From the introduction of robotic surgery, the number of operations of laparoscopic surgery has decreased, and it is half of the heyday. We need to consider this in mind for future. “Fundamentals of surgical education” has shifted from open surgery to laparoscopic surgery with the spread of laparoscopic surgery, but in recent years it has become a robotic surgery in recent years. However, robotic surgery is a kind of laparoscopic surgery, I believe that it will not be a big shift. Rather, it is important to think that robotic surgery and laparoscopic surgery are parallel and complementary education is important.

  From January 2006 to May 2017, a total of 1,500 patients underwent Photoselective Vaporization of the Prostate (PVP) at our hospital. We investigated long-term outcomes of these cases, especially re-treatments, to identify countermeasures for its prevention. Significant improvement of symptoms was maintained for over 10 years after PVP. However, we observed 33 cases (2.2%) requiring re-operation of the prostate. The 10-year re-treatment-free survival rate was 84.7%. In order to prevent reoperation, we consider it important to reduce residual adenoma as much as possible and avoid deep coagulation / the necrosis layer. PVP is a minimally invasive and safe surgery, and further improvement of curability will make it a more effective method.

  We compared robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP) for prostate cancer in terms of the rate of positive surgical margins. Among prostate cancer patients who had ≤cT2-stage disease and ≤20 ng/ml PSA at diagnosis, the comparison included 178 patients who underwent RARP between December 2013 and August 2017 (RARP group) and 132 patients who underwent ORP between January 2011 and December 2012 (ORP group). Patients who received preoperative adjuvant chemotherapy were excluded. The rate of positive surgical margins in the RARP group was 16.9%, which was significantly lower than the 28.8% noted for the ORP group (p = 0.012). By disease staging, when the comparison was limited to pT2-stage patients, the positive surgical margin rate in the RARP group was significantly lower than that in the ORP group (10.9% versus 23.4% ; p = 0.011), while no significant difference was found between the two groups when only pT3-stage patients were included in the comparison (32.6% versus 42.1%). Among patients with lesions at the apex of the prostate, the positive surgical margin rate in the RARP group was 6.7%, which was significantly lower than 18.9% in the ORP group (p = 0.013). No significant differences between the two groups were noted among patients with lesions at other sites (lateral, anterior, posterior, and bladder neck). When the precise positions of positive surgical margins in the apex of the prostate were divided into the anterior, rectal, and lateral sides and compared separately, the result was significantly lower at rectal side of apex in the RARP group (1.1%) than the ORP group (10.4%) (p = 0.0014). These results suggested that the apical dissection under a good magnified visual field with less bleeding in RARP may contribute to decreasing the positive surgical margin rate at the apex.

  Objective : To evaluate the influence of off-clamping and non-renorrhaphy laparoscopic partial nephrectomy using soft coagulation on the renal function.

  Patients and Methods : A total of 86 patients received laparoscopic partial nephrectomy in our hospital between June 2009 and September 2017. We compared the perioperative renal function with the presence or absence of hilar clamping and renorrhaphy.

  Results : Although the median eGFR decreased only on the day after the operation and improved after 3-5 days in patients without hilar clamping or renorrhaphy, the decline in eGFR continued until one year after the operation in patients with hilar clamping and/or renorrhaphy.

  Conclusion : Off-clamping and non-renorrhaphy laparoscopic partial nephrectomy using soft coagulation was a favorable surgical technique for preservation of the post-operative renal function.

  Purpose : Primary ureteroscopic surgery for kidney or ureteral calculi occasionally encounters difficulty with insertion of the ureteroscope. These patients need a second procedure after stenting. We aim to define contemporary failure rate of primary ureteroscopy (URS) and identify predictive factors for access failure.

  Material and Methods : We conducted a retrospective review of 845 unstented patients undergoing primary URS form February 2010 to April 2018. The primary outcome was gaining access to the unstented ureter.

  Results : The failure rate for accessing the unstented ureter was 9.9% (84/845). There were no difference in the median age, gender, height, weight, and body mass index with access vs failure. On multivariable logistic regression, stone location (kidney > proximal ureter > middle & distal ureter), small diameter, no previous urolithiasis history, middle or severe hydronephrosis and emergent surgery revealed independent and significant predictors of failure. The stone free rate by re-URS after stenting was 84.6% (55/65).

  Conclusions : A certain overall rate of ureteral access failure in unstented patients is shown. This study provides the information that will help urologists counsel their patients preoperatively regarding their likelihood of failing primary URS necessitating a second procedure.

  Objectives : We investigated the incidence and risk factors for inaccessible difficult ureter (DU) during ureteroscopic lithotripsy (URS).

