Therapeutic Advances in Urology最新文献

Continent urinary diversion is the preferred method of bladder substitution for many patients who undergo cystectomy for benign conditions. Additional interventions are often necessitated after a continent diversion to achieve continence. One such procedure is the injection of botulinum toxin into the neobladder. Previous injections into the pouch bladder have been performed percutaneously. Here we present a less invasive endoscopic injection technique where flexible equipment has been used successfully to inject botulinum toxin into the pouch bladder via the pouch stoma. We demonstrate the feasibility of the injection and its efficacy in reducing pouch contractions and the patient's symptoms. A 36-year-old female presented with persistent urinary incontinence symptoms 1 year after Indiana pouch diversion. Despite previous conservative measures and ileocecal valve reinforcement surgery, incontinence persisted. The endoscopic injection, facilitated through the pouch stoma, proved effective in decreasing muscle contractions and alleviating spasm-like sensations without observed side effects. This case shows the feasibility, safety and efficacy of botulinum toxin injection into Indiana pouch endoscopically.

Objectives: To review outcomes for patients with irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD) who undergo holmium laser enucleation of prostate (HoLEP) for bothersome urinary symptoms related to benign prostatic hyperplasia (BPH).

Methods: We performed a retrospective review of patients who had undergone HoLEP by a single surgeon between January 2021 and August 2023. Preoperative, intraoperative, and postoperative characteristics were compared between patients with an ICD-10 diagnosis of IBS or IBD and those without, using Chi-square and paired T-tests as appropriate.

Results: Out of 918 men, 24 (2.6%) had a diagnosis of IBS, and 36 (3.9%) had a diagnosis of IBD. There were no differences in age, BMI, preoperative American Urological Association symptoms score (AUASS), preoperative Michigan Incontinence Symptom Index (MISI) score, and history of urinary retention or incontinence. The IBS + IBD cohort had smaller prostates (100.9 vs 124.2 mL, p = 0.01) and shorter procedure times (57.0 vs 66.5 min, p = 0.02) than controls. IBS patients were more likely to require anticholinergic therapy at a 3-month follow-up (31% vs 13%, p = 0.03) and had more postoperative encounters within 90 days of HoLEP (3.7 vs 2.6, p = 0.01). There were no differences regarding changes in AUASS and MISI scores, same-day trial of void and same-day discharge rates, or complication rates.

Conclusion: IBS patients who underwent HoLEP had more symptomatic postoperative courses requiring higher rates of anticholinergic medication use and more provider interactions compared to men without IBS, despite similar AUASS and MISI scores. These trends were not observed in patients with IBD.

Urinary tract fistulas (UTFs) are abnormal connections between the urinary tract and adjacent structures such as the bowel, vagina, or blood vessels. UTFs result in significant personal, social, and financial challenges to patients worldwide. This review investigates the various causes, risk factors, symptoms, and historical evolution of repair techniques of UTFs. This focuses on the shift from open surgery to minimally invasive techniques, particularly the growing utilization of robot-assisted laparoscopic (RAL) approaches. This review emphasizes the growing role of RAL surgery in treating UTFs, citing its advantages of reduced blood loss, low recurrence rates, and decreased postoperative complications while acknowledging challenges such as limited access to the RAL platform and longer surgical times. The study concludes with advocacy for more widespread access to the RAL platform as well as more research, including randomized controlled trials, to further refine the body of evidence and promote patient outcomes.

Background: Transurethral resection of the bladder (TURB) harbors a high-risk for postoperative bleeding, especially in patients requiring anticoagulation. Recently, direct oral anticoagulants (DOACs) have become a popular alternative to vitamin K antagonists (VKAs), though their impact on TURB complications remains unclear.

Objectives: To assess the postoperative complications of TURB from patients taking DOACs and VKAs.

Design: Retrospective cohort study.

Materials and methods: We retrospectively identified anticoagulated patients undergoing a TURB at our institution between 2012 and 2022 and divided them into two groups: whether they received VKA or DOAC. Follow-up of each patient was performed for 3 months. Occurrence and time to event of postoperative bleeding and thromboembolic events were recorded. A multivariable regression analysis was performed to assess risk differences.

Results: A total of 167 patients (11.7%) fulfilled the inclusion criteria, of which 102 patients (61.1%) received a DOAC and 65 patients (38.9%) a VKA. Postoperative bleeding led to re-catheterization in 13 (12.8%) DOAC and 6 (9.2%) VKA patients (p = 0.49) and re-intervention in 7 (6.9%) DOAC and 4 (6.2%) VKA patients (p = 0.86). Blood transfusions were administered to 3 DOAC patients (2.9%), none in the VKA group. No thromboembolic events were reported.

Conclusion: TURB carries low morbidity in anticoagulated patients. Thromboembolic events and the need for blood transfusion are infrequent. No substantial difference between the postoperative bleeding risk of patients receiving DOAC or VKA was found. All bleeding complications occurred within 2 weeks, marking it a potentially safe point in time to restart the OAC thereafter.

