; 4; 0; 0; p = 0.03). Overall, 75% and 65% of patients achieved day-time and nigh-time continence, respectively. Twenty-seven patients experienced disease recurrence. Cancer-specific and overall survival were equal to 80%. CONCLUSIONS: RARC with FloRIN reconfiguration showed worthy functional and survival outcomes, with learning curve improvement significantly influencing operative time and early complications rate across series.

Clinical predictors and significance of adherent perinephric fat assessed with Mayo Adhesive Probability (MAP) score and perinephric fat surface density (PnFSD) at the time of partial nephrectomy for localized renal mass. A single high-volume referral center experience.

BACKGROUND: Adherent perinephric fat (APF) could negatively influence surgical outcomes of partial nephrectomy (PN). Novel radiological scores have been introduced to preoperatively detect APF, i.e. Mayo Adhesive Probability (MAP) score and perinephric fat surface density (PnFSD). We aimed to evaluate clinical predictors of APF and the association of MAP and PnFSD with perioperative outcomes after PN. METHODS: Clinical and radiological data of patients undergoing open or robotic PN were prospectively gathered. Perinephric fat was retrospectively measured by a single expert uro-radiologist. Patients were divided into MAP 0-3 vs. MAP 4-5 and high vs. low PnFSD. Multivariable analysis was performed to seek for clinical predictors of APF. RESULTS: Overall, 175 patients were entered. Patients with vs. without APF were significantly different regarding age, gender, ASA score, Charlson Comorbidity Index, Body Mass Index, waist circumference, HDL status and metabolic syndrome. Conversely, tumor-related characteristics were not significantly different between the groups. At multivariable analysis, metabolic syndrome was confirmed as the only independent predictor of APF (OR: 24.9; P<0.001). Notably, APF assessed by MAP score or PnFSD was not associated with perioperative outcomes after PN. CONCLUSIONS: In experienced hands, APF did not impact on intra- or perioperative outcomes after PN. Metabolic syndrome was the only significant predictor of APF in our series.

How far is too far? Exploring the indications for robotic partial nephrectomy in a highly complex kidney tumor

ABSTRACT Purpose: The conservative management of localized renal masses has been recently widened to cT2 tumors showing encouraging functional and oncological outcomes (1). This video aims to report the conservative management of a highly complex renal tumor treated with robotic pure enucleation in our center, specifically focusing on preoperative work-up, video-reported surgical steps and perioperative outcomes. Materials and Methods: A 63 year-old lady underwent CT scan revealing a single 75 x 68mm, mainly endophytic, right renal mass dislocating the vascular pedicle (cT3a). Two renal arteries and two veins were identified. PADUA, RENAL and simplified SPARE scores were 14a, 12a and 12 respectively. Since the contralateral kidney was hypotrophic, the indication for nephron-sparing approach was considered absolute. Preoperative surgical planning included the employment of 3D-virtual models (2). Results: Operative time was 150 minutes and warm ischemia time was 25 minutes. No major complication occurred. Histopathological analysis revealed a cromophobe renal cell carcinoma with extension to perirenal fat tissue (pT3a). Resection technique was classified as pure enucleation since Surface-Intermediate-Base (SIB) score was 0-0-0 (3, 4). At seven-months follow-up no signs of local or systemic recurrence were recorded. Postoperative CT-scan revealed optimal parenchymal volume preservation with last creatinine blood level of 1.16mg/dL. Conclusion: This video highlights how, in experienced hands, robotic partial nephrectomy represents a feasible, effective treatment option for surgical management of highly complex renal tumors. The employment of intraoperative ultrasonography and 3D-virtual models allowed to accurately tailor surgical approach, improving the perception of tumor anatomy and its vascularization and maximizing perioperative outcomes.

Oncologic outcomes in patients treated with endoscopic robot assisted simple enucleation (ERASE) for renal cell carcinoma: Results from a tertiary referral center.

INTRODUCTION: Open Simple Enucleation (OSE) has been demonstrated to be an oncologically safe alternative to standard partial nephrectomy. We assessed the mid-term oncologic outcomes and predictors of disease recurrence in patients treated with Endoscopic Robot-Assisted Simple Enucleation (ERASE) verified through a standardized reporting system at a single institution. MATERIAL AND METHODS: The clinical data of patients treated with ERASE for renal cell carcinoma at our Institution from January 2012 to September 2018 were retrospectively reviewed. Surface-Intermediate-Base (SIB) score was evaluated immediately after surgery. Patients with a ≥2 SIB score were excluded. The local and distant recurrence rates, the recurrence-free (RFS), cancer-specific (CSS) and overall (OS) survival were assessed. Kaplan-Meier and log-rank test were used to estimate survivals and to compare recurrence-free survival. RESULTS: Overall, 259 patients were considered eligible for the present study. The median PADUA score was 7 (interquartile range [IQR] 6-9). Positive surgical margins (PSM) were registered in 7 (2.7%) cases. Median (IQR) follow-up time was 36 (27-51) months. Overall, 4 (1.5%) patients experienced systemic recurrence (SR) and 5 (1.9%) patients experienced local recurrence alone (LR) of whom 3 (1.1%) were on tumor resection bed, and 2 (0.8%) experienced recurrence elsewhere in the ipsilateral kidney. The 5-year RFS, CSS and OS were 94.2%, 98.9% and 93.6%, respectively. Higher nucleolar grade and PSM were the two factors significantly associated with worse RFS. CONCLUSIONS: ERASE is a safe procedure, achieving negative surgical margins in the vast majority of patients and providing excellent mid-term local control and oncologic outcomes.

