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ABSTRACT Introduction: Male factors contribute to 30 to 50% of infertility in couples. Treatment options for male infertility are limited, so antioxidant supplementation for idiopathic male infertility is currently being studied. Alpha lipoic acid (ALA) has a high antioxidant capacity and the potential to penetrate tissues, cells, and organelles, including mitochondria, due to its water and lipid solubility properties. The recent inclusion of randomized trials in the literature has required a new systematic review and meta-analysis to evaluate the efficacy of alpha lipoic acid in sperm parameter changes. Purpose: We aimed to perform a systematic review and meta-analysis of the currently available randomized trials comparing the effects of ALA supplementation versus placebo on sperm function in infertile male patients. Material and Methods: Pubmed, Embase, Cochrane Library, and Scopus databases were searched from inception to June 2024. A random-effects model was employed to compute mean differences and risk ratios for continuous and binary endpoints. Heterogeneity was evaluated through the prediction interval. A sensitivity analysis was conducted by systematically excluding one study at a time and recalculating the pooled effect. All statistical analysis was conducted using R software 4.4.1. The certainty of evidence was evaluated with the GRADE approach. Results were reported following the PRISMA statement guidelines. This study was registered in PROSPERO. Results: Five randomized trials comprising 250 patients with a mean age of 28 to 40 years were included in this analysis. Over a mean follow-up time of 3 months, ALA was associated with a reduced proportion of abnormal sperm morphology (MD −0.89; 95% CI −1.48 to −0.29; p=0.003), increased total motility (MD 13.49; 95% CI 3.52 to 23.46; p=0.008), and increased sperm progressive motility (MD 12.43; 95% CI 2.89 to 21.97; p=0.01). Additionally, ALA was associated with a higher pregnancy rate in two individual studies reporting the outcome, however, no significance was found in our pooled analysis (RR 2.28; 95% CI 0.66 to 7.85; p=0.1). Finally, ALA did not change ejaculation volume (MD 0.14; 95% CI −0.54 to 0.83; p=0.6), sperm concentration (MD 11.99; 95% CI −0.67 to 24.66; p=0.06), live sperm (MD 4.42; 95% CI −3.17 to 12.02; p=0.2), or total antioxidant capacity (MD 0.43; 95% CI −0.02 to 0.87; p=0.06). No adverse events were reported. Conclusion: In this meta-analysis, ALA was associated with a favorable change in sperm quality. However, there were no effects on pregnancy rates. ALA should be considered for patients with idiopathic infertility.

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ABSTRACT Purpose: The adoption of novel multi-port, single-port and modular robotic platforms has significantly increased in the last years. We aim to provide an overview of the preliminary clinical outcomes of the procedures performed with these new robotic systems, assessing their particular features and safety profile during the learning curve Material and methods: A systematic literature search was performed on 15th May 2023 on PubMed, Embase, Scopus and Web of Science databases, to identify original articles presenting clinical outcomes of new robotic systems for abdominal urologic surgery. The study protocol was registered on PROSPERO (CRD 42023437863). Results: Six new robotic platforms were identified. Of 2925 papers identified, 71 met our inclusion criteria: 49 on single-port system and 22 on novel multi-port systems. We found variable outcomes for the most common procedures performed with these new systems. However, all of them showed acceptable perioperative and oncologic outcomes during the learning curve and good safety profile. Functional outcomes were underreported Conclusions: The adoption of novel multi-port and single-port robotic systems in urologic surgery can offer new opportunities for enhanced precision, reduced invasiveness, and potentially improved patient outcomes. The variability in outcomes across different platforms underscores the need for continued research and standardized training.

