Journal of endourology最新文献

Background: Bladder outlet obstruction (BOO) and urinary retention were recognized contributing factors to bladder cancer (BCa) recurrence and progression due to prolonged urothelial exposure to carcinogens, chronic inflammation, and incomplete bladder emptying. Holmium laser enucleation of prostate (HoLEP) is a minimally invasive and highly effective procedure that completely removes obstructive prostatic tissue, thus resolving BOO. To explore the HoLEP impact on BCa recurrence and progression by improving voiding dynamics and reducing post-void residual (PVR).

Materials and methods: We carried out a retrospective case-control study, based on a multicenter prospectively maintained database, on 100 consecutive male patients (cases) with a first diagnosis of non-muscle-invasive bladder cancer, with BOO and urinary retention and treated with HoLEP (in case of at least 3-months of timor-free status). The cases were compared with 200 patients (controls) with same baseline characteristics but not treated with HoLEP. We evaluated PVR, International Prostatic Symptoms Score-IPSS, BCa recurrence and progression rates. The t-Test, χ2-test, logistic correlations, multivariate analysis were applied to evaluate the association between the BOO resolution and urinary retention by HoLEP and BCa recurrence and progression.

Results: Patients treated with HoLEP showed a significant PVR reduction compared with controls (p < 0.01). The HoLEP group demonstrated statistically significant improvements in IPSS scores, indicating better urinary symptom control. The rates of recurrence and progression were significantly lower in the HoLEP-treated group (p < 0.01). Multivariate analysis identified the BOO resolution by HoLEP as an independent predictor of reduced BCa recurrence (odds ratio 0.65, 95% CI 0.45-0.85, p < 0.001). The control group exhibited persistently elevated PVR and higher rates of BCa recurrence and progression.

Conclusions: Urinary retention could represent a prognostic factor of treatment response, and its active treatment by HoLEP should be considered as an important therapeutic step in the clinical management of patients with BCa.

Purpose: Radical cystectomy (RC) with urinary diversion (UD) is a complex procedure involving extensive bowel manipulation. The ileal conduit is the most commonly used form of UD. While technically less challenging, it is associated with notable complications, including postoperative ileus (POI). In this context, we present a novel robotic stapler technique for performing ileo-ileal anastomosis during robot-assisted radical cystectomy (RARC).

Methods: An IRB-approved prospectively maintained cystectomy database was queried for patients undergoing RC or radical cystoprostatectomy between 2020 and 2024. Demographic, perioperative, and complications data are reported using descriptive statistics and compared with the two-tailed Student's t-test when applicable. We defined POI as a lack of flatus or bowel movement after postoperative day 4.

Results: 170 patients underwent the proposed robotic stapler technique, with a median age of 73 years and a BMI of 27.5 kg/m². The majority of UDs performed were ileal conduit (75.8%), followed by neobladder (21%) and continent pouch (2.3%). 7.0% of patients experienced POI, and 4.7% had small bowel obstruction. There were no intraoperative injuries to the bowel.

Conclusion: Our described robotic stapler technique for ileo-ileal anastomosis has proven its utility as a method for UD during RARC with relatively low rates of gastrointestinal complications compared to the general literature. This is likely because of multiple components of this technique, including intracorporeal nature, stay sutures, and more.

Background and objective: Benign prostatic hyperplasia (BPH) represents a common condition in aging males. For prostates exceeding 80 g, robotic-assisted simple prostatectomy (RASP) and transurethral prostate enucleation have emerged as leading treatments. This study aimed to comprehensively compare outcomes between these approaches.

Methods: We conducted a systematic review and Bayesian network meta-analysis of randomized controlled trials and cohort studies. Outcomes included changes in urinary flow rate, International Prostate Symptom Score (IPSS), complication rates, operative bleeding, operative time, hospitalization duration, and catheterization period. Robotic interventions were classified as single-port (SP) or multiport with transvesical (TV), transperitoneal, or transcapsular techniques. Enucleation methods included holmium laser (HoLEP), thulium laser, bipolar, and GreenLight laser vapo-enucleation.Key Findings and Limitations:We included data from 25 studies with 3924 patients. Network meta-analysis showed no significant difference in overall complication rates between RASP and enucleation techniques, though RASP had the highest surface under the cumulative ranking curve scores in the SP approaches, particularly the SPTV approach. Both RASP and enucleation approaches showed similar improvements in urinary flow rates. RASP approaches, particularly SPTV, had the highest decrease in IPSS, but the changes were not statistically significant. Despite longer operative times and Foley catheterization durations for RASP, blood loss was comparable to enucleation techniques.

