Malla suburetral retropúbica (TVT): experiencia clínica y análisis de datos en el Hospital El Carmen de Maipú / Retropubic suburethral mesh (TVT): clinical experience and data analysis at the Hospital El Carmen de Maipú

La incontinencia urinaria de esfuerzo es la pérdida involuntaria de orina durante una maniobra de esfuerzo físico, ejercicio, estornudo o tos. Afecta aproximadamente al 15% de las mujeres de 30-60 años y su prevalencia es del 30-41%. Aunque existen terapias conservadoras para su manejo, muchas pacientes terminarán necesitando cirugía para su resolución. Las mallas suburetrales son alternativas para el manejo quirúrgico, existiendo dos vías de instalación, la transobturadora (TOT o TVT-O) y la retropúbica (del inglés tension-free vaginal tape o TVT), siendo esta última la que presenta mejores resultados y menos complicaciones posoperatorias. Objetivo: evaluar la tasa de efectividad y las complicaciones de la TVT en la Unidad de Piso Pélvico Femenino del Hospital El Carmen de Maipú entre los años 2015 y 2020. Materiales y Métodos: Se obtuvieron 715 registros de pacientes que fueron sometidas a TVT y se logró contactar telefónicamente con el 60,69% de ellas. Resultados: Los resultados muestran una tasa de efectividad del 94,8% y una tasa de complicaciones del 2,3%. Conclusión: Este estudio aporta evidencia local de los resultados posoperatorios en la IOE en pacientes que requirieron la instalación de una malla suburetal retropúbica, demostrando ser una cirugía altamente efectiva y segura.

Stress urinary incontinence is the involuntary loss of urine during physical exertion, exercise, sneezing, or coughing. It affects approximately 15% of women aged 30-60, with a prevalence of 30-41%. Although there are conservative therapies for its management, many patients will eventually require surgery for resolution. Suburethral sling are considered for surgical management, and there are two installation alternatives, transobturator (TOT or TVT-O) and retropubic (tension-free vaginal tape or TVT), with the latter presenting better results and fewer postoperative complications. Objetive: to evaluate effectiveness rate and complications of the TVT in the Female Pelvic Floor Unit of Hospital El Carmen de Maipú between 2015 and 2020. Materials and Methods: A total of 715 patient records were obtained for those who underwent TVT, and 60.69% of them were successfully contacted by telephone. Results: The results show an effectiveness rate of 94.8% and a complication rate of 2.3%. Conclusion: This study provides local evidence for the results of stress urinary incontinence that required the placement of a retropubic suburethral sling, proving to be a highly effective and safe surgery.

Hematoma retropúbico masivo posterior a TVT: enfrentamientos diferentes para una complicación infrecuente / Massive retropubic hematoma after TVT: different approaches for an uncommon complication

INTRODUCCIÓN: La TVT (tension-free vaginal tape) es una cirugía efectiva, pero no exenta de riesgos. Las complicaciones vasculares ocurren en un 0,9-1,7%; solo el 0,33% se presentan como hematoma masivo, en general asociado a la lesión de variante anatómica corona mortis (CM). OBJETIVO: Reportar tres tipos de manejo en pacientes con hematomas masivos después de cirugía para la incontinencia. MÉTODO: Revisión de casos de hematomas masivos tras TVT. Análisis de tres casos con diferente manejo. RESULTADOS: 1086 pacientes operadas en 10 años, 1% hematomas sintomáticos, 0,36% hematomas masivos. Se presentan tres casos. Caso 1: presenta inestabilidad hemodinámica sin respuesta a volumen ni vasoactivos, requirió laparotomía exploradora y se encontró un vaso sangrante retropúbico, compatible con CM, y un hematoma de 1000 cc. Caso 2: hipotensión que responde a volumen, asintomática al día siguiente de alta, reingresó 12 días después con caída de 6 puntos en la hemoglobina y la tomografía computarizada (TC) mostró un hematoma de 550 cc; recibió drenaje percutáneo. Caso 3: asintomática, alta el primer día posoperatorio, reingresa al quinto día con descenso de 4 puntos en la hemoglobina y la TC informa hematoma de 420 cc, que drena espontáneamente por vía vaginal. Todas las pacientes recibieron 14 días de antibióticos, y permanecieron continentes. CONCLUSIONES: Los hematomas retropúbicos masivos son una complicación poco frecuente. Su manejo considera la estabilización hemodinámica, el control del sangrado y el drenaje.

