Laparoscopic sacrocolpopexy (LSC) for pelvic organ prolapse has become the standard surgical procedure in Japan as a transabdominal surgical treatment. After conducting the laparoscopic sacrocolpopexy procedure 100 times, we introduced robotic-assisted sacrocolpopexy (RaSC) in February 2019 and performed it 21 cases. Since it’s early introduction, we have been trying to improve the surgical procedure by capitalizing on the merits of the characteristics of robotic-assisted surgery. By effectively using the extra arm in particular, we were able to reduce the burden on assistants and negate the need for the vaginal operation. We report on robotic-assisted sacrocolpopexy in our hospital, advancement ingenuity from the conventional method.

  In Japan, robot-assisted laparoscopic sacrocolpopexy (RSC) has been covered by medical insurance since April 2020. Not only in Europe and the United States, but also in Asian countries, the technical and clinical evidence of RSC has been accumulating. RSC can be easily performed with sutures and ligatures even in the deep pelvic floor. Because of plenty suturing procedure in laparoscopic sacrocolpopexy (LSC), the learning curve of RSC is shorter than that of LSC. As robot-assisted surgery becomes more popular and experienced, RSC is expected to make the surgical treatment of pelvic organ prolapse (POP) more accessible.

  On the other hand, the broad knowledge and experience of female urologist will strengthen the quality of the surgery. Both robotic surgical skills and LSC experience must be important to RSC and bringing benefits for POP patients.

Objects : We evaluated the outcomes of patients underwent RIRS or PNL in Nara Urological Research and Treatment Group.

Patients and Methods : From January 2014 to December 2018, 128 patients underwent RIRS or PNL for renal stone more than 10 mm. They classified into two groups according to the treatment. The outcomes were calculated and prognostic factors for residual stones were identified.

Results : Patients who underwent PNL were significantly younger and their stone volume were bigger, lowering rate of Hb were higher, and the rate of postoperative fever was higher. Multivariate analyses identified large stone size (≧20 mm) as independent poor prognostic factor for residual stone of RIRS and position of stones (not renal pelvis) as independent poor prognostic factor for postoperative fever of PNL.

Conclusion : Our findings suggest that patients with large stone size (≧20 mm) and renal pelvis stone should undergo PNL.

【Objective】To evaluate significance of maximum CT value for ureteral stones

【Materials and Methods】One hundred ninety-two patients were enrolled between 2012 to 2019. Stone free was defined as stones of 4 mm or smaller.

【Results】The median age was 65 years. Additional therapies were performed in 16 patients. The stone-free rate was 80.2％ (154/192). Multivariate analysis revealed a significant difference between the residual and stone free groups in the maximum diameter (median 13.0 vs 9.0 mm, p＝0.0108) and average CT value (median 1,259 vs 912 HU, p＝0.0070). The maximum CT value of the maximum cut surface was constant, but not the average CT value, according to the guideline on urolithiasis. There was no significant difference between them in this study.

【Conclusions】Ureteral stones with larger sizes and/or higher CT values require various measures for URS, and the maximum CT value may be used instead.

  Sixty-eight patients with obstructive pyelonephritis secondary to upper urinary calculi, who underwent transurethral ureterolithotripsy (TUL) after urethral drainage, etc., were retrospectively examined. E. coli was most commonly detected in preoperative urine cultures, with a median period of 3 days of perioperative antibiotic treatment. A stone-free status was achieved in 65 patients, and perioperative complications occurred in 6 patients, all of whom improved conservatively. Patients with severe ADL difficulty showed higher detection rates of ESBL-producing bacteria, extended periods of hospitalization, discharge after TUL, and perioperative antibiotic treatment, and significantly prolonged and increased complications. In patients with obstructive pyelonephritis secondary to upper urinary calculi, TUL could be safely performed with perioperative antibacterial treatment based on the results of urine cultures after infection control. However, patients with ADL difficulty should be carefully observed perioperatively because of the higher rates of drug-resistant bacteria.

  To compare surgical outcomes of minimum incision endoscopic radical nephrectomy (MIERN) and laparo-endoscopic single-site plus one radical nephrectomy (LESS＋1RN), we retrospectively evaluated medical records of the renal cell carcinoma patients. LESS＋1 RN was performed without specialized or articulated instruments through para-rectal incision, placed near the kidney. From November 2008 to November 2019, 46 patients were treated with LESS＋1RN and 48 received MIERN. LESS＋1RN was associated with a, longer operative time (average 251.6±56.5. 221.8±55.7 min, respectively, P＝0.01), but less blood loss (average 75.3±241.7. 377.7±473.4 mL, respectively, P＝0.0003) and shorter wound length (average 5.2±1.0. 6.9±1.7 cm, respectively, P＜0.001). Open conversion was required in 2 patients treated with LESS＋1RN. Surgical wound needed to be extended in two patients treated with MIERN. Although LESS＋1RN required a longer operative time, blood loss and wound length were significantly decreased. LESS＋1RN might be safely introduced and a less invasive alternative procedure.

