In Japan, robot-assisted radical cystectomy (RARC) for bladder cancer was covered by national insurance since 2018, and RARC has already been performed at many institutions. There are three methods of urinary diversion : intracorporeal urinary diversion (ICUD), extracorporeal urinary diversion (ECUD), and hybrid urinary diversion. In the Hybrid procedure, as in ECUD, visualization and palpation of the intestinal tract for urinary diversion, cleaning of the isolated intestinal tract, and anastomosis of the intestine can be performed as before. Furthermore, with the HYBRID technique, the fine anastomosis between the ureter and isolated intestine can be performed intracorporeally as with ICUD. In this article, we describe the tips and tricks of hybrid urinary diversion in RARC.

  Radical cystectomy (RC) is a gold standard procedure for muscle-invasive bladder cancer. Instead of open radical cystectomy, robot-assisted radical cystectomy (RARC) is gradually becoming more popular, and the number of the surgery undergone has increased worldwide as minimally invasive surgery. However, it is well known that RARC is one of the most challenging surgeries for inexperienced urologists. Surgeons performing RC is required high quality perioperative and postoperative outcomes. When performing this procedure, we must achieve the RC-pentafecta : negative soft tissue surgical margins, ≧16 lymph nodes yield, absence of major complications at 90 days, absence of urinary diversion-related surgical sequelae at ≦12 months, and absence of clinical recurrence at ≦12 months. Completing RC, it is required to perform multiple steps : removal of the bladder and other organs (including prostate, seminal vesicles, distal ureters, [and urethra] for men, and adjacent vagina, uterus, distal ureters and urethra for women), dissection of pelvic lymph nodes, and performing urinary diversion. Therefore, it is difficult for inexperienced urologists to complete all steps. Suppose they can perform even one of these procedures with prior experience. In that case, it will not only lead to shorter operation time and less stress, but it may also be possible to perform high-quality surgeries. Many urologists have experienced performing an ileal conduit as a urinary diversion in the era of open surgery. Therefore, extracorporeal urinary diversion (ECUD) is a familiar procedure for urologists and is easy to accept. This paper explains the advantages and disadvantages of ECUD and intracorporeal urinary diversion (ICUD), why ECUD is recommended to inexperienced urologists, and the surgical techniques for ECUD.

  Robotic-assisted radical cystectomy (RARC) followed by intracorporeal urinary diversion (ICUD) requires longer operative time but less blood loss and shorter hospital stay compared to open radical cystectomy (ORC). In this section, we will discuss tips for ICUD neobladder in particular. We use a U-shaped neobladder with a simple structure. The angle of the Trendelenburg position is set at 25° for RARC and changed to 12° for ICUD.

  During ICUD, we replace the forceps with non-sharp-tipped instruments featuring low grasping force, delicately manipulate the bowel, and utilize barbed sutures for efficient suturing. Performing RARC, lymph node dissection, bowel resection and reconstruction, and ICUD by a single surgeon is highly demanding on the surgeon. We divide the surgery into three parts, each performed by a different surgeon, in order to reduce the surgeon’s workload.

  Since robot-assisted radical cystectomy (RARC) was covered by insurance in Japan in 2018, we have performed intracorporeal urinary diversion (ICUD) in about 70 patients. Even with a surgeon and assistant who are experienced in extracorporeal urinary diversion (ECUD), ICUD may be a difficult procedure or may cause unexpected complications during the introduction phase even when it is normally considered as minimally invasive. This procedure may be complex to perform, and there may be points of caution and difficulties that are not present in ECUD. In this article, we will discuss tips to keep in mind when initiating the construction of an ileal conduit by ICUD based on the knowledge and lessons learned from the difficulties and complications our department has experienced.

  The standard surgical treatment for renal pelvis and ureter cancer is total nephroureterectomy. Recently, laparoscopic surgery has become less invasive than the previous open surgery. However, minimally invasive transurethral endoscopic treatment is considered useful for elderly patients with comorbidities or for patients with a single kidney who desire kidney-sparing surgery. It is expected to be highly beneficial to patients by reducing physical invasion and medical costs (avoiding dialysis therapy). In Europe and the United States, endoscopic kidney-sparing surgery has become widely used for low-grade non-muscle invasive cancer, and the transurethral endoscopic surgery for this disease has been proposed in European and American clinical guidelines (EAU/NCCN). Although this treatment was presented as an optional surgical treatment in the Japanese guidelines, it is actually performed only at a limited number of facilities and is not yet widely used. One of the reasons for this is that ureteroscopic surveillance is essential due to the high frequency of recurrence in the upper urinary tract, but the most important factor may be the lack of proficiency in ureteroscopic surgical techniques for this disease. At present, there is no educational system for ureteroscopic surgery for this disease in Japan, and the establishment of such a educational system in Japan is considered to be an urgent issue. This paper outlines the history and problems of ureteroscopic surgery in Japan.