Background: Technical advancements and intrarenal pressure are synergistic in improving perioperative outcomes during flexible ureteroscopy (FURS). Mismanaged intra-renal pressure (IRP) has negative consequences and it is associated with an increased risk of sepsis, bleeding, pelvicalyceal fluid extravasation, and even collecting system injuries and acute as well as chronic renal failure. The cornerstone of a safe FURS is the ability to continuously monitor IRP to avoid elevation of IRP above the normal range of 10 mmHg.

Objectives: This scoping review aims to report the current state of real-time IRP monitoring in in vivo clinical studies and the various monitoring methods and technology to understand how this may be best used in daily clinical practice.

Eligibility criteria: A systematic literature search was conducted. Only in vivo clinical studies published in English documenting IRP measurement methodologies during semirigid or flexible ureteroscopy for urolithiasis management were included.

Results: Out of 1326 retrieved papers, 17 studies met the inclusion criteria, comprising 2 randomized controlled trials, 2 retrospective studies, and 13 observational studies. Current noninvasive IRP monitoring devices include ureteric catheters placed retrogradely or via percutaneous tubing and connected to pressure transducers, amplified by cardiology-used pressure sensing systems or urodynamic systems, automated pressure-regulating systems, pressure sensing guidewires, and IRP sensing flexible ureteroscopes. The review revealed significant variations in IRP measurement methods, reporting units, and irrigation techniques. Notably, elevated IRP above 30 mmHg was consistently associated with increased postoperative complications, including sepsis.

Conclusion: Current clinical studies have only ascertained that increased IRP above 40 mmHg positively correlates with infectious complications and postoperative pain. No standardized values are available to predefine safe thresholds in practice. With the availability of noninvasive tools for IRP monitoring, future research should focus on multicenter studies to establish reference ranges and best practices for IRP management, ultimately improving patient outcomes in endourological procedures.

Urinary diversions are performed for a wide variety of indications, including bladder removal for cancer treatment, post-cancer treatment complications, trauma, or bladder pain. The robotic approach has been increasingly used in performing urinary diversions since the introduction of the surgical robot. A PubMed keyword search was performed on September 14, 2023 with the terms: robotic and urinary diversion. A narrative review of the literature was then conducted, with a focus on outcomes and complications following urinary diversion. Studies demonstrated that the robotic approach to cystectomy with urinary diversion was safe and productive, whether the diversion was performed intracorporeally or extracorporeally, and that outcomes are comparable to the open approach. Despite reports of successes and technique improvements, the complication rate following robotic cystectomy with urinary diversion is over 50%. Common complications associated with urinary diversion include bowel complications, ureteroenteric anastomotic strictures, urine leak, urinary tract infections, internal hernias, and parastomal hernias. Many strategies have been developed to improve the complication rate following robotic urinary diversion, including specialized training programs and enhanced recovery after surgery protocols. In conclusion, with the increasing adoption of the robotic approach for urinary diversions, it is important to continue to develop strategies to mitigate surgical risk. Future research should focus on further refinement of training and surgical approaches to prevent and treat complications following robotic urinary diversions.

What is this summary about? People with overactive bladder need to use the bathroom many times a day to urinate (pee). This need may often be sudden and may cause some people with overactive bladder to have accidental bladder leakage. The EMPOWUR trial looked at how well a medicine called vibegron worked to help people with overactive bladder. The study also included another drug that was already available for treating overactive bladder called tolterodine and a pill with no medicine called a placebo. Both vibegron and tolterodine were compared with placebo. Participants had improvements in their overactive bladder symptoms after taking either vibegron or tolterodine compared to placebo. The medicine vibegron was approved in 2020 by the US Food and Drug Administration (also called the FDA) to treat overactive bladder. Researchers next wanted to see how well vibegron worked in people from the EMPOWUR trial split into 2 groups. One group was made of participants with overactive bladder who have accidental leakage. The second group was made of participants with overactive bladder who do not have accidental leakage. This is a plain language summary of the study of how well vibegron works for those 2 groups from the EMPOWUR study that was published in the International Journal of Clinical Practice. What were the results? Study participants who took vibegron needed to pee fewer times per day. The number of times they had little warning before the need to pee was also lower. The results were the same for study participants who did and did not have accidental leakage related to overactive bladder. What do the results mean? This study suggests that vibegron can improve symptoms in people with overactive bladder whether or not they have accidental bladder leakage.

Background: The Optilume^® paclitaxel drug-coated balloon (DCB) is a relatively new-to-market alternative in the management of male anterior urethral stricture disease. The pivotal trial excluded patients with a history of urethroplasty, although these strictures may be amenable to endoscopic management. Therefore, we sought to assess the efficacy of the DCB in the management of recurrent strictures following urethroplasty.

