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IntroductionRobot-assisted surgery is becoming increasingly adopted by multiple surgical specialties. There is evidence of inherent risks of utilising new technologies that are unfamiliar early in the learning curve. The development of standardised and validated training programmes is crucial to deliver safe introduction. In this review, we aim to evaluate the current evidence and opportunities to integrate novel technologies into modern digitalised robotic training curricula.MethodsA systematic literature review of the current evidence for novel technologies in surgical training was conducted online and relevant publications and information were identified. Evaluation was made on how these technologies could further enable digitalisation of training.ResultsOverall, the quality of available studies was found to be low with current available evidence consisting largely of expert opinion, consensus statements and small qualitative studies. The review identified that there are several novel technologies already being utilised in robotic surgery training. There is also a trend towards standardised validated robotic training curricula. Currently, the majority of the validated curricula do not incorporate novel technologies and training is delivered with more traditional methods that includes centralisation of training services with wet laboratories that have access to cadavers and dedicated training robots.ConclusionsImprovements to training standards and understanding performance data have good potential to significantly lower complications in patients. Digitalisation automates data collection and brings data together for analysis. Machine learning has potential to develop automated performance feedback for trainees. Digitalised training aims to build on the current gold standards and to further improve the ‘continuum of training’ by integrating PBP training, 3D-printed models, telementoring, telemetry and machine learning.

PurposeTo develop a novel Taiwanese prostate cancer (PCa) risk model for predicting PCa, comparing its predictive performance with that of two well-established PCa risk calculator apps.Methods1545 men undergoing prostate biopsies in a Taiwanese tertiary medical center between 2012 and 2019 were identified retrospectively. A five-fold cross-validated logistic regression risk model was created to calculate the probabilities of PCa and high-grade PCa (Gleason score ≧ 7), to compare those of the Rotterdam and Coral apps. Discrimination was analyzed using the area under the receiver operator characteristic curve (AUC). Calibration was graphically evaluated with the goodness-of-fit test. Decision-curve analysis was performed for clinical utility. At different risk thresholds to biopsy, the proportion of biopsies saved versus low- and high-grade PCa missed were presented.ResultsOverall, 278/1309 (21.2%) patients were diagnosed with PCa, and 181 out of 278 (65.1%) patients had high-grade PCa. Both our model and the Rotterdam app demonstrated better discriminative ability than the Coral app for detection of PCa (AUC: 0.795 vs 0.792 vs 0.697, DeLong’s method: P < 0.001) and high-grade PCa (AUC: 0.869 vs 0.873 vs 0.767, P < 0.001). Using a ≥ 10% risk threshold for high-grade PCa to biopsy, our model could save 67.2% of total biopsies; among these saved biopsies, only 3.4% high-grade PCa would be missed.ConclusionOur new logistic regression model, similar to the Rotterdam app, outperformed the Coral app in the prediction of PCa and high-grade PCa. Additionally, our model could save unnecessary biopsies and avoid missing clinically significant PCa in the Taiwanese population.

Eastern Cooperative Oncology Group performance status (ECOG-PS) is a widely used functional status measure in oncology, yet its prognostic value in upper tract urothelial carcinoma remains unclear. In this multicenter study of 2473 patients undergoing radical nephroureterectomy, ECOG-PS ≥ 2 was independently associated with worse overall survival (hazard ratio [HR] 2.53, p  < 0.001), cancer-specific survival (HR 2.02, p  < 0.001), and disease-free survival (HR 1.50, p  = 0.003) than those with ECOG-PS 0–1. They also had a higher risk of major perioperative complications (odds ratio 2.46, p  < 0.001). These findings support ECOG-PS as a valuable preoperative risk stratification tool.

