Go Kaneko

Objectives: To evaluate the effect of neoadjuvant chemotherapy (NAC) on pathological response and oncologic outcomes in patients with high‐risk upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU) in a real‐world multicenter setting. Methods: We retrospectively analyzed data from 184 patients with high‐risk UTUC who underwent RNU across six institutions and were divided into NAC and non‐NAC groups. The primary endpoint was pathological downstaging. Secondary endpoints were non‐urinary‐tract recurrence‐free survival (NUT‐RFS) and overall survival (OS). We also compared the NAC group with the combined non‐NAC and adjuvant chemotherapy (AC) group. Propensity score matching (PSM) was performed to adjust for baseline differences. Results: 34.2% and 14.1% of 184 patients (median age, 75 years; men, 70.7%) received NAC and AC, respectively. NAC was not significantly associated with pathological downstaging. On multivariable analysis, positive urine cytology (bladder) was independently associated with a lower likelihood of downstaging, whereas a higher baseline eGFR was independently associated with a higher likelihood of downstaging. Neither NUT‐RFS nor OS differed significantly between the NAC and non‐NAC groups or between the NAC and non‐NAC plus AC groups, either in the overall cohort or after PSM. Conclusions: In this real‐world cohort, NAC did not significantly improve pathological or survival outcomes in patients with high‐risk UTUC. Oncological outcomes did not differ significantly between NAC and AC administered after pathological confirmation of risk, although this comparison is susceptible to selection and guarantee‐time bias. Pathology‐guided AC may be a reasonable perioperative strategy, but its relative benefit remains uncertain and warrants prospective validation.

Background/Aim: Platinum-ineligible patients with locally advanced or metastatic urothelial carcinoma represent a clinically vulnerable population with limited treatment options and poor historical outcomes. Although first-line enfortumab vedotin plus pembrolizumab has become a new standard treatment, evidence in platinum-ineligible patients remains limited. This study described the real-world clinical course of platinum-ineligible patients treated with first-line enfortumab vedotin plus pembrolizumab within a consecutive cohort. Patients and Methods: This retrospective single-center study included 40 consecutive patients with locally advanced or metastatic urothelial carcinoma who initiated first-line enfortumab vedotin plus pembrolizumab between December 2024 and March 2026. Platinum eligibility was determined using prespecified creatinine clearance-based criteria. Tumor response, progression-free survival, overall survival, treatment-related adverse events, and individual treatment courses were evaluated descriptively. Results: Among 40 patients, eight were classified as platinum ineligible. Tumor response was evaluable in six platinum-ineligible patients, of whom one achieved complete response and three achieved partial response. Median progression-free survival and overall survival were not reached in the platinum-ineligible subgroup. Grade ≥3 treatment-related adverse events were infrequent. The swimmer plot demonstrated heterogeneous clinical trajectories, including early discontinuation in some patients and prolonged treatment exposure or off-treatment disease control in others. Conclusion: First-line enfortumab vedotin plus pembrolizumab showed encouraging clinical activity and acceptable tolerability in selected platinum-ineligible patients with advanced urothelial carcinoma. Given the small subgroup size, these findings should be interpreted as descriptive and hypothesis-generating.

Robot-assisted radical prostatectomy (RARP) using the da Vinci system (Intuitive Surgical, Inc., Sunnyvale, CA) has become a standard minimally invasive treatment for nonmetastatic prostate cancer. The next-generation da Vinci 5 system incorporates integrated motion analytics and force-feedback instruments, enabling quantitative visualization of console behavior during robotic surgery. In this case-based technical report, we describe our initial real-world experience with these functions in two patients who underwent RARP at a single institution. Both procedures were performed via a standard transperitoneal approach without pelvic lymph node dissection, and perioperative outcomes were acceptable in both cases. Digital logs obtained from the cloud-based My Intuitive platform (Intuitive Surgical) provided instrument-tip force categories, kinematic metrics including instrument and endoscope path lengths, and system events such as endoscope clutches, hand-controller clutches, and energy-pedal activations. The procedures were automatically segmented into three steps by the My Intuitive platform algorithm, and the analytics were reviewed in synchronization with the corresponding operative videos. Quantitative review demonstrated differing patterns of console motion, clutch use, and force application between the two analyzed procedures, particularly during dissection between the rectum and prostate and during vesicourethral anastomosis. Case 1 showed more frequent clutch use and a broader working range, whereas Case 2 showed a higher proportion of time categorized as force ≥ 6.5 N despite similar mean forces. This report demonstrates the technical feasibility of capturing, synchronizing, and visualizing console behavior using the integrated analytics of the da Vinci 5 system during RARP. Although the findings are descriptive and hypothesis-generating only, this integrated review approach may have potential value for structured technical reflection, data-guided feedback, and future surgical education research.

