This review explores the critical anatomical insights essential for optimizing functional outcomes in surgical management of benign prostatic hyperplasia (BPH). With the introduction of minimally invasive surgical therapies (MIST), such as Prostatic Urethral Lift (PUL) and WAVE (Water Vapor Energy Treatment), as well as Urethral-sparing Robot-assisted Simple Prostatectomy (usRASP), significant advances have been achieved in preserving urinary continence and ejaculatory function. These techniques highlight the precise anatomical regions that govern these functions, underscoring their importance in contemporary practice.

  Holmium Laser Enucleation of the Prostate (HoLEP), while widely accepted, has traditionally been associated with postoperative stress urinary incontinence (SUI). Yet, innovations like the Omega Sign technique and early apical releasing have allowed for greater protection of the external urethral sphincter, markedly reducing the risk of SUI.

  In terms of preserving ejaculatory function, the integrity of tissues surrounding the verumontanum remains vital. Techniques such as TURP and Photoselective Vaporization of the Prostate (PVP) have demonstrated high ejaculatory preservation rates, whereas HoLEP faces inherent limitations in sparing urethral tissue. Aquablation, using the “butterfly cut” approach, shows promising reproducibility in ejaculatory preservation.

  Integrating advanced anatomical understanding with these surgical innovations holds the potential to enhance patient quality of life, refining functional outcomes and supporting a nuanced, patient-centered approach to BPH management.

  A thulium laser’s wavelength range (1,940-2,013 nm) is highly absorbed by water molecules, resulting in a shallow penetration depth of approximately 0.2 mm into prostatic tissue. The laser can operate in both continuous and non-continuous modes, making it suitable for soft tissue incision, vaporization, enucleation, and dissection in cases of benign prostatic hyperplasia (BPH). The American Urological Association and the European Association of Urology recognize thulium laser prostate enucleation as a standard treatment comparable to holmium laser prostate enucleation and transurethral resection of the prostate. A key feature of thulium laser vaporization is that high-power irradiation enhances vaporization efficiency while exerting minimal impact on penetration depth. Recently, a hybrid laser technology has been developed for thulium lasers, allowing operation in both continuous-wave and pulsed modes. This advancement is expected to improve the efficiency of tissue dissection, incision, and vaporization. A thorough understanding of thulium laser characteristics is essential for performing transurethral endoscopic surgery using this technology.

  There are many surgical treatments for benign prostatic hyperplasia (BPH), and endoscopic enucleation has become the most commonly performed procedure in Japan in recent years. On the other hand, there are a certain number of patients who cannot undergo surgical treatment for various reasons, and until now there has been no effective treatment for these patients. The water vapor energy therapy (WAVE) using the Rezum^TM system, which was approved in Japan in September 2022, is a minimally invasive surgical treatment (MIST) using water vapor under an endoscope.

  WAVE is a treatment to release lower urinary tract obstruction and improve urinary output by shrinking the enlarged prostate gland through thermal denaturation of the tissue by steam, but after the treatment, the prostate gland becomes temporarily swollen and dysuria increases, requiring the placement of a balloon catheter. Prostate shrinkage is observed over a period of 3 to 6 months, and the effectiveness of the treatment has been confirmed over a 5-year period¹⁾. We are awaiting the reports on the results of this treatment, which is expected to become a new treatment option for benign prostatic hyperplasia in Japan.

  The Prostatic Urethral Lift (PUL) is a minimally invasive surgical treatment for benign prostatic hyperplasia that bridges the gap between drug therapy and conventional surgical treatment such as TURP. The PUL using the UroLift2^® system has been covered by insurance in Japan since April 2022. In a super-aging society that many baby boomers are entering the late-stage seniors, this technique is currently expected to be a safe and effective treatment for high-risk patients with frequent complications and for elderly people who are concerned about the effects of polypharmacy. This procedure is effective for lower urinary tract symptoms by creating an appropriate anterior channel. As the technique uses a dedicated device, it is necessary to learn intraoperative surgical precautions and understand how to select and place implants according to the different shapes of the prostate. Although rare, specific complications such as pelvic hematomas can occur and require the surgeon to acquire sufficient skill. In this article, we describe the tips and tricks for appropriate channel formation in PUL.

