Objectives: While the coronavirus disease 2019 (COVID-19) pandemic captures healthcare resources worldwide, data on the impact of prioritization strategies in urology during pandemic are absent. We aimed to quantitatively assess the global change in surgical and oncological clinical practice in the early COVID-19 pandemic. Methods: In this cross-sectional observational study, we designed a 12-item online survey on the global effects of the COVID-19 pandemic on clinical practice in urology. Demographic survey data, change of clinical practice, current performance of procedures, and current commencement of treatment for 5 conditions in medical urological oncology were evaluated. Results: 235 urologists from 44 countries responded. Out of them, 93% indicated a change of clinical practice due to COVID-19. In a 4-tiered surgery down-escalation scheme, 44% reported to make first cancellations, 23% secondary cancellations, 20% last cancellations and 13% emergency cases only. Oncological surgeries had low cancellation rates (%): transurethral resection of bladder tumor (27%), radical cystectomy (21–24%), nephroureterectomy (21%), radical nephrectomy (18%), and radical orchiectomy (8%). (Neo)adjuvant/palliative treatment is currently not started by more than half of the urologists. COVID-19 high-risk-countries had higher total cancellation rates for non-oncological procedures (78% vs. 68%, p = 0.01) and were performing oncological treatment for metastatic diseases at a lower rate (35% vs. 48%, p = 0.02). Conclusion: The COVID-19 pandemic has affected clinical practice of 93% of urologists worldwide. The impact of implementing surgical prioritization protocols with moderate cancellation rates for oncological surgeries and delay or reduction in (neo)adjuvant/palliative treatment will have to be evaluated after the pandemic.

Introduction: While various surgical techniques have been reported for open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) with bladder cuff has never been reported using only retroperitoneum without entering abdominal cavity. We developed a novel port placement and technique allowing to perform robot-assisted NU by a unique retroperitoneal approach. Methods: Between February and June 2021 patients with history of UTUC were treated by robot-assisted NU completely restricted to retroperitoneal space using a singular trocar placement and a two-step docking without relocation of the surgical robot. Patient characteristics, perioperative outcomes and short-term follow-up were prospectively analyzed. Results: The analysis included five patients [median age: 73 years; BMI: 27.2 kg/m²; Charlson comorbidity index 5]. All five patients had UTUC with a mean tumor size of 3.02 cm (range 0.9–6.0). UTUC was localized to distal ureter in two and to kidney in three cases. No positive surgical margins were noted for all patients with UTUC [1 low-grade and 4 high-grade]. Retroperitoneal lymphadenectomy in three patients did not reveal positive nodes. No intraoperative adverse events exceeding EAUiaiC classification ≥ 2 were observed, while median EBL was 150 ml (IQR 100–250). No patient experienced postoperative complications exceeding Clavien–Dindo classification ≥ 3a. Median hospital stay was 5.4d without any 30-d readmission. Conclusion: We demonstrate safety and feasibility of the first entire robot-assisted retroperitoneal nephroureterectomy (RRNU) with bladder cuff. This surgical technique is easily reproducible, while surgical outcomes are similar to other established techniques.

Purpose: Focal therapy (FT) for localized prostate cancer (PCa) is only recommended within the context of clinical trials by international guidelines. We aimed to investigate oncological follow-up and safety data of focal high-intensity focused ultrasound (HIFU) treatment. Methods: We conducted a single-center prospective study of 29 patients with PCa treated with (focal) HIFU between 2016 and 2021. Inclusion criteria were unilateral PCa detected by mpMRI-US-fusion prostate biopsy and maximum prostate specific antigen (PSA) of 15 ng/ml. Follow-up included mpMRI-US fusion-re-biopsies 12 and 24 months after HIFU. No re-treatment of HIFU was allowed. The primary endpoint was failure-free survival (FFS), defined as freedom from intervention due to cancer progression. Results: Median follow-up of all patients was 23 months, median age was 67 years and median preoperative PSA was 6.8 ng/ml. One year after HIFU treatment PCa was still detected in 13/ 29 patients histologically (44.8%). Two years after HIFU another 7/29 patients (24.1%) were diagnosed with PCa. Until now, PCa recurrence was detected in 11/29 patients (37.93%) which represents an FFS rate of 62%.One patient developed local metastatic disease 2 years after focal HIFU. Adverse events (AE) were low with 70% of patients remaining with sufficient erectile function for intercourse and 97% reporting full maintenance of urinary continence. Conclusion: HIFU treatment in carefully selected patients is feasible. However, HIFU was oncologically not as safe as expected because of progression rates of 37.93% and risk of progression towards metastatic disease. Thus, we stopped usage of HIFU in our department.

