Panagiotis Mourmouris

The adoption of robotic platform was mainly driven by its ability to overcome the inherited limitations of conventional laparoscopy. Articulated instruments, elimination of hand tremors both enhanced with 3D vision improved ergonomics and introduced robot assisted laparoscopy mainly to prostate and renal surgery. The foundations for the next implosion have been placed: nowadays the question is no longer whether robotic surgeons can perform an even complex procedure, but whether they can invent better surgical strategies. The contemporary robotic surgeon is nowadays able to modify established surgical procedures based on patient's specific factors. Retzius sparing approach in robotic radical prostatectomy is a basic example. In their study, Zeng et al, compared Retziussparing and standard robotic radical prostatectomy in 120 patients. They concluded that the modified approach resulted in better early continence rates, maintaining the oncological and perioperative parameters of the procedure. We are aware of the advantages that this outcome can produce: Patients will choose a method that diminishes post-operative troublesome symptoms and enables their early return to their everyday life 1 . The study reinforces one of the basic evolutionary steps of robotic surgery: enhancement of functional maintaining the oncological and surgical outcomes of a surgical procedure.The most striking manifestation of robotic evolution is the progressive expansion of indications towards more complex and demanding procedures. Doganca et al examined the role of PADUS and RENAL nephrometry scores in patients with large renal tumors. Authors concluded that robotic partial nephrectomy can be efficient and safe for tumors more complex than a simple small and exophytic renal mass. They also highlight one possible limitation of conventional anatomical scoring: complexity of renal masses could be underestimated without taking account of multifactorial determinants of the robotic approach 2 . The abovementioned conclusion could open a debate about a possible transitions from static anatomical scores towards multidimensional and personalized risk models incorporating, except from the anatomy, more factors like patient characteristics, surgeons experience, imaging derived features and intraoperative parameters.Perhaps an even more compelling example of the expanding boundaries of robotic surgery is provided by Gu et al and Jia et al who reported the use of the robotic platform for complex procedures like intracorporeal bilateral ileal ureter replacement for highly complex post radiation stricture complicated by uretero-arterial fistula and ileocystoplasty for bladder augmentation [3][4] . As one can understand, these procedures are two of the most complex procedures in urological practice that require sophisticated reconstructive steps, involving precise dissection, suturing and tissue handling, demonstrating the significant improvements robotic technology has undergone.The next generation of robotic surgery will increasingly depend on the intraoperative dynamic change of the anatomy rather than relying on surgeon's visual interpretation of solid postoperative images. The work of Sun et al exploring binocular vision guidance in the female pelvis represent an example of the emerging direction 4 . The development of more stable and precise visual navigation systems will surely facilitate accurate localization and manipulation within complex environments that will ultimately result in enhanced postoperative outcomes. Although such technologies remain at an early stage, their implications are substantial. The future operating room is unlikely to consist simply of a surgeon controlling robotic instruments while viewing a conventional endoscopic image. Instead, surgical navigation may increasingly integrate three-dimensional anatomical reconstruction, real-time image interpretation, augmented visualization, and intraoperative guidance. In this context, the robotic platform should be regarded not merely as a mechanical interface but as a potential surgical information platform.One of the most important goals of robotic platform is to improve the postoperative outcomes of a procedure and of course the quality of life of the patient after a major operation. The systematic review by Mourmouris et al provides insights into one of the major factors that decreases quality of life of patients after radical prostatectomy: postoperative indwelling catheterization time. The study of more than 4000 patients concluded that catheter removal on 3 rd or 4 th postoperative day (much earlier than the open procedure) after robotic radical prostatectomy is not only safe but also seems to enhance anastomosis recovery in selected patients 5 . This work illustrates an important point: improved surgical precision achieved by contemporary robotic approach helps surgeon's reconsider established peri and postoperative knowledge, based on individualized patient's characteristics and intraoperative factors.Even though robots are evolving, the role of surgeon remains central and his training remains vital. More sophisticated cockpits in a plane demand a better trained pilot. The traditional training model, based predominantly on observation followed by progressively independent operating, is increasingly complemented by simulation, video analysis, threedimensional anatomical models, structured assessment, and individualized feedback. The commentary by Yang on personalized video feedback for robotic partial nephrectomy training using realistic three-dimensional tumor-kidney models illustrates this transition. Rather than simply reproducing the operating room environment, contemporary training technologies seek to reproduce patient-specific anatomy and provide structured feedback regarding technical performance 6 . This may represent one of the most important developments in robotic surgery. If surgical performance can be recorded, segmented, analyzed,...

