Implementation of ERAS (Enhanced Recovery After Surgery) protocols for radical cystectomy patients: The pathway to standardization. A systematic review. / Aplicación de protocolos ERAS (Enhanced Recovery After Surgery) en pacientes cistectomizados: el camino hacia la estandarización. Una revisión sistemática.

CONTEXT: The development of ERAS (Enhanced Recovery After Surgery) protocols in patients undergoing major surgery has brought perioperative benefits in several disciplines. Its main application in urology is focused on patients undergoing radical cystectomy. OBJECTIVE: Systematic review of the available literature on ERAS protocols applied to patients undergoing radical cystectomy in terms of perioperative outcomes as well in the analysis of their implementation. EVIDENCE ACQUISITION: A bibliographic search was conducted in the electronic databases PubMed, Embase, Cochrane and Scopus, using the terms «Cystectomy¼, «Enhanced Recovery After Surgery¼ and «Fast-Track¼. Randomized and non-randomized studies that compared the implementation of an ERAS protocol versus a traditional protocol in patients undergoing radical cystectomy were selected. EVIDENCE SYNTHESIS: 869 articles were identified; 25 were selected for final analysis: 22 non-randomized and 3 randomized studies. No differences were observed in terms of demographic characteristics between studies. Statistically significant differences were identified in favor of the ERAS protocol: length of hospital stay, major complication rate, time to first ambulation and return of bowel function. In the analysis of protocols, a high variability was detected in the number of items and in the implementation method. CONCLUSIONS: The multidisciplinary nature and the number of items of the ERAS protocols imply a high heterogeneity in their implementation. Further randomized studies, standardized reporting and analyzing results, as well as a systematic analysis of subsequent adherence are required to increase comparability between groups.

Objective assessment of early urinary continence by analysis and visualisation of intraoperative variables of radical robotic prostatectomies with a video editor. / Valoración objetiva de la continencia urinaria precoz mediante el análisis y la visualización de variables intraoperatorias de prostatectomías radicales robóticas con un editor de vídeos.

INTRODUCTION: UI after RP is a factor that has a major impact on patients' quality of life and the associated healthcare costs. The definition of UI is very variable in the literature. Similarly, a great many predictors have been studied that affect recovery of continence after surgery, the most important of which are intraoperative. MATERIAL AND METHODS: a retrospective and observational study performed between September 2008 and March 2015. We studied intraoperative factors through visualisation using a video editor of 148 patients who underwent robot-assisted radical prostatectomy, together with other perioperative factors associated with continence, and described in the literature. We assessed continence through ICQ questionnaires, urinary loss calculated by pad count, and clinical interview in the first, third, sixth month and at one year after surgery. We defined continence as not having to use a pad or using a pad for protection socially, or an ICQ ≤ 7. We used binary and lineal logistic regression analysis to study the relationship between the intraoperative and perioperative variables on urinary continence measured at the first, third, sixth month and one year after the operation, and on continence stability. RESULTS: In our study, 72.9% of the patients were continent at one year after surgery with a mean continence stabilisation time at 4.3 months. In our lineal logistic regression analyses we found no significant relationship with the continence variable analysed during the first year. In the lineal logistic regression analysis we found that tension-free sutures had a direct positive effect (P≤.05) on the stability time of continence, as well as the urinary losses measured in the first month after surgery. CONCLUSION: In conclusion, we found in our study that the tension-free sutures were able to help towards early stability of continence. We found no other intraoperative predictors that influenced urinary continence. The urinary losses measured in the first month related to early recovery of continence.

[Scrotal mass presenting as giant urethral diverticulum]. / Masa escrotal como presentación de divertículo uretral gigante.

Urethral diverticulum in the male is a rare entity that may be congenital or acquired. They are common in paraplegic patients, who are prone to developing this disorder on an acquired basis because of prolonged catheterization. The most common diseases in patients with spinal cord injury are stricture, fistula and diverticula. Patients with diverticula typically present with symptoms of urinary incontinence, dysuria, perineal pain, or a mass on the ventral aspect of the genitalia or perineum. Treatment of choice is always surgical and a complete extirpation should be performed.

[Prostatic enucleation with holmium laser]. / Enucleación prostática con láser holmium.

OBJECTIVES: Benign prostatic hyperplasia (BPH) affects a growing percentage of males over the age of 40 years, increasing with age. Currently, we have a new therapeutic tool available: the holmium laser. METHODS: We retrospectively collected data of 300 patients undergoing holmium laser enucleation of the prostate (HoLEP) in our center. RESULTS: The results are: mean hospital stay 1.8 days (range 1-15 days, median 1.8); mean bladder catheter time 30.6 hours (range 12-312, median 30.3), total operative room time 75 minutes (range 38-150, median 71), maximal flow rate at six months 24.7 ml/sec. and 23.9 ml/sec. at 12 months. Surgical performance, number of grams resected per minute, is 0.48 for the whole group. We observed a variation in data from the first 20 cases, with worse results in this group. CONCLUSIONS: In our opinion holmium laser enucleation is an adequate method that the guarantees optimal results, comparable to those obtained with classic endoscopic and open surgical techniques, with a low rate of complications, which benefits the patient by diminishing the need for transfusions, catheterization time, and hospital stay; conversely, it has a learning curve of around 20 procedures, which may be associated with complications that may discourage the surgeon and stop the project of technique implementation in a center, having easy, accessible, established alternative procedures.