Application of a retrograde resection technique in robot-assisted laparoscopic nephron-sparing surgery for large complex renal tumors

Use, Costs and Comparative Effectiveness of Robotic Assisted, Laparoscopic and Open Urological Surgery

To report our experience of pure laparoscopic and robot-assisted laparoscopic reconstructive surgery in congenital megaureter, seven patients (one bilateral) with symptomatic congenital megaureter underwent pure laparoscopic or robot-assisted laparoscopic surgery. The megaureter was exposed at the level of the blood vessel and was isolated to the bladder narrow area. Extreme ureter trim and submucosal tunnel encapsulation or papillary implantations and anti-reflux ureter bladder anastomosis were performed intraperitoneally by pure laparoscopic or robot-assisted laparoscopic surgery. The clinical data of seven patients after operation were analyzed, including the operation time, intraoperative complications, intraoperative bleeding volumes, postoperative complications, postoperative hospitalization time and pathological results. All of the patients were followed. The operation was successfully performed in seven patients. The mean operation times for pure laparoscopic surgery and robotic-assistant laparoscopic surgery were 175 (range: 150–220) and 187 (range: 170–205) min, respectively, and the mean operative blood loss volumes were 20 (range: 10–30) and 28.75 (range: 15–20) ml, respectively. There were no intraoperative complications. The postoperative drainage time was 5 (range: 4–6) and 5.75 (range: 5–6) d, respectively, and the indwelling catheter time was 6.33 (range: 4–8) d and 7 (range: 7–7) d, respectively. The postoperative hospitalization time was 7.67 (range: 7–8) d and 8 (range: 7–10) d, respectively. There was no obvious pain, no secondary bleeding and no urine leakage after the operation. Postoperative pathology reports revealed chronic urothelial mucosa inflammation. The follow-up results confirmed that all patients were relieved of their symptoms. Both pure laparoscopic and robot-assisted laparoscopic surgery using different anti-reflux ureter bladder anastomoses are safe and effective approaches in the minimally invasive treatment of congenital megaureter.

Cost in healthcare is an increasing and justifiable concern that impacts decisions about the introduction of new devices such as the da Vinci(®) surgical robot. Because equipment expenses represent only a portion of overall medical costs, we set out to make more specific cost comparisons between open and robot-assisted laparoscopic surgery. We performed a retrospective, observational, matched cohort study of 146 pediatric patients undergoing either open or robot-assisted laparoscopic urologic surgery from October 2004 to September 2009 at a single institution. Patients were matched based on surgery type, age, and fiscal year. Direct internal costs from the institution were used to compare the two surgery types across several procedures. Robot-assisted surgery direct costs were 11.9% (P=0.03) lower than open surgery. This cost difference was primarily because of the difference in hospital length of stay between patients undergoing open vs robot-assisted surgery (3.8 vs 1.6 days, P<0.001). Maintenance fees and equipment expenses were the primary contributors to robotic surgery costs, while open surgery costs were affected most by room and board expenses. When estimates of the indirect costs of robot purchase and maintenance were included, open surgery had a lower total cost. There were no differences in follow-up times or complication rates. Direct costs for robot-assisted surgery were significantly lower than equivalent open surgery. Factors reducing robot-assisted surgery costs included: A consistent and trained robotic surgery team, an extensive history of performing urologic robotic surgery, selection of patients for robotic surgery who otherwise would have had longer hospital stays after open surgery, and selection of procedures without a laparoscopic alternative. The high indirect costs of robot purchase and maintenance remain major factors, but could be overcome by high surgical volume and reduced prices as competitors enter the market.

Robot-assisted laparoscopic surgery has been performed in various fields, especially in the pelvic cavity. However, little is known about the utility of robot-assisted laparoscopic rectal cancer surgery associated with robot-assisted radical prostatectomy (RARP). We herein report the clinical impact of robot-assisted laparoscopic rectal cancer surgery associated with RARP. We experienced five cases of robot-assisted laparoscopic rectal cancer surgery associated with RARP. One involved robot-assisted laparoscopic abdominoperineal resection with en bloc prostatectomy for T4b rectal cancer, and one involved robot-assisted laparoscopic intersphincteric resection combined with RARP for synchronous rectal and prostate cancer. The remaining three involved robot-assisted laparoscopic low anterior resection (RaLAR) after RARP. For robot-assisted laparoscopic rectal cancer surgery, the da Vinci Xi surgical system was used. We could perform planned robotic rectal cancer surgery in all cases. The median operation time was 529 min (373-793 min), and the median blood loss was 307 ml (32-1191 ml). No patients required any transfusion in the intra-operative or immediate peri-operative period. The circumferential resection margin was negative in all cases. There were no complications of grade ≥III according to the Clavien-Dindo classification and no conversions to conventional laparoscopic or open surgery. Robot-assisted laparoscopic surgery associated with RARP is feasible in patients with rectal cancer. The long-term surgical outcomes remain to be further evaluated.

