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The trend towards the organ sparing and robotic assisted surgeries is clear and is going to expand in the future. Hence, the tools surgeons need to facilitate such minimallly invasive approaches are going to be even more important. The Indocyanine green (ICG) is a water-soluble, relatively hydrophobic dye which bounds to plasma protein and can be used intraoperatively as real time contrast agent. Near infrared fluorescence (NIRF) helps in differentiating the renal planes, and the most common reagent used for the NIRF is ICG. The combination is used frequently during nephron sparing surgery in urology to ensure the ischemia of the kidney after clamping the renal artery, moreover it can help to identify the arterial blood supply to the tumor allowing selective clamping and thus minimizing the ischemia time. Several studies assessed the role of ICG in nephron-sparing surgery and provided evidence that its use allows to improve perioperative and oncological outcomes. This review provides an overview of the articles published regarding the use of ICG during partial nephrectomy, about the oncological outcomes and safety.
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OBJECTIVES: The use of intraoperatory laparoscopic ultrasound for nephron sparring surgery (partial nephrectomy) in patients with technically challenging tumors has emerged during the last years. The objective of this work is to present a literature review and analysis of the published series, as well as the surgical technique of intraoperatory laparoscopic guided partial nephrectomy. METHODS: Pubmed and Scopus serch was performed in January 2019 including the following keywords: “intraoperative ultrasonography”, “laparoscopic ultrasonography” and “partial nephrectomy”, the published series are presented. We describe the laparoscopic technique of intraoperatory ultrasound during partial nephrectomy.RESULTS: All the published series present similar results in terms of tumour size which varies from 2.3 to 4 cm. Complications results are also very similar in the comparative series to the ones published in partial nephrectomies. They show promising oncological results during follow up with a rate superior to 90% of negative margins, comparable to those of exophytic tumor partial nephrectomies.CONCLUSIONS: The use of intraoperatory ultrasound during laparoscopic surgery to localize intraparenchymatous renal lesions can expand the indications of partial nephrectomy to more technically challenging tumors.These indications are not yet well standardized. Due to its complexity, the need of previous surgical experience is required to achieve good results and corroborate the security and feasibility of this procedure. Prospective randomized trials are needed to confirm the benefits of intraoperatory laparoscopic ultrasound for nephron sparring surgery (partial nephrectomy).
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OBJECTIVE: Nephron sparing surgery is the gold standard in cT1 renal tumor. In order to perform a safe and effective surgery is essential a good radiological study. 3D printing is a new tool that allows the creation of virtual and physical trustworthy 3D reproduction of organs or anatomical structures of patients.METHOD: Non systematic review of PubMed database about the usefulness of 3D printing in renal surgery. RESULTS: 3D printing has a potential use in surgery planning, resident education and improving the communication and understanding of our patients.CONCLUSION: Today the number of publications and the use of these technique are still low. 3D printing is a useful tool in order to improve communication with patients and has a potential role in resident education. 3D printing technology could be useful in surgically complex cases since provides an exact model of the organ and the lesion before the intervention allowing a better surgery planning to the surgeon.
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OBJECTIVE: To perform a literature review on the use of cavoscopy during surgery for renal cell carcinoma with vena cava thrombus (RCCVCT), according to the criteria of Evidence-Based Medicine.MATERIAL AND METHODS: We performed a Pubmed search for studies published with the following keywords: “renal tumor thrombus”, “renal tumor cavoscopy” and “cystoscopy thrombus”, without time limit and in English. With these criteria, 5 articles were identified with a total of 41 patients. All studies found are case series and expert opinions, so the degree of evidence in the use of cavoscopy in RCCVCT is low.RESULTS: RCCVCT surgery is a complex technique, which can reach over 50% 5-year survival, when a complete oncological resection is achieved. One of the keys for surgical success is complete resection of tumor thrombus, having used different techniques for its verification. One of them is cavoscopy, which consists on the introduction of a flexible cystoscope through the cavotomy incision after thrombectomy, checking the lumen of the vena cava with saline serum irrigation. In two series of clinical cases, cavoscopy detected thrombus persistence in 22% and 43% of patients respectively, allowing resection. The entire resected thrombus showed malignancy in several cases.CONCLUSION: Cavoscopy is a technique that improves detection of tumor remnants after thrombectomy in comparison to indirect review methods. Although oncological impact of caval thrombus is controversial, the use of cavoscopy allows a more complete resection of the thrombus, and it may offer a possible increase in the recurrence-free survival of these patients.
