Iatrogenic ureteric injury during abdominal or pelvic surgery: a meta-analysis.

OBJECTIVE: To assess the incidence of ureteric injuries, clinical value of prophylactic ureteric stenting and impact of intra- or postoperative detection of ureteric injuries in patients treated with gynaecological or colorectal surgery. METHODS: Multiple databases were searched for articles published before September 2021 according to the Preferred Reporting Items for Systematic Review and Meta-Analyses statement. Studies were deemed eligible if they evaluated the differences in the rate of ureteric injuries between laparoscopic and open surgery, prophylactic ureteric stenting or not, and those of final treatment success between intra- and postoperative detection in patients who underwent gynaecological or colorectal surgery. RESULTS: Overall, 46 studies were eligible for this meta-analysis. Compared to open surgery, laparoscopic hysterectomy was associated with a higher incidence of ureteric injuries (pooled odds ratio [OR] 2.12, 95% confidence interval [CI] 1.71-2.62), but there was no statistically significant difference in colectomy (pooled OR 0.89, 95% CI 0.77-1.03). Prophylactic ureteric stenting was associated with a lower incidence of ureteric injuries during gynaecological surgery (pooled OR 0.61, 95% CI 0.39-0.96). The number needed to perform ureteric stenting to prevent one ureteric injury was 224 in gynaecological surgery. On the other hand, prophylactic ureteric stenting did not reduce the risk of ureteric injuries during colorectal surgery. Intraoperative detection of a ureteric injury was associated with a lower rate of complication management failure compared to postoperative detection (pooled OR 0.22, 95% CI 0.12-0.41). CONCLUSIONS: Laparoscopic hysterectomy seems to be associated with a higher rate of ureteric injuries compared to an open approach. Prophylactic ureteric stenting seems to reduce this risk during gynaecological surgery. Intraoperative detection of a ureteric injury during abdominal/pelvic surgery improves outcomes, suggesting the need for awareness and proactive problem identification. Further well-designed studies assessing the candidates who are more likely to benefit from prophylactic ureteric stenting including cost analysis are needed.

Impact of COVID-19 pandemic on functional urology procedures in France: a prospective study.

PURPOSE: To evaluate the impact of COVID-19 pandemic on functional urology procedures in France. METHODS: A prospective study was conducted within 11 secondary and tertiary referral centers in France. Patients aged > 18 years who were diagnosed with a functional urology disease before the national lockdown (March 17th, 2020) and who required a surgery were included. Study period went from March 17th to September 30th 2020. The included interventions were listed according to the guidelines for functional urology enacted by the French Association of Urology and delay of reoperation was compared to the guidelines' delay. The primary outcome was the number of procedures left unscheduled at the end of the study period. Descriptive statistics were performed. RESULTS: From March 17th 2020 to September 3 rd 2020, 1246 patients with a previous diagnosis of a functional urological disease requiring a surgery were included. The mean follow-up was 140.4 days (± 53.4). Overall, 316 interventions (25.4%) were maintained whereas 74 (5.9%) were canceled, 848 (68.1%) postponed and 8 patients (0.6%) died. At the end of the follow-up, 184 patients (21.7%) were still not rescheduled. If the intervention was postponed, the mean delay between the initial and final date was 85.7 days (± 64.4). CONCLUSION: Overall, more than two thirds of interventions had to be postponed and the mean delay between the initial and final date was about three months.

[The use of "Fast-Track" in pediatric urology].

