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Course review: Yorkshire clinical courses - essential plastic surgery skills for junior doctors courseCircumspectus Medicinae Course Review: Yorkshire Clinical Courses - Essential Plastic Surgery Skills for Junior Doctors Course Rajananthanan, Asveny MBChB Author Information Annals of Plastic Surgery 96(1):p 7-9, January 2026. | DOI: 10.1097/SAP.0000000000004543 Buy Abstract Plain Language Summary Contemporary medical curricula exhibits substantial gaps in plastic surgery education, with 70 percent of medical students completing their training without formal exposure to the specialty. The Essential Plastic Surgery Skills (EPS) course addresses these educational deficits through simulation-based learning for junior trainees. The 2-day program, conducted at Waterton Park Hotel, Wakefield, attracted a global audience from medical students to general practitioners. Faculty comprised 17 experienced educators providing 1:3 teacher to student ratios with continuous feedback and personalised instruction. Day 1 covered fundamental skills including skin closure, lesion excision, and tendon repair using biological specimens. Day 2 advanced to burns management, skin grafting, flap reconstruction and microsurgical techniques utilising porcine and poultry models. Course evaluation demonstrated adequate simulation equipment with sufficient time allocation for comprehensive skill development. The EPS course bridges the gap between undergraduate and postgraduate surgical training through simulation, addressing practical skill deficits while providing skill acquisition opportunities in a controlled learning environment. The program represents structured experience for those trainees interested in seeking broad plastic surgery exposure or transferable surgical skills.
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Pedicled flaps versus free radial forearm flap for phalloplasty in female to male gender-confirming surgery: a systematic reviewBackground: The field of gender-affirming surgery is rapidly evolving, with plastic surgery units worldwide increasingly offering these services. Phalloplasty is a critical component of female-to-male (FTM) transition, providing significant psychological and functional benefits. Although robust comparative trials are scarce, expert consensus favors the radial forearm free flap (RFF) when feasible. This systematic review directly compares outcomes of pedicle anterolateral flap (pALT) and the RFF in FTM gender-affirming surgery. Methods: A systematic review was conducted following the PRISMA guidelines, searching PubMed/Medline, Scopus, Web of Science, ProQuest, and EBSCO for eligible studies. Two independent reviewers screened and selected studies, resolving discrepancies by consensus. Flap survival and patient satisfaction were the primary outcome measures. Secondary outcomes included standing voiding ability, penetrative sexual function, number of operative stages, surgical duration, anesthetic techniques, and donor site morbidity or acceptance. Risk of bias was assessed using ROBINS-I, and evidence quality was evaluated using GRADE. Results: A total of 19 studies comprising 769 patients (614 RFF, 155 pALT) were included. Both techniques demonstrated comparable outcomes, although the ALT required significantly less operative time (RFF vs pALT, 290 vs 516 minutes). Flap failure rates were low for both groups (1.9% RFF, 0.6% pALT; P = 0.348), and patient satisfaction was high (78% RFF vs 76.2% pALT; P = 1.0). Risk of bias assessment indicated serious selection bias due to the observational nature of studies. GRADE evaluation rated the evidence as low, reflecting the absence of randomized trials in this field. Conclusions: The RFF remains the most reliable technique for phalloplasty, with the pALT serving as a secondary option when the RFF is not feasible. However, the limited number of studies and the lack of standardized outcome reporting in gender-affirming surgery make it difficult to draw definitive conclusions or establish evidence-based recommendations. Although both flap types are considered safe for female-to-male phalloplasty, the small patient cohorts and absence of randomized data contribute to the ongoing uncertainty in determining the optimal approach.
