OBJECTIVE: Advancements in the robotic surgical technology have revolutionized the standard of care for many surgical procedures. The purpose of this review is to focus on the different issues involved in de-velopmental phase of starting a robotic program and to evaluate the important considerations in developing this program at a given healthcare institution. METHODS & RESULTS: Although every hospital might desire a robotic program, there are many requirements needed to uphold a successful and self-sustainable pro-gram in the current healthcare market. Patients’ interest in robotic-assisted surgery has and continues to grow because of improved outcomes and decreased periods of hospitalization. Resulting market forces have created a solid foundation for the implementation of robotic sur-gery into surgical practice. A thorough market analysis, including that of competing entities and estimated surgical volume, is necessary prior to purchasing a robot. Another issue to be addressed is determining whether one has trained surgeons or the capability to recruit the appropriately trained surgeons to keep a robotics program afloat. Formally trained robotic surgeons have better patient outcomes and shorter oper-ative times. An assessment of facilities and staff is also imperative prior to making such a substantial investment. Ultimately, after a well thought-out analysis, a decision must be made as to whether the institution can support and maintain a robotics program. CONCLUSIONS: Individual economic factors of local healthcare settings must be evaluated when planning for a new robotics program. The high cost of the robotic surgical platform is best offset with a large surgical vol-umen, interdisciplinary utilization of the technology may be the solution. A mature, experienced surgeon is inte-gral to the success of a new robotics program. Define procedures to be performed, necessary training, staff in-volved, equipment, facilities, setting-up, economical re-sources and marketing are important issues to be teaken into account before acquiring a surgical robotic system.

OBJECTIVE OF THE REVIEW: Robot as-sisted Radical prostatectomy (RARP) has generated a new trend in the binomial teaching/learning, grouping these techniques in training modules such as theoretical learning, practice, personalized counseling, and mod-ern tools like simulation and practice in virtual models. This review summarizes the current trend in the teaching process of RARP. RECENT FINDINGS: Current trends in the acquisition of the RARP learning curve is to provide the Urologist with a well-structured teaching process, implementing gradual training modules, which make possible to understand all aspects of the development of prostate surgery with a robotic system. This process consists in analyzing the theoretical aspects, perform training with high quality simulators and proctorization, in both cases in vivo and as assistant, until completion of the advanced phase in console with haptic training and proctor’s direct advice, while the learning curve is being completed. The evi-dence shows that student and proctor feedback with the use of virtual models, immediately post-procedure video analysis, and a high-volume center are able to shorten the teaching process. The learning process never culmi-nates, in other words, the final phase of the student, is when he is prepared to teaching the multiplier effect of his learning curve.CONCLUSIONS: Virtual models in Robotic surgery has changed the perspective teaching process of medicine. Theoretical knowledge, virtual training and Proctor’s ad-vice are essential steps in the learning curve. Future di-rections, evolution of virtual models in a similar fashion to the real scenario.

OBJECTIVE: Robot-assisted laparoscopic radical prostatectomy (RARP) is nowadays considered the main surgical option for localized prostate cancer (PCa). We recently developed a new approach for RARP avoiding all the Retzius structures involved in continence and potency preservation, the so called Retzius-sparing technique (RSP). The objective of the paper is to report technical aspects and functional results of RSP.METHODS: We evaluated our data and available liter-ature regarding RSP, functional results and advantages.RESULTS: RSP is oncologically safe and guarantee high early continence rates. CONCLUSION: Long-term, prospective, comparative, and possibly randomized studies are needed but RSP is now spreading all over the world thanks to the different advantages that offers to patients. The most recognized benefit is surely the achievement of early continence, as well documented in multiple studies and papers, without compromising the oncological outcomes.

