Impact of the COVID-19 pandemic on urology residency training in Italy

In the global emergency scenario caused by COVID-19 pandemic, the Urology residents' training might be critically affected. To provide insights on this issue, a 25-item online Survey was sent to all Italian residents one month after the first case of COVID-19 in Italy, to evaluate their routine involvement in "clinical" (on-call duty, outpatient visits, diagnostic procedures) and "surgical" (endoscopic, open and minimally invasive surgery) training activities before and during the COVID-19 period. Overall, 351 of 577 (60.8%) residents completed the Survey. Before the COVID-19 pandemic, the proportion of residents routinely involved in "clinical" and "surgical" activities ranged from 79.8% to 87.2% and from 49.3% to 73.5%, respectively. In the COVID-19 period, the proportion of residents experiencing a severe reduction (>40%) or complete suppression (>80%) of training exposure ranged between 41.1% and 81.2% for "clinical" activities while between 44.2% and 62.1% for "surgical" activities. This reduction was even more pronounced for residents attending the final year of training. Our study is the first to provide real-life data on how Urology residency training can be impaired during an emergency period. To address this challenge, strategies aiming to increase the use of telemedicine, "smart learning" programs and tele-mentoring of surgical procedures, are warranted.

Telehealth in Urology: A Systematic Review of the Literature. How Much Can Telemedicine Be Useful During and After the COVID-19 Pandemic?

Context

Coronavirus disease 2019 (COVID-19) pandemic has caused increased interest in the application of telehealth to provide care without exposing patients and physicians to the risk of contagion. The urological literature on the topic is sparse.

Objective

To perform a systematic review of the literature and evaluate all the available studies on urological applications of telehealth.

Evidence acquisition

After registration on PROSPERO, we searched PubMed and Scopus databases to collect any kind of studies evaluating any telehealth interventions in any urological conditions. The National Toxicology Program/Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal Studies was used to estimate the risk of bias. A narrative synthesis was performed.

Evidence synthesis

We identified 45 studies (11 concerning prostate cancer [PCa], three hematuria management, six urinary stones, 14 urinary incontinence [UI], five urinary tract infections [UTIs], and six other conditions), including 12 randomized controlled trials. The available literature indicates that telemedicine has been implemented successfully in several common clinical scenarios, including the decision-making process following a diagnosis of nonmetastatic PCa, follow-up care of patients with localized PCa after curative treatments, initial diagnosis of hematuria, management diagnosis and follow-up care of uncomplicated urinary stones and uncomplicated UTIs, and initial evaluation, behavioral therapies, and pelvic floor muscle training in UI patients, as well as follow-up care after surgical treatments of stress urinary incontinence or pelvic organ prolapse. The methodological quality of most of the reports was good.

Conclusions

Telehealth has been implemented successfully in selected patients with PCa, UI, pelvic organ prolapse, uncomplicated urinary stones, and UTIs. Many urological conditions are suitable for telehealth, but more studies are needed on other highly prevalent urological malignant and benign conditions. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine. More robust data on long-term efficacy, safety, and health economics are necessary.

Patient summary

The diffusion of coronavirus disease 2019 (COVID-19) infections has recently increased the interest in telehealth, which is the adoption of telecommunication to deliver any health care activity. The available literature indicates that telemedicine has been adopted successfully in selected patients with several common clinical urological conditions, including prostate cancer, uncomplicated urinary stones, uncomplicated urinary infections, urinary incontinence, or pelvic organ prolapse. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine, but more robust data on long-term efficacy, safety, and costs are necessary.

Three-dimensional Augmented Reality Robot-assisted Partial Nephrectomy in Case of Complex Tumours (PADUA ≥10): A New Intraoperative Tool Overcoming the Ultrasound Guidance

BACKGROUND

Despite technical improvements introduced with robotic surgery, management of complex tumours (PADUA score ≥10) is still a matter of debate within the field of transperitoneal robot-assisted partial nephrectomy (RAPN).

OBJECTIVE

To evaluate the accuracy of our three-dimensional (3D) static and elastic augmented reality (AR) systems based on hyperaccuracy models (HA3D) in identifying tumours and intrarenal structures during transperitoneal RAPN (AR-RAPN), compared with standard ultrasound (US).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study was conducted, including 91 patients who underwent RAPN for complex renal tumours, 48 with 3D AR guidance and 43 with 2D US guidance, from July 2017 to May 2019.

SURGICAL PROCEDURE

In patients who underwent 3D AR-RAPN, virtual image overlapping guided the surgeon during resection and suture phases. In the 2D US group, interventions were driven by US only.

MEASUREMENTS

Patient characteristics were tested using the Fisher's exact test for categorical variables and the Mann-Whitney test for continuous ones. Intraoperative, postoperative, and surgical outcomes were collected. All results for continuous variables were expressed as medians (range), and frequencies and proportions were reported as percentages.

RESULTS AND LIMITATIONS

The use of 3D AR guidance makes it possible to correctly identify the lesion and intraparenchymal structures with a more accurate 3D perception of the location and the nature of the different structures relative to the standard 2D US guidance. This translates to a lower rate of global ischaemia (45.8% in the 3D group vs 69.7% in the US group; p = 0.03), higher rate of enucleation (62.5% vs 37.5% in the 3D and US groups, respectively; p = 0.02), and lower rate of collecting system violation (10.4% vs 45.5%; p = 0.003). Postoperatively, 3D AR guidance use correlates to a low risk of surgery-related complications in 3D AR groups and a lower drop in estimated renal plasma flow at renal scan at 3 mo of follow-up (-12.38 in the 3D group vs -18.14 in the US group; p = 0.01). The main limitations of this study are short follow-up time and small sample size.

