Urology Section Research Articles

Operative outcomes 24 hours after retrograde intrarenal surgery for solitary renal calculi using a flexible and navigable suction ureteral access sheath. A prospective global multicenter study by the European Association of Urology Section on Urolithiasis.

Suction techniques showed potential to improve outcomes of retrograde intra-renal surgery (RIRS). We assessed the 24-hour stone-free rate (SFR) and complications after RIRS using flexible and navigable suction ureteral access sheaths (FANS-UAS). Sixteen centers prospectively contributed to data (August 2023-October 2023). Inclusion criteria: age ≥18 years, single renal stone, pre and 24-hour post-RIRS CT scan. Exclusion criteria were: ureteral stone, anomalous kidney, multiple stones. SFR was divided into: 1) grade A - no fragments; 2) grade B - fragments ≤2 mm; 3) grade C - fragments 2.1-4 mm; and 4) grade D - fragments >4 mm. A multivariable logistic regression analysis model was performed to assess factors associated with the odds of having grade A stone-free status. Data are expressed as median (interquartile range), absolute numbers and frequencies, odds ratio (OR), and 95% confidence interval (CI). One hundred forty-two patients with a median age of 52 years (40-61) were enrolled. 61.3% were males. Median stone volume was 1165 mm3 (656-1936). Median operative time was 48.5 (36.25-71.75) min. Transient fever (37°C-37.5°C) occurred in 10 (7%) patients. No sepsis case occurred. 96.5% of patients were stone-free (Grade A+B). Grade A SFR was 52.8%. All patients were discharged within 48 hours. Bone window (OR 3.156 95% CI 1.177-9.130, P=0.027) was the only factor significantly associated with higher odds of 100% SFR, while stone volume (OR 0.999, 95% CI 0.999-1.000, P=0.007) was significantly associated with lower odds. Imaging and clinical evidence demonstrate excellent perioperative outcomes just 24 hours post RIRS with FANS-UAS. The technique demonstrates a good safety profile, ability for immediate high SFR, and a low rate of infective complications.

VJY33 Surgical technique, perioperative and postoperative outcomes of robot-assisted radical cystectomy with HugoTM RAS robotic platform: First case series by the European Association of Urology Robotic Urology Section Scientific Working Group

VJY33 Surgical technique, perioperative and postoperative outcomes of robot-assisted radical cystectomy with HugoTM RAS robotic platform: First case series by the European Association of Urology Robotic Urology Section Scientific Working Group

British Association of Urological Surgeons (BAUS) consensus document for the management of benign female urethral lesions.

To provide a consensus document for the management of benign female urethral lesions. The British Association of Urological Surgeons (BAUS) Female, Neurological and Urodynamic Urology (FNUU) Section created a consensus document to guide the management of the commonest of urethral swellings using expert consensus with a modified Delphi technique. Benign urethral lesions in females can include urethral mucosal prolapse, urethral caruncle, Skene's gland cysts and urethral diverticulum. They can present in a variety of ways including haematuria, lower urinary tract symptoms and voiding dysfunction, and can initially be overlooked or not recognised, resulting in delayed management. This consensus statement led by the FNUU Section of the BAUS, in consultation with BAUS members and consultants working in units throughout the UK, aimed to create a comprehensive and pragmatic management pathway for the assessment, investigation and treatment of benign urethral lesions in females.

Foley catheter after ureteroscopy and JJ stent placement: a randomised prospective European Association of Urology Section of Urolithiasis-Young Academic Urologists (EULIS-YAU) endourology study.