OBJECTIVE: To review the literature evalu-ating the role of the extended pelvic lymph node dissec-tion ePLND during robot assisted radical prostatectomy (RARP) in the management of PCa patients, as well as the preoperative clinic pathologic factors that predict lymph node metastases (LNM). The technique and cur-rent outcomes of robotic ePLND will be presented.METHODS: Medline®/Pubmed® were searched up to august 2018 to find comparative studies of different anatomic limits of pelvic lymph node dissection (PLND) during RARP, open or pure laparoscopic surgery that re-ported number of nodes retrieved, oncologic outcomes and complications. The search was complemented to identify studies that evaluated diagnostic images and factors that predict LNM. Overall, 44 articles were in-cluded for full text review.RESULTS: There is not an imaging technique with an acceptable performance to select patients for PLND, the decision to perform a PLND is based on clinical char-acteristics described on validated nomograms. Median lymph node yield at RARP range from 5 to 21 depend-ing on the extent of PLND, positivity rate of LN as high as 37% depending on the risk stratification of patients. Robot-assisted can be carried out to any extent with lymph node yields and safety concerns comparable to the open approach.CONCLUSION: Extended pelvic lymph node dissection is recommended to be performed at the time of RARP in intermediate and high-risk patients and cannot be replaced by other modalities. A benefit in terms of on-cologic outcomes remains to be established. The robot assisted approach offers shorter length of hospital stay, lower transfusion rates and comparable outcomes com-pared to other surgical approaches.

The urology community has adopted ro-bot-assisted radical prostatectomy (RARP) as the most preferred surgical therapeutic approach in the manage-ment of localized prostate cancer. Safety and potential complications of RARP should be clearly known prior to attempting the surgery. The complications have been categorized as anesthesia & patient positioning related, vascular, non-vascular and delayed. European Associ-ation of Urology guidelines recommend the use of Cla-vien –Dindo grading to report surgical complications. The median rate of overall complications of RARP is 12.6%, with a range of 3.1–42%. Most of the compli-cations are minor (Clavien-Dindo grades 1 and 2). With a dedicated approach, increasing experience, being aware of possible complications, and strict adherence to safety measures, most complications are preventable. RARP is a safe and reproducible technique.

Prostate cancer represents the most com-monly diagnosed cancer in men and is the second-lead-ing cause of cancer related death in the United States. Primary treatment for prostate cancer includes radiother-apy or ablative procedures such as cryotherapy, and high-intensity focused ultrasound (HIFU). Unfortunately, a large proportion of these patients, especially with high-risk features, may experience disease recurrence within 10 years. Management of recurrent localized prostate cancer is heterogeneous, and radical surgery remains as a salvage option in these patients. The purpose of this article is to offer oncological argu-ments in favor of salvage robotic radical prostatectomy (sRARP), which could benefit a certain group of patients. Tips and tricks in order to perform a challenging salvage surgery are summarized, as evidence of modern series with acceptable morbidity rates.

OBJECTIVE: Robot assisted partial ne-phrectomy (RAPN) is a minimally invasive option for patients with small renal masses undergoing partial nephrectomy. In this review we provide an update on the oncological safety and renal functional outcomes following RAPN. We also discuss the novel techniques and technological advances that have contributed to the outcomes of RAPN. METHODS: A Medline search using the keywords “partial nephrectomy”, “robotic partial nephrectomy”, “robot assisted partial nephrectomy”, “robot assisted laparoscopic partial nephrectomy” and “laparoscopic partial nephrectomy” was conducted to identify original articles, review articles, and editorials on RAPN. RESULTS: A review of the literature suggests that RAPN is emerging as the preferred approach to minimally in-vasive nephron sparing surgery. RAPN is superior to lap-aroscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) in terms of perioperative outcomes with equivalent mid-term oncological outcomes. RAPN has proven safety and efficacy even in complex renal tumors with equivalent oncological and functional out-comes. Novel techniques and advances in technology have contributed to the safety and efficacy of RAPN. CONCLUSION: RAPN can be considered to be the gold standard approach to minimally invasive nephron sparing surgery with equivalent oncological and renal functional outcomes and superior perioperative out-comes when compared to OPN. Newer techniques and developments in robotic technology have contributed to improved outcomes following RAPN.