Purpose: With our experience of surgery for adrenal tumors with diameter larger than 10 cm and feasibility and limitations of laparoscopic resection was discussed.

Case presentations: 1) 56 years old, male, pheochromocytoma (right, 10 cm), retroperitoneoscopy, 2) 63 years old, male, myelolipoma (right, 10 cm), retroperitoneoscopy, 3) 68 years old, male, chronic expanding hematoma (left, 18 cm), retroperitoneoscopy with hand-assisted approach 4) 51 years old, male, pheochromocytoma (left, 17 cm), retroperitoneoscopy with lumbar oblique incision. No recurrence was observed for pheochromocytoma.

Conclusion: Early transection of feeding artery caused shrinkage of tumor, less blood loss and facilitated retroperitoneoscoic resection for three cases. On the other hand, increased blood loss was observed after open conversion for two cases, which may be caused by incomplete hemostat during pneumoperitonem. These observations need further discussions for surgical approach against giant adrenal tumors.

Objective : We retrospectively analyzed clinical outcome robot-assisted radical prostatectomy (RARP) using retroperitoneal approach in prostate cancer patients.

Patients and Methods : Between September 2011 and March 2019, a total of 1,156 patients underwent RARP using transperitoneal approach (TP group). From July 2015, we also started to perform RARP with RP approach in 127 patients (RP group). We conducted a retrospective study aimed to investigate oncological outcome and continence recovery rates in two cohorts.

Results : The median console time significantly lower and blood loss was higher in RP group when compared to those in TP group (167 and 172 minutes, p＝0.015 ; 150 and 50 mL, p＜0.001). There was no significant difference in the positive surgical margin rates (22.8 and 22.9％), the 3-year RFS rates (83.1 and 82.2％) and the 3-year continence recovery rate (90 and 92％) in RP and TP groups.

Conclusion : RARP with RP approach was performed safely and effectivity.

Objective : To evaluate the outcome and safety of robot-assisted laparoscopic radical prostatectomy using the extraperitoneal approach (eRALP) for patients with localized prostate cancer compared with robot-assisted laparoscopic radical prostatectomy using the peritoneal approach (RALP).

Materials and Methods : We retrospectively investigated the surgical results of 12 eRALP and 394 RALP procedures performed in our department between November 2013 and May 2020.

Results : The port placement time was significantly longer in eRALP, but there was no significant difference in the console or operative time. The amount of blood loss was significantly higher in eRALP, but there were no cases requiring blood transfusion with either approach. There was no significant difference in the complication rate, and no significant difference in the duration of urinary catheter placement, hospital stay, or postoperative recurrence rate.

Conclusion : eRALP was safe and effective, with no clinically significant complications compared with RALP.

Objective : We compared the surgical outcomes of robot-assisted partial nephrectomy (RAPN) for cT1a and cT1b patients at our hospital.

Subjects and Methods : We retrospectively examined 210 (T1a : 177, T1b : 33) patients who underwent RAPN at our hospital between March 2016 and June 2019.

Results : There were no significant differences in age, sex, affected side, BMI, or preoperative eGFR, but the RENAL nephrometry score was significantly higher in the cT1b group. The operative, pneumoperitoneum, console, and ischemic times were significantly longer in the cT1b group, and the estimated blood loss was also significantly greater. There were no significant differences in blood transfusions, complications, or the positive margin rate. In addition, there was no significant difference in the postoperative renal function.

Conclusion : RAPN for a cT1b renal tumor at our hospital, compared with cT1a, increased the operative time, ischemic time, and bleeding, but the complications, positive margin rate, and postoperative renal function were the same.

Objective

  The purpose of this study was to evaluate the effect of Advanced Reconstruction of Vesicourethral Support on early urinary continence after robot-assisted radical prostatectomy.

Methods

  We compared the preoperative, intraoperative, and postoperative findings and urinary incontinence of patients who underwent non-nerve-sparing robot-assisted radical prostatectomy in an Advanced Reconstruction of Vesicourethral Support group (Group A) and a non-Advanced Reconstruction of Vesicourethral Support group (Group B).

