Could Use of a Flexible and Navigable Suction Ureteral Access Sheath Be a Potential Game-changer in Retrograde Intrarenal Surgery? Outcomes at 30 Days from a Large, Prospective, Multicenter, Real-world Study by the European Association of Urology Urolithiasis Section.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the stone-free status (SFS) rate and complications after flexible ureteroscopy (fURS) for treatment of renal stones using a flexible and navigable suction (FANS) ureteral access sheath. METHODS: Data for adults undergoing fURS in 25 centers worldwide were prospectively collected (August 2023 to January 2024). Exclusion criteria were abnormal renal anatomy and ureteral stones. All patients had computed tomography scans before and within 30 d after fURS with a FANS ureteral access sheath. SFS was defined as follows: grade A, zero fragments; grade B, a single fragment ≤2 mm; grade C, a single fragment 2.1-4 mm; and grade D, single/multiple fragments >4 mm. Data for continuous variables are presented as the median and interquartile range (IQR). Multivariable logistic regression was performed to evaluate predictors of grade A SFS. KEY FINDINGS AND LIMITATIONS: The study enrolled 394 patients (59.1% male) with a median age of 49 yr (IQR 36-61). The median stone volume was 1260 mm3 (IQR 706-1800). Thulium fiber laser (TFL) was used in 45.9% of cases and holmium laser in the rest. The median lasing time was 18 min (IQR 11-28) and the median operative time was 49 min (IQR 37-70). One patient required a blood transfusion and 3.3% of patients had low-grade fever. No patient developed sepsis. Low-grade ureteral injury occurred in eight patients (2%). The grade A SFS rate was 57.4% and the grade A + B SFS rate was 97.2%, while 2.8% of patients had grade C or D SFS. Eleven patients underwent repeat fURS. Multivariable analysis revealed that a stone volume of 1501-3000 mm3 (odds ratio 0.50) and of >3000 mm3 (odds ratio 0.29) were significantly associated with lower probability of grade A SFS, while TFL use was associated with higher SFS probability (odds ratio 1.83). Limitations include the lack of a comparative group. CONCLUSIONS AND CLINICAL IMPLICATIONS: fURS using a FANS ureteral access sheath resulted in a high SFS rate with negligible serious adverse event and reintervention rates. PATIENT SUMMARY: We looked at 30-day results for patients undergoing telescopic laser treatment for kidney stones using a special type of vacuum-assisted sheath to remove stone fragments. We found a high stone-free rate with minimal complications.

First prospective clinical assessment of the ILY® robotic flexible ureteroscopy platform.

PURPOSE: To present the initial prospective clinical assessment of the ILY® robotic ureteroscopy manipulator platform, focusing on its safety and effectiveness. METHODS AND MATERIALS: Data gathered from 31 kidney units which underwent elective robotic flexible ureteroscopy (FURS) for renal stone management utilizing the ILY® robotic system. Patient demographics, stone characteristics, surgical durations, perioperative and post-operative complications, and follow-up parameters were collected. Our primary outcome was evaluating the efficacy and safety of the ILY® robotic ureteroscopy for treating kidney stones. Therefore, we analyzed complication rates, surgical durations, and the stone-free rate during follow-up. RESULTS: Our cohort consisted of 29 patients, presenting with 45 stones with a median volume of 736.22 mm3. The median operation time was 85 min, accompanied by 3 min for robot draping, 3.5 min for robot docking, 48 min of console operation, and lasing time of 36.75 min. Post operative stay for all patients was 1 day, while complications were observed in 9.68% of cases. Notably, all complications were classified as CVD (Clavien-Dindo) class 1 due to pain requiring emergency department visit. The stone-free rate achieved was 93.55%, and none of the patient required reoperation for the treated stone. CONCLUSION: In the first prospective clinical experience of the ILY® robotic FURS, we demonstrated its efficacy and safety. To further investigate its clinical practical value, additional investigations are warranted, including direct comparative analyses with manual flexible ureteroscopy techniques.

Prostate cancer presentation and management in the Middle East.