To evaluate the effects of inserting a Foley catheter after ureteroscopy (URS) and JJ stent placement on pain scores, voiding patterns, biochemical parameters and postoperative complications. A randomised clinical trial (1:1) with adult patients following unilateral URS + JJ stent placement was planned. In Group A, no Foley catheter was placed, in Group B, a Foley catheter was placed following URS + JJ stent placement. The primary objective was to evaluate effect of placing a Foley catheter on International Prostate Symptom Score (IPSS), Ureteric Stent Symptom Questionnaire (USSQ) score and postoperative biochemical parameters. The secondary objective was to evaluate postoperative complications. A total of 112 patients were included (56/group). A ureteric access sheath was used in each patient. Patients had similar demographic and surgical parameters. The pre- and postoperative biochemical analyses including white blood cell count, C-reactive protein, procalcitonin and creatinine levels were similar between the two groups. The IPSS were similar between the two groups. All the subdomains of the USSQ were similar between two groups except Total Body Pain score, which was lower in Group B. The visual analogue scale scores were similar. Complications were all Clavien-Dindo Grade I and II, and the complication rate was 5.4% and 8.9% in Group A and B, respectively. Placing a Foley catheter following URS + JJ stent placement did not show significant effects on postoperative biochemical parameters and voiding symptoms. However, a Foley catheter lowered the Total Body Pain score on the USSQ without having significant effects on VAS scores. The practice of placing a Foley catheter following URS and JJ stent placement should be based on surgeon's preference keeping in mind the potential positive effect on pain scores.

CT-Based Predictors of Spontaneous Ureteral Stone Passage.

To assess CT-scan based parameters, particularly ureteral wall thickness (UWT), in predicting spontaneous ureteral stone passage. Cross-sectional, analytical study. Place and Duration of the Study: Section of Urology, Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from June to November 2023. Patients with symptomatic, single, radio-opaque, unilateral ureteral stones having size ≤10 mm with normal kidney functions, diagnosed by non-contrast CT-scan KUB, and treated by conservative option for four weeks were enrolled. Clinical and radiological predictors for stone passage (SP), including stone size, area, laterality, location, density, degree of hydronephrosis, maximal UWT at the stone site, and ureteral diameter and density above and below the stone, were evaluated. Binary logistic regression analysis was employed to identify predictors of stone passage. Receiver operating characteristic (ROC) curve was used to find the optimal cut-off for UWT. Among 34 eligible patients, 22 (64.7%) passed their stones spontaneously. Patients who passed had smaller stone size and area and lesser UWT. Stone location, laterality, degree of hydronephrosis, stone density, ureteral wall diameter, and density above and below stones were not associated with SP. Multivariate analysis revealed maximum UWT as the independent predictor of SP, with a cut-off of 1.95 mm and an accuracy of 0.94. UWT was the single most convincing factor for the spontaneous passage of ureteral stone in this study. By applying UWT's optimal cut-off value, it might be an extremely significant tool when taking decisions in daily practice. Ureteral wall thickness, Medical expulsive therapy, Non-contrast computed tomography.

Overactive Bladder (OAB) Symptoms in Patients Undergoing Flexible Cystoscopy.

The objective is to measure the change in overactive bladder (OAB) symptoms in patients undergoing flexible cystoscopy in the early postoperative period using a validated OAB-V8 tool. It was a prospective, cross-sectional, observational study conducted by a section of Urology at the Aga Khan University Hospital, Karachi. The total duration of the study was 12 months (July 2022 to June 2023). All adult patients who underwent flexible cystoscopy under local anesthesia for diagnostic and surveillance purposes were included in the study. OAB symptoms were evaluated using the validated eight-item OAB-V8 tool just before the cystoscopy and on postoperative days 1 and 4. Patients were categorized as either OAB-negative (<8) or OAB-positive (≥8) based on their sum scores. Mean sum scores of different variables and OAB subdomains were assessed. Sixty-three patients were included in the final analysis with a predominantly male population. The mean pre-cystoscopy (screen) score was 7.46 + 5.58, which increased to 9.89 + 6.82 on day 1 (p<0.01) before decreasing back to 7.68 + 5.7 on day 4 (p=0.08). Twenty-one patients (33.3%) were labeled OAB positive on day 0. Following cystoscopy, this number increased to 32 patients (50.8%) as 11 patients (26.2 %) developed de-novo OAB symptoms. The sub-group analysis showed an insignificant impact of age (p=0.5), gender (p=0.51), indication (p=0.22), and use of alpha-blocker (p= 0.30) on change in OAB score. OAB symptoms are frequently encountered in patients undergoing awake (flexible) cystoscopy. This procedure can also trigger de novo OAB symptoms, albeit transiently, which typically resolve over time. This information could help in patient counseling, management, and the need for intervention in the future.

