Luca Sarchi

Objective: The aim of this paper is to evaluate fellowship outcomes 10 years after implementation of the European Association of Urology Robotic Section (ERUS) structured curriculum for robot‐assisted radical prostatectomy (RARP), with a focus on completion rates and reasons for non‐completion. Subjects and methods: Data were obtained from institutional records and a trainee survey. The primary outcome was fellowship completion (i.e., Certificate of Excellence achievement). Secondary outcomes included reasons for non‐completion and satisfaction. Completion rates were analysed annually, with trends assessed using the Cochran–Armitage test and log‐linear regression for the Estimated Annual Percentage Change (EAPC). Comparisons before and after introduction of a procedural diary (2023) and between pandemic and non‐pandemic years used Fisher's Exact Test. Results: Among 126 fellows, a total of 42 (33%) completed the fellowship by achieving the Certificate of Excellence. The trainee survey achieved a response rate of 77%, supporting the representativeness of the collected data. The main barriers to fellowship completion included limited console access (49%), insufficient programme duration (20%), logistical difficulties (20%) and COVID‐19‐related disruptions (11%). Despite these limitations, overall satisfaction with the fellowship was high (83%), with particularly strong approval of the ORSI hands‐on training week (100%). Completion rates demonstrated a progressive increase over time, rising from 20% in 2018 to 52% in 2023. The Cochran–Armitage test confirmed a statistically significant upward trend in completion rates over the study period ( p < 0.001), while log‐linear regression analysis showed a numerical but non‐significant EAPC of 13% (95% CI –0.6 to 28.6). Although 2023 represented the highest observed completion rate, this peak was not significantly different from previous years (OR 2.63, 95% CI 0.91–7.63). Conclusions: The RARP ERUS Fellowship remains a benchmark in robotic training, but unsatisfactory completion rates highlight the need for improvement. Recent reforms, including the procedural diary, show promise and warrant expansion.

Objectives: To evaluate whether cumulative smoking exposure and time since cessation are associated with perioperative morbidity after robot‐assisted radical cystectomy (RARC). Patients and Methods: We retrospectively analysed 475 patients who underwent RARC with urinary diversion at a high‐volume tertiary centre between 2004 and 2024. Outcomes of interest were postoperative early complications, postoperative readmission, overall risk of postoperative morbidity according to smoking status, cumulative smoking exposure, and time since smoking cessation. Multivariable logistic regressions were performed to explore the effect of smoking status, cumulative smoking exposure, and time since smoking cessation on perioperative morbidity after RARC. The locally estimated scatterplot smoothing (LOESS) function was used to graphically explore this relationship. Results: Early complications occurred in 60% of current smokers, 50% of former smokers, and 37% of never smokers. Compared with never smokers, former (odds ratio [OR] 3.83, 95% confidence interval [CI] 1.73–9.38) and current smokers (OR 6.75, 95% CI 2.85–12.40) had significantly higher odds of perioperative morbidity. Each 10 additional pack‐years increased complication risk (OR 1.20, 95% CI 1.05–1.40), whereas each year since cessation reduced risk (OR 0.84, 95% CI 0.76–0.91). The LOESS curves showed a steadily increasing risk with cumulative exposure and a gradual decline following cessation. Conclusion: Both lifetime smoking burden and time since cessation are strong and independent predictors of perioperative morbidity after RARC. Evaluating smoking exposure as a continuous variable improves risk stratification and provides more accurate information for preoperative counselling in patients undergoing RC.

Introduction: Laparoscopic and robotic bladder diverticulectomy is a successful option to correct bladder diverticula (BD). Nevertheless, the identification of BD could be a tricky step, due to the presence of pneumoperitoneum compressing the bladder. This occurrence could be particularly evident for the posterior or postero-lateral location of BDs. We present a novel technique to overcome this concern based on a rigid guidewire previously endoscopically placed and coiled inside BD, to ensure it expands and remains stable during the dissection. The technique was used in cases of diverticulectomy concomitant to other prostatic procedures. Methods: This is a multicentric series of laparoscopic and robotic diverticulectomy performed with this original technique in 34 patients. The procedure was concomitant to other prostatic intervention in most of the cases: TURP or bladder neck incision (16); radical prostatectomy (three); Millin adenomectomy (four cases). Surgical procedure: The first step of the procedure endoscopic, consisting of the retrograde insertion of a stiff guidewire inside the BD via cystoscopy; the guidewire is pushed in until it coils inside the diverticulum, and then enlarged to make it visible transperitoneally. The guidewire stretches the diverticulum and guides the dissection up to identify its neck. The primary endpoint is to address the feasibility of the technique by considering the operative time (OT, min) and the complication rate. Results: The median size of the BDs was 5.1 cm. The location of the BD was postero-lateral or posterior in all except one case. Bladder diverticulectomy was laparoscopically performed in 25 and robotically assisted in nine cases. Median OT was 179 min (DS 42). The post-operative course was uneventful for all except two patients with symptomatic urinary tract infections. Conclusions: The use of a stiff guidewire coiling and expanding the BD is a simple and useful trick to aid BD’s identification and dissection; it aids diverticulectomy and is also concomitant to other prostatic procedures.

