Since robot-assisted laparoscopic radical prostatectomy in 2012 was covered by insurance, robotic surgery has rapidly spread. At the Okayama University Hospital-related facilities, da Vinci has spread rapidly over the past few years, and 13 da Vinci (including Okayama University Hospital) are in operation and 45 surgeons are operating. However, the surgical methods and instruction methods at each facility are not the same. Due to personnel changes in related facilities, surgeons with various backgrounds have become enrolled at Okayama University Hospital, and multiple surgical methods have been disrupted even within the same facility. The robot surgery education of our facility could not cope well with this situation, and the perioperative results tended to deteriorate from around 2015. In order to solve this problem, we tried to overcome this situation by applying the concept of “unifying the surgery contents, improving the reproducibility of the surgery contents and aiming for a short learning curve” cultivated in laparoscopic education.

  Minimally invasive endoscopic combined intrarenal surgery (mini-ECIRS) was performed by one operator for 59 cases of coral stones in conjunction with transurethral lithotripsy under nephrostomy. We examined its usefulness, safety, and differences compared with conventional mini-ECIRS. Transurethral lithotripsy using a flexible ureteroscope is a surgical procedure performed in many facilities, and nephrostomy is also a procedure performed in daily urological practice. By combining these two, although it is inferior to conventional mini-ECIRS regarding the operative time and hospitalization period, a relatively good stone-free rate can be achieved and the risk of bleeding due to tract creation that makes beginners feel uneasy can be reduced. This time, a relatively good stone-free rate was achieved by performing the operation up to twice for cases with a stone volume of 17 cc or less. For stones over 17 cc, conventional mini-ECIRS using a compressed air crusher may be favorable, but one-surgeon mini-ECIRS may be sufficient for stones under 17 cc.

  Stress urinary incontinence (SUI) is a perioperative complication in holmium laser enucleation of the prostate (HoLEP). Herein, we developed a HoLEP operation method that preserves the anterior fibromuscular stroma (AFS) to prevent SUI. In this technique, the mucous membrane separated in HoLEP is first incised to reveal the boundaries, which simplifies the procedure and facilitates orientation. Expert surgery with hundreds of cases has no problem with SUI even with conventional surgical procedures. However, for developing surgeons, it is necessary to devise ways to improve this surgical technique to achieve the same results as experts.

  【Objective】 To evaluate the treatment outcomes of URS for renal stones

  【Materials and Methods】 Fifty-four patients from 2012 to 2019. Stone free (SF) was defined as 4 mm or smaller.

  【Results】 The median age was 60 years. Additional therapies were performed in 19 patients. Finally, the stone free rate was 55.6％ (30/54). Multivariate analysis revealed a significant difference only in the CT value (median : 1,261 vs. 857 HU, p＝0.0017). Of the 30 SF patients, 12 were SF immediately after URS, but 18 were not. Comparing the final 18 patients with SF and 24 with residual stones, multivariate analysis revealed a significant difference only in the CT value (median : 1,013 vs. 1,261, p＝0.0253).

  【Conclusions】 Renal stones with higher CT values are significantly more likely to cause residual stones after URS, while those with lower CT values could become SF.

Purpose : This study aimed to define the efficacy and safety of retrograde intrarenal surgery (RIRS) using a semirigid and flexible ureterorenoscope with a holmium : yttrium-aluminum-garnet (Ho : YAG) laser as the initial treatment for upper urinary tract stones.

Methods : A total of 263 renal units (RUs) with upper urinary tract stones underwent RIRS as the initial operative treatment. Patients with no remaining fragments of ≧2 mm were considered stone free.

Results : The mean size of the stones was 10.8 mm (range : 3-40 mm). The stone-free rate was 70.0％ for all 263 RUs after only one transurethral lithotripsy treatment. For patients with stones measuring ≦10 mm in maximum diameter, a ＞80.0％ stone-free rate was achieved. Adverse events were found in 14.7％ cases.

Conclusion : RIRS using a semirigid and flexible ureterorenoscope with a Ho : YAG laser is effective and safe for upper urinary tract stone management.