INTRODUCTION: TVT (tension-free vaginal tape) is an effective surgery, not without risks. Vascular complications occur in 0.9 to 1.7%, of which 0.33% present as massive hematoma, generally associated with injury of an anatomical variant, Corona Mortis (CM). OBJECTIVE: To report three types of management in patients with massive hematomas after anti-incontinence surgery. METHOD: Review of cases of massive hematomas after TVT surgery. Analysis of three cases with different management. RESULTS: 1086 patients operated in 10 years, 1% symptomatic hematomas, 0.36% massive. Three cases are presented. Case 1: hemodynamic instability without response to volume or vasoactive agents, required reoperation with exploratory laparotomy, a retropubic bleeding vessel, compatible with CM, and hematoma 1000 cc was found. Case 2: hypotension responds to volume, asymptomatic at next day in discharge conditions, she was readmitted 12 days later with falled 6-point in Hb, and CT showed hematoma 550 cc; she received percutaneous drainage. Case 3: asymptomatic, discharge on the first day after TVT, readmitted on the 5th day with falled 4-point in Hb, CT informed hematoma 420 cc, spontaneously drains vaginally. Patients received 14 days of antibiotics, remained continent. CONCLUSIONS: Massive retropubic hematomas are an infrequent complication, and management considers hemodynamic stabilization, bleeding control and drainage.

How we do it: robotic-assisted distal ureterectomy with ureteral reimplantation

ABSTRACT Background: High risk upper tract urothelial carcinoma (UTUC) is typically managed with radical nephroureterectomy, however, renal preservation can be attempted when UTUC is localized to the distal ureter in the presence of chronic kidney disease (1-3). Distal ureterectomy is typically managed with a ureteral reimplantation and psoas hitch in order to maintain urothelial continuity, to avoid comprising the contralateral ureter, and reducing risk of chronic urinary tract infections and electrolyte abnormalities (4). We present our case of distal ureteral UTUC managed robotically with a distal ureterectomy with ureteral reimplantation. Technique and Follow-Up: Initially, an Orandi needle on a resectoscope circumscribed the left ureteral orifice. Next, robotically, the retroperitoneum was exposed and a left sided pelvic lymphadenectomy was completed. The left ureter was mobilized and the diseased ureteral segment was transected. The mobilized bladder was sutured to psoas fascia. After a cystotomy, the ureter was re-anastomosed to the bladder. The patient was discharged on postoperative day three and re-evaluated one week later with a cystogram. Final pathology was downgraded to non-invasive low-grade papillary urothelial carcinoma with negative lymph nodes and margins. Conclusion: High risk UTUC localized to the distal ureter in the setting of chronic kidney disease can be managed with a distal ureterectomy (3). Robotic distal ureterectomy with ureteral reimplantation can be assisted by an Orandi needle to achieve negative margins. Utilizing a robotic technique can offer challenges with the ureteral spatulation and reanastomosis (5-7). By fixating the ureter to the bladder prior to reanastomosis, our technique offers a solution for these difficulties.

Relationship between maximum voided volume obtained by bladder diary compared to contemporaneous uroflowmetry in men and women

ABSTRACT Introduction: The 24-hour bladder diary is considered to be the gold standard for evaluating maximum voided volume (MVV). However, we observed that patients often have a greater MVV during office uroflowmetry than that seen in the bladder diary. The purpose of this study is to compare these two non-invasive methods by which MVV can be determined - at the time of uroflowmetry (Q-MVV), or by 24hour bladder diary (BD-MVV). Materials and Methods: This was an Institutional Review Board approved retrospective study of patients evaluated for LUTS who completed a 24hour bladder diary and contemporaneous uroflowmetry. For Q-MVV, the patient was instructed to wait to void until their bladder felt full. Sample means were compared, and Pearson's correlations were calculated between the Q-MVV and BD-MVV data across the total sample, women, and men. Results: Seven hundred seventy one patients with LUTS completed bladder diaries. Of these, 400 patients, 205 women and 195 men, had contemporaneous Q-MVV. Mean BD-MVV was greater than mean Q-MVV. However, Q-MVV was larger in a sizable minority of patients. There was a weak correlation between BD-MVV and Q-MVV. Furthermore, there was a difference ≥50% between Q-MVV and BD-MVV in 165 patients (41%). Conclusions: The data suggest that there is a difference between the two measurement tools, and that the BD-MVV was greater than Q-MVV. For a more reliable assessment of MVV, this study suggests that both Q-MVV and BD-MVV should be assessed and that the larger of the two values is a more reliable assessment of MVV.