OBJECTIVES: Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in Urology. Several retrospective and prospective studies have demonstrated that robotic-assisted RC (RARC) rep-resents a minimally invasive alternative to open surgery, showing non-inferiority in mid-term oncological outcomes. Moreover, important advantages related with perioper-ative complications have also been published. The aim of this article is to describe RARC surgical steps and to review the most relevant ndings in the eld of RARC, fo-cusing on its strengths and weaknesses when compared with open RC.METHODS: We performed a detailed step-by-step de- scription of the RARC surgical technique, paying particu-lar attention to its specific surgical details and adding our tips and tricks for an outstanding performance. We also conducted a review of the most relevant articles in litera-ture in terms of oncological, pathological and periopera-tive results. All these findings have been compared with the classical open radical cystectomy (ORC) technique. RESULTS: None of the studies published have demon-strated RARC to have worse oncological outcomes (PSM, RFS, CSS, OS) compared to ORC. RARC shows a de-crease in blood loss and transfusion rates. No dif- ferenc-es have been observed in complications rate, length of hospital stay, quality of life, and time to bowel movement between both approaches. The two disad- vantages of RARC compared to ORC are a longer oper- ative time and increased cost. Operating time can be re- duced with surgeons gaining experience and technique standardiza-tion. The cost disparities and operative time between ORC and RARC at high-volume academic cen- ters are less pronounced than in the general medical community.CONCLUSIONS: RARC is a technically feasible and safe approach, with oncological, pathological and periopera-tive results, at least, equivalent to ORC.

OBJECTIVE: To present a review of the technical aspects of robotic intracorporeal ileal conduit (IC) reconstruction after robot assisted radical cystecto-my (RARC).METHODS: A non-systematic review is performed in or-der to summarize technical aspects on robot assisted ileal conduit procedure following radical cystectomy in patients with muscle invasive bladder cancer. RESULTS: Radical cystectomy with pelvic lymph node dissection and urinary diversion is the gold-standard therapy for localized muscle-invasive bladder cancer. IC is the most common diversion utilized by surgeons. Min-imally invasive approaches to IC were proposed with the intention of decreasing the morbidity associated to open surgery. Several oncological, and functional fac-tors should be taken into consideration for the selection of patients undergoing this procedure together with sur-geons and patients’ preferences. The stoma marking of the patient is of critical importance. Identification of the ureters should be done assuring careful handling of the tissue and then isolation of the bowel segments should be performed after confirming proper length of the seg-ment. Side to side anastomosis of the antimesenteric bor-ders of the bowel is performed with linear staplers, and the ureteroileal anastomosis is done. Finally, the ileal conduit is positioned close to the stoma marking site and is fixed to the skin. Urinary diversion and radical cystec-tomy is a very morbid procedure. Mainly, complications are gastrointestinal, stoma-related, or associated to the ureter-enteric anastomosis.CONCLUSIONS: The advantages of the robotic plat-form concerning postoperative outcomes may be more evident if the procedure is done in an intracorporeal fashion. Proper knowledge and mastery of the technical aspects of this procedure are critical.

OBJECTIVE: It is well known that RARC with intracorporeal diversion is being increasingly per-formed worldwide. In this article, we review the current situation of the intracorporeal neobladder. METHODS: We discuss the principles of intracorporeal orhotopic diversion, focusing on the most relevant: The Karolinska-modified Studer neobladder, the University of Southern California-modified Studer neobladder. the pyr-amid pouch and the modified Y-shaped orthotopic neo-bladder. We also compare functional and perioperative outcomes from our series and the available studies re-garding RARC and intracorporeal orthotopic diversion.RESULTS: Review of existing literature suggests that RARC with totally intracorporeal neobladder, in some cases, has improved operative, postoperative, and functional outcomes, becoming a safe and feasible alternative to ORC.CONCLUSIONS: The results from the intraorporeal neo-bladders series appear to be promising, but high-qual-ity randomized controlled trials comparing to ICUD to ECUD should be performed in order to define the ad-vantages and disadvantages of totally intracorporeal urinary diversion and its future role in the treatment of invasive bladder cancer.