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OBJECTIVE: Renal cryotherapy (RC) is an alternative therapeutic option to partial nephrectomy in elderly patients and/or patients with comorbidities. The technique can be guided by ultrasound, CT and MRI. Although CT is the most used technique, there are no comparative studies. The objective of this study was to review the current status of ultrasound as a guide for the planning and execution of RC.METHODS: A systematic review of the literature was carried out in the Pubmed/Medline database following the PRISMA guidelines. We used 42 articles that met the inclusion criteria for the synthesis of the evidence.RESULTS: Ultrasound allows dynamic and real-time monitoring of the entire procedure to guide the biopsy, placement of the cryoprobes, cryoball formation, and early identification of complications. The success rate and recurrences found in the percutaneous renal cryotherapy (PRC) were 97.04% and 1.81%, respectively, with 9.35% complications. The ultrasound during laparoscopic renal cryotherapy (LRC) has been shown to reduce the time spent in localizing the renal mass and also decreases the need for large dissections. On the other hand, contrast-enhanced ultrasound during follow-up shows a concordance with the CT or MRI of 72-96% and no complications have been described associated with its execution.CONCLUSION: Renal cryotherapy guided by ultrasound is a feasible technique, its main advantage is based on real-time monitoring during the procedure. The PRC presents an acceptable rate of complications and excellent oncological results. The LRC allows a rapid localization of the renal mass and reduces extensive dissections. During follow-up, the use of contrast ultrasound is a safe alternative that has been shown to have a good degree of agreement with respect to CT and MRI.
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The experience with robotic reconstructive surgery has been reported previously. Many studies have demonstrated that the use of robotic surgery for those procedures is safe and effective. However, the characteristics related to those cases, make reconstructive surgery a very complex procedure that is usually managed in some referral centers only. Indocyanin green (ICG) is a substance that could be visualized using near-infrared fluorescence (NIRF). This fluorescence could help the surgeon for orientation and evaluation of viability of the tissues.OBJECTIVE: This article describes the literature and our experience using ICG for reconstructive surgery of the ureter.METHODS: We describe the literature and our approach for the evaluation and treatment of the ureteral stricture using ICG. CONCLUSION: The use of ICG has demonstrate to be safe, easy to perform and reproducible. In this article, we showed the ICG usefulness for complex reconstructive cases. Prospective studies with long follow up and bigger simple will permit a better evaluation of its results.
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OBJECTIVES: Confocal lasser endomicroscopy (CLE) is an optical technique that enables in vivo cytological characterization of a tissue. Previous studies have shown it useful in the evaluation of urinary and respiratory tracts for a better characterization of mucosal lesions, showing a high concordance between in vivo and final histopathological results. Recently, the use of CLE has been proposed for the study of transitional cell carcinoma of the upper urinary tract (UUT) during ureteroscopy, because it enables real time information about tumor grade and supplements the information of ureteroscopic biopsies, which may understimate the grade and stage of the lesion up to 43% of the cases due to its limitiations.METHODS: We performed a systematic review of the literature in the Pubmed/Medline database following the PRISMA standard. We selected 20 articles that complied with the inclusion criteria for evidence synthesis.RESULTS: Equipment miniaturization has enabled CLE as part of the diagnostic options in upper urinary tract tumors. This technique performs in vivo cytological characterization of the evaluated tissue, accomplishing differentiation between tumor and normal tissue, as well as tumor grade identification. Its communicated sensitivity and specificity reach 79%/78% respectively for low grade tumors and 67%/79% for high grade, with a substantial inter observer concordance (surgeon/pathologist; k=0.64). No complications have been communicated in the literature with the use of fluorescein or confocal laser microscopy probes in patients undergoing this technique.CONCLUSIONS: CLE represents a useful and safe tool, capable of providing cytological real time information of UUT tumors that enables tumor grade identification with substantial concordance between in vivo tumor typifying and the final histopathological analysis. For this, CLE is currently considered a tool for conservative management of UUT transitional cell carcinoma in the European Association of Urology (EAU) guidelines.