  Despite surgical antimicrobial prophylaxis, febrile urinary tract infection (fUTI) occasionally occurs after transurethral lithotripsy (TUL). The aim of this study was to examine the incidence of fUTI and the risk factors of fUTI postoperatively. A total of 345 patients underwent TUL for renal stones and ureteral stones between 2013 and 2015. The median age at surgery was 64 years (range, 17-93) and 192 were males (55.7％). Mean operative time was 48±33 minutes, and the mean stone size was 12±9 mm. Altogether, 154 patients (44.6％) underwent fTUL. The incidences of pyelonephritis and septic shock after TUL were 14.5％ and 1.7％, respectively. A history of fUTI (p＜0.001) and flexible TUL (p＝0.039) were significant risk factors of fUTI after TUL. For these high risk cases, we should consider perioperative management carefully in addition to obtaining fully informed consent preoperatively.

(Objectives) We retrospectively considered transurethral ureterolithotripsy (TUL) and extracorporeal shock wave lithotripsy (ESWL) for ureteral stones with pyelonephritis at our hospital.

(Materials and Methods) A total of 104 patients who developed ureteral stones with obstructive pyelonephritis from January 2014 to March 2019 were reviewed. We analyzed curative effects and complications of TUL (71) and ESWL (9).

(Results) One patient (11％) receiving ESWL and 14 patients (19.7％) receiving TUL developed fever of 38 degrees or higher. The stone-free rate was 95.1％ with TUL and 66.6％ with ESWL.

(Conclusions) TUL after obstructive pyelonephritis is associated with an increased risk of the fever. In our hospital, many people developed fever after TUL, but it could be safety and successfully performed.

We retrospectively evaluated the effects of nephrostomy on pyelonephritis after transurethral lithotripsy (TUL). Between April 2008 and March 2020, 1,236 TUL procedures without nephrostomy and 74 with nephrostomy were performed. Risk factors for pyelonephritis after TUL were female gender (p＜0.0001), history of pyelonephritis (p＜0.0001), PS1 or higher (p＝0.003), stone size 2 cm or greater (p＝0.014) and a history of diabetes (p＝0.022). In patients with three or more risk factors, nephrostomy reduced the incidence of septic shock (p＝0.034) and shortened the period of fever (p＝0.043).

  In this study, we investigated the reliability and efficacy of photodynamic-diagnosis assisted transurethral resection of bladder tumor (PDD-TURBT) using ALAGLIO^®. In 74 patients with bladder tumor who received oral ALAGLIO^® before surgery, the diagnostic accuracy was then assessed, based on the pathological results obtained from the bladder biopsy specimens and intraoperative findings. Comparing the efficacy between the use of white light and PDD, it is found that the sensitivity of PDD was higher (PDD＝88.4％ vs. white light＝71.3％). Furthermore, the sensitivity of PDD was much higher than that of the white light (PDD＝86.5％ vs. white light＝48.6％), especially in CIS lesions. Overall, the findings suggest that the additional tumor detection rate, which was not detectable by white light but was detectable by PDD alone, was 19.4％. Therefore, PDD, in contrast to white light, is more efficient in the diagnosis of bladder cancer.

  To assess the outcomes of laparoscopic pyeloplasty (LP) for ureteropelvic junction obstruction (UPJO), we retrospectively reviewed the records of 100 patients who underwent transperitoneal laparoscopic dismembered Anderson-Hynes pyeloplasty at our institution between 2002 and 2019. Eighty-seven patients had symptoms of UPJO. Mean operating time was 270 min (178-389 min). Crossing vessels were identified in 26 patients, and 16 patients (16％) had complications. Only one patient had a complication above Clavien-Dingo grade III ; that patient’ s double J stent was pushed up after LP and had to be removed 2 months later under spinal anesthesia. The success rate was 94.6％. LP provided significant functional improvement in poorly functioning kidneys. LP is a minimally invasive method that produces excellent results in patients with UPJO.