British Association of Urological Surgeons Consensus statements on the management of ketamine uropathy.

To provide guidance in the form of consensus statement in the management of ketamine uropathy. A literature review of ketamine uropathy was performed. The consensus method was of a modified nominal group technique and has been use in the previous British Association of Urological Surgeons (BAUS) consensus documents and was led by the Female, Neurological and Urodynamic Urology Section of the BAUS. A number of consensus statements detailing the assessment and management of urological complications relate to the recreational use of ketamine (ketamine uropathy) in both elective and emergency urology settings. Comprehensive management pathway for ketamine-related urinary tract dysfunction and uropathy has been detailed.

The ERUS course on robot-assisted kidney transplantation

PurposeRobot-assisted kidney transplantation (RAKT) is being increasingly performed at selected referral institutions worldwide. Yet, surgical training in RAKT is still unstructured and not grounded into formal credentialing courses including simulation, lab facilities, and modular training with animal models. As such, developing standardized, modular training programs is warranted to provide surgeons with the RAKT-specific skillset needed for a “safe” learning curve.MethodsThe 3-day course on RAKT developed at the EAU Skills Center in Orsi Academy was designed as a standardized, modular, step-by-step approach aiming to provide theoretical and practical skills. The course is held by expert proctors with extensive experience in RAKT. To maximize the course’s usefulness, a solid knowledge of robotics and transplantation is desirable for participants.ResultsFrom January 2016 to July 2023, 87 surgeons from 23 countries (of which 36% from extra-European countries) participated in the RAKT course performed at the EAU Skills Center in Orsi Academy. Of these, 58/87 (67%) were urologists, while 27/87 (31%) were general surgeons and 2/87 (2%) were vascular surgeons. To date, 18 participants (20.6%) are actively involved in RAKT programs at institutions included in the European Association of Urology (EAU) Robotic Urology Section (ERUS)–RAKT network.ConclusionLeveraging the potential of simulation, wet-lab training, live porcine models, and experienced proctors, the RAKT course performed at the EAU Skills Center in Orsi Academy represents the first structured teaching effort aiming to offer surgeons a full immersion in RAKT to train the core technical skills.

Robotic kidney transplantation.

Kidney transplantation is the best treatment option for patients with end-stage renal disease owing to improved survival and quality of life compared with dialysis. The surgical approach to kidney transplantation has been somewhat stagnant in the past 50 years, with the open approach being the only available option. In this scenario, evidence of reduced surgery-related morbidity after the introduction of robotics into several surgical fields has induced surgeons to consider robot-assisted kidney transplantation (RAKT) as an alternative approach to these fragile and immunocompromised patients. Since 2014, when the RAKT technique was standardized thanks to the pioneering collaboration between the Vattikuti Urology Institute and the Medanta hospital (Vattikuti Urology Institute-Medanta), several centres worldwide implemented RAKT programmes, providing interesting results regarding the safety and feasibility of this procedure. However, RAKT is still considered an alternative procedure to be offered mainly in the living donor setting, owing to various possible drawbacks such as prolonged rewarming time, demanding learning curve, and difficulties in carrying out this procedure in challenging scenarios (such as patientswith obesity, severe atherosclerosis of the iliac vessels, deceased donor setting, or paediatric recipients). Nevertheless, the refinement of robotic platforms through the implementation of novel technologies as well as the encouraging results from multicentre collaborations under the umbrella of the European Association of Urology Robotic Urology Section are currently expanding the boundaries of RAKT, making this surgical procedure a real alternative to the open approach.

