"Self-Designed Simulation-Based Laparoscopic Training Program for Urology Residents: Results After 6 Years of Experience".

Introduction: Learning laparoscopy (LAP) is challenging and requires different skills to conventional open surgery. There is a recognized need for a standardized laparoscopic training framework within urology to overcome these difficulties and to shift learning curve from patient to skills laboratory. Simulation-based training has been widely commented, but implementation in real day practice is lacking. We present our "LAP training program for residents". Material: Between 2017 and 2022, 11 residents participated in our self-designed program: Theoretical: (Moodle platform) basic knowledge and multimedia content for initiation into LAP. Evaluated through online exam. Practical: exercises for LAP skills acquisition were proposed and encouraged residents' practice in a box trainer available and experimental surgery sessions on a porcine model. On-site E-BLUS (European Basic Laparoscopic Urologic Skills) examination was performed annually. Feedback was obtained through an anonymous online survey. Results: All residents positively evaluated the program. Theoretical: 82% passed the online exam. The most valued topics: LAP in special clinical situations, complications, instruments, and configuration of the operating room (OR). Practical: all residents increased dry-lab box practices. A total of 23 experimental surgical sessions were carried out. For 64%, simulation in the experimental OR was a necessary complement to achieve laparoscopic skills and allowed them to feel more confident. Forty-five percent considered it essential to improve their surgical technique. E-BLUS evaluation was valued as a means to achieve dexterity and safer surgery by 90%. Reduction in time and errors were observed through time, although only 2 passed the E-BLUS. Conclusion: Our program for learning LAP includes the acquisition of knowledge, training of basic skills and surgical technique in a safe environment, as well as an objective evaluation. Encouraged practice of basic skills and surgical technique simulation and improved objective evaluation. It is structured, reproducible, systematic and has been positively valued, although it requires commitment for success.

[Renal harvest. State of the art.] / Extracción renal. Situación actual.

Kidney transplantation (KT) is the best treatment for end-stage renal disease. Despite Spain isone of the leading countries in donation, the need for transplantable organs exceeds the available supply. Graft survival depends on the quality of the organ, the damage it suffers during the donation and transplantation process, as well as the risk of rejection. Among the factors that must be controlled and minimized are the ischemia-reperfusion injuries that occurs in the moments surrounding the death of the donor, the procurement and the preservation of the organ until kidney transplantation. Static cold storage is the traditional method of preservation of the organ until the moment of implantation, since it is a technique with wide availability and low cost. The use of perfusion machines in DCD and expanded criteria has shown better short-term results (primary failur delayed on set of function) without affecting recipient orgraft survival. The objective of our article is to review the current situationand the resources available to increase the pool of transplantable organs and their quality. We conducted a systematic review on kidney extraction, donor management, preservation methods and techniques to optimize cadaveric donor kidney donation.

El trasplante renal (TR) es el mejor tratamiento para la enfermedad renal crónica terminal. En España no se dispone de suficientes órganos para suplirla demanda de pacientes en lista de espera a pesar deser uno de los países líderes en donación. La supervivencia del injerto depende de la calidad delórgano, el daño que sufre durante el proceso de donacióny trasplante, así como de la posibilidad de que seproduzca rechazo. Entre los factores que debemos minimizar y optimizar se encuentran las lesiones inducidas por los mecanismos de isquemia-reperfusión, en los momentos que rodean la muerte del donante, la extracción y la preservación del órgano hasta su trasplante.Tradicionalmente la preservación del órgano hasta elmomento del implante se ha llevado a cabo mediante la conservación en frío, ya que es una técnica con amplia disponibilidad y bajo coste. El uso de máquinas de perfusiónen donaciones en asistolia y criterio expandido,ha demostrado mejores resultados a corto plazo (fallo primario, inicio retrasado de función) sin afectar a la supervivencia del receptor o del injerto. El objetivo de este trabajo es revisar la situación actual,así como los recursos disponibles para aumentar el poolde órganos trasplantables y la calidad de estos. Hemos realizado una revisión sobre la extracción renal, manejo del donante, métodos y técnicas de preservación para optimizar la donación renal de donante cadáver.

[Renal transplantation during COVID-19 period in Spain.] / Trasplante renal en época COVID-19 en España.