Robotic rectal cancer surgery is gaining popularity, but limited data are available regarding safety and efficacy. To compare robotic-assisted vs conventional laparoscopic surgery for risk of conversion to open laparotomy among patients undergoing resection for rectal cancer. Randomized clinical trial comparing robotic-assisted vs conventional laparoscopic surgery among 471 patients with rectal adenocarcinoma suitable for curative resection conducted at 29 sites across 10 countries, including 40 surgeons. Recruitment of patients was from January 7, 2011, to September 30, 2014, follow-up was conducted at 30 days and 6 months, and final follow-up was on June 16, 2015. Patients were randomized to robotic-assisted (n = 237) or conventional (n = 234) laparoscopic rectal cancer resection, performed by either high (upper rectum) or low (total rectum) anterior resection or abdominoperineal resection (rectum and perineum). The primary outcome was conversion to open laparotomy. Secondary end points included intraoperative and postoperative complications, circumferential resection margin positivity (CRM+) and other pathological outcomes, quality of life (36-Item Short Form Survey and 20-item Multidimensional Fatigue Inventory), bladder and sexual dysfunction (International Prostate Symptom Score, International Index of Erectile Function, and Female Sexual Function Index), and oncological outcomes. Among 471 randomized patients (mean [SD] age, 64.9 [11.0] years; 320 [67.9%] men), 466 (98.9%) completed the study. The overall rate of conversion to open laparotomy was 10.1%: 19 of 236 patients (8.1%) in the robotic-assisted laparoscopic group and 28 of 230 patients (12.2%) in the conventional laparoscopic group (unadjusted risk difference = 4.1% [95% CI, -1.4% to 9.6%]; adjusted odds ratio = 0.61 [95% CI, 0.31 to 1.21]; P = .16). The overall CRM+ rate was 5.7%; CRM+ occurred in 14 (6.3%) of 224 patients in the conventional laparoscopic group and 12 (5.1%) of 235 patients in the robotic-assisted laparoscopic group (unadjusted risk difference = 1.1% [95% CI, -3.1% to 5.4%]; adjusted odds ratio = 0.78 [95% CI, 0.35 to 1.76]; P = .56). Of the other 8 reported prespecified secondary end points, including intraoperative complications, postoperative complications, plane of surgery, 30-day mortality, bladder dysfunction, and sexual dysfunction, none showed a statistically significant difference between groups. Among patients with rectal adenocarcinoma suitable for curative resection, robotic-assisted laparoscopic surgery, as compared with conventional laparoscopic surgery, did not significantly reduce the risk of conversion to open laparotomy. These findings suggest that robotic-assisted laparoscopic surgery, when performed by surgeons with varying experience with robotic surgery, does not confer an advantage in rectal cancer resection. isrctn.org Identifier: ISRCTN80500123.

Carotid corrected flow time (FTc) and tidal volume challenge pulse pressure variation (VtPPV) are useful clinical parameters for assessing volume status and fluid responsiveness in robot-assisted surgery, but their usefulness as goal-directed fluid therapy (GDFT) targets is unclear. We investigated whether FTc or VtPPV as targets are inferior to PPV in GDFT. This single-center, prospective, randomized, non-inferiority study included 133 women undergoing robot-assisted laparoscopic gynecological surgery in the modified head-down lithotomy position. Patients were equally divided into three groups, and the GDFT protocol was guided by FTc, VtPPV, or PPV during surgery. Primary outcomes were non-inferiority of the time-weighted average of hypotension, intraoperative fluid volume, and urine output. Secondary outcomes were optic nerve sheath diameter (ONSD) pre- and post-operatively and creatinine and blood urea nitrogen preoperatively and on day 1 post-operatively. No significant differences were observed in intraoperative hypotension index, infusion and urine volumes, and ONSD post-operatively between the FTc and VtPPV groups and the PPV group. No differences in serum creatinine and urea nitrogen levels were identified between the FTc and VtPPV groups preoperatively, but on day 1 post-operatively, the urea nitrogen level in the FTc group was higher than that in the PPV group (4.09 ± 1.28 vs. 3.0 ± 1.1mmol/L, 1.08 [0.59, 1.58], p < 0.0001), and the difference from the preoperative value was smaller than that in the PPV group (-2 [-2.97, 1.43] vs. -1.34 [-1.9, -0.67], p = 0.004). FTc- or VtPPV-guided protocols are not inferior to that of PPV in GDFT during robot-assisted laparoscopic surgery in the modified head-down lithotomy position.Trial registration: Chinese Clinical Trial Registry (ChiCTR2200064419).

Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial

The American Urological Association (AUA) and the Japanese Urological Association (JUA) have been working hard to promote collaboration in the science and art of urology between the two societies. On behalf of JUA, we are pleased to announce the 8th AUA/JUA International Affiliate Society Meeting at the 108th Annual Meeting of AUA (4–8 May 2013, San Diego, CA, USA). We are grateful for the support of AUA to prepare this joint program. We also would like to express our sincere appreciation to all people concerned, including the moderators, speakers and panelists of both societies. This year's program covers two video case discussions and three lectures on up-to-date management of urological cancers and stone. Dr William D Steers, Editor of The Journal of Urology, is invited for a lecture entitled “How to prepare a manuscript for publication in major medical journals”. We are very proud of the outstanding quality of the program. We look forward to the participation of many members of both societies in this joint program. Lastly, we would like to thank Dr Dennis A Pessis, AUA President; Dr Gopal H Badlani, AUA Secretary; and Dr Robert C Flanigan, AUA International Education Consultant, for their dedication to develop and extend mutual relationship between AUA and JUA. Introduction and objectives: Minimally-invasive renal surgery (MIRS) was described over 20 years ago, and its use has continued to increase. Here we will review trends in MIRS for resection of kidney tumors, and evaluate the impact of MIRS on utilization of partial (PN) versus radical nephrectomy (RN). We will also present comparative effectiveness data of MIRS versus open surgery for renal tumors. The role of technological advancements in MIRS, specifically robotic-assisted surgery (RAS), will be discussed as well. Methods: Data from peer-reviewed publications on renal surgery were reviewed. Results: MIRS currently accounts for the minority of overall renal tumor surgeries. Nevertheless, increased adoption of MIRS has shown an interesting interaction with practice patterns over time. That is, data from the early experience with laparoscopy suggest high utilization of laparoscopic RN among small renal tumors. Although PN remains underutilized today, a modest relative increase in this approach has been noted in recent years. Furthermore, continued efforts to improve the ease and efficacy of MIRS have been reported, including the application of RAS to minimize renal ischemia, and facilitate tumor resection and reconstruction during PN. Notably, a paucity of prospective data exist to compare the effectiveness of various approaches to renal surgery. With regard to PN, initial results suggested greater ischemia times and higher complication rates for laparoscopic versus open surgery. More recently, the application of RAS to PN has been associated with decreased warm ischemia times compared with laparoscopic PN, and decreased operative blood loss and length of hospital stay compared with open PN. Cost comparisons across techniques can be particularly challenging given the difficulties with assigning fixed costs and accounting for surgical volumes; however, limited evidence suggest an increased cost associated with RAS for PN in particular. Conclusions: The adoption of MIRS has coincided with changes in utilization of PN versus RN. The potential role of RAS in facilitating an albeit modest contemporary increase in nephron-sparing surgery must nevertheless be balanced against cost implications and relative perioperative safety and oncological efficacy. Introduction: Interest and experience in minimally-invasive surgery for renal tumors has continued to increase. Defining patient and tumor characteristics to identify the optimal candidates for this approach remains critical to ensuring treatment efficacy and safety. At the same time, the challenge remains to carry out tumor resection and reconstruction maintaining maximal renal function while ensuring complete tumor eradication. Objectives: To understand current indications/contraindications for minimally-invasive partial nephrectomy. To show the approach for tumor resection and subsequent parenchymal reconstruction during minimally-invasive and open partial nephrectomy. To discuss techniques for minimizing renal ischemia during partial nephrectomy. Case 1: A 28-year-old male with incidental 2.7 × 2.7 × 2.2 cm left upper pole partially exophytic solid renal mass. No past medical/surgical history. Creatinine 0.8. Question 1: What criteria do you use to recommend a robotic/conventional laparoscopic versus open approach to partial nephrectomy? Would the presence of chronic kidney disease (CKD) impact your choice of surgical approach? Question 2: How do you carry out reconstruction of the renal parenchymal defect robotically/laparoscopically? Case 2: A 62-year-old female with incidental 2.6 × 2.5 cm left upper pole partially exophytic renal tumor. No significant past medical/surgical history. Creatinine 0.71. Question 1: What is your choice of treatment for the left kidney tumor? Question 2: In doing conventional laparoscopic or robot-assisted partial nephrectomy, what is your routine practice to minimize ischemic time and maximize the restoration of renal function? Case 3: A 59-year-old male status post-right radical nephrectomy. Multifocal small sold lesions within remaining left kidney. Hypertension. Creatinine 1.2. Question 1: Optimal surgical approach for patient with sporadic unilateral multifocal renal tumors? Question 2: Technique for tumor resection during partial nephrectomy: enucleation or resection with margin of “normal” renal parenchyma? Case 4: A 52-year-old female with von Hippel-Lindau (VHL). Left radical nephrectomy 7 years earlier. Now with multifocal right renal tumors. Creatinine 0.78. Question 1: What is your choice of treatment for right kidney tumor(s)? Question 2: What is your choice of treatment for recurrent right kidney tumor(s)? Answer 1: In general, I approach all renal masses with robotic partial nephrectomy, regardless of size unless technically not feasible. The presence of CKD usually does not change my plan of approach, as I try to partial most lesions. Answer 2: I use a double-armed 90-day, 12-inch, 0 and 6-inch 3-0 V-Loc suture (Covidien, Mansfield, MA, USA). I run the 3-0 in the inner layer to close collecting system and vessels. I then exteriorize the 3-0 V-Loc and anchor to a sliding Covidien absorbable Laproclip. I then unclamp early and look for major bleeders that might require additional sutures. I then run a horizontal mattress on the outer layer using 0 V-Loc and use sliding Covidien absorbable Laproclip on all the exiting bites. I rarely use bolsters, but often will use Evicel as a hemostatic agent. Answer 1: Robotic partial nephrectomy, possible off clamp depending on how exophytic and how polar the lesion is. Answer 2: When possible, off clamp partial is carried out. Polar ischemia by providing regional compression can be applied using a (i) robotic non-traumatic 55-mm Grasping Retractor from the fourth arm; (ii) laparoscopic Simon Pole Clamp; (iii) twisting the blue ribbon on the end of an E-tape sponge. Using intravenous indocyanine green and da Vinci Firefly scope, the zero ischemia technique as popularized by Gill is also a great way to minimize renal ischemic injury by dissecting and micro-clamping a branch renal artery. Lastly, if clamping the main renal artery, utilizing V-Loc sutures, sliding clips (Weck or absorbable Laproclip), double armed sutures (minimizing numbers of sutures) and early unclamping techniques have all helped to minimize ischemia time. Using intravenous mannitol might possibly decrease ischemic injury as well. Most importantly, using a very experienced assistant (I use a physician assistant and not residents) is probably my most effective means to decrease ischemia time. Answer 1: Unless they appear to be lesions that can