Worldwide variations in the knowledge and use of fluoroscopy during percutaneous nephrolithotomy—should we do better? A survey by the European Association of Urology Section for Uro-Technology and the International Alliance of Urolithiasis

ObjectiveThis study aimed to investigate the level of knowledge among urologist of usage of fluoroscopy during percutaneous nephrolithotomy. MethodsWe conducted an anonymous internet-based survey addressed to ESUT/IAU members with particular interest in stone treatment at all levels of expertise. The final version of the questionnaire included 30 questions, evaluated the level of knowledge on X-rays utilization and exposure, and identified correlations between geographic areas, levels of seniority, surgical volumes, and awareness on radiation protection. ResultsIn total, 586 respondents were included. Knowledge of fluoroscopy settings appeared low, particularly among trainees (up to 87.5% were uninformed, p=0.008). Precautions to reduce exposure appeared poorly followed as up to 25.4% of respondents would regularly use continuous fluoroscopy, and up to 20.5% used regularly high-frequency setting and this trend was more obvious among senior specialists (6.2% of trainees use high-frequency settings vs. 21.3% of consultants, p<0.05). Additionally, only 24.9% of respondents would provide X-ray protection to patients too. ConclusionAlthough high and routinary utilization of X-ray, the level of awareness and adhesion to “as low as reasonably achievable” principles among endourologists seems suboptimal in 65.0% of all respondents. Highest volume surgeons, inevitably at higher risk, do not seem to adopt more precautions. More efforts should be addressed to improve these results, reducing the risk related to excessive radiation exposure for both surgical staff and patients in order to minimize health related issues.

The birth of pediatric urology in the United States: From pioneers to subcertification

Pediatric urology is a subspecialty of urology that emerged from a culture in which children with urological disorders were cared for by general urologists and general pediatric surgeons. The development of pediatric urology as a subspecialty was years in the making, highlighted by individuals who recognized that children with urological conditions were not just "small adults," but required special experience and training. Subspecialization was initiated by persistent visionaries who recognized the need for a trained cadre of experts to provide better care for children. It took the coordinated effort of all subgroups and leaderships in pediatric urology to push these efforts over the goal line. The focus of this review is to highlight certain individuals who played major roles in this vision and to document the efforts of many to coordinate the pathways to sub-specialization. The careers of Meredith F. Campbell and Frank B. Bicknell were researched to identify their rationale and roles in developing pediatric urology as a distinct medical specialty in the United States. In addition, the minutes of the meetings of the Pediatric Urology Advisory Council (PUAC) with the American Board of Urology (ABU) were reviewed. The origins of the Society for Pediatric Urology (SPU) and the American Academy of Pediatrics Section of Urology (AAP-SOU) were researched. The contributions of each to the certification of pediatric urology as a distinct subspecialty was delineated. Campbell was Chair of Urology at the New York University (NYU) School of Medicine and wrote prolifically about pediatric urology. He published one of the first practical textbooks in pediatric urology, almost completely self-written, in 1937. Bicknell, a general urologist in Michigan on the faculty at Wayne State University School of Medicine, led the initiative to create the Society for Pediatric Urology (SPU) that first met at the 1951 annual American Urological Association (AUA) meeting in Chicago and included nine attendees. Subsequently, John Lattimer (College of Physicians and Surgeons at Columbia University) organized a well-attended meeting of urologists interested in pediatrics at the 1964 annual AAP meeting in New York City. This led to the formation of the AAP Section on Urology. Integral to the justification for the development of a subspecialty was evidence of a published corpus of content. In addition to published textbooks devoted exclusively to pediatric urology, this was further fulfilled by the AAP Section on Urology Pediatric Supplement to the Journal of Urology, first published in 1986, and later with the Journal of Pediatric Urology in 2005. The SPU and the AAP Section on Urology came together to form the Pediatric Urology Advisory Council (PUAC) in 2000, which worked with the ABU to create subspecialty certification in pediatric urology with an independent exam, first administered in 2008 to 176 applicants. The metaphor "We have stood on the shoulders of giants" is apt for pediatric urology: Meredith Campbell, Frank Bicknell, David Innes Williams (Hospital for Sick Children, London), and J. Herbert Johnston (Alder Hay Hospital, Liverpool) come to mind among the first generation of pediatric urology pioneers, and others among their colleagues also had significant impact. Clearly this is a story of persistence and attention to detail on the part of those giants and those who followed. Pediatric urology became a distinct discipline after the SPU and AAP-SOU came together to create a robust cohort of pediatric urologists who through education and negotiation were able to help the ABU and the American Board of Medical Specialties (ABMS) recognize that subspecialization would lead to better care for children with urologic disorders. This benchmark set a high bar for future subspecialization in urology and other fields.