Methods: A retrospective, multi-institutional review of male patients undergoing DCB dilation from 1/1/2022 to 11/1/2023 by five surgeons at four institutions was performed. Patients were stratified by history of urethroplasty; demographics, stricture characteristics, and outcomes (surgical success, time to recurrence). Success was defined as freedom from re-intervention in patients with at least 3 months of follow-up.

Results: Among the 122 cases assessed, 33 (27.0%) had previously undergone urethroplasty. Patients in the urethroplasty group were younger than those in the control group (51.6 vs 58.8 years, p = 0.022). The two groups were otherwise similar with regard to background characteristics and comorbidities. Patients in both groups had similar stricture characteristics with short bulbar strictures being the most common. When compared to the control group, those with a history of prior urethroplasty had a greater median number of interventions prior to DCB treatment (3 vs 1, p < 0.001). Postoperative cystoscopy was performed in 37 cases, with similar patency rates between groups (p > 0.999). Early success rates were similarly high in both groups (80.0% post-urethroplasty vs 88.9% control, p = 0.338), although follow-up was limited to a median of 3.5 months in the urethroplasty group and 2.9 months in the control group (p = 0.069).

Conclusion: Despite a greater number of prior surgical interventions, patients with a history of urethroplasty achieve similarly high success rates after treatment with DCB compared to those without a history of urethroplasty.

Background: Clean intermittent catheterization (CIC) is the golden standard in patients with lower urinary tract dysfunction, leading to bladder emptying problems, due to neurogenic or non-neurogenic causes. CIC affects patient Quality of Life (QoL) both positively and negatively.

Objectives: The aim of this systematic review is to determine which measurements are used to report on the QoL of patients who are on CIC in the currently available literature, to determine the overall QoL of patients who are on CIC and lastly, to determine whether QoL in patients who are on CIC is dependent on the underlying cause (neurogenic vs non-neurogenic).

Design: This systematic review was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Data sources and methods: The Embase, Medline, Web of Science Core Collection, CINAHL, Google Scholar, and the Cochrane CENTRAL register of trials databases were systematically searched for relevant publications until March 2023.

Results: A total of 4430 abstracts were screened and 43 studies were included. Studies were published between 1993 and 2022 and consisted of only neurogenic patients in 22 studies, the others included a mixed population. The included patient populations and the used measurements/tools were heterogeneous. There were 21 measurements/tools used to measure QoL, of which 3 were not validated. One questionnaire was developed to measure QoL in patients on CIC (intermittent self-catheterization questionnaire). Other measurements were suitable for general health-related QoL, to evaluate neurogenic bladder symptoms or incontinence oriented.

Conclusion: The 43 included studies showed a great variety of used tools to measure QoL in patients on CIC due to neurogenic and non-neurogenic causes. Because of lacking uniformity of the measured aspects of QoL, the different included studies could not be compared and subgroup analysis was not performed. Recommendations for future research and practice are provided.

Trial registration: This systematic review was registered and published beforehand at Prospero (CRD42020181777; https://www.crd.york.ac.uk/prospero).

Background: The 3D models' use for surgical planning has recently gained an ever-wider popularity, in particular in the urological field. Different ways of fruition of this technology have been evaluated over the years. Today, new technological developments allow us to enjoy 3D models in the metaverse.

Objectives: The aim of this study is to report the preliminary experience and surgeon's perception of preoperative planning performed in the metaverse.

Design: During the eleventh edition of the Techno-Urology Meeting, all the attendees enjoyed the metaverse experience (META_EXP) for pre-surgical planning of both robot-assisted radical prostatectomy and partial nephrectomy. Users' perception was then evaluated with the Health Information Technology Usability Evaluation Scale (Health-ITUES) and the Face & Content validity questionnaire.

Methods: The 3D virtual models, obtained from standard bi-dimensional imaging, were uploaded on a metaverse platform. Surgeons, thanks to dedicated visors, could plan their surgical strategy immersed in this virtual environment and discuss it with other attendees. Answers to the questionnaires were then evaluated and a stratification was subsequently performed based on surgical expertise, dividing participants in residents (Re), young urologists (YU) and senior urologists (SU).

Results: Sixty-six participants filled out the questionnaires. As emerged from the Health-ITUES questionnaire, META_EXP covers an important role in the presurgical/surgical planning and decision-making process and appears to be useful for preoperative planning, with a median response of 4 and 5, respectively. Such results were also confirmed at the Face & Content validity questionnaire, with a median rate of 9/10 regarding its usefulness for surgical planning. Also, anatomical accuracy was positively rated regarding both organ's and disease's details, with a median response of 9.

Conclusion: In conclusion, the metaverse experience for preoperative surgical planning appears to be useful, user-friendly and accurate. This technology has been widely appreciated by surgeons, irrespective of their experience.