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OBJECTIVES: Systematic review of the treatment of small testicular masses (STM) by testicular sparing surgery (TSS), including indications, surgical techniques and complications, as well as the correlation of the analysis of frozen sections (FSE) with the final tumor histology. As a secondary objective we report the initial experience of our center in TSS.MATERIAL AND METHODS: A systematic literature search of the Medline/PubMed database for studies published until June 30, 2019 with the following keywords: “testis sparing surgery”, “conservative surgery”, “partial orquiectomy” “testicular neoplasms”, “testis tumour”, “Sex cord tumor”, “intraoperative ultrasonography”, “enucleation”, “excision” or “resection” without time limits, in English and Spanish, identifying 20 articles with a total of 204 TSS, being the series with the largest sample size of 28. In our service, 8 TSS were performed in 6 patients (two bilateral tumor) distributed between 2016-2019.RESULTS: No randomized controlled trials comparing TSS with radical orchiectomy have been reported. The indications for TSS are controversial, especially for patients with normal contralateral testicles. Tumor size has been identified as an important predictor of malignant disease and although there is no approved cut-off point, STM ≤2 cm are the ones that can benefit most from TSS.The use of intraoperative ultrasound (IU) is essential for the location of STM, whether a macroscopic or microsurgical resection is being performed, helping to reduce the rate of complications of the procedure, described in <6%. The FSE is key at the time of the TSS, discriminating between benign and malignant neoplasms, maintaining a good correlation with the final histology.CONCLUSIONS: TSS for STM allows greater preservation of healthy parenchyma, but should be performed only in selected cases and in experienced centers. The surgical technique is safe and viable, the use of the IU and the FSE of the lesion being essential to facilitate the surgical decision making.
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INTRODUCTION: Bothersome lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) are increasingly common amongst ageing men leading to poor quality of life. Surgical treatment options targeted at the obstructing prostate are often required to relief the bladder outlet obstruction, following failure or discontinuation of medical therapies. Transurethral resection of the prostate (TURP) has been the mainstay and gold standard for benign prostate surgery for last few decades. Currently with technological advancements, numerous minimally invasive surgical therapies have been employed to provide effective symptom relief while minimalizing morbidities and preserving sexual function. Prostatic hydroablation (Aquablation) is a new technique which involves high velocity water jets used in non-thermal ablation of the obstructing prostatic tissue robotically delivered by a transurethral cystoscopic handpiece and guided by real time transrectal ultrasound imaging. Recent trials have shown that aquablation is safe and effective in the treatment of symptomatic BPH while maintaining sexual preservation. METHOD: Aquablation using the Aquabeam system (PROCEPT BioRobotics, Redwood Shores, CA, USA) combines the precision of autonomous robotic execution in delivering high velocity waterjets via a cystoscopic handpiece with accurate anatomical prostatic mapping using real time transrectal ultrasound imaging. The initial part of the surgery involves careful treatment planning tailored to the prostatic anatomy with preservation of important landmarks nearby, then, high velocity waterjet streams are delivered to ablate the obstructing prostatic tissue without use of any heat. Following the ablation and removal of handpiece, a routine cystoscopic bladder washout is performed and haemostasis achieved with balloon tamponade from a 3 way catheter placed under tension empolying a custom designed catheter tensioning device. RESULTS: Initial studies involving a few case series and a phase II trial demonstrated the safety and effectiveness of aquablation in treatment of symptomatic BPH. Subsequently, a large multicentre international prospective randomised blinded clinical trial (WATER) was conducted to assess the efficacy of aquablation versus TURP. Results from this pivotal trial showed non-inferior symptom relief compared to transurethral prostate resection but with a lower risk of sexual dysfunction. WATER II study was then conducted to assess the safety and feasibility from a multicentre prospective study of aquablation in the treatment of symptomatic large-volume BPH. The results from this study showed that aquablation is feasible and safe in treating men with men with large prostates (80-150 mL).CONCLUSION: The current landscape of BPH surgical treatment should be individualized with a shared decision-making process based on prostatic anatomy and clinical parameters combined with patient’s preferences to select the ideal treatment option for each patient. Aquablation is one such option that involves a robotically delivered hydroablation technique based on individualised real time ultrasonic prostatic mapping that can offer safe and effective treatment for symptomatic BPH while minimising sexual dysfunction. Larger trials with longer follow up data will be required to further validate the long term effectiveness of aquablation.