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ABSTRACT Quality management is essential to ensure consistent, safe, and effective outcomes in assisted reproductive technology (ART) centers. However, traditional quality assessments often overlook male infertility, which contributes to nearly half of all infertility cases. This article explores the implementation of a quality management system (QMS), specifically ISO 9001, tailored to ART centers that prioritize male reproductive health. Drawing from our experience at ANDROFERT, a male-focused fertility clinic, we demonstrate how process standardization, structured workflows, and continuous improvement strategies can optimize diagnostics, microsurgical procedures, and laboratory practices. Integrating male-specific procedures—such as varicocele repair, microdissection testicular sperm extraction (micro-TESE), and vasovasostomy—into the QMS is discussed, along with performance monitoring tools, including key performance indicators and patient satisfaction metrics. Collaboration with an academic institution is essential to support education and ensure training is aligned with quality and safety protocols. Our center's dual IVF laboratories and andrology services exemplify how advanced testing, including sperm DNA fragmentation analysis and handling of surgically retrieved sperm, are seamlessly integrated into quality pathways. By embedding male reproductive health into QMS frameworks, ART centers can improve clinical outcomes, foster interdisciplinary collaboration, and enhance patient engagement. We advocate for a multidimensional approach to quality—beyond pregnancy rates—encompassing safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. This model strengthens clinical performance and ensures sustainable, evidence-based fertility care for male patients.

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ABSTRACT Purpose: To evaluate the efficacy of parasacral transcutaneous electric nerve stimulation (PTENS), in comparison to darifenacin for the reduction of OAB symptoms in patients infected with HTLV-1. Materials and Methods: This proof-of-concept randomized clinical trial was carried out at the HTLV-1 Outpatient Clinic of the University Hospital. Participants included 42 HTLV-1 infected subjects with symptoms OAB. The OAB symptoms score questionnaire (OABSS) was applied before and after treatment to evaluate each group: group1-received darifenacin and group 2-treated with PTENS. Random sequences and statistical analysis were generated by SPSS statistical package, version 27 (IBM Inc™). Results: There was no difference between groups regarding demographic, socio-economic and clinical characteristics. The initial median and interquartile (IQR) range of OABSS were 11.2 (9.5 - 14.0) in G1 and 10.7 (8.0 - 12.7) in G2. There was a reduction in the frequency, nocturia and urgency in both groups. However, 5 (23.8%) of the patients in the group treated with darifenacin abandoned the therapy, while only 1 patient (4,8%) stopped PTENS. Conclusions: Both protocols used in this study were effective in treating OAB syndrome and reducing OABSS. However, therapy abandonment and adverse events were more frequent in the darifenacin group compared to the PTENS group.

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ABSTRACT Objective: Robotic surgery has enhanced minimally invasive procedures with greater precision and control, but high costs have limited its widespread adoption. The Sentire® surgical system is hypothesized to achieve clinical outcomes comparable to those of the da Vinci® system while demonstrating superior cost-effectiveness in robot-assisted radical prostatectomy (RARP) procedures. This study aimed to compare RARP outcomes using Sentire® and da Vinci®, focusing on clinical efficacy and economic impact. Materials and Methods: A retrospective analysis was conducted at three high-volume urology centers in China, including 22 patients who underwent RARP with the Sentire® system and 287 patients who underwent RARP with the da Vinci® system. After 1:3 propensity score matching (PSM), 66 patients were successfully matched in the control group. Perioperative outcomes and cost metrics were assessed. Key measures included operative and console times, docking time, blood loss, recovery, positive surgical margins, surgeon evaluations of performance and comfort, and cost-effectiveness. Results: The Sentire® group had a longer median operative time (143 vs. 112 minutes, p=0.024), while console time (85 vs. 76 minutes, p=0.323) and docking time (9.0 vs. 6.0 minutes, p=0.279) were comparable. Blood loss was also similar between the groups (p=0.093). Positive surgical margin rates were 22.7% for Sentire® and 20.0% for da Vinci® (p=1.000), and no significant differences were observed in pathological ISUP grades or prostate volumes (p=0.327 and p=0.856, respectively). At 1-year follow-up, PSA recurrence was observed in 3 patients in the Sentire® group (4.5%) and 4 in the control group (6.1%) (p=0.625), with similar median PSA levels (0.012 vs. 0.014 ng/mL, p=0.410). Urinary continence rates were also comparable at 1, 3, and 12 months (all p > 0.05). Cost-effectiveness analysis revealed lower total and direct costs in the Sentire® group, including surgery expenses ($8,750 vs. $10,500, p=0.021), although differences in consumable and indirect costs were not statistically significant. Surgeon satisfaction scores for performance and comfort were slightly better for Sentire® but did not reach statistical significance (p > 0.05). Conclusion: This study demonstrates that the Sentire® system is well-suited for urological surgeries, offering comparable clinical outcomes and shorter hospital stays while improving cost-effectiveness compared to the da Vinci® system.

