Tunable tension tape versus transobturator tape in treatment of stress urinary incontinence in women: Randomized controlled trial.

INTRODUCTION: The synthetic mid-urethral slings are currently considered to be the most widely used technique for the surgical treatment of stress urinary incontinence (SUI). The most challenging aspect of the existing approaches is to achieve the optimal tension of the sling which treatment results are directly dependent on. To solve this problem, sling systems enabling an adjustment of the tension in the early postoperative period were created. A comparative study of the effectiveness and safety of such a system and a nonadjustable sling seems to be a relevant task. MATERIALS AND METHODS: A double-blind, randomized, multicenter trial enrolled 320 patients with a mean age of 55.2 ± 11.2 years and confirmed SUI. Patients were randomized into two groups: the first group underwent a standard synthetic suburethral sling (transobturator tape [TOT]) procedure and the second group underwent a tunable tension tape sling (TTT) procedure. All patients underwent stress test, uroflowmetry and ultrasound scan to determine the postvoid residual volume. Urinary Distress Inventory Short Form 6, International Consultation on Incontinence Questionnaire-Short Form, Pelvic Organ Prolapse Incontinence Sexual Questionnaire 12 questionnaires were used to assess subjective efficacy. RESULTS: Enhancement of prosthesis tension in the second group was required in 44 (28%) patients. Due to the possibility of tightening of the sling in the early postoperative period, the operation was effective in 143 (89%) patients in the adjustable sling group and in 109 (68%) patients in Group 1, p < 0.001. Loosening of the sling tension was performed in 25 (16%) patients in Group 2. The signs of obstructive voiding symptoms at the follow-up time of 36 months remained in Group 1 in 13 (8%) patients. Subjective satisfaction with treatment on the PGI-I scale was higher in Group 2: 100 (62%) versus 132 (82%), p < 0.001. CONCLUSION: A synthetic mid-urethral TTT is superior to a standard nonadjustable sling in long-term effectiveness and safety.

Ergonomic Considerations in Urologic Surgery.

PURPOSE OF REVIEW: This paper aims to discuss the various work-related musculoskeletal disorders (WRMDs) among urologists and provide an overview of the latest recommendations to improve awareness of ergonomic principles that can be applied in the operating room, with special consideration of challenges faced during pregnancy. RECENT FINDINGS: Urologists suffer from a large burden of WRMDs. The main drivers of pain associated with the various surgical approaches include repetitive movements, static and awkward body positions, and the use of burdensome equipment. Pregnant surgeons are at an even greater risk of WRMDs and face high rates of pregnancy complications. Laparoscopy, endoscopy, robot-assisted surgeries, and open surgeries present unique ergonomic challenges for the practicing urologist. Proper posture and equipment use, optimal operating room setup, intraoperative stretching breaks, and an emphasis on teaching ergonomic principles can reduce the risk of WRMDs. Surgeons are also at increased risk of WRMDs during pregnancy but may continue to operate while taking measures to limit physical exertion and fatigue. Improving awareness of and incorporating ergonomic principles early in a urologist's career may reduce the risk of injury and improve operative performance and longevity.

[Analysis of surgical complications of reconstructive plastic surgery according to the ClavienDindo classification].

