Therapeutic Advances in Urology最新文献

Background: Robotic-assisted radical prostatectomy (RARP) has been found to be comparable and, in some cases, favorable to open surgical approaches, while being used in a frailer population.

Objectives: We aimed to illustrate the trend in population frailty and compare morbidity and mortality postoperatively in patients who underwent RARP.

Design and methods: The National Surgical Quality Improvement Program data set was used to select patients who underwent RARP between the years 2011-2019. Age, frailty indicators, surgical characteristics, and perioperative morbidity and mortality were compared between the years 2011-2019 using the chi-square test (χ²) for categorical variables and the one-way analysis of variance (ANOVA) for continuous variables.

Results: Our patient population consisted of 66,683 patients who underwent RARP. There was an increase in mean age and frailty indicated by an increase in 5-item frailty score ⩾2, metabolic syndrome index = 3, and American Society of Anesthesiologists' (ASA) class ⩾3 between the years 2011-2019 (p < 0.001). Whereas the rate of mortality and morbidity, indicated by postoperative Clavien-Dindo grade ⩾4 and major morbidity, remained the same over the same period (p > 0.264). Furthermore, operative time and length of stay decreased over the same period (p < 0.001).

Conclusion: RARP is being performed on more frail patients, with no added morbidity or mortality.

Background: Radical cystectomy (RC) is considered a complex procedure that entails significant morbidity and mortality.

Objectives: We aimed to determine pre-operative patient characteristics that help predict a prolonged length of hospital stay (PLOS) following RC.

Design and methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to select patients who underwent RC between the years 2011 and 2020. Prolonged length of stay was defined as a hospital stay ⩾9 days. We compared patient demographics, pre-operative labs, surgical characteristics, and medical history between patients with or without PLOS. Multivariable logistic regression models controlling for pre-operative characteristics and propensity score matching for post-operative complications were conducted to control for possible confounders.

Results: The analysis yielded details of 19,158 RC patients of which 6007 (31%) patients had a PLOS. Patients with PLOS were more likely to have post-operative complications that could serve as predictors for the PLOS rather than their pre-operative characteristics. Hence, we matched our cohort for these complications. After matching, patient pre-operative characteristics that predict PLOS included female gender (Odds Ratio (OR) = 5.91), 10-year increase in age (OR = 1.15), non-White race (OR = 1.98), partially or totally dependent functional health status (OR = 2.86), bleeding disorders (OR = 4.67), congestive heart failure (OR = 1.59), pre-operative transfusion (OR = 3.03), and a 20-min increase in operative time (OR = 1.01) (p < 0.046).

Conclusion: Patient demographics and pre-operative factors can help predict PLOS in RC patients. These predictors could serve as tools for patient counseling and risk stratification.

Background: The diagnosis of a clinically significant catheter-associated urinary tract infection (CAUTI) in patients performing clean intermittent catheterization (CIC) or with an indwelling catheter (IC) can be challenging.

Objective: To get an insight into the variation of the used definition, diagnosis and management of CAUTIs by relevant healthcare workers in the Netherlands.

Design: An online clinical scenario-based survey.

Methods: The survey was built in Limesurvey and distributed to healthcare workers from randomly selected urology departments, rehabilitation departments/centres and general practice offices between January and May 2022. Questions regarding their field of experience, management strategies, used guidelines and two hypothetical cases with clinical scenarios of a possible CAUTI were included.

Results: A total of 172 individuals participated, of which 112 completed the survey. In all, 32 individuals who completed the survey partially were also included. Participants consisted of 68 [44 urologists, 22 rehabilitation doctors (RDs) and 2 general practitioners (GPs)] doctors, 60 nurses (46 from the urology department and 14 from rehabilitation centres/departments) and 16 medical assistants (13 from urology department and 3 from GP offices). The majority consulted patients with an IC or on CIC on a daily/weekly or monthly basis. In all, 35 urologists (79.5%), 9 RDs (40.9%), 21 (45.7%) nurses in the urology department and 6 (42.9%) nurses from a rehabilitation department/centre indicated bladder irrigation as a treatment option for prevention/treatment of CAUTIs, treatment of symptoms or treatment of blockage of the catheter. In the clinical scenarios presented, treatment discrepancies were seen between subspecialties and healthcare workers. Various guidelines were named for the definition of CAUTIs.

Conclusion: A considerable variation in diagnoses and management of CAUTIs between the healthcare workers involved was seen. Uniformity in diagnosing and managing CAUTIs, to prevent overtreatment and possible resistance to antibiotics, is advised. Suitable multidisciplinary guidelines are preferred.