Conclusion and clinical implications: Our results suggest that robotic approaches have similar performance to HoLEP when managing large prostates. However, robotic approaches may have slight differences including improved symptom scores, lower incontinence rates, longer operative times, and longer hospital stays.

Patient summary: In this study, we compared two modern surgical approaches for treating enlarged prostates over 80 g-robotic surgery and laser/electrical techniques that remove prostate tissue through the urethra. We found both approaches work equally well for improving urinary flow, with similar bleeding risks, though the robotic approach may better reduce urinary symptoms but requires longer surgery and hospital stays. This information helps doctors and patients choose the most suitable treatment option for large prostate enlargement.

Introduction: Artificial intelligence (AI) is transforming health care, including patient communication. Large language models, like ChatGPT-4, also show great promise for enhancing patient communication and decision-making. This study evaluates ChatGPT-4's ability to produce readable, accurate, evidence-based patient information leaflets (PILs) for three common endourological procedures.

Materials and methods: ChatGPT-4 was given a short prompt to create PILs for extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy, and ureteroscopic removal of stones. A 10-question survey was sent to urology teams in the United Kingdom to assess their accuracy, readability, and up-to-date content.

Results: We received 105 responses (35 per procedure). The AI-generated PILs were rated highly across all domains, including: 85.71% found them evidence-based, 92.40% accurate, 99.05% clear and patient-friendly, and 96.19% would share them with patients despite knowing they were AI-generated.

Conclusions: ChatGPT-4 shows promise as a low-input tool for creating high-quality patient materials. It could support broader health care use with tailored, accessible communication. However, ethical and long-term reliability concerns need further study before wider adoption.

Objective: Retrograde intrarenal surgery is limited by the narrow caliber of the human ureter, resulting in both reluctance to deploy larger ureteral access sheaths and, at times, failed primary ureteral access, requiring placement of a ureteral stent and a delayed second procedure. In this study, we sought to evaluate the application of electromotive drug administration (EMDA) to deliver smooth muscle relaxants to the porcine ureter to facilitate acute ureteral dilation.

Methods: Eighteen juvenile female Yorkshire pigs were randomized into three treatment groups (alfuzosin, aminophylline, or isoproterenol; n = 6 per group). Within each animal, one ureter received an intraureteral drug infusion with EMDA, while the contralateral ureter served as a control, receiving 0.9% normal saline (NS). Ureteral size was assessed before and after treatment by passing sequentially larger urethral dilators starting at 10 Fr, with a maximum insertion force of 3.5 N.

Results: Only alfuzosin with EMDA increased ureteral size compared with NS alone (alfuzosin vs NS, 0.8 Fr vs 0.1 Fr, p = 0.031). Neither aminophylline nor isoproterenol with EMDA resulted in a significant increase in ureteral size compared with their respective NS controls (aminophylline vs NS, 0.3 Fr vs -0.6 Fr, p = 0.344; isoproterenol vs NS, 0.1 Fr vs -0.4 Fr, p = 0.125).

Conclusion: In this first report, EMDA-mediated in vivo delivery of alfuzosin into the porcine ureter acutely increased ureteral distensibility.

Background: Focal ablative therapy is an alternative treatment option for selected patients with prostate cancer. Despite growing interest, its initial adoption in the United States has been limited, and its real-world utilization remains insufficiently characterized at the national level. With recent expansions in Medicare coverage, we aimed to use national claims data to analyze the utilization patterns and regional variability in ablative therapies across the United States.