be resected off clamp (superficial, small and polar), they should be resected open on ice. Answer 2: Often this depends upon the lesion. I usually prefer leaving a margin of parenchyma if the lesion appears cystic, infiltrative or multi-lobulated. Finding the enucleation plane on the tumor pseudo-capsule usually results in less bleeding especially when going off-clamp. Answer 1: My treatment choice is no different for left versus right side tumors. In VHL cases with multifocal recurrences, the small tumors could be cryoablated. The lesions should be monitored until they reach about 3 cm. If operative intervention is decided for multiple tumors, in general, I would recommend an open partial nephrectomy using cold ischemia. In very select cases if the lesions are polar and superficial, I might consider off-clamp or zero-ischemia technique robotic partial nephrectomy. Answer 2: If this is a re-do case on the right side for recurrence, I would recommend open partial nephrectomy using cold ischemia. Partial nephrectomy (PN) is now the standard treatment for clinical T1 tumor because of oncological equivalence and functional superiority to radical nephrectomy (RN). Recently, many expert surgeons have been making an effort to minimize the therapeutic invasiveness of PN through laparoscopic and robot-assisted surgical approaches. Here, let me give a short introduction about GasLESS clampless PN, which we have developed as one of the options of minimally-invasive PN, before answering the questions. Since the late 1990s, we have developed gasless laparoendoscopic single-port surgery (GasLESS) for urological tumors as one of the options of minimally-invasive surgery (Kihara et al. Int J Urol 2004, 2009). A wide surgical field is created by dissecting anatomical planes using specialized long retractors and spatulas through a single port, approximately 4 cm in diameter, instead of CO2 gas insufflation. In Japan, GasLESS for urological tumors has been covered by the National Universal Health Insurance System since 2008. Recently, we have applied a new 3-D head-mounted display system (RoboSurgeon system) to GasLESS (Kihara et al. AUA 2013, EAU 2013). We have developed a novel technique of GasLESS “clampless” PN for maximal preservation of renal function, which is applied to a wide range of renal tumors (EAU video library #160204, EAU 2013 video, AUA 2012/2013, EAU 2010/2012/2013 posters, Kihara et al. Int J Urol 2009). The main steps to accomplishing GasLESS clampless PN are: (i) mobilization of the kidney, so that the tumor is located just beneath the single port; and (ii) tumor excision using a “mushroom technique”, which allows clampless tumor excision and ensures negative surgical margin. Tumor excision, assisted with ultrasonography, consists of three parts: (i) creating a circumferential groove around the tumor using an ultrasonic coagulator; (ii) creating a mushroom stalk-like shape in the tumor base and drawing the stalk upward with a thread tying the stalk; and (iii) transecting the mushroom stalk, within which tumor vessels often exist, little by little. Comment: Another reason why PN is recommended for clinical T1 tumors is a relatively high incidence (approximately 20%) of benign neoplasms (i.e. renal oncocytoma, fat-poor angiomyolipoma) at nephrectomy. The predicting factors for benign pathology include female sex, younger age and smaller tumor size (Fujii et al. AUA 2011). Therefore, I believe that state-of-the-art imaging including dynamic computed tomography scan and diffusion weighted magnetic resonance imaging is necessary for this young patient with a small renal mass. Answer 1: Minimally-invasive PN, such as laparoscopic or robot-assisted PN, is recommended for the patient. As aforementioned, we normally carry out GasLESS clampless PN for almost all the patients with clinical T1a tumors, regardless of tumor location or renal function. Recently, the clampless rate is more than 95% in all T1a tumors and 99% in peripheral tumors. Answer 2: In GasLESS clampless PN, after confirmation of hemostasis, reconstruction of the renal parenchymal defect is avoided as much as possible, and the resection bed remains unclosed. It is because there are some concerns that reconstruction using sutures might be the cause of additional impairment of renal function due to loss of nephron units and delayed bleeding. In our experience of more than 200 patients of clampless PN, none developed delayed bleeding or pseudoaneurysm formation after surgery. Only when the collecting system is opened or renal vessels are clamped is the reconstruction carried out as follows: the bed is closed with interrupted sutures with 1-0 threads after placing absorbable hemostats using a ValveGateTM needle holder (Geister, Tuttlingen, Germany). Answer 1: We recommend GasLESS clampless PN carried out retroperitoneally in the patient. The results for endophytic tumors are favorable. The standard of care for small renal cell carcinoma (RCC) is, whether the tumor is exophytic or endophytic, complete surgical resection. Answer 2: We carry out “clampless” PN retroperitoneally. When requiring vascular clamping, although it is very rare, ice slush is used for cold ischemia. Answer 1: Generally, PN should be strongly considered in imperative cases. If PN is technically infeasible, cryotherapy or radiofrequency ablation can be alternatives. I wonder how many tumors the patient has: 10, 20 or more? He has at least eight tumors even on a single-slice magnetic resonance image. I would basically recommend minimally-invasive RN to this patient in the clinical setting; particularly if he is Japanese, because Japanese hemodialysis patients live relatively long life spans with an estimated 10-year survival rate of 40%. Also, hemodialysis is covered by the National Universal Health Insurance System. Answer 2: Once PN is selected, enucleation is recommended to this patient to preserve renal function, because some previous studies have reported that positive surgical margins appear to have little to no impact on survival in patients undergoing PN for RCC. Comment: For VHL patients, the goal is to maintain the patient's own kidney function throughout their lifetime, to minimize the number of surgeries and yet remove tumors before they metastasize. The current consensus is to recommend surgery when the largest tumor is larger than 3 cm. Answer 1: Observation is recommended until the tumor becomes 3 cm. At the time, PN is recommended. We would select GasLESS clampless PN. Answer 2: Open (smaller incision) right PN (and left adrenalectomy?) is my choice of treatment. Cryotherapy or radiofrequency ablation might be added after surgery if necessary. Answer 1: We use two indications for conventional laparoscopic partial nephrectomy (LPN): (i) the tumor is 3 cm or less; and (ii) it is exophytic. Based on these criteria, I recommend using a transperitoneal approach. For most T1b tumors and T1a tumors for which LPN is not indicated, we choose to use open partial nephrectomy (OPN). The presence of CKD strongly influences our choice of surgical procedure. If CKD is stage 4 or higher, we choose laparoscopic radical nephrectomy, because the benefit of parenchymal preservation makes no difference in the prognosis of the kidney. Answer 2: I oversaw the opening of the renal sinus with 2-0 Vicryl running sutures if we enter the collecting system or large vessels in the renal sinus. The renal parenchymal is then closed with 2-0 Vicryl running sutures with a sliding Hem-o-Lok clip placed after each suture that is passed through the capsule. Answer 1: We would choose the same strategy as used in the case 1 patient because of the similarity of the location of the tumor and the lack of CKD. Answer 2: We do not use a “specific” technique, but we always make an effort to keep the ischemic time under 30 min. Mannitol is widely used for reducing ischemic renal injury, but our results show no benefit in the preservation of renal function