BACKGROUND: Current trends in the anesthesiology require a change in the perioperative management of patients, with a consideration of new approaches to anesthesia and the introduction of methods that reduce the stress response to surgery. AIM: To introduce the "fast-track" concept with the analysis of systemic hemodynamics and stress markers at the perioperative stage in children with urological diseases. MATERIALS AND METHODS: A prospective and retrospective analysis of the results of 42 children with urological disorders treated from 09.2016 to 04.2021 under spinal anesthesia (SA) was carried out. In each case, perioperative parameters were evaluated, including central hemodynamics and biochemical markers of stress response. RESULTS: Hemodynamic stability under SA in young children has an evidence base and a physiological explanation. Changes in stress response markers in various anesthesia methods revealed a more pronounced stress-protective effect in SA than in general anesthesia. CONCLUSIONS: Our data have shown that combined SA for urological procedures in children allows to more effectively and reliably prevent and block the manifestations of stress-induced reactions of hemodynamics and metabolism than general anesthesia. The introduction of fast-track approach in pediatric urology resulted in the faster postoperative recovery and shorter length of stay.

[Urological problems related to coloproctology. Part 1].

The aim of this review was to characterize the possible urological manifestations of rectal disorders in case of the involvement of the genitourinary system, as well as the symptoms of urological diseases involving the distal part of the large bowel. In urological and coloproctological practice, the anatomical and physiological proximity of the distal part of the intestine and the urogenital organs is of importance (for example, the common innervation of the pelvic organs, the synergy of the pelvic floor muscles, etc.), since it results in similar clinical manifestations, making it difficult to make a diagnosis. The most relevant and common urological and proctological diseases, including prostatitis, intestinovesical and rectourethral fistulas, damage to the ureter and bladder during colorectal surgery are discussed in the article. Particular attention is paid to the interdisciplinary cooperation of urologists and proctologists and the frequent need for their joint participation in the diagnosis and treatment of the pelvic organs disorders.

A Critical Appraisal of the American College of Surgeons Medically Necessary, Time Sensitive Procedures (MeNTS) Scoring System, Urology Consensus Recommendations and Individual Surgeon Case Prioritization for Resumption of Elective Urological Surgery During the COVID-19 Pandemic.

PURPOSE: Resumption of elective urology cases postponed due to the COVID-19 pandemic requires a systematic approach to case prioritization, which may be based on detailed cross-specialty questionnaires, specialty specific published expert opinion or by individual (operating) surgeon review. We evaluated whether each of these systems effectively stratifies cases and for agreement between approaches in order to inform departmental policy. MATERIALS AND METHODS: We evaluated triage of elective cases postponed within our department due to the COVID-19 pandemic (March 9, 2020 to May 22, 2020) using questionnaire based surgical prioritization (American College of Surgeons Medically Necessary, Time Sensitive Procedures [MeNTS] instrument), consensus/expert opinion based surgical prioritization (based on published urological recommendations) and individual surgeon based surgical prioritization scoring (developed and managed within our department). Lower scores represented greater urgency. MeNTS scores were compared across consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores. RESULTS: A total of 204 cases were evaluated. Median MeNTS score was 50 (IQR 44, 55), and mean consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores were 2.6±0.6 and 2.2±0.8, respectively. Median MeNTS scores were 52 (46.5, 57.5), 50 (44.5, 54.5) and 48 (43.5, 54) for individual surgeon based surgical prioritization priority 1, 2 and 3 cases (p=0.129), and 55 (51.5, 57), 47.5 (42, 56) and 49 (44, 54) for consensus/expert opinion based surgical prioritization priority scores 1, 2, and 3 (p=0.002). There was none to slight agreement between consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores (Kappa 0.131, p=0.002). CONCLUSIONS: Questionnaire based, expert opinion based and individual surgeon based approaches to case prioritization result in significantly different case prioritization. Questionnaire based surgical prioritization did not meaningfully stratify urological cases, and consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization frequently disagreed. The strengths and weaknesses of each of these systems should be considered in future disaster planning scenarios.

The dramatic COVID 19 outbreak in Italy is responsible of a huge drop of urological surgical activity: a multicenter observational study.