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Evaluation of mesh closure of laparotomy and extraction incisions in open and laparoscopic colorectal surgery: a systematic review and Meta-AnalysisBackground and Objectives: Evisceration and incisional hernia (IH) represent a significant morbidity following open or laparoscopic colorectal surgery where midline laparotomy or extraction incision (EI) are performed. We executed a systematic review to evaluate primary mesh closure of laparotomy or EI in colorectal resections of benign or malignant conditions. Methods: A comprehensive literature search was performed using PubMed, Science Direct, Cochrane, and Google Scholar databases for studies comparing prophylactic mesh to traditional suture techniques in closing laparotomy in open approach or EI when minimally invasive surgery was adopted in colorectal procedures, regardless of the diagnosis. Both IH and evisceration were identified as primary outcomes. Secondary outcomes included surgical site infections (SSI), postoperative seroma, and length of hospital stay (LOS). Results: Six studies were included in our analysis with a total population of 1398 patients, of whom 411 patients had prophylactic mesh augmentation when closing laparotomy or EI, and 987 underwent suture closure. The mesh closure group had a significantly lower risk of developing IH compared to the conventional closure group (OR 0.23, p = 0.00001). This result was significantly consistent in subgroup analysis of open laparotomy or EI of laparoscopic surgery subgroups. There was no statistically notable difference in evisceration incidence (OR 0.51, p = 0.25). Secondary endpoints did not significantly differ between both groups in terms of SSI (OR 1.20, p = 0.54), postoperative seroma (OR 1.80, p = 0.13), and LOS (MD -0.54, p = 0.63). Conclusions: primary mesh reinforcement of laparotomy or EI closure in colorectal resections lessens IH occurrence. No safety concerns were identified; however, further high-quality research may provide more solid conclusions.
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Comparing urethral stricture rates following bipolar and monopolar transurethral resection of the prostate: a retrospective studyAim The aim is to compare the incidence of urethral strictures and other complications following monopolar and bipolar transurethral resection of the prostate (TURP). Method We conducted a retrospective study to compare patients who underwent bipolar TURP with those who underwent monopolar TURP between 2017 and 2023. The collected data included demographics, age, history of urethral stricture, prostate size, operation duration, and postoperative complications, such as blood transfusion, transurethral resection (TUR) syndrome, and other relevant data points. Results The COVID-19 pandemic significantly affected the number of surgeries performed. A total of 572 patients who underwent TURP at our center during this period were identified, 302 of whom underwent monopolar TURP, and 270 underwent bipolar TURP. Bladder neck stenosis was more frequently identified in the monopolar group compared to the bipolar group (1.99% (6) vs. 0.7% (2)). In the monopolar group, 6.62% (20) of the patients had strictures compared to 4.07% (11) in the bipolar group; however, this difference is not statistically significant. The bipolar group had a higher incidence of urinary incontinence (5.6% (15) vs. 3.3% (10)), whereas the monopolar group had higher readmission rates (18.8% (57) vs. 13.7% (37)) and a higher frequency of delayed trial without catheter (TWOC) (84% (254) vs. 75.9% (205)). Conclusion We believe that our findings contribute towards resolving the debate between stricture complication rates in monopolar versus bipolar TURP. Our analysis revealed no statistically significant differences in stricture rates between the two groups. However, we noted differences in other complications, such as higher rates of urinary incontinence in the bipolar group, whereas the monopolar group had increased rates of readmission and bladder neck stenosis.
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Extrahepatic gallstones and abscess formation post-cholecystostomy: a rare complication in high-risk acute cholecystitis managementThis intriguing case report explores an interesting complication following percutaneous cholecystostomy for the management of acute cholecystitis in an elderly female with multiple comorbidities. Despite initial improvement, she later presented with recurrent symptoms, due to a collection of gallstones, that had migrated through the cholecystostomy tract, requiring exploration, stone retrieval and abscess drainage. While percutaneous cholecystostomy remains an effective treatment for managing acute cholecystitis in high-risk surgical candidates, this case highlights the rare yet critical risk of extrahepatic gallstones and abscess formation. It emphasises the necessity for vigilance in detecting and managing complications associated with percutaneous transhepatic cholecystostomy, ensuring timely diagnosis and effective treatment.
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Cost-effectiveness of routine histopathological analysis of doughnuts after colorectal surgery three-year single-centre experienceAim. This study aimed to assess the impact of routine histological examination of stapled colorectal anastomotic doughnuts in patients undergoing rectal cancer surgery (RCS). Justification of biopsy examination could form part of the strategies of NHS net zero practice with effort to reduce wastage and carbon footprint. Method. A data analysis of all patients undergoing RCS during 2019–2021 at our institute was performed. We also analysed the cost of preparing and reviewing histology slides. Results. 52 patients underwent anterior resection during the aforementioned period. Doughnuts were sent in 37 (71%) patients. 23 (62%) patients were male, and 14 (38%) were female. The median age at diagnosis was 68 (range 54–84) years. All resected specimens were adenocarcinomas. Of the 37 patients, 18 (49%) underwent low anterior resection and 19 (51%) underwent high anterior resection. Proximal doughnuts were sent in 26 (70%) patients, whereas distal doughnuts were sent in all cases. Mean distal microscopic resection margin from tumour was 22 mm (range 6–45 mm). Each doughnut required 3 slides, each costing £50 and requiring 82 minutes to fix and read. This incurred a cost of £13,650 and required 19,656 hours of preparation time. All of the doughnuts as well as resection margins were negative for malignancy. Conclusion. Routine histopathological examination of doughnuts is time and cost-intensive however provides little or no clinical value (particularly analysis of the proximal doughnut). Distal doughnuts should only be sent for histological examination in exceptional circumstances.