Tumor-parenchyma interface and long-term oncologic outcomes after robotic tumor enucleation for sporadic renal cell carcinoma.

OBJECTIVE: Tumor enucleation has been shown to be oncologically safe for elective treatment of renal cell carcinoma (RCC); yet, evidence on long-term oncologic outcomes after robotic tumor enucleation is lacking. In this study we provide a detailed histopathological analysis of tumor-parenchyma interface and the long-term oncologic outcomes after robotic tumor enucleation for sporadic RCC in a high-volume referral center. MATERIALS AND METHODS: We selected consecutive patients undergoing robotic tumor enucleation for sporadic RCC by experienced surgeons with at least 4 years of follow-up. Pattern of pseudocapsule (PC) invasion, thickness of healthy renal margin removed with the tumor, margin status and recurrence rate were the main study endpoints. Multivariable models evaluated independent predictors of PC invasion. RESULTS: Overall, 140 patients were eligible for the study. Of these, 127 (91%) had complete data available for analysis. Median thickness of healthy renal margin was 0.57 mm (interquartile range [IQR] 0.24-103). A distinct peritumoral PC was present in 121/127 (95%) tumors with a median thickness of 0.28 mm (IQR 0.14-0.45). In 24/121 (19.8%) cases, RCC showed complete PC invasion. At multivariable analysis, increasing tumor diameter, endophytic rate > 50% and papillary histology were significantly associated with complete PC invasion. Positive surgical margins were reported in 3/127 (2.4%) cases. At a median follow-up of 61 months (range 48-76), one patient died due to metastatic RCC. Among patients alive at follow-up, no cases of recurrence at the enucleation site were recorded, while three cases (2.4%) of renal recurrence (elsewhere in the ipsilateral kidney) and three cases (2.4%) of systemic recurrence were found. CONCLUSIONS: Distinct RCC-related features were associated with complete PC invasion. By providing a microscopic layer of healthy renal margin in almost all cases, robotic tumor enucleation achieved negative surgical margins in the vast majority of patients, even in case of complete PC invasion. At long-term follow-up, no recurrences were found at the enucleation site. Although our findings need to be confirmed by larger studies with longer follow-up, robotic tumor enucleation appears oncologically safe in experienced hands for the treatment of sporadic RCC.

Impact of the off-clamp endoscopic robot-assisted simple enucleation (ERASE) of clinical T1 renal tumors on the postoperative renal function: Results from a matched-pair comparison.

PURPOSE: To evaluate the surgical and functional outcomes of a matched-paired series of on-clamp vs off-clamp endoscopic robot-assisted simple enucleation (ERASE) and standardized renorraphy in a tertiary referral institution, to search for predictors of functional drop after surgery and to investigate the influence of off-clamp technique in patients presenting these characteristics. MATERIALS AND METHODS: A matched-pair comparison of 120 on-clamp vs 120 off-clamp over 491 patients treated with ERASE was performed. Perioperative and functional outcomes were compared between groups. RESULTS: Patients treated with on-clamp and off-clamp technique had comparable complication and positive surgical margin rate. The off-clamp group had a significantly lower eGFR drop compared to the on-clamp group at 3rd postoperative day (POD) (1% vs 7%, p = 0.0001) and at 30th POD (2.5% vs 9%, p = 0.01) from baseline. This difference lost its statistical significance at 6th month and at last follow-up (median 40 months). At multivariable analysis the Charlson comorbidity index (OR 2.06, p < 0.0001), uncontrolled type 2 diabetes mellitus (OR 4.13, p < 0.001) were independent predictive factors of a >15% eGFR drop from baseline to last follow-up. In a subanalysis over 64 comorbid patients, those patients who underwent off-clamp ERASE had a significantly lower eGFR drop compared to the comorbid counterpart during the whole follow-up. CONCLUSIONS: The off-clamp ERASE is a safe surgical technique with a significantly lower renal function drop compared to on-clamp ERASE in the early perioperative time. Patients with comorbidity might represent a subgroup of patients having a functional benefit after off-clamp RAPN even in the long-term period.

Perineal schwannoma: an unusual tumor and clinical presentation - first case with erectile dysfunction associated with this neoplasm.

INTRODUCTION: Perineal schwannomas (PS) are very rare benign tumors with few cases reported in literature and none of these reports erectile dysfunction among clinical presentations. CASE DESCRIPTION: We report a case of PS with unusual clinical presentation showing erectile dysfunction associated with perineal pain and discomfort during defecation, and the postoperative residual pain and erectile dysfunction treatment. CONCLUSIONS: On the basis of a literature review of all cases reported and on our case reported, we have delineated a clinical, diagnostic, and therapeutic profile of PS, summarized in a useful table.