CONCLUSIONS

HA3D models that overlap in vivo anatomy during AR-RAPN for complex tumours can be useful for identifying the lesion and intraparenchymal structures that are difficult to visualise with US only. This translates to a potential improvement in the quality of the resection phase and a reduction in postoperative complications, with better functional recovery.

PATIENT SUMMARY

Based on our findings, three-dimensional augmented reality robot-assisted partial nephrectomy seems to help surgeons in the management of complex renal tumours, with potential early postoperative benefits.

Retzius-sparing robot-assisted radical prostatectomy vs the standard approach: a systematic review and analysis of comparative outcomes

OBJECTIVES

To summarize the current evidence on Retzius-sparing (RS)-robot-assisted radical prostatectomy (RARP) and to compare its oncological, peri-operative and functional outcomes with those of standard retropubic RARP (S-RARP).

MATERIALS AND METHODS

After establishing an a priori protocol, a systematic electronic literature search was conducted in January 2019 using the Medline (via PubMed), Embase (via Ovid) and Cochrane databases. The search strategy relied on the 'PICO' (Patient Intervention Comparison Outcome) criteria and article selection was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only studies reporting the oncological and functional outcomes of RARP (as determined by type of procedure [RS-RARP vs S-RARP]) were considered for inclusion. Risk of bias and study quality were assessed. Finally, peri-operative and functional outcomes were recorded and analysed.

RESULTS

A shorter operating time was associated with RS-RARP (weighted mean difference [WMD] 14.7 min, 95% confidence interval [CI] -28.25, 1.16; P = 0.03), whereas no significant difference was found in terms of estimated blood loss (WMD 1.45 mL, 95% CI -31.18, 34.08; P = 0.93). Also, no significant difference between the two groups was observed for overall (odds ratio [OR] 0.86, 95% CI 0.40, 1.85; P = 0.71) and major (Clavien >3; OR 0.88, 95% CI 0.30, 2.57) postoperative complications; however, the likelihood of positive surgical margins (PSMs) was lower for the S-RARP group (rate 15.2% vs 24%; OR 1.71, 95% CI 1.12, 2.60; P = 0.01). The cumulative analysis showed a statistically significant advantage for RS-RARP in terms of continence recovery at 1 month (OR 2.54, 95% CI 1.16, 5.53; P = 0.02), as well as at 3 months (OR 3.86, 95% CI 2.23, 6.68; P < 0.001), 6 months (OR 3.61, 95% CI 1.88, 6.91; P = 0.001), and 12 months (OR 7.29, 95% CI 1.89, 28.13; P = 0.004).

CONCLUSION

Our analysis confirms that RS-RARP is a safe and feasible alternative to S-RARP. This novel approach may be associated with faster and higher recovery of continence, without increasing the risk of complications. One caveat might be the higher risk of PSMs, and this can be regarded as a current pitfall of the technique, probably related to an expected learning curve.

Artificial intelligence and neural networks in urology: current clinical applications

INTRODUCTION

As we enter the era of "big data," an increasing amount of complex health-care data will become available. These data are often redundant, "noisy," and characterized by wide variability. In order to offer a precise and transversal view of a clinical scenario the artificial intelligence (AI) with machine learning (ML) algorithms and Artificial neuron networks (ANNs) process were adopted, with a promising wide diffusion in the near future. The present work aims to provide a comprehensive and critical overview of the current and potential applications of AI and ANNs in urology.

EVIDENCE ACQUISITION

A non-systematic review of the literature was performed by screening Medline, PubMed, the Cochrane Database, and Embase to detect pertinent studies regarding the application of AI and ANN in Urology.

EVIDENCE SYNTHESIS

The main application of AI in urology is the field of genitourinary cancers. Focusing on prostate cancer, AI was applied for the prediction of prostate biopsy results. For bladder cancer, the prediction of recurrence-free probability and diagnostic evaluation were analysed with ML algorithms. For kidney and testis cancer, anecdotal experiences were reported for staging and prediction of diseases recurrence. More recently, AI has been applied in non-oncological diseases like stones and functional urology.

CONCLUSIONS

AI technologies are growing their role in health care; but, up to now, their "real-life" implementation remains limited. However, in the near future, the potential of AI-driven era could change the clinical practice in Urology, improving overall patient outcomes.

Three-dimensional Elastic Augmented-reality Robot-assisted Radical Prostatectomy Using Hyperaccuracy Three-dimensional Reconstruction Technology: A Step Further in the Identification of Capsular Involvement

BACKGROUND

In prostate cancer (PCa) surgical procedures, in order to maximize potency recovery, a nerve-sparing (NS) procedure is preferred. However, cancer abutting or focally extending beyond the prostate capsule increases the risk of a positive surgical margin.

OBJECTIVE

To evaluate the accuracy of our new three-dimensional (3D) elastic augmented-reality (AR) system in identifying capsular involvement (CI) location of PCa during the NS phase of robot-assisted radical prostatectomy (RARP). Secondarily, the accuracy of this technology was compared with two-dimensional (2D)-based cognitive procedures.

DESIGN, SETTING, AND PARTICIPANTS

A prospective study, enrolling 40 patients with PCa undergoing RARP at our center, from May to October 2018.

SURGICAL PROCEDURE

Patients underwent 3D AR RARP or, in case of unavailability of this technology, 2D cognitive RARP. In all patients, total anatomical reconstruction was used.

MEASUREMENTS

Clinical data were collected. In order to compare the two groups, nonparametric Mann-Whitney and chi-square tests were performed. A metallic clip was placed at the level of suspicious CI on the basis of images given by the 3D AR or magnetic resonance imaging (MRI) report. The pathological analysis evaluated the presence of tumor at the level of the clip.

