Search Results (60)

Background/Objectives: Renal cell carcinoma (RCC) with venous tumor thrombus (VTT) extending into the inferior vena cava (IVC) occurs in 4–10% of patients and represents one of the most technically demanding scenarios in urologic surgery. Open radical nephrectomy with en bloc thrombectomy remains the gold standard for infradiaphragmatic disease (Mayo Levels 0–III), offering the only realistic prospect for long-term cure. This narrative review provides a technically oriented, evidence-based guide for surgical urologists managing these complex cases. Methods: PubMed/MEDLINE, Scopus, and Web of Science were searched (1970–March 2025) using terms related to RCC, venous tumor thrombus, IVC thrombectomy, and perioperative management. Priority was given to prospective studies, systematic reviews, large retrospective cohorts, and current guidelines (EAU 2025, NCCN v2.2024). Original intraoperative photographs supplement procedural descriptions. Results: We detail the complete perioperative pathway: VTT classification (Mayo/AJCC), multimodal imaging, patient optimization, and level-specific open surgical techniques—ranging from Satinsky clamping for Level 0–I thrombi to full piggyback liver mobilization with hepatic vascular exclusion for Level III disease. Contemporary perioperative mortality is <2% at high-volume centers (reported in single and multicenter retrospective series from high-volume institutions), with 5-year cancer-specific survival of approximately 50–60% in non-metastatic cases. Adjuvant pembrolizumab is now a standard of care following the KEYNOTE-564 trial. Neoadjuvant immune checkpoint inhibitor plus tyrosine kinase inhibitor combinations show promising VTT downstaging rates (44–100%), though their role remains investigational. Robotic-assisted thrombectomy demonstrates favorable perioperative outcomes for Level I–II thrombi at experienced centers. Conclusions: Open surgery remains the cornerstone of curative treatment for RCC with infradiaphragmatic VTT, requiring meticulous preoperative planning and multidisciplinary collaboration at high-volume centers. Integration of perioperative systemic therapies and robotic-assisted approaches holds promise for further improving outcomes in this challenging patient population. Full article

Background: The role of minimally invasive surgery (MIS) for hepatocellular carcinoma (HCC) remains controversial because of concerns regarding oncologic adequacy, particularly margin status. While robotic-assisted hepatectomy has gained adoption, its true perioperative advantages over conventional laparoscopy and open surgery remain unclear. SIMMILR-5 was designed to evaluate the short-term outcomes of open, laparoscopic, and tele-robotic laparoscopic hepatectomy for HCC using rigorous adjustment for confounding. Methods: A retrospective international multicenter study was conducted including patients undergoing liver resection for HCC between June 2004 and November 2024 at five high-volume hepatobiliary centers. Surgical approaches included open (O), conventional laparoscopy (L), and tele-robotic laparoscopy (TRL). Propensity score matching was performed using demographic, clinical, and tumor-related variables. The primary endpoint was short-term mortality (30 and 90 days). Secondary outcomes included estimated blood loss (EBL), operative time, length of stay (LOS), R0 resection status, and major complications. Results: A total of 904 patients were identified (302 O, 568 L, 34 TRL). After matching, conventional laparoscopy was associated with significantly lower EBL, shorter operative time, and shorter LOS compared with open surgery (all p < 0.00001). Compared with open surgery, TRL was associated with lower EBL but no improvement in operative time or LOS. Compared with laparoscopy, TRL was associated with longer operative time and longer LOS. Short-term oncologic surrogates were comparable across approaches. Conclusions: Minimally invasive hepatectomy offers perioperative advantages over open surgery for selected patients with HCC, driven primarily by conventional laparoscopy. Tele-robotic hepatectomy is feasible and safe in experienced centers but does not demonstrate superiority over advanced laparoscopic techniques. Full article

