World Journal of Urology最新文献

Purpose: To evaluate the influence of detrusor apron preservation on continence in Retzius-sparing Robotic assisted radical prostatectomy (RS-RARP).

Materials and methods: A prospective study was carried out on patients who underwent RS-RARP at our institute from January 2019 to June 2022. We aimed to identify potential factors that could affect continence, including age, BMI, ISUP Grade Group, bladder neck sparing, fascial plane of dissection, and degree of preservation of the detrusor apron. The detrusor preservation was graded from 0 to 3, where grade 0 the detrusor apron is sacrificed and grade 3 it is complete preservation.

Result: The study included 311 patients. There was a significant correlation between the degree of detrusor preservation and continence at three months, with significance escalating with greater detrusor preservation. The OR for grade 1, grade 2 and grade 3 stood at 3.84 (p = 0.026), 9.83 (p < 0.001) and 16.06 (p = 0.03) respectively. This correlation in the three groups at six months was 29.38 (p < 0.001), 26.57 (p < 0.001), and 17.29 (p = 0.005) respectively, showing an even stronger association with continence recovery. The OR for detrusor apron preservation at 12 months was 21.89 (p = 0.003), 14.21 (p = 0.006), and 6.31 (p = 0.105) respectively. We observed that the association between detrusor apron preservation persisted at 12 months, although the odds ratios (OR) were diminished compared to the six-month periods.

Conclusion: The study emphasizes the critical role of the detrusor apron in achieving both early and superior continence rates. Sacrificing the detrusor apron was associated with delayed continence recovery and an increased incidence of incontinence. To achieve good continence with reduced incidence of margin positivity detrusor can be preserved in a graded manner.

Objective: To test the impact of fixing a peritoneal flap of the bladder to the plexus Santorini as final step of robot-assisted radical prostatectomy (RARP) to reduce the incidence of symptomatic lymphoceles and postoperative complications.

Patients and methods: A two-armed prospective randomised, controlled, single-centre trial on 1080 patients with prostate cancer who underwent RARP with bilateral pelvic lymph node dissection was carried out. Patients in the intervention arm received fixation of the peritoneal flap of the bladder to the plexus Santorini at the end of surgery (Michl-technique, MT); in the control group, surgery was performed without this modification. The primary endpoint was the rate of lymphoceles requiring intervention. Secondary endpoints were total lymphocele rate, other complications ≥ grade IIIa according to Clavien-Dindo and continence rates within one year after RARP.

Results: Overall, between June 2017 and October 2019, 531 patients were randomised to the MT and 549 to the control arm. There were no differences in both arms with respect to age at surgery, PSA, BMI, prostate volume, surgical time, blood loss, and time to removal of the catheter. Overall, in median 14 lymph nodes were dissected and 337 (32%) patients had a lymphocele. There was no statistically significant difference in lymphoceles requiring intervention (7.2% in MT-group versus 8.8% in control group, p = 0.4). There was no difference in continence rates and other complications between the two groups after one-year-follow-up.

Conclusions: There was no significant reduction in symptomatic lymphoceles observed when using the Michl-technique. Lymphoceles remain a significant complication post lymph node dissection in RARP patients.

Purpose: Chronic kidney disease (CKD) is frequent in bladder cancer patients undergoing radical cystectomy (RC) with ileal conduit. However, the effect of CKD on adverse in-hospital outcomes after ileal conduit RC is not well known.

Methods: Descriptive analyses, propensity score matching (PSM), and multivariable logistic and Poisson regression models were used to address National Inpatient Sample patients treated with ileal conduit RC between 2006 and 2019. CKD severity was stratified as mild (stage II) vs. moderate (stage III) vs. severe (stage IV/V).

Results: Of 13,359 patients treated with RC with ileal conduit, 1973 (14.8%) had CKD. Of those, 956 (48.5%), 802 (40.6%), and 215 (10.9%) were classified as mild, moderate, or severe CKD, respectively. CKD rate increased from 4.1 to 21.9% (2006-2019, EAPC: +8.9%, p < 0.001). CKD RC patients exhibited higher rates of adverse in-hospital outcomes in 11 of 15 categories. The absolute differences were largest for overall complications (+ 13.2%), prolonged length of stay (+ 7.0%), blood transfusions (+ 6.0%, all p < 0.001). After detailed multivariable adjustment, CKD was an independent predictor of 11 of 15 adverse in-hospital outcomes' categories. The detrimental effect of CKD was most pronounced for dialysis (OR 7.09), overall complications (OR 1.84), and neurological complications (OR 1.61, all p < 0.001). Finally, a dose-response effect according to CKD severity on adverse in-hospital outcomes was observed in eight of 15 categories.

Conclusions: CKD RC patients invariably exhibited higher rates of adverse in-hospital outcomes after RC with ileal conduit. In consequence this patient group should receive particularly strong consideration for preoperative optimization.

Purpose: Caudal analgesia (CA) is a widely used method to tackle pain after hypospadias repair. Complications related to temporary penile engorgement has made people concerned about CA and switch to pudendal analgesia (PA). In this prospective randomized blinded study we compared CA and PA among children undergoing hypospadias repair. We hypothesized that pudendal analgesia would be equally effective as caudal analgesia, with no altered risk of surgical complications.