INTRODUCTION: The COVID-19 pandemic poses significant challenges in the area of kidney donation and transplantation. The objective of this article is to establish general recommendations for surgical teams to manage the kidney transplant program duringthe COVID-19 era. MATERIAL AND METHODS: This document is based on the scientific evidence available on the infection caused by SARS-CoV-2 and the experience of authors during the COVID-19 pandemic. A web and Pubmed search was performed using the keywords "SARS-CoV-2"," COVID-19", "COVID Urology", "COVID-19 surgery", and "kidney transplantation." A modified nominal group technique was used. RESULTS: When health system saturation occurs, kidney transplants should be deferred, except in patients with low transplant possibilities and an optimal kidney available, combined transplants or life-threatening situations. Screening for the SARS-CoV-2 virus should be done in all those donors and recipients with clinical symptoms consistent with COVID-19, who have visited or live inhigh-risk areas, or who have been in close contact with confirmed cases of COVID-19. Donation and transplantation will not proceed in confirmed cases of COVID-19. Surgeries should be based on general recommendations in the COVID-19 era and will be efficient, short, and focused on those with the shortest hospital stay. In emergencies, protective measures will be taken with persona lprotection equipment. Surgical staff will be only the strictly necessary, and permanence in the OR should be minimized. Transplant urology consultations will be conducted by teleconsultation when possible. CONCLUSION: The safety of potential donors and recipients must be guaranteed, adopting individual protection measures and screening for SARS-CoV-2. Kidney transplant surgery must be efficient in terms of health, human resources, and clinical benefit. All non-urgent transplant activities should be delayed until the improvement of the local condition of each center.

INTRODUCCIÓN: La epidemia de COVID-19 plantea importantes retos en el ámbito de la donación y el trasplante renal. El objetivo de este artículo es establecer unas recomendaciones generales dirigidas a los equipos quirúrgicos de trasplante renal durante la era COVID-19. MATERIAL Y MÉTODOS: El documento se basa en la evidencia científica disponible sobre la infección causada por SARS-CoV-2 y la experiencia de los autores en la pandemia COVID-19. Se realizó una búsqueda web y en PubMed utilizando las palabras clave "SARSCoV-2", "COVID-19", "COVID Urology", "COVID-19 surgery" y "kidney transplantation". Se ha utilizado una técnica de grupo nominal modificada.RESULTADOS: En momentos de saturación del sistema sanitario, se deberán diferir los trasplantes renales, salvo en pacientes con bajas posibilidades de trasplante y un riñón óptimo disponible, trasplantes combinados o pacientes en situación de urgencia vital. Se deberá hacer cribado del virus SARS-CoV-2 en todos aquellos donantes y receptores que tengan sospecha clínica, hayan estado en zonas de alto riesgo o hayan compartido proximidad con casos confirmados de COVID-19. Nos e procederá con la donación ni con el trasplante en casos confirmados de COVID-19. Las cirugías deberáns er eficientes, cortas y centradas en las que menor estancia hospitalaria conlleven. En casos de urgencia, se extremarán las medidas de protección con equipos de protección individual. El personal quirúrgico será el menor posible y se minimizarán las estancias en quirófano. Las consultas urológicas de trasplante sin riesgo serán realizadas telemáticamente cuando sea posible. CONCLUSIÓN: La cirugía de trasplante renal debe ser eficiente en cuanto a recursos sanitarios, humano sy beneficio clínico. Se debe garantizar la seguridad de los potenciales donantes y receptores, adoptando medidas de protección individual y realizando cribado para SARS-CoV-2.

Cadaveric Models for Renal Transplant Surgery Education: a Comprehensive Review.

PURPOSE OF REVIEW: To evaluate the utility of cadaveric models for kidney transplant (KT) surgery training. RECENT FINDINGS: Medline® and PubMed® databases were searched for English and Spanish language articles published describing different learning models used in KT formation. We evaluated the use of cadavers preserved by Thiel's embalming method (TEM) as KT simulation models. Students were divided in groups of 4 people: four trainees mentored by an expert in KT surgery. Among the trainees were surgical residents and low-experience surgeons. A total of 39 TEM preserved bodies were used, of which 75 viable renal grafts were obtained. In each cadaver, two complete transplantation processes were performed, each consisting of en bloc nephrectomy with the trunk of aorta and inferior vena cava, bench surgery and perfusion with saline of the organ, and KT surgery. As with any surgical procedure, learning KT surgery is a stepwise process that requires years of dedication. The models available for the surgical simulation of KT surgery allow to practice and achieve dexterity in performing the procedure in a safe and reproducible way. Training on TEM-preserved corpses offers a highly realistic model for the surgical simulation of KT surgery.

PGC-1α deficiency causes spontaneous kidney inflammation and increases the severity of nephrotoxic AKI.