  While radical nephroureterectomy was previously the gold standard treatment for nonmetastatic upper tract urothelial carcinoma, owing to recent endourologic progress, kidney-sparing management including ureteroscopic treatment has become widespread. According to the NCCN guideline, favorable clinical and pathologic criteria for nephron preservation include : a papillary, unifocal, low-grade tumor, and size less than 1.5 cm, where cross-sectional imaging shows no signs of the presence of invasive disease. On the other hand, according to the EAU guideline, endoscopic ablation should be considered in the presence of clinically low-risk cancer, unifocal disease, tumor size < 2 cm, negative for high-grade cytology, low-grade URS biopsy, and no invasive sign on CT. Kidney-sparing surgery, including ureterscopy or segmental ureterectomy, can be considered on a case-by-case basis for high-risk patients with indications such as solitary kidney, bilateral UTUC, chronic kidney disease, or any other comorbidity compromising the use of RNU. Among patients with non-metastatic, cT1, or lowe-stage UTUC diagnosed in 2004-2012 collected from the National Cancer Database in the United States, 19.7％ of patients with low-grade tumors and 6.4％ of those with high-grade tumors underwent endoscopic treatment. The proportion of patients receiving definitive endoscopic treatment increased gradually.

  Endoscopic techniques include cystoscopy, retrograde pyelography, semi-rigid ureteroscopy, flexible ureteroscopy, biopsy, laser ablation, and indwelling of a ureteral stent. Close attention should be paid to prevent a guidewire or ureteroscope from traumatizing the urothelium before its observation under direct vision.

  Refined techniques for diagnosis and treatment by ureteroscopy will facilitate improved clinical outcomes including renal preservation and survival. We believe that ureteroscopic treatment for UTUC will continue to evolve and become applicable to a wider selection of patients.

  Conservative treatment for upper tract urothelial cancer (UTUC) has been carried out for about 20 years since the early 2000s, and thanks to a better understanding of the characteristics of each laser energy used, how to use it, and advances in devices, it has become completely curable in recent years. Laser ablation has been shown to be a possible treatment method for this purpose. We report our experience with kidney-sparing surgery for UTUC, and use holmium : yttrium aluminum garnet (Ho : YAG) and neodymium : yttrium aluminum garnet (Nd : YAG) alone or in combination to achieve tissue ablation and hemostasis. We conducted a review of the results of kidney-sparing surgery and the results of thulium (Thu : YAG) laser alone.

  The standard treatment for nonmetastatic upper tract urothelial carcinoma (UTUC) is radical nephroureterectomy. However, removing one kidney increases the possibility of postoperative renal failure and dialysis, especially in patients with renal failure or diabetes.

  In recent years, kidney-sparing surgery (KSS) has become a treatment option for low-risk UTUC for considering renal function. Appropriate patient selection before surgery is important and determines cancer control. In particular, ureteroscopy (URS) is necessary for the risk classification of UTUC in the EAU guidelines, and accurate preoperative ureteroscopy is important. It has been reported that if appropriate patient selection and accurate diagnosis of low-risk UTUC are possible, KSS can provide an equivalent cancer-specific disease survival rate comparing to that of radical nephroureterectomy. At our facility, we have been performing endoscopic laser ablation since September 2018, and have been using the Thulium laser since July 2021. We experienced 14 laser ablation procedures on 7 patients during between September 2018 and May 2022. Five of the seven patients could be treated with laser ablation, but two patients had high-risk UTUC and were difficult to treat, so radical nephroureterectomy was performed as an additional treatment. There were 3 cases of recurrence after complete ablation, but all were well controlled with additional ablation. In this study, no obvious complications were observed. Appropriate patient selection and timing of secondary treatment interventions are important for KSS, and we will report on this with a review of the literature.