  The primary goal of surgery for benign prostatic hyperplasia (BPH) has been to improve the lower urinary tract symptoms caused by bladder outlet obstruction associated with prostate enlargement. Major surgical techniques include transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), and photoselective vaporization of the prostate (PVP), all aimed at the removal of prostate tissue, and these procedures are widely performed in Japan.

  In recent years, several new techniques have been introduced under the concept of minimally invasive surgical therapies (MIST). Techniques such as the prostatic urethral lift and water vapor energy therapy represent this new approach. These methods are characterized by a reduced incidence of adverse events, such as bleeding, and a decreased requirement for general anesthesia. As a result, these techniques can be performed on patients in poor general condition, those taking antithrombotic drugs, and in other cases where conventional surgical therapies might be challenging or inappropriate.

  Furthermore, MIST techniques have the added benefit of preserving ejaculatory function postoperatively, making them an appealing option for patients who seek improvement in lower urinary tract symptoms without compromising postoperative quality of life. In recent years, the surgical landscape in the United States has shifted significantly, with a marked increase in the use of MIST procedures.

  In Japan, laser surgeries like HoLEP and PVP have recently come to represent a larger proportion of surgeries compared to TURP. With the advent of MIST, the surgical trend in Japan may be expected to shift even more substantially in the future. As surgeons, having access to a broad range of techniques for treating benign prostatic hyperplasia enables us to provide treatments that are tailored to the diverse needs of our patients. Each surgical approach has its own distinct characteristics, and it is essential that we fully understand these in order to provide the most appropriate treatment for patients requiring surgical intervention.

  Understanding the pathogenesis of urinary stone disease is important not only for preventing recurrence after surgery, but also for assessing the suitability of surgery. In addition, obtaining the anatomical information through preoperative imaging studies is essential for selecting the appropriate surgical approach and for performing efficient and safe surgery. This article explains the pathogenesis of urinary stone disease and the anatomy of the kidney and ureter that urologists involved in stone surgery should understand. (1) Pathogenesis of urinary stone disease : In recent years, the molecular mechanisms (tubular cell damage, inflammation, oxidative stress, osteopontin, macrophages, etc.) and histopathological mechanisms (Randall’s plaque, etc.) of urinary stone formation have been clarified. However, the treatments currently being applied in clinical practice are based on physicochemical mechanisms (crystal nucleation, growth, aggregation and stone formation). It should be noted that in some cases, surgery can be avoided by alkalinization therapy for uric acid stones and cystine stones, and in cases where the patient has an underlying disease such as primary hyperparathyroidism, renal tubular acidosis, or intestinal hyperoxaluria, treatment of the underlying disease should be prioritized over surgery for renal stones. (2) Anatomy of the kidney and ureter : This is an important factor that affects the treatment outcomes of ESWL, TUL, and PNL/ECIRS. Lower calyceal stones are difficult to remove with ESWL, therefore f-TUL and PNL/ECIRS are preferred. Furthermore, it has been reported that the anatomy of the lower calyx affects the treatment outcomes of f-TUL as well as ESWL. For TUL, it is necessary to understand the physiological narrowing of the ureter and its three-dimensionally curved course, and for PNL/ECIRS, it is necessary to understand the anatomical relationship between the kidney and surrounding organs and the internal structure of the kidney (blood vessels and urinary tract).

  The prevalence of urolithiasis is increasing, making the selection of appropriate treatment strategies a critical issue in clinical practice. Extracorporeal Shock Wave Lithotripsy (ESWL) offers a minimally invasive option with significant advantages for suitable cases, including shorter hospital stays and lower complication rates. However, its effectiveness can vary depending on factors such as stone characteristics and patient-specific variables, leading to the necessity for retreatments in some cases. Conversely, Transurethral Lithotripsy (TUL) has gained prominence with higher single-treatment success rates but poses concerns regarding perioperative complications including infection and ureteral strictures. Recent updates in treatment guidelines and technological advancements have further refined the indications for ESWL, emphasizing the importance of accurate patient selection and the integration of innovative approaches. This review reevaluates the role of ESWL, exploring its current indications, factors influencing treatment success, and methodologies to optimize outcomes. By addressing these aspects, we aim to highlight the potential for ESWL to remain a viable and patient-friendly option in the evolving landscape of urolithiasis management.

