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BackgroundTo improve patient safety, there is an imperative to develop objective performance metrics for basic surgical skills training in robotic surgery.ObjectiveTo develop and validate (face, content, and construct) the performance metrics for robotic suturing and knot tying, using a chicken anastomotic model.Design, setting and participantsStudy 1: In a procedure characterization, we developed the performance metrics (i.e., procedure steps, errors, and critical errors) for robotic suturing and knot tying, using a chicken anastomotic model. In a modified Delphi panel of 13 experts from four EU countries, we achieved 100% consensus on the five steps, 18 errors and four critical errors (CE) of the task.Study 2: Ten experienced surgeons and nine novice urology surgeons performed the robotic suturing and knot tying chicken anastomotic task. The mean inter-rater reliability for the assessments by two experienced robotic surgeons was 0.92 (95% CI, 0.9–0.95). Novices took 18.5 min to complete the task and experts took 8.2 min. (p = 0.00001) and made 74% more objectively assessed performance errors than the experts (p = 0.000343).ConclusionsWe demonstrated face, content, and construct validity for a standard and replicable basic anastomotic robotic suturing and knot tying task on a chicken model.Patient summaryValidated, objective, and transparent performance metrics of a robotic surgical suturing and knot tying tasks are imperative for effective and quality assured surgical training.

IntroductionThe available studies comparing robot-assisted radical cystectomy (RARC) with intracorporeal (ICUD) vs. extracorporeal (ECUD) urinary diversion have not relied on a standardized methodology to report complications and did not assess the effect of different approaches on postoperative outcomes.MaterialsTwo hundred and sixty seven patients treated with RARC at a single center were assessed. A retrospective analysis of data prospectively collected according to a standardized methodology was performed. Multivariable logistic regression models (MVA) assessed the impact of ICUD vs. ECUD on intraoperative complications, prolonged length of stay (LOS), 30-day Clavien Dindo (CD) ≥ 2 complications and readmission rate. Interaction terms tested the impact of the approach on different patient subgroups. Lowess graphically depicted the probability of CD ≥ 2 after ICUD or ECUD according to patient baseline characteristics.ResultsOverall, 162 ICUD vs 105 ECUD (61 vs. 39%) were performed. Intraoperative complications were recorded in 24 patients. The median LOS and readmission rate were 11 vs. 13 (p = 0.02) and 24 vs. 22% (p = 0.7) in ICUD vs. ECUD, respectively. Overall, 227 postoperative complications were recorded. The overall rate of CD ≥ 2 was 35 and 43% in patients with ICUD vs. ECUD, respectively (p = 0.2). At MVA, the approach type was not an independent predictor of any postoperative outcomes (all p ≥ 0.4). Age-adjusted Charlson Comorbidity Index (ACCI) was associated with an increased risk of CD ≥ 2 (OR: 1.2, p = 0.006). We identified a significant interaction term between ACCI and approach type (p = 0.04), where patients with ICUD had lower risk of CD ≥ 2 relative to those with ECUD with increasing ACCI.ConclusionsRelying on a standardized methodology to report complications, we observed that highly comorbid patients who undergo ICUD have lower risk of postoperative complications relative to those patients who received ECUD.