Methods: All children undergoing single-stage distal hypospadias repair were randomized into CA or PA groups. In both groups, analgesia was provided under ultrasound guidance with 0.2% ropivacaine and 1 mcg/kg clonidine. FLACC score (Face, Leg, Anxiety, Crying, Consolability) for pain and urethroplasty complications were compared between the groups.

Results: During the study period, a total 72 patients were recruited (36 in each group). There was no significant difference between the groups in terms of FLACC score.Rescue analgesia was required in 2/36 (5%) in CA and 3/36(8%) in PA with no significant difference (p = 1). Post-operative complications were encountered in 4/36 (11.1%) in CA (1 glans dehiscence, 2 fistulae, 1 partial skin-flap necrosis) while 3/36 (8.3%) in PA group (1 glans dehiscence, 2 fistulae) with no significant difference (p = 1).

Conclusions: There was no difference between CA and PA in terms of analgesic effects or postoperative complications. While PA is as effective in pain relief, conventional CA is not associated with higher complications. Further larger studies are warranted comparing penile, caudal and pudendal blocks in hypospadias.

Purpose: Prostate cancer is under-researched in many Asian countries because the paucity of comprehensive cancer registries has prevented large studies from comparing primary prostate cancer therapies. We aimed to provide further insights into recent trends in primary prostate cancer management across multiple Asian countries and regions according to universal health coverage.

Methods: This is part of the Asian Prostate Cancer (A-CaP), a prospective and multicenter study conducted in 12 Asian countries. The study cohort comprised patients newly diagnosed between January 2016 and December 2018. Patients were allocated to three categories according to the universal health coverage effective coverage index (Category 1 ≥ 80; Category 2, 70-79; and Category 3, < 70). We assessed primary management of prostate cancer according to these categories and by clinic pathological characteristics such as clinical stage, and D'Amico risk group.

Results: In total, 34,994 patients were included in the final analysis. Category 1 had the highest proportion of patients diagnosed at early stages and Category 3 had the highest proportion of patients diagnosed at advanced stages. Most patients in Category 1 had undergone computed tomography scans, magnetic resonance imaging, and bone scans. In contrast, only 1.7% and 5.4% of men in Categories 2 and 3, respectively, had undergone all three of these investigations. The proportion of patients who had undergone radiation and androgen deprivation therapy as primary treatment was highest in Category 1, whereas the rate of conservative management was highest in Category 2. More patients in Category 3 than in the other two categories had undergone radical prostatectomy, but fewer had been treated with radiation therapy.

Conclusions: Our findings highlighted differences in patterns of treatment of newly diagnosed prostate cancer across 12 Asian countries and regions and suggest that, despite guidelines, health access affects treatment received.

Background: Laser Anatomical Endoscopic Enucleation of the Prostate (LAEEP) techniques offer a promising solution for patients seeking to alleviate urinary symptoms while preserving sexual function. The ejaculation preservation approach has been shown to achieve an impressive 90% success rate in maintaining antegrade ejaculation.

Purpose: To explore the effect of the ejaculatory preservation HoLEP technique on postoperative continence and ejaculation.

Patients and methods: We conducted a prospective randomized study adhering to CONSORT guidelines. Patients with prostate sizes between 40 and 80 gm, IPSS scores > 20, Qmax < 10 ml/s, and IIEF-5 scores  > 22 were eligible for inclusion. A total of 43 patients were randomized into two groups: Group 1 (n = 22) underwent HoLEP, while Group 2 (n = 21) underwent EP HoLEP. We assessed functional outcomes and ejaculatory dysfunction at baseline and 1-, 3-, and 6- month. The study period was from October 2022 to March 2024.

Results: Data from 40 patients were analyzed. Functional outcomes showed significant improvement in Group 1, with IPSS (median 12.5, P < 0.006) and Qmax (median 15, P < 0.04) at 3-month. ICIQ-UI SF scores showed a significant difference in the incontinence episodes (domain Q3), which were lower (P < 0.023) in Group 2 compared to Group 1 during the 1-month visit. MSHQ-EjD-SF scores were significantly higher in Group 2 at both 3- and 6- month (P < 0.01 and P < 0.02, respectively). IIEF-5 scores showed no significant difference between both groups during the study period.

Conclusion: Implementing the ejaculation preservation technique during HoLEP appears to improve early postoperative continence and preserve ejaculation.

Purpose: Endoscopic lithotripsy has become widely adopted worldwide and is considered the gold standard for managing upper urinary tract lithiasis. One of its possible complications is post-operative infection. We aimed to review available literature about the role of preoperative antibiotic prophylaxis and its indications.

Methods: We performed a systematic search of the literature including "ureteroscopy", "PNL", "retrograde intrarenal surgery", "antibiotic prophylaxis" and "sepsis" as keywords. Out of 760 relevant studies only 13 met our inclusion criteria: at least 10 adult patients (≥ 18 years old) diagnosed with kidney or ureteral stones; antibiotic prophylaxis described and reported; post-operative sepsis, UTI or SIRS assessed.