INTRODUCTION: The systematization of surgical complications has long been a serious problem since different types of surgical procedures have specific complications, in addition to general consequences. Created in 1992 and improved in 2004, the Clavien-Dindo classification was successfully validated in surgical centers in different countries and recognized as an important tool for the qualitative assessment of surgical complications. AIM: To improve reconstructive procedures by systematizing complications based on the ClavienDindo classification. MATERIALS AND METHODS: The results of substitution ileocystoplasty in 95 patients with contracted bladder due to tuberculosis and other diseases are presented. In 50 (52.6%) cases, the length of the bowel segment was 30-35 cm (group 1, main), while in 45 patients (47.4%) a segment of 45-60 cm was chosen (group 2, control). RESULTS: Early complications of grade II developed in 11 (22.0%) patients in the group 1 and in 13 (28.9%) in group 2, while grade III in 5 (10.0%) and 6 (13.3%) cases, respectively. Complications of IIIb grade were seen among patients of the main group in 9 (18.0%) cases compared to 12 (26.7%) in the control group. Severe complications of IVa and IVb grades were documented with the same frequency in both groups, in one case each. Complications of V grade (death) were recorded only in the group 2. Late complications were registered in 63 out of 94 patients. In group 1, there were 26 complications (16 somatic and 10 surgical), while in group 2, a total of 37 complications (24 somatic and 13 surgical) were seen, which indicates a significant higher rate in the control group (p<0.05). In group 1, transurethral resection of urethral-enteric anastomosis and ureteral reimplantation were performed less frequently than in group 2, while transurethral resection of the prostate was done with the same frequency. At the same time, percutaneous nephrostomy was required more often in the group 1 (6% vs. 4.5% in the group 2). After intestinal cystoplasty with a shortened fragment of the ileum, the voiding volume was significantly lower but corresponded to the physiological value (more than 150 ml). In this group, there was sufficient capacity of neobladder with a minimum amount of residual urine, effective emptying, satisfactory urinary continence, and low intraluminal pressure, which contributes to the protection of kidneys from reservoir-ureteral-pelvic reflux. The serum chloride level after surgery was 106.2+/-0.4 in the group 1 compared to 109.7+/-0.3 in the group 2, while base excess was -0.93+/-0.3 and -3.4+/-0.65, respectively (p<0.05). CONCLUSION: Early serious postoperative complications according to Clavien-Dindo were registered with approximately the same frequency in both groups, while late complications developed significantly more often in the group 2. The urodynamic parameters of a neobladder formed from ileum segment of 30-35 cm are satisfactory. In addition, a decrease in the length of the intestinal segment prevents the development of hyperchloremic metabolic acidosis.

Vascular hitch for paediatric pelvi-ureteric junction obstruction with crossing vessels: institutional analysis and systematic review with meta-analysis.

OBJECTIVE: To compare the outcomes for laparoscopic vascular hitch (VH) and dismembered pyeloplasty in patients with pelvi-ureteric junction obstruction (PUJO) secondary to crossing vessels (CV). PATIENTS AND METHODS: Patients who underwent laparoscopic management of CV at our institution were identified between 2008 and 2020. Baseline characteristics and outcome measures were compared between those who underwent VH and those who underwent dismembered pyeloplasty. Those who underwent VH were selected intraoperatively by identifying CV in the absence of intrinsic obstruction by assessing resolution of hydronephrosis after cranially displacing the CV away from the PUJ, followed by intraoperative fluid bolus and diuretic test. In addition, a systematic search and meta-analysis were performed in June 2020 (International Prospective Register of Systematic Reviews [PROSPERO] ID CRD42020195833). RESULTS: A total of 20 patients underwent VH and 74 dismembered pyeloplasty. On multivariate analysis, VH was associated with: shorter operative time (P = 0.001; odds ratio [OR] 0.455, 95% confidence interval [CI] 0.294-0.705) and length of stay (P = 0.012; OR 0.383, 95% CI 0.183-0.803), lower use of stents (P < 0.001; OR 0.024, 95% CI 0.004-0.141) and opioid administration (P = 0.005; OR 0.157, 95% CI 0.044-0.567). From our literature search, 194 records were identified and 18 records were included (three comparative and 16 non-comparative). Meta-analysis of the comparative studies and our institutional data showed similar success rates (relative risk [RR] 1.77, 95% CI 0.33-9.52) and complication rates (RR 0.75, 95% CI 0.20-2.82). VH was associated with shorter operative time (standardised mean difference [SMD] -1.65, 95% CI -2.58 to -0.72 h) and hospital stay (SMD -1.41, 95% CI -2.36 to -0.47 days). The VH success rates ranged from 87.5% to 100% in the identified studies. Failure of VH was associated with unrecognised concomitant intrinsic obstruction in addition to CV. CONCLUSIONS: A VH, for well-selected patients with CV without concomitant intrinsic obstruction, offers a high success rate with shorter operative times.