Urothelial carcinomas of the upper urinary tract (UTUC) are rare tumors with a high malignancy degree. Radical nephroureterectomy (RNU) with bladder cuff excision remains one of the standard treatments in clinically localized or locally advanced UTUCs. However, the role of cytoreductive RNU in treating clinically lymph node-positive (N+) UTUCs remains unclear. A nationwide retrospective study was conducted by the Taiwan UTUC Collaboration Group from July 1988 to June 2022. Patients with clinical N + UTUC before initiation of cancer therapy were included in this study. Initial clinically node-positive disease was noted in 288 (5.4%) of the 5,301 patients. Of the patients, 239 (83%) patients underwent RNU. UTUC-related mortality was markedly higher among patients not receiving RNU than among those who underwent surgery (69.4% vs. 36%). After adjusting for the effects of stepwise enrolled parameters, multivariate analysis showed that undergoing RNU (or not) and smoking (or not) were the only independent predictors of overall survival (OS). After adjusting for the effects of significant stepwise enrolled variables, multivariate analysis showed that RNU and smoking (or not) were the only independent predictors of cancer-specific survival (CSS). Our findings showed that RNU is associated with better OS and CSS in Taiwanese patients with N + UTUC. Common patient characteristics and most cancer characteristics were not related to the outcome. Our results provide new evidence on the efficacy of RNU for patients with N + UTUC, which could alter and guide the direction of future treatment guidelines.

PurposeThe COVID-19 pandemic has led to the cancellation or deferment of many elective cancer surgeries. We performed a systematic review on the oncological effects of delayed surgery for patients with localised or metastatic renal cell carcinoma (RCC) in the targeted therapy (TT) era.MethodThe protocol of this review is registered on PROSPERO(CRD42020190882). A comprehensive literature search was performed on Medline, Embase and Cochrane CENTRAL using MeSH terms and keywords for randomised controlled trials and observational studies on the topic. Risks of biases were assessed using the Cochrane RoB tool and the Newcastle–Ottawa Scale. For localised RCC, immediate surgery [including partial nephrectomy (PN) and radical nephrectomy (RN)] and delayed surgery [including active surveillance (AS) and delayed intervention (DI)] were compared. For metastatic RCC, upfront versus deferred cytoreductive nephrectomy (CN) were compared.ResultsEleven studies were included for quantitative analysis. Delayed surgery was significantly associated with worse cancer-specific survival (HR 1.67, 95% CI 1.23–2.27, p < 0.01) in T1a RCC, but no significant difference was noted for overall survival. For localised ≥ T1b RCC, there were insufficient data for meta-analysis and the results from the individual reports were contradictory. For metastatic RCC, upfront TT followed by deferred CN was associated with better overall survival when compared to upfront CN followed by deferred TT (HR 0.61, 95% CI 0.43–0.86, p < 0.001).ConclusionNoting potential selection bias, there is insufficient evidence to support the notion that delayed surgery is safe in localised RCC. For metastatic RCC, upfront TT followed by deferred CN should be considered.

Background Nephroureterectomy with bladder cuff excision is the standard treatment for high-risk upper urinary tract urothelial carcinoma (UTUC). The role of minimally invasive surgery in treating locally advanced UTUC remains controversial. This study aimed to compare the outcomes of open , laparoscopic , and robotic surgeries for managing locally advanced UTUC. Methods We retrospectively reviewed 705 patients with locally advanced UTUC from multiple institutions throughout Taiwan. Perioperative outcomes and oncological outcomes, such as cancer-specific survival , overall survival , disease-free survival and bladder-free survival , were compared between the open, laparoscopic and robotic groups. Results The minimally invasive group had better overall and cancer-specific survival (CSS) rates. The 2-year CSS rates of the open, laparoscopic and robotic groups were 71%, 83%, and 77% respectively ( p  < 0.001). The robotic group had similar outcomes to the laparoscopic group. ( p  = 0.061, 0.825, 0.341 for OS, CSS, DFS respectively.) More lymph node dissections were performed and more lymph nodes were harvested in the robotic group ( p  = 0.009). Conclusions Our results demonstrated that minimally invasive surgery, including laparoscopic and robotic surgery, for locally advanced UTUC resulted in oncological outcomes that are non-inferior to those of open surgery.

