Robot-assisted laparoscopic partial nephrectomy (RAPN) for small renal cell carcinoma has become wide-spread in Japan as a standard treatment. Compared with laparoscopic partial nephrectomy (LPN), RAPN provides better operability in resection and suturing, and it has been reported to reduce complications such as bleeding and urinary leakage in addition to shortening the ischemic time.

  However various cases are candidates for RAPN, and the risk of complications differs depending on the size and location of the tumor, so a standardized index is required to determine the difficulty of the surgical procedure and risk of complications before surgery. Therefore, it is common to evaluate the difficulty using the RENAL score or PADUA classification, which score 4-6 items, such as the tumor size, location, degree of embeding, and positional relationship with the vascular system, and classify them into three levels from low to high risk.

  To preserve the renal function, it has been reported that the ischemic time should be within 25 minutes, but there are selective ischemic and non-ischemic methods that aim to preserve the renal function even further. It is desirable to select an appropriate ischemic method depending on the preoperative renal function and tumor condition. However, it goes without saying that the priorities should be to maintain a good view of the resection surface and not cut into the tumor during resection.

  Accurate recognition of the anatomy of renal blood vessels is important for selecting an ischemic method, and three-dimensional recognition of the tumor is necessary for precise tumor resection. For these purposes, we believe that the use of preoperative 3D imaging is effective. Also, an appropriate intraoperative navigation system is important.

  Complete endophytic renal tumors are among the most challenging tumors for RAPN. In confronting completely endophytic renal tumors, we try to keep several points in mind in our RAPN. Specifically, we use careful intraoperative marking and large margins at the beginning of resection. We proceed with the resection at the finest possible pitch until the tumor capsule is identified, always circling the tumor and resecting with a wide field of view. Careful dissection of the tumor capsule and renal sinus fat is performed to preserve as much of the urinary tract and blood vessels around the tumor as possible, and the tumor base is selectively sutured after tumor resection.

  Analysis of the outcomes of RAPN for complete endophytic renal tumors in our institution showed that the complete endophytic renal tumor group had smaller tumor diameter, a higher frequency of renal hilar tumors, higher N and L scores, longer warm ischemia time, a higher frequency of positive surgical margins, and a relatively lower trifecta achievement rate than the non-complete endophytic renal tumor group. Furthermore, complete endophytic renal tumor was a significant independent predictor of achieving trifecta, but not of achieving pentafecta. This suggests that the impact of complete endophytic renal tumor on long-term preservation of renal function was limited, but had a strong impact on short-term surgical outcomes. RAPN for complete endophytic renal tumors should always be performed by an expert or under the strict supervision of an expert.

  While patients with multifocal renal tumors are required to receive surgical treatments such as partial nephrectomy, radical nephrectomy, or ablative therapy, the selection is dependent on the institutional strategy, patients background or tumor factors. In our institution, robot-assisted laparoscopic partial nephrectomy is standard therapy for multifocal renal tumors. We introduced our experience for multifocal renal tumors.

  With the expanding indications for local therapy for small renal cell carcinoma (RCC), there has been an increase in instances of local recurrence following nephron-sparing therapy. Recently, reports of salvage robot-assisted laparoscopic partial nephrectomy (RAPN) for such recurrent tumors have become more common. However, compared to standard RAPN, these procedures are more challenging and require careful attention to various intraoperative considerations. This review outlines the indications for RAPN after renal local therapy and highlights key points to consider during surgery.

  Local treatments for RCC include partial nephrectomy (PN) and thermal ablation (TA). The indications and outcomes of salvage RAPN vary depending on the type of prior local treatment. For local recurrence after TA, salvage RAPN is often performed for tumors in areas difficult to re-ablate or for larger tumors. The adhesions outside the ablation site are relatively mild, making the procedure more feasible. In contrast, salvage RAPN after PN involves significant adhesions around the kidney, renal vessels, and tumor resection site. Therefore, its indications need thorough consideration. However, with careful patient selection, it can be a suitable option with minimal ischemia time, blood loss, and postoperative complications.

  Local recurrence can be broadly classified into recurrence at the treatment site and recurrence at a different site within the same kidney. Due to the anatomical differences depending on the recurrence pattern, it is crucial to consider these variations during surgery.

  In conclusion, salvage RAPN for recurrence after local therapy is a significant treatment option. Careful selection of treatment methods and surgical approaches, taking into account prior treatments and the characteristics of recurrent tumors, is essential for successful outcomes.