Assessing the Impact of Positive Surgical Margins on Mortality in Patients Who Underwent Robotic Radical Prostatectomy: 20 Years’ Report from the EAU Robotic Urology Section Scientific Working Group

BackgroundPositive surgical margins (PSMs) are frequent in patients undergoing radical prostatectomy (RP). The impact of PSMs on cancer-specific (CSM) and overall (OM) mortality has not yet been proved definitively. ObjectiveTo evaluate whether the presence and the features of PSMs were associated with CSM and OM in patients who underwent robotic-assisted RP. Design, setting, and participantsA cohort of 8141 patients underwent robotic-assisted RP with >10 yr of follow-up. Outcome measurements and statistical analysisCox multivariable analyses assessed the impact of margin status (positive vs negative) and PSM features (negative vs <3 mm vs >3 mm vs multifocal) on the risk of CSM, OM, and biochemical recurrence (BCR) after adjusting for potential confounders. We repeated our analyses after stratifying patients according to clinical (Cancer of the Prostate Risk Assessment [CAPRA] categories) and pathological characteristics (adverse: pT 3–4 and/or grade group [GG] 4–5 and/or pN1 and/or prostate-specific antigen [PSA] persistence). Results and limitationsPSMs were found in 1348 patients (16%). Among these, 48 (3.6%) patients had multifocal PSMs. Overall, 1550 men experienced BCR and 898 men died, including 130 for prostate cancer. At Cox multivariable analyses, PSMs were associated with CSM in patients with adverse clinical (Intermediate risk: hazard ratio [HR]: 1.71, p = 0.048; high risk: HR: 2.20, p = 0.009) and pathological (HR: 1.79, p = 0.005) characteristics. Only multifocal PSMs were associated with CSM and OM in the whole population (HR for CSM: 4.68, p < 0.001; HR for OM: 1.82, p = 0.037) and in patients with adverse clinical (intermediate risk: HR for CSM: 7.26, p = 0.006; high risk: HR for CSM: 9.26, p < 0.001; HR for OM: 2.97, p = 0.006) and pathological (HR for CSM: 9.50, p < 0.001; HR for OM: 2.59, p = 0.001) characteristics. Potential limitations include a selection bias and a lack of information on the Gleason score at PSM location. ConclusionsWe did not find an association between unifocal PSMs and mortality. Conversely, our results underscore the importance of avoiding multifocal PSMs in patients with adverse clinical (intermediate- and high-risk CAPRA score) and pathological (GG ≥4, pT ≥3, pN1, or PSA persistence) characteristics, to enhance overall survival and reduce CSM. Patient summaryIn this study, we evaluated whether the presence and the characteristics of positive surgical margins were associated with mortality in patients who underwent robotic-assisted radical prostatectomy. We found that the presence of positive surgical margins, particularly multifocal margins, was associated with mortality only in patients with adverse clinical and pathological characteristics.