Introduction: Simultaneous resection of primary colorectal malignancies and liver metastases resulted in outcomes comparable to those achieved through a two-stage procedure, while offering the advantage of a single surgical intervention. The role of the robotic approach remains underexplored because of the lack of comprehensive evidence. The objective of our study was to examine the safety of the robotic surgical platform, assess its short-term outcomes, and compare them with those of open procedures. Methods and Material: We retrospectively analyzed data from an initial small series of eight consecutive patients treated at the UMC Ljubljana between March 2023 and December 2025. These patients underwent robot-assisted simultaneous resection of colorectal malignancies and liver metastases. Their outcomes were compared with those of an open cohort of eight patients. Results: The median operative time was 334 min (range, 193–415 min). No conversions or transfusions were required. Three patients experienced severe complications, accounting for 37.5% of the cohort. The median duration of hospitalization was 9.5 days. The median number of lymph nodes retrieved was 22. Complete (R0) resection of the primary tumor was achieved in all cases (100%), whereas resection of the liver was achieved in 87.5% of the cases. Importantly, there were no instances of re-hospitalization within 30 days or mortality within 90 days. Conclusions: Although the rate of severe complications is relatively high, the robotic surgical platform allows for the safe simultaneous resection of colorectal malignancies and liver metastases, achieving short-term outcomes comparable to those of open surgery. Full article

Surgical navigation and augmented reality (AR) are widely used in neurosurgery, spinal surgery, and orthopedics. However, their use in minimally invasive abdominal and thoracic soft-tissue surgery is limited, as tracking deformable, mobile organs is challenging. Recent advances in AR may address these challenges to improve intraoperative navigation. This systematic review, registered in PROSPERO (2024) and based on PRISMA guidelines, analyzes literature from 2014 to 2024 about AR in minimally invasive abdominal and thoracic soft-tissue surgery. It identifies target organs, describes AR hardware and software, and evaluates accuracy levels, usability outcomes, clinical benefits, technical limitations, and research needs. Searches of PubMed, Web of Science, and Embase for English-language studies found 1297 records, of which only 28 (2%) met the inclusion criteria. Nearly half (n =12; 42%) focused on liver surgery; none on gynecologic surgery. The AR devices varied in tracking methods, image processing, visualization, and display. Overall, AR improved anatomical guidance and procedural planning, especially in complex surgeries. Integration with robotic systems may further boost visualization, precision, and workflow, though challenges remain in standardization, large-cohort validation, and workflow integration. Full article

Background: Clear cell renal cell carcinoma (ccRCC) constitutes 75–80% of all renal cell carcinomas and exhibits aggressive behavior with high metastatic potential. Common metastatic sites include lungs, bones, lymph nodes, and liver, while urinary bladder involvement is exceedingly rare. Early detection of atypical metastases is critical for risk stratification, surgical planning, and systemic therapy selection. Methods: We report a 69-year-old male presenting with recurrent, painless gross hematuria and dysuria. Contrast-enhanced computed tomography revealed a left renal mass with bilateral pulmonary nodules, regional lymphadenopathy, and a bladder lesion. The patient underwent transurethral resection (TUR) of the bladder lesion, followed by robot-assisted left nephro-adrenalectomy with para-aortic lymphadenectomy. Histopathology and immunohistochemistry (PAX8+, CD10+, CAIX+, CK7−, GATA3−) confirmed ccRCC with synchronous bladder metastasis. Postoperatively, combined immune checkpoint inhibitor (ICI) therapy and tyrosine kinase inhibitors (TKIs) were initiated. Results: TUR provided symptomatic relief and diagnostic confirmation. Robot-assisted surgery enabled precise, oncologically safe excision of the primary tumor and regional metastases with minimal blood loss and no perioperative complications. Pathological staging was pT3aN1M1, ISUP grade 2, with lymphovascular invasion, confirming advanced disease requiring systemic therapy. Early initiation of ICI plus TKI therapy targeted residual micrometastases to potentially prolong survival. Conclusions: This case highlights the rare occurrence of ccRCC with synchronous bladder metastasis and underscores the importance of comprehensive imaging, detailed morphologic and immunohistochemical evaluation, and a multidisciplinary approach. Robot-assisted cytoreductive surgery combined with modern systemic therapy represents an effective strategy for advanced ccRCC, emphasizing the need for individualized treatment and long-term follow-up in atypical metastatic scenarios. Full article