  The concept of pelvic lymph node dissection has changed significantly over time. In January 2023, the Japanese Society of Urological Endoscopy and Robotics established a working group on standardization of robot-assisted pelvic lymph node dissection, where experts discussed the optimal extent of pelvic lymph node dissection in the era of robotic surgery. This paper describes the pelvic anatomy necessary for pelvic lymph node dissection and outlines the new concept of extent of pelvic lymph node dissection that we propose as an approach to standardization of robot-assisted pelvic lymph node dissection.

  The Working Group for Standardization of Pelvic Lymph Node Dissection has now established anatomical definitions for the obturator, internal iliac, external iliac, common iliac, and presacral regions. The obturator region is defined as follows : cephalic for bifurcation of common iliac artery, caudal for levator ani muscle, lateral for external iliac vein and pelvic wall, medial for vesicohypogastric fascia, and dorsal for the anterior surface of the sacral plexus, and coccygeus muscle.

  This article explains the method of the internal approach for obturator lymph node dissection.

  In the pelvic lymphadenectomy in the urological surgery, the anatomical definition of the lymphadenectomy was uncertain until now. Recently, the obturator region based on anatomical landmarks has been proposed by the transregional working group of the Japanese Society of Endoscopic Surgery.

  Each region of the pelvic lymph node was defined by the working group in the Japanese Society of Endourology and Robotics. The obturator lymph node region, as defined by the working group of the Japanese Society for Endoscopic Surgery, is the region surrounded by the vesicohypogastric fascia, pelvic wall, and external iliac vein. It is defined as a obturator region including the area dorsal to the obturator nerve which has not been regarded as important in the urology until now and the fat of the para vesical and rectum which is often regarded as the internal iliac region distal side. It includes parts that urologists have not been actively dissecting, and it is necessary to understand the detailed anatomy of the coccygeal muscle, sciatic nerve, and internal iliac vessels that constitute the bottom of the obturator region. There are two methods for dissecting the obturator region. The approach from the so-called Marseilles fossa between the external iliac vessel and iliopsoas muscle (lateral approach) and the approach from the ventral side of the external iliac vessel (medial approach). In the lateral approach, the cranial side of the obturator region is developed, and the obturator nerve and internal iliac blood vessel are easy to be identified.

  Previous reports have failed to show consensus on the definition of the area for each dissecting regions regarding pelvic lymph node dissection. The working group launched by the Japanese Society of Endourology and Robotics has a new proposal regarding this matter. In this section, the definitions of external iliac region and common iliac region are described. External iliac region has anatomical limits as follows : proximal limit to the bifurcation of the common iliac artery, distal limit to the deep circumflex iliac vein, lateral limit to the genitofemoral nerve, medial limit to external iliac vein, and dorsal limit to external iliac vein and iliopsoas muscle. The boundaries of the common iliac region are bifurcation of the aorta proximally, bifurcation of the common iliac artery distally, genitofemoral nerve laterally, common iliac artery medially, and common iliac vein and iliopsoas muscle dorsally.

  The significance of pelvic lymph node dissection in prostate and bladder cancer remains a subject of debate, compounded by the lack of a clear definition regarding the anatomical boundaries of the procedure. This ambiguity stems from historical reliance on open surgical approaches, necessitating a reevaluation to accommodate the nuances introduced by robot-assisted surgery. In response to this challenge, a working group convened by the Japanese Society of Endourology and Robotics in 2023 embarked on defining the pelvic lymph node regions. Notably, the internal iliac lymph node region was proposed to encompass the area delineated by the internal iliac artery bifurcation, inferior vesical vein, vesicohypogastric fascia, uretero-hypogastric nerve fascia, and internal iliac vein. This redefinition clarified the distinction between the internal iliac and obturator lymph nodes, aligning with contemporary surgical practices. Approaching the internal iliac region necessitates mastery of robot-assisted pelvic surgery, owing to the intricate network of nerves originating from the sacrum and the constrained operative cavity, which poses challenges for hemostasis in the event of bleeding. Sequentially, dissection of the internal iliac region should follow the meticulous dissection of the obturator and external iliac areas, ensuring a comprehensive approach while mitigating procedural complexities.

  Strategically, preemptive removal of the internal iliac region before lateral deployment enhances visualization but carries the risk of early complications impeding subsequent procedures. Alternatively, initiating dissection post-obturator and external iliac dissection minimizes such risks, optimizing procedural safety and efficacy. Central to operative success is the creation of an optimal surgical field centered on the umbilical arterial cord, facilitating access to critical anatomical structures such as the inferior ureteric and inferior bladder fascia. Emphasizing the importance of a well-developed surgical field, safety and precision are ensured, thereby minimizing intraoperative risks and enhancing patient outcomes.

  In summary, defining the anatomical boundaries of pelvic lymph node dissection is pivotal in advancing surgical precision and safety in prostate and bladder cancer management. By incorporating insights from robot-assisted surgery and collaborative efforts within the academic community, this endeavor holds promise for optimizing patient care and outcomes.