Clinical and radiographic outcomes following salvage intervention for ureteropelvic junction obstruction

ABSTRACT Purpose: We aimed to assess failure rates of salvage interventions and changes in split kidney function (SKF) following failed primary repair of ureteropelvic junction obstruction (UPJO). Materials and Methods: A retrospective review of adult patients at an academic medical center who underwent salvage intervention following primary treatment for UPJO was performed. Symptomatic failure was defined as significant flank pain. Radiographic failure was defined as no improvement in drainage or a decrease in SKF by ≥7%. Overall failure, the primary outcome, was defined as symptomatic failure, radiographic failure, or both. Results: Between 2008-2017, 34 patients (median age 38 years, 50% men) met study criteria. UPJO management was primary pyeloplasty/secondary endopyelotomy for 21/34 (62%), primary pyeloplasty/secondary pyeloplasty for 6/34 (18%), and primary endopyelotomy/secondary pyeloplasty for 7/34 (21%). Median follow-up was 3.3 years following secondary intervention. Patients undergoing primary pyeloplasty/secondary endopyelotomy had significantly higher overall failure than those undergoing primary pyeloplasty/secondary pyeloplasty (16/21 [76%] vs. 1/6 [17%], p=0.015). Among patients undergoing secondary endopyelotomy, presence of a stricture on retrograde pyelogram, stricture length, and SKF were not associated with symptomatic, radiographic, or overall failure. Serial renography was performed for 28/34 (82%) patients and 2/28 (7%) had a significant decline in SKF. Conclusions: Following failed primary pyeloplasty, secondary endopyelotomy had a greater overall failure rate than secondary pyeloplasty. No radiographic features assessed were associated with secondary endopyelotomy failure. Secondary intervention overall failure rates were higher than reported in the literature. Unique to this study, serial renography demonstrated that significant functional loss was overall infrequent.

Turning Problems into Opportunities: How to Resume Urological Elective Surgery Using a Scoring System during COVID-19 Outbreak / Convirtiendo problemas en oportunidades: como reanudar la cirugía urológica electiva utilizando un sistema de puntaje durante la pandemia por COVID-19

Objective Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which is the largest pandemic in the last century and has created a health care crisis worldwide. Contingency plans have led to put on hold all urological elective surgeries. The aim of the present article is to report the adaptation of theMedically Necessary Time-Sensitive (MeNTS) scoring systemto triage patients who were awaiting urological elective surgery during the COVID-19 pandemic. Methods The present study was conducted as a part of a necessary transition of care delivery at a tertiary care institution in order to re-establish urological elective surgery. We triaged all urological elective surgeries with the MeNTS instrument and proposed a cutoff value of 45 points to avoid complications in the COVID-19 crisis while resuming elective procedures. Results A total of 91 patients awaiting elective urological surgery pending to be rescheduled were identified. Their median age was 60.5 years old (interquartile range [IQR]: 46­93). Twenty-five patients were American Society of Anesthesiologists (ASA) class I, 51 (56%) were class II, and 12 (13%) were class III. The median MeNTS score was 42 points (IQR: 36­59). Twenty-nine patients had aMeNTS score>45 and were advised to postpone their surgery. Sixty-two had a score 45 and were gradually rescheduled. Conclusions The present study may have practical implications regarding the selection of urological elective surgeries in the challenging health care situation caused by the COVID-19 pandemic. Our real-life data showed us that 32% of our procedures must be postponed, and 68% could be carefully considered and gradually rescheduled for surgery.

Introducción El coronavirus del síndrome de dificultad respiratoria aguda 2 (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2, en inglés) causa la llamada enfermedad por coronavirus 2019 (coronavirus disease 2019, COVID-19, en inglés) que ha generado la pandemia más grande en el último siglo, y ha llevado a una crisis en el sistema de salud a nivel mundial. El objetivo de este artículo es reportar la utilización del sistema médicamente necesario, sensible al tiempo (medically necessary, time-sensitive, MeNTS, en inglés) para gradualmente reanudar la cirugía urológica programada durante la pandemia. Metodos Este estudio se llevó a cabo como parte de una transición necesaria en la atención en salud para restablecer la cirugía urológica programada. Clasificamos a todos los pacientes utilizando el instrumento MeNTS, y arbitrariamente propusimos un punto de corte de 45 puntos, dinámico de acuerdo con el momento y la situación de la pandemia. Resultados Un total de 91 pacientes en espera de cirugía urológica programada fueron identificados. La mediana de edad fue de 60.5 años (rango intercuartil [RIC]: 46 a 93 años). En total, 25 (27.4%) pacientes eran clase I en la clasificación de la Sociedad Americana de Anestesiólogos (American Society of Anesthesiologists, ASA), 51 (56%) eran ASA II, y 12 (13%), ASA III. La mediana del puntaje del MeNTS fue de 42 puntos (RIC: 36 a 59). En total, 29 pacientes tuvieron un puntaje de MeNTS mayor a 45 puntos, y se les recomendó posponer su cirugía electiva; 62 (68%) tuvieron un puntaje ≤ 45 puntos, y se reprogramaron gradualmente a partir del 1ro de mayo de 2020. Conclusiones Este estudio puede tener varias implicaciones practicas a la hora de seleccionar pacientes para reprogramar su cirugía urológica electiva durante situaciones desafiantes para los sistemas de salud, como la pandemia por COVID-19. Nuestros datos de la práctica clínica real muestran que el 32% de los procedimientos se deben posponer, y el 68% pueden considerarse cuidadosamente para ser reprogramados gradualmente.