  Endoscopic Combined Intrarenal Surgery (ECIRS) is one of the most advanced techniques in renal endoscopic surgery and is becoming increasingly recognized as the standard treatment for complex kidney stones, such as staghorn calculi. This surgical method combines percutaneous nephrolithotomy (PNL) and transurethral lithotripsy (TUL) to treat upper urinary tract stones, offering a more effective approach to stone fragmentation and removal compared to traditional standalone PNL or TUL procedures. However, the necessity for a percutaneous approach still presents a significant technical challenge. This article examines the indications, limitations, and future perspectives of ECIRS.

  As current engineering of medical equipment has been advancing fast, endoluminal technology and technique have also developed for a couple of years. Mostly, the indication and surgical methods in retrograde intrarenal surgery (RIRS) have rapidly changed in accordance with the advancement of flexible ureteroscope, laser technology compared to past decade. We, clinical physicians will have to catch up this trend and need to figure out the novel knowledge.

  In the treatment of urolithiasis, new technologies are being developed to perform surgical procedures safely and effectively. This article summarizes the indications and scope of treatment based on the latest evidence. While advancements in endoscopic technology have facilitated the widespread adoption of minimally invasive surgery, postoperative complications remain a significant concern. The thulium fiber laser, compared to traditional holmium lasers, offers higher energy efficiency, the generation of finer stone fragments, and a reduction in residual stone rates. Additionally, the introduction of renal pelvic pressure control devices and suction-equipped access sheaths has enabled better intraoperative pressure management, contributing to improved safety.

  Moreover, robotic technologies have reduced the physical burden on surgeons, enhanced operational precision, and expanded applicability to complex cases. However, challenges such as high costs and steep learning curves have hindered their broader adoption. Artificial intelligence shows promise for predicting treatment success rates in extracorporeal shock wave lithotripsy and optimizing personalized care for patients. Nevertheless, the development of technologies for real-time tracking of stone positions and evaluation of fragmentation efficacy remains a future challenge.

  In conclusion, urolithiasis treatment continues to evolve toward minimally invasive approaches, improved patient quality of life, and enhanced safety. It is essential to remember that the safest treatment is avoiding surgery whenever possible. Accurate diagnosis, appropriate selection of surgical indications, careful device selection, risk assessment, and preventive measures are all critical. It is hoped that this article will serve as a valuable resource for readers involved in urolithiasis management.

  In the treatment of non-muscle invasive bladder cancer (NMIBC), transurethral resection of bladder tumor (TURBT) is the most crucial procedure that serves both diagnostic and therapeutic purposes. TURBT combined with photodynamic diagnosis (PDD) using oral 5-aminolevulinic acid (5-ALA) has been shown to improve the detection rate of carcinoma in situ (CIS) and reduce the rate of bladder cancer recurrence. In addition, there has been growing interest in en-bloc TURBT, which involves the resection of the tumor in one piece. Traditional TURBT has involved challenges, such as the potential for tumor cell seeding in the urinary tract and reduced pathological accuracy due to resected-tumor fragmentation. En-bloc TURBT is gaining attention as a technique that may address these issues. However, there is a lack of clear evidence supporting the effectiveness of en-bloc TURBT in preventing bladder cancer recurrence. Therefore, in Japan’s 2019 bladder cancer treatment guidelines, there is no mention of en-bloc TURBT for NMIBC treatment. With recent advancements in medical devices, we has been actively performing PDD-assisted en-bloc TURBT in NMIBC cases. Here, we discuss our experiences and the potential of this approach.