RESULTS AND LIMITATIONS

Twenty patients were enrolled in each group. Focusing on the 3D AR group at macroscopic evaluation, the metallic clip was placed at the tumor and capsular bulging in all cases. At microscopic assessment, cancer presence was confirmed in the suspicious area in 95.4% of the cases. Moreover, CI was correctly identified in 100.0% of the cases, thanks to the 3D image overlap. These results were compared with the 2D MRI cognitive group, showing, at microscopic analysis, statistically significant superiority of the 3D AR group in CI detection during the NS phase (100% vs 47.0%; p<0.05). The main limitation of this technique is that the segmentation and overlapping of the images are performed manually.

CONCLUSIONS

Our findings suggest that, with the introduction of the elastic 3D virtual models, prostate deformation is correctly simulated during surgery and lesion location is correctly identified, even in dynamic reality with a subsequent potential reduction of positive surgical margin rate and, in the meantime, maximization of functional outcomes.

PATIENT SUMMARY

On the basis of our findings, the three-dimensional elastic augmented-reality technology seems to help the surgeon in lesion location identification even in a dynamic phase of the intervention, optimizing the oncological outcomes.

The use of 3D laparoscopic imaging systems in surgery: EAES consensus development conference 2018

BACKGROUND

The use of 3D laparoscopic systems is expanding. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference with the aim of creating evidence-based statements and recommendations for the surgical community.

METHODS

Systematic reviews of the PubMed and Embase libraries were performed to identify evidence on potential benefits of 3D on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by an international surgical and engineering expert panel which were presented and voted at the EAES annual congress, London, May 2018.

RESULTS

9967 abstracts were screened with 138 articles included. 18 statements and two recommendations were generated and approved. 3D significantly shortened operative time (mean difference 11 min (8% [95% CI 20.29-1.72], I² 96%)). A significant reduction in complications was observed when 3D systems were used (RR 0.75, [95 CI% 0.60-0.94], I² 0%) particularly for cases involving laparoscopic suturing (RR 0.57 [95% CI 0.35-0.90], I² 0%). In 69 box trainer or simulator studies, 64% concluded trainees were significant faster and 62% performed fewer errors when using 3D.

CONCLUSION

We recommend the use of 3D vision in laparoscopy to reduce the operative time (grade of recommendation: low). Future robust clinical research is required to specifically investigate the potential benefit of 3D laparoscopy system on complication rates (grade of recommendation: high).

Assessing the Burden of Nondeferrable Major Uro-oncologic Surgery to Guide Prioritisation Strategies During the COVID-19 Pandemic: Insights from Three Italian High-volume Referral Centres

The coronavirus 2019 (COVID-19) pandemic has led to an unprecedented emergency scenario for all aspects of health care, including urology. At the time of writing, Italy was the country with the highest rates of both infection and mortality. A panel of experts recently released recommendations for prioritising urologic surgeries in a low-resource setting. Of note, major cancer surgery represents a compelling challenge. However, the burden of these procedures and the impact of such recommendations on urologic practice are currently unknown. To fill this gap, we assessed the yearly proportion of high-priority major uro-oncologic surgeries at three Italian high-volume academic centres. Of 2387 major cancer surgeries, 32.3% were classified as high priority (12.6% of radical nephroureterectomy, 17.3% of nephrectomy, 33.9% of radical prostatectomy, and 36.2% of radical cystectomy cases). Moreover, 26.4% of high-priority major cancer surgeries were performed in patients at higher perioperative risk (American Society of Anesthesiologists score ≥3), with radical cystectomy contributing the most to this cohort (50%). Our real-life data contextualise ongoing recommendations on prioritisation strategies during the current COVID-19 pandemic, highlighting the need for better patient selection for surgery. We found that approximately two-thirds of elective major uro-oncologic surgeries can be safely postponed or changed to another treatment modality when the availability of health care resources is reduced. PATIENT SUMMARY: We used data from three high-volume Italian academic urology centres to evaluate how many surgeries performed for prostate, bladder, kidney, and upper tract urothelial cancer can be postponed in times of emergency. We found that approximately two-thirds of patients with these cancers do not require high-priority surgery. Conversely, of patients requiring high-priority surgery, approximately one in four is considered at high perioperative risk. These patients may pose challenges in allocation of resources in critical scenarios such as the current COVID-19 pandemic.

Five-year Outcomes for a Prospective Randomised Controlled Trial Comparing Laparoscopic and Robot-assisted Radical Prostatectomy

BACKGROUND

The literature is lacking randomised controlled trials comparing robot-assisted (RARP) and laparoscopic (LRP) radical prostatectomy, especially for follow-up >1 yr.

OBJECTIVE

To report 5-yr outcomes for our previously published prospective randomised study comparing RARP and LRP.

DESIGN, SETTING, AND PARTICIPANTS

From January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned to RARP or LRP.

INTERVENTION

A single surgeon performed all interventions using the same transperitoneal anterograde technique.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Continence, potency, and serum prostate-specific antigen were assessed postoperatively at 1, 3, 6, and 12 mo, and then every 6 mo until 60 mo. At the end of the follow-up period, patients were administered questions 1 and 46 of the Expanded Prostate Cancer Index Composite questionnaire to assess their satisfaction with the intervention and general health status. A generalised estimating equations model was used to compare time series data for functional results, and Kaplan-Meier and Cox models were used to analyse oncologic outcomes.