Síndrome compartimental bilateral de pierna tras posición de litotomía prolongada: presentación de un caso clínico / Bilateral leg compartment syndrome after prolonged lithotomy position: clinical case report

INTRODUCCIÓN: El síndrome compartimental es una complicación infrecuente pero severa que puede aparecer ante una posición de litotomía prolongada y el uso de perneras. OBJETIVO: Presentar un caso de síndrome compartimental bilateral tras posición de litotomía prolongada asociada con el uso de perneras. MATERIAL Y MÉTODOS: Paciente varón de 43 años sometido a una cirugía urológica en posición habitual de litotomía durante un periodo de 6 horas. A las 2 horas de finalizar la cirugía, el paciente presentó dolor intenso y endurecimiento de compartimento anterior y lateral de ambas piernas, junto con una elevación de la creatina quinasa sérica (valor inicial de 109 U/L que se elevó hasta 7.689 U/L a las 12 horas) y una imposibilidad para la flexión dorsal pasiva de ambos tobillos. El paciente no sentía dolor en el resto de los compartimentos. RESULTADOS: Ante la sospecha de un síndrome compartimental anterolateral, se realizó fasciotomía bilateral urgente, y se observó una disminución de la perfusión muscular y mejoría de la misma tras apertura de la fascia. Se realizaron curas periódicas cada 48 horas, y se observó viabilidad del tejido hasta su cierre definitivo a los 4 días. A las 2 semanas, el paciente presentó fatiga ligera para la deambulación sin ayuda, con tumefacción en el compartimento lateral de ambas piernas. A los 10 meses de evolución, el paciente caminaba sin ayuda y con función muscular completa. CONCLUSIONES: El conocimiento de la asociación del síndrome compartimental y la cirugía laparoscópica prolongada es esencial para un diagnóstico precoz y un tratamiento quirúrgico inmediato, para evitar graves secuelas. Los buenos resultados de nuestro paciente se deben a la rápida actuación, ya que normalmente se suele demorar. Para evitar su aparición o disminuir su incidencia, la posición de litotomía debería limitarse a aquellos momentos de la cirugía en los que sea imprescindible, modificando la posición de las piernas cada dos horas en caso de cirugías prolongadas, para prevenir dicha complicación.

Compartment syndrome is a rare but severe complication resulting from a prolonged lithotomy position and the use of leg loops. PURPOSE: To present a case of bilateral compartment syndrome after prolonged lithotomy position associated with the use of leg loops. METHODS: A 43-year-old man underwent urological surgery in the usual lithotomy position for a 6-hour period. Two hours after the end of the surgery, the patient presented severe pain and stiffening of the anterior and lateral compartments of both legs, elevated serum creatine kinase levels (the baseline value of 109 U/L increased to 7,689 U/L at 12 hours), and inability for passive dorsiflexion of both ankles. The patient reported no pain in the other compartments. RESULTS: Suspicion of an anterolateral compartment syndrome resulted in an urgent bilateral fasciotomy; muscle perfusion was decreased, and it improved after fascial opening. Dressings were changed every 48 hours, and tissue viability was observed until the final closure at 4 days. At two weeks, the patient presented slight fatigue when walking with no assistance, in addition to swelling in the lateral compartment of both legs. Ten months after surgery, the patient walked with no assistance and with complete muscle function. CONCLUSION: Knowledge of the association between compartment syndrome and prolonged laparoscopic surgery is essential for an early diagnosis and immediate surgical treatment to avoid serious sequelae. In our patient, the good outcomes resulted from quick action, since diagnosis is often delayed. Limiting the lithotomy position to those surgical moments in which it is essential and changing the position of the legs every 2 hours during prolonged procedures can reduce the occurrence and incidence of compartment syndrome, preventing this complication.