OBJECTIVE: To describe the trend in surgical volume in urology in Italy during the coronavirus disease 2019 (COVID-19) outbreak, as a result of the abrupt reorganisation of the Italian national health system to augment care provision to symptomatic patients with COVID-19. METHODS: A total of 33 urological units with physicians affiliated to the AGILE consortium (Italian Group for Advanced Laparo-Endoscopic Surgery; www.agilegroup.it) were surveyed. Urologists were asked to report the amount of surgical elective procedures week-by-week, from the beginning of the emergency to the following month. RESULTS: The 33 hospitals involved in the study account overall for 22 945 beds and are distributed in 13/20 Italian regions. Before the outbreak, the involved urology units performed overall 1213 procedures/week, half of which were oncological. A month later, the number of surgeries had declined by 78%. Lombardy, the first region with positive COVID-19 cases, experienced a 94% reduction. The decrease in oncological and non-oncological surgical activity was 35.9% and 89%, respectively. The trend of the decline showed a delay of roughly 2 weeks for the other regions. CONCLUSION: Italy, a country with a high fatality rate from COVID-19, experienced a sudden decline in surgical activity. This decline was inversely related to the increase in COVID-19 care, with potential harm particularly in the oncological field. The Italian experience may be helpful for future surgical pre-planning in other countries not so drastically affected by the disease to date.

Impact of Multidisciplinary Audit of Enhanced Recovery After Surgery (ERAS)® Programs at a Single Institution.

BACKGROUND: As Enhanced Recovery After Surgery (ERAS®) programs expand across numerous subspecialties, growth and sustainability on a system level becomes increasingly important and may benefit from reporting multidisciplinary and financial data. However, the literature on multidisciplinary outcome analysis in ERAS is sparse. This study aims to demonstrate the impact of multidisciplinary ERAS auditing in a hospital system. Additionally, we describe developing a financial metric for use in gaining support for system-wide ERAS adoption and sustainability. METHODS: Data from HPB, colorectal and urology ERAS programs at a single institution were analyzed from a prospective ERAS Interactive Audit System (EIAS) database from September 2015 to June 2019. Clinical 30-day outcomes for the ERAS cohort (n = 1374) were compared to the EIAS pre-ERAS control (n = 311). Association between improved ERAS compliance and improved outcomes were also assessed for the ERAS cohort. The potential multidisciplinary financial impact was estimated from hospital bed charges. RESULTS: Multidisciplinary auditing demonstrated a significant reduction in postoperative length of stay (LOS) (1.5 days, p < 0.001) for ERAS patients in aggregate and improved ERAS compliance was associated with reduced LOS (coefficient - 0.04, p = 0.004). Improved ERAS compliance in aggregate also significantly associated with improved 30-day survival (odds ratio 1.04, p = 0.001). Multidisciplinary analysis also demonstrated a potential financial impact of 44% savings (p < 0.001) by reducing hospital bed charges across all specialties. CONCLUSIONS: Multidisciplinary auditing of ERAS programs may improve ERAS program support and expansion. Analysis across subspecialties demonstrated associations between improved ERAS compliance and postoperative LOS as well as 30-day survival, and further suggested a substantial combined financial impact.

Management of the Transitional Urology Patient: the Role of the Adult Reconstructive Urologist.

PURPOSE OF REVIEW: Patients with congenital urologic conditions present unique challenges as adults. Herein, we review the literature relevant to the adult reconstructive urologist confronted with complex surgical concerns affecting their patients with a history of hypospadias, spina bifida, and other syndromes affecting the genitourinary tract. RECENT FINDINGS: Urethral stricture disease related to hypospadias is complex, but successful urethroplasty and penile curvature correction can be achieved with an anatomically minded approach. Multiple urinary diversion techniques can be considered in a patient-centered approach to bladder management in the adult spina bifida patient, but complications are common and revision surgeries are frequently required. Strong evidence is lacking for most surgical techniques in this population, but experiences reported by pediatric and adult urologists with genitourinary reconstruction training can help foster consensus in decision-making. Urologists trained in genitourinary reconstruction may be uniquely positioned to care for the transitional urology patient as they enter adolescence and adulthood.