PGC-1α (peroxisome proliferator-activated receptor gamma coactivator-1α, PPARGC1A) regulates the expression of genes involved in energy homeostasis and mitochondrial biogenesis. Here we identify inactivation of the transcriptional regulator PGC-1α as a landmark for experimental nephrotoxic acute kidney injury (AKI) and describe the in vivo consequences of PGC-1α deficiency over inflammation and cell death in kidney injury. Kidney transcriptomic analyses of WT mice with folic acid-induced AKI revealed 1398 up- and 1627 downregulated genes. Upstream transcriptional regulator analyses pointed to PGC-1α as the transcription factor potentially driving the observed expression changes with the highest reduction in activity. Reduced PGC-1α expression was shared by human kidney injury. Ppargc1a-/- mice had spontaneous subclinical kidney injury characterized by tubulointerstitial inflammation and increased Ngal expression. Upon AKI, Ppargc1a-/- mice had lower survival and more severe loss of renal function, tubular injury, and reduction in expression of mitochondrial PGC-1α-dependent genes in the kidney, and an earlier decrease in mitochondrial mass than WT mice. Additionally, surviving Ppargc1a-/- mice showed higher rates of tubular cell death, compensatory proliferation, expression of proinflammatory cytokines, NF-κB activation, and interstitial inflammatory cell infiltration. Specifically, Ppargc1a-/- mice displayed increased M1 and decreased M2 responses and expression of the anti-inflammatory cytokine IL-10. In cultured renal tubular cells, PGC-1α targeting promoted spontaneous cell death and proinflammatory responses. In conclusion, PGC-1α inactivation is a key driver of the gene expression response in nephrotoxic AKI and PGC-1α deficiency promotes a spontaneous inflammatory kidney response that is magnified during AKI. © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Cell death-based approaches in treatment of the urinary tract-associated diseases: a fight for survival in the killing fields.

Urinary tract-associated diseases comprise a complex set of disorders with a variety of etiologic agents and therapeutic approaches and a huge global burden of disease, estimated at around 1 million deaths per year. These diseases include cancer (mainly prostate, renal, and bladder), urinary tract infections, and urolithiasis. Cell death plays a key role in the pathogenesis and therapy of these conditions. During urinary tract infections, invading bacteria may either promote or prevent host cell death by interfering with cell death pathways. This has been studied in detail for uropathogenic E. coli (UPEC). Inhibition of host cell death may allow intracellular persistence of live bacteria, while promoting host cell death causes tissue damage and releases the microbes. Both crystals and urinary tract obstruction lead to tubular cell death and kidney injury. Among the pathomechanisms, apoptosis, necroptosis, and autophagy represent key processes. With respect to malignant disorders, traditional therapeutic efforts have focused on directly promoting cancer cell death. This may exploit tumor-specific characteristics, such as targeting Vascular Endothelial Growth Factor (VEGF) signaling and mammalian Target of Rapamycin (mTOR) activity in renal cancer and inducing survival factor deprivation by targeting androgen signaling in prostate cancer. An area of intense research is the use of immune checkpoint inhibitors, aiming at unleashing the full potential of immune cells to kill cancer cells. In the future, this may be combined with additional approaches exploiting intrinsic sensitivities to specific modes of cell death such as necroptosis and ferroptosis. Here, we review the contribution of diverse cell death mechanisms to the pathogenesis of urinary tract-associated diseases as well as the potential for novel therapeutic approaches based on an improved molecular understanding of these mechanisms.

Is There a New Alternative for a Safer Kidney Artery Ligation in Laparoscopic Donor Nephrectomy?

Controlled ligation and division of the renal hilum are critical steps during laparoscopic living donor nephrectomy. Major hemorrhage from technical failure, although an infrequent occurrence, can cause significant, yet preventable, morbidity or death. Polymer-secured nontransfixion clips are used worldwide for renal pedicle control during laparoscopic nephrectomy, but their use is contraindicated for renal artery ligation during laparoscopic living donor nephrectomy. Laparoscopic staplers are reliable transfixion systems for controlling kidney pedicle. However, stapler malfunction is not negligible, reaching up to 1.7%. A new double shank (DS) titanium-secured nontransfixion clip can dodge legal concerns on polymer-secured clips, while maintaining most of their advantages, without technical failures that may be seen in laparoscopic staplers. New alternatives must be proposed and explored to reach an agreement of the urological community. The new DS-titanium-secured clips could be a step forward toward a safer surgery for kidney donors, at least equivalent to hand ties to occlude the renal artery.

An experimental model for training in renal transplantation surgery with human cadavers preserved using W. Thiel's embalming technique.