Interface interaction mechanics analysis is of great significance for robot-assisted insertion surgery in minimally invasive surgery and therapy. Previous work indicates that the accurate modeling of soft tissue puncture forces plays a crucial role in surgical planning, robotic needle insertion, and biomechanical simulation, which can give insights useful for physicians to guide and operate assisted robots. The objective of this study is to develop a dynamic multi-component force model that integrates cutting force, stiffness resistance, and frictional interaction to characterize needle–soft tissue interaction during puncture. A dynamic force model is proposed, and a lateral periodic disturbance mechanism is introduced into the simulation framework in order to enhance the robustness and realism of the model under micro-manipulation scenarios. The model has been validated using a series of controlled puncture experiments on porcine liver and renal tissues under varying insertion angles (15°, 30°, 45°) and speeds (0.5 mm/s, 1.5 mm/s, 2.5 mm/s). Corresponding finite element simulations were also conducted using ANSYS software. The agreement between simulation and experiment has been quantitatively evaluated by comparing force–depth and force–time curves, and the statistical significance of the impact of angle and speed on puncture forces has been assessed using ANOVA and Tukey’s HSD tests. Quantitative comparison demonstrated strong consistency, with the optimal case reaching a coefficient of determination (R²) value of 0.96 and Root Mean Square Error (RMSE) below 0.13 N after incorporating a 0.05 mm lateral perturbation. Statistical analysis confirmed the impact of angle and speed on puncture force responses (p < 0.05). Furthermore, comparative analysis revealed that porcine liver exhibits more consistent biomechanical behavior than renal tissue, particularly under perturbation-enhanced simulation. This study successfully establishes a dynamic multi-component force model for soft tissue puncture, validated with high fidelity against experimental data. The incorporated lateral disturbance mechanism enhanced the model’s realism. This work can provide a reliable foundation for the future design of intelligent robot-assisted puncture systems and high-fidelity simulation-based training platforms. Full article

Background and Objectives: Robot-assisted procedures represent a significant advancement in minimally invasive liver resection techniques. Nonetheless, the introduction of a novel surgical technique in a new environment necessitates meticulous planning and a gradual, stepwise approach. This study describes the adoption of a robotic surgical platform for liver resection at a high-volume tertiary care center. Materials and Methods: We retrospectively analyzed data that had been prospectively collected from fifty robot-assisted liver resections. Descriptive statistics, including frequencies, percentages, means/medians, and standard deviations, were employed for description and summary. Results: The median operative duration was 166 min (range: 85–400 min), with an average intraoperative blood loss of 200 mL (range: 50–1000 milliliters). Intraoperative or postoperative blood transfusion was required in 8% of patients. Conversion to open resection was necessary in one patient (2%). The mean duration of hospitalization was 5 days (range: 3–20 days), with a 30-day readmission rate of 6% and no mortality within 90 days. Postoperative complications classified as Clavien-Dindo grade 3 or higher were observed in five patients (10%). The mean tumor size varied according to pathology: 58.5 mm (range: 30–120 mm) in the hepatocellular carcinoma group; 27.4 mm (range: 10–32 mm) in the secondary malignancy group; and 42.6 mm (range: 24–60 mm) in the intrahepatic cholangiocarcinoma group. The median number of lymph nodes harvested during lymphadenectomy (IHHCA/GBCA) was 5.4, ranging from 1 to 11. The R0 resection rate for malignant tumors was 88.2% (of 30/34). Conclusions: This study validates the safe integration of robot-assisted surgery into liver disease treatment, supported by our initial experience. Despite its technical advantages, robotic-assisted liver surgery remains complex and demanding. Structured robotic training within established programs, meticulous patient selection, and a stepwise implementation approach are critical during the early phases to optimize the outcomes. Full article