  In pelvic lymph node dissection (PLND) for prostate and bladder cancer, the anatomical landmarks for defining PLND have been insufficiently detailed. Specifically, the internal iliac region has not been clearly defined in urology until now.

  A working group from the Japanese Society of Endourology and Robotics has recently provided definitions for each region of the pelvic lymph nodes, including the internal iliac area. This region is delineated by the internal iliac artery bifurcation, inferior vesical vein, vesicohypogastric fascia, ureterohypogastric nerve fascia, and internal iliac vein, aligning closely with the 263 regions used in gastrointestinal surgery.

  The ureterohypogastric nerve fascia and vesicohypogastric fascia serve as key landmarks in PLND. Dissecting these fascia reveals the internal iliac and obturator lymph node regions. Typically, by first dissecting these fascia, the anatomical relationship between the internal and external iliac vessels becomes clear, creating a broad working space. However, clearing the internal iliac region requires traction on the umbilical artery stalk, necessitating the use of a clamp. Alternatively, if dissection of the internal iliac lymph node region precedes the expansion of the vesicohypogastric fascia, the need for umbilical artery stalk traction is eliminated, resulting in a better field of view, which is a viable option with sufficient experience.

  During radical cystectomy, removing the internal iliac lymph nodes exposes the branches from the internal iliac vessels to the bladder. Managing these branches near the internal iliac vessel trunk allows for their safe excision along with the bladder.

  Pelvic lymph node dissection for prostate and bladder cancer is a surgical technique recommended in guidelines, but there is no fixed opinion on the extent and classification of such dissection. In this study, the Working Group for Standardization of robotic-assisted pelvic lymph node dissection of the Japanese Society of Endourology and Robotics defined anatomical divisions for the obturator, internal iliac, external iliac, common iliac, and pre-sacral regions. Here, we describe the pre-sacral region which is considered the following boundaries by cephalic for aortic bifurcation, caudal for the level of common iliac bifurcation, lateral for inside of common iliac artery, and dorsal for common iliac vein, sacrum.

  Rectal injury is a complication of robot-assisted radical prostatectomy (RARP). When detected intraoperatively, the primary suture of the rectum often results in an uneventful postoperative course without the need of colostomy. However, when a urethrorectal fistula develops after rectal injury, spontaneous closure of the fistula is rare, and surgical repair is required in most cases. We present a case of urethrorectal fistula that developed after RARP along with the treatment algorithm. Rectal injury was detected during RARP in a 64-year-old man, and it was closed by suturing with robotic assistance. The urethral catheter was removed on postoperative day 9, and he was discharged on postoperative day 15. On postoperative day 26, cystourethrography showed leakage of contrast medium into the rectum, which led to the diagnosis of urethrorectal fistula. Since it was detected early, the fistula was closed by urethral catheterization for 3 months. No recurrence of urethrorectal fistula was observed thereafter. Fortunately, conservative management cured this patient. Nevertheless, the urethrorectal fistula imposes a substantial burden on health care professionals and patients because of impaired quality of life and its refractoriness. Avoiding rectal injury is essential. When seminal vesicle detachment is performed at our hospital, which is a likely cause of rectal injury, we use the following innovative technique. In case of difficulty in locating the seminal vesicles, we use the Tile-Pro function to confirm the location of the seminal vesicles by intraoperative ultrasound imaging (with a linear probe that is used for robot-assisted partial nephrectomy) during robotic surgeries. This technique is simple and may aid in avoiding rectal injury.

  Open conversions are sometimes necessary in laparoscopic surgery. Robotic surgery may also require open transfer, although to a lesser extent than laparoscopy. Emergency rollout simulations should be performed to ensure a prompt and appropriate response in the event of an emergency.

  The following two cases made us demonstrate that simulations should also be performed to prepare for possible mechanical issues in robotic surgery. Case 1 was of a robot-assisted radical cystectomy. During surgery, the daVinci Xi^® stopped due to a “non-recoverable fault” during suturing of the dorsal vein complex. It was impossible to continue the procedure for 18 minutes, after which the device recovered. Case 2 was of a robot-assisted left partial nephrectomy. The daVinci Xi^® stopped due to a “non-recoverable fault” during dissection of the left renal hilum. Nothing could be done for 23 minutes until the robot recovered. Based on the experience of these two cases, we simulated a situation in which the robot stopped in emergency situations.

  Emergencies such as bleeding can occur unexpectedly and must be addressed immediately. Issues with robotic equipment can also occur unexpectedly. Therefore, when robot-assisted surgery is performed, both emergency rollout simulations and robotic equipment failure management simulations are necessary to ensure safe and successful surgery.