OBJECTIVE: To describe a novel cadaver-based model for practicing renal transplant (RT) surgery. DESIGN: A simulating model using cadavers preserved by Thiel's method is developed to teach surgical anatomy and operative skills in RT surgery. Participants were asked to complete a voluntary, anonymous survey evaluating perceptions of the model and comparing cadaver sessions to other types of learning (rating questions from 0-10). SETTING: Large university teaching hospital. PARTICIPANTS: A total of 28 residents, junior transplant surgeons, and faculty members were participants in the cadaver simulation. RESULTS: Overall, 9 cadavers were used with 17 grafts transplanted. Kidney procurement in human cadavers preserved using Thiel's embalming technique was performed following the conventional protocol; en bloc nephrectomy with the trunk of aorta and inferior vena cava. Bench surgery was performed, perfusing artery with saline and checking vascular permeability. Once suitability is established, RT was performed as is done in clinical practice. This embalming method enables tissue dissection that is comparable to the living body and provides suitable conditions for realistic RT simulation; handling human tissues and vessels in the same surgical field as the clinical scenario. This experimental model approximates to in vivo RT, providing a realistic and interesting learning to inexperienced surgeons. Overall, participants held a positive view of the cadaver sessions, believed them to be useful in their daily practice, and felt that the proposed model was similar to the clinical setting. Trainees believed that these practices improved skills and confidence in performing an RT. CONCLUSIONS: The proposed method of kidney procurement and RT in human cadavers preserved by Thiel's embalming technique is a promising, realistic, and reproducible method of practicing RT surgery.

Inflatable penile prosthesis implantation without corporeal dilation: a cavernous tissue sparing technique.

PURPOSE: We compared the advantages and disadvantages of initial penile implantation with vs without prior dilation of the corpora cavernosa. MATERIALS AND METHODS: Patients implanted for the first time with a 700CX or an antibiotic coated 700CX InhibiZone 3-piece prosthesis by a single surgeon during January 2005 to December 2006 were included in the study. They were randomized to penile implantation without (group 1) or with (group 2) penile dilation. Postoperative pain was measured on the day after surgery and at day 7 postoperatively. Perioperative and postoperative complications were recorded. Residual erectile activity without prosthesis inflation was evaluated using the International Index of Erectile Function at 3-month intervals for 9 months. Patients recorded penile length and girth during maximum sexual stimulation during this time. RESULTS: A total of 100 patients were included in the study. Intraoperative complications occurred in 2 group 1 and 3 group 2 patients. Postoperatively complication rates and types were similar in the 2 groups. Pain was significantly greater in group 2 (p <0.01). Immediately postoperatively, and at 3 and 6 months penile length was significantly greater in group 1 than in group 2 (p <0.05). Mean International Index of Erectile Function scores were higher in group 1 (12, range 10 to 14 vs 7, range 6 to 8). CONCLUSIONS: Results suggest that penile dilation is not necessary in primary implantation cases.

Herniation of renal pelvis and ureteropelvic junction resulting from superior lumbar triangle hernia.

A 79-year-old female admitted as a result of respiratory insufficiency due to pneumonia presented with a painful swelling in the left lumbar region and acute ureteral colic pain. The diagnosis of Grynfeltt's bilateral hernia was made by means of CT, which revealed herniation in the left side of the renal pelvis and proximal ureter.

Renal allograft laceration treated by superselective embolization.

PURPOSE: To report an illustrative case demonstrating the efficacy of endovascular treatment for traumatic blunt renal allograft injury. CASE REPORT: A 19-year-old man sustained an injury to his renal allograft after a traffic accident secondary to lap belt compression. Angiography revealed contrast extravasation from 2 disrupted upper pole renal artery branches, which were successfully embolized with microcoils. The creatinine level was transiently elevated to 4.1 mg/dL, but it improved to 2.9 mg/dL at discharge 13 days after admission. After 1 year, the serum creatinine level was 1.9 mg/dL. CONCLUSION: As in the native kidney, superselective embolization can also be used safely in the management of blunt injury to a renal allograft, avoiding surgery and preserving graft function.

[Surgical treatment of renal adenocarcinoma with venous thrombus]. / Tratamiento quirúrgico del adenocarcinoma renal con trombo venoso.