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ABSTRACT Purpose: To evaluate the trifecta outcomes of ultrasound-guided radiofrequency ablation (RFA) of T1a renal masses and to identify factors influencing trifecta outcomes. Materials and Methods: We retrospectively reviewed data from patients who underwent ultrasound-guided RFA at Peking University First Hospital between March 2017 and May 2024. Baseline demographics, perioperative outcomes and follow-up results were collected. The trifecta outcomes were defined as the absence of severe complications, incomplete ablation and tumour recurrence. Multivariate logistic regression analysis was performed to identify risk factors for trifecta failure. Results: Among 270 patients (140 left-sided and 130 right-sided), the median tumour size was 1.97 (range 0.80-3.86) cm, and 32 (11.9%) patients had a history of ipsilateral partial nephrectomy. During the median follow-up of 35.6 (range 6.2-91.4) months, the rates of severe complications, tumour recurrence, and incomplete ablation were 1.1%, 7.4%, and 7.4%, respectively. The trifecta outcome was achieved in 227 (84.1%) patients. Multivariate analysis revealed that tumour size [odds ratio (OR): 2.144, p = 0.007] and history of ipsilateral partial nephrectomy (OR: 3.894, p = 0.002) independently predicted trifecta failure. Conclusion: Ultrasound-guided RFA is a safe and effective treatment for T1a renal masses. Tumour size and a history of ipsilateral partial nephrectomy were significantly associated with trifecta failure.

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ABSTRACT Purpose: The use of patient prioritization tools is one of several methods to enhance the management of waiting times for elective surgeries. Developing these tools specifically for urinary stones in the Brazilian context may enhance queue management and increase patient satisfaction. This study aims to adapt two previously published scores, the WCWL (Western Canada Waiting List - general criteria) and the SCQ-score (specific to urinary stone criteria), into Brazilian Portuguese. Materials and Methods: Our study adhered to established protocols for the cross-cultural adaptation and translation of health-related questionnaires. The process for translating both original scores involved four steps: initial translation, back-translation, committee review, and pre-testing. The translations were conducted by professionals proficient in the relevant languages. The pre-test phase engaged eight endourologists who applied the translated versions of the scores to twelve hypothetical patient cases. Results: Our study successfully produced Brazilian Portuguese versions of the SCQ and WCWL scores. During the pre-testing, these scores were found to be quick to perform (with an average completion time of 1 minute and 35 seconds) and were deemed easy to understand and use by the endourologists. However, there was a concern regarding the practical utility and interpretability of the WCWL score due to its more generalized criteria. Conclusion: We successfully developed the Brazilian Portuguese version of the Western Canada Waiting List and SCQ-score. This development will allow further studies to evaluate the impact of their use within the Brazilian healthcare environment.

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ABSTRACT Introduction: We performed the first study exploring telesurgery's teleproctoring potential while performing long-distance procedures between Orlando (USA) and Shanghai (China) over a distance of 13,000 km. The objective was to evaluate telesurgery's performance and teaching potential using the MicroPort® MedBot™ robotic platform and fiber-optic technology in real-time collaboration during urologic procedures. Materials and Methods: We simulated a real-life scenario where surgeons could communicate and send mutual inputs during telesurgery cases. A prospective study using live porcine models was conducted on July 23–24, 2024. Surgeons in Orlando and Shanghai took turns controlling the robotic system, performing nephrectomies, pyeloplasties, and ureteroureterostomies while transferring control between locations. Latency and system performance were continuously monitored, and real-time communication between the surgeons was facilitated by fiber-optic technology. Results: Surgeons successfully completed numerous urologic procedures, including nephrectomies, pyeloplasties, and ureteroureterostomies, with seamless control transfers. Remote surgeons provided teleproctoring and assistance during the procedures. The robotic system operated without issues throughout the two-day study. The median latency was 139 milliseconds (range 137–216 ms) on the first day and 139 milliseconds (range 137–185 ms) on the second day. Conclusions: This study demonstrates the feasibility of long-distance telesurgery and highlights its potential to improve surgical outcomes, facilitate training, and offer remote assistance for complex cases. Telesurgery could play a significant role in expanding access to specialized care and enhancing robotic surgical training globally.