  Transurethral resection of bladder tumors (TURBT) is an essential endoscopic surgery as the starting point for bladder cancer treatment, enabling tumor removal, diagnosis, and staging. However, the biological features of bladder cancer including residual tumor at the resection margin and the presence of invisible carcinoma in situ lead to compromising oncological outcomes. Seven years have passed since TURBT combined with photodynamic diagnosis (PDD-TURBT) using oral 5-aminolevulinic acid hydrochloride was approved by Japanese insurance in December 2017. This intraoperative imaging technology has contributed to improving treatment outcomes by compensating conventional white-light TURBT and by leveling surgical skills. It is the time to clarify the true clinical significance of this new imaging technology from a variety of perspectives, including efficacy, safety, and medical economics. Much attention and research has been focused on oncological aspects such as bladder recurrence, progression, and time to cancer death, as well as functional aspects such as side effects, complications, quality of life, and satisfaction to date. However, evidence regarding the economic benefits of PDD-TURBT is missing. Thus, this paper evaluates the PDD-TURBT by the economic aspects and overviews real-world data analysis of our department.

  In 2017, photodynamic diagnosis (PDD) using 5-aminolevulinic acid (ALA) was approved for insurance coverage in Japan, and is also recommended in the Bladder Cancer Clinical Practice Guidelines edited in 2019. Prior to insurance coverage, photodynamic diagnosis assisted transurethral resection of bladder tumor (PDD-TURBT) was shown to reduce the postoperative recurrence rate compared to conventional white light transurethral resection of bladder tumor (WL-TURBT). However, analysis of real-world data after insurance coverage revealed a significant decrease in the residual tumor rate and cumulative recurrence rate by PDD-TURBT. Moreover, it was reported that the cumulative recurrence rate may decrease by resecting PDD false positive lesions. On the other hand, photosensitivity and liver dysfunction were reported as side effects. However, after the insurance coverage was introduced, new cases of ALA-induced hypotension were reported, and further caution is now required. Thus, urologists need to consider the balance between the benefits and risks of PDD and make appropriate judgments regarding its indication.

  Vertebrates have a system circulating body fluids that consists from lymphatic system and cardiovascular system. The lymphatic system transports lymph fluid from peripheral tissues to the central vena cava. In addition to proteins and tissue metabolites, lymph fluid contains immune cells represented by lymphocytes, and plays an important role in infection defense and cancer immunity. Cancer cells mainly metastasize via vascular and lymphatic systems. In lymphatic metastasis, cancer cells spread from the primary tumor to the lymph nodes along the lymphatic vessels. Then, lymph node dissection is recommended for the diagnosis of lymph node metastasis and for therapeutic intent in some cancers. Lymph node dissection in the abdomen is performed for adrenal cancer, renal cell carcinoma, upper tract urothelial carcinoma, and testicular cancer. However, lymph node dissection can cause complications by damaging the lymphatic vessels, such as lymphedema due to retention of lymph fluid, lymph fistula due to overflow of lymph fluid, and lymph cysts, as well as complications by damaging the arteriovenous vessels and surrounding nerves. Therefore, abdominal lymph node dissection in the management of urologic cancer requires a thorough understanding of the local anatomy of the lymphatic vessels and their surrounding vascular, nerve, and membrane structures. This article outlines the knowledge required for abdominal lymph node dissection, focusing on anatomy.

  Testicular cancer is the most common solid tumor in adolescent and young adult men. Most patients with metastases from testicular cancer have enlarged retroperitoneal lymph nodes. The treatment for testicular cancer has improved, and even patients with metastases are expected to achieve long-term survival by appropriate treatment with chemotherapy and/or post-chemotherapy residual tumor resection, including retroperitoneal lymph node dissection (RPLND). Consequently, RPLND plays an important role in the treatment of testicular cancer.

  The aim of post-chemotherapy residual tumor resection is to determine if any cancer cells remain and to remove teratomas. Post-chemotherapy RPLND is generally performed by template when testicular tumor markers are normalized and retroperitoneal lymph node metastases remain. The right-sided template includes para-caval and inter-aortocaval lymph nodes, and the left-sided template includes para-aortic lymph nodes between the renal and iliac arteries. The postganglionic sympathetic fibers from the lumbar splanchnic nerves run in that area, and resection of these fibers by bilateral RPLND results in ejaculatory dysfunction. To reduce postoperative ejaculatory dysfunction, it is important to preserve the nerves as much as possible during bilateral RPLND.