PurposeTo compare outcomes of robotic-assisted partial nephrectomy (RAPN) and minimally invasive radical nephrectomy (MIS-RN) for complex renal masses (CRM).MethodsWe conducted a retrospective multicenter analysis of CRM patients who underwent MIS-RN and RAPN. CRM was defined as RENAL score 10–12. Primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS), recurrence, and complications. Multivariable analysis (MVA) and Kaplan–Meier Analysis (KMA) were used to analyze functional and survival outcomes for RN vs. PN by pathological stage.Results926 patients were analyzed (MIS-RN = 437/RAPN = 489; median follow-up 24.0 months). MVA demonstrated lack of transfusion (HR = 1.63, p = 0.005), low-grade (HR = 1.18, p = 0.018) and smaller tumor size (HR = 1.05, p < 0.001) were associated with OS. Younger age (HR = 1.01, p = 0.017), high-grade (HR = 1.18, p = 0.017), smaller tumor size (HR = 1.05, p < 0.001), and lack of transfusion (HR = 1.39, p = 0.038) were associated with CSS. Increasing tumor size (HR = 1.18, p < 0.001), high-grade (HR = 3.21, p < 0.001), and increasing age (HR = 1.02, p = 0.009) were independent risk factors for recurrence. Type of surgery was not associated with major complications (p = 0.094). For KMA of MIS-RN vs. RAPN for pT1, pT2 and pT3, 5-year OS was 85% vs. 88% (p = 0.078); 82% vs. 80% (p = 0.442) and 84% vs. 83% (p = 0.863), respectively. 5-year CSS was 98% for both procedures (p = 0.473); 94% vs. 92% (p = 0.735) and 91% vs. 90% (p = 0.581). 5-year non-CSS was 87% vs. 93% (p = 0.107); 87% for pT2 (p = 0.485) and 92% for pT3 for both procedures (p = 0.403).ConclusionRAPN in CRM is not associated with increased risk of complications or worsened oncological outcomes when compared to MIS-RN and may be preferred when clinically indicated.

The integration of Augmented Reality (AR) into daily surgical practice is withheld by the correct registration of pre‐operative data. This includes intelligent 3D model superposition whilst simultaneously handling real and virtual occlusions caused by the AR overlay. Occlusions can negatively impact surgical safety and as such deteriorate rather than improve surgical care. Robotic surgery is particularly suited to tackle these integration challenges in a stepwise approach as the robotic console allows for different inputs to be displayed in parallel to the surgeon. Nevertheless, real‐time de‐occlusion requires extensive computational resources which further complicates clinical integration. This work tackles the problem of instrument occlusion and presents, to the authors’ best knowledge, the first‐in‐human on edge deployment of a real‐time binary segmentation pipeline during three robot‐assisted surgeries: partial nephrectomy, migrated endovascular stent removal, and liver metastasectomy. To this end, a state‐of‐the‐art real‐time segmentation and 3D model pipeline was implemented and presented to the surgeon during live surgery. The pipeline allows real‐time binary segmentation of 37 non‐organic surgical items, which are never occluded during AR. The application features real‐time manual 3D model manipulation for correct soft tissue alignment. The proposed pipeline can contribute towards surgical safety, ergonomics, and acceptance of AR in minimally invasive surgery.

Background Simultaneous urothelial cancer manifestation in the lower and upper urinary tract affects approximately 2% of patients. Data on the surgical benchmarks and mid-term oncological outcomes of enbloc robot-assisted radical cystectomy and nephro-ureterectomy are scarce. Methods After written informed consent was obtained, we prospectively enrolled consecutive patients undergoing enbloc radical cystectomy and nephro-ureterectomy with robotic assistance from the DaVinci Si-HD® system in a prospective institutional database and collected surgical benchmarks and oncological outcomes. Furthermore, as one console surgeon conducted all the procedures, whereas the team providing bedside assistance was composed ad hoc, we assessed the impact of this approach on the operative duration. Results Nineteen patients (9 women), with a mean age of 73 (SD: 7.5) years, underwent simultaneous enbloc robot-assisted radical cystectomy and nephro-ureterectomy. There were no cases of conversion to open surgery. In the postoperative period, we registered 2 Clavien-Dindo class 2 complications (transfusions) and 1 Clavien-Dindo class 3b complication (port hernia). After a median follow-up of 23 months, there were 3 cases of mortality and 1 case of metachronous urothelial cancer (contralateral kidney).The total operative duration did not decrease with increasing experience (r = 0.174, p  = 0.534). In contrast, there was a significant, inverse, strong correlation between the console time relative to the total operative duration and the number of conducted procedures after adjusting for the degree of adhesions and the type of urinary diversion(r = -0.593, p  = 0.02). Conclusions These data suggest that en bloc simultaneous robot-assisted radical cystectomy and nephro-ureterectomy can be safely conducted with satisfactory mid-term oncological outcomes. With increasing experience, improved performance was detectable for the console surgeon but not in terms of the total operative duration. Simulation training of all team members for highly complex procedures might be a suitable approach for improving team performance. Trial registration : Not applicable. Dm4iGs5nWD8FkGrYCfJL2M Video Abstract