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ABSTRACT Objective: To evaluate the impact of a urological neoplasm diagnosis on male sexuality and examine patient perceptions of healthcare professionals’ engagement with sexuality at diagnosis. Materials and Methods: This study included adult men diagnosed with urological neoplasms across two urology cancer centers from October 2022 to April 2024. Exclusions applied to those with prior cancer treatment, inactive sexual lives, or histories of anxiety/depression treatment. Data were retrospectively gathered from medical records and individual interviews using a semi-structured questionnaire on male sexuality, relationship dynamics, and perceptions of physicians’ approach to sexuality. Analysis was conducted in RStudio using chi-square tests. Results: A cohort of 211 patients were included in this study, with an age range of 22 to 85 years (mean = 65.4). Among these patients, the diagnoses of urogenital cancer included cases of prostate (79.1%), bladder (9.9%), kidney (4.2%), testicular (3.7%), and penile (2.8%) neoplasms. Sexual activity was considered important by 90.5%, with 75.8% reporting decreased frequency post-diagnosis (99.5% were heterosexual and 72.5% were married). Anxiety or depression was reported by 46.9%, while 72% developed specific fears, primarily concerning erectile function and partner satisfaction. Only 23.2% of physicians addressed sexuality at diagnosis, with patient satisfaction significantly higher when these discussions occurred. Satisfaction levels were notably correlated with tumor site, with bladder cancer patients reporting higher satisfaction compared to those with prostate or penile cancer. Conclusions: Sexual issues extend beyond genital urological cancers, affecting patients with kidney and bladder cancers, with impacts often beginning at diagnosis. Early discussions on sexual health, combined with empathetic support, sexual education, and multidisciplinary care, are essential for the well-being of patients and their partners.