  During laparoscopic or robot-assisted laparoscopic surgery, carbon dioxide gas is generally used for insufflation. Pulmonary carbon dioxide gas embolization, which is one of the complications during laparoscopic or robot-assisted laparoscopic surgery, is rarely symptomatic, while some reports indicate a high mortality rate in symptomatic cases. Pulmonary carbon dioxide gas embolization should be suspected if there is a sudden decrease in end-tidal CO₂ (EtCO₂) and/or saturation of percutaneous oxygen (SpO₂) intraoperatively. In such cases, we should interrupt insufflation or decrease the insufflation pressure, provide pure oxygen, and close the injured vessels. Here, we encountered a case of cerebral gas embolization following pulmonary gas embolization. To our knowledge, only six cases of cerebral gas embolization during laparoscopic or robot-assisted laparoscopic renal surgery have been reported, and two of seven patients, including our case, resulted in death. Although hyperbaric oxygen therapy has been reported to be effective for cerebral gas embolization, it is important to prevent gas embolization itself due to its severity. Therefore, it is important not to excessively raise the pneumoperitoneal pressure, apply renal vein clamping in some cases, clip the vascular vessels as much as possible, and suture them as soon as possible when they are injured.

  We report two cases of severe surgery-related perioperative complications after robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion. Case 1 is an 86-year-old man with bladder cancer who diagnosed clinical T4aN0M0. He underwent RARC with intracorporeal bilateral ureterocutaneostomy. On postoperative day 6, he developed severe abdominal pain, fever, and hypotension. Due to suspected perforation of the rectum, emergency laparotomy and colostomy were required. Case 2 is a 50-year-old male who diagnosed bladder cancer with clinical T3aN0M0. He received neoadjuvant gemcitabine and cisplatin therapy. He underwent RARC with intracorporeal neobladder reconstruction. On postoperative day 6, drainage resembling intestinal fluid was observed emanating from the urethral catheter. Suspecting anastomotic leakage of the ileum, a diagnostic laparotomy was performed and revealed intestinal fluid leakage from the anastomosis site and anastomotic failure of the neobladder wall. The neobladder was resected, and bilateral ureterocutaneostomy were created after the resection of ileal resection with suture failure.

  The first robot-assisted adrenalectomy was reported in 1999. Since the introduction of the da Vinci surgical system, reports on robot-assisted adrenalectomy for adrenal tumors have increased. To date, multiple meta-analyses have shown that robot-assisted surgery reduces blood loss, complication rate, and length of hospital stay as compared to open surgery. Robot-assisted surgery has also been shown to be equivalent to or better than laparoscopic surgery in terms of blood loss, complication rates, rate of conversion to open surgery, and length of hospital stay. Further, robot-assisted partial adrenalectomy has been shown to have favorable surgical outcomes and be advantageous in terms of avoiding postoperative steroid replacement.

  The adrenal gland is an endocrine organ comprising the mesoderm-derived adrenal cortex and ectoderm-derived medulla. The adrenal cortex consists of three layers, the zona glomerulosa, zona fasciculata, and zona reticularis, which secretes aldosterone, cortisol, and adrenal androgens, respectively. The medulla secretes catecholamines. The adrenal glands are encased in the renal fascia along with the kidneys, with their dorsal aspect in contact with the diaphragm and psoas muscle. The right adrenal gland is adjacent to the inferior vena cava, liver, duodenum, and right kidney, whereas the left adrenal gland is adjacent to the aorta, pancreas, splenic vein, and left kidney. The adrenal arteries primarily arise from the inferior phrenic artery, aorta, and renal artery, branching into 10-50 fine branches that reach the adrenal gland, making them difficult to identify intraoperatively. Conversely, the adrenal central vein has to be ligated with silk threads or clips, or sealed with vessel-sealing devices. The left adrenal central vein is 2-3 cm long and drains into the left renal vein, whereas the right adrenal central vein is approximately 1 cm long and drains directly into the inferior vena cava at a 45º caudal angle, slightly dorsal to the vena cava. Consequently, the right adrenal central vein is prone to injury, which is almost equivalent to an inferior vena cava injury, necessitating careful handling.

  The standard treatment for adrenal tumors is laparoscopic surgery, including robot-assisted surgery ; however, open surgery may be required for large or invasive tumors. At our institution, open surgery is performed via Chevron incision or midline abdominal incision. For larger malignant tumors located cranially, a thoracoabdominal approach is utilized, which is especially useful for right-sided tumors, because herniation of the liver into the thoracic cavity provides a wide operative field. This study outlines the anatomical considerations for safe performance of adrenal tumor surgery, including open surgery.