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Transrectal ultrasound has been a diagnostic method for diagnosis of prostate cancer for more than 30 years. It increased its options after the incorporation of MRI in the 90s. The association of real-time ultrasound with anatomical and functional data of multiparametric magnetic resonance imaging (mpMRI) has changed the prostate cancer scenario and presumably will modify the therapeutic alternatives.OBJECTIVES AND METHODS: In the following non systematic review of the literature, we present the current situation of different types of fusion biopsy, the initial preclinical and clinical results as well as the data collected in the different meta-analyses.RESULTS: Although “in bore” biopsy has shown the best sensitivity, its economic and accessibility problems make it the least widespread. Cognitive biopsy is one of the most widespread despite being the one that provides the least objective results. Fusion biopsies with Software Platform are being developed as the most reproducible and affordable in our environment. The data in the literature is still insufficient to establish what is the best software. There are many points of controversy such as number of cores, approach, associated systematic biopsies and possible connotations when assessing the therapeutic attitude.CONCLUSION: None of the Software platforms have demonstrated superiority in the diagnosis of cancer, although their results are superior to those obtained through standard and cognitive biopsy and are more affordable than the “In bore” biopsy. It is necessary to standardize the publications to be able to compare results (classification of risk in resonance, number of cores, approach). The diagnosis of cancer guided by MRI should be a factor to consider in therapeutic decision nomograms. The next challenge is the incorporation of these systems in the protocols of active surveillance and Focal Therapy.
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OBJECTIVE: Prostate cancer (PCa) diagnosis has improved with multiparametric magnetic res onance (mpMRI) and new more specific biomarkers. However, mpMRI has some limitations such as variability, long learning curve and high cost. More progress is needed in the PCa diagnosis scenario, and it is here where high resolution micro-ultrasound (MUS) imaging system emerge. MATERIAL AND METHODS: Retrospective study between February (2017-2018); including 96 patients with PCa suspicion, undergoing transrectal prostate biopsy guided by MUS. Procedure was performed by 2 urologists blinded to mpMRI results at first (92% available). PRI-MUS protocol was used to identify suspicious features. 2 core targeted biopsy of suspicious areas (PRIMUS >3) was completed first and then it was followed by a 12-core systematic biopsy and finally sampling of mpMRI targets if available. Data were collected reporting sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) to detect clinically significant PCa (csPCa) (Gleason score >7).RESULTS: Overall, MUS csPCa detection rate was 59.37%. 171 cores were registered, of them csPCa were distributed as follow: 1.2% PRI-MUS 1, 16.3% PRIMUS 2, 28% PRI-MUS 3, 39% PRI-MUS 4 and 15% PRI-MUS 5. Sensitivity in csPCa detection for PRI-MUS >3 was 82% with 93% NPV, but with low 39% specificity and 19% PPV. Comparing 79 patients with mpMRI available; sensitivity by area of MUS was 82% versus 30% of mpMRI, with 93% NPV versus 88%. Specificity and PPV were higher in mpMRI in comparison to MUS.CONCLUSIONS: Although this is a preliminary series, MUS is presented as an attractive imaging technique, cost-effective, easy to learn and with high efficacy in image-guided prostate biopsy. Overall PCa detection rate increases over conventional ultrasound; and offers high sensitivity and NPV in csPCa detection over mpMRI but with lower specificity.
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INTRODUCTION: Prostate cryotherapy has been consolidated as an alternative minimally invasive treatment.OBJECTIVE: To exposed its historical development, its action mechanism and the surgical technique. Regarding its indications, we expose the different option of treatment- primary cryotherapy, salvage and focal- emphasizing its oncological results in the absence of randomized studies.RESULTS: Cryotherapy is a safe technique with low complication rate, although incidence of erectile dysfunction is 40-90% in case of full-gland cryotherapy. Nowadays, it is recommended as a therapeutic alternative for low and intermediate risk localized prostate cancer, although in clinical trials. Recurrence-free survival is close to 96% in low-risk tumors and 90% in intermediate-risk tumors. On the other hand, it is a salvage treatment option for local recurrence after radiotherapy. Focal therapies including focal cryoablation have an important development, with recurrence-free survival of 75%.CONCLUSION: Waiting for randomized studies that provide more scientific evidence, available retrospective studies show cryotherapy as a safe and effective treatment option in patients with localized prostate cancer.