  Methods : We analyzed 322 adult patients underwent URS by a single surgeon. We defined DU if the stone was inaccessible by insertion of ureteroscope or ureteral access sheath due to narrowing of the lower ureteral lumen. In cases of DU, ureteral stent was usually left in place during 2 weeks without active dilation.

  Results : The incidence rate of DU was 3.7%. In comparison with the patients without DU, the patient with DU was significantly younger and had smaller stone burden. Young age and small stone length were significant preoperative risk factors for DU by logistic regression analysis. Each cut-off point for the age and stone length were indicated to be 49.0 years and 8.5 mm, respectively.

  After a mean interval of 14.4 days, all DU were then sufficiently dilated to allow passage and the second URS was successfully completed in all DU patients.

  Conclusions : DU is rare situation in adult patients. The preoperative risk factors for DU were younger age and small stone burden. We suggest that ureteral stenting is the principal choice for this rare situation.

  Purpose : To elucidate the association between the operative time and stone volume using different access sheath diameters during ureteroscopic lithotripsy.

  Method : A total of 43 patients who underwent ureteroscopic lithotripsy from October 2014 to September 2017 for upper urinary stones were retrospectively analyzed regarding their operative time, stone volume, ureteral access sheath diameter, and complications.

  Results : Operative times were 45-350 minutes. Stone volumes calculated from the three dimensional stone diameter by CT were 45-1440 mm³. Stone residue were not present in any cases. Linear regression analysis revealed that there were no significant differences in operative time according to differences in the access sheath diameter.

  Conclusions : There were no significant differences in the operative time according to differences in the access sheath diameter.

  Objective : To evaluate how to treat acute obstructive pyelonephritis associated with upper urinary tract calculi at Osaka Rosai Hospital in a conventional manner.

  Methods : Seventy-three patients who had received hospital treatment between 2007 to 2018 were analyzed regarding the presence or absence of ureteral stent placement.

  Results : Twenty-seven nonstented patients had a significantly smaller stone size (7 vs. 10 mm, respectively, p=0.0393) and fewer WBC (12,000 vs. 15,900, respectively, p=0.0428) and neutrophils (9,354 vs. 11,882, respectively, p=0.0199) than 46 stented patients. TUL, ESWL, and nephrectomy were performed in 22, 32 (+TUL in 5), and 1 patient, respectively. Fourteen patients passed ureteral stones without treatment. Four patients could not undergo treatment because of poor ADL and high risks associated with surgery, and so they underwent stent replacement. Stone- and stent-free rates were 84 and 95%, respectively.

  Conclusion : Our conventional treatment was suggested to be useful.

  ［Objective］ Robotic-assisted radical prostatectomy (RARP) is widely performed in Japan. Recently, it became possible for those who have yet to obtain the license of a specialist in urology to perform RARP under certain conditions. As a result, the number of surgeons for whom RARP is their first experience of radical prostatectomy is increasing. These beginners may sometimes cut into the prostate when dissecting the bladder neck or may open the bladder too widely. As it is difficult to identify seminal vesicles, the rectum can be damaged if detachment occurs in the wrong direction. Thus, robotic echography during RARP is useful in bladder neck dissection and seminal vesicle detachment, which are comparatively difficult for beginners. This report discusses the technique.

  ［Method］ Using intraoperative echography (linear probe for intraoperative use), sites of interest are confirmed before bladder neck dissection and seminal vesicle detachment.

  ［Results］ In cases of bladder neck dissection, it was possible to identify the dissection site after confirming the position of the urethral catheter and prostate with echography. Moreover, confirmation of the location made it possible to safely detach the seminal vesicles.

  ［Conclusion］ Intraoperative robotic echography is useful for bladder neck dissection and seminal vesicle detachment in RARP performed by beginners. For both beginners and experienced surgeons, the use of intraoperative echography is effective in cases of prostate protrusion into the bladder or when the seminal vesicles and ampulla of the deferent duct are difficult to locate.

  We report a case of partial cystectomy using laparoscopic endoscopic cooperative surgery (LECS) to treat a vesicosigmoidal fistula. A 53-year-old man presented to our hospital with urinary tract infection. Computed tomography and a barium enema study led to a suspicion of vesicosigmoidal fistula secondary to diverticulitis. Laparoscopic partial cystectomy and sigmoidectomy were performed. Intraoperatively, following a transurethral marking incision of the mucosa surrounding the fistula at the posterior wall, the bladder was resected laparoscopically along the marked line. The bladder defect seemed to be small ; therefore, the bladder capacity stayed almost the same as before.

  Laparoscopic partial cystectomy using LECS is a less invasive technique to preserve bladder function.