Background: Robotic Radical Prostatectomy has become the dominant surgical approach for localized prostate cancer, offering offers many advantages in postoperative recovery and quality of life. Despite these advances, the standard duration of urethral catheterization- typically 7 days- has remained largely unchanged. Objective: To systematically evaluate the feasibility and safety of early urethral catheter removal after robotic radical prostatectomy and to identify the optimal timing for catheter removal. Methods: A systematic review was conducted according to PRISMA guidelines. PubMed, Web of Science, Cochrane Library, Google Scholar and Scopus databases were searched from inception to August 2025. Case reports, non robotic studies and non English publications were excluded Study quality was assessed using the Newcastle-Ottawa Scale for non randomized studies and the Jadad scale for randomized controlled trials. Results: Thirteen studies involving 4.055 patients met inclusion criteria, including three randomized controlled trials. Early catheter removal was variably defined, most commonly between 1 and 4 post operative days. Across studies early removal was not associated with increased rates of anastomotic leakage, urethral stricture or bladder neck contracture. Continence recovery seams to be occur earlier with early removal although higher short term urinary retention rates were reported. Overall complications and readmission rates were low. Study quality was acceptable despite the limited evidence from high quality randomized studies. Conclusions: Early catheter removal after robotic radical prostatectomy appears both safe and feasible in appropriate selected patients and may accelerate continence recovery without compromising long-term outcomes. Catheter removal on postoperative days 3-4 appears to offer the most favora.

Despite the high incidence of bladder cancer (it represents the 7th most common cancer in males), EAU guidelines do not recommend any technique for screening and prevention, whereas the main diagnostic tools remain computed tomography urography (CTU), cytology, and cystoscopy. Unfortunately, these gold-standard modalities are mainly characterized by low sensitivity and accuracy. To minimize the limitations and increase the detection rates of urothelial cancer, several technologies have been developed. In our review, we summarize all the available data concerning the contemporary technological novelties that include imaging, cytology, and endoscopic techniques in pursuit of finding the optimal combination of diagnostic tools that can provide better detection accuracy.

Objective: To determine whether preoperative use of JJ stents in patients undergoing shockwave lithotripsy (SWL) impacts on stone clearance and the rate of postoperative complications. Patients and Methods: We screened multiple databases from inception to January 2021, using the relevant search terms for SWL in patients with a preoperative stent. Inclusion criteria were randomised controlled trials of ≥20 patients aged >18 years who had had SWL with a JJ stent. This review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42023443195). Statistical analysis was performed using ‘meta’ in R. Results: There were seven eligible studies (403 patients receiving JJ stents and 394 controls). There was no significant difference in the stone‐free rate (SFR) following SWL with a JJ stent compared to SWL alone. When considering the complication rates, there was a significantly reduced risk of steinstrasse in patients with a JJ stent. However, there was no significant difference in the risk of other complications including pain, fever, and haematuria, and no significant difference in the likelihood of requiring auxiliary procedures or re‐treatment. Conclusions: There was a reduced risk of steinstrasse in patients undergoing SWL with a JJ stent compared to SWL alone. However, there was no significant difference in the risk of other postoperative complications. Use of a JJ stent had no effect on the efficacy of SWL, with no significant difference in the SFR.

Background: Urinary incontinence and other urinary symptoms tend to be frequent at menopause because of hormonal modifications and aging. Urinary symptoms are associated with the genitourinary syndrome of menopause which is characterized by physical changes of the vulva, vagina and lower urinary tract. The treatment strategies for postmenopausal urinary incontinence are various and may include estrogens, anticholinergics, and pelvic floor muscle training. A comparison of these treatments is difficult due to the heterogeneity of adopted protocols. We systematically reviewed the evidence from randomized controlled trials (RCTs) focusing on treatment of postmenopausal women with urge incontinence. Methods: We conducted a systematic review and meta-analysis by searching PubMed and EMBASE databases for randomized controlled trials (RCTs) reporting results of treatments for postmenopausal urinary urge incontinence. Odds ratios for improvement of urinary incontinence were calculated using random effect Mantel-Haenszel statistics. Results: Out of 248 records retrieved, 35 eligible RCTs were assessed for risk of bias and included in the meta-analysis. Compared with placebo, systemic estrogens were associated with decreased odds of improving urinary incontinence in postmenopausal women (OR = 0.74, 95% CI: 0.61-0.91, 7 series, 17132 participants, Z = 2.89, P = 0.004, I2 = 72%). In most studies, no significant improvement in urinary symptoms was observed in patients treated with local estrogens, although they showed to be helpful in improving vaginal symptoms. Vitamin D, phytoestrogens and estrogen modulators were not effective in improving symptoms of incontinence and other symptoms of genitourinary menopause syndrome or yielded contradictory results. A randomized controlled trial demonstrated that oxybutynin was significantly better than placebo at improving postmenopausal urgency and urge incontinence. The combination of anticholinergics with local estrogens has not been shown to be more effective than anticholinergics alone in improving urinary incontinence symptoms in postmenopausal women. Physical therapy showed an overall positive outcome on postmenopausal urinary incontinence symptoms, although such evidence should be further validated in the frame of quality RCTs. Conclusions: The evidence for effective treatment of postmenopausal urinary incontinence is still lacking. Welldesigned large studies having subjective and objective improvement primary endpoints in postmenopausal urinary incontinence are needed. At present, a combination of different treatments tailored to the characteristics of the individual patient can be suggested.