after partial nephrectomy. We do not use cold ischemia or the early unclamping technique. If we need more time for suturing the parenchyma, however, we unclamp the hilum between 25 and 30 min. Answer 1: This patient has a solitary left kidney with multiple lesions. Because the patient is relatively young, it is important not to compromise the oncological outcome, although preservation of renal function is also important. I would choose open partial nephrectomy with under cold ischemia with surface cooling with slush ice. Answer 2: I would avoid enucleation because of the risk of positive surgical margin. I would carry out a conventional partial nephrectomy. Answer 1: For right kidney tumor(s), I would choose open partial nephrectomy under cold ischemia. For patients with VHL, I would excise the tumors with enucleation. Answer 2: I would carry out repeat partial nephrectomy as much as possible. Introduction and objective: The U.S. Preventive Services Task Force (USPSTF) has recommended against routine screening for prostate cancer using prostate-specific antigen (PSA). This lecture will help urologists understand how the USPSTF panel came to this conclusion. Methods: A review of the clinical evidence supporting the efficacy of PSA testing. Results: PSA screening results in significant overdiagnosis of localized prostate cancer. Furthermore, there is no consensus regarding optimal management of men with localized disease. Conclusions: The reduction in prostate cancer mortality 10–14 years after PSA-based screening is, at most, very small, even for men in the optimal age range of 55–69 years. Unfortunately, the harms of screening include pain, fever, bleeding, infection and, occasionally, urinary difficulties. More importantly, many men diagnosed with localized prostate cancer receive treatments that result in erectile dysfunction, urinary incontinence, bowel dysfunction and a small risk of premature death. Because urologists cannot distinguish between indolent tumors and clinically significant tumors, many men who will not benefit from treatment are exposed to the complications. Therefore, the benefits of PSA based screening do not outweigh the harms over a period of 10–14 years. Although men might experience a greater benefit with longer follow up, this belief has yet to be supported with data from randomized trials. The Göteborg randomized study showed a significant mortality reduction of 44% in the screening group after 14 years of median follow up. The efficacy of cancer screening should be evaluated as the probability of mortality reduction throughout the life. The Swedish study contributes to answering that question. The number of men needed to be detected (NND) amounted to 12, and was very low in comparison with the other cancer screening program. However, fundamentally, NND cannot predict how large drawbacks of screening would be, because it is based on the assumption that any stage of prostate cancer is equal, whereas the socioeconomic and physical damages are not comparable between metastatic and localized prostate cancer. The ERSPC data published in 2012 clearly showed that the initial exposure of PSA screening in men aged 55–69 years might relate with a high likelihood of delay to detect potentially lethal prostate cancer, because 74% of prostate cancer deaths were in cancers diagnosed at the first screening round. In contrast, a significant (38%) decrease in prostate cancer death at 10 and 11 years was found, indicating that long-term PSA screening exposure in the community might substantially decrease life-time risk of prostate cancer death. Although, all-cause mortality was identical between the two arms, any screening or definitive treatment intervention would not significantly affect it. Prostate cancer death could be the defined end-point. Progress in effective primary and a number of medical the use of PSA could be at least one of can significantly life screening for cancer to the it should be whether cancer screening in the community life years compared with routine medical care cancer a socioeconomic of it might be important to the in the screening In to PSA an optimal screening which and socioeconomic and screening in of mortality reduction and of metastatic prostate cancer, must be our in Introduction: What a very manuscript of publication from a A cannot make for whereas a can For for is not their the challenge is often to so does not the or a or clinical study might not be of to an community of because it in or unless the study is novel or the or changes disease or treatment Methods: A approach to a manuscript is the to if the is to is the study complete or will more or the for an a novel the of published is a for even if and there are no major to be published more but the negative study might be just as important. Another of the is more if a review published and for a A manuscript is and with data and the then often try to review the in the Introduction or and that from overall on the of manuscript and by to It to the of for the past years to if very or have been the likelihood of will help and and for such as in the A the Introduction and why important. The should of but if are published just a and the of your of in the using and If a clinical the should be Data shown in a or should not be in the The is the most important you your data yet the and does not or that that and present a such as or other If this is a first then to our The is Results: to in a with a high impact a and a Unfortunately, greater than of the urological is on the quality or relative of the carried out. show that are often used in urological the of evidence for urological practice to be low and their quality clinical randomized trials. are of limited and to be more to science studies in clinical should some clinical to be more reviewed. to be if and but are often review are to because they are more to be the field of the often with recent in the field also the number of with higher for cancer, and disease and less for female and science often clinical by and to help a impact based on the of in the years. urological that are more to be based on recent in to the impact the of small has over the past as has the number of However, less than of more than one rarely their in such as The Journal of Urology, one for will often result in the of a manuscript for of of and data are and if the will be or in two given the of and is not an for is the to of a manuscript to a major by of the to the and of published over past years to make the is and does not recent Although and of might high a carried out study with significant even if or that is not should be strongly considered for publication in the major Introduction: a results from between and National in show an increase in the incidence of that of the of in use for associated with are used for and are associated with a used for renal and in higher among is also associated with used in and the risk of by reducing based on the of formation cell injury by through is to be the initial of renal We that which is by is associated with and of in the initial steps of renal for are to this of risk by using If a to can be can be show that of D and are with studies show that in and and in Japanese are associated with would in the of risk and Conclusions: and with complete of will help Introduction and objectives: a long-term for patients with clinically localized prostate cancer. However, after a radical there might be significant functional to urinary and erectile function. prostate-specific antigen screening and the of prostate cancer in younger and men with disease have the of urinary and function after surgery. all three results patients while and function that is, the has the in men with cancer who are and before radical radical might functional and oncological than conventional as and can be under laparoscopic However, is a technically that is associated with a long The application of robotic in surgery has including 3-D