Monopolar versus bipolar transurethral resection of lateral wall-located bladder cancer under obturator nerve block: a single center prospective randomized study

ABSTRACT Introduction: The aim of the present prospective-randomized study was to compare perioperative outcomes and complications of bipolar and monopolar TURBT for lateral wall-located non-muscle invasive bladder cancers (NMIBC) under obturator nerve block (ONB). Patients and Methods: 80 patients who underwent TURBT for lateral wall-located primary bladder tumors under ONB from March, 2016 to November, 2019 were included in the present study. The patients were randomized equally into two groups; monopolar TUR (M-TURBT) and bipolar TUR (B-TURBT). The primary and secondary outcomes were safety (obturator jerk and bladder perforation) and efficacy (complete tumor resection and sampling of the deep muscle tissue). Results: Obturator jerk was detected in 2 patients (5%) in M-TURBT while obturator jerk was not observed during B-TURBT (p=0.494). Bladder perforation was not observed in both groups. All of the patients underwent complete tumor resection. There was no significant difference in muscle tissue sampling (67.5% vs. 72.5%, p=0.626) and thermal tissue damage rates (12.5% vs. 25%, p=0.201). The majority of complications were low-grade and the differences in Clavien grade 1-3 complications between groups were not statistically significant. Conclusion: In the treatment of lateral-wall located NMIBCs, either M-TURBT or B-TURBT can be safely and effectively performed by combining spinal anesthesia with ONB. Even so, it should be taken into consideration that low-grade postoperative hemorrhagic complications may occur in patients who undergo M-TURBT.

False-negative finding in urodynamic study for the chief complaint. Does it interfere with the clinical outcomes for the treatment of SUI or OAB syndromes?

ABSTRACT Purpose: False-negative urodynamic findings may mislead or prevent planned treatments due to unmatched findings with the clinical presentation. We hypothesized that the absence of urodynamic demonstration of SUI or OAB on urodynamics would interfere with clinical outcomes. Materials and Methods: Materials and Methods: We prospectively studied 124 women with (94) or without (30) demonstrable SUI after sling operations. Similarly, 64 women with OAB syndrome with (38) or without (26) demonstrable DO were also compared after treatment with anticholinergic agents. Patients were assessed with the UDI-6 and IIQ-7 questionnaires 3 and 6 months after treatment. Results: Only 76% of SUI patients demonstrated urine leakage during urodynamics. The UDI-6 score was higher in the demonstrable-SUI and demonstrable-DO groups, while the IIQ-7 score was comparable within the incontinence or urgency/frequency groups. Demonstrable and non-demonstrable SUI-operated patients showed similar outcomes. Patients with urgency syndromes with or without demonstrable DO had a similar rate of improvement with anticholinergic therapy. Conclusions: Women with clinical complaints of SUI objectively demonstrated on urodynamics presented the same subjective clinical outcome as those with SUI lacking objective demonstration when measured by the UDI-6 and IIQ-7 questionnaires. Similarly, patients with OAB syndrome with or without demonstrable DO had similar clinical improvement when treated with anticholinergics and measured using the same questionnaires.

Caracterización de pacientes con antecedente de colposuspensión de Burch que consultan en uroginecología / Characterization of patients with a background of Burch colposuspension consulting in urogynecology

INTRODUCCIÓN Y OBJETIVOS: La incontinencia de orina de esfuerzo (IOE) es una patología muy frecuente. El tratamiento estándar corresponde al uso de cintas medio uretrales. Dentro de las técnicas quirúrgicas clásicas se encuentra la colposuspensión de Burch (CSB), poco frecuente en la actualidad. El objetivo de este estudio es describir las características de las pacientes con antecedentes de una CSB que consultan en la unidad de Uroginecología. MÉTODOS: Revisión tipo transversal de los datos ingresados a la unidad de Uroginecología del Hospital Dr. Sótero Del Río desde 2007 al 2019. Análisis descriptivo de los antecedentes de las pacientes con antecedente de CSB. RESULTADOS: Durante el periodo analizado, 63 pacientes presentaban antecedentes de CSB. La edad promedio fue 68 años, 88% eran post menopáusicas, 60% fueron sometidas a histerectomía y 24% a cirugías por prolapso (POP). La paridad promedio fue 3 hijos, 15% tuvieron al menos un parto por fórceps. Un 51% consultó por IOE, 54% por vejiga hiperactiva (VH) y 56% por sensación de bulto o peso. El 38% consultó por incontinencia de orina mixta, 37% por IOE + POP y 41% por VH + POP. 22% fueron reoperadas, 16% por medio de TVT y 6% por TOT. CONCLUSIONES: El antecedente de CSB es infrecuente en nuestra población. Similar a lo descrito en la literatura, más de un 50% de las pacientes consultó por síntomas de recurrencia y por complicaciones como POP y VH. Próximos estudios deberían evaluar si el antecedente de CSB es un factor de riesgo de complicaciones quirúrgicas o recurrencia.