BACKGROUND: Although prostate cancer is a prevalent malignancy worldwide, its clinical presentation and management in the Middle East are not well-documented. This study aims to provide insights into the initial clinical presentation and management of prostate cancer in this region. METHODS: A retrospective review was conducted on seven institutional databases from six Middle Eastern countries, including Türkiye, Lebanon, Iraq, Syria, Bahrain, and Jordan, to identify patients diagnosed with prostate cancer in 2021. Descriptive analysis was performed on the collected data to provide an overview of the demographic, clinical, and treatment variables. RESULTS: A total of 1,136 patients were identified with a median age of 70 (range, 50-84). Most patients (78%) received their prostate cancer diagnosis after presenting with symptoms, as opposed to routine PSA screening. At the time of diagnosis, 35% of men had clinical T3 or T4 disease, 54% with Stage IV disease and 50% with Gleason score ≥ 8. Regarding treatment, 20% of non-metastatic and 22% of metastatic patients received no treatment. CONCLUSION: Most men in this study sought prostate cancer evaluation due to symptoms and were subsequently diagnosed with advanced-stage disease, providing a foundation for future research aimed at understanding the underlying factors behind the observed trends and enabling informed interventions.

The impact of AirSeal® on complications and pain management during robotic-assisted radical prostatectomy: a single-tertiary center study.

PURPOSE: We aimed to compare perioperative outcomes, post-operative complications, and opioid use between AirSeal® and non-AirSeal® robotic-assisted radical prostatectomy (RARP). METHODS: We retrospectively collected data on 326 patients who underwent elective RARP at our institution either with or without AirSeal®. The first 60 cases were excluded accounting for the institutions' learning curve of RARP. Patient demographics, oncologic, pathologic, and surgical characteristics between AirSeal® and non-AirSeal® cases were compared. Furthermore, outcomes of interest including operative time, length of stay, morbidity, and opioid use for pain management were compared between the two groups. Univariate linear and logistic regression models were developed. RESULTS: The AirSeal® group consisted of 125 (38.3%) patients while the non-AirSeal® group consisted of 201 (61.7%) patients. No statistically significant difference was seen in terms of patient demographics, oncologic characteristics, surgical characteristics, and pathologic characteristics between the two groups. In addition, univariate linear regression showed that RARP with AirSeal® displayed shorter operative times by 12.3 min and a shorter length of hospital stay by 0.5 days compared to the non-AirSeal® group (p < 0.001). Furthermore, the AirSeal® group witnessed lower odds of Clavien-Dindo (CVD) Class > 2 complications (OR = 0.102) and a lower need for opioid use (OR = 0.49) compared to the non-AirSeal® group (p < 0.022). CONCLUSION: RARP using AirSeal® is associated with shorter operative times, shorter length of hospital stays, lower odds of CVD > 2 complications, and lower odds of opioid use with respect to non-AirSeal® RARP. The efficacy and cost effectiveness of using the AirSeal® system during RARP should be further studied and evaluated by clinical trials.

Preoperative predictors of prolonged length of stay in radical cystectomy: a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Program Dataset.

Background: Radical cystectomy (RC) is considered a complex procedure that entails significant morbidity and mortality. Objectives: We aimed to determine pre-operative patient characteristics that help predict a prolonged length of hospital stay (PLOS) following RC. Design and Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to select patients who underwent RC between the years 2011 and 2020. Prolonged length of stay was defined as a hospital stay ⩾9 days. We compared patient demographics, pre-operative labs, surgical characteristics, and medical history between patients with or without PLOS. Multivariable logistic regression models controlling for pre-operative characteristics and propensity score matching for post-operative complications were conducted to control for possible confounders. Results: The analysis yielded details of 19,158 RC patients of which 6007 (31%) patients had a PLOS. Patients with PLOS were more likely to have post-operative complications that could serve as predictors for the PLOS rather than their pre-operative characteristics. Hence, we matched our cohort for these complications. After matching, patient pre-operative characteristics that predict PLOS included female gender (Odds Ratio (OR) = 5.91), 10-year increase in age (OR = 1.15), non-White race (OR = 1.98), partially or totally dependent functional health status (OR = 2.86), bleeding disorders (OR = 4.67), congestive heart failure (OR = 1.59), pre-operative transfusion (OR = 3.03), and a 20-min increase in operative time (OR = 1.01) (p < 0.046). Conclusion: Patient demographics and pre-operative factors can help predict PLOS in RC patients. These predictors could serve as tools for patient counseling and risk stratification.