Single Port Robotic Surgery in Urology.

PURPOSE: To provide a comprehensive review on the new da Vinci SP (single port) robotic surgical system. The published literature to date within urology and a description of the new system will be discussed. FINDINGS: There are currently no high-quality published studies with the SP robotic system. All studies are case series, many with 10 or fewer patients. However, all studies have found the SP system to be safe and feasible in performing most urological procedures. Renal and pelvic surgery using the SP robotic system is safe and feasible in the hands of expert robotic surgeons. Long-term, high-quality data is lacking. While the current high price and the learning curve will limit the SP systems' use in many health care systems, new updates and the release of robotic surgical systems from other developers may help drive down costs and encourage uptake.

Risk-based stratification triaging system in pediatric urology: what COVID-19 pandemic has taught us.

INTRODUCTION AND OBJECTIVE: SARS-COV-2 pandemic has affected the population worldwide requiring social distancing, quarantine and isolation as strategies to control virus propagation. Initial measures to reduce the burden to the health care system during the pandemic included deferring elective surgery. These damage control measures did not take into account the mid- and long-term implications. Management of congenital anomalies can be time sensitive with delays resulting in permanent disability, morbidity and increased costs to the healthcare system. This study reports the results of using a novel scoring system that enables triage of time sensitive congenital anomalies and pediatric surgical conditions and how implementation of Enhanced Recovery After Surgery (ERAS®) principles allowed optimization of resources and reduced the burden to the system while allowing for appropriate care of pediatric patients with urgent urologic surgical conditions. METHODS: We present a prospective case series of patients with congenital urological conditions scheduled and taken to surgery during COVID-19 pandemic. All pediatric urology cases that were pending and or scheduled for surgery at the moment the pandemic struck as well as all cases that presented to the emergency department with urological conditions were triaged and included for analysis using a modified Medically Necessary, Time-Sensitive Procedures: Scoring System (MeNTS). A modified MeNTS was implemented for pediatric patients, giving more priority to the impact of deferring surgical intervention on patient's prognosis. An individualized evaluation using this scoring system was applied to each patient. Intra- and postoperative ERAS® principles were applied to all cases operated during the pandemic between March 20th and April 24th to reduce the burden to the healthcare system. RESULTS: A total of 49 patients were triaged and included for analysis with a mean age of 6.47 years of age. Adjusted MeNTS showed that all clinically emergent cases had a score of 12 or less. Cases that could be postponed for 2 weeks but no longer had a score between 13 and 15. The ones that could wait 6 weeks or longer had scores higher than 16. Score results were not the same for similar procedures and individualized assessments resulted in scores based on an individual patient's conditions. From the total cases, implementation of ERAS® principles increased outpatient procedures from 68 to 90.4%. CONCLUSION: Our results provide a novel triaging method to rank pediatric urological surgical management based on individualized patient's clinical conditions. Cutoff values of 12 and 16 allowed appropriate triage preventing the postponement of urgent urologic cases during the COVID-19 pandemic. Implementation of ERAS® principles allowed for these procedures to be done in the outpatient setting, preserving valuable healthcare resources. TYPE OF STUDY: Prospective cohort study. LEVEL OF EVIDENCE: IV.

[Outcomes following the triage of patients for urological cancer and non-cancer surgery during Covid-19 pandemic peak]. / Évaluation des mesures de triages de la première vague pandémique Covid-19 pour sélectionner les patients à opérer pour cancers et urgences urologiques.