OBJECTIVES: There has been growing interest in intracorporeal techniques to urinary diversion during cystectomy in the modern area. There is little high-quality evidence that this technique is superior to extracorporeal diversion in patients who are obtaining an orthotopic intracorporeal neobladder urinary diver-sion. This study describes the proposed advantages and disadvantages of intracorporeal orthotopic neobladder urinary diversion and expert opinion on preference. METHODS: We reviewed the literature for all studies discussing the outcomes and advantages of intracorpo-real orthotopic neobladder urinary diversion, including those comparing the intracorporeal and extracorporeal approach. The studies were reviewed and these findings were summarized based on categories of the proposed advantages and disadvantages of the intracorporeal ap-proach. We provided an assessment of the claims made in favor of the intracorporeal approach and discussed advantages of the extracorporeal approach that may persuade even the most experienced robotic surgeons to lean away from the former. RESULTS AND CONCLUSIONS: Herein we review the studies that propose advantages of the intracorporeal diversion, as well as the studies that do not demonstrate any advantage to this approach. Some of the proposed advantages addressed include decreased stricture rate, lower complications and shorter hospitalization. Fur-thermore, we address the issues of the steep learning curve and the impact on resident education. We con-clude that the proposed benefits of an intracorporeal approach to urinary diversion are not substantiated and it is the preference of the authors to primarily perform extracorporeal urinary diversions.

Three-dimensional, high-definition imag-es, small instruments with endowrist technology, ergo-nomic position and the easiness to teach, are possibly the main reasons why robotic surgery will continue to gain ground to others forms of surgery. The current appli-cations of robotics in functional urology are: the correc-tion of pelvic organ prolapse, the correction of female stress urinary incontinence (artificial urinary sphincter) and the treatment of chronic pelvic pain (pudendal nerve neurolysis). In this paper, we explain our robotic tech-niques in these three scenarios, as well as, provide the most updated data of our series.

OBJECTIVES: Open kidney transplanta-tion (OKT) represents the standard approach in patients with end-stage renal disease, but recently robotic-assist-ed kidney transplantation (RAKT) has also become an accepted approach.METHODS: We conducted a systematic review using the PubMed/Medline and Embase databases and the keywords “Robotic kidney transplantation” and “Robot-ic-assisted kidney transplantation”.RESULTS: Past studies of RAKT have tended to suffer from patient selection bias, but, following completion of the learning curves in specialized centers, the indications for RAKT have recently been expanded to include more complex cases. The technique has evolved over the years, and currently both intraperitoneal and extra-peritoneal approaches are accepted; however, it has been suggested that the intraperitoneal technique offers advantages in obese patients. The Vattikuti-Medanta technique of RAKT with regional hypothermia, in which the graft is surrounded by a gauze jacket filled with ice slush, is the most widely accepted technique for mainte-nance of the graft temperature at below 18-20°C during surgery. A number of perioperative variables have been described, including operative time (145-255 min), to-tal ischemia time (73-96 min), rewarming time (40-73 min), blood loss (88-150 mL), high-grade complication rate (3.75%-12.5%), and hospital stay (6-14 days). The data regarding functional outcomes show that RAKT presents a similar profile to OKT in terms of functionality at short- and long-term follow-up. While RAKT has been proposed as a safe and effective alternative in obese patients, such patients should be included in a weight loss program or undergo simultaneous bariatric surgery.CONCLUSION: Despite its limitations, RAKT seems to be an attractive, feasible, safe, and reproducible sur-gery. It offers surgical advantages and a lower compli-cation rate, especially in obese patients, and delivers functional outcomes comparable to those achieved us-ing OKT.

OBJECTIVE: We relate a single-center experience in virtual surgical planning to demonstrate interests and perspectives in pediatric urology.METHOD: From 2004 to April 2017, 4 patients were analyzed before intervention at our institution. All pa-tients had undergone a low dose CT scan. The acqui-sition was then treated by a surface rendering software Pre-, per- and post-operative outcome were retrospec-tively collected.RESULTS: 4 patients were operated on from 2004 to April 2017: two for oncological pathologies and two for congenital malformations. Mean age at intervention was 61 months (21-156 months). Two interventions were performed laparoscopically with one conversion. Mean operative time was 135 min (80-180 min). There were no complications. CONCLUSION:3D surgical planning should be man-datory in pediatric urology to perform the safest, the most accurate and effective surgery as possible.