What credentials are required for robotic-assisted surgery in reconstructive and functional urology?

Introduction: The increasing popularity of robotic assisted surgery (RAS) as it is implemented in to sub specialities poses many challenges to ensuring standards in quality and safety. The area of Reconstructive and Functional Urology (RFU) has a wide range and largely complex heterogeneous procedures. In recent years RFU has started to incorporate RAS as the primary method to undertake these procedures due to improved vision, dexterity, and access to deep cavities. To ensure patient safety majority of institutions maintain minimal requirements to operate using RAS however across specialities and institutions these greatly vary. Methods: A narrative review of all the relevant papers known to the author was conducted. Results: Specific challenges facing RFU is the inability to rely on case numbers as a surrogate means to measure competency as well the ongoing consideration of how to differentiate between surgeons with robotic training and those with the clinical experience specific to RFU. Conclusion: This review explores current models of training and credentialling and assess how it can be adapted to suggest a standardised guideline for RFU to ensure the highest standards of patient care.

Systematic review of urological injury during caesarean section and hysterectomy.

INTRODUCTION AND HYPOTHESIS: We aim to review iatrogenic bladder and ureteric injuries sustained during caesarean section and hysterectomy. METHODS: A search of Cochrane, Embase, Medline and grey literature was performed using methods pre-published on PROSPERO. Eligible studies described iatrogenic bladder or ureter injury rates during caesarean section or hysterectomy. The 15 largest studies were included for each procedure sub-type and meta-analyses performed. The primary outcome was injury incidence. Secondary outcomes were risk factors and preventative measures. RESULTS: Ninety-six eligible studies were identified, representing 1,741,894 women. Amongst women undergoing caesarean section, weighted pooled rates of bladder or ureteric injury per 100,000 procedures were 267 or 9 events respectively. Injury rates during hysterectomy varied by approach and pathological condition. Weighted pooled mean rates for bladder injury were 212-997 events per 100,000 procedures for all approaches (open, vaginal, laparoscopic, laparoscopically assisted vaginal and robot assisted) and all pathological conditions (benign, malignant, any), except for open peripartum hysterectomy (6,279 events) and laparoscopic hysterectomy for malignancy (1,553 events). Similarly, weighted pooled mean rates for ureteric injury were 9-577 events per 100,000 procedures for all hysterectomy approaches and pathologies, except for open peripartum hysterectomy (666 events) and laparoscopic hysterectomy for malignancy (814 events). Surgeon inexperience was the prime risk factor for injury, and improved anatomical knowledge the leading preventative strategy. CONCLUSIONS: Caesarean section and most types of hysterectomy carry low rates of urological injury. Obstetricians and gynaecologists should counsel the patient for her individual risk of injury, prospectively establish risk factors and implement preventative strategies.

Xanthogranulomatous pyelonephritis: a systematic review of treatment and mortality in more than 1000 cases.

OBJECTIVES: To systematically review the current demographics, treatment and mortality rate associated with xanthogranulomatous pyelonephritis (XGP) and to test the hypothesis that the weighted pooled peri-operative mortality rate will be <10%. METHODS: Searches were performed of the Cochrane, Embase and Medline databases and the grey literature for studies published during the period 1 January 2000 to 30 August 2021. Eligible studies reported cohorts of ≥10 predominantly adult patients with XGP and described either average patient age or mortality rate. RESULTS: In total, 40 eligible studies were identified, representing 1139 patients with XGP. There were 18 deaths, with a weighted pooled peri-operative mortality rate of 1436 per 100 000 patients. The mean age was 49 years, 70% of patients were female and 28% had diabetes mellitus. The left kidney was more commonly affected (60%). Four patients had bilateral XGP, and all of whom survived. Renal or ureteric stones were present in 69% of patients, including 48% with staghorn calculi. Urine culture was positive in 59% of cases. Fistulae were present in 8%. Correct preoperative diagnosis occurred in only 45% of patients. Standard treatment continues to comprise a short cause of antibiotics and open radical (total) nephrectomy. Preoperative decompression occurred in 56% of patients. When considered at all, laparoscopic nephrectomy was performed in 34% of patients. Partial nephrectomy was conducted in 2% of patients. CONCLUSIONS: Xanthogranulomatous pyelonephritis has a lower mortality rate than historically reported. A typical patient is a woman in her fifth or sixth decade of life with urolithiasis. While open radical nephrectomy remains the most common treatment method, laparoscopic, and to a lesser degree partial nephrectomy, are feasible in well selected patients.

