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Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Robot‐assisted (RA) procedures are increasingly being performed as minimally invasive surgical approaches. RA radical cystectomy (RARC) has the advantages of decreased blood loss, decreased time to flatus, decreased time to bowel movement and decreased analgesic use compared with open RC. Positive surgical margin rates and lymph node yields are similar to open RC. RARC was suggested to have the advantage of having fewer complications compared with open RC. To date, very few authors have reported their experience with totally intracorporeal RARC including the urinary diversion. This case series of totally intracorporeal RARC including the urinary diversion reports the operative and postoperative variables, pathological variables, complications, oncological outcomes, functional outcomes and the feasibility of these complex procedures. Advantages of using the surgical robot enable the console surgeon to preserve the neurovascular bundles with excellent surgical oncological safety. Outcomes of the present series suggest that RARC seems to have excellent short‐term surgical and pathological outcomes and satisfactory functional results. Additionally, performing the whole procedure totally intracorporeally might lead to decreased insensible fluid loss from the bowels, which might also prevent development of electrolyte imbalance resulting in earlier bowel function recovery. Additional advantages of this approach include decreased wound infection and dehiscence, better wound healing and better cosmesis. OBJECTIVE To report the outcomes of 27 patients whom we performed robot‐assisted radical cystoprostatectomy and cystectomy (RARC) with intracorporeal urinary diversion (Studer pouch and ileal conduit) for bladder cancer. PATIENTS AND METHODS Between December 2009 and December 2010, we performed RARC in 25 men (intrafascial bilateral [22], unilateral [one], non‐neurovascular bundle [NVB] sparing [two]), NVB‐sparing RARC with anterior pelvic exenteration in two women, bilateral extended robot‐assisted pelvic lymph node dissection (RAPLND) (25), intracorporeal Studer pouch (23), ileal conduit (two), and extracorporeal Studer pouch (two) construction. Patient demographics, operative and postoperative variables, pathological variables, complications (according to modified Clavien system) and functional outcomes were evaluated. RESULTS The mean (sd, range) operative duration, intraoperative estimated blood loss and mean lymph node (LN) yield were 9.9 (1.4, 7.1–12.4) h, 429 (257, 100–1200) mL and 24.8 (9.2, 8–46), respectively. The mean (sd, range) hospital stay was 10.5 (6.8, 7–36) days, there was one perioperative death (3.7%), lodge drains were removed at a mean of 11.3 (5.6, 9–35) days and surgical margins were negative in all but one patient who had pT4b disease. The postoperative pathological stages were: pT0 (five), pTis (one), pT1 (one), pT2a (five), pT2b (three), pT3a (six), pT3b (two), pT4a (three) and ...

To compare the perioperative outcomes of intracorporeal (ICUD) vs extracorporeal urinary diversion (ECUD) after robotassisted radical cystectomy (RARC). Patients and MethodsWe retrospectively reviewed the prospectively maintained International Robotic Cystectomy Consortium (IRCC) database. A total of 972 patients from 28 institutions who underwent RARC were included. Propensity score matching was used to match patients based on age, gender, body mass index (BMI), American Society of Anesthesiologists Score (ASA) score, Charlson Comorbidity Index (CCI) score, prior radiation and abdominal surgery, receipt of neoadjuvant chemotherapy, and clinical staging. Matched cohorts were compared. Multivariate stepwise logistic and linear regression models were fit to evaluate variables associated with receiving ICUD, operating time, 90-day high-grade complications (Clavien-Dindo Classification Grade ≥III), and 90-day readmissions after RARC. ResultsUtilisation of ICUD increased from 0% in 2005 to 95% in 2018. The ICUD patients had more overall complications (66% vs 58%, P = 0.01) and readmissions (27% vs 17%, P = 0.01), but not high-grade complications (21% vs 24%, P = 0.22). A more recent RC era and ileal conduit diversion were associated with receiving an ICUD. Higher BMI, ASA score ≥3, and

Laparoscopic ureteral reimplantation is an effective procedure with good medium-term results. We believe that this procedure will become an established treatment option.

One proposed solution is to use artificial intelligence (AI)-based detection systems.With the help of machine learning, classification algorithms can be trained to predict results and outcomes, provided that enough training data are available. In 2017, we at the National Cancer Institute [7] proposed an AI system based on intensity and texture analysis and a random forest classification algorithm. This system was validated in a large multireader multicenter study in 2018 [8]. Results of that study revealed an increase in detection of transition zone lesions among moderately experienced readers only. Overall, however, the AI system was equivalent to conventional MRI interpretation [8]. In that study, color-coded prediction maps were used to draw attention to AI-detected lesions. Feedback from the study suggested that prediction maps compromised the interaction between the radiologists and the AI system with resultant decreased accuracy for some readers. To address this issue a new AI detection system with more expert annotated