Objective : This study investigates the initial experiences with robot-assisted adrenalectomy.

Methods : We conducted a retrospective review of 43 patients who underwent robot-assisted adrenalectomy for adrenal tumors at Kobe University Hospital between April 2022 and April 2024. We assessed the safety and perioperative outcomes of these procedures.

Results : The median age was 56 years (range 24-81), comprising 17 males and 26 females. The diagnoses included 10 cases of non-functioning adenomas, 11 cases of primary aldosteronism, 10 pheochromocytomas, 6 subclinical Cushing’s syndrome, 5 Cushing’s syndrome, and 1 myelolipoma. Nineteen procedures targeted the right adrenal gland, while 24 were on the left. Forty-two surgeries employed a transperitoneal approach, and one used a retroperitoneal approach. The robotic systems used were the da Vinci X in 37 cases, da Vinci Xi in 4 cases, and Hinotori in 2 cases. The number of robotic arms used was three in 29 cases and four in 14 cases. The median surgical time was 151 minutes (range 78-317), median pneumoperitoneum time was 117 minutes (range 57-275), and median console (cockpit) time was 88 minutes (range 38-249). The median blood loss was minimal at 0 mL (range 0-300). There was one intraoperative complication of capsular pancreatic injury classified as Clavien-Dindo grade I ; no other perioperative complications were observed. A weak correlation was noted between the console time and both tumor size and resected weight.

Conclusion : Robot-assisted laparoscopic adrenalectomy can be safely performed with complication rates, surgical durations, and blood loss comparable to existing reports, even in an initial experience setting.

  Since the advent of the Da Vinci Surgical System, reports on robot-assisted adrenalectomy (RAA) have been gradually increasing. Several systematic reviews and meta-analyses have reported that the outcomes are equivalent to or better than those of laparoscopic adrenalectomy (LA) regarding blood loss, complication rates, conversion rate to open surgery, and length of hospital stay. In the case of large adrenal cortical tumors and the case of partial resection, the usefulness of RAA has begun to be suggested. However, there are limited reports on RAA for pheochromocytoma (PCC), and the long-term outcomes are still unclear. Our hospital introduced RAA using the Da Vinci Xi in October 2022, and by March 2024, RAA had been performed on 4 of the 13 PCC patients. The operative time tended to be longer than that of LA performed on nine PCC patients during the same period, but the short-term outcomes were comparable to those of LA. Although the statistical comparison is difficult due to the timing of RAA introduction and the small number of cases, the usefulness of RAA in intraoperative hemodynamics is apparent based on the changes in intraoperative systolic blood pressure and the amount of phentolamine used. LA, for which long-term data is clear and surgical procedures are established, has become established as the standard treatment for PCC. In this review, I would like to discuss the significance and challenges of selecting RAA for PCC, based on perioperative data from RAA performed on patients with PCC in our department and recent findings from the literature.

  Here, the definition of surgeons is as follows, doctors who are board certified surgeons and also board certified gastroenterological or endocrine surgeons or opt to be them. Common background of them is being skilled for maneuver of digestive tract but relatively unfamiliar with retroperitoneal organs. Our department is named for breast and endocrine surgery and offers surgical treatment of adrenal gland and retroperitoneal tumors such as paragangliomas. Young surgeons who have little experience of adrenal gland surgery during residency join our department at around seven years after graduation. Even in our department at the university hospital, the number of adrenal gland surgeries is limited, therefore it is relatively difficult for applicants to gain enough experience of adrenal gland surgeries. However, these applicants have ample experience of endoscopic surgeries for gastrointestinal tracts before joining our department, therefore, the technical obstacle for adrenal gland surgeries is low once they are familiar with anatomy of the retroperitoneal structures. An important aspect of this situation is the guidance provided by the supervising surgeons during endoscopic surgery. In our department, supervising surgeons in general are scopists, and try to provide as much of a bird’s eye view as possible.

  On the other hand, adrenal tumors, including paragangliomas, sometimes invade adjacent structures or are so large that simultaneous resection of surrounding organs is required. To ensure the good surgical field, thoracotomy is occasionally required. In our department, thoracotomy in the higher intercostal space is employed in case that thoracotomy is required. Pheochromocytomas requiring reconstruction of blood vessels or transient vessel obstruction require not only technical issues but also collaboration with other disciplines and knowledge of hormonal dynamics.

  In this article, we introduce the camera work in endoscopic surgery, the thoracoabdominal approach in high intercostal space to giant adrenal tumors and technical issues for the adrenal tumors requiring vessel reconstruction. The essentials of technique and perioperative management are also discussed.

Objective : To investigate the safety of transurethral lithotripsy (TUL) during anticoagulant treatment.