Methods: We analyzed 100% Medicare claims data to identify patients newly diagnosed with prostate cancer from 2019 to 2023 who underwent ablative therapies, including high-intensity focused ultrasound, cryoablation, and laser ablation. Regional variability was assessed by hospital referral regions, which are designed to capture regional health care markets. We conducted descriptive analyses to examine the uptake of ablative therapies across sociodemographic and clinical variables, including metro, urban, or rural residence (from most to least densely populated areas), United States region, age, race, Medicare/Medicaid eligibility factors, year of diagnosis, and comorbidities.

Results: We identified 5462 Medicare beneficiaries newly diagnosed with prostate cancer who underwent ablative therapies from 2019 to 2023, with a median age of 73 years. Most patients were White (84.9%) and had multiple comorbidities (81.1%). Ablative therapies were more commonly performed in metro areas (78.8%) and the South region (39.6%), with utilization rates varying across 306 hospital referral regions from 0% to 6.13% of newly diagnosed prostate cancer cases. Cryotherapy (74.9%) and high-intensity focused ultrasound (24.3%) were the most frequently used ablation techniques.

Conclusions: Despite expanded insurance coverage, ablative therapies remain infrequently used for prostate cancer, with substantial regional variations in their adoption. These findings highlight the need for continued data collection and outcomes evaluation to define the optimal use of ablative therapy in prostate cancer care.

Purpose: This study investigates the efficacy of an innovative anatomical enucleation prostate technique, utilizing a low-energy pulsed thulium:YAG laser emission, to spare the ventral urethral plate (or "lissosphincter") and the ejaculatory hoods in 50 patients with high-volume benign prostatic hyperplasia (BPH). The primary aim was to assess its impact on preserving antegrade ejaculation while obtaining relief from obstruction.

Materials and methods: In this prospective study, 50 patients were evaluated using the following validated instruments: the International Prostate Symptom Index (IPSS), Quality of Life (QoL) score, and Male Sexual Health Questionnaire Ejaculatory Dysfunction Short Form (MSHQ-EjD SF). Assessments were performed preoperatively and at 6 months postoperation.

Results: Significant improvements were observed postoperatively in functional outcomes: IPSS decreased from 20.42 to 5.76, and QoL score improved from 4.2 to 1.2 (both p < 0.001, if significant). Mean Qmax significantly increased from 8.11 mL/min preoperatively to 20.6 mL/min at 6 months (p < 0.001), accompanied by a significant reduction in postvoid residual (PVR) volume. Crucially, antegrade ejaculation was preserved. While MSHQ-EjD SF analysis indicated a nonsignificant reduction in semen volume (Item 3), other parameters, including ejaculation frequency (Item 1), strength of expulsion (Item 2), and bother/satisfaction (Item 4), were not significantly modified, but the patients were satisfied.

Conclusion: The ejaculation-sparing pulsed thulium:YAG laser anatomical enucleation technique shows promising results for preserving antegrade ejaculatory function (70% preservation rate) while achieving effective relief of cervico-prostatic obstruction. However, these preliminary findings from a limited cohort require validation through larger, randomized controlled studies with longer follow-up before establishing this technique as a standard approach for ejaculation preservation in BPH operations.

Introduction: Holmium laser enucleation of the prostate (HoLEP), multi-port robotic simple prostatectomy (MP-RASP), and single-port robotic simple prostatectomy (SP-RASP) are three widely accepted treatment options for benign prostatic hyperplasia. We present the first study to directly compare all three modalities.

Methods: Patients undergoing HoLEP, MP-RASP, or SP-RASP between 2022 and 2024 were retrospectively analyzed. Various preoperative, perioperative, and postoperative variables and outcomes were assessed.

Results: A total of 92 HoLEP, 42 MP-RASP, and 59 SP-RASP patients were analyzed. The mean prostate size was larger for MP-RASP compared to HoLEP and SP-RASP (p < 0.001). Mean operative times were lower for HoLEP compared to MP-RASP and SP-RASP (p < 0.001). Estimated blood loss (EBL) was significantly different between all three cohorts (p < 0.001). Transfusion rates were no different (p = 0.2). The mean prostate tissue removed during the surgical procedure was significantly higher for MP-RASP vs HoLEP (p < 0.001) and MP-RASP vs SP-RASP (p < 0.001) but not for SP-RASP vs HoLEP (p = 0.22). Mean catheter duration was significantly higher for MP-RASP compared to HoLEP and SP-RASP (p < 0.001). 31% of MP-RASP and 63% of SP-RASP patients were discharged the same day compared to 8% of HoLEP. The transient incontinence rates were 30% for HoLEP vs 17% for MP-RASP vs 8% for SP-RASP (p = 0.004).