Florence robotic intracorporeal neobladder (FloRIN): a new reconfiguration strategy developed following the IDEAL guidelines.

OBJECTIVE: To describe our step-by-step technique for robotic intracorporeal neobladder configuration, including the stages of conception, development and exploration of this surgical innovation, according to the Idea, Development, Exploration, Assessment, Long-term follow-up (IDEAL) Collaboration guidelines. PATIENTS AND METHODS: The Florence robotic intracorporeal neobladder (FloRIN) was performed employing the following main surgical steps: isolation of 50 cm of ileum; bowel anastomosis; urethro-ileal anastomosis creating an asymmetrical 'U'-shape (30 cm distally and 20 cm proximally to anastomosis), ileum detubularisation; posterior wall reconfiguration as an 'L'; bladder neck reconstruction; anterior folding of the posterior plate to reach the 12 o'clock position; uretero-enteral 'orthotopic' bilateral anastomosis. The conception and development of the FloRIN followed the IDEAL guidelines recommended stages: Phase 1 (simulation) involved the neobladder robotic configuration using silicone models. Phase 2a (development) aimed to reproduce the configuration in an open fashion in one patient, and then in the first three robotic procedures. Phase 2b (exploration) consisted of the technique standardisation in 15 consecutive robotic approaches. Phase 2a and 2b included urodynamics and imaging assessment of the patients treated. RESULTS: From February 2016 to September 2017 FloRIN was performed in 18 patients. Comparing the first three (Phase 2a) with the subsequent 15 patients (Phase 2b), the median (interquartile range [IQR]) reconstruction operating time was 260 (220-340) vs 160 (150-210) min, respectively. Postoperative surgical complications occurred in four of the 18 patients (22.1%), including one surgical Clavien-Dindo Grade III and three Grade I, postoperative medical Clavien-Dindo Grade II complications occurred in three (16.7%) patients. On urodynamic examination (available in nine [50%] patients) the median (IQR) reservoir cystometric capacity, compliance, and post-void residual were 240 (220-267) mL, 18 (12.5-19.8) mL/cmH2 O, and 0 (0-50) mL, respectively. Ultrasonography showed no Grade ≥2 vesico-ureteric reflux. CONCLUSION: We describe the FloRIN configuration, showing its technical feasibility with acceptable time efficiency. The first cases studied had good reservoir capacity, low pressure with no reflux, and complete voiding.

Hemidiaphragm Paralysis after Robotic Prostatectomy: Medical Malpractice or Unforeseeable Event?

The authors present a case of suspected malpractice linked to the onset of hemidiaphragm paralysis after robot-assisted radical prostatectomy (RARP). The approach to the case is shown from a medico-legal point of view. It is demonstrated how, after a thorough review of the literature, this was not a case of medical malpractice but an unforeseeable event. This paper aims at contributing to the very few reports dealing with the onset of hemidiaphragm paralysis after RARP, thus fostering clinical knowledge of these rare events and meanwhile providing useful data for the medico-legal handling in case of alleged negligence of surgeons.

Endoscopic robot-assisted simple enucleation (ERASE) for clinical T1 renal masses: description of the technique and early postoperative results.

BACKGROUND: Simple enucleation (SE) has proven to be oncologically safe. We describe the surgical steps and report the results of the Endoscopic Robotic-Assisted Simple Enucleation (ERASE) technique. METHODS: Data were gathered prospectively from 130 consecutive patients undergone ERASE for intracapsular kidney cancer, between 2010 and 2013. ERASE was performed using the 4S Da Vinci surgical system, (Intuitive Surgical, Sunnyvale, CA, USA) in a three-arm configuration. Patients' characteristics and surgical outcomes of ERASE in cT1 were analyzed and the results in cT1a tumors were compared to those of pure laparoscopic SE performed in the same institution in the same time period. RESULTS: The mean (range) preoperative tumor size was 3.2 cm (0.8-10.0 cm), and clinical stage was T1a for 101 patients, T1b for 28, and T2a for 1. Median PADUA score was 8 (IQR 7-9). In 33.9% of patients, ERASE was done without pedicle clamping. Mean (±SD) warm ischemia time (WIT) was 18 ± 6 min. According to Clavien system, 1 grade 1 (0.8%), 5 grade 2 (3.1%), 4 grade 3 (3.8%), and 1 grade 4 (0.8%) surgical complications occurred. Positive surgical margin (PSM) rate was 2.8%. ERASE in cT1a tumors was associated with a significantly lower need for pedicle clamping, shorter WIT, and lower estimated blood loss (EBL) along with similar operative time and intra and postoperative complication rates but with a significantly lower incidence of urinary fistulas requiring stent insertion compared to laparoscopic SE. Also mean time to drainage removal and length of hospital stay (LOS) were significantly lower in for ERASE. The two groups had comparable PSM rate. CONCLUSIONS: ERASE has proven to be a feasible technique for the minimal invasive treatment of clinical stage T1 renal masses. The robotic approach can achieve surgical results superior to those of pure laparoscopy by reducing the need for clamping, WIT, EBL, and LOS.