The objective is to explore the application effect of comprehensive nursing intervention in prevention of lower extremity deep vein thrombosis and pulmonary embolism in urological patients undergoing laparoscopic and robot-assisted laparoscopic surgery. From April 2019 to April 2020, 200 patients who received urological laparoscopic surgery and robot-assisted laparoscopic surgery were selected. According to the random number table method, they were divided into control group and observation group, 100 cases in control group and 100 cases in observation group. Patients in control group received routine nursing, while patients in observation group received comprehensive nursing intervention. The skin condition, swelling, pain, and occurrence of deep venous thrombosis and pulmonary embolism of lower extremities in 2 groups were observed. The experimental results showed that the lower limb swelling, lower limb pain, and lower limb deep vein thrombosis in the control group were significantly higher than those in the observation group, but all patients were cured and discharged after taking effective symptomatic treatment and nursing measures in time. In the control group, pulmonary embolism occurred in 3 patients, all of whom died. There was no significant difference in skin changes of lower limbs (P > 0.05), and there were significant differences in other skin changes (P < 0.05). It proved that comprehensive nursing intervention can effectively prevent the formation of lower extremity deep vein thrombosis and pulmonary embolism in urological patients undergoing laparoscopic and robot-assisted laparoscopic surgery with high-risk factors.