A survey-based study about burnout among postgraduate medical trainees: implications for leaders in healthcare management.

Introduction: The goal of the study is to assess burnout among postgraduate medical trainees, evaluate the association with sociodemographic features and offer potential wellness strategies for leaders responsible for their education, training, management, and wellbeing. Methods: The Oldenburg Burnout Inventory was used. The web-based, voluntary, and anonymous survey was sent to postgraduate medical trainees from various specialties and all years of training in a tertiary medical center in Beirut, Lebanon. Additional questions were added after the survey regarding reporting channels for burnout and possible interventions for wellbeing. Results: The total number of valid responses are 188. The prevalence rates of high burnout are 37.2% for disengagement and 51.1% for exhaustion. There is a significant difference between the mean of exhaustion and gender (p = 0.003). There is a significant difference between the mean of disengagement and year of training (p = 0.017). There is a significant difference between the mean of exhaustion and year of training (p = 0.029). There is a significant difference between the frequency of disengagement and year of training (p = 0.027). Conclusion: The study reveals how postgraduate medical training program is impacted by the existing challenges from social, health, and financial standpoint, along with the instabilities encountered such as multiple wars and port blast in 2020 and how these variables aggravate burnout. Burnout severely impacts the education and training of PGMT and promoting wellbeing can help reverse the process. Findings contribute to establishing effective strategic interventions for leaders in healthcare management to adopt.

Robotic-assisted radical prostatectomy is pushing the boundaries: a national survey of frailty using the national surgical quality improvement program.

Background: Robotic-assisted radical prostatectomy (RARP) has been found to be comparable and, in some cases, favorable to open surgical approaches, while being used in a frailer population. Objectives: We aimed to illustrate the trend in population frailty and compare morbidity and mortality postoperatively in patients who underwent RARP. Design and Methods: The National Surgical Quality Improvement Program data set was used to select patients who underwent RARP between the years 2011-2019. Age, frailty indicators, surgical characteristics, and perioperative morbidity and mortality were compared between the years 2011-2019 using the chi-square test (χ2) for categorical variables and the one-way analysis of variance (ANOVA) for continuous variables. Results: Our patient population consisted of 66,683 patients who underwent RARP. There was an increase in mean age and frailty indicated by an increase in 5-item frailty score ⩾2, metabolic syndrome index = 3, and American Society of Anesthesiologists' (ASA) class ⩾3 between the years 2011-2019 (p < 0.001). Whereas the rate of mortality and morbidity, indicated by postoperative Clavien-Dindo grade ⩾4 and major morbidity, remained the same over the same period (p > 0.264). Furthermore, operative time and length of stay decreased over the same period (p < 0.001). Conclusion: RARP is being performed on more frail patients, with no added morbidity or mortality.

Comparative analysis of partial versus radical nephrectomy for renal cell carcinoma: Is oncologic safety compromised during nephron sparing in higher stage disease?