Background Most cases of upper tract urothelial carcinoma (UTUC) exhibit recurrence within the first year following surgery. The time from surgery to recurrence significantly impacts cancer-specific survival. In this study, we analyzed patients with localized UTUC (pTis–3N0/xcM0) who experienced postoperative recurrence to identify an appropriate early recurrence time point and the associated risk factors. Methods From July 1988 to October 2022, we retrospectively analyzed 3435 localized UTUC patients after undergoing radical nephroureterectomy using Taiwan's UTUC Collaboration Group Database. Early recurrence time point was defined according to oncologic outcome. Variables including clinical and pathological characteristics were assessed in relation to early recurrence. A prediction model was constructed by factors associated with early recurrence and externally validated. Results Early recurrence time point in localized UTUC was determined at 9 months post-surgery, with patients experiencing early recurrence exhibiting worse overall and cancer specific survival. Diabetes mellitus, multifocality, lympho-vascular invasion, tumor necrosis and pathologic T stage were independent factors associated with early recurrence. The predictive model for early recurrence achieved an area under the curve (AUC) of 0.84 (95%CI: 0.82–0.86). External validation demonstrated that the model exhibited good discrimination (AUC: 0.76, 95%CI: 0.73–0.79), calibration (Brier score: 0.08) and clinical utility in a distinct cohort. Conclusions This study identified the optimal time point for early recurrence and its associated risk factors. A prediction model for early recurrence was developed based on these factors and validated externally, demonstrating good generalizability. This clinical tool can facilitate early identification of high-risk patients, enabling targeted surveillance and timely intervention. Future studies should explore effective treatment strategies for preventing early recurrence.

Purpose To evaluate predictive factors of increasing intravesical recurrence (IVR) rate in patients with upper tract urothelial carcinoma (UTUC) after receiving radical nephroureterectomy (RNUx) with bladder cuff excision (BCE). Materials and methods A total of 2114 patients were included from the updated data of the Taiwan UTUC Collaboration Group. It was divided into two groups: IVR-free and IVR after RNU x , with 1527 and 587 patients, respectively. To determine the factors affecting IVR, TNM stage, the usage of pre-operative ureteroscopy, and pathological outcomes were evaluated. The Kaplan–Meier estimator was used to estimate the rates of prognostic outcomes in overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and bladder recurrence-free survival (BRFS), and the survival curves were compared using the stratified log-rank test. Results Based on our research, ureter tumor, female, smoking history, age (< 70 years old), multifocal tumor, history of bladder cancer were determined to increase the risk of IVR after univariate analysis. The multivariable analysis revealed that female (BRFS for male: HR 0.566, 95% CI 0.469–0.681, p  < 0.001), ureter tumor (BRFS: HR 1.359, 95% CI 1.133–1.631, p  = 0.001), multifocal (BRFS: HR 1.200, 95% CI 1.001–1.439, p  = 0.049), history of bladder cancer (BRFS: HR 1.480, 95% CI 1.118–1.959, p  = 0.006) were the prognostic factors for IVR. Patients who ever received ureterorenoscopy (URS) did not increase the risk of IVR. Conclusion Patients with ureter tumor and previous bladder UC history are important factors to increase the risk of IVR after RNU x . Pre-operative URS manipulation is not associated with higher risk of IVR and diagnostic URS is feasible especially for insufficient information of image study. More frequent surveillance regimen may be needed for these patients.