  In Japan, laparoscopic RPLND (L-RPLND) became covered under the national health insurance system in 2020. L-RPLND is performed with a template including post-chemotherapy residual tumor when retroperitoneal lymph node metastases before chemotherapy are limited. In this chapter, RPLND for testicular cancer is summarized based on our experience in our department.

  Lymph node dissection (LND) for upper urothelial carcinoma is recommended in advanced cases of upper tract urothelial carcinoma (UTUC), although the recommendation is weak in each guideline. The reason for the weak recommendation is the lack of randomized trials, but the fact is that standardization of LND techniques is difficult. Another reason is that the results from previous retrospective studies have not been consistent in their therapeutic role. However, we have reported reasonable anatomical template of reginal lymph nodes in UTUC. Template-based LND appears to improve oncological outcome in many previous studies.

  Robotic-assisted total nephroureterectomy (RANU) will be covered by insurance in Japan from 2022. The number of cases of RANU has been increasing both globally and domestically. The issue is the feasibility of LND in robotic surgery. Although the data has not accumulated enough, we believe that LND during RANU can be done as effective as that in open surgery. Laparoscopic radical nephroureterectomy has also been reported to provide poorer cancer control than open surgery in patients with pT3 or more advanced cancer according to the randomized trial. By ensuring lymph node dissection, RANU is expected to show similar results to open surgery, even in patients with pT3 or higher.

  High-level evidence is limited regarding the indication, extent, and therapeutic significance of lymph node dissection for renal cell carcinoma. In practice, extensive lymph node dissection is rarely performed except in advanced cases. Lymph node metastasis is associated with poor prognosis, and accurate staging through lymph node dissection can aid in predicting prognosis and decision-making for postoperative adjuvant therapy. Preoperative lymph node enlargement often results in false positives, and cases without enlargement exhibit a low frequency of pathologically positive lymph nodes, even if lymph node dissection is performed. Therefore, routine lymph node dissection is not recommended in all cases ; however, it has diagnostic value in cases with a high risk of pathologically positive lymph nodes. In contrast, little evidence supports its therapeutic significance, and prospective studies have not demonstrated its therapeutic benefits. Retrospective studies have demonstrated improvements in the prognosis of high-risk patients. There is no consensus on the extent of lymph node dissection or the necessity for extended dissection, making the appropriate extent of dissection difficult to determine. Considering the complications associated with extensive lymph node dissection, the decision whether to perform lymph node dissection and its extent must be made carefully.

  Lymph node dissection is often deemed not to provide sufficient benefits compared to the complexity of the procedure and the risk of complications, leading to differences in practice between medical institutions. In urological cancers requiring retroperitoneal lymph node dissection, testicular cancer, renal pelvis/ureteral cancer, and renal cancer are notable examples. Although the extent of the dissection is not significantly different among these cancers, the purpose of lymph node dissection varies.

  For testicular cancer, lymph node dissection aims to completely remove residual cancer cells following chemotherapy for advanced cancer. While there are slight differences in the indication between seminoma and non-seminoma, in seminoma, if the residual tumor is small, the detection rate of cancer is low, allowing for the possibility of observation while considering imaging findings. In renal pelvis and ureteral cancer, while there are many reports supporting the diagnostic value of lymph node dissection, its therapeutic significance has not been fully investigated. Recently, risk stratification has been recommended, suggesting lymph node dissection be performed with nephroureterectomy in high-risk patients. However, there is no clear evidence of improved prognosis, and more data are needed. The significance of lymph node dissection in renal cancer depends on the preoperative assessment. If there is no preoperative lymph node enlargement, the likelihood of lymph node metastasis is low, and dissection is not considered to contribute to recurrence prevention or improved survival. On the other hand, if lymph node metastasis is suspected preoperatively, many believe that lymph node dissection has diagnostic value, as it enables pathological diagnosis, which may guide the selection of adjuvant chemotherapy after surgery.