Background/Objectives: Robotic-assisted surgery (RAS) has emerged as a technological advancement in gastrointestinal (GI) procedures, addressing limitations of conventional laparoscopy through enhanced dexterity, three-dimensional visualization, and ergonomic improvements. While its clinical use is expanding, the comparative benefits and cost-effectiveness of RAS across different GI domains remain unclear. Methods: An umbrella review was conducted to evaluate RAS across six GI domains: esophageal, gastric, liver, biliary, pancreatic, and colorectal. A systematic literature search of PubMed was performed in April 2025, yielding 8961 articles. Reviews published in English since 2018 and comparing RAS with laparoscopic or open approaches in human GI surgery were eligible. A total of 250 articles met the inclusion criteria. Data on technical feasibility, clinical outcomes, and cost-effectiveness were extracted. Methodological quality was appraised using the AMSTAR 2 checklist. Results were synthesized narratively. The study was supported by the National Research Foundation of Korea grant, and the protocol was registered in PROSPERO (CRD420251042541). Results: RAS demonstrated domain-specific advantages. Esophageal and gastric surgeries benefited from enhanced precision and lymphadenectomy, while long-term outcomes were comparable to laparoscopy. Robotic liver and biliary surgeries offered technical advantages in complex cases, but evidence was limited. The most significant clinical benefits were observed in pancreatic and colorectal procedures, in which RAS reduced conversion rates and improved short-term outcomes in anatomically challenging scenarios. Cost-effectiveness was generally unfavorable but showed improvement in high-volume centers due to reduced complications and shorter hospital stays. Conclusions: Robotic assistance provides the most consistent clinical benefit in pancreatic and colorectal surgery, especially for complex, high-risk cases. While high procedural costs remain a barrier, selective use of RAS in appropriate settings may yield improved outcomes. These findings support the need for ongoing evaluation of cost-effectiveness and long-term results to guide evidence-based integration of robotics into GI surgery. Full article

Introduction: Robotic-assisted surgery offers technological advantages such as three-dimensional visualization and improved dexterity, yet its clinical adoption in gastrointestinal (GI) malignancies is supported by evidence of varying quality, consisting mainly of retrospective studies. This review provides a structured summary of the current evidence for robotic surgery in pancreatic, gastric, liver, and colorectal cancers. Methods: A comprehensive literature review was conducted to assess and summarize the perioperative, long-term, and oncological outcomes of robotic-assisted surgery compared to laparoscopic and open approaches for the aforementioned GI malignancies. Results: The application of the robotic platform is most advanced in colorectal surgery. High-quality evidence for rectal cancer demonstrates improved quality of mesorectal specimens, better preservation of urinary and sexual function, and lower local recurrence rates. Across all reviewed GI malignancies, robotic surgery consistently shows advantages in lower conversion-to-open rates, reduced intraoperative blood loss, and shorter hospital stays, though it is associated with longer operative times and higher costs. The evidence for pancreatic and liver surgery is less mature due to the complexity of these procedures. Data for gastric surgery suggests improved lymph node retrieval and, in one long-term study, better disease-free survival. Conclusions: The highest-quality evidence supports the robotic approach for rectal cancer, showing clear functional and oncological benefits. While several perioperative advantages are consistently reported across all GI sites, robust data demonstrating superior long-term survival are still limited for most procedures. Full article

Robotic surgery has grown tremendously in the past decade and has been applied in many surgical specialties, including hepatobiliary surgery. The complexity associated with hepatobiliary surgery initially limited the growth of implementing the use of robotics; however, technological breakthroughs made to the robotic surgical system and the superior patient outcomes have contributed to its exponential growth in the field. This article explores the evolution of robotic-assisted hepatobiliary surgery, from the advancement of the robotic surgical system to the progression of techniques applied in hepatobiliary surgery, and how this positively affected patient outcomes. Full article