Objectives: Over the past 20 years, the utility of partial nephrectomy (PN), compared to radical nephrectomy (RN), for the management of localized renal cell carcinoma (RCC) has progressively increased, particularly for larger and more complex masses. We sought to compare the recurrence-free survival (RFS) outcomes of PN versus RN in a single-institution cohort. Methods: Between 2002 and 2017, 228 patients underwent RN or PN for lcT1a-T2b, N0M0 RCC at a single tertiary referral center, performed by five surgeons. The clinical end point result was (local or distant) RFS. Univariate and multivariate (cox regression) models were used to evaluate the association between type of surgery (PN vs. RN) and RFS, in the overall cohort and in a subgroup of patients with cT1b. Results: The median age was 59 (interquartile range [IQR] 48-66), and the median tumor size was 4.5 cm (IQR 3-7). There were 128 PN and 100 RN. Over a median follow-up of 4.2 years (IQR 2.2-6.9), the Kaplan-Meier analysis showed no significant RFS difference between PN and RN (logrank P = 0.53). On multivariate analysis, pathologic stage ≥T2a, Fuhrman Grade ≥3, and chromophobe histology were associated with a worse RFS. PN was not significantly associated with diminished RFS (Hazard ratio [HR] 1.78, 95% confidence interval [CI] 0.74-4.3, P = 0.199) in the overall cohort compared to RN. However, in the cT1b subgroup, PN was associated with a significant increase in recurrence compared to RN (HR = 12.4, 95% CI 1.45-133.4, P = 0.038). Conclusions: Our institutional data highlight the possibility of compromise in RFS for clinically localized RCC treated with PN compared to RN, particularly for larger and more complex masses. These data raise concern, especially in light of the nonproven association of survival benefit of PN over RN, warranting future randomized prospective studies for further evaluation.

Comparison of Postoperative Outcomes of Trans-urethral Resection of the Prostate, Laser Vaporization, and Laser Enucleation: A Double Propensity Score Matched Analysis.

OBJECTIVE: To compare postoperative outcomes of 3 types of endourologic surgeries (trans-urethral resection of the prostate [TURP], laser vaporization [LVP], and laser enucleation [LEP]) for benign prostatic hypertrophy (BPH) treatment using the ACS-NSQIP database. METHODS: The ACS-NSQIP database was queried for men who underwent TURP, PVP, and LEP for treatment of BPH from 2011 till 2019. Demographics, clinical, operative characteristics, and 30-day outcomes were compared. Univariate and multivariate regression models were constructed. Propensity score matching was then performed as a sensitivity analysis. RESULTS: A total of 74,273 patients underwent endourologic surgeries for BPH, 65.4% had TURP, 28.6% PVP, and 5.9% LEP. Patients undergoing TURP were more likely to be older with higher ASA class, abnormal labs, and comorbidities (diabetic, congestive heart failure, and bleeding requiring transfusion) (P-value <.001). After adjusting for covariates and propensity score matching, LVP demonstrated shorter hospital stays, shorter operative times, less reoperation rates, decreased DVT/PE risk, with, however, higher odds of urinary tract infection and sepsis as compared to TURP (P-value<.028). Furthermore, LEP was found to have shorter hospital stays, longer operative times, and decreased odds of urinary tract infections and sepsis as compared to TURP (P-value<.006). CONCLUSION: LVP and LEP showed better surgical outcomes and characteristics as compared to TURP. Further research is needed to account for longer duration of follow-up and patient-specific urologic outcomes, such as prostate size, urinary incontinence, erectile dysfunction, and retrograde ejaculation.

Concurrent radical cystectomy and nephroureterectomy indications and outcomes: a systematic review and comparative analysis.

Introduction: Urothelial carcinoma can arise from the urinary bladder or from the upper urinary tract. In some instances, urinary bladder cancer (UBC) and upper tract urothelial carcinoma (UTUC) can be concurrently diagnosed, necessitating a combined radical cystectomy (RC) with radical nephroureterectomy (RNU). A systematic review was done on the combined procedure exploring outcomes and indications, in addition to a comparative analysis between the combined procedure and cystectomy alone. Methods: For the systematic review, three databases (Embase, PubMed, and Cochrane) were queried, selecting only studies that included intraoperative and perioperative data. For the comparative analysis, using the NSQIP database, CPT codes for RC and RNU were used to identify two cohorts, one with RC and RNU and one with RC alone. A descriptive analysis was performed on all preoperative variables, and propensity score matching (PSM) was performed. Postoperative events were then compared between the two matched cohorts. Results: For the systematic review, 28 relevant articles were included amounting to 947 patients who underwent the combined procedure. The most common indication was synchronous multifocal disease, the most common approach was open surgery, and the most common diversion technique was using an ileal conduit. Almost 28% of patients required blood transfusion and remained in the hospital for an average of 13 days. The most common postoperative complication was prolonged paralytic ileus. For the comparative analysis, 11,759 patients were included of which 97.5% underwent RC only and 2.5% underwent the combined procedure. After PSM, the cohort that had undergone the combined procedure showed an increased risk of renal injury, increased readmission rates, and increased reoperation rates. Whereas the cohort that had undergone RC only showed an increased risk of deep venous thrombosis (DVT), sepsis, or septic shock. Conclusion: A combined RC and RNU is a treatment option for concurrent UCB and UTUC that should be cautiously utilized as it is associated with high morbidity and mortality. Patient selection, discussion of the risks and benefits of the procedure, and explanation of the available treatment options remain the most important pillars in managing patients with this complex disease.