  Laparoscopic excision of urachal remnants has been gradually gaining popularity ; however, no operative standard has been established to data yet. We retrospectively reviewed clinical outcomes and perioperative complications from 96 cases from March 2014 to March 2019 to determine whether surgical techniques have improved. The median estimated blood loss was 35 mL and median operative time was 160 minutes. Eleven perioperative complications occurred including abdominal incisional hernia and postoperative bleeding in 2 patients each. As preventative measures, we modified the surgical techniques to limit the resection area to urachal remnants and hemostasis at the umbilical defect was checked under laparoscopy. For cosmesis of umbilical reconstruction, the number of ports was reduced, and the position of the port placed at the umbilicus was changed.

Purpose : To analyze the effectiveness of magnetic resonance imaging (MRI)-guided prostate needle biopsies using BioJet navigation.

Methods : We retrospectively reviewed 280 patients who underwent MRI-guided biopsies at our institution. Patients with a prostate specific antigen (PSA) level＞4.0 ng/mL and suspicious prostate cancer (PCa) lesions by multiparametric MRI (mpMRI) underwent 2-core MRI-guided targeted needle (TB) and conventional 12-core systematic biopsies (SB) using BioJet navigation.

Results : The median age of patients was 68 years (range 53-79) and median PSA was 7.0 ng/mL (3.1-45.3). The total number of suspicious cancer lesions by mpMRI was 329. Total and clinically significant PCa cases detected were 172 (61.4％), and 139 (49.6％), respectively. On a core-basis analysis, the detection rate for TB was significantly better than for SB (38.3％ vs. 9.2％, respectively ; p＜0.0001).

Conclusions : MRI-guided targeted needle biopsy using BioJet navigation is effective for diagnostic procedures and estimations of PCa.

  Inguinal hernia (IH) after radical prostatectomy (RP) is a frequent but non-serious complication. A retrospective analysis of IH in 555 patients who underwent RP was conducted to examine operative approaches. METHODS. The median age and body mass index (BMI) were 68 and 24.0, respectively. Previous IH repair was recorded in 33 patients. Operative approaches were extraperitoneal, transperitoneal, urachal-sparing, and Retzius-sparing in 168, 253, 94, and 40 patients, respectively. RESULTS. Postoperative IH was noted in 72 patients (13％). Proportional-Hazard model analysis revealed that IH was significantly correlated with a low BMI and Retzius-sparing approach, but not with age, or peritoneal-sparing, nor urachal-sparing approach. CONCLUSION. The Retzius-sparing approach could help prevent IH in radical prostatectomy patients.

  The aim of this study was to evaluate the perioperative outcome of intracorporeal urinary diversion (ICUD) after robot-assisted laparoscopic total cystectomy (RARC).

  We retrospectively evaluated 23 consecutive patients who underwent ICUD after RARC from February 2018 to February 2020. Twelve cases in the initial group at the time of its introduction were compared with 11 cases in the latter group after it had become established.

  The rates of postoperative complications within 90 days and Clavien-Dindo classification were significantly lower in the latter group than in the initial group. No significant differences were noted in the operative time, estimated blood loss, blood transfusion, postoperative maximum CRP, WBC, or LDH between the two groups.

  This study has shown the learning curve in the rates of postoperative complications and postoperative recovery in the introduction period.

  Subjects were 344 high-risk prostate cancer patients who underwent Robot-assisted radical prostatectomy (RARP) at our hospital up to April 2019 and who were available for assessment. Median age of 68.0 (50-78) years and a median initial PSA level of 9.2 (1.9-99.5) ng/mL. A total of 94 patients were cT1c, 86 were cT2, and 164 were cT3. The mean follow-up period was 51.0 (5.7-99.4) months. The therapeutic method involves 6 months of neoadjuvant chemohormonal therapy using LHRH analogue and low-dose estramustine (EMP), followed by RARP.

  The overall survival rate was 98.5％ for 5 years, and PSA free survival was 97.6％ for 1 year, 86.5％ for 3 years, and 83.6％ for 5 years.

  It was possible to safely perform RARP following neoadjuvant chemohormonal therapy for high-risk prostate cancer. However, a longer follow-up period than that of the present study is needed to establish cancer control.