Over the past 30 years surgical training, including urology training, has changed from the Halstedian apprenticeship-based model to a competency-based one. Simulation-based education (SBE) is an effective, competency-based method for acquiring both technical and non-technical surgical skills and has rapidly become an essential component of urological education. This article introduces the key learning theory underpinning surgical education and SBE, discussing the educational concepts of mastery learning, deliberate practice, feedback, fidelity and assessment. These concepts are fundamental aspects of urological education, thus requiring clinical educators to have a detailed understanding of their impact on learning to assist trainees to acquire surgical skills. The article will then address in detail the current and emerging simulation modalities used in urological education, with specific urological examples provided. These modalities are part-task trainers and 3D-printed models for open surgery, laparoscopic bench and virtual reality trainers, robotic surgery simulation, simulated patients and roleplay, scenario-based simulation, hybrid simulation, distributed simulation and digital simulation. This article will particularly focus on recent advancements in several emerging simulation modalities that are being applied in urology training such as operable 3D-printed models, robotic surgery simulation and online simulation. The implementation of simulation into training programmes and our recommendations for the future direction of urological simulation will also be discussed.

Testicular tumours in prepubertal children tend to be pure yolk sac tumours detected in stage I and have good prognosis. We describe a case of a 2-year old male child with a mixed testicular tumour presenting with stage IIC disease and managed with retroperitoneal lymph node dissection for residual retroperitoneal disease post adjuvant chemotherapy.

Several mobile healthcare (mHealth) apps are available in various marketplaces, but there is still concern about their accuracy, data safety, and regulation. The goal of this review was to critically analyze the mobile apps created for education, diagnosis, and medical and surgical treatment of patients with kidney stone disease (KSD), as well as to assess the level of data security, the contribution of physicians in their development and adherence to the Food and Drug Administration (FDA) and Medical Device Regulation (MDR) guidance. A comprehensive literature search was performed using PubMed (September 2022), in the Apple App Store and Google Play store using relevant keywords and inclusion criteria. Information was extracted for the name of the app, primary and additional functionalities, release and last update, number of downloads, number of marks and average rating, Android/iOS compatibility, initial and in-app payments, data safety statement, physician involvement statement, and FDA/MDR guidance. A total of 986 apps and 222 articles were reviewed, of which based on the inclusion, 83 apps were finally analyzed. The apps were allocated to six categories about their primary purpose: education (n = 8), fluid trackers (n = 54), food content description and calculators (n = 11), diagnosis (n = 3), pre- and intra-operative application (n = 4), and stent trackers (n = 2). Of these apps, the number of apps supported for Android, iOS, and both of them were 36, 23, and 23, respectively. Despite a wide range of apps available for KSD, the participation of doctors in their development, data security, and functionality remains insufficient. Further development of mHealth should be carried out properly under the supervision of urological associations involving patient support groups, and these apps must be regularly updated for their content and data security.

Over the past 20 years, the field of robotic surgery has largely been dominated by the da Vinci robotic platform. Nevertheless, numerous novel multiport robotic surgical systems have been developed over the past decade, and some have recently been introduced into clinical practice. This nonsystematic review aims to describe novel surgical robotic systems, their individual designs, and their reported uses and clinical outcomes within the field of urologic surgery. Specifically, we performed a comprehensive review of the literature regarding the use of the Senhance robotic system, the CMR-Versius robotic system, and the Hugo RAS in urologic procedures. Systems with fewer published uses are also described, including the Avatera, Hintori, and Dexter. Notable features of each system are compared, with a particular emphasis on factors differentiating each system from the da Vinci robotic system.

Introduction: Urothelial carcinoma can arise from the urinary bladder or from the upper urinary tract. In some instances, urinary bladder cancer (UBC) and upper tract urothelial carcinoma (UTUC) can be concurrently diagnosed, necessitating a combined radical cystectomy (RC) with radical nephroureterectomy (RNU). A systematic review was done on the combined procedure exploring outcomes and indications, in addition to a comparative analysis between the combined procedure and cystectomy alone.

Methods: For the systematic review, three databases (Embase, PubMed, and Cochrane) were queried, selecting only studies that included intraoperative and perioperative data. For the comparative analysis, using the NSQIP database, CPT codes for RC and RNU were used to identify two cohorts, one with RC and RNU and one with RC alone. A descriptive analysis was performed on all preoperative variables, and propensity score matching (PSM) was performed. Postoperative events were then compared between the two matched cohorts.