Synthetic mid-urethral slings for the treatment of stress urinary incontinence in women with neurogenic lower urinary tract dysfunction: a systematic review.

INTRODUCTION AND HYPOTHESIS: The aim of our study was to evaluate the efficiency and safety of synthetic mid-urethral slings (sMUS) for the treatment of stress urinary incontinence (SUI) in women with neurogenic lower urinary tract dysfunction (NLUTD). METHODS: A systematic review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. MEDLINE, Embase and Cochrane controlled trials databases were systematically searched from January 1995 to April 2021. Studies including adult women with NLUTD who had a sMUS for SUI were considered for inclusion. Primary outcome was success of the surgery according to study criteria. Secondary outcomes were complications, especially de novo urgency, urinary retention, tape exposure and revision for complications. RESULTS: A total of 752 abstracts were screened and 9 studies were included, representing 298 patients. The mean age was 52 years and median follow-up was 41.3 months. sMUS insertion was successful in 237 patients (79.5%). The median rate of de novo urgency was 15.7% (range 8.3-30%). In patients with spontaneous voiding, the median rate of retention was 19.3% (range 0-46.7%) and 21 out of 26 patients required intermittent self-catheterisation. Four cases of tape exposure were reported, and 8 patients underwent a revision for complications. CONCLUSIONS: This review suggests that sMUS might offer interesting success rates and acceptable morbidity and could be considered for the treatment of SUI in women with NLUTD. Further studies are required to define which patients would be more likely to benefit from this intervention, as well as its place among the other surgical treatments for SUI.

[Complications in urological surgery: Bladder surgery]. / Les complications chirurgicales en urologie adulte : chirurgie de la vessie.

CONTEXT-OBJECTIVE: The management of bladder tumors is based on two major interventions, the risks of complications of which can be significant. The objective of this work is to provide an update on the complications related to bladder surgery, to detail the preventive measures and management strategies in practice. METHODS: Bibliographic search using Medline bibliographic database (Pubmed) using the following keywords: transurethral resection of the bladder, cystectomy, neobladder, Bricker, complications, anastomotic strictures. RESULTS: Trans-urethral resection of the bladder (TURB) essentially exposes to the risk of hemorrhage (2 to 4%) and bladder perforation (1 to 3%). Total cystectomy is associated with significant morbidity and mortality, despite recent technical advances. The most frequent early complications are ileus (23 to 30%) and infectious complications (29 to 38%). Late complications included by functional complications (urinary and sexual), anastomotic strictures (7 to 12%), metabolic complications of continent derivation (25 to 46%) and stomial complications in case of non-continent derivation. The management of complications is well codified. It is however essential to anticipate and put in place preventive measures, especially for infectious and thromboembolic complications, including an exhaustive pre-operative assessment, prehabilitation of the patient and enhanced recovery after surgery. CONCLUSION: Preventing, analyzing and understanding complications in bladder surgery is essential to reduce mortality and morbidity.

Impact of detrusor underactivity on the postoperative outcomes after benign prostatic enlargement surgery.