BackgroundSurgeons are among the most at risk of work-related musculoskeletal health decline because of the physical demands of surgery, which is also associated with cognitive fatigue. Minimally invasive surgery offers excellent benefits to patients but the impact of robotic or laparoscopic surgery on surgeon well-being is less well understood. This work examined the musculoskeletal and cognitive demands of robot-assisted versus standard laparoscopic surgery. MethodsMedline, Embase and Cochrane databases were systematically searched for ‘Muscle strain’ AND ‘musculoskeletal fatigue’ AND ‘occupational diseases’ OR ‘cognitive fatigue’ AND ‘mental fatigue’ OR ‘standard laparoscopic surgery’ AND ‘robot-assisted laparoscopic surgery’. Primary outcomes measured were electromyographic (EMG) activity for musculoskeletal fatigue and questionnaires (NASA-TLX, SMEQ, or Borg CR-10) for cognitive fatigue. A systematic review was conducted in accordance with the Synthesis Without Meta-analysis (SWiM) Guidelines. The study was preregistered on Prospero ID: CRD42020184881. ResultsTwo hundred and ninety-eight original titles were identified. Ten studies that were all observational studies were included in the systematic review. EMG activity was consistently lower in robotic than in laparoscopic surgery in the erector spinae and flexor digitorum muscles but higher in the trapezius muscle. This was associated with significantly lower cognitive load in robotic than laparoscopic surgery in 7 of 10 studies. ConclusionsEvidence suggests a reduction in musculoskeletal demands during robotic surgery in muscles excluding the trapezius, and this is associated with most studies reporting a reduced cognitive load. Robotic surgery appears to have less negative cognitive and musculoskeletal impact on surgeons compared to laparoscopic surgery.

IntroductionThere is a lack of multi-institutional large-volume and long-term follow-up data on comparisons between robot-assisted surgery and conventional laparoscopic surgery. This study compared the surgical and long-term survival outcomes between...