Background and Objectives:To compare open versus totally intracorporeal robotic-assisted radical cystectomy, bilateral extended pelvic lymph node dissection, and Studer urinary diversion in bladder cancer patients.Methods:A retrospective comparison of open (n = 42) versus totally intracorporeal (n = 32) robotic-assisted radical cystectomy, bilateral extended pelvic lymph node dissection, and Studer urinary diversion was performed concerning patient demographic data, operative and postoperative parameters, pathologic parameters, complications, and functional outcomes.Results:Patient demographic data and the percentages of patients with pT2 disease or lower and pT3–pT4 disease were similar between groups (P > .05). Positive surgical margin rates were similar between the open (n = 1, 2.4%) and robotic (n = 2, 6.3%) groups (P > .05). Minor and major complication rates were similar between groups (P > .05). Mean estimated blood loss was significantly lower in the robotic group (412.5 ± 208.3 mL vs 1314.3 ± 987.1 mL, P < .001). Significantly higher percentages of patients were detected in the robotic group regarding bilateral neurovascular bundle–sparing surgery (93.7% vs 64.3%, P = .004) and bilateral extended pelvic lymph node dissection (100% vs 71.4%, P = .001). The mean lymph node yield was significantly higher in the robotic group (25.4 ± 9.7 vs 17.2 ± 13.5, P = .005). The number of postoperative readmissions for minor complications was significantly lower in the robotic group (0 vs 7, P = .017). Better trends were detected in the robotic group concerning daytime continence with no pad use (84.6% vs 75%, P > .05) and severe daytime incontinence (8.3% vs 16.6%, P > .05). No significant differences were detected regarding postoperative mean International Index of Erectile Function scores between groups (P > .05).Conclusions:Robotic surgery has the advantages of decreased blood loss, better preservation of neurovascular bundles, an increased lymph node yield, a decreased rate of hospital readmissions for minor complications, and a better trend for improved daytime continence when compared with the open approach.

BackgroundRobot-assisted radical cystectomy (RARC) with intracorporeal diversion has been shown to be feasible in a few centers of excellence worldwide, with promising functional and oncologic outcomes. However, it remains unknown whether the complexity of the procedure allows its duplication in other non-pioneer centers. We attempt to address this issue by presenting our cumulative experience with RARC and intracorporeal neobladder formation.MethodsWe retrospectively identified 62 RARCs in 50 men and 12 women (mean age 63.6 years) in two tertiary centers. Intracorporeal Studer neobladders were created, duplicating the steps of standard open surgery. Perioperative and postoperative variables and complications were analyzed using standardized tools. Functional and oncological results were assessed.ResultsThe mean operative time was 476.9 min (range, 310 to 690) and blood loss was 385 ml (200 to 800). The mean hospital stay was 16.7 (12 to 62) days with no open conversion. Perioperative complications were grade II in 15, grade III in 11, and grade IV in 5 patients. The mean nodal yield was 22.9 (8 to 46). Positive margins were found in in 6.4%. The 90- and 180-day mortality rates were 0% and 3.3%. The average follow-up was 37.3 months (3 to 52). Continence was achieved in 88% of patients. The cancer-specific survival rate and overall survival rate were 84% and 71%, respectively.ConclusionsA RARC with intracorporeal neobladder creation is safe and reproducible in ‘non-pioneer’ tertiary centers with robotic expertise with acceptable operative time and complications. Further standardization of RARC with intracorporeal diversion is a prerequisite for its widespread use.

Introduction: This article sets out to be a review regarding agents that affect contraction and relaxation of the ureter in order to establish a basis for current and future treatments for upper urinary tract obstruction. Material and Methods: A complete review of the English literature using MEDLINE was performed between 1960 and 2007 on ureter physiology and pharmacology with special emphasis on signal transduction mechanisms involved in the contractile regulation of the human ureter. Results: Activation of muscarinic and adrenergic receptors increases the amplitude of ureteral contractions. The sympathetic nerves modulate the contractions by α-adrenoceptors and relaxation by β-adrenoceptors. The purinergic system is important in sensory/motor functions and ATP is an important non-adrenergic non-cholinergic (NANC) agent causing contraction. Nitric oxide (NO) is a major inhibitory NANC neurotransmitter causing relaxation. Serotonin causes contraction. Prostaglandin-F₂α contracts whereas prostaglandin-E₁/E₂ relaxes the ureter. Phosphodiesterases (PDE) and the Rho-kinase pathway have recently been identified in the human ureter. PDE-IV inhibitors, K⁺ channel openers, calcium antagonists, α₁-adrenoceptor antagonists and NO donors seem to be promising drugs in relieving obstruction and facilitating stone passage. Conclusions: Further understanding of the ureteral function and pharmacology may lead to the discovery of promising new drugs that could be useful in relieving ureteral colic, facilitating spontaneous stone passage, preparing the ureter for ureteroscopy as well as acting adjunctive to extracorporeal shock-wave lithotripsy.