Subjects and methods : The study included 72 patients who underwent TUL at our hospital between December 2021 and July 2023. The patients were divided into two groups : a group taking oral antithrombotic medication and a control group. Outcome measures included postoperative hematuria, postoperative fever, hospitalization extension, prolonged catheterization, and stone-free rate.

Results : The oral antithrombotic group had 13 patients, and the control group had 59 patients. In the antithrombotic group, 4 patients were administered antiplatelet medication (aspirin), 8 patients were administered anticoagulant medication (2 rivaroxaban, 2 edoxaban, 1 dabigatran, 1 apixaban, and 2 warfarin), and 1 patient was administered both antiplatelet and anticoagulant medication (apixaban and clopidogrel). The median ages of the antithrombotic and control groups were 79 (55-85) and 61 (38-90) years, respectively. Hematuria was found in 38％ and 18％ of the oral antithrombotic and control groups, respectively (P＝0.15), postoperative fever in 7.7％ and 6％ (P＝1.00), prolonged hospital stays in 23.1％ and 6.8％ (P＝0.11), and catheterization in 38.5％ and 17％ (P＝0.13). The stone-free rates were 100％ and 84％, respectively (P＝0.2). In terms of side effects, there was no statistically significant difference between the antiplatelet or antithrombotic and the controls.

Conclusion : The use of antithrombotic drugs did not increase the incidence of side effects, indicating that TUL can be performed safely under antithrombotic medication.

【Objective】To review the outcomes of endoscopic combined intrarenal surgery (ECIRS) using a vacuum-assisted access sheath at our hospital.

【Materials and Methods】We retrospectively analyzed outcomes and complications of 26 patients (30 sessions) who underwent ECIRS with a vacuum-assisted access sheath at our hospital between April 2020 and March 2023.

【Results】The age was 67±13 years, 13 patients were male and 13 patients were female, and the stone volume was 5.7 ± 6.0 cm³. SFR at initial surgery was 69.2％, and final SFR was 84.6％. Postoperative febrile urinary tract infection was observed in 7 patients in 7 sessions (23. 3％). The stone volume was associated with residual stones at initial surgery, and preoperative bacteriuria was a predictor of postoperative febrile urinary tract infection.

【Conclusion】We reported surgical outcomes following ECIRS with a vacuum-assisted access sheath at our hospital. The larger the stone volume, the more likely it is to require two or more operations, and preoperative antibiotic therapy should be considered in cases of preoperative bacteriuria.

【Purpose】In this study, we retrospectively compared the treatment results and postoperative complications between cases using the vacuum-assisted sheath (Clear Petra^® ; CP) and a conventional access sheath (CON) for endoscopic combined intrarenal surgery (ECIRS).

【Materials and Methods】 134 patients who underwent initial ECIRS from June 2011 to March 2023 were included. Access sheaths were used in the 18 Fr CP group, 18 Fr CON group, and 24 Fr CON group, and background factors and perioperative results were compared by sheath diameter among the three groups.

【Results】 The type of access sheath was 48 patients in the 18 Fr CP group, 48 patients in the 18 Fr CON group, and 38 patients in the 24Fr CON group. The initial complete lithotripsy rate for each sheath (18Fr CP vs. 18 Fr CON vs. 24 Fr CON) was 54.2％, 54.2％, and 47.4％, and postoperative fever ≧38℃ was 52.1％, 54.2％ and 36.8％, with no significant difference. The mean duration of fever was significantly shorter with 18 Fr CP group at 0.9 days, 1.8 days, and 1.2 days. In addition, postoperative Hb decrease change was significantly lower in the CP group.

【Conclusion】 The treatment results in the CP group were comparable to those in the CON group, with less intraoperative bleeding and less postoperative fever.

Objective

  To compare the changes in irrigation volume when an automatic irrigation pump is connected to single-use flexible ureteroscopes and the device is inserted.

Methods

  An automatic irrigation pump was connected to three different types of single-use flexible ureteroscopes. Irrigation volume of saline was measured for different types of device insertion. Irrigation pressure was set at 40 to 200 mmHg. Each measurement was performed 5 times for 20 seconds.

Results

  The irrigation volume increased linearly with increasing irrigation pressure with or without device insertion. Irrigation volume was significantly decreased with device insertion compared to without device insertion (p＜0.05).

Conclusion

  Irrigation volume decreased with the size of the device insertion. Understanding the relationship between the size of the device and the change of irrigation volume is helpful in performing the operation safely.