PE090 - Postoperative complications following robotic-assisted radical cystectomy with intracorporeal neobladder reconstruction. report from the EAU Robotic Urology Section (ERUS) Scientific Working Group

PE090 - Postoperative complications following robotic-assisted radical cystectomy with intracorporeal neobladder reconstruction. report from the EAU Robotic Urology Section (ERUS) Scientific Working Group

PE020 - The impact of positive surgical margins on long term survival after robot assisted radical prostatectomy: 20 years’ report from the EAU Robotic Urology Section (ERUS) Scientific Working Group

PE020 - The impact of positive surgical margins on long term survival after robot assisted radical prostatectomy: 20 years’ report from the EAU Robotic Urology Section (ERUS) Scientific Working Group

Prostate Cancer–specific and All-cause Mortality After Robot-assisted Radical Prostatectomy: 20 Years’ Report from the European Association of Urology Robotic Urology Section Scientific Working Group

BackgroundEvidence on long-term oncological efficacy is available only for open radical prostatectomy but remains scarce for robot-assisted radical prostatectomy (RARP). ObjectiveTo validate the long-term survival rates after RARP and provide stratified outcomes based on contemporary prostate cancer (PCa) risk-stratification tools. Design, setting, and participantsA retrospective analysis of the European Association of Urology (EAU) Robotic Urology Section Scientific Working Group international multicenter database for RARP was performed. Patients who underwent RARP at seven pioneer robotic urology programs in Europe and the USA between 2002 and 2012 were included. Outcome measurements and statistical analysisThe primary outcomes were PCa-specific mortality and all-cause mortality. The probability of cancer-specific survival (CSS) was estimated with the competing risks method, and the probability of overall survival (OS) was estimated with the Kaplan-Meier method. Results and limitationsA total of 9876 patients who underwent RARP between 2002 and 2012 were included. Within follow-up, 1071 deaths occurred and 159 were due to PCa. At 15 yr of follow-up, CSS and OS were 97.6% (97.2%, 98.0%) and 85.5% (84.6%, 86.4%), respectively. Stratified analyses based on EAU risk groups at diagnosis and pT stage showed favorable survival rates, with low-risk (n = 4601, 46.6%), intermediate-risk (n = 4056, 41.1%), and high-risk (n = 1219, 12.3%) patients demonstrating CSS rates of 99%, 98%, and 90% at 15 yr, respectively. Notably, patients with pT3a disease had similar survival outcomes to those with pT2 disease, with worse CSS in patients with pT3b PCa (98.9% vs 97.4% vs 86.5%). Multivariable analyses identified age, prostate-specific antigen, biopsy Gleason grade group, clinical T stage, and treatment year as independent predictors of worse oncological outcomes. ConclusionsOur multicenter study with long-term follow-up confirms favorable survival outcomes after RARP for localized PCa. Patients with low- and intermediate-risk disease face a higher risk of mortality from causes other than PCa. On the contrary, high-risk patients have a significantly higher risk of PCa-specific mortality. Patient summaryIn the present study, we reported the outcomes of patients with prostate cancer (PCa) who underwent robot-assisted radical prostatectomy between 10 and 20 yr ago, and we found a very low probability of dying from PCa in patients with low- and intermediate-risk PCa.

PE014 - Robotic approach to the distal ureter in Children: A survey from the European Association of Urology Robotic Urology Section Working Group for Reconstructive Urology

PE014 - Robotic approach to the distal ureter in Children: A survey from the European Association of Urology Robotic Urology Section Working Group for Reconstructive Urology

PE028 - Prostate cancer specific and all-cause mortality after robot-assisted radical prostatectomy: 20 years’ report from the EAU Robotic Urology Section (ERUS) Scientific Working Group

PE028 - Prostate cancer specific and all-cause mortality after robot-assisted radical prostatectomy: 20 years’ report from the EAU Robotic Urology Section (ERUS) Scientific Working Group

Concomitant Introduction of New Robotic Systems (Hugo RAS and Versius) at a Single Center: Analysis of First Clinical Cases of Radical Prostatectomy by a Single Surgeon