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OBJECTIVE: High-intensity focused ultrasound (HIFU) Focal therapy appears to have encouraging oncologic outcomes and urinary and erectile function. The control of the treated area can be done using contrast enhanced ultrasound with sulfur hexafluoride (Sonovue®) at the end of the procedure. We report oncological and functional outcomes in HIFU focal therapy (FT) for prostate cancer (PCa) management using sonovue.METHODS: A total of 274 HIFU procedures were found in our registry in the period between June 2014 and July 2018. Prospective data of 59 consecutive patients after focal high-intensity focused ultrasound (HIFU) using Sonovue were collected. FT failure was defined as positive biopsy Gleason score (GS) ≥ 7 in- or out-field, local or systemic salvage treatment, PCa-metastasis or PCa-specific death. RESULTS: A total of 59 patients submitted to HIFU with median follow-up of 18 months were included in the analysis. Median age was 66.7 yr (IQR 59.1-74.3). Median preoperative prostate-specific antigen (PSA) was 7.6 ng/ml (IQR 5-10.2) and preoperative biopsies GS 6, 7(3+4), 7(4+3) were found in 26 (44%), 30 (50.8%) and 3 (5%), respectively. Failure was found in 16 (27.1%) patients. Failure-free survival (FFS) in 2 and 4yr was 83% and 74% respectively (Figure 1). No PCa-specific death was registered in the period of study. Median nadir PSA after FT was 2.67 ng/ml. Sexual potency was achieved in 75% of previous potent patients and urinary continence in 93.4% of patients at 3 months. Fourteen (23%) patients presented with complications. Four (6.7%) patients have presented complications grade 1 and 10 (16.9%) patients have presented complications grade 2. Six (10.1%) patients have presented acute urinary retention. CONCLUSIONS: Our study shows that the use of Sonovue after HIFU FT was safe. Patients present a significant proportion of failure after HIFU FT but with good functional outcomes and without incidence of severe complications.
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OBJECTIVE: ICG navigation in cancer surgery may help during pelvic lymphadenectomy. METHODS: We performed a systematic review combining the terms: bladder cancer or radical cystectomy and ICG, and prostate cancer or radical prostatectomy and ICG. We used the PRISMA guidelines recommendations. We describe the populations studied in each work, the pathological results, as well as the parameters specificity, sensitivity and predictive values.RESULTS: In muscle-invasive bladder cancer, 4 case series analyzed the performance of lymphography with ICG. The most accepted injection method is under endoscopic vision. Several punctures are done in the submucosa and the detrusor surrounding the scar. Sentinel nodes were found in up to 92% of patients with a technique sensitivity to find metastases of 88% in the series with largest casuistry.In prostate cancer, we collected data from 11 case series. Nine of them apply transrectal or transperineal dilution immediately before surgery. Sensitivity in the detection of all adenopathies ranged between 44% and 100%. The sensitivity of the technique to know the lymph node stage ranges between 67% and 100%.CONCLUSIONS: There is little experience of ICG-guided lymph node dissedction in bladder tumors. Endoscopic fluorophore injection allows us to find the nodes that drain the infiltrated area. However, the use of this technique is not widespread. In prostate cancer, it is a reproducible and efficient technique for staging patients with prostate cancer.
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OBJECTIVE: To validate the sentinel lymph node selective biopsy (SLNSB) in the staging of Prostate Cancer with Briganti Index > 5 by comparison with extended lymphadenectomy (ePLND) in a prospective longitudinal study.METHODS: SLNSB has been performed in 84 patients, the first 70 by injection of nanocoloids marked with Tc99m and preoperative SPECT-CT, and in the last 14 with mixed radiotracer (99mTc + ICG). After laparoscopic removal of sentinel nodes all patients underwent an ePLND.RESULTS: SPECT-CT showed radiotracer deposits outside the territory of the ePLND in 76% of patients and laparoscopic gamma probe in 57%. The median number of sentinel nodes removed was 5.2 with a total average number of lymph nodes removed of 22. In all cases with metastatic nodes (28% in the series) there was at least one positive sentinel node but metastatic sentinel nodes outside of the territory of the ePLND were found in 6/24 patients (25%). The sensitivity, specificity, PPV and NPV of 99mTc were 100%, 96.07%, 90.47% and 100%, respectively. In 5 out of 14 patients with mixed radiotracer, lymph node involvement was detected. In all of them there was at least one sentinel node affected with 99mTc, and only 3 showed fluorescence with 100% sensitivity and 100% NPV for 99mTc and 60% sensitivity and 77.77% NPV for ICG.CONCLUSION: The SLNSB with 99mTc has a high sensitivity and a VPN of 100%, increasing the identification of lymphatic metastases outside the territory of the ePLND. Fluorescence can facilitate the visualization of the sentinel nodes when they have been previously located by the SPECT-CT, although the sensitivity and the NPV of the ICG are lower than that of the 99mTc.