RESULTS AND LIMITATIONS

The probability of achieving continence (odds ratio [OR] 2.47, p<0.021) and potency (OR 2.35, p<0.028) over time was more than doubled for the RARP compared to the LRP group. There was no difference between the two approaches in terms of patient survival. Pathologic Gleason score, positive surgical margins, and pT stage were associated with significantly higher biochemical recurrence in Cox multivariate models. Patient satisfaction with the intervention and their general health status was significantly higher in the RARP group.

CONCLUSIONS

Throughout the 5-yr follow-up, RARP yielded better functional results compared to LRP, without compromising oncologic outcomes.

PATIENT SUMMARY

In this report we looked at 5-yr outcomes for a study comparing robot-assisted radical prostatectomy (RARP) and laparascopic radical prostatectomy for the treatment of prostate cancer. We found that continence and potency are better among patients treated with RARP, while oncologic results are comparable.

Augmented-reality robot-assisted radical prostatectomy using hyper-accuracy three-dimensional reconstruction (HA3D™) technology: a radiological and pathological study

OBJECTIVES

To assess the use of hyper-accuracy three-dimensional (HA3D™; MEDICS, Moncalieri, Turin, Italy) reconstruction based on multiparametric magnetic resonance imaging (mpMRI) and superimposed imaging during augmented-reality robot-assisted radical prostatectomy (AR-RARP).

PATIENTS AND METHODS

Patients with prostate cancer (clinical stages cT1-3, cN0, cM0) undergoing RARP at our Centre, from June 2017 to April 2018, were enrolled. In all cases, cancer was diagnosed with targeted biopsy at the level of index lesion based on high-resolution (1-mm slices) mpMRI. HA3D reconstruction was created by dedicated software to obtain the 3D virtual model of the prostate and surrounding structures. A specific system was used to overlay virtual data on the endoscopic video displayed by the remote da Vinci® surgical console (Intuitive Surgical Inc., Sunnyvale, CA, USA), and the virtual images were superimposed by the surgeon by the means of the TilePro™ multi-input display technology (Intuitive Surgical Inc.). The AR technology was used in four standardised key steps during RARP. The procedures were modulated differently in cases of prostate cancer without extracapsular extension (ECE) at mpMRI (Group A) or in cases of prostate cancer with ECE (Group B) at mpMRI. In Group A, the virtual image of the prostate was overlaid on the endoscopic view and the intraprostatic lesion was marked on the prostate surface by a metallic clip at the level of the suspicious lesion as identified by the 3D virtual AR image. In Group B, the same step was performed; moreover, a metallic clip was placed at the level of the suspicious ECE on the neurovascular bundles (NVBs) according to the virtual images. Finally, selective biopsies were taken from the NVBs at this level, and then, the entire NVBs were removed for final pathological examination, according to standard clinical indications. For Group A, the pathologist performed a targeted needle biopsy at the level of the metallic clip on the surface of prostate before the sample reduction. For Group B, the presence of tumour was evaluated during the reduction phase, at the level of metallic clip on the prostate surface and at the level of NVBs, sent separately. Finally, an image 3D scanner (Kinect, Microsoft) was used to perform a dimensional comparison between the mpMRI-based 3D virtual reconstruction and the whole-mount specimen.

RESULTS

In all, 30 patients were enrolled in the present study, 11 (36.6%) included in Group A and 19 (63.4%) in Group B. In all cases (30/30), final pathology confirmed the location of the index lesion, as cancer was found at the level of the metallic clip. The suspected ECE was confirmed on final pathology in 15/19 cases (79%). The AR-guided selective biopsies at the level of the NVBs confirmed the ECE location, with 11/15 (73.3%) biopsies at the level of NVBs positive for cancer. The mismatch between the 3D virtual reconstruction and the prostate 3D scanning based on the whole-mount specimen was <3 mm in >85% of the gland.

CONCLUSION

Our results suggest that a HA3D virtual reconstruction of the prostate based on mpMRI data and real-time superimposed imaging allow performance of an effective AR-RARP. Potentially, this approach translates into better outcomes, as the surgeon can tailor the procedure for each patient.

Three-dimensional virtual imaging of renal tumours: a new tool to improve the accuracy of nephrometry scores

OBJECTIVES

To apply the standard PADUA and RENAL nephrometry score variables to three-dimensional (3D) virtual models (VMs) produced from standard bi-dimensional imaging, thereby creating three-dimensional (3D)-based (PADUA and RENAL) nephrometry scores/categories for the reclassification of the surgical complexity of renal masses, and to compare the new 3D nephrometry score/category with the standard 2D-based nephrometry score/category, in order to evaluate their predictive role for postoperative complications.

MATERIALS AND METHODS

All patients with localized renal tumours scheduled for minimally invasive partial nephrectomy (PN) between September 2016 and September 2018 underwent 3D and 2D nephrometry score/category assessments preoperatively. After nephrometry score/category evaluation, all the patients underwent surgery. Chi-squared tests were used to evaluate the individual patients' grouping on the basis of the imaging tool (3D VMs and 2D imaging) used to assess the nephrometry score/category, while Cohen's κ coefficient was used to test the concordance between classifications. Receiver-operating characteristic curves were produced to evaluate the sensitivity and specificity of the 3D nephrometry score/category vs the 2D nephrometry score/category in predicting the occurrence of postoperative complications. A general linear model was used to perform multivariable analyses to identify predictors of overall and major postoperative complications.

RESULTS

A total of 101 patients were included in the study. The evaluation of PADUA and RENAL nephrometry scores via 3D VMs showed a downgrading in comparison with the same scores evaluated with 2D imaging in 48.5% and 52.4% of the cases. Similar results were obtained for nephrometry categories (29.7% and 30.7% for PADUA risk and RENAL complexity categories, respectively). The 3D nephrometry score/category demonstrated better accuracy than the 2D nephrometry score/category in predicting overall and major postoperative complications (differences in areas under the curve for each nephrometry score/category were statistically significant comparing the 3D VMs with 2D imaging assessment). Multivariable analyses confirmed 3D PADUA/RENAL nephrometry category as the only independent predictors of overall (P = 0.007; P = 0.003) and major postoperative complications (P = 0.03; P = 0.003).