  The novel hinotori surgical robot system, developed in Japan, received regulatory approval in August 2020, and the first Robot-Assisted Radical Prostatectomy (RARP) utilizing hinotori was successfully conducted in December of the same year. As of September 2023, Japan has introduced 36 hinotori systems, facilitating over 2,000 urological surgeries. Significant advancements and refinements have been integrated into the hinotori surgical system, suggesting an ongoing evolution and the potential for widespread adoption in the future. For the safe introduction of surgeries using hinotori surgical system, a comprehensive understanding of structure and functionality between hinotori surgical system and the conventional da Vinci Surgical System (DVSS) is paramount. Based on our institutional experience, urological surgeries conducted with hinotori surgical system are as safe and successful as DVSS. The future of robot-assisted surgery looks set to grow further due to expected increases in insurance coverage for urologic procedures and the approval of new robotic surgical systems. This growth will require ongoing focus on understanding the unique features of each system and providing proper training for the successful introduction of different robot-assisted surgical platforms. This review aims to examine the specific features of hinotori surgical system, highlighting the differences between hinotori and DVSS for its effective use in clinical practice. It also explores the potential advancements and prospects linked with the hinotori surgical system.

  Most robot-assisted radical prostatectomy (RARP) for prostate cancer has been performed with the da Vinci Surgical system (da Vinci). In August 2020, the hinotori^TM Surgical Robot System (hinotori), a domestically produced surgical robot, was approved for production and marketing, making it the device of choice for robot-assisted surgery as well. Nagoya Central Hospital introduced hinotori, the first domestically produced surgical robot, in March 2022, while several large hospitals in the neighborhood introduced da Vinci. The background to the introduction and the changes in the number of patients due to the introduction of hinotori are described, along with the advantages of hinotori.

  In Japan, robot-assisted radical prostatectomy (RARP) has rapidly gained popularity since it became eligible for insurance coverage in 2012, and RARP can be considered the standard surgical procedure for prostate cancer which general urologists should acquire. Initially, only the daVinci was available for use, but later, hinotori received approval. Each surgical robot has its specific advantages, but there are many common aspects in terms of operation. On the other hand, the biggest difference between hinotori and daVinci is that hinotori’s arm does not grip the port. This allows for a wider operating space for the assistant doctor and the ability to manipulate nearby objects, which has its merits. However, it can result in disadvantages such as the movement of forceps and a sense of floating. To make the most of hinotori’s strengths and safely perform RARP, it is necessary to keep in mind the differences from daVinci that exist in each surgical step. Robot-assisted surgery is considered to have many advantages compared to open and laparoscopic surgery, but sufficient caution is required for specific complications. While this is true for hinotori as well as daVinci, it is known that surgery is more challenging, especially for initial cases with obesity, narrow pelvis, prostate enlargement, middle-lobe protrusion, previous intra-abdominal surgery, previous TURP, and cases after inguinal hernia surgery, so it is advisable to avoid them during the initial introduction.

  Partial nephrectomy for small renal tumors not only has anticancer properties equivalent to radical nephrectomy, but also has a clear advantage in preserving renal function, so it has been designated as the standard therapy for small renal tumors in overseas guidelines. It is also recommended in Japanese guidelines.

  Since robot-assisted partial nephrectomy (RAPN) was first reported by Gettman et al. in 2004, it is now being performed at many institutions around the world, taking advantage of fine bright field and multi-joint forceps manipulation. This is the main treatment in partial nephrectomy. RAPN has shown better results than laparoscopic artial nephrectomy in terms of rate of transition to open surgery, warm ischemia time, postoperative renal function, and length of hospital stay, and has been widely used in Japan since being covered by insurance in April 2016. It is widespread.

  This time, we will report on the RAPN surgical technique using the Japanese surgical robot hinotori and a comparison of the surgical results with da Vinci at our hospital.

  The first surgical robot system in Japan, hinotori, was newly developed by Medicaloid and was approved for manufacturing and marketing in August 2020. hinotori has unique characteristics that make it different from the conventional system, da Vinci, including docking-free design, 8-axis arm and 3D high-definition imaging. In recent years, it has gradually become popular in robotic surgery associated with renal cell carcinoma. However, there have been limited reports on the usefulness of hinotori in robotic surgery targeting renal cell carcinoma, particularly high complex renal tumors. This review focuses on robot-assisted partial nephrectomy for patients with high complex tumors as well as robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy for renal cell carcinoma with inferior vena cava thrombus, and discusses the application of hinotori to these procedures based on our experiences.