Results

  There were 59 cases in Group A and 46 cases in Group B. A significant difference between the two groups was noted in the posterior urethral bladder angle on postoperative cystography (median : 131 vs. 138 degrees, respectively, p＝0.041). In multivariate analysis, the factors that resulted in urinary incontinence of less than 150 mL on the day after catheter removal were age (＜68 years, p＝0.014, Odds Ratio : 3.1) and Advanced Reconstruction of Vesicourethral Support (p＝0.024, Odds Ratio: 2.9).

Conclusion

  Advanced Reconstruction of Vesicourethral Support may affect urinary abstinence in the early postoperative period.

【Objectives】

  Forty-seven patients underwent RASC in our clinic. Here, we report a comparison of early proficiency on introducing RASC between 2 operators.

【Subjects/Methods】

  Gynecologist A and urologist B performed laparoscopic sacral colpopexy (LSC) in 44 and 13 patients, respectively. We examined 43 patients (31 operated on by A and 12 by B) with pelvic organ prolapse stage 2 or more who underwent the surgery using single mesh. We measured the operative time of each part of RASC.

【Results】

  There were no differences in the background between the patients operated on by A and B. No significant differences in the operative time, console time, or time of each part of the operation were observed between the operators.

【Discussion】

  The results suggest that the operator’s proficiency in robot-assisted surgery contributes to shortening the RASC operative time rather than the number of LSC operations.

  Here, we report our initial experience of robot-assisted laparoscopic nephroureterectomy with bladder cuff excision (RNU) for patients with upper tract urothelial carcinoma (UTUC).

  We performed RNU using the da Vinci Si (for 4 patients) or Xi (for 2 patients) Surgical System between July 2019 and July 2020. All procedures involved and it was not necessary to reposition the 6 to 7 ports positioned transperitoneally, patient cart during surgery.

  The RNUs were successfully completed without the need for open conversion or blood transfusion in all patients. The median operative time was 308 (range : 242-391) min and median estimated blood loss was 63 (range : 21-426) mL. A positive periureteric margin was noted in a patient with pT3 disease. Two patients suffered from a Clavien-Dindo grade II complication with chylous ascites or diarrhea, respectively.

  Although RNU is a feasible option for UTUC patients, standardization of the operative procedure and longer follow-up studies with a larger number of patients are required.

Objective :

  To compare the surgical and functional outcomes of robotic and laparoscopic dismembered pyeloplasty for the treatment of patients with ureteropelvic junction obstruction (UPJO).

Patients and Methods :

  A review was performed of all procedures of Robot-assisted laparoscopic pyeloplasty (RAPP) and laparoscopic pyeloplasty (LPP) performed at our hospital. Perioperative results and follow-up data were subsequently compared. All operations were performed with transperitoneal approach and using the Anderson-Hynes method.

Results :

  Thirty patients were treated with RAPP and 50 patients were treated with LPP during the study period. RAPP was performed by 6 surgeons and LPP was performed by 2 surgeons. Patient demographics were similar between the two groups. Mean operative times were similar in RAPP and LPP groups (170 vs. 181 min, respectively［p＝0.33］) and the anastomosis time was shorter in the RAPP group (41 vs. 54 min, respectively［p＝0.002］). Operative Blood loss was greater in the RAPP group (13 vs. 5 mL, respectively［p＜0.01］).

Conclusion :

  RAPP was non-inferior to LPP in terms of the operative time, hospitalization time, and success rate.

  Salvage robot-assisted laparoscopic radical prostatectomy (sRARP) has been reported to be a feasible treatment for local recurrence of prostate cancer after primary treatment. We have been providing focal therapy using low-dose-rate brachytherapy (focal brachytherapy) in patients with localized prostate cancer. In this study, we retrospectively evaluated perioperative, functional, and oncological outcomes of sRARP in 2 patients with local recurrence in the therapeutic area following primary focal brachytherapy. Surgery was performed using the da Vinci surgical system with similar transperitoneal approach as primary RARP. Intraoperatively, adhesions and fibrosis were detected around the therapeutic area of previous focal brachytherapy but were not observed in the non-therapeutic area. Neither patient experienced any perioperative complications. Postoperatively, they achieved social continence without biochemical recurrence. Although further investigation is needed, sRARP may be a feasible approach for the management of local recurrence after focal brachytherapy with acceptable perioperative complications, functional outcomes, and oncological outcomes.

OBJECTIVE : To develop a preoperative nomogram to predict the non-biochemical recurrence (non-BCR) after robot-assisted radical prostatectomy (RARP).

METHODS : A thousand patients who underwent robot-assisted radical prostatectomy at the Tokyo Medical University were studied. Based on Cox hazard regression analysis, a nomogram was developed to predict non-biochemical recurrence at 1, 3, and 5 years after robot-assisted radical prostatectomy. For external validation, the parameters of 200 patients who underwent robot-assisted radical prostatectomy at the Shin-Yurigaoka General Hospital were used to calibrate the actual and predicted values using our nomogram.