INTRODUCTION: Faced with the first wave of Covid-19 pandemic, guidelines for surgical triage were developed to free up healthcare resources. The aim of our study was to assess clinical characteristics and surgical outcomes of triaged patients during the first Covid-19 crisis. METHOD: We conducted a cohort-controlled, non-randomized, study in a University Hospital of south-eastern France. Data were collected prospectively from consecutive patients after triage during the period from March 15th to May 1st and compared with control data from outside pandemic period. Primary endpoint was intensive care unit (ICU) admissions for surgery-related complications. Rates of surgery-specific death, postponed operations, positive PCR testing and Clavien-Dindo complications and data from cancer and non- cancer subgroups were assessed. RESULTS: After triage, 96 of 142 elective surgeries were postponed. Altogether, 71 patients, median age 68 y.o (IQR: 56-75 y.o), sex ratio M/F of 4/1, had surgery, among whom, 48 (68%) had uro-oncological surgery. No patients developed Covid-19 pneumonia in the post-surgery period. Three (4%) were admitted to the ICU, one of whom died from multi-organ failure due to septic shock caused by klebsiella pneumonia following a delay in treatment. Three Covid-19 RT-PCR were done and all were negative. There was no difference in mortality rates or ICU admission rates between control and Covid- era patients. CONCLUSIONS: Surgery after triage during the first Covid-19 pandemic was not associated with worse short-term outcomes. Urological cancers could be operated on safely in our context but delays in care for aggressive genitourinary diseases could be life threatening. LEVEL OF EVIDENCE: 3.

Does "MyChart" Benefit "My" Surgery? A Look at the Impact of Electronic Patient Portals on Patient Experience.

PURPOSE: Electronic patient portals can be beneficial in providing direct engagement and clarity to avoid unnecessary extra provider encounters. In this study we assessed whether portal usage among endourology patients affected telephone call frequency, unscheduled physician visits, emergency department presentations and complication rates. MATERIALS AND METHODS: We conducted a retrospective chart review of patients undergoing elective endourology procedures by a single surgeon at a tertiary urology center from July 2017 to July 2018. Patient demographics, operative details, patient portal (MyChart) registration, patient initiated MyChart messages, telephone encounters, unscheduled physician visits and emergency department presentations during a 1-month period before and after the procedure were identified. Logistic regression analysis assessed relationships between MyChart use and study outcomes. RESULTS: We identified 313 patients (200 MyChart users, 113 nonusers) who underwent 374 procedures. MyChart users were younger (age 56 vs 61, p=0.0011) and more likely to be married (69.5% vs 48.7%, p=0.0004). MyChart users made fewer telephone calls before (1.1 vs 1.2, p=0.005) and after procedure (0.9 vs 1.3, p=0.029), and had fewer emergency department visits (8 vs 18, p=0.0005) than nonusers. On multivariable analysis MyChart nonusers were 4.55 (95% CI 1.92-11.11) times more likely to have an unscheduled clinic visit (p=0.0006), 1.92 (95% CI 1.075-3.333) times more likely to have an emergency department visit (p=0.028) and 2.7 (95% CI 1.43-5.26) times more likely to have a postoperative complication (p=0.0026). CONCLUSIONS: Patients undergoing endourology procedures who use MyChart make fewer telephone calls and are significantly less likely to have an unscheduled clinic/emergency department visit or a complication.

Relative Value Units do Not Adequately Account for Operative Time of Urological Surgery.

PURPOSE: Physician work relative value units are determined based on operative time, technical skill, mental effort and stress. In theory, work relative value units should account for the operative time involved in a procedure, resulting in similar work relative value units per unit time for short and long procedures. We assessed whether operative time is adequately accounted for by the current work relative value units assignments. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed from 2015 to 2017. The 50 most frequently coded urology CPT codes were included in the study. The primary variable was work relative value units per hour of operative time (work relative value units per hour). Linear regression analysis was used to assess the associations between work relative value units, operative time and the work relative value units per hour variable. RESULTS: A total of 105,931 cases were included in the study. Among the included urology CPTs the median work relative value units was 15.26, median operative time was 48 minutes and median work relative value units per hour was 11.2. CPTs with operative time less than 90 minutes had higher work relative value units per hour compared with longer procedures (12.2 vs 8.7, p <0.001). Univariable analysis revealed that each additional hour of operative time was associated with a decrease in work relative value units per hour by 1.32 (-0.022 per minute, 95% CI -0.037 - -0.001, p <0.001) and that work relative value units were not statistically associated with work relative value units per hour (-0.093, 95% CI -0.193 - 0.007, p=0.07). CONCLUSIONS: This analysis of large population, national level data suggests that the current work relative value units assignments do not proportionally compensate for longer operative times.