INTRODUCTION AND OBJECTIVES: Stress urinary incontinence (SUI) is a common pathology. The standard treatment corresponds to the mid urethral slings. Among the classic surgical techniques is Burch colposuspension (CSB), currently rare. The objective of this study is to describe the characteristics of the patients with a previous history of CSB who consult in the Urogynecology unit. METHODS: Cross sectional review of the data of all the patients admitted to the Urogynecology unit of the Dr. Sótero Del Río Hospital from 2007 to 2019. Descriptive analysis of the antecedents of the patients with a history of CSB. RESULTS: During the analyzed period, 63 patients had a history of CSB. The average age was 68 years. 88% were postmenopausal, 60% underwent hysterectomy, and 24% underwent prolapse (POP) surgery. The average parity was 3, 15% had at least one forceps delivery. 51% consulted for SUI, 54% for overactive bladder (OAB) and 56% for sensation of lump or weight. 38% consulted for mixed urine incontinence, 37% for SUI + POP and 41% for OAB + POP. 22% were reoperated, 16% through TVT and 6% through TOT. CONCLUSION: The history of CSB is infrequent in our population. Similar to that described in the literature, more than 50% of the patients consulted for recurrence symptoms and complications such as POP and OAB. Future studies should assess whether a history of CSB is a risk factor for surgical complications or recurrence.

Effect of preoperative urodynamic study on urinary outcomes after transobturator sling / Efeito do estudo urodinâmico pré-operatório nos resultados pós-operatórios do sling transobturador

Abstract Objective To evaluate whether performing preoperative urodynamic study influences postoperative urinary symptoms of women with stress urinary incontinence that underwent transobturator sling. Methods Retrospective analysis of patients treated for stress urinary incontinence by transobturator sling from August 2011 to October 2018. Predictor variables included preoperative urodynamic study, age, incontinence severity, body mass index, preoperative storage symptoms and previous anti-urinary incontinence procedure. Outcome variables were postoperative subjective continence status, storage symptoms and complications. Logistic regression after propensity score was employed to compare outcomes between patients who underwent or not pre-operative urodynamic study. Results The present study included 88 patients with an average follow-up of 269 days. Most patients (n = 52; 59.1%) described storage symptoms other than stress urinary incontinence, and 38 patients (43.2%) underwent preoperative urodynamic studies. Logistic regression after propensity score did not reveal an association between urinary continence outcomes and performance of preoperative urodynamic study (odds ratio 0.57; confidence interval [CI]: 0.11-2.49). Among women that did not undergo urodynamic study, there was a subjective improvement in urinary incontinence in 92% of the cases versus 87% in those that underwent urodynamic study (p = 0.461). Furthermore, postoperative storage symptoms were similar between women who did not undergo urodynamic study and those who underwent urodynamic study, 13.2% versus 18.4%, respectively (p = 0.753). Conclusion Preoperative urodynamic study had no impact on urinary incontinence cure outcomes as well as on urinary storage symptoms after the transobturator sling in women with stress urinary incontinence.

Resumo Objetivo Avaliar a influência do estudo urodinâmico pré-operatório nos resultados miccionais pós-operatórios em mulheres com incontinência urinária de esforço submetidas a sling transobturador. Métodos Análise retrospectiva de mulheres com incontinência urinária de esforço submetidas a sling transobturador entre agosto de 2011 e outubro de 2018. As variáveis preditoras pré-operatórias, entre outras, foram a realização do estudo urodinâmico, gravidade da incontinência e sintomas urinários de armazenamento. As variáveis de desfecho pós-operatórias foram o status subjetivo da continência, sintomas de armazenamento urinário e complicações cirúrgicas. A regressão logística após o escore de propensão foi empregada para comparar os resultados entre os pacientes que foram submetidos ou não ao estudo urodinâmico pré-operatório. Resultados Foram incluídas no presente estudo 88 pacientes com um seguimento médio de 269 dias. A maioria das pacientes apresentava sintomas miccionais de armazenamento (n = 52; 59,1%) concomitantes à incontinência urinária de esforço. Um pouco menos da metade das pacientes (n = 38; 43,2%) foram submetidas a estudo urodinâmico pré-operatório. A regressão logística após o escore de propensão não revelou associação entre os resultados de continência urinária e a realização de estudo urodinâmico pré-operatório (odds ratio 0,57; intervalo de confiança [IC]: 0,11-2,49). Além disso, os sintomas de armazenamento urinário pós-operatórios foram similares entre as pacientes que não realizaram e aquelas que realizaram o estudo urodinâmico, 13,2% e 18,4% respectivamente (p = 0,753). Conclusão O estudo urodinâmico pré-operatório não teve impacto nos resultados de continência urinária, bem como nos sintomas de armazenamento urinário após o sling transobturatório.