INTRODUCTION AND OBJECTIVE: Previous studies suggest that men with detrusor underactivity (DUA) have less symptomatic improvement after prostate surgery than those with normal contractility, but the available data is controversial. We aim to determine the differences in functional outcomes of patients with or without DUA who underwent photovaporization of the prostate (PVP) with GreenLight™180 W XPS. METHODS: A cohort of patients with lower urinary tract symptoms (LUTS) who underwent PVP between 2012 and 2019 was evaluated. Patients were stratified according to bladder contractility index (BCI). DUA was defined as BCI < 100. Those with normal contractility (BCI = 100-150) were included in Group 1, and those with DUA (BCI < 100) in Group 2. Primary outcomes were symptomatic improvement defined as a reduction ≥ 4 points in the international prostate symptom score (IPSS) and a reduction of at least 1 point in the quality of life (IPSS-QoL). Complications according to the Clavien-Dindo classification were also recorded. RESULTS: A total of 271 patients who underwent PVP with GreenLight™ and met the inclusion criteria were assessed. Group 1 included 158 patients, while Group 2 included 113 patients. Mean follow-up was 24 months. Patients with normal contractility had a median reduction of 11 points (18.9 ± 8.0 to 7.1 ± 7.0) while patients with DUA had a median reduction of 10 points (19.3 ± 6.9 to 8.6 ± 8.4) in IPSS score; these differences were not statistically significant (p = .20). Patients in Group 1 had a 1.92 higher chance of QoL improvement (OR, 1.92; 90% CI, 1.10-3.37), compared to those in Group 2. Failure to void after PVP was most frequently reported in DUA patients (OR, 2.36; 90% CI, 1.26-4.43). Sociodemographic characteristics, intraoperative complications, conversion rates, hospital stay, and urinary catheterization time were similar between groups. CONCLUSIONS: Patients with LUTS, regardless of their BCI, improved their symptoms after PVP according to the IPSS. However, patients with DUA were more likely not to improve their QoL after the procedure and had a higher chance of failure to void in the immediate postoperative period. An appropriate counseling process with the patient discussing possible outcomes based on these findings should be encouraged.

Is antibiotic prophylaxis necessary in mid-urethral sling surgery?

INTRODUCTION AND HYPOTHESIS: Antibiotic prophylaxis is commonly used when implanting a mid-urethral sling (MUS) for female stress urinary incontinence. Use of antibiotics may lead to adverse events and the development of antibiotic resistance. This study compared a variety of outcomes after MUS surgery with and without antibiotic prophylaxis using data from the national Norwegian Female Incontinence Registry. METHODS: Preoperative and 6-12 months postoperative subjective and objective data from 28,687 patients who received MUS surgery from 1998 through 2017 were extracted from the registry. Categorical outcomes were compared between women with or without antibiotic prophylaxis using chi-square test for independence. Primary outcome was incidence of postoperative surgical site infection (SSI). Secondary outcomes were incidence of tape exposure, de novo or persistent urgency urinary incontinence, postoperative pain > 3 months, subjective and objective cure rates, and patient satisfaction. RESULTS: Antibiotic prophylaxis was used in 9131 and not used in 19,556 patients. SSIs and prolonged postoperative pain occurred significantly more often without antibiotic prophylaxis. Subjective and objective cure rates were significantly higher and tape exposures significantly lower in women not receiving prophylactic antibiotics. There were no significant differences in other outcomes. CONCLUSIONS: Antibiotic prophylaxis resulted in fewer women developing postoperative infections or prolonged postoperative pain after MUS surgery, but did not offer protection against tape exposure. The differences in cure rates were small and probably without clinical relevance. If a small increase in surgical site infections is accepted, the routine use of antibiotic prophylaxis can probably be omitted.

[Complications of mid-urethral sling - A review from the Committee for Female Urology and Pelviperineology for the French Association of Urology]. / Complications des bandelettes sous urétrales : une revue de la littérature par le Comité d'urologie et pelvipérinéologie de la femme de l'Association française d'urologie.