A Systematic Review of Complications of Minimally Invasive Surgery in the Pediatric Urological Literature.

PURPOSE: Minimally invasive surgery has been gaining momentum in pediatric urology and it is essential to analyze the unique complications pertinent to this approach. We conducted a systematic review to evaluate pediatric minimally invasive surgery complications in the published urological literature. MATERIALS AND METHODS: We searched PubMed®/MEDLINE® using relevant pediatric minimally invasive surgery terminology and applied specified eligibility criteria. The Clavien-Dindo classification scheme was used to categorize postoperative complications. For studies not using Clavien-Dindo, complications were recategorized into Clavien-Dindo grades. Primary outcome was frequency of grade III complications and conversions to open surgery. Covariates were surgery type (pyeloplasty, nephrectomy, partial nephrectomy, ureteral reimplantation and complex reconstruction) and surgical approach (laparoscopic, robotic assisted and/or laparoendoscopic single site). Proportions were compared using the chi-square test (α=0.05). RESULTS: Overall 123 studies met the inclusion criteria, reporting outcomes of 5,864 patients. About a third (35.8%) of studies used the Clavien-Dindo classification. Nephrectomy had a significantly lower frequency of grade III complications (1.18%) compared to pyeloplasty (3.64%), ureteral reimplantation (6.65%) and complex reconstruction (11.76%) (p <0.05). Complex reconstruction had a significantly higher frequency of grade III complications (11.39%) compared to all other analyzed surgeries (p <0.05). CONCLUSIONS: The rate of complications and open conversions varies by surgical procedure in pediatric urological minimally invasive surgery. Despite the existence of a standardized complication classification system, the majority of reviewed publications did not report complications in a standardized fashion. Our findings call for more robust studies in pediatric minimally invasive surgery and universal implementation of standardized complication reporting.

The LACE + index as a predictor of 90-day urologic surgery outcomes.

PURPOSE: This study assessed the ability of the LACE + [Length of stay, Acuity of admission, Charlson Comorbidity Index (CCI) score, and Emergency department visits in the past 6 months] index to predict adverse outcomes after urologic surgery. METHODS: LACE + scores were retrospectively calculated for all consecutive patients (n = 9824) who received urologic surgery at one multi-center health system over 2 years (2016-2018). Coarsened exact matching was employed to sort patient data before analysis; matching criteria included duration of surgery, BMI, and race among others. Outcomes including unplanned hospital readmission, emergency room visits, and reoperation were compared for patients with different LACE + quartiles. RESULTS: 722 patients were matched between Q1 and Q4; 1120 patients were matched between Q2 and Q4; 2550 patients were matched between Q3 and Q4. Higher LACE + score significantly predicted readmission within 90 days (90D) of discharge for Q1 vs Q4 and Q2 vs Q4. Increased LACE + score also significantly predicted 90D emergency room visits for Q1 vs Q4, Q2 vs Q4, and Q3 vs Q4. LACE + score was also significantly predictive of 90D reoperation for Q1 vs Q4. LACE + score did not predict 90D reoperation for Q2 vs Q4 or Q3 vs Q4 or 90D readmission for Q3 vs. Q4. CONCLUSION: These results suggest that LACE + may be a suitable prediction model for important patient outcomes after urologic surgery.

The changing role of lasers in urologic surgery.