Conclusions: Antibiotic prophylaxis strategies for stone surgery show different degrees of effectiveness depending on both the approach and the patient's condition. Today's evidence suggests that while routine antibiotic prophylaxis might not be necessary for all patients with sterile urine undergoing ureterorenoscopy and lithotripsy vs. percutaneous nephrolithotripsy, for those patients with positive preoperative urine cultures it is beneficial reducing the risk of postoperative infective complications.

Purpose: To assess the 30-day stone-free rate and peri-operative outcomes of flexible ureteroscopy (FURS) with flexible and navigable suction ureteral access sheaths (FANS) in adults undergoing same-sitting bilateral retrograde intrarenal surgery (SSB-RIRS).

Methods: Prospectively data of 115 adult patients with bilateral kidney stone disease undergoing SSB-RIRS across 14 global centers between July 2023 and March 2024 were analyzed. Patient demographics, stone characteristics and operative outcomes were recorded. A low-dose non contrast CT scan was performed at 30 days to assess the stone-free rate and clinical outcomes.

Results: Overall bilateral zero residual fragment(ZRF) was 42.6%; unilateral ZRF was 75.7%. Only two patients were noted to have residual fragments > 4 mm. 1.7% experienced Traxer-Thomas grade 1 ureteric injury which was managed with a ureteral stent for four weeks. No pelvicalyceal injury occured. Postoperative mean loin pain score was 1.7 ± 1.0. None had sepsis nor required blood transfusion. 4.3% required readmission within 30 days of surgery. Multivariate analysis indicated longer total operation time correlated with lower odds of achieving a 100% bilateral stone-free (ZRF) (OR 0.978, 95%CI = 0.959-0.994, p = 0.013).

Conclusion: To our knowledge, this is the first multicenter study demonstrating the use of FANS in SSB-RIRS can achieve bilateral ZRF with low complication and re-intervention rates. However, prolonged surgical time may negatively impact outcomes. The indications of bilateral renal stones management with FURS can be expanded in appropriate chosen patients.

Purpose: Pelvic mesh has been used for the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Between 3 and 20% suffer complications with debilitating long-term outcomes. Uncommon complications include mesh perforation into viscus however there is minimal published data regarding outcomes following surgical management.

Methods: A retrospective observational study of patients with diagnosis of mesh in viscus at three tertiary urogynaecology units was performed to report on clinical outcomes following surgical management.

Results: Fifty-eight patients were diagnosed with mesh in viscus following cystourethroscopy and thorough examination of vagina/rectum. Mesh involved included mid-urethral slings-retropubic (36.9%), transobturator (18.5%), single incision slings (10.8%); transvaginal POP mesh (15.4%); sacrocolpopexy (13.8%); uncertain type (4.6%). Viscus involved included bladder (39.7%), urethra (50%), bladder and urethra (3.4%), and rectum (6.9%). Main presenting symptoms included mixed urinary incontinence (UI) (75.9%), recurrent urinary tract infections (rUTIs) (48.3%) and rectal/pelvic pain (56.9%). Fifty-one patients underwent mesh excision and viscus repair, with successful repair in all (100%). 48% had complete mesh excision. Mean follow up was 9.5 months (range 0.5-96 months). Post-operatively, there was a statistically significant reduction in rUTIs (p = 0.0004) as well as pain (p = 0.000005). None had recurrent mesh erosion, lower genitourinary tract fistula or wound breakdown.

Conclusions: All patients required thorough examination and cystourethroscopy for diagnosis. Surgical management of mesh in viscus appears to have low morbidity and is shown to reduce symptoms of rUTIs and pain as well as risk of recurrent mesh erosion and fistulae.

Background: Urolithiasis, a prevalent condition characterized by a high rate of incidence and recurrence, necessitates accurate preoperative diagnostic methods to determine stone composition for effective clinical management. Current diagnostic practices, reliant on postoperative specimen analysis, often fail to facilitate timely and precise therapeutic decisions, leading to suboptimal clinical outcomes. This study introduces an artificial intelligence model developed to predict infectious and non-infectious urolithiasis preoperatively using clinical data and CT imaging.

Methods: Data from December 2014 to November 2021 involving 642 patients undergoing surgical treatment for urolithiasis were used to train and validate the model. The model integrates Visual and Textual Transformation (VTT) and Multimodal-Segmentation Attention Fusion (MSAF) modules to enhance the diagnostic process.

Results: The model demonstrated superior accuracy and reliability in differentiating between infectious and non-infectious urolithiasis compared to traditional diagnostic methods. It achieved a classification accuracy of 79.66%, Area Under Curve of 86.74%, significantly outperforming conventional ResNet architectures and similar models. The inclusion of clinical parameters substantially improved the model's predictive capabilities.

Conclusions: Our model provides an efficient tool for the preoperative identification of urolithiasis type, supporting clinical decisions regarding surgical planning and postoperative care. Its ability to process and analyze complex clinical and imaging data preoperatively positions it as a valuable adjunct in urological practice, particularly in settings with limited access to specialized medical resources.