Abstract Introduction: Radical prostatectomy is a standard option for clinically localized prostate cancer. The first robot-assisted radical prostatectomy (RARP) was performed in 2001 with the DaVinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA); after 2 decades from the first procedure and the expiry of the patents, new systems are entering the market to improve the existing technology and increase the whole accessibility to robotic surgery. Currently, a face-to-face comparison of systems is still unavailable. The aim of the study was to report the first case of concomitant introduction of new systems—Hugo robot-assisted surgery (RAS) and Versius surgical system—at a single center already equipped with a Da Vinci. Methods: This is a prospective study that analyzes the first cases performed with the Hugo RAS and Cambridge Medical Robotics Versius for RARP at a single center. Three patients with clinical organ-confined prostate cancer were selected to receive a Hugo RAS, a CMR Versius, or a DaVinci—as standard reference—radical prostatectomy. All procedures were recorded, and videos were reviewed by internal and external reviewers. RARP was evaluated according to the definition of metric errors and critical errors (Mottrie et al, BJU 2020) (See Supplemental Data, http://links.lww.com/JU9/A20). The primary end point is to evaluate the safety of novel systems; outcome measure is the absence of critical errors or intraoperative adverse events. Results: Surgical procedures were fully completed with all robotic systems. No intraoperative adverse events occurred, nor surgical errors classified as “critical” according to the European Association of Urology Robotic Urology Section metric system. None of the metric error nor technological issues were clinically significant to invoke a change in surgical strategy. Conclusions: This is the first analysis of concomitant introduction of new robotic systems at a single institution. Even if the shift from one model to another is expected to pose some challenges for surgeons, RARP is feasible with HugoRAS and Versius systems by an already experienced surgeon with the Da Vinci. A proper structured training is mandatory; the impact of prior console expertise is unknown and still unmeasured, but is expected to have significance. The current clinical experience supports the feasibility of the implementation of a new surgical system into surgical practice; however, further studies are required to evaluate outcomes in an unselected cohort.

Teaching robotic cystectomy: prospective pilot clinical validation of the ERUS training curriculum.

To provide the first clinical validation of the European Association of Urology Robotic Urology Section (ERUS) curriculum for training in robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC). The ERUS proposed a structured curriculum, divided into 11 steps, to train novice surgeons and help overcome the steep learning curve associated with iRARC. In this study, one trainee completed the curriculum under the mentorship of an expert. Twenty-one patients were operated on by the trainee following the proposed iRARC curriculum [(t)iRARC group] and were compared with 42 patients treated with the standard of care by the mentor [(m)iRARC group]. To evaluate curriculum safety, peri-operative outcomes, surgical margins and complications were assessed. Propensity-score matching (1:2) was used to identify comparable (t)iRARC and (m)iRARC cases. Matched variables included age, body mass index, neoadjuvant therapy, American Society of Anesthesiologists score and cT stage. Mann-Whitney and chi-squared tests were used to compare peri- and postoperative outcomes between the two cohorts. To evaluate curriculum efficacy, steps attempted and completed by the trainee were assessed and studied as a function of growing surgical experience of the trainee. The trainee progressed in proficiency-based training through steps of increasing difficulty. No differences in estimated blood loss, positive soft tissue margins, number of resected lymph nodes, overall and high-grade complications, or 90-day readmissions between the (t)iRARC and (m)iRARC groups were observed (all P> 0.05). However, operating time was significantly longer in the (t)iRARC group (P= 0.01). Of the 209 available steps, the trainee attempted 168 (80%) and successfully performed 125 (60%). Increasing experience was associated with more steps being successfully performed (P< 0.001). The proposed ERUS curriculum assists naïve surgeons during the learning curve for iRARC and should be encouraged in order to guarantee optimal outcomes during the learning phase of this procedure.

Does kidney side matters in Robot-Assisted Kidney Transplantation (RAKT) from living donors? Insights from the European Robotic Urology Section (ERUS) RAKT working group

Does kidney side matters in Robot-Assisted Kidney Transplantation (RAKT) from living donors? Insights from the European Robotic Urology Section (ERUS) RAKT working group