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Surgical training in the United Kingdom's National Health Service: the challenges for International Medical GraduatesBackground: The UK's National Health Service (NHS) is a hub that trainees from all over the world want to join. However, there are many challenges for International Medical Graduates (IMGs). The aim of this study is to raise awareness of these challenges and to attempt to identify areas for improvement in the surgical training experience for international graduates wishing to join the NHS and obtain a National Training Number (NTN). Methods: A 33-question survey was designed and distributed to the surgical community via The Upper Gastrointestinal Surgery Society (TUGSS) and social media. Eighty-five respondents, IMGs from 25 countries, participated. Results: The results showed that 43.5% of doctors had a Master's degree (MSc). Most IMGs joined as locally employed doctors at the senior house officer or registrar level. They all faced many challenges in the UK, including difficulties finding a job in the NHS, obtaining an NTN, and adapting to the differences between UK surgical practice and their home country. More than 50% of doctors did not have a named educational/clinical supervisor, and 63.2% of them felt that the supervisor helped them to become more familiar with the system. The support doctors received from the human resources department of the hospital they joined was poor. In addition, more than half of the IMGs changed their career plans after joining the NHS (56.4%) and would like to stay in the UK (52.9%). The majority of them (43.9%) plan to obtain an NTN. Conclusions: This study showed that there is a need to support international doctors who wish to start or continue their training in the UK. Furthermore, IMGs should expect to face several challenges when applying to work in the UK NHS.
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Serbian National Training Programme for minimally invasive colorectal surgery (LapSerb): short-term clinical outcomes of over 1400 colorectal resectionsIntroduction: The Serbian National Training Programme for minimally invasive colorectal surgery (LapSerb) was introduced to implement laparoscopic colorectal surgery across Serbia. The programme aimed to accelerate training of established colorectal surgeons through a competency-based programme. This involved knowledge assessment, workshops, live operating, and competency-based assessment of unedited videos. The aim of this study is to report the outcomes of laparoscopic colorectal resection performed by LapSerb certified surgeons. Methods: LapSerb prospectively maintained multicentred database was analysed for laparoscopic colorectal resections from January 2015 to February 2021. Data collected included patient demographics, indications for surgery, perioperative data, and 30-day outcomes. Results: A total of 1456 laparoscopic colectomies by 24 certified surgeons were included in the final analysis. Mean age was 67 (± 12) years old and male to female ratio was 1:1.5. 83.1% of the colectomies were malignant, mainly due to adenocarcinoma. Anterior resection was the most common procedure with 699 (48%) cases, followed by right and left colectomies with 357 (24.5%) and 303 (21%) procedure respectively. 4.8% of patients required conversion to open surgery. Thirty-day readmission and reoperation rates were 2.3% and 4.7%, respectively. Overall mortality in all cases was 1.1% and R0 resections were achieved in 97.8% of malignant colectomies. Conclusion: The LapSerb programme successfully and safely established laparoscopic colorectal surgery across the country with comparable and acceptable short-term clinical outcomes.
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Robot-assisted radical nephroureterectomy for locally advanced upper tract urothelial carcinoma: a multicenter study by the Junior ERUS/YAU Working Group on Robot-assisted SurgeryIntroduction Aim of the study was investigate outcomes of patients affected by locally advanced (pT3-pT4 and/or pN+) upper tract urothelial carcinoma (UTUC) and treated with robot-assisted radical nephroureterectomy (RNU). Materials and methods Clinical and surgical data of newly-diagnosed UTUC patients referring to 9 high-volume centres from January 2019 to March 2023 undergoing RNU were collected. Results 191 patients showed locally advanced disease. Da Vinci and Hugo RAS ™ System were employed in 95.8 % and 4.2 % of cases, respectively. Bladder cuff removal was carried out in 161 (84.3 %) patients, by using either an intravesical and extravesical approach in 50 (31.1 %) and 111 (68.9 %) respectively. Open and robotic approaches for bladder cuff removal were preferred in 107 (66.5 %) and 54 (33.5 %) patients, respectively. Lymph node dissection was performed in 55 % of patients. Median follow up was 19 (IQR 10–23) months and 31 (16.4 %) patients experienced bladder recurrence. On multivariate analysis, in those patients receiving RNU and bladder cuff removal, the approach for bladder cuff management (extravesical vs intravesical) was the only independent predictor of bladder recurrence (hazard ratio [HR]: 1.34; 95 % confidence interval [CI] 1.12–2.11; p = 0.03). Surgical approach for bladder cuff management (open vs robot) was not independently associated with bladder recurrence or tumor progression (both p > 0.05) Conclusions In experienced hands, the robotic approach showed satisfactory survival outcomes also for the surgical treatment of pathological locally advanced UTUC. Extravesical approach for bladder cuff management may be burdened by a higher risk for bladder recurrence in locally advanced disease.