Modified GLIM Status as a Predictor of Morbidity and Mortality After Radical Cystectomy: A Propensity Matched Analysis.

INTRODUCTION: To assess the modified Global Leadership Initiative on Malnutrition (mGLIM) status as a predictor of postoperative mortality and morbidity in patients undergoing Radical Cystectomy (RC). METHODS AND MATERIALS: The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to select patients who underwent RC between the years 2011 to 2020. A positive mGLIM status includes patients with preoperative albumin levels < 3.5 g/L or patients with ≥ 10% weight loss over 6 months or BMI ≤ 21 kg/m2. We compared prolonged length of stay, mortality, major morbidity and Clavien-Dindo complications between mGLIM positive and negative patients. A multivariable logistic regression model was also performed to control for possible confounders. Furthermore, a sensitivity analysis was performed by propensity score matching. RESULTS: Our cohort consisted of 12,760 patients who underwent RC. The matched cohort yielded 4864 matched patients. After propensity score matching, patients with a positive mGLIM status had higher odds of prolonged length of stay (OR = 1.99, 95%CI [1.75, 2.27]), mortality (OR 1.56, 95%CI [1.08, 2.26]), major morbidity (OR = 1.69, 95%CI [1.51, 1.90]), Clavien-Dindo class I and II (OR = 1.77, 95%CI [1.58, 1.99]), and lower odds of Clavien-Dindo class III (OR = 0.72, 95%CI [0.57, 0.92]) as compared to those with a negative mGLIM status (P < .018). CONCLUSION: A positive mGLIM status is associated with prolonged hospital stay, morbidity, and mortality following RC. This indicates that the mGLIM criteria could serve as an independent predictor of morbidity and mortality in an attempt to optimize patient counseling and preoperative care.

The 5-item frailty index predicts 30-day morbidity and mortality in radical nephrectomy patients: A propensity matched analysis.

PURPOSE: To assess the ability of the 5-item frailty index (5-IFi) score to predict 30-day morbidity and mortality post-radical nephrectomy (RN). METHODS: ACS-NSQIP database was used to select patients who underwent RN from 2011 to 2020. 5-IFi score was calculated by assigning a point for each of the following comorbidities: chronic obstructive pulmonary disease or pneumonia, congestive heart failure, dependent functional status, hypertension, and diabetes. Patients were divided into 3 frailty groups 0, 1, and ≥2. Patient demographics, medical comorbidities, prolonged length of stay, and prolonged operative time were compared between different groups; mortality and morbidity using the Clavien-Dindo classification (CVD). Multivariable logistic regression models and propensity score matching were performed as a sensitivity analysis to control for possible confounders. RESULTS: Cohort consisted of 36,682 patients whereby 5-IFi class 0, 1, and ≥2 included 11,564 (31.5%), 16,571 (45.2%), and 8,547 (25.3%) patients respectively. A multivariable analysis and propensity score matching revealed that patients with 5-IFi classes 1 and ≥ 2 were more likely to have a prolonged length of stay (OR = 1.11, 1.3, respectively) and to mortality (OR = 1.85 for frailty class ≥2); in addition to CVD class 1 & 2 (OR = 1.51, OR = 1.13, respectively), and CVD ≥ 4 (OR = 1.41, 1.86, respectively) as compared to 5-IFi class 0 (P < 0.001). CONCLUSION: The 5-IFi score was found to be an independent predictor of prolonged length of stay, morbidity, and mortality after RN. This tool can play a major role in preoperative risk assessment and patient counseling based on individualized risks.