INTRODUCTION: Placement of a mid-urethral sling is the gold standard in the surgical management of stress urinary incontinence in women in France. The cure rate of this material is no longer to be demonstrated, but the per- and post-operative complications are currently the subject of a growing controversy not only in Europe but also across the Channel and across the Atlantic, having led to the modification of operative indications. In France, recommendations are also evolving with a stricter framework for indications for surgery by multidisciplinary consultation meeting and an obligation for postoperative follow-up in the short and long term. OBJECTIVES: In this context, CUROPF realized a review of the literature bringing together the available scientific evidence concerning the occurrence of per- and post-operative complications relating to the installation of mid urethral sling. The bibliographic search was carried out using the Medline database and 123 articles were selected. RESULTS: Analysis of the data highlights various complications, depending on the implanted material, the patient and the indication for surgery. The retro-pubic mid urethral sling provides more bladder erosion during surgery (up to 14%), more suprapubic pain (up to 4%) and more acute urinary retention (up to 19,7%) and postoperative dysuria (up to 26%). The trans obturator mid-urethral sling is responsible for more vaginal erosion during the operation (up to 10,9%), more lower limb pain of neurological origin (up to 26,7%). The risk of developing over active bladder is similar in both procedures (up to 33%). But these risks of complications must be balanced by the strong impact of urinary incontinence surgery on the overall quality of life of these women. CONCLUSION: Thus, surgical failure and long term complications exist but should not limit the surgical management of stress urinary incontinence with mid urethral tape. Women should be treated with individualized decision-making process and long-term follow -up is necessary.

Associated measures to antibiotic prophylaxis in urology.

PURPOSE: Urinary tract infections are amongst the most frequent nosocomial infections followed by surgical site infections (SSI). Antibiotic prophylaxis is only one way to reduce the risk of post-operative infection. Our aim was to establish a review of the literature on measures to reduce post-operative infections outside antibiotic prophylaxis. METHODS: We performed a review of the literature in February 2019 using Medline database to identify relevant studies published in the last 10 years. We arbitrarily decided to fix our limit to the 10 last years considering that the resistance rate of bacteria to antibiotics and the surgical technics evolve over time. This search identified 229 studies. We included 53 studies selected upon the title or the abstract. RESULTS: Forty-four studies were finally included. We evaluated the efficacy to prevent SSI by skin antisepsis, surgical hand hygiene and technique, type of surgeons' caps, preservation of normothermia, hair removal, increased oxygen delivery, wound protectors, bathing, normoglycemia and immunonutrition. CONCLUSIONS: Antibiotic prophylaxis represents one way to prevent SSI but various other measures should be known and considered by anesthesiologists and surgeons. Some measures to reduce post-operative infections are not clearly established yet and more studies are needed.

Complications after active stone removal.

PURPOSE OF REVIEW: Active stone removal has been entirely revolutionized in the past decades. Smaller instruments, scope and laser technology advancements and novel lithotripter modalities have entirely changed the way urological surgeons treat stones. Nevertheless novel technologies may lead to different and difficult to manage complications. Accurate knowledge of indications, limitations and technical details of these novel modalities can significantly decrease complication rates. The purpose of this review is to provide the most recently acquired knowledge to decrease patient's morbidity after active stone removal. RECENT FINDINGS: Complications of active stone removal are well known for many years, nevertheless novel technologies in stone management can substantially differentiate their rates. Minimal invasive techniques are becoming even more minimal which reflects on the complications. SUMMARY: Mastering the novel techniques in active stone removal and knowing their inherent limitations, in association with the recognition of predisposing factors and preventing measures have led to a highly acceptable low complication rate. Further refinements and technical improvement will reduce even more the complication incidence in the future.

Safety and efficacy of en bloc transurethral resection versus conventional transurethral resection for primary nonmuscle-invasive bladder cancer: a meta-analysis.