  We retrospectively evaluated treatment outcomes following Endoscopic Combined Intra Renal Surgery (ECIRS) and Transurethral lithotripsy (TUL) for kidney stones. From June 2019 to April 2023, 26 patients in the ECIRS group and 24 patients in the TUL group treated in our hospital were enrolled. There were significant differences between the two groups in age, BMI, and stone length. The stone-free rate after the first treatment was not significantly different between the ECIRS (65％) and TUL (50％) groups, and there was no significant difference in perioperative complications between the two groups. However, there was a significant difference in the stone surface area before and after surgery/total operation time between the ECIRS (2.38 mm²/min) and TUL (1.15 mm²/min) groups (p＜0.001). Furthermore, in patients with lower and multiple calyceal stones, the stone-free rate was significantly better in the ECIRS group, with rates of 62 vs. 27％ (p＝0.049) and 69 vs. 23％ (p＝0.043), respectively. We considered these cases to be good indications for ECIRS.

Objective : To evaluate the usefulness of preoperative examination.

Patients and Methods : A total of 108 patients underwent examination for upper tract urothelial carcinoma diagnosis. We identified the predictive factors for the diagnosis of upper tract urothelial carcinoma.

Results : Eighty-five patients were diagnosed with upper tract urothelial carcinoma and 23 were diagnosed with other diseases. The respective sensitivity and specificity were as follows selective urine cytology, 82.2 and 75.0, as follows ureteroscopy, 89.6 and 85.7. Multivariate analyses identified selective urine cytology (OR : 42.7, P＝0.003) and ureteroscopy (OR : 27.1, P＝0.038) as independent predictive factors for the diagnosis of upper tract urothelial carcinoma. We performed scoring of selective urine cytology as follows suspected as one point and positive as two points, and ureteroscopy positive as two points. AUC of the diagnosis of upper tract urothelial carcinoma was 0.91.

Conclusion : Our findings suggest that ureteroscopy and selective urine cytology show higher diagnostic ability.

  Since 2017, polyurethane-coated metal stents (Tumor Stent^®, Create Medic) have been available for use in the treatment of malignant ureteral obstruction (MUO) in Japan. We investigated 65 cases in which polyurethane-coated metal stents were used from April 2019 to April 2023. In the first 10 cases, more than 50％ became occluded within 6 to 12 months. Therefore, from the 11th case onwards, we managed patients with regular replacement every 6 months, and the patency rate was extremely high, at 93％. Furthermore, re-indwelling was successful in all cases of which the transurethral procedure. Polyurethane-coated metal stents for MUO are considered useful devices because they reduce the occlusion rate by being replaced every 6 months and can be readily reinserted in the event of occlusion.

  A review of surgical outcomes of laparoscopic radical prostatectomy (LRP) procedures at Toyooka Hospital were reviewed, with 150 cases treated from July 2014 to December 2017 included in the analysis. There were six different primary surgeons. The median operative time was 202 minutes and median blood loss in the cases was 200 mL. Furthermore, the median postoperative observation period was 2,205 days and late complications included inguinal hernia in 32 cases (21.3％). A positive resection margin was noted in 45 (30％), while the overall three- and five-year PSA recurrence-free rates were 88.4％ and 86.1％, respectively. Although the rates for positive resection margin, postoperative hernia incidence, and urinary abstinence were somewhat higher than those presented in previous studies, PSA recurrence rates were similar to those previously reported.

  We compared the short-term outcomes between laparoscopic pyeloplasty (LPP) and robot-assisted pyeloplasty (RAPP) for ureteropelvic junction obstruction (UPJO) to evaluate the efficacy of RAPP.

  We analyzed 24 patients who underwent LPP or RAPP in our department between 2014 and 2023. Patient demographics, operating time, length of hospital stay, estimated blood loss, postoperative symptom and complication rates, and renal function after surgery were compared between the two surgeries.

  Thirteen patients underwent LPP, whereas eleven underwent RAPP. There were no significant differences in patient demographics. Although the two groups showed no significant differences in blood loss, the operating time and length of hospital stay were significantly shorter in the RAPP group than in the LPP group. Postoperative complications, including pyelonephritis and ureteral stent stones, did not differ between the two groups. There were no significant differences in renal function after surgery.

  Both LPP and RAPP showed favorable short-term outcomes ; however, the operating time and length of hospital stay were significantly shorter in the RAPP group.

  The standard surgical procedure for upper tract urothelial carcinoma (UTUC) is nephroureterectomy. In April 2022, robot-assisted laparoscopic nephroureterectomy (RANU) was newly covered by insurance. We initiated RANU using hinotori^TM in October 2022 and reviewed our initial experience. The median operative time was 233 minutes (range : 191-291 minutes), with a median cockpit time of 166 minutes (range : 108-231 minutes), and no perioperative complications of Clavien-Dindo classification Grade 3 or higher were observed. RANU using hinotori^TM for UTUC is feasible and safe, suggesting comparable perioperative outcomes to RANU using the da Vinci Xi system.