Conclusion: HoLEP had a decreased operative time, shorter catheter duration, and increased incontinence rates, whereas both MP-RASP and SP-RASP had a greater amount and percentage of prostatic tissue removed. MP-RASP removed a greater amount of tissue and had a longer catheter duration compared to SP-RASP.

Purpose: Ureteral complications are among the most common types of complications following kidney transplantation (KT). In the past, these complications were often managed using endoscopic and open surgical approaches. However, the robot-assisted approach has been recently implemented. Nevertheless, the available data regarding the potential impact of robotic surgery in this field are sparse. This systematic review (SR) aims to summarize the available evidence of robot-assisted ureteral reconstruction following KT, focusing on postoperative outcomes and complications.

Methods: Studies eligible for inclusion focused on evaluating the success and/or complications associated with robot-assisted ureteral reconstruction after KT. An SR was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The literature search was performed using the Web of Science, PubMed, and Scopus databases, with no restrictions on the time period. Only articles published in English were considered.

Results: After screening 5337 publications, this SR included 9 studies with a total of 127 patients. The most common indication for reconstruction was ureteral stricture (n = 108, 85%), and the most frequently performed procedure was ureteroneocystostomy (n = 59, 46.8%). Following robot-assisted ureteral reconstruction procedures, the average success rate was 91.3%. Regarding intraoperative complications, six patients (4.7%) required conversion to open surgery. As for postoperative complications, the number of patients experiencing Clavien-Dindo Grade 1, 2, 3, and 4 complications were 15/121 (12.4%), 20/121 (16.5%), 4/121 (3.3%), and 2/121 (1.6%), respectively.

Conclusion: With the advancements in robotic platforms as well as KT surgeons' expertise in minimally invasive surgery, robot-assisted ureteral reconstruction after KT is increasingly recognized as a safe and effective option for recipients with ureteral complications.

Introduction and objectives: Traditionally, robot-assisted kidney transplant (RAKT) is performed using a transperitoneal approach, with patient in steep Trendelenburg position, leading to potential concerns for cardio-respiratory, bowel, and ocular complications. To circumvent these, we evaluated the feasibility, technical aspects, and outcomes of an extraperitoneal approach (EP-RAKT) and compared it with the transperitoneal approach (TP-RAKT).

Materials and methods: We reviewed our prospective database of patients who underwent RAKT with extraperitoneal approach between June 2023 and May 2024. This cohort was propensity matched in a 12 ratio with patients who underwent RAKT with transperitoneal approach for confounding variables (age, sex, BMI, graft kidney GFR, and graft number of vessels). Clinical parameters were recorded for all patients, including their demographic profile, radiological parameters, operative details and postoperative outcomes, and the cohorts were compared for intraoperative and postoperative outcomes.

Results: During our study period, 10 patients underwent EP-RAKT and were propensity matched with 20 patients with similar characteristics who underwent TP-RAKT. The mean duration of postoperative ileus (1.3 vs. 2.9 days), mean drain output (131 vs. 786 mL), and mean postoperative pain score (Visual Analog Scale score 10.2 vs. 14.8) were shorter for the extraperitoneal when compared with transperitoneal approach. No statistical differences were observed between the two groups for blood loss, rewarm ischemia time, vascular anastomosis time, or graft function. Patients in EP-RAKT group had more consistent tacrolimus levels in the therapeutic range in early postoperative period. However, the mean total operative time (288 ± 35.2 vs. 240 ± 28.2 minutes) and the mean time spent in port placement and bed preparation (50.8 ± 8.4 vs. 28.3 ± 6.1 minutes) were longer in EP-RAKT vs TP-RAKT.

Conclusions: EP-RAKT is a safe and feasible procedure, with similar graft function and reduced early postoperative complications compared with TP-RAKT, albeit with higher operative times.