Despite the advent of robotics and the decreasing rate of complications after radical cystectomy, several factors are renowned to impair the early outcomes of this procedure. The aim of this paper is to provide a multivariate analysis (MVA) of patient and surgical procedure-related variables likely to affect postoperative course and 30-day complication rate. Fifty-five robotic-assisted radical cystectomies (RARCs) performed at a single center from July 2021 to March 2023 were enrolled. Baseline demographics, comorbidities, and intraoperative and postoperative data were collected. Uni- and multivariate analyses were performed to evaluate the relationship with Clavien ≥ II complications arising within 30 days of surgery. A postoperative Clavien ≥ II complication was evident in 15 patients (28%), whereas Clavien ≥ III occurred only in 5 (9%). At MVA, the only independent predictor of Clavien ≥ II complications was a prior neoadjuvant chemotherapy (OR 5.6; 95% CI 1.22–25.3, p = 0.026). Recognized the small sample size, patients who received a prior NAC should deserve special care within the postoperative course.

Despite the arising interest in three-dimensional (3D) reconstruction models from 2D imaging, their diffusion and perception among urologists have been scarcely explored. The aim of the study is to report the results of an international survey investigating the use of such tools among urologists of different backgrounds and origins. Beyond demographics, the survey explored the degree to which 3D models are perceived to improve surgical outcomes, the procedures mostly making use of them, the settings in which those tools are mostly applied, the surgical steps benefiting from 3D reconstructions and future perspectives of improvement. One hundred responders fully completed the survey. All levels of expertise were allowed; more than half (53%) were first surgeons, and 59% had already completed their training. Their main application was partial nephrectomy (85%), followed by radical nephrectomy and radical prostatectomy. Three-dimensional models are mostly used for preoperative planning (75%), intraoperative consultation and tailoring. More than half recognized that 3D models may highly improve surgical outcomes. Despite their recognized usefulness, 77% of responders use 3D models in less than 25% of their major operations due to costs or the extra time taken to perform the reconstruction. Technical improvements and a higher availability of the 3D models will further increase their role in surgical and clinical daily practice.

Introduction: Ex-vivo FCM is a novel digital optical technique that provides images of fresh tissues in a real-time fashion with magnification to subcellular details of a flattened unprocessed sample. Digital images are hematoxylin-eosin-like and can be shared and interpreted remotely. In urology, FCM has been successfully applied for prostate tissue interpretation, either during biopsy and radical prostatectomy. Possible applications of FCM may reflect those of frozen section analysis and can be extended to all fields in which the intra-operative microscopical control is advisable. Materials and methods: This is an investigative prospective case series that aims to explore FCM feasibility in novel surgical settings and provide a depiction of FCM digital images in those fields. The definite purpose is to check the accuracy of surgical specimen during the following interventions: (a) trans-urethral resection of bladder tumors, to confirm the presence of muscular layer; (b) biopsy of a retroperitoneal mass, to check for the location and quality of cores; (c) training in robotic radical prostatectomy, to control surgical margins after a nerve sparing performed by a trainee. To this aim, we collected FCM images during seven surgical procedures. FCM findings were compared to those from the final histopathological analysis and the agreement was assessed. Results: In all cases, FCM digital images were obtained in the OR. FCM was able to confirm the presence of muscular layer in TURB specimen, the presence of lymphomatous tissue, surgical margins at prostate specimen. FCM intra-operative interpretation was consistent with final histopathology in all cases. Conclusions: Ex vivo FCM may represent a novel approach to control the quality of specimens, likely to tailor surgical strategy in a real-time fashion. Moreover, digitalization represents a step toward the implementation of telepathology in clinical practice.