BACKGROUND: The purpose of this meta-analysis is to compare the safety and efficacy of en bloc transurethral resection of bladder tumor (EBRT) versus conventional transurethral resection of bladder tumor (CTURBT). METHODS: We performed a meta-analysis of relevant articles through November 2019 using PubMed, Embase, and Cochrane Central Register to compare the safety and efficacy of EBRT versus CTURBT. The main endpoint included the operation time (OT), hospitalization time (HT), catheterization time (AT), perioperative period complications, bladder detrusor muscle found in the specimen, the residual tumor on the base, the ratio of the same site recurrence, and 12/24/36-month recurrence rate. Cochrane Collaboration's Revman software, version 5.3, was used for statistical analysis. RESULTS: A total of 19 studies with 2651 patients were included, 1369 underwent EBRT and 1282 underwent CTURBT. Patients treated with EBRT had a significantly lower AT, HT, obturator nerve reflex, bladder perforation, bladder irritation, postoperative complications, and 24-month recurrence rate than those who underwent CTURBT. While no significant difference was found in terms of OT, the ratio of bladder detrusor muscle found in the specimen, the residual tumor on the base, 12-month recurrence rate, 36-month recurrence rate, and the ratio of the same site recurrence. In mitomycin subgroup, EBRT was superior to CTURBT in terms of 12/24-month recurrence rate. Similarly, in the prospective subgroup and retrospective subgroup, EBRT had a lower 24-month recurrence rate than CTURBT. However, no significant difference was found in the low, intermediate, and high-risk group in the light of 12-36-month recurrence rate. CONCLUSIONS: Based on the included 19 articles, EBRT had a significantly lower AT, HT, intraoperative and postoperative complications, and 24-month recurrence rate than those treated with CTURBT. Well-designed randomized controlled trials were needed to reevaluate these outcomes. TRIAL REGISTRATION: This meta-analysis was reported in agreement with the PRISMA statement and was registered on PROSPERO 2019 CRD42019121673.

Emergency Surgery in Urology during the COVID-19 Pandemic.

Proposal: To highlight the indications for emergency surgery during the 2019 Coronavirus pandemic (COVID-19) that support recommendations published in mid-March 2020 by the American Confederation of Urology on its website. MATERIALS AND METHODS: A bibliographic search was conducted in PubMed and Cochrane Library to perform a non-systematic review, using key words: Urology, Emergency and COVID-19, to determine recommendations for patients that should receive emergency care due to urological pathology. RESULTS: The main recommendations and protocols in the management of different urological emergencies during the COVID-19 pandemic are reviewed and discussed. CONCLUSIONS: We are living a new condition with the COVID-19 pandemic, which obliges urologists to conform to the guidelines that appear on a daily basis formulated by multidisciplinary surgical groups to manage urological emergencies. Consequently, in this time of health crisis, we must adapt to the resources available, implementing all biosecurity measures to protect patients and all health personnel who are in charge of patient management.

[Short-term evaluation of Altis® single-incision sling in women stress urinary incontinence]. / Évaluation à court terme de la mini-bandelette Altis® dans l'incontinence urinaire d'effort chez la femme.

INTRODUCTION: Midurethral slings are the main surgical treatment of stress urinary incontinence. Altis is a minimally invasive single-incision sling system. The aim of this study is to report the safety and efficacity results during a year of follow up. MATERIALS AND METHODS: This single-centre and retrospective study has been performed in a university hospital, between February 2015 and May 2018. We included women aged more than 18, complaining a stress urinary incontinence with a urethral hypermobility and positive support maneuvers, who had failed from non surgical treatment. A prospective data collection has been done at the moment of inclusion, peroperative time, at 6 weeks, 6 months and a year after the procedure. The main evaluation criteria was the cure rate at twelve months. RESULTS: Thirty patients were included in our study. The mean age was 45,4±12,9 years old, the mean ICIQ-UI score was 13,5±4,06 and the median pad test was at 12g. Ninety three percent of the procedures were done as ambulatory surgery. The average operating time was at 22,2minutes. Overall, 75% of our patients were objectively cured and 14,2% were in fail of this treatment. CONCLUSION: The short term results show a good efficacity and safety of this procedure. But its place remains to be defined in relation to other techniques, TVT, TOT and non-prosthetic techniques. LEVEL OF EVIDENCE: 3.

3-Dimensional Magnetic Resonance Imaging Guided Pelvic Floor Dissection for Bladder Exstrophy: A Single Arm Trial.