Complicaciones en posoperatorio inmediato de cirugía uretral anterior; ¿existe relación con la recaída? / Early complications in urethral anterior surgery; is there any relationship with recurrence?

INTRODUCCIÓN/OBJETIVO: La estrechez uretral puede causar síntomas miccionales, dolor, disfunción vesical y eyaculatoria. La tasa de complicaciones en uretroplastía anterior es baja. El principal objetivo es evaluar complicaciones del posoperatorio (pop) inmediato (dentro de los 30 días pop). El objetivo secundario es valorar la relación entre complicaciones y la tasa de recaída. MATERIALES Y MÉTODO: Se realizó una revisión retrospectiva de las uretroplastías anteriores realizadas entre octubre del 2012 y junio del 2017. Se valoró: reinternación, reingreso a cirugía, infarto agudo de miocardio, tromboembolismo de pulmón, trombosis venosa profunda, óbito, infecciones, dehiscencia de herida, hematomas, sangrados, etc. Se definió recaída a la necesidad de realizar cualquier instrumentación uretral secundaria a la uretroplastía. Las variables se analizaron estadísticamente con Chi square y Mann-Whitney U test. RESULTADOS: Se incluyeron 92 pacientes, con un seguimiento mínimo de 12 meses. Las edades fueron de 18 a 88 años (mediana, 61,5 años). En 58 pacientes, se utilizaron transferencia de tejidos (27 injertos y 31 colgajos). La longitud de la estrechez fue desde 1-15 cm (media, 3,25 cm). La iatrogénica (56%) fue la etiología más frecuente. 56 pacientes (63%) tenían tratamientos previos. La tasa de complicaciones pop inmediato fue del 32%, las infecciones fueron las más frecuentes. Según Clavien, se clasificaron: I: 40%; II: 47%; III: 10%; IV: 3%. Hubo 17 recaídas (18%), 13 dentro de los primeros 6 meses del pop. De los pacientes que presentaron complicaciones, recayó el 23%; solo 16% de los que no las presentaron (p: 0,4). Aquellos pacientes con complicaciones graves presentaron mayor tasa de recaída (p: 0,2). CONCLUSIÓN: La tasa de complicaciones pop inmediata de uretroplastía anterior fue de 32%; las infecciones fueron las más frecuentes. La mayoría fue Clavien I y II. La recaída fue mayor en aquellos pacientes que sufrieron complicaciones en pop inmediato.

INTRODUCCION/OBJECTIVE: Urethral stenosis can cause mictional symptoms, pain, bladder dysfunction and ejaculatory problems. Complications rate in anterior urethroplasty is low. Main objetive is to evaluate early post operatory complications Secondary objetive is to assess the relationship between complications and recurrence rate. MATERIALS AND METHODS: We performed a restrospective review of our anterior urethroplasty database between October 2012 and June 2017. We recorded: patients readmission, return to operating room, acute myocardial infarction, pulmonary embolism, deep venous thrombosis, death, infections, wound dehiscense, hematomas, bleedings, etc. We defined recurrence as any urethral instrumentation after urethroplasty. Variables were analyzed using Chi Square and Mann Whitney U test. RESULTS: 92 patients were included in the study with at least 12 months follow up. Age range was between 18-88 years. (median 61,5 years) Substitution urethroplasty were performed in 58 patients (grafts 27 and flaps 31) Urethral stenosis lenght range was between 1 and 15 cm (mean 3,25cm) Most frequent cause of urethral stenosis was iatrogenic (56%) 56 patients underwent previous treatment (63%) Complication rate in early post operative period was 32%, most of them infections. Clavien clasiffication: I: 40%; II: 47%; III: 10%; IV: 3%. There were 17 recurrences (18%), 13 during the first 6 months after surgery. 23 % of patients with complications had recurrence and only 16% of patients without, had recurrence (p:0,4) Patients with serious complications had greater recurrence rate (p: 0,2) CONCLUSION: Recurrence rate in early complications of anterior urethroplasty was 32%, most of them infections. Clavien I and II are the most frequent. Recurrence was greater in patients who suffered early complications