  Laparoscopic sacrocolpopexy (LSC) is often considered the first choice for pelvic organ prolapse surgery due to its high safety and effectiveness, but LSC is not a almighty for all POP. LSC is highly effective when it comes to level 1 repairs, but there are limits to level 2 reinforcement, and in principle, level 3 reinforcement is not possible. For severe cystoceles with level 2 lateral defects, the small LSC mesh alone may not provide sufficient lateral support, and transvaginal mesh surgery (TVM) is also a treatment option. The dilation of the genital hiatus in level 3 injuries is considered to be a risk for the development of pelvic organ prolapse, but LSC alone, which cannot repair level 3, is not recommended because the risk of recurrence is high if the genital hiatus remains dilated. Concomitant use of perineoplasty is required. Collaboration across institutions is desired so that other surgery can be used in cases where LSC is not indicated or in case of recurrence.

  NOTES (Natural orifice transluminal endoscopic surgery) is a technique in which an endoscope is inserted through a natural orifice such as the vagina, mouth, or anus and passes through the lumen wall to reach the body cavity. This technique allows diagnosis and treatment without making incisions on the body surface. The development of endoscopic equipment has improved the mobility, resolution, and strength of flexible scopes, and they have also become smaller, making minimally invasive surgery possible. Intraperitoneal observation, cholecystectomy, local gastric resection, and appendectomy are performed. NOTES does not damage the body wall, so it is expected to be less invasive than laparoscopic surgery, reduce postoperative pain, eliminate hernias, and be more cosmetic. Adnexectomy and total hysterectomy were also reported in vNOTES. In Japan, a device exclusively for vNOTES called GelPOINT^® V-Path (Applied Medical, Rancho Santa Margarita, CA, USA) has been available for use since January 2020. Pelvic organ prolapse surgery using vNOTES technique is also performed. This paper describes the surgical method of vNOTES.

  In robot-assisted surgery, a close approach to organs without screen blurring allows the recognition of microstructures. The risk of bladder injury and mesh erosion, which are complications of sacrocolpopexy, can be reduced by precise dissection in the vesicovaginal space. Here, we report the importance of identifying the ideal layer in anterior vaginal wall dissection, recognizing microstructures, such as muscle bundles, adventitia, and capillaries. We also describe the specific techniques in robot-assisted sacrocolpopexy.

  Laparoscopic sacrocolpopexy became covered by health insurance in Japan 7 years ago. It is a well-established procedure for the treatment of vaginal vault prolapse and uterovaginal prolapse. Recently, the indications for laparoscopic sacrocolpopexy were expanded to include multicompartmental pelvic organ prolapse, and this procedure has become more widely adopted. Robotic-assisted sacrocolpopexy has also become an option, and the number of surgeries is increasing. Although pelvic organ prolapse is a disease that adversely affects the quality of life and is not a life-threatening condition, it is important for surgeons to be well-informed about the condition, subjective symptoms, evaluation methods, conservative treatment, and surgical treatment options and to provide patients with necessary information. Laparoscopic sacrocolpopexy is a procedure aimed at restoring function to the female pelvic floor. It requires knowledge of the anatomy of the common iliac vessels in front of the sacral promontory, which is unfamiliar to urologists and gynecologists, and mesh implantation in the body. When obtaining informed consent for laparoscopic sacrocolpopexy, the surgeon should explain the known complications of the procedure as well as those specific to laparoscopic sacrocolpopexy. Therefore, the surgeon must have sufficient experience and expertise to share this information with the patient. Of particular concern is the occurrence of mesh-related complications. These complications should be noted because they are difficult to detect without long-term follow-up and are likely to go untreated. In this article, we review the perioperative complications (intraoperative and within 30 days after discharge) and postoperative complications (from 31 days after discharge) in 648 patients who were treated at our hospital.

Objective : Upper tract urothelial cancer with positive lymph nodes has a poor prognosis, so the diagnosis by lymph node dissection is important. The purpose of this study was to evaluate the outcomes of laparoscopic nephroureterectomy and lymph node dissection.

Materials and Methods : We included 151 patients who underwent laparoscopic nephroureterectomy for upper tract urothelial cancer between January 2010 and December 2021 in our hospital. Patients with distant metastasis were excluded. Extravesical recurrence-free survival and cancer-specific survival were evaluated by log-rank test. Risk factors of positive lymph nodes were evaluated by logistic regression analysis.