A novel nephrectomy-specific respiratory failure index using the ACS-NSQIP dataset.

PURPOSE: Post-operative pulmonary failure is a major complication of nephrectomy that may lead to severe morbidity and mortality. Hence, we aimed to derive a nephrectomy-specific post-operative respiratory failure index. METHODS: Our cohort was derived from The American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2019. The outcome of interest was post-operative respiratory failure (PRF) defined as any incidence of unplanned intubation post-operatively or requiring mechanical ventilation post-operatively for a period > 48 h. A multivariable logistic regression model was constructed, and model calibration and performance were assessed using a ROC analysis and the Hosmer-Lemeshow test. Finally, we derived the nephrectomy-specific respiratory failure (NSRF) index and compared it to Gupta's index. RESULTS: Seventy-nine thousand five hundred and twenty-three patients underwent nephrectomy between the years 2005 and 2019 of which nine hundred and sixty-two patients developed PRF. The final NSRF model encompassed ten variables: age, smoking status, American society of anesthesiology class, abnormal creatinine (≥ 1.5 mg/dL), anemia (< 36%), functional health status, chronic obstructive pulmonary disease, surgical approach, emergency case, and obesity (≥ 40 kg/m2). The NSRF ROC analysis provided C-statistic = 0.78, calibration R2 = 0.99, and proper goodness of fit. In comparison, the C-statistics of Gupta's index was found to be 0.71 (p value < 0.001). CONCLUSION: The NSRF is a procedure tailored index for predicting post-operative respiratory failure. It is a valuable tool in the pre-operative evaluation setting that can help identify high-risk patients who will require additional respiratory evaluation and preparation for their surgery.

Sedation as an alternative anesthetic technique for frail patients in transurethral resection of the prostate.

Background: Transurethral resection of the prostate (TURP) under Monitored Anesthesia Care MAC/Sedation (macTURP), as compared with TURP under general (genTURP) or spinal (spTURP) anesthesia, is a safer and infrequently used technique reserved for high-risk patients. Objectives: The aim of this study is to compare 30-day postoperative outcomes of TURP using the three types of anesthesia techniques. Design and methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent TURP between 2008 and 2019. Demographics, lab values, medical history, and 30-day outcomes were compared. Univariate and multivariate regression models for postoperative complications were constructed. A propensity score-matched analysis was then performed for genTURP and macTURP and for spTURP and macTURP as a sensitivity analysis. Results: A total of 53,182 patients underwent TURP. Older patients (>80) with diabetes requiring insulin (7.9%), leukocytosis (7.4%), history of chronic obstructive pulmonary disease (COPD) (7.8%), dyspnea (7.2%), and of ASA > 2 (58.8%) were more likely to undergo macTURP as compared with genTURP (p < 0.013). SpTURP showed lower rates of urinary tract infection (UTI) [odds ratio (OR) = 0.869] as compared with genTURP (p = 0.049), whereas macTURP showed higher rates of major adverse cardiovascular events (OR = 2.179) as compared with genTURP (p = 0.005). All other postoperative complications showed similar rates between the three procedures. The propensity-matched cohorts demonstrated that no differences in postoperative complication rates were noted between macTURP and genTURP and between macTURP and spTURP. Conclusion: MacTURP was found to be feasible with a good safety profile as compared with genTURP and spTURP. MacTURP could be used in elderly, frail, and co-morbid patients with a similar safety profile as compared with more invasive anesthetic techniques.

Surgical Complications Requiring Reoperation in Open Versus Minimally Invasive Radical Nephrectomy: A Contemporary Analysis of the National Surgical Quality Improvement Program.