PURPOSE: We determined the safety and efficacy of intraoperative magnetic resonance imaging guided surgical reconstruction of bladder exstrophy for the identification of the urogenital diaphragm fibers and the thickened muscular attachments between the posterior urethra, bladder plate and pubic rami. MATERIALS AND METHODS: Institutional review board and U.S. Food and Drug Administration approval was obtained for the use of Brainlab (Munich, Germany) intraoperative magnetic resonance imaging guided navigation of the pelvic floor anatomy during closure of classic bladder exstrophy and cloacal exstrophy at our institution. Preoperative pelvic 3-dimensional magnetic resonance imaging was obtained 1 day before closure in patients undergoing pelvic osteotomies. Intraoperative registration was performed after preoperative planning with a pediatric radiologist using 5 anatomical landmarks immediately before initiation of surgery. Accuracy of pelvic anatomy identification was assessed by 2 pediatric urological surgeons and 1 pediatric radiologist. RESULTS: In 43 patients with classic bladder exstrophy and 4 patients with cloacal exstrophy closed at our institution, Brainlab technology was used successfully to navigate and guide the dissection of the pelvic floor intraoperatively. In all patients there was 100% accuracy in the correlation of gross anatomical landmarks with 3-dimensional magnetic resonance imaging identified landmarks intraoperatively, and all patients had successful closure without any major complications. CONCLUSIONS: Brainlab intraoperative 3-dimensional magnetic resonance imaging guided pelvic floor navigation and dissection is an effective way to accurately identify pelvic anatomy during classic bladder exstrophy and cloacal exstrophy closure. This technology offers a unique opportunity for surgical skill education in this complex reconstructive operation.

The role of extended venous thromboembolism prophylaxis for major urological cancer operations.

OBJECTIVES: Venous thromboembolism (VTE), consisting of both pulmonary embolism (PE) and deep vein thromboses (DVT), remains a well-recognised complication of major urological cancer surgery. Several international guidelines recommend extended thromboprophylaxis (ETP) with LMWH, whereby the period of delivery is extended to the post-discharge period, where the majority of VTE occurs. In this literature review we investigate whether ETP should be indicated for all patients undergoing major urological cancer surgery, as well procedure specific data that may influence a clinician's decision. METHODS: We performed a search of six databases (PubMed, Cochrane, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and British Nursing Index (BNI)) from inception to June 2019, for studies looking at adult patients who received VTE prophylaxis after surgery for a major urological malignancy. RESULTS: Eighteen studies were analysed. VTE risk is highest in open and robotic Radical Cystectomy (RC) (2.6-11.6%) and ETP demonstrates a significant reduction in risk of VTE, but not a significant difference in Pulmonary Embolism (PE) or mortality. Risk of VTE in open Radical Prostatectomy (RP) (0.8-15.7%) is comparable to RC, but robotic RP (0.2-0.9%), open partial/radical nephrectomy (1.0-4.4%) and robotic partial/radical nephrectomy (0.7-3.9%) were lower risk. It has not been shown that ETP reduces VTE risk specifically for RP or nephrectomy. CONCLUSION: The decision to use ETP is a fine balance between variables such as VTE incidence, bleeding risk and perioperative morbidity/mortality. This balance should be assessed for each specific procedure type. While ETP still remains of net benefit for open RP as well as open and robotic RC, the balance is closer for minimally invasive RP as well as radical and partial nephrectomy. Due to a lack of procedure specific evidence for the use of ETP, adherence with national guidelines remains poor. Therefore, we advocate further studies directly comparing ETP vs standard prophylaxis, for specific procedure types, in order to allow clinicians to make a more informed decision in future.

How cure rates drive patients' preference for urethral bulking agent or mid-urethral sling surgery as therapy for stress urinary incontinence.