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Oncologic outcomes of template versus radioguided salvage lymph node dissection for node-only recurrent prostate cancer on prostate-specific membrane antigen Positron emission tomography scan: results from a multi-institutional collaboration.In patients treated with salvage lymph node dissection (sLND) for nodal recurrence of prostate cancer, whether radioguided surgery (RGS) might improve oncologic outcomes as compared with template sLND remains unknown. This study included 259 patients who experienced a prostate-specific antigen (PSA) rise and nodal-only recurrence after radical prostatectomy and underwent pelvic sLND at 11 tertiary referral centers between 2012 and 2022. Lymph node recurrence was documented by prostate-specific membrane antigen positron emission tomography scans. The outcomes included biochemical recurrence (BCR) and clinical recurrence (CR) after sLND. The probability of freedom from each outcome was calculated using Kaplan-Meier analyses. A Cox regression analysis was used to test the hypothesis that surgical technique for sLND (template vs RGS) might be associated with oncologic outcomes. Overall, 80 (31%) and 179 (69%) patients received template and radioguided sLND, respectively. PSA level at sLND was higher in the template than in the radioguided group (median: 1.3 vs 0.6 ng/ml; p < 0.0001), whereas the number of positive nodes on final pathology did not differ between the groups (p = 0.13). The first postoperative PSA level was higher in the template than in the radioguided group (median: 0.5 vs 0.1 ng/ml; p < 0.0001). Overall, there were 181 cases of BCR and 76 cases of CR after sLND. The median follow-up for survivors was 21 mo (interquartile range: 7, 36). The 2-yr BCR-free survival rate for patients in the template versus RGS sLND group was 18% (95% confidence interval [CI]: 9%, 29%) versus 30% (95% CI: 22%, 37%). The 2-yr CR-free survival rate for the template versus RGS sLND group was 51% (95% CI: 35%, 65%) versus 73% (95% CI: 65%, 80%). On multivariable analyses, we did not find evidence of a statistically significant difference between the groups with respect to BCR after sLND (p = 0.7), whereas men treated with RGS had a lower risk of CR after sLND than those receiving template sLND (hazard ratio: 0.51; 95% CI: 0.29, 0.92; p < 0.026). Results of the sensitivity analyses were generally consistent with our main findings. Our data suggest that, in men with node-recurrent prostate cancer treated with sLND, RGS may offer important surgical guidance for surgeons, and this may eventually translate into improved oncologic outcomes. Awaiting further evidence on long-term outcomes of RGS, our study represents the most solid comparative data on different techniques for sLND and provides relevant data for counseling patients with node-only recurrent prostate cancer.
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Current training landscape for novice robotic surgeons: an international investigative survey by the Junior-ERUS/Young academic urologists (YAU) robotics in urology working groupIntroduction While robotic surgical training is crucial for preparing skilled surgeons, the landscape of available training programs is not well-defined. Many institutions offer structured curricula, yet transparency about training modalities, caseloads, and eligibility criteria for novice surgeons is limited. To address this gap, a structured survey was designed to assess robotic education offerings globally. Patients and methods A web-based survey was distributed to different robotic societies, institutions and dedicated robotic surgery experts, based on the Junior European Association of Urology Robotic Section (J-ERUS) network and the Young Academic Urologists (YAU) Robotic Section between February and September 2024. Furthermore, a peer-esteem snowballing approach allowed the survey to expand its reach through expert referrals. The survey captured information on training modalities, infrastructure, caseload, and case mix. Respondents were required to provide contact details for further follow-up, while their identities and institutions remained confidential. Results The survey achieved a 16.5% response rate, with 80 respondents from 49 institutions confirming robotic training opportunities. Training platforms included Da Vinci multi-port systems (71%), HUGO-RAS (15%), and Versius (8%). Training methods featured simulators (89%), dual-console training (65%), dry-labs (39%), and wet-labs (16%). Variability in training structures was observed, with 32% of institutions offering dedicated fellowships and 68% combining training with clinical duties. Institutions varied in case volumes (100–500 cases per year), and 41% indicated performing over 500 robotic procedures annually. Respondents predominantly answered that robotic surgery novices may access about 20% of these cases. Conclusion This study highlights the heterogeneity of robotic surgical education and the need for standardized, globally accessible training frameworks. Establishing an international consortium to map training programs and content could enhance transparency and support novice surgeons in selecting institutions that align with their career goals. It is critical to integrate emerging robotic platforms and evolving methodologies into curricula to ensure comprehensive and effective training.