Introduction: MRI‐guided targeted biopsy has become standard of care for diagnosis of prostate cancer, with establishment of several biopsy techniques and platforms. Augmented reality smart glasses have emerged as novel technology to support image‐guided interventions. We aimed to investigate its usage while prostate biopsy.Methods: MRI with PIRADS‐lesions ≥3 was uploaded to smart glasses (Vuzix Blade^R) and augmented reality smart glasses‐assisted targeted biopsy (SMART‐TB) of the prostate was performed using cognitive fusion technology at the point of care. Detection rates were compared to systematic biopsy. Feasibility for SMART‐TB was assessed (10 domains from bad [1] to excellent [10]).Results: SMART‐TB was performed for four patients. Prostate cancer detection was more likely for SMART‐TB (46%; 13/28) than for systematic biopsy (27%; 13/48). Feasibility scores were high [8–10] for practicality, multitasking, execution speed, comfort and device weight and low [1–4] for handling, battery and image quality. Median execution time: 28 min; Investment cost smart glass: 1017 USD.Conclusion: First description of SMART‐TB demonstrated convenient feasibility. This novel technology might enhance diagnosis of prostate cancer in future.

Einleitung Virtual Reality (VR) ist die künstlich simulierte Umgebung, mit der eine Interaktion möglich ist. Die Augmented Reality (AR) hingegen überlagert reale und künstliche Informationen. Beide Verfahren sind im Klinikalltag bereits vielerorts integriert und werden zunehmend auch für den chirurgischen Sektor beworben. Welche Möglichkeiten die vielfältigen Anwendungsmöglichkeiten bieten, ist dabei vielen Ärzten unklar. Ziel Erfassung der aktuellen und zukünftigen Verwendung von AR und VR im perioperativen Umfeld sowie die Veranschaulichung der zu erwartenden Verbesserungen und Probleme durch diese neuen Technologien. Methoden: Systematische Literaturrecherche der Medizinbibliothek PubMed mit Inklusion von Reviews, die Bezug nehmen auf das Thema AR und VR mit Fokus auf Artikel, die das perioperative Feld berühren. Schlagwörter waren: Augmented Reality, Virtual Reality, Telementoring, Telechirurgie („Telesurgery“). Zudem Durchführung einer Recherche innerhalb der Grauliteratur zur Analyse der Investitionsbereitschaft im Gesundheitswesen durch private Technologiekonzerne. Resultate Zum Thema „Augmented Reality“ wurden 1222 Artikel bei 119 Reviews und zu „Virtual Reality“ 7766 Artikel bei 878 Reviews angezeigt. Die Anzahl der veröffentlichten Artikel ist dabei über die letzten Jahre hinweg stark zunehmend. 45 Artikel wurden eingeschlossen. Multiple AR- und VR-Geräte sind bereits im operativen Setting etabliert. Die nächsten vielversprechenden Anwendungsbereiche werden hier v. a. die intraoperative Überlagerung von bildgebenden Verfahren über AR-Geräte sowie das Telementoring und die vermehrte Anwendung im Bereich operativer bzw. anatomischer Ausbildung betreffen. Die zu erhoffenden Vorteile wie Senkung der Komplikationsrate, Kosteneinsparungen, flächendeckender Wissenszuwachs und Optimierung des chirurgischen Ergebnisses müssen erst in wissenschaftlichen Studien nachgewiesen werden. Aus der Recherche der Grauliteratur geht ein enormes finanzielles Bestreben der Technologiekonzerne in diesem Sektor hervor. Schlussfolgerung AR und VR werden aufgrund ihres enormen Verbesserungspotenzials zunehmend in den perioperativen Sektor integriert. Dabei ist der Nutzen dieser Technologien für relevante Endpunkte weitestgehend unklar. Diese sollten in gut-designten klinischen Studien rigoros getestet werden. Ärzte sollten diese technische Revolution aktiv mitgestalten, um das enorme Potenzial von AR und VR zum Wohle ihrer Patienten auszuschöpfen. Introduction Virtual reality (VR) is an artificially simulated environment permitting interaction. On the other hand, augmented reality (AR) is an enhanced version of reality created by the use of technology to overlay digital information on an image of something being viewed through a device. Both technologies have partially been implemented in clinical daily routine. Surgical applications of VR and AR are currently evaluated. Yet it is still unclear which possibilities these new and versatile applications offer for physicians. Intention The goal of this article was to assess current and future use of AR und VR, with a special focus on surgery. We also summarised obstacles for AR and VR use as well as potential clinical improvements through these new technologies. Methods Systematic literature research in PubMed with inclusion of reviews referring to AR and VR, especially focused on articles on surgery. Keywords were Augmented Reality, Virtual Reality, Telementoring and Telesurgery. Furthermore we briefly analysed the investment volume and investment strategy in medicine from the ten largest private technology companies of the USA. Results The keyword “Augmented Reality” leads to 1222 articles and 119 reviews, while “Virtual Reality” offered 7766 articles and 878 reviews. In recent years, the amount of published articles has increased. 45 articles were included. Multiple AR- and VR-applications are already integrated in surgical daily routine. The next promising applications will concern the possibility of intraoperative overlap with radiological imaging via AR-tools, as well as telementoring and the use of AR and VR in surgical and anatomical education. The expected – but unproven – advantages include cost savings, reduction in complications, comprehensive knowledge acquisition and improvement in surgical results. In addition, we notice enormous financial investment by technology companies in this sector. Conclusion Due to their tremendous potential, AR and VR technologies will be increasingly integrated into surgery. However, the benefit of these new technologies for relevant endpoints are currently unclear. This should be examined in rigorous clinical trials. Physicians should play a key role in this technological revolution to exploit the potential of AR and VR for their patients.