CONCLUSIONS

In the present study, we showed that 3D VMs were more precise than 2D standard imaging in evaluating the surgical complexity of renal masses according to nephrometry score/category. This was attributable to a better perception of tumour depth and its relationships with intrarenal structures using the 3D VM, as confirmed by the higher accuracy of the 3D VM in predicting postoperative complications.

Forecasting the Future of Urology Practice: A Comprehensive Review of the Recommendations by International and European Associations on Priority Procedures During the COVID-19 Pandemic

Context

The unprecedented health care scenario caused by the coronavirus disease 2019 (COVID-19) pandemic has revolutionized urology practice worldwide.

Objective

To review the recommendations by the international and European national urological associations/societies (UASs) on prioritization strategies for both oncological and nononcological procedures released during the current emergency scenario.

Evidence acquisition

Each UAS official website was searched between April 8 and 18, 2020, to retrieve any document, publication, or position paper on prioritization strategies regarding both diagnostic and therapeutic urological procedures, and any recommendations on the use of telemedicine and minimally invasive surgery. We collected detailed information on all urological procedures, stratified by disease, priority (higher vs lower), and patient setting (outpatient vs inpatient). Then, we critically discussed the implications of such recommendations for urology practice in both the forthcoming “adaptive” and the future “chronic” phase of the COVID-19 pandemic.

Evidence synthesis

Overall, we analyzed the recommendations from 13 UASs, of which four were international (American Urological Association, Confederation Americana de Urologia, European Association of Urology, and Urological Society of Australia and New Zealand) and nine national (from Belgium, France, Germany, Italy, Poland, Portugal, The Netherlands, and the UK). In the outpatient setting, the procedures that are likely to impact the future burden of urologists’ workload most are prostate biopsies and elective procedures for benign conditions. In the inpatient setting, the most relevant contributors to this burden are represented by elective surgeries for lower-risk prostate and renal cancers, nonobstructing stone disease, and benign prostatic hyperplasia. Finally, some UASs recommended special precautions to perform minimally invasive surgery, while others outlined the potential role of telemedicine to optimize resources in the current and future scenarios.

Conclusions

The expected changes will put significant strain on urological units worldwide regarding the overall workload of urologists, internal logistics, inflow of surgical patients, and waiting lists. In light of these predictions, urologists should strive to leverage this emergency period to reshape their role in the future.

Patient summary

Overall, there was a large consensus among different urological associations/societies regarding the prioritization of most urological procedures, including those in the outpatient setting, urological emergencies, and many inpatient surgeries for both oncological and nononcological conditions. On the contrary, some differences were found regarding specific cancer surgeries (ie, radical cystectomy for higher-risk bladder cancer and nephrectomy for larger organ-confined renal masses), potentially due to different prioritization criteria and/or health care contexts. In the future, the outpatient procedures that are likely to impact the burden of urologists’ workload most are prostate biopsies and elective procedures for benign conditions. In the inpatient setting, the most relevant contributors to this burden are represented by elective surgeries for lower-risk prostate and renal cancers, nonobstructing stone disease, and benign prostatic hyperplasia.

Current Use of Three-dimensional Model Technology in Urology: A Road Map for Personalised Surgical Planning

CONTEXT

Despite the current era of "precision surgery", an unmet need for an optimal surgical planning and navigation still remains for most genitourinary malignancies. In this setting, the 3D virtual reconstruction of 2D cross-sectional imaging has been increasingly adopted to facilitate the surgeon in better understanding the surgical anatomy.

OBJECTIVE

To provide a short overview of the most recent evidences on the current applications of 3D virtual and printed reconstructions in urologic surgery.

EVIDENCE ACQUISITION

A non-systematic review of the literature was performed. Medline, PubMed, the Cochrane Database and Embase were screened for studies regarding the use of 3D models in urology.

EVIDENCE SYNTHESIS

3D reconstruction technology has been primarily implemented with the purpose of surgical planning and navigation, especially in the management of prostate and kidney cancer. Augmented reality is still in a rudimental phase, especially in the field of prostate cancer. The (poor) Literature already published suggests that the 3D virtual and printed models could be helpful for the comprehension and learning of the surgical strategy by the young urologists and, at the meantime, could enhance the quality of the dialog with the patients, giving them a direct perception of the disease and its treatment.

CONCLUSION

Notwithstanding the current limitations and the sporadic experiences available in the Literature, 3D models technology is perceived as a useful tool for the surgical planning, especially in the field of kidney and prostate cancer, physician education/training and patient counselling.

PATIENT SUMMARY

In the field of prostate and kidney cancer, the optimal surgical planning and the patient counselling seems to be improved by the use of 3D reconstruction technology based on the preoperative imaging.

3-Year follow-up of temporary implantable nitinol device implantation for the treatment of benign prostatic obstruction

OBJECTIVES

To report 3-year follow-up results of the first implantations with a temporary implantable nitinol device (TIND^® ; Medi-Tate Ltd., Or Akiva, Israel) for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

In all, 32 patients with LUTS were enrolled in this prospective study. The study was approved by the local Ethics Committee. Inclusion criteria were: age >50 years, International Prostate Symptom Score (IPSS) ≥10, peak urinary flow (Q_max ) <12 mL/s, and prostate volume <60 mL. The TIND was implanted within the bladder neck and the prostatic urethra under light sedation, and removed 5 days later in an outpatient setting. Demographics, perioperative results, complications (according to Clavien-Dindo classification), functional results, and quality of life (QoL) were evaluated. Follow-up assessments were made at 3 and 6 weeks, and 3, 6, 12, 24 and 36 months after the implantation. The Student's t-test, one-way analysis of variance and Kruskal-Wallis tests were used for statistical analyses.