  Retroperitoneal lymph node dissection is neither standardized in terms of indications nor surgical techniques, raising questions about the reproducibility of previous reports. Additionally, the risk of complications, including lymphatic fistula, remains a concern. In the future, it is hoped that the widespread adoption of robot-assisted surgery will address these issues.

  The hinotori Surgical Robot System, a domestically developed robot-assisted surgical system, was developed by Medicaroid Co., Ltd., and the first robot-assisted radical prostatectomy was performed in December 2020. Since then, the system has been more widely adopted in Japan, and as of August 2024, more than 60 units are in operation, with over 6,000 surgeries performed in various fields, including urology, gastrointestinal surgery, and gynecology. Compared with da Vinci Xi, hinotori offers a more flexible robot arm and is designed to reduce surgeon fatigue. Additionally, the long-awaited update in 2023 introduced a finger clutch button. One of hinotori’s key features is its docking-free design, which secures a large working space and minimizes interference between the robot arms and the patient-side surgeon. This design also reduces excessive stress on the patient’s abdominal wall, potentially lowering postoperative pain.

  In 2022, the Hugo RAS System from Medtronic received manufacturing and marketing approval and became available for use in clinical practice in Japan. The Hugo RAS System is a surgical assist robot with a new concept compared to other models, and is composed of four independent arm carts, an open surgeon console, and a system tower. This paper will outline the Hugo RAS System and discuss the current state of surgery using this system. It will also compare the Hugo RAS System with the da Vinci surgical system and consider the future improvements that have become apparent from our initial experience using the Hugo RAS System.

  With the progress and widespread adoption of robotic surgical systems, the indications for robot-assisted surgery have expanded, becoming a widely accepted standard treatment. The da Vinci SP Surgical System, received regulatory approval in Japan in January 2023, is the first single-port surgical systems. The most important feature of da Vinci SP is that it enables Regionalized surgery. In the field of urology, which treats retroperitoneal organs, the transperitoneal approach is no longer necessary, and a new approach method has become available. In SP-RARP, the retroperitoneal approach has become the standard surgical procedure, and a further minimally invasive transvesical approach is also available as an option. Similarly, in SP-RAPN, the retroperitoneal approach through the lower abdomen has become the standard technique, enabling a supine position approach that eliminates the need for patient repositioning. The introduction of the SP system and the capability of Regionalized Surgery have significantly broadened the range of surgical approaches. By selecting appropriate patients, the SP system facilitates the provision of less invasive and more cosmetically superior treatments.

  In July 2023, a new surgical assist robot, “Saroa,” was introduced in Japan. Saroa is the world’s first robot equipped with tactile feedback. Since August 2023, it has been applied clinically for the first time worldwide in urological surgery at our institution. This paper describes the features of Saroa, its application in urological surgery, and future prospects.

  Saroa offers high operability with features beyond traditional robotic surgery, including an expanded field of view and reduced venous bleeding. The tactile feedback, roll clutch function, and compact and lightweight design provide significant advantages during surgery.

  At our institution, Saroa has been used for procedures such as radical prostatectomy, nephrectomy, adrenalectomy, and partial nephrectomy. Although initial challenges included arm interference and limited instrument availability, collaboration with developers has led to significant improvements, enabling markedly better surgical outcomes. Additionally, Saroa’s compatibility with existing laparoscopic instruments offers potential cost-saving benefits. We anticipate further development of Saroa and strongly hope for its widespread adoption, leveraging its strengths as a domestically produced robot.

Objective : To compare the outcomes of robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC) for bladder cancer (BC).

Material and Methods : Patients who underwent RARC or ORC for BC between January 2010 and December 2019 at Tottori University and affiliated hospitals were divided into two groups (RARC or ORC) and matched by age, Eastern Cooperative Oncology Group-Performance-status, clinical T stage, pathological T stage, and presence of neoadjuvant chemotherapy.