Factores asociados a complicaciones infecciosas posoperatorias en pacientes con urolitiasis / Factors Associated with Postoperative Infectious Complications in Patients with Urolitiasis

Introducción Se encuentran múltiples tratamientos para la urolitiasis, los cuales dependen en gran medida del tamaño y la ubicación de la litiasis. Dentro de las opciones terapéuticas se encuentran la expulsión activa, utilización de ondas de choque, las ureterolitotomias, y procedimientos endoscópicos, todas con diferentes tasas de efectividad y riesgo de complicación infecciosa. El objetivo del estudio fue evaluar los factores asociados a la complicación infecciosa posterior al procedimiento urológico en pacientes con urolitiasis. Métodos Estudio de casos y controles anidado a una cohorte de pacientes programados para procedimientos urológicos como tratamiento para la urolitiasis durante el periodo 2015 - 2019. Se consideraron casos, aquellos con complicación infecciosa posoperatoria dentro de los 30 días posteriores al procedimiento urológico. Los controles se seleccionaron de la cohorte inicial y fueron los pacientes que no presentaron complicación infecciosa. Resultados En el periodo de estudio, fueron atendidos 350 pacientes con litiasis renal, con un total de 1258 cálculos. El número promedio de cálculos por paciente fue de 3,59; la prevalencia de litiasis bilateral fue del 57%, siendo similar la cantidad de cálculos en el lado izquierdo (promedio = 1,4) y en el derecho (promedio = 1,44). La tasa de complicación infecciosa posquirúrgica fue del 4% (n= 14) y se asoció con la presencia de al menos un cálculo mayor de 20 mm (OR 4,49 IC95% 1,39­14,52). Conclusión La tasa de complicación infecciosa posoperatoria en pacientes con urolitiasis y programados para procedimientos urológicos es baja. Una longitud del cálculo mayor de 20 mm es un factor asociado a la infección posoperatoria.

Introduction There are multiple treatments for urolithiasis, which largely depend on the size and location of the lithiasis. Among the therapeutic options are active expulsion, use of shock waves, urolithotomies, and endoscopic procedures, all with different rates of effectiveness and risk of infectious complications. The objective of the study was to evaluate the factors associated with the infectious complication after the urological procedure in patients with urolithiasis. Methods Case-control study nested in a cohort of patients scheduled for urological procedures as treatment for urolithiasis during the period 2015-2019. Cases were considered, those with postoperative infectious complication within 30 days after the urological procedure. The controls were selected from the initial cohort and were the patients who did not present an infectious complication. Results During the study period, 350 patients with kidney stones were treated, with a total of 1258 stones. The average number of stones per patient was 3.59; the prevalence of bilateral lithiasis was 57%, the number of stones being similar on the left side (average = 1.4) and on the right (average = 1.44). The postoperative infectious complication rate was 4% (n = 14) and was associated with the presence of at least one stone larger than 20 mm (OR 4.49 95% CI 1.39 - 14.52). Conclusion The postoperative infectious complication rate in patients with urolithiasis and scheduled for urological procedures is low. A stone length greater than 20 mm is a factor associated with postoperative infection.

Impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists

ABSTRACT Objectives To evaluate the impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists during the month of April 2020. Materials and Methods A 39-question, web-based survey was sent to all urologist members of the Brazilian Society of Urology. We assessed socio-demographic, professional, health and behavior parameters. The primary goal was to evaluate changes in urologists' clinical practice and income after two months of COVID-19. We also looked at geographical differences based on the incidence rates of COVID-19 in different states. Results Among 766 urologists who completed the survey, a reduction ≥ 50% of patient visits, elective and emergency surgeries was reported by 83.2%, 89.6% and 54.8%, respectively. An income reduction of ≥ 50% was reported by 54.3%. Measures to reduce costs were implemented by most. Video consultations were performed by 38.7%. Modifications in health and lifestyle included weight gain (32.9%), reduced physical activity (60.0%), increased alcoholic intake (39.9%) and reduced sexual activity (34.9%). Finally, 13.5% of Brazilian urologists were infected with SARS-CoV-2 and about one third required hospitalization. Urologists from the highest COVID-19 incidence states were at a higher risk to have a reduction of patient visits and non-essential surgeries (OR=2.95, 95% CI 1.86 - 4.75; p< 0.0001) and of being infected with SARS-CoV-2 (OR=4.36 95%CI 1.74-10.54, p=0.012). Conclusions COVID-19 produced massive disturbances in Brazilian urologists' practice, with major reductions in patient visits and surgical procedures. Distressing consequences were also observed on physicians' income, health and personal lives. These findings are probably applicable to other medical specialties.