RESULTS

At baseline, the mean (standard deviation, sd) patient age was 69.4 (8.2) years, prostate volume was 29.5 (7.4) mL, and Q_max was 7.6 (2.2) mL/s. The median (interquartile range, IQR) IPSS was 19 (14-23) and the QoL score was 3 (3-4). All the implantations were successful, with a mean total operative time of 5.8 min. No intraoperative complications were recorded. The change from baseline in IPSS, QoL score and Q_max was significant at every follow-up time point. After 36 months of follow-up, a 41% rise in Q_max was achieved (mean 10.1 mL/s), the median (IQR) IPSS was 12 (6-24) and the IPSS QoL was 2 (1-4). Four early complications (12.5%) were recorded, including one case of urinary retention (3.1%), one case of transient incontinence due to device displacement (3.1%), and two cases of infection (6.2%). No further complications were recorded during the 36-month follow-up.

CONCLUSIONS

The extended follow-up period corroborated our previous findings and suggests that TIND implantation is safe, effective and well-tolerated, for at least 36 months after treatment.

Augmented Reality Robot-assisted Radical Prostatectomy: Preliminary Experience

OBJECTIVE

To present our preliminary experience with augmented reality robot-assisted radical prostatectomy (AR-RARP).

MATERIALS

From June to August 2017, patients candidate to RARP were enrolled and underwent high-resolution multi-parametric magnetic resonance imaging (1-mm slices) according to dedicated protocol. The obtained three-dimensional (3D) reconstruction was integrated in the robotic console to perform AR-RARP. According to the staging at magnetic resonance imaging or reconstruction, in case of cT2 prostate cancer, intrafascial nerve sparing (NS) was performed: a mark was placed on the prostate capsule to indicate the virtual underlying intraprostatic lesion; in case of cT3, standard NS AR-RARP was scheduled with AR-guided biopsy at the level of suspected extracapsular extension (ECE). Prostate specimens were scanned to assess the 3D model concordance.

RESULTS

Sixteen patients underwent intrafascial NS technique (cT2), whereas 14 underwent standard NS+ selective biopsy of suspected ECE (cT3). Final pathology confirmed clinical staging. Positive surgical margins' rate was 30% (no positive surgical margins in pT2). In patients whose intraprostatic lesions were marked, final pathology confirmed lesion location. In patients with suspected ECE, AR-guided selective biopsies confirmed the ECE location, with 11 of 14 biopsies (78%) positive for prostate cancer. Prostate specimens were scanned with finding of a good overlap. The mismatch between 3D reconstruction and scanning ranged from 1 to 5 mm. In 85% of the entire surface, the mismatch was <3 mm.

CONCLUSION

In our preliminary experience, AR-RARP seems to be safe and effective. The accuracy of 3D reconstruction seemed to be promising. This technology has still limitations: the virtual models are manually oriented and rigid. Future collaborations with bioengineers will allow overcoming these limitations.

Multiparametric Magnetic Resonance/Ultrasound Fusion Prostate Biopsy: Number and Spatial Distribution of Cores for Better Index Tumor Detection and Characterization

PURPOSE

We evaluated the minimum core number for better index tumor detection to determine the best core site as well as biopsy Gleason score heterogeneity in the same index lesion. The aim was to optimize the highest Gleason score detection.

MATERIALS AND METHODS

A total of 327 patients with negative digital rectal examination underwent magnetic resonance imaging/transrectal ultrasound fusion targeted biopsy for elevated/rising prostate specific antigen and/or 1 or more detectable lesions on multiparametric magnetic resonance imaging after a previous negative standard biopsy. Depending on the diameter of each index lesion (8 or less, or greater than 8 mm) 4 or 6 cores, respectively, were taken according to a well determined sequence.

RESULTS

Of the patients 166 (50.7%) had prostate cancer, including 79 (47.6%) with an 8 mm or less index lesion and 87 (52.4%) with a greater than 8 mm index lesion. Of patients with an index tumor 8 mm or less 7 (8.9%) had 1, 31 (39.2%) had 2, 27 (34.2%) had 3 and 14 (17.7%) had 4 positive cores. Similarly, of patients with a lesion greater than 8 mm 8 (9.2%) had 1, 30 (34.5%) had 2, 13 (14.9%) had 3, 14 (16.1%) had 4, 12 (13.8%) had 5 and 10 (11.5%) had 6 positive cores. The major prevalence of positive cores was observed in the center of the target. Gleason score heterogeneity was found in 12.6% of those with an 8 mm or less target vs 26.4% with a target greater than 8 mm. In the center of the target there was a slight prevalence of Gleason pattern 4 or greater, or a lesser pattern.

CONCLUSIONS

Approaching magnetic resonance imaging/transrectal ultrasound fusion targeted biopsy with a single core might be inadequate. Rather, taking 2 cores in the center of the index lesion may provide more accurate cancer detection and optimize the chances of finding the highest Gleason pattern.

Robot-assisted Surgery for Benign Ureteral Strictures: Experience and Outcomes from Four Tertiary Care Institutions

BACKGROUND

Minimally invasive treatment of benign ureteral strictures is still challenging because of its technical complexity. In this context, robot-assisted surgery may overcome the limits of the laparoscopic approach.