Locally advanced or metastatic urothelial carcinoma (la/mUC) has a poor prognosis. In routine clinical practice, platinum-based chemotherapy has generally been used as first-line treatment. Enfortumab vedotin plus pembrolizumab (EVP) has recently been introduced as another first-line option; however, patients who are platinum-ineligible, such as those with severe renal dysfunction and/or poor performance status, are often underrepresented in clinical studies, and the optimal systemic therapy for this group remains uncertain. Herein, we report three platinum-ineligible patients with la/mUC who received standard-dose EVP as first-line therapy. Platinum ineligibility was defined as creatinine clearance (CrCl) < 30 mL/min and/or Eastern Cooperative Oncology Group performance status (ECOG PS) ≥ 3. In Case 1 (hemodialysis; ECOG PS 1), EVP resulted in improvement of bone metastases and durable disease control, with manageable adverse events (AEs), including grade 2 skin toxicity, dysgeusia, hypothyroidism, and transient peripheral sensory neuropathy that resolved after temporary treatment interruption. In Case 2 (CrCl 23.1 mL/min; ECOG PS 2), EVP induced a partial response in the bladder and nodal lesions; however, treatment was complicated by early-onset grade 4 immune-related nephritis requiring high-dose corticosteroids. Best supportive care was adopted at progression. In Case 3 (ECOG PS 3), rapidly progressive renal pelvic la/mUC showed early disease progression with spinal cord compression despite EVP, leading to the patient being transitioned to best supportive care. Across all three cases, no life-threatening toxicity was clearly attributable to enfortumab vedotin. These observations suggest that standard-dose EVP may be a feasible first-line option for carefully selected platinum-ineligible patients, when administered with close monitoring, flexible dose adjustment, and prompt management of immune-related and other AEs.

Robot-assisted partial nephrectomy (RAPN) requires secure and efficient hemostasis at the resection margin to prevent bleeding-related complications while preserving renal function. Flowable gelatin-thrombin matrix sealants, such as FloSeal®, are useful adjuncts for hemostasis in partial nephrectomy; however, their use is limited in Japan. We report two cases of right-sided clinical T1a renal cell carcinoma treated with RAPN in which a gelatin-thrombin matrix sealant was applied. Standard tumor excision, meticulous coagulation, and inner-layer parenchymal renorrhaphy were successfully performed under renal artery clamping. A 14-Fr flexible feeding tube was then introduced through the assistant port to deliver an adequate amount of FloSeal® to the resection bed, after which the sealant layer was gently compressed with saline-moistened gauze. This procedure achieved complete parenchymal hemostasis after clamp release without the need for extensive cortical suturing. Both surgeries were completed without conversion and with minimal blood loss, negative surgical margins, uneventful postoperative courses, and preservation of early postoperative renal function. These two cases illustrate a practical technique for precise delivery of FloSeal® using a low-cost feeding tube during RAPN. This approach may serve as an option for standardized parenchymal hemostasis, particularly when the surgeon aims to minimize cortical suturing and warm ischemia time. Further studies are warranted to investigate the indications and long-term outcomes of this FloSeal®-assisted hemostatic strategy in nephron-sparing surgery.

The Senhance robotic system (Asensus Surgical, Durham, NC, USA) is an innovative platform for minimally invasive surgery. It enables surgeons to perform precise and cost-effective procedures using reusable instruments and has advanced features such as haptic feedback and eye-tracking camera control. Herein, we present the first application of the "double bipolar method" (DBM) in a Senhance-assisted laparoscopic partial cystectomy utilizing 3 mm Maryland bipolar instruments. The DBM technique allows for the simultaneous use of bipolar instruments in both hands, thereby providing exceptional control in tissue dissection and coagulation, which are critical for delicate urologic procedures such as partial cystectomy. We present a case of a 62-year-old female patient who had a 2 cm tumor located at the bladder's dome. Following comprehensive preoperative imaging and cystoscopic evaluation, the tumor was deemed suitable for resection using the Senhance system. The DBM technique enabled the precise and bloodless resection of the bladder wall. Intraoperative evaluation confirmed the complete removal of the tumor and the successful closure of the bladder defect using a barbed suture. The patient had an uncomplicated recovery and was discharged on the eighth postoperative day. The combination of Senhance's advanced features and the DBM technique with 3 mm instruments offers a significant advantage in urologic surgery, providing enhanced precision, cost-efficiency, and improved cosmetic outcomes. The DBM technique in conjunction with the Senhance system represents a promising approach for bladder-sparing surgeries, with the potential for widespread adoption in clinical practice.

We report our initial experience and the utility of 3 mm bipolar forceps in laparoscopic renal surgery using the Senhance robotic system. We performed laparoscopic nephroureterectomy for upper tract urothelial carcinoma in two patients: an 80-year-old female with a left renal pelvic tumor and an 80-year-old male with a right ureteral tumor. Both surgeries were successfully completed without conversion to conventional laparoscopic surgery or laparotomy. The console times for the procedures were 101 and 108 minutes, with estimated blood losses of 5 and 50 milliliters, respectively. The postoperative courses were uncomplicated, with histopathological examinations confirming high-grade urothelial carcinoma with negative surgical margins in both patients. The 3 mm Maryland bipolar instrument was able to grasp membranes with sufficient gentleness and precision. The relatively narrow diameter of the shaft posed a challenge in terms of shaft strength; however, it did not deflect even when it was used to lift the kidney, indicating sufficient robustness. When utilized in the cutting mode, the incision capacity of the 3 mm Maryland bipolar instrument was higher than that of the 5 mm instrument, which allowed for expedient and precise incision. Since only the tissue held by the forceps was incised, it was possible to perform a safe incision even in areas near blood vessels and other organs. Although the tip of the 3 mm Maryland instrument is more sharply pointed than that of the 5 mm instrument, no tissue damage was observed even when the 3 mm instrument was used for blunt dissection. Our initial results suggest that the 3 mm Maryland bipolar instrument is efficacious for performing laparoscopic renal surgery. The instrument may be suitable for a range of surgical procedures in laparoscopic renal surgery using the Senhance system. Further studies are necessary to establish the role and effectiveness of this instrument in broader clinical applications.