OBJECTIVES: To analyze therapeutic management and survival of renal adenocarcinoma with tumor venous extension treated by surgery in our experience. METHODS: We retrospectively evaluate a series of 29 cases of renal adenocarcinoma with venous thrombus who underwent radical nephrectomy and thrombectomy from January 1986 to November 2003. Mean age was 63.4 11.9 (29-79) years. 23 patients were males (79%) and 6 (21%) females. 17 (59%) patients had the tumor in the right kidney and 12 (42%) in the left kidney. Tumor thrombus level was: Level I (renal vein-inferior vena cava) 13 (45%), Level II (infrahepatic vena cava) 9 (31%), Level III (retrohepatic vena cava/suprahepatic) 3 (10%), and Level IV (auricula) 4 (14%). 92% of the cases presented perirenal fat involvement. Survival analysis was performed including 24 cases of the 29. We analyzed overall and cancer-specific survival, as well as possible influence of tumor thrombus level, fat involvement, and tumor grade as prognostic factors. RESULTS: Mean tumor size was 8.15 +/- 2.25 cm (5-13). Surgical approach was purely abdominal in 23 cases (79%) and thoraco-phreno-laparotomy in 6 (21%). Hepatic mobilization maneuvers and hepatic pedicle clamping were performed in 5 (17%) patients. Venous clamping was: renal-cava 13 cases (44%), triple clamping I1 (37%) (9 infrahepatic and 2 suprahepatic), and supradiaphragmatic-auricula 5 (17%). Conventional extracorporeal circulation (CEC) with moderate hypothermia (26-28 degrees C) was employed in 4 cases and CEC with heart arrest (4 min) in one. Mean follow-up was 52 months. At the time of review 9 patients were alive, 11 had died from tumor and 4 had died from other causes. Mean overall survival was 71 +/- 12 months and cancer specific survival 86 +/- 14 months. Neither renal fat involvement (p=0.6) nor tumor thrombus level (p = 0.9) were prognostic factors for survival in the univariant analysis, but tumor grade was (p = 0.03). CONCLUSIONS: Patients with venous tumor extension without lymph node involvement or metastasis should be treated by radical surgery with complete excision of the tumor thrombus. Tumor grade was a prognostic factor for survival, but venous involvement level and presence of perirenal fat involvement were not.

[Methodology in infertility studies. Outcome measures for therapeutic success. When should we consider that has been a change in semen quality?]. / Características metodológicas de los estudios de infertilidad. Parámetros de éxito terapeútico. Cuándo considerar que ha habido un cambio en la calidad seminal de un varón?

OBJECTIVES: Surgery has been largely indicated for varicocele with the aim of improving semen parameters in male patients with subfertility or infertility. However, the criteria for therapeutic success in which its usefulness has been based on have never been clear. Our objective was to analyze current criteria for therapeutic success after surgical treatment of varicocele, studying in depth the possible influence of varicocele on semen quality, its impact on fertility, and possible advantages of treatment. METHODS: We reviewed a group of original articles, systematic reviews, and metanalysis on the issue after MEDLINE search. We mainly focus on randomized placebo-controlled prospective studies the aim of which was to evaluate the improvement in semen quality and/or pregnancy rates in subfertile/infertile couples after treatment of varicocele. CONCLUSIONS: There is great study heterogeneity, both in methods and possible interpretation of results. Although it seems treatment of varicocele may improve some semen quality parameters, it does not seem to represent an effective treatment for male subfertility.

Radiological assessment of penile prosthesis: the role of magnetic resonance imaging.

Penile implants offer a dependable way of restoring erections in virtually all motivated patients. The satisfaction rate among both patients and partners using these devices is high. Advances in technology have reduced the infection rate and increased the mechanical reliability of these products. However, too often, urologists do not present this option with the same authority as other treatments. The reason is fear of complications and lack of expertise in managing them. Although they are not very frequent, complications may be catastrophic. The most significant postoperative complication associated with the implant surgery is infection of the device, which is quite frequent, but some other important complications are distal and proximal perforation of the albuginea, SST deformity, "S-shaped" deformity of the penis, erosion of a component, and mechanical malfunction of the device. The best way to manage complications is to prevent them, but we do not have many diagnostic tools available. Diagnosis is based on clinical history and physical examination, but imaging techniques are also needed to explore the prosthesis "in situ" to plan the surgical approach if it is needed. In this article we review the different imaging techniques used for the diagnosis of complications of prosthetic surgery of the penis, including conventional radiology, use of sonography, the role of CT scan and the magnetic resonance imaging (MRI) of the penile prosthesis. We conclude that MRI is the most valuable method for the diagnosis of penile prosthesis complications. It is not an ionizing radiation imaging method and has the unique feature among imaging techniques of demonstrating penile anatomy in three orthogonal planes. It is superior to any other imaging method in the definition of soft tissue contrast.