Results : On pT stage, 92 patients (60.9％) had pT2 or less, and 59 (39.1％) had pT3 or more. On pN stage, 109/16/26 (72.2％/10.6％/17.2％) had pN0/pN positive/pNx, respectively. The median number of lymph nodes dissected was 10 (range : 0-33). Patients with pN-positive had significantly poorer prognosis than those with pN0 or pNx ; Median extravesical recurrence-free survival and cancer-specific survival of pN positive patients were 13.9 months and 45.0 months, respectively (both P＜0.001). Multivariate analysis revealed that pN-positive were significantly associated with positive lymphovascular invasion (odds ratio 4.120, P＝0.034) and pT3 or higher (odds ratio 4.344, P＝0.049), and the number of dissected lymph nodes (odds ratio 10.937, P＝0.053) tended to be associated with pN-positive.

Conclusion : In lymph node dissection under laparoscopic nephroureterectomy for upper tract urothelial cancer, a high number of lymph nodes dissected tended to be associated with pN-positive, suggesting the importance of lymph node dissection.

【Introduction and Methods】Postoperative complications of continuous ambulatory peritoneal dialysis (CAPD) catheter placement, such as catheter malposition and peritoneal dialysis-related infections, pose significant challenges. We conducted a study evaluating the effectiveness of laparoscopic CAPD catheter placement using the abdominal wall anchor technique (PWAT) in preventing these complications.

【Results】The study included 25 male and 32 female cases, with a median age of 59 years (range : 35-87 years). The 5-year CAPD continuation rate was 65.4％. Postoperative complications included peritonitis in 9 cases (15.8％), exit site or tunnel infections in 8 cases (14.0％), and catheter malposition in 1 case (1.8％). The factor associated with postoperative infections was found to be related to Body Mass Index.

【Conclusion】The findings suggest that laparoscopic CAPD catheter placement using PWAT is a valuable technique with an exceptionally low incidence of catheter malposition.

Objective : Pelvic organ prolapse (POP) and rectal prolapse (RP) have many causes and pathogenesis in common. Herein, we report 15 patients with coexisting POP and RP who underwent laparoscopic sacrocolpopexy (LSC) and laparoscopic ventral rectopexy (LVR) concomitantly.

Methods: We retrospectively investigated the medical records of 1,530 patients who underwent LSC in our institution between December 2012 and March 2022. We analyzed 15 patients who underwent LSC and LVR concomitantly, 7 of whom had RP recurrence after previous transanal or laparoscopic surgery.

Results: Patients’ mean age was 82 (72-89) years old. The mean total operation time was 233 (126-504) minutes. Fecal incontinence disappeared in 8 out of 13 patients, and constipation improved in 3 out of 13 patients. One patient each experienced perioperative death, rectal suture exposure, and pyogenic spondylitis. RP recurred in 4 patients, 2 of which required further transanal surgery. POP recurrence over Stage II occurred in 3 patients, but there were no complaints of symptoms.

Conclusion: LSC combined with LVR is beneficial to patients with coexisting POP and RP resulting in considerable improvement of QOL. It is advantageous to treat the two diseases together, rather than performing two separate operations. Furthermore, LVR can be effective for patients with recurrent RP after transanal surgery. However, most patients with both POP and RP are in their 70s or 80s. Thus, tolerance for being under general anesthesia for long hours in a head-down tilt position should be carefully considered before planning concomitant LSC and LVR.

Objectives : The hinotori surgical robot system (hinotori^TM) is the first made-in-Japan robotic system, which initially used in urological surgeries. We evaluated the safety and efficacy of robot-assisted radical prostatectomy (RARP) using hinotori^TM.

Methods : From November 2021 through October 2022, 82 patients underwent RARP for clinically localized prostate cancer. We used a transperitoneal approach with six ports technique, just as da Vinci surgical system. Lymphadenectomy was not performed for any patients. We retrospectively collected the baseline characteristics, the perioperative data and postoperative complications of the population studied.

Results: Median patient age and serum prostate-specific antigen level were 70 years and 7.5 ng/mL, respectively. The procedures by hinotori^TM were successfully completed in all 82 cases, whereas robot recoverable malfunctions were observed in 2 cases. Median cockpit and total operative times were 164 and 249 min, respectively. Median estimated blood loss was 20 mL. The total perioperative complication rates were 13％, with about half of complications being anastomosis leakage. The specific complications by Clavien-Dindo grade 3 were inguinal hernia in 2 cases and intraoperative small bowel injury in one case. Positive surgical margin rates for pT2 and T3 were 27 and 48％, respectively. Continence recovery rates at 1, 3, 6 months postoperatively were 48, 78, 86％, respectively.