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Clinical outcomes of robotic versus laparoscopic colorectal surgery during the early learning curve: a systematic review and meta-analysisSurgery is a cornerstone for colorectal cancer treatment. Though laparoscopy surgery is a well-established technique for colorectal patients and has shown reduced hospital stay and postoperative morbidities, it has inherent limitations due to straight instruments and limited views in areas such as the pelvis. Nevertheless, recently, the robotic approach has aimed to overcome the limitations of laparoscopic techniques and offers EndoWrist technology with 3D, high definition, and stable views for precise dissection. This review aims to compare the clinical outcomes of laparoscopic and robotic surgery for colorectal cancer during the initial adoption phase of robotic techniques. A comprehensive literature search was conducted according to the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines, resulting in the inclusion of six randomized controlled trials (RCTs) and 17 observational studies. Eligibility criteria focused on adult patients undergoing elective resection for colorectal neoplasia. A total of 23 articles were analyzed for various outcomes. Robotic surgery demonstrated a shorter postoperative hospital stay compared to laparoscopic surgery (MD = −0.132; p = 0.031) and significantly lower conversion to open surgery (OR = 1.480; 95% CI: 0.364-0.635; p = 0.000). No significant difference was observed in 30-day mortality, early postoperative complications, readmission, and reoperation rates between the two groups. Emerging evidence suggests that, during the early adoption phase, robotic surgery for colorectal cancer is associated with reduced conversion rates to open surgery and shorter postoperative hospital stays compared to laparoscopic surgery. However, comprehensive evaluation through future studies is required to elucidate long-term outcomes, cost-effectiveness, and patient-reported measures related to robotic colorectal surgery.
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Surgical presentations of Eosinophilic Gastroenteritis: a case reportEosinophilic gastroenteritis (EGE) is a rare disorder characterized by eosinophilic infiltration of the gastrointestinal (GI) tract without any definitive cause of eosinophilia. It presents with various non-specific GI symptoms, depending on the affected site and layer of involvement, often leading to delayed diagnosis and treatment. While the primary treatment consists of oral corticosteroids, extreme cases may necessitate surgical intervention. We present a case of a 50-year-old female who arrived at the emergency department with a three-day history of vomiting, diffuse abdominal pain, and tachycardia. She underwent emergency surgery due to acute abdominal symptoms. Intraoperatively, a mass-like lesion was identified in the distal antrum of the stomach, causing pyloric narrowing. Histopathological examination confirmed EGE. The patient had previously undergone laparoscopic cholecystectomy and open appendectomy for abdominal pain, which we now believe were misdiagnosed as separate surgical pathologies when they were possibly early manifestations of EGE. After an extensive literature review, this may be the first reported case of EGE in Jordan and the first case requiring a surgical procedure in the country.
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Primary HypercortisolismPrimary hypercortisolism, commonly known as Cushing's syndrome, is an endocrine disorder characterized by excessive cortisol production by the adrenal glands, independent of adrenocorticotropic hormone stimulation. This disorder presents with a wide range of clinical manifestations, including metabolic, cardiovascular, and psychological disturbances, making its diagnosis and management complex. This document aims to provide a detailed review of primary hypercortisolism, including its pathophysiology, clinical presentation, diagnostic approaches, and treatment modalities. Special attention is given to the molecular mechanisms underlying cortisol overproduction, differential diagnosis from other forms of Cushing's syndrome, and the challenges posed by this condition in clinical practice.