Primary non-metastatic extra-nodal diffuse large B-cell lymphoma of the prostate and seminal vesicle.

Extra-nodal lymphoma accounts for 30-50% of non-Hodgkin lymphoma, and most of the cases are of the diffuse large B-cell lymphoma (DLBCL) type. Primary malignant lymphomas of the prostate are extremely rare, representing 0.09% of prostate neoplasms. Prostatic cancers can be classified into various subtypes, which have distinct molecular pathologies and clinical features. Lymphoma is seldom considered as a differential diagnosis of prostatic enlargement considering the low incidence. We present a case of an 85-year-old gentleman diagnosed with Primary Extra-nodal DLBCL of the Seminal Vesicle and Prostate.

Ureteric inguinal herniation with obstructing bladder tumour.

While ureteric orifice obstruction by bladder tumour is common, an inguinal hernia containing ureter is rare. The simultaneous occurrence of both has not previously been reported and made management both challenging and unique. We present the case of a 75-year-old man who presented with a symptomatic right inguinal hernia, which was found on imaging to include the right ureter. Cystoscopy to perform right ureteric stent insertion revealed bladder tumour obstructing the ipsilateral ureteric orifice. A multi-disciplinary approach involving urology, general surgery and interventional radiology was successful in achieving tumour resection, ureterolysis with preservation of ureter and inguinal hernia repair.

Hypertension with or without adrenal hyperplasia due to different inherited mutations in the potassium channel KCNJ5.

We recently implicated two recurrent somatic mutations in an adrenal potassium channel, KCNJ5, as a cause of aldosterone-producing adrenal adenomas (APAs) and one inherited KCNJ5 mutation in a Mendelian form of early severe hypertension with massive adrenal hyperplasia. The mutations identified all altered the channel selectivity filter, producing increased Na(+) conductance and membrane depolarization, the signal for aldosterone production and proliferation of adrenal glomerulosa cells. We report herein members of four kindreds with early onset primary aldosteronism of unknown cause. Sequencing of KCNJ5 revealed that affected members of two kindreds had KCNJ5(G151R) mutations, identical to one of the prevalent recurrent mutations in APAs. These individuals had severe progressive aldosteronism and hyperplasia requiring bilateral adrenalectomy in childhood for blood pressure control. Affected members of the other two kindreds had KCNJ5(G151E) mutations, which are not seen in APAs. These subjects had easily controlled hypertension and no evidence of hyperplasia. Surprisingly, electrophysiology of channels expressed in 293T cells demonstrated that KCNJ5(G151E) was the more extreme mutation, producing a much larger Na(+) conductance than KCNJ5(G151R), resulting in rapid Na(+)-dependent cell lethality. We infer that this increased lethality limits adrenocortical cell mass and the severity of aldosteronism in vivo, accounting for the milder phenotype among these patients. These findings demonstrate striking variations in phenotypes and clinical outcome resulting from different mutations of the same amino acid in KCNJ5 and have implications for the diagnosis and pathogenesis of primary aldosteronism with and without adrenal hyperplasia.

The safety and use of short-acting nifedipine in hospitalized hypertensive children.

Recent reports suggest that calcium channel blockers are harmful in the treatment of acute hypertension in adults. However, short-acting nifedipine is an effective and useful medication in pediatric hypertension and is currently utilized for hypertensive emergencies. This study will address these safety concerns in hypertensive children. Medical records (from five Canadian pediatric hospitals) of all pediatric hypertensive hospitalized children who were treated with short-acting nifedipine from January 1995 to December 1998 were retrospectively reviewed for patient demographics, dosing regimen, use of concomitant medications, co-morbid conditions, and presence/absence of minor and serious adverse events. Final data were extracted from 182 patients. Each patient had an average of 2.6 episodes of hypertension in hospital that required treatment, totaling 477 episodes. Within the 477 episodes, 1,162 doses of short-acting nifedipine were administered. The mean dose was 0.22 mg/kg (range 0.043-0.67 mg/kg, median 0.19 mg/kg) with 55.6% (260/468 episodes) receiving the drug via the sublingual route. Hypertension resolved in 85.5% (408/477) of the episodes. There were only 29 of 574 (5.1%) minor adverse events that were definitely or probably related to short-acting nifedipine administration. Two patients experienced a serious adverse event that involved of a reduction in blood pressure of more than 40%, but neither had any symptomatology from the serious adverse event and recovered spontaneously within 2 h. Short-acting nifedipine in hypertensive, hospitalized children appears to be a safe and efficacious medication with minimal side effects.