Conclusions: Our results suggest that RARP by hinotori^TM is safe, feasible, and effective. Robot-assisted surgery skills using da Vinci surgical robot system might be transferrable to surgery by hinotori^TM, even during the very initial experience.

  Objectives : The aim of the present study was to clarify the safety and usefulness of robot-assisted laparoscopic pyeloplasty (RAPP) compared with laparoscopic pyeloplasty (LPP).

Methods : From November 2009 to April 2021, 32 patients (LPP : 24, RAPP : 9) underwent pyeloplasty. The perioperative parameters and complications were compared between the two groups.

Results : There was no significant difference in the operative time, but the pneumoperitoneum time was significantly shortened in the RAPP group. (RAPP : LPP＝165±19 (min) : 225±68 (min), P＝0.02) There were no significant differences in the durations of drain placement, bladder catheter placement, hospitalization, or ureteral stent placement. There were no intraoperative complications in either group, and there was no significant difference in the incidence of postoperative complications between the two groups.

Conclusions : The perioperative outcomes of RAPP were equal to or better than those of LPP.

  Doctors’ working hours are restricted due to work style reforms. Thus, it is necessary to consider the improvement of working environments aiming at patient safety and the health and safety of medical staff. There have been no reports on the mental workload experienced by urologists during surgery. We compared patient backgrounds and surgical outcomes for cases of laparoscopic and robot-assisted nephrectomy or nephroureterectomy performed in our department. In addition, we collected the background of the four urologists who performed the operations and investigated their mental workload using the NASA-Task Load Index questionnaire.

  Laparoscopic surgery was performed in 14 cases (nephrectomy : 11 cases, nephroureterectomy : 3 cases) and robot-assisted surgery in 18 cases (nephrectomy : 5 cases, nephroureterectomy : 13 cases). Robot-assisted surgery was performed more frequently among patients who received nephroureterectomy (p＝0.0035). The operation time was 189 minutes for laparoscopic surgery and 202 minutes for robot-assisted surgery (p＝0.4866), and the amount of blood loss was 55 cc and 45 cc (p＝0.6632), respectively. There was one case of open conversion in laparoscopic surgery because of adhesion due to pyonephrosis, and there was one case of small bowel injury in robot-assisted surgery. We found that the operator’s mental workload was significantly lower in the robotic surgery group than the laparoscopic surgery group (p＝0.0254). Our findings suggest that robot-assisted surgery was as safe as laparoscopic surgery. As robot-assisted surgery is a surgical procedure with less mental workload on doctors, and its use should be expanded in the future.

  A total of 54 patients undergoing robot-assisted radical cystectomy (RARC) at our hospital were studied. Our hospital is characterized by the coexistence of intracorporeal urinary diversion (ICUD) and extracorporeal urinary diversion (ECUD). The perioperative outcomes were compared between 24 patients who underwent ICUD and 16 patients who underwent ECUD in ileal conduit diversion. The total operation time was significantly shorter for ECUD than for ICUD (median, 491 vs. 555 min; p＝0.034) ; however, the time required for lymph node dissection and cystectomy was significantly shorter for ICUD than for ECUD (213 vs. 272 min; p＝0.006). Wound dehiscence occurred as a complication in significantly more number of patients undergoing ECUD (p＝0.016). As RARC is performed by a single surgeon until the end of the operation at our hospital, a surgeon who takes more time to perform the process up to lymph node dissection and cystectomy selects ECUD to prevent the prolongation of the total operation time. Therefore, it is important to carefully select the appropriate surgical procedure considering the advantages and disadvantages of the procedure and the competence of the surgeon and surgical team, after fully understanding that RARC is a highly invasive surgery.

  Robotic-assisted laparoscopic partial nephrectomy for renal cancer is a diverse procedure. To accommodate this diversity, a 3D model of the kidney has been developed and its usefulness for preoperative and intraoperative simulation has been reported. In this study, we established the nephrectomy analysis of REVORAS, a new 3D reconstruction software for 3D medical imaging workstation, in cooperation with ZIOSOFT^®, and investigated its usefulness for preoperative simulation and intraoperative navigation. Methods : The subjects were 207 patients who underwent robot-assisted laparoscopic partial nephrectomy at our hospital between June 2015 and February 2023. Of these, 35 were operated on using 3D reconstructed images (3D-NAVI group) and 172 were not (control group). Surgical outcomes were examined by matching patient background and tumor factors using propensity score matching. The 3D-NAVI group had a significantly shorter ischemia time and a higher rate of Trifecta achievement than control group. Conclusion : Preoperative and intraoperative simulation and navigation using REVORAS may improve surgical outcomes in robot-assisted laparoscopic partial nephrectomy for renal cancer.