PURPOSE OF REVIEW: To summarize recent publications on the topic of laser in urology and explore new developments which may impact the future role of lasers in surgery. RECENT FINDINGS: Ho: Yttrium-aluminium garnet (YAG) laser with Moses technology allows less retropulsion during a lithotripsy, yet its efficacy needs to be tested in clinical trials. Data on the efficacy of this device for benign prostatic obstruction treatment is also pending. A new promising generation of laser systems - thulium-fiber (Tm-fiber) lasers - has been introduced. Tm-fiber has already been shown to be effective and well tolerated in endoscopic enucleation of the prostate and has demonstrated favorable outcome compared with Ho:YAG in preclinical lithotripsy studies. However, more studies are needed to better understand the use of this novel technology and elucidate its role within the armamentarium of available technologies. SUMMARY: Lasers remain an integral part of benign prostatic hyperplasia surgery and stone treatment and gain popularity in en-bloc resection of bladder cancer. Current efficacy of laser systems in prostate cancer ablation and their place in laparoscopy remain unclear, despite promising initial reports.

Robotic treatment for urinary tract endometriosis: preliminary results and surgical details in a high-volume single-Institutional cohort study.

BACKGROUND: Aim of the study was to present the surgical techniques and the postoperative outcomes in women treated with robotic excision for deep endometriosis involving the urinary tract. MATERIALS AND METHODS: We retrospectively reviewed the prospectively recorded clinical data of women consecutively undergoing minimally invasive treatment for complex endometriosis involving urinary tract in our center between January 2012 and June 2018. All the patients received a preoperative multidisciplinary evaluation with the general surgeon, the gynecologist and the urologist due to the frequent concomitant involvement of bowel and genital system. Patients undergoing robotic surgery were treated with the Si or Xi da Vinci surgical system. RESULTS: A total of 74 consecutive patients were enrolled. Twenty-eight (37.8%) patients underwent conventional laparoscopy and 46 (62.2%) robotic surgery. Only patients treated with robotic approach were considered for the final analyses. Overall, 17 (36.9%) patients were treated with partial cystectomy, 13 (28.3%) with ureteral reimplantation, 10 (21.7%) patients were treated with ureteral lysis, 4 (8.7%) with removal of bladder endometrial node without opening the mucosa layer and 2 (4.3%) with ureteral end-to-end anastomosis. Concomitant involvement of bowel and genital system was registered in 14 (30.4%) and 32 (69.5%) patients, respectively. No conversions to laparotomy were recorded. Overall, 5 (10.9%) patients experienced postoperative complications, of which only one was a major complication (Clavien 3b). At a median follow-up of 31.3 (IQR 17.6-43.3) months, 4 (8.7%) patients experienced disease recurrence at the level of urinary tract. CONCLUSIONS: Robotic excision of urological endometriosis represents a safe and effective treatment option, since a limited rate of surgical complications was recorded even in cases of multi-organ disease.

Urological implications of SARS CoV-19.

INTRODUCTION: The novel coronavirus disease 2019 (COVID-19), pandemic has afflicted > 3.3 million people around the world since December 2019. Though, more than 1000 publications have appeared in scientific journals addressing a plethora of questions, there is a considerable hiatus in understanding of the behavior and natural history of the virus and its impact on urology. Also, a modified approach is the need of hour in taking care of patients as urologists should safeguard their teams, families, and patients. MATERIAL AND METHODS: The authors have used guidelines from USA, Canada, UK, Europe and India for making recommendations to help urologist define their own policies that may have to be fine-tuned on the basis of continued and evolving challenges they would encounter and the local resources at their disposal. RESULTS: COVID-19 do effect genitourinary system from kidney to testis. The authors provide scientific basis to urologists to help identify patients by remote consultation who are likely to be harmed by coming to the hospital, and not to miss those who need hospitalization for diagnostic or therapeutic interventions. There is uncompromised need of specific precautions during surgery to safe guard the surgeon and his team along with the patient. CONCLUSIONS: Urological operations during COVID-19 pandemic should be limited to emergency cases during the acute phase with an exit strategy planned in a staggered manner, based on the scientific risk stratification. Telemedicine (e-clinics or virtual clinics) would help achieve the goal of risk stratification.