BACKGROUND: To explore reoperation rates for different radical nephrectomy (RN) approaches that are experiencing a shift from open radical nephrectomy (ORN) toward minimally invasive surgery (MIS), we aimed to compare reoperation rates along with their culprit etiologies between the different types of surgical approaches for RN. METHODS: The national surgical quality improvement program dataset was used to select patients who underwent RN between the years 2012-2019. A 1:1 propensity score matched analysis was used. Reoperation rates and causes were then compared between open and MIS approach. RESULTS: The propensity matched cohort included 15,294 patients. Reoperation rates due to large bowel injury (0.01 vs. 0.14%), vascular injury (0.07 vs. 0.22%), and other abdominal (0.5 vs. 0.77%) were more common in ORN as compared to MIS (MIS vs. ORN, respectively, p < 0.034). Reoperation due to hernia (0.14 vs. 0.03%) was more common in MIS as compared to ORN (p = 0.027). No difference was seen for small bowel injury and incision/wound debridement. General reoperation (1.61 vs. 2.22%) and mortality (0.57 vs. 1.47%) were also more common in ORN as compared to MIS (p < 0.008). CONCLUSION: Reoperation due to large bowel injury, vascular injury, and other abdominal was more likely to occur in ORN. Whereas reoperation due to hernia was more likely to occur in MIS. Surgical approach was an independent risk factor for immediate and early reoperation rates in RN patients. These results could be used to counsel patients pre-operatively on possible surgical approaches and complications.

Muscle invasive bladder cancer and radical cystectomy: a risk predictive model.

Background: Radical cystectomy (RC) for muscle invasive bladder cancer (MIBC) remains the historical gold standard for treatment despite significant perioperative morbidity and subsequent quality of life concerns. Trimodal therapy (TMT) is gaining acceptance as an alternative bladder preserving approach. We aim to identify patients for whom TMT may be the optimal approach by constructing risk calculators of morbidity and mortality associated with RC. Methods: Using the American College of Surgeons National Surgical Quality Improvement Program database, we selected patients diagnosed with MIBC undergoing RC, with a total of 10,642 patients identified. The primary outcome was mortality and secondary outcome was morbidity within 30 days of the procedure. We conducted multivariate logistic regression to obtain the best fit model for each outcome on 70% of the sample. Validation of the models was then performed on the remaining 30% of the sample. Model performance was assessed using discrimination and calibration abilities and a risk calculator was constructed for pre-operative counselling. Results: Of the full cohort, 199 patients (1.9%) died and 2,328 patients (21.9%) experienced morbidity. Variables selected for the model predicting mortality included age, frailty, the American Society of Anesthesiologists status and preoperative creatinine. For the mortality model, the area under the curve was 72% with a Hosmer-Lemeshow statistic of 0.722. For the morbidity model, the area under the curve was 60% with a Hosmer-Lemeshow statistic of 0.287. Variables significant in the model included continent diversion, smoking and frailty. Conclusion: We have constructed statistically significant and clinically relevant models using readily available health indicators to be used in multi-disciplinary discussion to provide high-risk patients with individualised risks of morbidity and mortality from RC, allowing for counselling for alternative treatments such as TMT.

Preoperative MELD score predicts mortality and adverse outcomes following radical cystectomy: analysis of American College of Surgeons National Surgical Quality Improvement Program.

Background: The model for end-stage liver disease (MELD) has been widely used to predict the mortality and morbidity of various surgical procedures. Objectives: We aimed to correlate a high preoperative MELD score with adverse 30-day postoperative complications following radical cystectomy. Design and Methods: Patients who underwent elective, non-emergency radical cystectomy were identified from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2017. Patients were categorized according to a calculated MELD score. The primary outcomes of this study were 30-day postoperative mortality, morbidity, and length of hospital stay following radical cystectomy. For further sensitivity analysis, propensity score matching was used to yield a total of 1387 matched pairs and primary outcomes were also assessed in the matched cohort. Results: Compared with patients with a MELD < 10, those with MELD ⩾ 10 had significantly higher rates of mortality [odds ratio (OR) = 1.71, p = 0.004], major complications (OR = 1.42, p < 0.001), and prolonged hospital stay (OR = 1.29, p < 0.001) on multivariate analysis. Following risk-adjustment for race, propensity-matched groups revealed that patients with MELD score ⩾ 10 were significantly associated with higher mortality (OR = 1.85, p = 0.008), major complications (OR = 1.34, p < 0.001), yet similar length of hospital stay (OR = 1.17, p = 0.072). Conclusion: MELD score ⩾ 10 is associated with higher mortality and morbidity in patients undergoing radical cystectomy compared with lower MELD scores. Risk-stratification using MELD score may assist clinicians in identifying high-risk patients to provide adequate preoperative counseling, optimize perioperative conditions, and even consider nonsurgical alternatives.