AIMS: To assess the patients' median-accepted threshold of cure rate for urethral bulking agent (UBA) treatment compared to mid-urethral sling (MUS) surgery for treatment of female stress urinary incontinence (SUI). Secondly, to determine the correlation between treatment trade-off point and patient characteristics. METHODS: Women older than 18 years, with predominant SUI, seeking treatment, underwent a structured interview. The treatment trade-off point was determined in scenario one: UBA vs transobturator standard MUS surgery (SMUS) performed under general/spinal anesthesia with one-night hospital stay, and scenario 2: UBA compared to single-incision MUS surgery (SIMS) performed under local analgesia (with sedation) in a daycare setting. The treatment trade-off point was assessed by decreasing the cure rate of UBA from 85% to 10% with steps of 2% until the patient's treatment preference switched to SMUS/SIMS. RESULTS: One hundred and five patients were interviewed. Mean age was 52 years (SD, ±13.4). The median trade-off point for scenarios 1 and 2 was 79% (interquartile range [IQR]: 69, 85) and 85% (IQR: 71, 85), respectively. Patients with longer duration of SUI symptoms were willing to trade more efficacy to prefer UBA treatment. CONCLUSIONS: Patients with SUI are willing to trade a lower cure rate to prefer UBA over SMUS to avoid hospitalization and general anesthesia. When SIMS is performed in a daycare setting under local analgesia, the majority of patients with SUI are of the opinion that cure rates of UBA should be at least as high as SIMS to be worth considering. The treatment preference is not strongly correlated with the patients' characteristics.

Vascular Injury During Urologic Surgery: Somebody Call My Mother.

PURPOSE OF REVIEW: To provide the critical elements to effectively manage hemorrhage from vascular injuries sustained during planned urological interventions. RECENT FINDINGS: The frequency of intraoperative vascular injuries is increasing. However, literature concerning the management of iatrogenic operative vascular injuries is scarce. Although rare, intraoperative vascular injuries may be associated with potential catastrophic complications and death. The decision-making process following a potential life-threatening intraoperative vascular injury occurs in a very short time frame. Appropriate knowledge of the critical elements to identify the source of bleeding, initiate first-line hemostatic measures, select the candidate for damage control strategies, and perform the indicated operative repairing maneuvers and techniques have been proved crucial to ensure hemodynamic stability and bleeding cessation. The key surgical principles to counteract the impact of exsanguinating bleeding, and the aim to obtain the best achievable outcomes after definitive repair, are described in detail in this review.

Pericardium in Reconstructive Urologic Surgeries: A Systematic Review and Meta-Analysis.

INTRODUCTION: The use of pericardium has been expanded into different surgical modalities; however, there are scarce data regarding the feasibility of the pericardium in reconstructive urologic surgeries. We systematically reviewed the literature on the effectiveness of the pericardial tissue for reconstructive urologic surgeries. MATERIALS AND METHODS: PubMed and Scopus were searched online for evidence on the use of the pericardium in urologic surgeries. Through the methodology recommended by the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, 38 of 4,071 studies were identified. RESULTS: A total of 715 patients and 139 animals underwent reconstructive urologic surgeries using the pericardium. Bladder, urethral, and renal reconstructions were successful in 100% of the human cases. The rates of dissatisfaction, glans hypoesthesia, and penile shortening were comparable between the pericardial graft surgeries and the other operations during penile straightening, but there was a trend among the patients with pericardial grafts toward having a more penile curvature at follow-up (risk ratio [RR] 2.03, 95% CI 0.90-4.61, p = 0.09; I2 = 0%). Among the animal studies, there were 4 reports of penile reconstruction, 7 studies of bladder reconstruction, and 1 study of urethroplasty. Bladder reconstruction and urethroplasty were successful in 83 and 20% of the animals, respectively. The pooled result of the stimulated intracorporeal pressure 5 V significantly favored pericardial grafts during penile reconstruction (RR 2.61, 95% CI 1.26-3.97, p = 0.0002; I2 = 0%). CONCLUSIONS: Our systematic review demonstrates the feasibility of the pericardium, regardless of its type, in urologic surgeries. It, however, seems that urethral substitution needs further investigation. Given the lower cost, easier handling, and less immunogenicity of the pericardium, further studies are required to examine its pros and cons.