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Post-ERCP clearance of bile duct stones: should the gallbladder be left in-situ?BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has become the gold standard management for patients who present with common bile duct stone (CBDS). Although laparoscopic cholecystectomy is generally recommended for patients who have CBDS clearance, there is still a significant proportion of patients who are managed expectantly. Our study aimed to evaluate the outcomes of expectant management (EM) versus prophylactic cholecystectomy after initial endoscopic removal of CBDS., METHOD: We performed a retrospective review of all patients who underwent ERCP for choledocholithiasis from 1st January 2017 to 31st December 2019. Patients were further classified into young or elderly group using age 60 years as the cut-off. Primary outcomes measured biliary-related complications in each interventional group whereas secondary outcomes measured all-cause mortality., RESULTS: 136 patients (51.3%) had EM whereas 129 patients (48.7%) were initially planned for LC. There was 20.6% of recurrence of biliary events in EM group as compared to 3.9% in LC group. The median time from first ERCP to recurrence of biliary events in the EM group was 14 months. Overall complications of LC group was low (5.4%) with nil operative-related mortality. However, there was a significant higher proportion of elderly patients in EM group in comparison to LC group (88.2% vs 31%) and 51.4% of EM group died during follow-up period with only one biliary-related death., CONCLUSION: Prophylactic cholecystectomy should be recommended for patients who have undergone ERCP clearance of CBDS. A watch-and-wait approach may be justified for elderly populations who are not ideal surgical candidates and a follow-up duration of up to 2 years is recommended. Copyright ┬® 2025. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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Sigmoid Diverticulitis in a tight spot: an atypical presentation within a ventral herniaVentral hernia and acute diverticulitis may present with similar symptoms posing difficulty in clinical diagnosis. Rarely, complicated sigmoid diverticulitis is found within an irreducible ventral hernia sac in the emergency setting. Intraoperative decision on the appropriate surgical option depends on the surgeon’s experience and the patient’s clinical state. We present a case of a middle-aged female who came in with infraumbilical hernia containing necrotic sigmoid diverticulitis. Her surgical history was cesarean section and total abdominal hysterectomy with a re-look laparotomy. She had an emergency exploration of the hernia through a midline incision, excision of the necrotic diverticulum, and the formation of loop colostomy at the site of the hernia. Post-operative recovery was uneventful and she has been scheduled for an elective sigmoid colectomy and reversal of the stoma. This study highlights that complicated sigmoid diverticulitis can rarely present as an irreducible ventral hernia and that less is often more in safely getting patients out of trouble in an emergency.
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Intraoperative image-guidance during robotic surgery: is there clinical evidence of enhanced patient outcomes?Background To date, the benefit of image guidance during robot-assisted surgery (IGS) is an object of debate. The current study aims to address the quality of the contemporary body of literature concerning IGS in robotic surgery throughout different surgical specialties. Methods A systematic review of all English-language articles on IGS, from January 2013 to March 2023, was conducted using PubMed, Cochrane library’s Central, EMBASE, MEDLINE, and Scopus databases. Comparative studies that tested performance of IGS vs control were included for the quantitative synthesis, which addressed outcomes analyzed in at least three studies: operative time, length of stay, blood loss, surgical margins, complications, number of nodal retrievals, metastatic nodes, ischemia time, and renal function loss. Bias-corrected ratio of means (ROM) and bias-corrected odds ratio (OR) compared continuous and dichotomous variables, respectively. Subgroup analyses according to guidance type (i.e., 3D virtual reality vs ultrasound vs near-infrared fluoresce) were performed. Results Twenty-nine studies, based on 11 surgical procedures of three specialties (general surgery, gynecology, urology), were included in the quantitative synthesis. IGS was associated with 12% reduction in length of stay (ROM 0.88; p = 0.03) and 13% reduction in blood loss (ROM 0.87; p = 0.03) but did not affect operative time (ROM 1.00; p = 0.9), or complications (OR 0.93; p = 0.4). IGS was associated with an estimated 44% increase in mean number of removed nodes (ROM 1.44; p < 0.001), and a significantly higher rate of metastatic nodal disease (OR 1.82; p < 0.001), as well as a significantly lower rate of positive surgical margins (OR 0.62; p < 0.001). In nephron sparing surgery, IGS significantly decreased renal function loss (ROM 0.37; p = 0.002). Conclusions Robot-assisted surgery benefits from image guidance, especially in terms of pathologic outcomes, namely higher detection of metastatic nodes and lower surgical margins. Moreover, IGS enhances renal function preservation and lowers surgical blood loss.