Although SGLT2 inhibitors have been initially employed in the treatment of type 2 diabetes, their clinical use was later extended to the treatment of other conditions such as heart failure, chronic kidney disease and obesity. In patients with type 2 diabetes, the administration of SGLT2 inhibitors has been associated with an increased incidence of urogenital infections, which may be linked to high glucose levels in the urine. The rate of urogenital side effects may be different in non-diabetic patients. The aim of this study was to review the risk of urogenital infections in non-diabetic patients taking SGLT2 inhibitors. Materials and methods: We conducted a systematic review and meta-analysis by searching PubMed and EMBASE for randomized controlled trials (RCTs) reporting urogenital adverse effects in non-diabetic patients treated with SGLT2 inhibitors. Odds ratios for urogenital infections were calculated using random effect Mantel-Haenszel statistics. Results: Out of 387 citations retrieved, 12 eligible RCTs were assessed for risk of bias and included in the meta-analysis. Compared to placebo, SGLT2 inhibitors were associated with increased odds of genital infections (OR 3.01, 95% CI: 1.93- 4.68, 9 series, 7326 participants, Z = 5.74, p < 0.0001, I2 = 0%) as well as urinary tract infections (OR 1.33, 95% CI: 1.13-1.57, 9 series, 7326 participants, Z = 4.05, p < 0.0001, I2 = 0%). When four trials investigating the effects of SGLT2 inhibitors in populations including both diabetic and non-diabetic patients were considered, administration of SGLT2 inhibitors in diabetic patients was associated with significantly higher odds of genital infections but not urinary tract infections compared to patients without type 2 diabetes. In patients taking placebo, the odds for urinary tract infections were significantly increased in diabetic patients compared to non-diabetic patients. Conclusions: The risk of genital infections is increased also in non-diabetic patients taking SGLT2 inhibitors although at a lesser extent that in diabetics. A careful assessment of the local anatomical conditions and of the history of previous urogenital infections is desirable to select those patients who need more intense follow-up, possibly combined with prophylactic measures of infections during treatment with SGLT2 inhibitors.

Background: Overactive bladder (OAB) symptoms of frequency, urgency and urge incontinence are frequently associated with known neurological diseases like multiple sclerosis (MS), spinal cord injury (SCI), Parkinson’s disease (PD), stroke. Objective: The aim of our study was to review the efficacy of pharmacological and non-pharmacological treatments for neurogenic overactive bladder. Materials and methods: We searched two electronic databases (PubMed and EMBASE) for randomized controlled trials focusing on pharmacological and non-pharmacological medical treatments for overactive bladder symptoms associated with neurological diseases published up to 30 April 2022. Results: A total of 157 articles were retrieved; 94 were selected by title and abstract screening; after removal of 17 duplicates, 77 records were evaluated by full-text examination. Sixty-two studies were finally selected. The articles selected for review focused on the following interventions: anticholinergics (n = 9), mirabegron (n = 5), comparison of different drugs (n = 3), cannabinoids (n = 2), intravesical instillations (n = 3), botulinum toxin (n = 16), transcutaneous tibial nerve stimulation (TTNS) (n = 6), acupuncture (n = 2), transcutaneous electrical nerve stimulation TENS (n = 4), pelvic floor muscle training (PFMT) (n = 10), others (n = 2). Anticholinergics were more effective than placebo in decreasing the number of daily voids in patients with PD (mean difference [MD]- 1.16, 95 % CI - 1.80 to - 0.52, 2 trials, 86 patients, p < 0.004), but no significant difference from baseline was found for incontinence episodes and nocturia. Mirabegron was more effective than placebo in increasing the cystometric capacity in patients with MS (mean difference [MD] 89.89 mL, 95 % CI 29.76 to 150.01, 2 trials, 98 patients, p < 0.003) but no significant difference was observed for symptom scores and bladder diary parameters. TTNS was more effective than its sham-control in decreasing the number of nocturia episodes (MD -1.40, 95 % CI -2.39 to -0.42, 2 trials, 53 patients, p < 0.005) but no significant changes of OAB symptom scores were reported. PFMT was more effective than conservative advice in decreasing the ICIQ symptom score (MD, -1.12, 95 % CI -2.13 to -0.11, 2 trials, 91 patients, p = 0.03), although the number of incontinence episodes was not significantly different between groups. Conclusions: The results of the meta-analysis demonstrate a moderate efficacy of all considered treatments without proving the superiority of one therapy over the others. Combination treatment using different pharmacological and non-pharmacological therapies could achieve the best clinical efficacy due to the favorable combination of the different mechanisms of action. This could be associated with fewer side effects due to drug dosage reduction. These data are only provisional and should be considered with caution, due to the few studies included in metaanalysis and to the small number of patients.