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ABSTRACT Introduction Pre-engagement hypospadias repairs are not uncommon in developed countries like India. Male genital malformations that are not associated with voiding dysfunction are often underreported by families or male patients until the boy reaches marriageable age. At that point, they seek consultation, fearing rejection by potential partners and desiring a rapid and possibly single-stage repair. Therefore, it is not uncommon for primary repair to be performed after puberty, once the penis has fully developed. This may also have consequences on the complexity of surgical repair (1), given that ventral chordee can alter penile development, leading to a higher degree of corporal fibrosis and consequently a more severe ventral curvature. Additionally, the proportion between penile dimensions and craniofacial dimensions is not constant throughout childhood. Genitals are underdeveloped during prepubescence, while the craniofacial region reaches adult dimensions more rapidly, resulting in tissues like buccal mucosa being more abundant compared to adults for pendular urethra reconstruction. These concepts are crucial when planning primary hypospadias repair in adults, as the severity of genital hypospadias may be greater and graft availability may be insufficient. Surgical technique In our practice, it has not been uncommon to encounter cases of primary hypospadias repair where common techniques such as Asopa (2) buccal mucosa graft (BMG) urethoplasty or Bracka two-stage repair were not applicable due to limited availability of BMG to reconstruct the entire penile urethra. In this article, we aim to describe a technique for repairing severe primary hypospadias, where the urethra is reconstructed in a single stage using a pedicle preputial tube, and severe chordee resulting from delayed hypospadias repair combined with corporal fibrosis is resolved through BMG grafting. Patients are typically assessed preoperatively to evaluate the development of the glans for a glansplasty, the availability of the prepuce, and the condition of the buccal mucosa on both cheeks. Subsequently, surgery is performed under general anesthesia with the patient in a supine position. Initially, artificial erection is induced to accurately gauge the severity of curvature. This technique is typically reserved for severe cases of hypospadias where the ventral curvature exceeds 60°. Degloving is then carried out while preserving the vascular support of the prepuce. A circumferential incision is made 5 mm below the coronal sulcus, and both the skin and the dartos are dissected up to the level of Buck's fascia. It is crucial to preserve the vascularization of the dartos during this step, as failure to do so may prevent subsequent flap harvesting. Next, the curvature is reassessed. If a severity above 60° is confirmed, the urethra is transected. However, this step often does not fully resolve the ventral chordee, as the development of the two corpora bodies may have been compromised by the shortened urethra, leading to frequent ventral fibrosis. To straighten the penis, ventral corporotomies are performed. If necessary, a Nesbit procedure is conducted, involving the removal of a wedge of fibrotic tunica albuginea without suturing the two edges. This approach avoids affecting the final length of the penis through plication of the tunica albuginea. Instead, we opt to patch the albuginea defect with buccal mucosa graft. Once the albuginea graft is secured, the straightness of the penis is reassessed to confirm the resolution of the chordee. Finally, urethral reconstruction is performed. A pedicle preputial flap is harvested following the standard technique (3). Careful attention is given to mobilizing the preputial skin from the underlying dartos. Once harvested, the flap is tubularized over a 14 Ch Foley catheter and anastomosed to the proximal urethral end. Subsequently, glans wings are developed, and the distal end of the preputial tube is positioned over the glans sulcus. Glans wings are then closed in two layers over the tube. Placing the suture line of the tubularized flap towards the corpora bodies may reduce the risk of fistula formation. Finally, the penile skin is closed over and sutured to the glans sulcus. A compressive dressing is maintained for two days. The catheter is left in place for three weeks and then removed without performing pericatheter urethrography. Results This is a prospective study done at our Institute from July 2016 to July 2023. A total of 23 male patients were included in the study. Age range was from 16 years to 27 years. All patients underwent correction in a single stage. For 2 patients bovine pericardium was used for corporal augmentation. For remaining 21 patients buccal graft was used for corporal augmentation. All patients had urethral reconstruction in single stage using the pedicled preputial tube. Catheter was kept for 6 weeks. Minimum follow up was 6 months. Two patients developed meatal stenosis which was managed by meatotomy. Two patients developed urethro-cutaneous fistula which was repaired after 6 months. Three patients developed anastomotic narrowing at the proximal junction of pedicled tube and native urethra. They were initially managed with dilatation. They required a small dorsal inlay BMG graft with Asopa technique and are now doing well. One patient with bovine pericardium used developed wound complications and complete dehiscence. He was reoperated at 1 year interval. One patient developed distal penile skin blackening which was treated conservatively. Overall, 20 patients had successful outcome in first surgery. No patient required any reintervention for chordee. Conclusions Single-stage pedicle preputial tube substitution urethroplasty with corpora cavernosa augmentation using BMG for primary peno-scrotal hypospadias repair in adults is safe and feasable surgery, despite a 30.4% complication rate. This is the option for penile lengthening as well as single stage urethral reconstruction.

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ABSTRACT Introduction: Severe iatrogenic ureteral injuries are uncommon but challenging clinical scenarios, mostly related to abdominal and gynecological surgery (1) but lately also to spinal surgery (2). Prompt management is mandatory to avoid impaired outcomes (3). Moreover, a minimally invasive approach is desirable to minimize surgical morbidity and expedite recovery (4). Single Port robotic surgery is being implemented for a variety of indications, including ureteral surgery (5, 6). Materials and Methods: We present the case of a 48-year-old, who underwent lumbar spinal fusion surgery and 3 days after discharge was readmitted presenting abdominal pain. A CT scan revealed a large abdominal fluid collection and consequently a percutaneous drain was placed. A subsequent CT-urogram revealed a right ureteral injury at level of the ureteropelvic junction (UPJ). A percutaneous nephrostomy was inserted after unsuccessful retrograde and anterograde stent placement attempts. The patient underwent SP robotic early repair of the ureter 3 weeks after spinal surgery. Results: SP robotic ureteral injury repair with transperitoneal approach was performed. The surgery was well tolerated without intraoperative complications, patient was discharged on post-operative day 2. Right percutaneous nephrostomy was removed after 2 weeks and ureteral stent after 4. At 6-months follow-up the patient was asymptomatic and CT-urogram confirmed symmetric contrast excretion without hydroureteronephrosis or contrast leakage. Conclusion: SP robotic repair of the UPJ injury is safe and feasible. This procedure provides the benefits of minimally invasive surgery, and it should be considered as a valid alternative to traditional multiport robotic approach.