PurposeTo assess the available literature evidence that discusses the effect of surgical experience on patient outcomes in robotic setting. This information is used to help understand how we can develop a learning process that allows surgeons to maximally accommodate patient safety.MethodsA literature search of the MEDLINE/PubMed and Scopus database was performed. Original and review articles published in the English language were included after an interactive peer-review process of the panel.ResultsRobotic surgical procedures require high level of experience to guarantee patient safety. This means that, for some procedures, the learning process might be longer than originally expected. In this context, structured training programs that assist surgeons to improve outcomes during their learning processes were extensively discussed. We identified few structured robotic curricula and demonstrated that for some procedures, curriculum trained surgeons can achieve outcomes rates during their initial learning phases that are at least comparable to those of experienced surgeons from high-volume centres. Finally, the importance of non-technical skills on patient safety and of their inclusion in robotic training programs was also assessed.ConclusionTo guarantee safe robotic surgery and to optimize patient outcomes during the learning process, standardized and validated training programs are instrumental. To date, only few structured validated curricula exist for standardized training and further efforts are needed in this direction.

Background/Objectives: Robot-assisted radical cystectomy (RARC) has demonstrated improved perioperative outcomes and recovery in bladder cancer (BCa) patients. This study compares patient and tumor characteristics, operative time (OT), length of stay (LOS), and complication rates between a historical (2003–2016) and a contemporary cohort (2017–2024) treated at a high-volume robotic center. Methods: Data from 274 BCa patients who underwent RARC at AZORG Hospital, Aalst, Belgium, were analyzed. Perioperative outcomes were compared between cohorts. Multivariable Poisson regression models identified predictors of longer OT and LOS, while multivariable logistic regression models (MLRMs) assessed predictors of higher complication rates. Results: Overall, 274 BCa patients who underwent RARC were identified (38% historical cohort vs. 62% contemporary cohort). The contemporary cohort had a significantly shorter median OT (345 vs. 360 min; p = 0.048) and LOS (8 vs. 12 days; p < 0.001) compared to the historical cohort. Postoperative complications were lower in the contemporary group, with more cases experiencing no complications (60% vs. 41%) and fewer grade 3–4 complications (10% vs. 27%; p < 0.001). In multivariable Poisson regression, the contemporary cohort was an independent predictor of shorter OT (Incidence Rate Ratio [IRR]: 0.94, 95% [Confidence Interval] CI: 0.93–0.96; p = 0.04) and shorter LOS (IRR: 0.65, 95% CI: 0.60–0.69; p < 0.001). In MLRMs predicting complications, the contemporary cohort was associated with lower risk (Odds Ratio: 0.42, 95% CI: 0.23–0.76; p = 0.005). Conclusions: RARC outcomes improved significantly over time, with reduced OT, LOS, and complication rates in the contemporary cohort, highlighting advancements in surgical techniques, perioperative care, and patient safety. These findings reinforce the role of RARC in optimizing BCa treatment.