Mobile health apps have emerged as useful tools for patients and clinicians alike, sharing health information or assisting in clinical decision-making. Prostate cancer (PCa) risk calculator mobile apps have been introduced to assess risks of PCa and high-grade PCa (Gleason score ≥7). The Rotterdam Prostate Cancer Risk Calculator and Coral-Prostate Cancer Nomogram Calculator apps were developed from the 2 most-studied PCa risk calculators, the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the North American Prostate Cancer Prevention Trial (PCPT) risk calculators, respectively. A systematic review has indicated that the Rotterdam and Coral apps perform best during the prebiopsy stage. However, the epidemiology of PCa varies among different populations, and therefore, the applicability of these apps in a Taiwanese population needs to be evaluated. This study is the first to validate the PCa risk calculator apps with both biopsy and prostatectomy cohorts in Taiwan. The study's objective is to validate the PCa risk calculator apps using a Taiwanese cohort of patients. Additionally, we aim to utilize postprostatectomy pathology outcomes to assess the accuracy of both apps with regard to high-grade PCa. All male patients who had undergone transrectal ultrasound prostate biopsies in a single Taiwanese tertiary medical center from 2012 to 2018 were identified retrospectively. The probabilities of PCa and high-grade PCa were calculated utilizing the Rotterdam and Coral apps, and compared with biopsy and prostatectomy results. Calibration was graphically evaluated with the Hosmer-Lemeshow goodness-of-fit test. Discrimination was analyzed utilizing the area under the receiver operating characteristic curve (AUC). Decision curve analysis was performed for clinical utility. Of 1134 patients, 246 (21.7%) were diagnosed with PCa; of these 246 patients, 155 (63%) had high-grade PCa, according to the biopsy results. After confirmation with prostatectomy pathological outcomes, 47.2% (25/53) of patients were upgraded to high-grade PCa, and 1.2% (1/84) of patients were downgraded to low-grade PCa. Only the Rotterdam app demonstrated good calibration for detecting high-grade PCa in the biopsy cohort. The discriminative ability for both PCa (AUC: 0.779 vs 0.687; DeLong's method: P<.001) and high-grade PCa (AUC: 0.862 vs 0.758; P<.001) was significantly better for the Rotterdam app. In the prostatectomy cohort, there was no significant difference between both apps (AUC: 0.857 vs 0.777; P=.128). The Rotterdam and Coral apps can be applied to the Taiwanese cohort with accuracy. The Rotterdam app outperformed the Coral app in the prediction of PCa and high-grade PCa. Despite the small size of the prostatectomy cohort, both apps, to some extent, demonstrated the predictive capacity for true high-grade PCa, confirmed by the whole prostate specimen. Following our external validation, the Rotterdam app might be a good alternative to help detect PCa and high-grade PCa for Taiwanese men.

The clinical efficacy of adjuvant chemotherapy in upper tract urothelial carcinoma (UTUC) is unclear. We aimed to assess the therapeutic outcomes of adjuvant chemotherapy in patients with advanced UTUC (pT3-T4) after radical nephroureterectomy (RNU). We retrospectively reviewed the data of 2108 patients from the Taiwan UTUC Collaboration Group between 1988 and 2018. Comprehensive clinical features, pathological characteristics, and survival outcomes were recorded. Univariate and multivariate Cox proportional hazards models were used to evaluate overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS). Of the 533 patients with advanced UTUC included, 161 (30.2%) received adjuvant chemotherapy. In the multivariate analysis, adjuvant chemotherapy was significantly associated with a reduced risk of overall death (hazard ratio (HR), 0.599; 95% confidence interval (CI), 0.419–0.857; p = 0.005), cancer-specific mortality (HR, 0.598; 95% CI, 0.391–0.914; p = 0.018), and cancer recurrence (HR, 0.456; 95% CI, 0.310–0.673; p < 0.001). The Kaplan–Meier survival analysis revealed that patients receiving adjuvant chemotherapy had significantly better five-year OS (64% vs. 50%, p = 0.002), CSS (70% vs. 62%, p = 0.043), and DFS (60% vs. 48%, p = 0.002) rates compared to those who did not receive adjuvant chemotherapy. In conclusion, adjuvant chemotherapy after RNU had significant therapeutic benefits on OS, CSS, and DFS in advanced UTUC.