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OBJECTIVES: To describe the available techniques to prevent and treat complications related with surgery involving lymphatic nodes and drainage: lymphorrea, lymphocele and lymphedema.METHODS: Bibliographic review and personal experience communication of different image-assisted techniques in the prevention and management of lymphatic related complications.RESULTS: We describe the conventional lymphography with ethiodized oil contrast (lipiodol) by lymphatic catheterization and intranodal percutaneous puncture used in diagnostics and interventional radiology; the gammagraphic lymphography with radioactive isotopes for diagnostic use; and the utilization of colorants/dyes (patent blue, V-blue, methylene blue, indocyanine green) for diagnostic and therapeutic procedures. CONCLUSIONS: Lipiodol lymphography offers well-defined radiologic images and it is useful in interventional radiology procedures. It has the inconvenience of lymphatics catheterization and is not available for surgical dynamic identification of lymphatics. Isotopic techniques are used for diagnostics and sentinel-node procedures. Colorants and dyes have several advantages: no need for catheterization, not expensive technology, price, availability, easy management. It allows the dynamic identification of lymphatics for surgical resolution of lymph-related complications.
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OBJECTIVE: Intraoperative neurophysiological monitoring (INM) allows obtaining real-time information on the functional integrity of nervous system structures. The objective of this article is to present the role of clinical neurophysiology in Urology in the identification and preservation, on the one hand, of the prostate neurovascular bundles in radical prostatectomy (RP), and of the pudendal nerve in the release of this in Pudendal Nerve Entrapment Syndrome (PNS).METHODS: A bipolar laparoscopic probe was used for intraoperative stimulation for both the identification in PNS and neurovascular bundles in RP, obtaining response at the external anal sphincter in the first one; and intracavernous pressure in the second through needle electrodes.RESULTS: Preservation of the periprostatic neurovascular bundles allows to increase rates of sexual potency and urinary continence after surgery. However, it has been shown that the innervation of the corpora cavernosa and the urinary sphincter has a variable disposition. Intraoperative neurostimulation allows the most precise identification and dissection of the vascular and nervous structures that surround the prostate.In the diagnosis of PNS, the neurophysiological study allows to rule out pathology at other levels, such as, primary muscular pathology of the anal sphincter. There are no pathognomonic neurophysiological findings of PNS. In addition, it allows the identification of the nerve during the laparoscopic release of the nerve at the entrance of the Alcock channel, as well as the evaluation of its functional integrity after the end of the dissection.CONCLUSIONS: The INM is a fundamental tool to allow an improved identification of nerve structures during RP and PNS in order to preserve them. It also helps with the diagnosis of PNS.
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OBJECTIVE: To provide an overview of the meaning and types of virtual reality (VR) system, its current applications in the field of urology and future implications. Synthesis of the evidence: The concept of VR involves the generation of computer environments with which a user can interact directly. Urology technologies and surgical practices are constantly evolving and RV simulation has become an important complement in urologist training curricula, taking into account not only simulations in surgical techniques, but also in non-surgical techniques such as communication and decision making.VR approaches for image-guided surgery have demonstrated potential in the field of urology by supporting guidance for various disorders. An increasing number of pre and intraoperative imaging modalities have been used to create detailed surgical route maps. The tracing of these surgical roadmaps with the surgical vision of real life has been produced in different ways (electromagnetic, acoustic, optical ...), recommending the combination of several approaches to provide a superior result. One of the disadvantages of navigation systems is soft tissue deformations, requiring confirmatory images. Although early studies report that navigation surgeries provide results equal to or greater than conventional approaches, most of the work has been done in relatively small groups of patients, thus requiring studies with larger sample sizes. CONCLUSIONS: The development of VR offers urologists many opportunities, with surgical simulation being one of its most important applications today. Likewise, the first clinical studies have demonstrated the potential of augmented reality (2D and 3D models) to improve surgical accuracy, describing different navigation systems for different urological surgical interventions.