OBJECTIVE

To evaluate outcomes for robotic ureteral repair in a multi-institutional cohort of patients treated for ureteropelvic junction obstruction and ureteral stricture (US) at four tertiary referral centres.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective study reports data for 183 patients treated with standard robot-assisted pyeloplasty (PYP) and robotic uretero-ureterostomy (UUY) at four high-volume centres from January 2006 to September 2014.

SURGICAL PROCEDURE

Robotic PYP and robot-assisted UUY were performed according to previously reported surgical techniques.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed.

RESULTS AND LIMITATIONS

No robot-assisted UUY cases required surgical conversion, while 2.8% of PYP cases were not completed robotically. The median operative time was 120 and 150min for robot-assisted PYP and robot-assisted UUY, respectively. No intraoperative complications were reported. The overall complication rate for all procedures was 11% (n=20) and complications were mostly of low grade. The high-grade complication rate was 2.2% (n=4). At median follow-up of 24 mo, the overall success rate was >90% for both procedures. The study limitations include its retrospective nature and the heterogeneity of the study population.

CONCLUSIONS

Robotic surgery for benign US is safe and effective, with limited risk of high-grade complications and good intermediate-term results.

PATIENT SUMMARY

In this study we review the use of robotic surgery at four different tertiary care centres in the treatment of patients affected by benign ureteral strictures. Our results demonstrate that robotic surgery is a safe alternative to the standard open approach in the treatment of ureteral strictures.

Robot-assisted partial nephrectomy: 7-year outcomes

BACKGROUND

The role of robot-assisted partial nephrectomy (RAPN) in the management of renal masses has exponentially grown over the past 10 years. Nevertheless, data on long term outcomes of the procedure remains limited. Herein we report oncological and functional outcomes of patients who underwent RAPN for a malignant mass with a median follow-up of 7 years, the longest follow-up to date.

METHODS

A retrospective analysis of an international multicenter database was performed. All consecutive patients undergoing surgery between 2009 and 2013 with a minimum of 3-year follow-up and complete data on renal function were included. Demographics, surgical and perioperative outcomes were analyzed. Overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS) were evaluated using Kaplan-Meier analysis.

RESULTS

Overall, our study cohort was composed of eighty-five patients with a median follow-up of 88 months. Median clinical tumor size was 3 cm, with mostly (74.1%) clinical stage T1a, and median RENAL score 6. Final histopathologic analysis revealed clear cell RCC in 76.5% of cases. PSM was present in seven patients (8.2%). Eleven overall deaths (12.9%) occurred in the cohort during the follow-up period. Two of these (2.33%) were attributed to metastatic RCC. The OS, CSS, and DFS rates were 91.7%, 97.7%, and 91.7% at 84 months, respectively. Regarding the renal functional outcomes, seventeen patients (20.1%) presented a CKD upstaging in our cohort.

CONCLUSIONS

Our findings show excellent 7-year oncologic and functional outcomes of the procedure, which duplicate those achieved in historical series of open and laparoscopic surgery.

Awareness and Use of ChatGPT and Large Language Models: A Prospective Cross-sectional Global Survey in Urology

BACKGROUND

Since its release in November 2022, ChatGPT has captivated society and shown potential for various aspects of health care.

OBJECTIVE

To investigate potential use of ChatGPT, a large language model (LLM), in urology by gathering opinions from urologists worldwide.

DESIGN, SETTING, AND PARTICIPANTS

An open web-based survey was distributed via social media and e-mail chains to urologists between April 20, 2023 and May 5, 2023. Participants were asked to answer questions related to their knowledge and experience with artificial intelligence, as well as their opinions of potential use of ChatGPT/LLMs in research and clinical practice.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Data are reported as the mean and standard deviation for continuous variables, and the frequency and percentage for categorical variables. Charts and tables are used as appropriate, with descriptions of the chart types and the measures used. The data are reported in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).

RESULTS AND LIMITATIONS

A total of 456 individuals completed the survey (64% completion rate). Nearly half (47.7%) reported that they use ChatGPT/LLMs in their academic practice, with fewer using the technology in clinical practice (19.8%). More than half (62.2%) believe there are potential ethical concerns when using ChatGPT for scientific or academic writing, and 53% reported that they have experienced limitations when using ChatGPT in academic practice.

CONCLUSIONS

Urologists recognise the potential of ChatGPT/LLMs in research but have concerns regarding ethics and patient acceptance. There is a desire for regulations and guidelines to ensure appropriate use. In addition, measures should be taken to establish rules and guidelines to maximise safety and efficiency when using this novel technology.

PATIENT SUMMARY

A survey asked 456 urologists from around the world about using an artificial intelligence tool called ChatGPT in their work. Almost half of them use ChatGPT for research, but not many use it for patients care. The resonders think ChatGPT could be helpful, but they worry about problems like ethics and want rules to make sure it's used safely.

Total anatomical reconstruction during robot-assisted radical prostatectomy: focus on urinary continence recovery and related complications after 1000 procedures

OBJECTIVES

To present the functional and oncological outcomes after ≥1 year of follow-up, following an experience of >1000 robot-assisted radical prostatectomies (RARPs) with our standardised total anatomical reconstruction (TAR) technique. To evaluate which factors influence postoperative continence recovery in order to obtain a nomogram to predict the risk of postoperative urinary incontinence (UI).