Background/Objectives: For surgical candidates with metastatic renal cell carcinoma with a tumor thrombus (mRCC-TT), surgery is cytoreductive nephrectomy with tumor thrombectomy (CN-TT). This is carried out through an open (OCN-TT), laparoscopic (LCN-TT), or robotic (RCN-TT) approach. The purpose of this study was to compare survival outcomes to CN-TT by operative approach. Methods: This was a retrospective analysis of all patients with a diagnosis of mRCC-TT, who underwent CN-TT from a multi-institutional database from 1999–2024. Metastatic locations were qualified as either lung, bone, brain, liver, retroperitoneum, adrenal, paraaortic nodes, or other nodes. Progression was defined as radiographic evidence of recurrence or metastasis not seen on imaging prior to CN-TT. Progression locations were all metastatic locales previously noted plus the nephrectomy bed. Overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) were calculated. Comparisons were performed between OCN-TT, LCN-TT, and RCN-TT. Results: A total of 131 patients were included in the analysis (97 OCN-TT, 25 LCN-TT, and 9 RCN-TT). The TT level was not different (p-value > 0.05) by approach (p-value > 0.05). Preoperative tumor size, final pathologic tumor subtype, and postoperative tumor size were equivalent between the three surgical approaches (p-value > 0.05). Rates of progression were equivalent as were all locations of disease progression in the study (p-value > 0.05). Median OS was 1.6 years in OCN-TT, 1.5 years in LCN-TT, and 2.5 years in RCN-TT (p-value = 0.42). Median CSS was 2.1 years in OCN-TT, 3 years in LCN-TT, and 2.5 years in RCN-TT (p-value = 0.86). PFS was 0.8 years in OCN-TT, 1.2 years in LCN-TT, and 1.2 years in RNC-TT (p-value = 0.76). Conclusions: The operative approach does not affect survival outcomes for CN-TT. Surgeon comfort and patient preference should weigh heavily in operative decision making. Full article

Background: Robotic liver surgery is emerging as a key advancement in minimally invasive techniques, though it still faces several challenges. Meanwhile, colorectal cancer (CRC) continues to be a leading cause of cancer deaths, with liver metastases affecting 25–30% of patients. These metastases significantly burden healthcare systems by raising costs and resource demands. Methods: A narrative literature review was performed, resulting in the inclusion of 14 studies in our analysis. Fourteen studies met the inclusion criteria and were analyzed with attention to patient characteristics, surgical details, perioperative outcomes, and reporting limitations. For consistency, simultaneous robotic-assisted resection (RAR) refers to cases in which the colorectal primary and liver metastasectomy were performed during the same operative session. Results: The 14 studies included a total of 771 patients (520 males and 251 females), aged between 31 and 88, undergoing simultaneous robotic-assisted resection (RAR). Most were affected by rectal cancer (76%) and unilobar liver metastases (82%). All surgeries using the DaVinci system are represented by 62% wedge resection and 38% anatomical (21.39% major and 16.61% minor). Patients’ BMI ranged from 19.5 to 40.4 kg/m², the average blood loss was 181.5 mL (30–780), the median hospital stay was 7 days (range 2–28), and the mean operative time ranged from 30 to 682 min. Data on POLF (postoperative liver failure) are reported in two studies: Rocca et al., 1/90 patients; Marino et al., 1/40 patients. Biliary leak is reported in one case by Marino et al., while Winckelmans et al. reported a 2.6% incidence of biliary leak in the laparoscopic group and 3.4% in the robotic group. Conclusions: As research advances and new therapies emerge for colorectal liver metastasis (CRLM), surgery remains the mainstay of treatment. However, evidence is limited by small sample sizes, heterogeneous study designs, inconsistent reporting of perioperative chemotherapy, timing of surgery, metastasis localization, and complications. Robotic liver surgery has become a well-established technique and possibly represents the future for managing colorectal liver metastases. Further prospective and comparative studies with standardized outcome reporting are needed to define optimal patient selection and long-term effectiveness. Full article

Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver cancer with a poor prognosis. Negative-margin resection is presently the only potentially curative treatment option. Emerging trends with direct applicability to surgical strategy include margin thickness, lymphadenectomy, optimization of future liver remnant (FLR), minimally invasive techniques, incorporation of systemic therapy, and reconsideration of liver transplantation. This review emphasizes areas of consensus and ongoing debate. Margins ≥5–10 mm are associated with improved results, but biology generally takes precedence over prognosis. Regional lymphadenectomy enhances staging accuracy, although its therapeutic benefit remains unsettled. PVE is standard for FLR enlargement, LVD provides faster hypertrophy, and ALPPS remains reserved for highly selective cases. Minimally invasive and robotic hepatectomy share oncologic results in skilled institutions. Systemic therapies, including immunotherapy and biomarker-directed targeted therapy, are increasingly being incorporated perioperatively. Liver transplant may be of potential value in early-stage disease or on strict indications after neoadjuvant treatment. The modern surgical management of iCCA encompasses a blend of oncologic considerations, FLR optimization, minimally invasive surgery, and systemic therapy according to tumor biology. Multidisciplinary planning and participation in clinical trials are necessary to align surgical innovation with advancements in molecular and systemic treatments, ultimately leading to improved long-term outcomes. Full article

Background: Robotic liver resection (RLR) has seen remarkable advancements in recent years, overcoming many limitations of laparoscopic liver resection (LLR). RLR has evolved to include increasingly complex procedures, offering enhanced precision, reduced blood loss, and lower complication rates. Materials and Methods: A total of 150 consecutive RLRs, performed at the Department of General Surgery II and HPB Unit of Santa Chiara Hospital (Trento, Italy), between January 2013 and June 2024 were retrospectively reviewed. Collected data included demographics, disease etiology, operative parameters, oncologic margins, and perioperative outcomes. Results: Indications were malignant disease in 83% of cases while benign disease accounted for 17%. Minor resections accounted for 91%. Cirrhosis was present in 49% of patients (Child–Pugh A 91%; B 9%; mean MELD 9). According to the Iwate difficulty score, resections were low difficulty in 38% of cases, intermediate in 50%, advanced in 7%, expert in 5%. Conversion rate was 12%, mainly for bleeding or adhesions. Mean blood loss was 159 mL (66% <100 mL); Pringle maneuver was used in 3%; drains omitted in 45%; ICG fluorescence used in 81%. Mean operative time was 250 min (console time 184 min). Mean lesion size was 34 mm; R0 margin rate was 82%. Overall mortality was 1.3%; morbidity 24% (Clavien–Dindo ≥ III in 10%). Mean hospital stay was 7 days (median 5; range 2–46). Conclusions: RLR is a safe and effective alternative to laparoscopy, providing comparable or superior perioperative outcomes. Medium-volume centers can achieve high-quality results with RLR. Continued technological advancements will further expand its applications to increasingly complex liver procedures. Full article

Background: Breast cancer is a widespread disease and, when metastatic, has a bleak prognosis. The surgical approach for BCLM has had a limited role, but robotic surgery could find an important place. Methods: Data were collected from a multicenter retrospective database that includes 1070 consecutive robotic liver resections performed in nine European hospital centers from 2011 to 2023. Of the entire series, 35 were performed for BCLM in five European hospital centers. Results: The post-operative complication rate was 11.44%, but no severe complications occurred. The mean hospital stay was 4.65 days. One patient (2.85%) was readmitted to the hospital within 90 days after discharge and died due to heart failure, with a 90-day mortality of 2.85%. Conclusions: Robotic liver resection for BCLM is feasible and safe when performed in experienced centers by surgeons who have completed the learning curve. Full article