Background : The clinical significance of pT3a upstaging in renal cell carcinoma (RCC) following robot-assisted laparoscopic partial nephrectomy (RAPN) remains to be confirmed.

Materials and Methods : In a cohort of 204 patients who underwent RAPN from March 2017 to May 2023, 12 patients who experienced pathological upstaging to pT3a were compared with the remaining 192 patients whose tumors did not upstage. The analysis focused on their perioperative course, including trifecta achievement and recurrence-free survival rates. Factors influencing upstaging were identified using univariate logistic regression analysis.

Results : The trifecta achievement rate for the upstaged group was 58％, comparable with the control group. There were no recurrences during a median observation period of 25 months, which was also comparable with the control group. Factors such as age at operation, tumor diameter, cT1b status, and lymphatic/blood vessel invasion were identified as risk factors for upstaging.

Conclusion : RAPN in patients with upstaged pT3a RCC in our institution showed favorable short-term anticancer outcomes. A larger cohort with detailed radiological and pathological analysis is required to ascertain the definitive effectiveness of RAPN in this group.

  In ileal urinary diversion, the clinical significance of retroperitonealization of the uretero-enteric anastomosis is unclear. Herein we retrospectively evaluated the relationship between retroperitonealization and the incidence of hydronephrosis in 223 patients with ileal conduit or an ileal neobladder who received follow-up computed tomography at our hospital between 2005 and 2016. The status of the retroperitonealization was determined by computed tomography. In seven patients, retroperotonealization failed. Of them, five patients developed intermittent hydronephrosis. Univariate analysis revealed that, patients with failure of the retroperotonealization had a significantly high incidence of hydronephrosis. This study suggests that retroperitonealization of the uretero-enteric anastomosis is effective for preventing the development of hydronephrosis.

  Cystoscopy was performed on a 54-year-old man to check for urinary occult blood, which was detected during a medical examination, and a tumor was found, so transurethral resection of the bladder tumor was performed. During surgery, anterior urethral stricture was noted. Subsequently, he underwent cystoscopy at an outpatient clinic, where he developed a high fever two days later and was diagnosed with acute bacterial prostatitis. Subsequently, he also developed acute prostatitis after cystoscopy nine and 11 years after his surgery. Meanwhile, four months before the onset of his third episode of prostatitis, serum PSA showed 10.8 ng/mL. For this reason, a prostate biopsy was performed, and after a diagnosis of prostate cancer, robot-assisted laparoscopic radical prostatectomy was performed. Prostate specimens showed signs of severe inflammation. Urethral stricture, performing cystoscopy and prostate biopsy are risk factors for acute bacterial prostatitis. In this case, we believe that due to these factors, the inflammation spread to the prostate and became chronic, resulting in acute exacerbation after cystoscopy.

  A 78-year-old man visited his previous physician for abdominal distention in August 2021. Abdominal US showed residual urine of 750 mL and estimated prostate volume of 50 mL. He was placed a urethral catheter with a diagnosis of urinary retention, which was removed four times under medical treatment, but he did not urinate by himself. Then, he underwent a prostatic urethral lift (PUL), but he was unable to remove the urethral catheter. And so, he was referred to our hospital in January 2023 for transurethral enucleation of the prostate (HoLEP), and HoLEP was performed in March of the same year. The patient underwent HoLEP in March of the same year. HoLEP was started after removal of an implant in the prostatic urethra. There were no intraoperative or postoperative complications, and no obvious malignant findings on histopathology. The patient was discharged from the hospital on the third postoperative day. Since PUL was not covered by insurance until April 2022 in Japan, and there have been few reports of HoLEP after PUL, we report here.

  In Japan, laparoscopic adrenalectomy (LA) is considered a standard procedure for adrenalectomy, and robotic-assisted adrenalectomy (RA) has been covered by the National Health Insurance system since April 2022. While many reports have claimed that the perioperative outcomes of RA are comparable to those of conventional LA, RA has also been reported to be effective in patients with other medical conditions, such large tumors, obesity, and a prior history of abdominal surgery. However, RA is expensive and it is crucial to minimize the use of robotic forceps and energy devices. At our hospital, laparoscopic ratchet grasping forceps are inserted from a robotic port connected to a robotic arm, and the arm clutch button is used to secure the surgical field and fix the forceps. This way, once the surgical field is secured, the grasping forceps can be fixed via the robotic arm, allowing a stable surgical field to be maintained without the need for an assistant to hold the forceps. Our innovative cost-reduction technique is easy to implement and allows surgeons to obtain a stable surgical field at a low cost. We consider that the proposed approach will contribute toward cost reduction in RA.