  We investigated the effects of extended lymph node dissection on postoperative functions in robot-assisted radical prostatectomy. The subjects were 222 Japanese patients who underwent robot-assisted radical prostatectomy for localized prostate cancer at our hospital between June 2013 and April 2018 and responded to questions on urinary and sexual functions in the Expanded Prostate Cancer Index Composite questionnaire during the first postoperative year. We conducted a retrospective cohort study to determine whether a relationship exists between disease-specific quality of life based on the scores in the domains of urination and sex domains, and various factors. The mean age of the subjects was 66.6 years, and 162 (73％) patients had extended lymph node dissection. We found no relationship between disease-specific quality of life and extended lymph node dissection. This study suggests that performing extended lymph node dissection in robot-assisted radical prostatectomy may not negatively affect urinary and sexual functions in Japanese patients.

Purpose : To elucidate clinical characteristics of patients who were incidentally diagnosed with prostate cancer after holmium laser enucleation of the prostate (HoLEP) and those who newly developed prostate cancer during follow-up of HoLEP.

Methods : Perioperative parameters of patients diagnosed with prostate cancer by either surgical specimen (incidental cancer) or postoperative biopsy (postoperative biopsy cancer) were compared with those of non-cancer patients.

Results : Thirty-six of 583 patients (6.2％) had incidental cancer, and 10 of the remaining 547 (1.8％) had postoperative biopsy cancer, respectively. In multivariate analysis, age and no preoperative biopsy were significant predictor for incidental cancer, and postoperative PSA was the only significant predictor for postoperative biopsy cancer. None of them died of cancer during follow-up.

Conclusion : While most patients with incidental prostate cancer had low-risk disease, few with postoperative biopsy cancer did. Long-term follow-up may thus be recommended for patients with high PSA after HoLEP.

Objective : To report the on-going status of randomized prospective study compared functional outcomes and complications over 12 months in BPH treated with ThuLEP or bipolar TURP.

Methods : We evaluated functional outcomes in 110 patients with BPH, in a randomized prospective study using IPSS, IPSS QOL, OABSS, uroflowmetry, and IIEF-5. Scores were taken before treatment and at 1, 3, 6, 9 and 12 months afterward.

Results : Both groups had significantly improved IPSS, IPSS QOL, OABSS, and uroflowmetry compared with pre-operative values. The ThuLEP group had lower median decrease in Hb (0.2 g/dL vs. 0.8 g/dL, P＝0.032) and shorter median catheterization (1 day vs. 2 days, P＝0.048) than the bipolar TURP group. In the ThuLEP group, erectile function was significantly impaired at 1 month post-treatment compared with pre-treatment, but improved to baseline at 3 months.

Conclusions : ThuLEP is superior to bipolar TURP in hemostasis, catheterization time, and preservation of erectile function in the progress report.

  Objective : The aim of this study was to evaluate the risk factor of persistent storage symptoms after holmium laser enucleation of the prostate. Methods : Subjects were a total of 277 patients who underwent holmium laser enucleation of the prostate. Patients who scored 8 points or more on the questionnaire on storage symptoms on the International prostate symptoms score in 3 or 6 months after surgery, or who started to take medication for storage symptom were defined as having storage symptoms. In addition to patients’ perioperative data including preoperative uroflowmetry, the membranous urethral length and bladder wall thickness on preoperative MRI were investigated. Logistic regression analysis was performed to assess variables associated with storage symptoms. Results : Patients’ age (P＝0.014) and prostate volume (P＝0.028) were risk factors for residual postoperative accumulation symptoms. Conclusion : The age and prostate volume can be used to predict storage symptoms after HoLEP surgery.

［Objective］ We report our experience of improved operability during retroperitoneal RAPN after adjusting the operating arm setting according to the intraoperative condition. ［Method］ During retroperitoneal RAPN for a tumor at the superior pole of the kidney, the operating arm setting was manually adjusted using the hand control assignments of da Vinci Xi when it was difficult to perform the operation with the usual arm setting. ［Results］Adjustment of the operating arm setting, thereby improving operability. ［Conclusion］ Operability during retroperitoneal RAPN was improved by adjusting the operating arm setting according to the intraoperative condition using hand control assignments. While it is necessary to master the settings and operating methods, having the operating arms in the most suitable positions may be the solution to difficult cases of RAPN and robotic surgery.