Results : Propensity score matching was performed from 50 RARC and 204 ORC cases, and 49 RARC and 49 ORC cases were compared. Preoperative patient characteristics did not differ between the two groups. The median (range) operative time was 545 min (360-872 min) in RARC and 416 min (238-755 min) in ORC, significantly longer in RARC, and the median (range) blood loss was 250 mL (50-710 mL) in RARC and 1,000 mL (500-3,404 mL) in ORC, significantly higher in ORC (p＜0.001). Transfusion rates were 6.1％ in RARC and 79.6％ in ORC, which were significantly higher in ORC (p＜0.001). The median (range) number of lymph nodes dissected was 22 (3-58) in RARC and 13.5 (2-30) in ORC, which was significantly higher in RARC (p＜0.001). The OS, RFS, and CSS tended to be better in RARC, although not significantly different (OS : p＝0.277, CSS : p＝0.185, RFS : p＝0.370).

Conclusion : We compared the perioperative outcomes of RARC and ORC for bladder. RARC was significantly superior to ORC in terms of blood loss, and number of lymph nodes dissected, and ORC was significantly superior to RARC in terms of operative time.

(Objective) We have developed a novel technique for robotic sacrohysteropexy using an extraperitoneal approach to avoid intraoperative and postoperative bowel complications.

(Materials and Methods) Patients with apical or anterior vaginal wall prolapse who had undergone robotic sacrohysteropexy with anterior mesh only were included. Patients who had undergone total hysterectomy and those who had difficulty of promontofixation were excluded. An extraperitoneal space was developed through an approximately 3 cm lower abdominal midline incision, the promontory was exposed from the right side, and the vesicovaginal space was dissected. An anterior vaginal mesh was placed near the bladder neck and extending to the uterine cervix, and the fixed uterine cervix was traction elevated toward the promontory using the mesh.

(Results) Between January 2023 and July 2024, 47 procedures were performed, with a mean patient age of 72.3 years and 33 (70％) Stage III cases. Mean total operation time was 192 min, mean console time was 132 min, mean estimated blood loss was 16 mL, and no patients required blood transfusion. There were no intraoperative complications and nine (19％) postoperative complications, including one case of Clavien-Dindo grade 3a (duodenal stenosis), but the causal relationship with the surgery was unclear.

(Conclusion) This procedure, which does not require a head-down position, appears to be less invasive than the transperitoneal approach and was found to be safe within the short-term observation period.

Objectives : This study compared the health-related quality of life (QOL) of patients who underwent robot-assisted radical prostatectomy (RARP), I-125 seed implantation brachytherapy (BT) with/without external beam radiation therapy (EBRT) as their initial curative treatment for prostate cancer.

Materials and Methods : Among 1,067 patients with localized prostate cancer, 260 cases were treated with RARP, 530 cases were treated with BT alone, and 277 cases were treated with BT and EBRT. Patients did not receive any neo-adjuvant and/or adjuvant hormonal therapy or salvage radiation therapy. The Expanded Prostate Cancer Index Composite (EPIC) questionnaire was used to investigate QOL (function and bother for urinary, bowel, sexual, and hormonal domains). QOL records were obtained at the baseline and at 3, 6, 12, 24, and 36 post-operative months. Only patients with IIEF5 higher than 11 underwent sexual function analysis.

Results : Cases treated with BT alone and BT+EBRT had a significantly better QOL regarding urinary function and incontinence compared with RARP, and this situation continued for 36 months after the treatment. Patients treated with RARP had a significantly better QOL regarding urinary bother, irritation, bowel and hormonal function and bother. Domains of sexual, patients treated with BT ± EBRT had a significantly better QOL until 12 months after treatment, but getting worse, and there was no significant difference between RARP at 36 months.

Objective : To compare the clinical effect of contact laser vaporization of the prostate (CVP) with that of transurethral electroresection of the prostate (TURP) for the treatment of patients with benign prostatic hypertrophy.

Subjects and Methods : The subjects were patients with a prostate volume ≧40 mL and follow-up period ≧12 months. They consisted of 93 patients who underwent CVP and 60 who received TURP. The patients’ background, peri- and postoperative data, and adverse events within 2 years after the operation were compared between the two groups.

Results : The CVP group included significantly more patients receiving antithrombotic therapy. Concerning perioperative data, the operative time was significantly shorter and changes in the hemoglobin level were significantly smaller in the CVP group. The urethral catheter indwelling and hospital stay times after the operation were also significantly shorter in the CVP group. Regarding adverse events based on postoperative data, no significant difference was observed between the groups. As improvement of urinary symptoms, there was also no significant difference between them. However, additional procedures for difficult voiding were needed only in the CVP group.