ObjectiveThere is a lack of multi-institutional large-volume and long-term follow-up data on comparisons between robot-assisted surgery and conventional laparoscopic surgery. This study compared the surgical and long-term survival outcomes between patients who underwent robot-assisted or conventional laparoscopic surgery for endometrial cancer.MethodsWe retrospectively reviewed the data of patients from five large academic institutions who underwent either robot-assisted or conventional laparoscopic surgery for the treatment of endometrial cancer between 2012 and 2017, ensuring at least 5 years of potential follow-up. Intra- and postoperative outcomes, long-term disease-free survival, and overall survival were compared.ResultsThe study cohort included 1,003 unselected patients: 551 and 452 patients received conventional laparoscopic and robot-assisted surgery, respectively. The median follow-up duration was 57 months. Postoperative complications were significantly less likely to occur in the robot-assisted surgery group compared to the laparoscopic surgery group (7.74% vs. 13.79%, P = 0.002), primarily limited to minor complications. There were no significant differences in survival: 5-year disease-free survival was 91.2% versus 90.0% (P = 0.628) and overall survival was 97.9% versus 96.8% (P = 0.285) in the robot-assisted and laparoscopic surgery cohorts, respectively. Cox proportional hazard regression models demonstrated that the mode of surgery was not associated with disease-free survival (hazard ratio, 0.897; confidence interval, 0.563–1.429) or overall survival (hazard ratio, 0.791; confidence interval, 0.330–1.895) after adjusting for confounding factors.ConclusionRobot-assisted surgery for endometrial cancer demonstrates comparable long-term survival outcomes and a reduced incidence of postoperative minor complications when compared to conventional laparoscopic surgery.

BackgroundThis retrospective cohort study compared short-term outcomes between robotic-assisted and conventional laparoscopic surgery for rectal cancer using data from the Swedish Colorectal Cancer Registry.MethodAll patients undergoing elective minimally invasive surgery for rectal cancer between 2014 and 2021 and registered in the Swedish Colorectal Cancer Registry were assessed for eligibility, with patients who underwent robotic-assisted and laparoscopic rectal cancer resection included in the study. The primary outcome was a positive circumferential resection margin (CRM+). Secondary outcomes included conversion to open surgery, total mesorectal excision (TME) specimen quality, and 30-day overall and surgical complications. Multivariable logistic regression analyses were performed.ResultsOf 12 703 patients registered during the study period, 10 914 underwent abdominal resection; of these, 5874 were analysed in this study (3578 robotic-assisted; 2296 conventional laparoscopic surgery). There was no difference in CRM+ between the robotic-assisted and conventional laparoscopic surgery groups (6.5% versus 5.9%, respectively; P = 0.291). Conversion to open surgery was more frequent in the conventional laparoscopic surgery group (16.1% versus 9.1%; P < 0.001). In addition, 30-day surgical complications were more common in the robotic-assisted laparoscopic surgery group (21.5% versus 19.3%; P = 0.044), including a higher rate of anastomotic leakage (10.9% versus 7.4%; P = 0.001). In multivariable analysis, neither technique was an independent predictor of CRM+ (odds ratio (OR) 0.99; 95% confidence interval (c.i.) 0.75 to 1.30; P = 0.925). For secondary outcomes robotic-assisted laparoscopic surgery reduced the risk of conversion to open surgery (OR 0.51; 95% c.i. 0.41 to 0.63; P < 0.001), but resulted in fewer complete TME specimens (OR 0.66; 95% c.i. 0.52 to 0.83; P < 0.001).ConclusionNo short-term oncological advantage in terms of radial margin positivity was demonstrated between the two techniques. Findings regarding conversion rates, TME specimen quality, and anastomotic leakage warrant further investigation.

Surgeons’ Perceptions and Injuries During and After Urologic Laparoscopic Surgery

This study aims to implement a set of wearable technologies to record and analyze the surgeon's physiological and ergonomic parameters during the performance of conventional and robotic-assisted laparoscopic surgery, comparing the ergonomics and stress levels of surgeons during surgical procedures. This study was organized in two different settings: simulator tasks and experimental model surgical procedures. The participating surgeons performed the tasks and surgical procedures in both laparoscopic and robotic-assisted surgery in a randomized fashion. Different wearable technologies were used to record the surgeons' posture, muscle activity, electrodermal activity and electrocardiography signal during the surgical practice. The simulator study involved six surgeons: three experienced (>100 laparoscopic procedures performed; 36.33 ± 13.65 years old) and three novices (<100 laparoscopic procedures; 29.33 ± 8.39 years old). Three surgeons of different surgical specialties with experience in laparoscopic surgery (>100 laparoscopic procedures performed; 37.00 ± 5.29 years old), but without experience in surgical robotics, participated in the experimental model study. The participating surgeons showed an increased level of stress during the robotic-assisted surgical procedures. Overall, improved surgeon posture was obtained during robotic-assisted surgery, with a reduction in localized muscle fatigue. A set of wearable technologies was implemented to measure and analyze surgeon physiological and ergonomic parameters. Robotic-assisted procedures showed better ergonomic outcomes for the surgeon compared to conventional laparoscopic surgery. Ergonomic analysis allows us to optimize surgeon performance and improve surgical training.