Results: For the systematic review, 28 relevant articles were included amounting to 947 patients who underwent the combined procedure. The most common indication was synchronous multifocal disease, the most common approach was open surgery, and the most common diversion technique was using an ileal conduit. Almost 28% of patients required blood transfusion and remained in the hospital for an average of 13 days. The most common postoperative complication was prolonged paralytic ileus. For the comparative analysis, 11,759 patients were included of which 97.5% underwent RC only and 2.5% underwent the combined procedure. After PSM, the cohort that had undergone the combined procedure showed an increased risk of renal injury, increased readmission rates, and increased reoperation rates. Whereas the cohort that had undergone RC only showed an increased risk of deep venous thrombosis (DVT), sepsis, or septic shock.

Conclusion: A combined RC and RNU is a treatment option for concurrent UCB and UTUC that should be cautiously utilized as it is associated with high morbidity and mortality. Patient selection, discussion of the risks and benefits of the procedure, and explanation of the available treatment options remain the most important pillars in managing patients with this complex disease.

Introduction: With several single-use ureteroscopes now available, our aim was to analyze and compare data obtained globally from high-volume centers using both disposable and reusable flexible ureteroscopes and see if indeed in real-world practice either scope has a distinct advantage.

Methods: Retrospective analysis was performed on the FLEXOR registry, which was created as a TOWER group (Team of Worldwide Endourological Researchers, research wing of the Endourological Society) endeavor. Patients who underwent retrograde intrarenal surgery (RIRS) for renal stones from January 2018 to August 2021 were enrolled from 20 centers globally. A total of 6663 patients whose data were available for analysis were divided into Group 1 (Reusable scopes, 4808 patients) versus Group 2 (Disposable scopes, 1855 patients).

Results: The age and gender distribution were similar in both groups. The mean stone size was 11.8 mm and 9.6 mm in Groups 2 and 1, respectively (p < 0.001). Group 2 had more patients with >2 cm stones, lower pole stones and of higher Hounsfield unit. Thulium fiber laser (TFL) was used more in Group 2 (p < 0.001). Patients in Group 2 had a slightly higher stone-free rate (SFR) (78.22%) and a lower number of residual fragments (RFs) compared with Group 1 (p < 0.001). The need for further treatments for RF and overall complications was comparable between groups. On multivariate analysis, overall complications were more likely to occur in elderly patients, larger stone size, lower pole stones, and were also more when using disposable scopes with longer operative time. RFs were significantly higher (p < 0.001) for lower pole, larger, harder, multiple stones and in elderly.

Conclusion: Our real-world practice observations suggest that urologists choose disposable scopes for bigger, lower pole, and harder stones, and it does indeed help in improving the single-stage SFR if used correctly, with the appropriate lasers and lasing techniques in expert hands.

Introduction: We wanted to analyze the trend of publications in a period of 30 years from 1994 to 2023, on the application of 'artificial intelligence (AI), machine learning (ML), virtual reality (VR), and radiomics in percutaneous nephrolithotomy (PCNL)'. We conducted this study by looking at published papers associated with AI and PCNL procedures, including simulation training, with preoperative and intraoperative applications.

Materials and methods: Although MeSH terms research on the PubMed database, we performed a comprehensive review of the literature from 1994 to 2023 for all published papers on 'AI, ML, VR, and radiomics' in 'PCNL', with papers in all languages included. Papers were divided into three 10-year periods: Period 1 (1994-2003), Period 2 (2004-2013), and Period 3 (2014-2023).

Results: Over a 30-year timeframe, 143 papers have been published on the subject with 116 (81%) published in the last decade, with a relative increase from Period 2 to Period 3 of +427% (p = 0.0027). There was a gradual increase in areas such as automated diagnosis of larger stones, automated intraoperative needle targeting, and VR simulators in surgical planning and training. This increase was most marked in Period 3 with automated targeting with 52 papers (45%), followed by the application of AI, ML, and radiomics in predicting operative outcomes (22%, n = 26) and VR for simulation (18%, n = 21). Papers on technological innovations in PCNL (n = 9), intelligent construction of personalized protocols (n = 6), and automated diagnosis (n = 2) accounted for 15% of publications. A rise in automated targeting for PCNL and PCNL training between Period 2 and Period 3 was +247% (p = 0.0055) and +200% (p = 0.0161), respectively.

Conclusion: An interest in the application of AI in PCNL procedures has increased in the last 30 years, and a steep rise has been witnessed in the last 10 years. As new technologies are developed, their application in devices for training and automated systems for precise renal puncture and outcome prediction seems to play a leading role in modern-day AI-based publication trends on PCNL.