ABSTRACT Introduction: Rectovesical fistula (RVF) is a rare complication after robot-assisted radical prostatectomy (RARP) (1), often requiring complex surgery (2). Robotic systems provide dexterity and visualization for deep pelvic procedures (3, 4). We report the first RVF repair using the Hugo™ RAS System. Materials and Methods: A 76-year-old male developed fecaluria one week after catheter removal following RARP. MRI revealed a 1.3 cm fistulous tract between the bladder and rectum. Initial management included transurethral and suprapubic catheters, plus a loop colostomy. Robotic repair was performed five months later. Trocar placement, adapted to the stoma, included four robotic and two assistant ports. Posterior bladder wall dissection allowed removal of two joined catheters. The posterior bladder wall, urethrovesical anastomosis dehiscence, and a 1 cm anterior rectal defect were repaired. Fibrotic tissue and residual clip were removed. A peritoneal flap was interposed between the bladder and rectum, and a new bladder neck and vesicourethral anastomosis were created using barbed sutures. Intraoperative testing confirmed integrity, and a bladder catheter was placed. Results: The postoperative course was uneventful, with patient discharge on day 4. The bladder catheter was removed after 3 weeks. At the 2-month follow-up, urinary function was normal with good continence. Ultrasound confirmed good bladder filling and no post-void residual. Cystoscopy showed a well-healed urethrovesical anastomosis without fistula. Colostomy reversal is pending. Conclusions: This case demonstrates the feasibility and effectiveness of the Hugo™ RAS System for RVF repair post-RARP. Robotic surgery can manage complex defects with favorable outcomes (5). Robotic platforms may expand telesurgery, allowing patients to undergo procedures locally with expert surgeons operating remotely (6).

ABSTRACT Purpose: The adoption of novel multi-port, single-port and modular robotic platforms has significantly increased in the last years. We aim to provide an overview of the preliminary clinical outcomes of the procedures performed with these new robotic systems, assessing their particular features and safety profile during the learning curve Material and methods: A systematic literature search was performed on 15th May 2023 on PubMed, Embase, Scopus and Web of Science databases, to identify original articles presenting clinical outcomes of new robotic systems for abdominal urologic surgery. The study protocol was registered on PROSPERO (CRD 42023437863). Results: Six new robotic platforms were identified. Of 2925 papers identified, 71 met our inclusion criteria: 49 on single-port system and 22 on novel multi-port systems. We found variable outcomes for the most common procedures performed with these new systems. However, all of them showed acceptable perioperative and oncologic outcomes during the learning curve and good safety profile. Functional outcomes were underreported Conclusions: The adoption of novel multi-port and single-port robotic systems in urologic surgery can offer new opportunities for enhanced precision, reduced invasiveness, and potentially improved patient outcomes. The variability in outcomes across different platforms underscores the need for continued research and standardized training.

Background The management of bleeding is paramount to any surgical procedure. With the increased use of less invasive laparoscopic and robotic methods, achieving hemostasis can be challenging since the surgeons cannot manually apply hemostatic agents directly onto bleeding tissue. In this study, we assessed the use of a pliable hemostatic sealant patch comprising fibrous gelatin carrier impregnated with poly(2-oxazoline) (NHS-POx) for hemostasis in robotic liver resection in a porcine bleeding model. Methods The NHS-POx-loaded patch (GATT-Patch), was first evaluated in a Feasibility Study to treat surgical bleeding in 10 lesions, followed by a Comparative Study in which the NHS-POx patch was compared to a standard-of-care fibrin sealant patch (TachoSil), in 36 lesions (superficial, resection, or deep injuries mimicking metastasectomies). For each lesion type, the NHS-POx and fibrin sealant patches were used in an alternating fashion with 18 lesions treated with NHS-POx and 18 with the fibrin patch. Animal preparation and surgical procedures were consistent across studies. The primary outcome was time to hemostasis (TTH) within 3 min for the Feasibility Study and within 5 min for the Comparative Study. Results In the Feasibility Study, 8 of the 10 NHS-POx-treated lesions achieved hemostasis at 30 s and 3 min. In the Comparative Study, all 18 NHS-POx patch-treated lesions and 9 of the 18 fibrin sealant patch-treated lesions achieved hemostasis at 5 min. Median TTH with NHS-POx vs fibrin sealant patch was 30 vs 300 s ( P  < 0.001). Conclusions In this animal study, hemostasis during robotic liver surgery was achieved faster and more often with the NHS-POx loaded vs fibrin sealant patch.