RESULTS : A hundred and sixty-eight patients had biochemical recurrence during the follow-up period (mean, 44.4 months). Analysis showed that age, PSA, biopsy primary and secondary Gleason pattern, clinical T stage, and the percentage of positive biopsy cores were significant predictors of biochemical recurrence.

CONCLUSION: The nomogram was validated with internal and external calibration to provide an accurate prediction of non-biochemical recurrence. It may help both patients and clinicians to determine the most appropriate initial treatment for clinically localized prostate cancer.

Objective : We reviewed the first 101 cases of Robot-assisted partial nephrectomy (RAPN).

Subjects and Methods : The mean age of the patients was 61.1 years. There were 72 men and 29 women. The right kidney was affected in 53 patients, and the left kidney in 48 patients. The median tumor size was 24 mm. The clinical stage was cT1a in 91 patients and cT1b in 10 patients. The mean R.E.N.A.L nephrometry score was 6.3. RAPN was performed by 5 surgeons, surgeon 1 was involved as a proctor in all the cases operated by surgeons 2 to 5.

Result : The median operative time was 249 minutes. The median console time was 183 minutes. The median warm ischemia time (WIT) was 19 minutes. The median volume of blood loss was 50 mL. The detected perioperative complications included postoperative hemorrhage in 6 patients, urinary fistula in 1 patient, and gas embolism in 1 patient. Postoperative pathological examination showed that the surgical margins were negative in all patients. Trifecta was achieved in 82.2％ of the patients. When surgeon 1 was compared to surgeons 2 to 5, the trifecta achievement rate was 90.9％ and 71.7％, respectively.

Conclusions : The overall trifecta achievement rate was 82.2％, which was comparable to the previously reported rates. On the other hand, the trifecta achievement rates differed between surgeon 1 and surgeons 2 to 5, although surgeon 1 was involved as a proctor in all the cases operated by surgeons 2 to 5. Educational training of surgeons for RAPN is a future issue to be addressed.

  We investigated the safety of and effective irrigation methods for holmium laser enucleation of the prostate (HoLEP) and tissue morcellation with and without using a lure lock cock with three companies’ endoscopes. Furthermore, the flow rates of the three companies’ irrigation tubes were compared. The flow rate exceeded 500 mL per minute for all manufacturers on performing HoLEP. In the morcellation setting, the presence of a lure lock cock did not affect the flow rate. The inflow rate of the irrigation port of the nephroscope in single route was lower than that of the outer sheath. The irrigation tube with the highest flow rate was had a large inside diameter and four connecting tubes.

  It is important to consider the difference in flow rates due to the difference in connection routes of an endoscope and choose an efficient irrigation route using a lure lock cock.

Objective : The aim of this study was to evaluate the effects of dutasteride on perioperative outcomes and the postoperative course of photoselective vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH).

Patients and Methods : A total of 54 patients who underwent PVP for BPH were included in this retrospective study : 31 patients who received alpha-1 blockade alone preoperatively, and 23 patients who received an alpha-1 blockade and dutasteride combination preoperatively and discontinued it postoperatively.

Results : The median age and prostate volume of all patients were 72 years old and 58.5 mL, respectively. There were no significant differences between the two groups in the operative time, total energy, lasing time, post-operative hemoglobin changes, post-operative complications, or vaporization efficacy. The International Prostate Symptom Score, maximum urine flow rate, and residual urine volume were significantly improved in both groups at 1 month post-operatively and thereafter.

Conclusion : Preoperative dutasteride was not associated with increased adverse effects on peri- or postoperative outcomes of PVP.

Objective : To evaluate the effectiveness and safety using contact laser vaporization of the prostate for symptomatic benign prostatic hyperplasia. Materials and Methods : From June 2019 to August 2020, 46 patients with benign prostatic hyperplasia underwent contact laser vaporization of the prostate at our institution. Patients were assessed preoperatively and at 1, 3 and 6 months postoperatively involving their IPSS, QOL score, maximum flow rate, and post-void residual urine volume. Results : The mean age was 70.3±6.4 years old. The preoperative mean prostate volume was 90.5±32.7 mL. The operative time was 102.5±21.4 minutes, and total applied laser energy was 466.4±110.6 kJ. The procedure was completed successfully in all patients without intraoperative complications. None of the patients required blood transfusion postoperatively. All of the parameters were improved and comparable with those in the Japanese clinical trial after surgery. Conclusions : contact laser vaporization of the prostate was demonstrated highly therapeutic potential and safety procedure for benign prostatic hyperplasia patients.