  Robotic-assisted laparoscopic pyeloplasty (RAPP) for pyeloureteric junction obstruction has recently become widely performed. While dismembered technique is considered the gold standard in pyeloplasty, we experienced six cases in which non-dismembered technique was required and effective, out of 33 RAPP performed in our institute. The non-dismembered techniques were used in two patients with long stenosis, two patients having problems with ureteral blood flow, and two patients having severe hydronephrosis with high insertion of the pyeloureteric junction. The techniques employed were flap technique in two, Fenger method in one, an N shaped ureteroplasty in one, and bypass ureteropyelostomy in two. All patients undergoing either technique had favorable outcomes. Non-dismembered techniques should be important surgical alternatives of RAPP.

  The aim of this study was to investigate changes in split renal function after minimally invasive surgery in patients with small renal masses. One hundred and thirty-one patients who underwent laparoscopic or robot-assisted laparoscopic partial nephrectomy and had a functioning contralateral kidney and whose split renal function was assessed preoperatively and postoperatively were enrolled in this study. Split renal function was assessed using mercaptoacetyltriglycine technetium (^99mTc-MAG3) scintigraphy. The median age was 66 years, and the median mass diameter was 2.7 cm. Of those patients, 66 underwent robot-assisted partial nephrectomy. The number of patients with tumors classified as having low, intermediate, and high complexity according to R.E.N.A.L nephrometry scores were 72, 52, and 7, respectively. The median surgical time and warm ischemic time were 223 and 22 minutes, respectively. Pathological examination revealed renal cell carcinoma in 121 (92.4％) patients. With ^99mTc-MAG3 renal scintigraphy, corrected effective renal plasma flow (cERPF) in the unaffected kidney increased by 5.4％ postoperatively, while cERPF in the affected kidney decreased by 21.6％ postoperatively. Multiple linear regression analyses revealed that factors predicting a greater reduction in cERPF in the affected kidney included a high complexity R.E.N.A.L nephrometry score, longer operative time, performance of renal calyceal repair, and higher preoperative cERPF in the affected and total kidneys. Both the amount and rate of reduction in cERPF in the affected and total kidneys were smaller when the total cERPF was ≦203 mL/min/1.73 m² than when the total cERPF was ≧204 mL/min/1.73 m².

Objective : We compared the perioperative outcomes of robot-assisted radical nephroureterectomy (RANU) and laparoscopic radical nephroureterectomy (LNU).

Material and Methods : From April 2019 to August 2023, 32 patients who received RANU and 44 patients who underwent LNU during the same period were included in the study to compare perioperative outcomes between the two groups.

Results : Median operative time was 327 and 341 minutes for RANU and LNU, respectively (p＝0.076), median blood loss was 50.0 and 82.5 mL, respectively (p＝0.050), postoperative Hb decreased to 1.8 and 2.2 g/dL, respectively (p＝0.002), postoperative CRP increased 6.9 mg/dL and 7.92 mg/L, respectively (p＝0.013), and the median number of lymphatic dissections was 11 and 7, respectively (p＝0.001).

Conclusion : Even in the early stages of RANU introduction, careful implementation facilitated perioperative results comparable to those of LNU.

  Perioperative outcomes including complications of robotic-assisted laparoscopic radical prostatectomy (RARP) surgery procedures performed at our institution were reviewed, with a total of 201 cases from December 2017 to March 2021 included in the analysis. There were five surgeons, with a median operative time of 240 minutes and console time of 179 minutes. Median blood loss amount was 68 mL and nerve sparing procedures were performed in 107 cases (53.2％). The median postoperative observation period was 1,315 days and a positive resection margin was noted in 47 (23.9％) patients. The overall 3-year PSA recurrence-free rate was 83.0％, while the rate of urinary abstinence (0-1 pads per day) at 3, 6, and 12 months after surgery was 74.9％, 87.7％ and 93.2％, respectively. Although the positive margin rate was found to be slightly worse as compared to other reports, rates for PSA recurrence, urinary abstinence, and postoperative complications were similar.

  A 79-year-old man. A close examination of repeated hematuria revealed a large 177-mL benign prostatic hyperplasia. Surgical treatment was considered, but was not feasible because he was unable to achieve an adequate lithotripsy position due to limited leg opening caused by right upper and lower extremity paralysis. He had frequent urinary retention due to bladder tamponade caused by hematuria due to benign prostatic hyperplasia, so transurethral steam therapy using Rezum^® was performed. The patient was able to void urine without urinary catheter.