Conclusion : As the operation for prostatectomy, CVP can be performed more safely than TURP but with the same efficacy. This laser operation for BPH has the potential to replace TURP for a super-aging society. Further long-term research is necessary.

Objective : Venous injury may occur during exposure of the anterior longitudinal ligament at the anterior sacral promontory (SP). We aimed to quantitatively measure the extent of the vascular window (VW) in front of the SP in patients with internal iliac vein (IIV) variations using preoperative three-dimensional computed tomography angiography (3DCTA). We hypothesized that patients with IIV variations would have a narrow VW.

Methods : This prospective observational study included patients scheduled for laparoscopic sacrocolpopexy (SCP) between July 2022 and April 2023 who underwent preoperative 3DCTA. The primary endpoint was the VW measurement in the standard and variant IIV groups using 3DCTA before SCP. The secondary endpoint was the difference between the two IIV groups adjusted for age, body mass index, hypertension, and diabetes using an analysis of covariance (ANCOVA) model. Multiple regression analysis was performed to analyze the effect of factors on the distance from the SP to great vascular bifurcations.

Results : There were 20 cases of IIV variation (20.2％). VW was 28.8±12.4 mm in the variant group and 39.6±12.6 mm in the standard group (p＝0.001). In the ANCOVA model, IIV variations affected VW (coefficient, －11.8 ; 95％ confidence interval ［CI］, －18.4 to －5.08, p＜0.001). Multivariate analysis revealed that the aorta-SP distance decreased with age (coefficient, −0.44 ; 95％CI, −0.77 to −0.11, p＝0.009).

Conclusions : One in five women has a vascular variant at the SP that restricts the “safe” zone of fxation to ＜3 cm.

Objective

  The purpose of this study was to examine the effects of mindfulness on stress during surgical procedures.

Methods

  Physicians who performed minimally invasive surgery were compared to a group of physicians who practiced mindfulness and a control group. Physiological assessment and stress assessment using the State-Trait Anxiety Inventory (STAI) were performed. For physicians who performed robot-assisted surgery, procedures were evaluated with the Global Evaluative Assessment of Robotic Skills (GEARS).

Results

  Twelve participants in the mindfulness group and seven in the control group participated in the study. The mindfulness group showed significantly lower STAI anxiety than the control group.

Conclusion

  Mindfulness may be useful in reducing stress during surgery.

Background : Robotic-assisted radical nephrectomy (RARN) has been widely adopted worldwide. This study aimed to compare perioperative outcomes between RARN and laparoscopic radical nephrectomy (LRN) in a single institution.

Methods : We retrospectively analyzed 40 RARN and 39 LRN cases performed between January 2019 and August 2024. Perioperative outcomes were compared between the two groups.

Results : The RARN group demonstrated significantly shorter operative time (126 vs 183 minutes, p＜0.01) and pneumoperitoneum time (98.5 vs 155 minutes, p＜0.01) compared to the LRN group. No significant differences were observed in patient characteristics, perioperative complications, or blood loss. Surgical material costs tended to be slightly higher in the RARN group.

Conclusion : RARN showed reduced operative time with comparable safety to LRN. Considering potential economic benefits with labor costs, RARN may be a viable option for suitable patients. Further studies are needed to validate these findings.

In our institution, we have developed and implemented an automated tracking surgical navigation system for RAPN (robot-assisted partial nephrectomy), and its clinical usefulness has been demonstrated. However, challenges have emerged with this system, precisely the blind spots in the surgical field and temporary interruptions of the optical tracking to chase the target. These issues compromise the stability and accuracy of navigation. As a result, multiple registrations (alignment) between the 3D images and endoscopic images were required to maintain navigation, potentially interrupting image guidance for the surgeon and hindering the progression of surgery. We report the improvement of a da Vinci Xi-compatible attachment designed to address these ‘blind spots’ and tracking ‘interruptions’ in the surgical field.