Objective: Proton pump inhibitors are widely used as treatment of acid-related disorders. They are considered safe although their long-term use has been associated with some adverse effects including an increased propensity for urinary calculi formation. The aim of this study was to systematically review available data from studies evaluating the association of PPIs and nephrolithiasis. Materials and methods: We searched two electronic databases (PubMed and EMBASE) for cohort studies or case-control studies evaluating the relationship between treatment with proton pump inhibitors and the risk of stone formation published up to 31 October 2022. The overall association of PPIs and urinary calculi was analyzed using a random effects model (RevMan5). The quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Results: A total of 550 studies were retrieved; 7 were selected by title and abstract screening; after removal of duplicates, 4 records were evaluated by full-text examination. An additional study was retrieved by handsearching the references included in screened studies. In the unadjusted analysis, the odds of urinary calculi were greater in subjects taking PPIs compared to controls (unadjusted OR = 2.10, 95% CI 1.74-2.52, p < 0.00001). The pooled odds ratio of two case-control studies confirmed that use of PPIs increased the odds of urinary calculi compared with non-use (OR 2.44, 95% CI 2.29 to 2.61). Pooled analysis of three cohort studies evaluating incident nephrolithiasis showed an overall hazard ratio estimate of 1.34 (95% CI = 1.28-1.40). One study found lower urinary citrate and urinary magnesium levels in subjects exposed to PPIs. The Newcastle-Ottawa Quality Assessment Scale scores ranged between 6 and 8. Conclusions: PPIs showed an association with urinary calculi in patients included in the studies included in this review. If these data will be confirmed in adequately powered randomized trials, clinicians may consider limiting the long-term use of PPIs, to avoid unnecessary prolongation of treatment. Urinary magnesium and citrate should be evaluated in renal stone forming patients taking PPIs to supplement their intake when requested.

Objectives: To determine stone‐free rate following shockwave lithotripsy (SWL) with/without alpha‐blockers as well as complication rates (individual and classified using the Clavien–Dindo system). Materials and Methods: We performed a systematic review of all randomized controlled trials that included more than 20 patients (age > 18 years) and examined the use of alpha‐blockers after SWL. Meta‐analysis was performed using ‘metafor’ in R. We report risk ratios (RRs) with 95% confidence intervals (95% CIs). The PROSPERO ID for the trial was: CRD42021248108. Results: We assessed 158 full‐text articles and included a total of 21 studies in our review. There were 1445 patients receiving alpha‐blockers and 1478 control patients. Those receiving alpha‐blockers were significantly more likely to be stone‐free (RR 1.12, 95% CI 1.07–1.16; P < 0.001). This effect was robust to ‘trim‐and‐fill’ adjustment. In those taking alpha‐blockers there was a significant reduction in Clavien III–V complications and, on trim‐and‐fill adjustment, a significant reduction in Clavien I–II complications. There were also significant reduction in rates of steinstrasse, pain and requirement for auxiliary procedures. There was no significant difference in retreatment rates. These effects were robust to trim‐and‐fill adjustment. Conclusions: There is a modest increase in stone‐free rates in those receiving alpha‐blockers following SWL, with a reciprocal modest risk reduction for steinstrasse, pain and auxiliary procedures. However, alpha‐blockers do not reduce the risk of requiring retreatment.

Introduction: The OSNA technique is based on reverse transcription loop-mediated DNA amplification for the detection of cytokeratin 19 (CK19) messen-ger RNA (mRNA). The purpose of our paper, which represents the first study in the literature, is to test the accuracy of this method in the detection of lymph node metastases in patients undergoing robotic radical prostatectomy with lymph node dis-section. Methods: Our cohort consisted of patients that have undergone robotic radical prostatectomy with extended lymph node dissec-tion. Lymph nodes were evaluated with imprint technique and then with frozen section examination. The remaining tissue was evaluated by OSNA method. Lymph nodes were defined as ‘neg-ative’ or ‘positive’ according to mRNA copy number. Results: 7 patients and 25 lymph nodes were included in our cohort. Two patients were found negative with all pathology methods. In one patient the standard stains revealed a suspi-cious outcome but it was positive for micrometastasis with OSNA. In another patient the outcome was positive for standard stains and negative for OSNA. Finally, 2 patients were found positive for OSNA and negative for imprint methods. Conclusions: One Step Nucleic Acid Amplification (OSNA) method using CK19 seems to fail in detection of lymph node metastases in prostate cancer patients undergoing radical prostatectomy and lymph node dissection.