[Clinical outcomes of simultaneous bilateral endoscopic surgery for bilateral upper urinary tract calculi].

OBJECTIVE: To discuss the efficacy and safety of simultaneous bilateral endoscopic surgery (SBES) for bilateral upper urinary tract calculi, and to summarize the initial experience. METHODS: Patients diagnosed with bilateral upper urinary tract calculi who underwent SBES in the Department of Urology, Beijing Chao-Yang Hospital from January 2019 to January 2020 were enrolled retrospectively. The demographic and clinical data of the patients were recorded, and the operation status, stone free rate (SFR) and peri-operative complications were analyzed. The primary end point was SFR, and second end point was peri-operative complications. RESULTS: A total of 23 patients underwent SBES, of which SBES was completed in 19 patients (12 males, and 7 females). The mean age was (41.3±12.0) years. Fourteen patients underwent modified supine position surgery and 4 patients in prone split-leg position. There was no statistical difference in the demographic and baseline clinical data of the patients in different positions. One patient underwent right percutaneous nephrolithotomy (PCNL) and left endoscopic combined intra-renal surgery (ECIRS) in the prone split-leg position, while 18 patients received simul-taneous surgery with PCNL and contralateral retrograde intra-renal surgery (RIRS). The mean anesthesia and operation time was (128.7±26.5) min and (70.7±20.3) min, respectively, which was significantly longer in the patients with prone split-leg position than in the patients with modified supine position, anesthesia time in the patients with prone split-leg position and modified supine position: (148.4±20.4) min vs. (121.6±25.3) min, respectively, t=－2.121, P=0.049, while the operation time in the patients with prone split-leg position and modified supine position: (86.4±21.1) min vs. (65.1±17.4) min, respectively, t=－2.222, P=0.040. There was no significant difference between the two groups in indwelling of nephrostomy [prone split-leg position and modified supine position: (2.6±0.9) d vs. (2.1±1.0) d, respectively; t=－0.880, P=0.391] and the length of hospital stay [prone split-leg position and modified supine position: (6.0±2.7) d vs. (5.2±1.8) d, respectively; t=－0.731, P=0.475]. One month after the operation, the SFR was 78.9%, and 3 patients had minor peri-operative complications (Clavien-Dindo grades Ⅰ/Ⅱ) without any serious complications (Clavien-Dindo grades Ⅲ/Ⅳ/Ⅴ). CONCLUSION: The simultaneous bilateral endoscopic surgery would decrease the operation time and anesthesia exposure under the premise of ensuring the SFR, which is helpful to reduce the risk of peri-operative complications, especially to the patients who can not tolerate the second-stage or long-time operation.

Enteric conversion after bladder-drained pancreas transplantation is not associated with worse allograft survival.

In the early experience of pancreas transplantation, bladder drainage was favored, but it often caused urologic, metabolic, and infectious complications that necessitated conversion to enteric drainage. Long-term graft survival after enteric conversion and the impact of time interval from transplantation to enteric conversion on graft survival is poorly understood. We studied all bladder-drained first-time pancreas transplantations performed at the University of Wisconsin from 1985 to 2000. Time to conversion was estimated with the Kaplan-Meier technique, whereas risk factors associated with conversion were estimated via a time-varying Cox proportional hazards model. Of 386 bladder-drained pancreata, 162 (41.9%) eventually required enteric conversion, 29 (17.9%) within the first year. Median time to conversion varied by indication: 0.68 years for surgical, 3.1 years for urologic, and 2.7 years for metabolic disorders. In a time-varying Cox model adjusting for donor and recipient factors, enteric conversion did not affect the risk of pancreas graft loss (hazard ratio [HR] 0.86, P = .26). Kidney survival was not associated with enteric conversion. When necessary due to symptoms or complications, enteric conversion of bladder-drained pancreata is safe and does not affect overall graft survival. This relationship appears to be true no matter when the conversion is performed.