  Transurethral hydrotherapy may be an effective treatment for large benign prostatic hyperplasia at high risk patients.

  Delayed surgical reconstruction of an iatrogenic ureteral obstruction is often a challenging procedure because spreading scar tissue impedes accurate identification and dissection of the injured ureter. We report technical tips for a real-time navigation system using a ureteral near-infrared ray catheter (NIRC) and indocyanine green (ICG) via a ureteral catheter and nephrostomy in delayed laparoscopic ureteral reconstruction. Two patients presented with complete obstruction of the upper ureter after surgery with extensive lymphadenectomy. After a nephrostomy tube was urgently placed and maintained for six months, laparoscopic ureteral reconstruction of the injured ureter was performed. A straight NIRC was placed in the ureter up to the obstruction point. Although the injured ureter could not be identified owing to the wide-spread scar, near-infrared light could help clearly visualize the ureter encased in scar tissue. ICG administered via a ureteral catheter and nephrostomy could indicate the obstruction point. With the aid of fluoroscopic guidance, both sides of the obstructed ureter were dissected and anastomosed successfully. We conclude that near-infrared navigation using ureteral NIRC and ICG via a ureteral catheter and nephrostomy is valuable for delayed laparoscopic reconstruction of an injured ureter.

  Laparoscopic sacrocolpopexy for pelvic organ prolapse is usually a surgical technique in which a mesh is fixed to the right promontory. Mesh fixation at the promontory is an important factor in surgical outcomes, but since this is a surgery aimed at improving QOL, measures must be taken to minimize the occurrence of complications. However, there are cases in which fixation of the promontory is difficult due to adhesions within the abdominal cavity or running blood vessels. To date, we have performed methods such as left promontory fixation and laparoscopic lateral suspension for cases presenting with difficult fixation of the right promontory. During pelvic organ prolapse surgery, there may be variations in the pelvic region depending on the anatomy of the pelvis and surgical history, and we believe that it is effective to perform the various surgical methods described above to accommodate these variations.

  Background

  The purpose of this article is to present the most recent method of patient positioning for robot-assisted nephroureterectomy (RANU).

  Methods

  We performed RANU with da Vinci Xi^® surgical system. The patient was first immobilized in the hemi-flank position using a HUG-U-VAC suction positional fixture. The operating table was rotated to the semi-flank position for renal and middle ureter dissections, and for distal ureteral dissection, the da Vinci was rolled out once, the operating table was rotated to the Trendelenburg position, and the da Vinci was rolled in again.

  Results

  We performed of RANU for the positional setting in four patients using HUG-U-VAC. The median operative time, console time, and estimated blood loss were 157.5 minutes, 108 minutes, and 16 mL, respectively. The median time from da Vinci roll-out to re-roll-in was 7.5 minutes. We performed pelvic lymph node dissection in two patients. None of the patients had serious complications (Clavien-Dindo grade 3 or higher).

  Conclusion

  We reported on the use of the HUG-U-VAC for RANU positioning and perioperative outcomes.

The “Oi-tore” is a system that applies the view-sharing technique to laparoscopic surgery, which aims at efficient learning by following a pre-recorded video of forceps manipulation by a skilled surgeon and superimposing his own forceps (i.e., training by following the surgeon). This time, we developed a system that enables “follow-up training” with a head-mounted display and its attached controller against Davinci’s 3D surgical videos. The attached controller is assigned to open and close the clutch button and the master controller, enabling the user to operate the translucent forceps superimposed on the actual surgical video recording. In addition, a system that recognizes the user’s own hands and fingers and allows them to move them freely on the video have also been created, aiming for easier and more immersive 3D training.

  Sacrocolpopexy for pelvic organ prolapse has been increasingly performed in recent years.

  The low recurrence rate is one of the reasons for selecting this technique.

  The following are five procedures to be performed intraoperatively to prevent recurrence.

  1. The right and left sacral uterine ligaments and uterine attachments are placed in the right and left fixation sutures of the mesh.

  2. Peritoneal suture for retroperitonealization of the mesh is performed with the Douglas fossa raised and the rectum straightened.

  3. The cervix is covered with a single piece of anterior wall mesh and the cervical canal is firmly connected to the anterior wall mesh.

  4. Perineoplasty is performed.

  5. If the cervix has dilated, cervical resection is performed transvaginally.