PATIENTS AND METHODS

The enrolment phase began in June 2013 and ended in May 2017. Patients were prospectively included in the study with the following inclusion criteria: (i) localised prostate cancer (clinical stages cT1-3, cN0, cM0); (ii) indication for RP; and (iii) preoperative multiparametric prostate magnetic resonance imaging. All patients underwent RARP with the TAR technique done at the end of the demolitive phase. The continence rates were assessed at 24 h, and 1, 4, 12, 24 and 48 weeks after catheter removal. Patients were defined as continent if they answered 'zero pad' or 'one safety pad' per day. A logistic regression model was used to evaluate the potential impact of some pre- and intraoperative factors on postoperative urinary continence recovery. Model discrimination was assessed using an area under (AUC) the receiver operating characteristic (ROC) curve. A nomogram to predict the risk of postoperative UI after RARP with the TAR technique was generated based on the logistic model.

RESULTS

In all, 1008 patients were enrolled in our study. At 24 h, and 1, 4, 12, 24 and 48 weeks after catheter removal, 621 (61.61%), 594 (58.93%), 803 (79.66%), 912 (90.48%), 950 (94.25%) and 956 (94.84%) patients were continent, respectively. In the logistic regression model, the variables analysed had a higher impact on continence recovery at 4 and 12 weeks. At 4 weeks, the postoperative odds of urinary continence recovery increased with the absence of diabetes [odds ratio (OR) 2.76, 95% confidence interval (CI) 1.41-5.41] and D'Amico low vs high risk (OR 2.01, 95% CI 1.01-3.99). At 12 weeks, urinary continence increased with the absence of diabetes (OR 3.01, 95% CI 1.23-7.35), D'Amico low vs high risk (OR 4.04, 95% CI 1.56-10.47), and D'Amico intermediate vs high risk (OR 3.33, 95% CI 1.66-6.70). ROC curves were drawn and an AUC value of 61.9% (95% CI 57.49-66.36) at 4 weeks and 63.8% (95% CI 58.03-69.65) at 12 weeks were computed. Based on these parameters, two nomograms (at 4 and 12 weeks postoperatively) were generated.

CONCLUSION

The TAR technique conferred excellent results in the early recovery of urinary continence. Two nomograms were created, to predict preoperatively the postoperative odds of urinary continence recovery at 4 and 12 weeks after RARP by integrating the presence of diabetes and D'Amico risk classification.

3D mixed reality holograms for preoperative surgical planning of nephron-sparing surgery: evaluation of surgeons' perception

BACKGROUND

3D reconstructions are gaining a wide diffusion in nephron-sparing surgery (NSS) planning. They have usually been studied on common 2D flat supports, with limitations regarding real depth comprehension and interaction. Nowadays, it is possible to visualize kidney 3D reconstructions as holograms in a "mixed reality" (MR) setting. The aim of this study was to test the face and content validity of this technology, and to assess the role of 3D holograms in aiding preoperative planning for highly complex renal tumors amenable by NSS.

METHODS

We evaluated surgeons' perception of mixed reality for partial nephrectomy during a urological international meeting organized at our Institution in January 2019. Thanks to the images of preoperative CT, hyper-accuracy 3D (HA3D^TM) reconstructions were performed. Then, a virtual environment was created, and it interacted with the models in mixed reality setting by using HoloLens. We submitted to all the attendees a questionnaire, expressed by the Likert scale (1-10), about their opinion over the use and application of the MR. Moreover, the attendees had the chance to perform a first-hand MR experience; then, they were asked to choose their clamping and resection approach.

RESULTS

Overall 172 questionnaires were collected. The scores obtained regarding both surgical planning (scored 8/10) and anatomical accuracy (9/10) were very positive. High satisfaction toward the potential role of this technology in surgical planning and understanding of surgical complexity (both scored 9/10) were expressed. After a first-hand experience with HoloLens and MR, 64.4% and 44.4% of the surgeons changed their clamping and resection approach, respectively - compared to CT image visualization only - choosing a more selective one.

CONCLUSIONS

Our study suggests that surgeons perceive holograms and MR as a useful and interesting tool for the preoperative setting before partial nephrectomy, in the direction of an ever more precise surgery.

Outcomes of robot-assisted partial nephrectomy for completely endophytic renal tumors: A multicenter analysis

INTRODUCTION

Multicenter retrospective analysis of robotic partial nephrectomy for completely endophytic renal tumors (i.e. 3 points for the 'E' domain of the R.E.N.A.L. nephrometry score) was performed.

MATERIALS AND METHODS

Patients' demographics, tumor characteristics, perioperative, functional, pathological and oncological data were analyzed and compared with those of patients with exophytic and mesophytic masses (i.e. 1 and 2 points for the 'E' domain, respectively). Multivariable logistic regression analysis was used to assess variables for trifecta achievement (negative margin, no postoperative complications, and 90% estimated glomerular filtration rate [eGFR] recovery).

RESULTS

Overall, 147 patients were included in the study group. Patients with a completely endophytic mass had bigger tumors (mean 4.2 vs. 4.1 vs. 3.2 cm; p < 0.001) on preoperative imaging and higher overall R.E.N.A.L. score. There was no difference in mean operative time. Estimated blood loss was higher in the endophytic group (mean 177.75 vs. 185.5 vs. 130 ml; p = 0.001). Warm ischemia time was shorter for the exophytic group (median 16 vs. 21 vs. 22 min; p < 0.001). Postoperative complications were more frequent in patients with endophytic tumor (24.8% vs. 19.5% vs. 14.8%; p < 0.001). Six (4.5%) patients had positive surgical margins, there was no difference between groups. Trifecta was achieved in 44 patients in endophytic group (45.4 vs. 68.8 and 50.9%, p < 0.001). Multivariable analysis for trifecta revealed that clinical tumor size (odds ratio: 0.667, 95% confidence interval: 0.56-0.79, p < 0.001) was only significant predictor for trifecta achievement.

CONCLUSIONS

Our findings confirm that RAPN in case of completely endophytic renal masses can be performed with acceptable outcomes in centers with significant robotic expertise.