Tommaso Calcagnile

Objectives: Radical cystectomy (RC) is a surgical procedure associated with high rates of morbidity. The aim of the study is to provide a comparison between robotic (RARC) and open RC (ORC) in patients elected to cutaneous ureterostomy (CUS).

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.

Radical cystectomy represents one of the most challenging surgical procedures, exhibiting a high morbidity rate. The transition to minimally invasive surgery in the field has been steep, due to either the technical complexity and prior concerns of atypical recurrences and/or peritoneal spread. More recently, a larger series of RCTs has proven the oncological safety of robot-assisted radical cystectomy (RARC). Beyond survival outcomes, the comparison between RARC and open surgery in terms of peri-operative morbidity is still ongoing. We present a single-center experience of RARC with intracorporeal urinary diversion. Overall, 50% of patients had an intracorporeal neobladder reconstruction. The series confirms a low rate of complications (Clavien Dindo ≥ IIIa 7.5%) and wound infections (2.5%) and the absence of thromboembolic events. No atypical recurrences were found. To discuss these outcomes, we reviewed the literature related to RARC including level-1 evidence. PubMed and Web of Science searches were performed using the medical subject terms “robotic radical cystectomy” and “randomized controlled trial (RCT)”. Six unique RCTs comparing robot and open surgery were found. Two clinical trials dealt with RARC with an intracorporeal reconstruction of UD. Pertinent clinical outcomes are summarized and discussed. In conclusion, RARC is a complex but feasible procedure. The transition from extracorporeal urinary diversion (UD) to a complete intracorporeal reconstruction could be the key to improving peri-operative outcomes and reducing the whole morbidity of the procedure.

The occurrence of asymptomatic bacteriuria concomitant to urolithiasis is an issue for patients undergoing renal stone treatment. Disposing of a preoperative urine culture is essential to reduce the risk of septic events. The endpoint of the study is to report which characteristics of candidates for renal stone treatment are frequently associated with positive urine culture. 2605 patients were retrospectively enrolled from 14 centers; inclusion criteria were age > 18 and presence of a single renal stone 1–2 cm in size. The variables collected included age, gender, previous renal surgery, comorbidities, skin-to-stone distance, stone size, location, density, presence of hydronephrosis. After a descriptive analysis, the association between continuous and categorical variables and the presence of positive urine culture was assessed using a logistic regression model. Overall, 240/2605 patients (9%) had preoperative bacteriuria. Positive urine culture was more frequent in females, patients with previous renal interventions, chronic kidney disease, congenital anomalies, larger stones, increased density. Multivariate analysis demonstrated that previous renal interventions (OR 2.6; 95% CI 1.9–3.4; p < 0.001), renal-related comorbidities (OR 1.31; 95% CI 1.19–1.4; p < 0.001), higher stone size (OR 1.06; 95% CI 1.02–1.1; p = 0.01) and density (OR 1.00; 95% CI 1.0–1.00; p = 0.02) were associated with bacteriuria; male gender and lower caliceal location were inversely related to it. Beyond expected risk factors, such as female gender, other parameters are seemingly favoring the presence of positive urine culture. The awareness of variables associated with bacteriuria allows to assess which individuals are at increased risk of presenting bacteriuria and reduce the rate of septic complications.