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ABSTRACT Introduction: The 2001 Lindbergh operation provided evidence for the feasibility of transatlantic telesurgery.(1-3) However, technological and economic challenges have limited the implementation of this technique.(4-6) This video illustrates details of a telesurgery connection over a 13,000 km distance between Orlando (USA) and Shanghai (China). Surgeons at both locations operated simultaneously on the same animals using telesurgery consoles (MicroPort® MedBot™) for teleproctoring, allowing for a robust evaluation of connectivity and robotic system performance across vast distances. Methods: On July 23rd and 24th, 2024, we conducted a prospective telesurgery study using live animal models (porcine) connecting Orlando to Shanghai. We reproduced a real-life telesurgery scenario where both ends of the connection had control over the robot. Four surgeons were in Orlando and one in Shanghai. We illustrated the communication between surgeons and highlighted the potential of telesurgery to improve outcomes and teaching robotic surgery. Results: Connectivity and robotic technology performed optimally for several hours without troubleshooting or malfunctions. Median delay was 139 milliseconds (137-216) on the first day and 139 milliseconds (137-185) on the second day. The surgeons were able to switch the console control multiple times during the procedures. They could communicate, discuss cases in real-time, and seamlessly transfer control in critical steps of the surgery. Conclusions: This video underscores the practical potential of Telesurgery use in teleproctoring, particularly when an experienced remote surgeon steps in to assist another surgeon during complex or challenging procedures. It highlights Telesurgery's potential for training and improving outcomes in robotic surgery.

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ABSTRACT Introduction: Prostate cancer is one of the most common malignancies in men, significantly impacting quality of life and survival (1, 2). Radical prostatectomy remains a key treatment for localized disease, with ongoing advancements in surgical techniques (3-5). The lateral approach in robotic-assisted prostatectomy was developed by Professor Richard Gaston and has emerged as a method designed to enhance anatomical preservation and functional outcomes, aligning with the growing demand for precision in prostate cancer management (6-8). Objective: To present for the first time in Brazil the step-by-step technique and initial experience with the lateral approach to radical prostatectomy, emphasizing its safety, feasibility, and reproducibility as a novel surgical option for prostate cancer treatment. Materials and Methods: This video demonstrates a lateral approach to radical prostatectomy in a 51-year-old male patient diagnosed with localized prostate cancer (Gleason 7 (3+4) in 2 out of 17 fragments). The surgical procedure was performed using a transperitoneal robotic approach, with lateral entry via the right paravesical space to optimize access and exposure of pelvic structures. Key technical steps included precise dissection of the endopelvic fascia, early identification and preservation of neurovascular bundles, and bladder neck preservation to enhance postoperative functional outcomes. Hemostasis was achieved using selective bipolar energy and clips, and urethrovesical anastomosis was performed using a running suture technique with barbed sutures. Results: The surgery was performed without complications, with an operative time of 150 minutes and estimated blood loss of 100 mL. The patient was discharged on the first postoperative day with adequate pain control. The urinary catheter was removed on the seventh postoperative day, and the patient reported complete continence from catheter removal onwards, requiring no pads. At three-month follow-up, the patient continued to report full urinary continence and satisfactory erectile function with phosphodiesterase type 5 inhibitors. His PSA levels remained undetectable at 3 and 6 months postoperatively. Conclusions: The lateral approach to radical prostatectomy represents a safe and reproducible technique for localized prostate cancer treatment. To our knowledge, this is the first reported case of this approach performed in Brazil, marking an important step in expanding surgical options for prostate cancer. Further studies are required to evaluate long-term clinical outcomes and comparative benefits.