The R.E.N.A.L score's relevance in determining perioperative and oncological outcomes: a Middle-Eastern tertiary care center experience.

Objective: The aim of this study is to evaluate the significance of the R.E.N.A.L nephrometry scoring system in predicting perioperative and oncological outcomes and determining the surgical approach of choice for kidney tumors.Patients and Methods: Our study retrospectively reviewed outcomes from the year 2002 to 2017. Mann-Whitney U test was used to compare continuous variables and chi-square test was used to compare categorical variables. Kaplan-Meier estimates and multivariable cox proportional hazard regression were performed to determine an association between the different R.E.N.A.L categories and disease recurrence or mortality. Results: A total of 325 patients underwent kidney surgery The most common R.E.N.A.L score category in our cohort study was intermediate (41.2%), followed by low, (33.2%) and high (25.5%). Patients with a high R.E.N.A.L score had worse perioperative outcomes compared to those with a low R.E.N.A.L score. High R.E.N.A.L score patients were 3 times more likely to receive blood transfusions compared to those with a low R.E.N.A.L score (19.4% vs 6.3%, p = 0.018), and a statistically significant longer hospital length of stay was also observed between the two groups (median 4.5 vs 4 days, p = 0.0419). In addition, the only predictor of disease recurrence or mortality was a high R.E.N.A.L score (Hazard Ratio (HR) 3.65, 95% Confidence Interval (CI) 1.05-12.7, p = 0.041). Conclusion: Our study sheds light on the use of R.E.N.A.L nephrometry score in predicting perioperative, postoperative, and oncological outcomes. Such findings may play a role in optimizing surgical approaches and pre-operative patient counseling.

A novel radical prostatectomy specific index (PSI) for the prediction of major cardiovascular events following surgery.

PURPOSE: Prostate cancer patients tend to be older with multiple comorbidities and are thus at increased risk for postoperative cardiovascular events after radical prostatectomy (RP). Thus, proper patient selection strategies are essential to decide for or against a surgical approach. We aimed to derive a prostatectomy specific index (PSI) for patients undergoing RP and compare its performance to universally used indices. METHODS: The cohort was derived from National Surgical Quality Improvement Program database between 2005 and 2012. The primary outcome was incidence of major adverse cardiovascular events at 30 days post-surgery including: death, myocardial infarction, or stroke. A multivariable logistic regression model was constructed, performance and calibration were evaluated using a ROC analysis and the Hosmer-Lemeshow test, the PSI index was derived and compared to the RCRI and AUB-HAS2 indices. RESULTS: A total of 17,299 patients were included in our cohort, with a mean age of 62 ± 7.4 years. Seventy three patients had a cardiac event post RP. The final PSI index encompassed six variables: history of heart disease, age, anemia, American society of anesthesiology class, surgical approach, and hypertension. The PSI ROC analysis provided C-statistic = 0.72, calibration R2 = 0.99 and proper goodness of fit. In comparison, the C-statistics of RCRI and AUB-HAS2 were found to be 0.57 and 0.65, respectively (p value < 0.001). CONCLUSION: The PSI model is a procedure tailored index for prediction of major cardiovascular events post RP. It was calibrated using a large national database aiming to optimize treatment selection strategies for prostate cancer patients.

Prostate cancer in the Arab world: Bibliometric review and research priority recommendations.

Objective: To conduct a scoping review examining the status of prostate cancer research in Arab countries and systematically map publications across the cancer care pathway. Prostate cancer incidence has been rising in the Arab world and tackling its increasing burden will require evidence-based policies. Methods: We searched Medline, PubMed and Scopus for peer-reviewed publications related to both our research topic and countries of interest by using controlled vocabulary and keywords. Search results were limited for the period between 2000 and 2020, screened for duplicates, and then included in our study based on pre-specified eligibility criteria. We used a structured data extraction form to extract information related to the article, its methodology, its cancer care pathway, funding status, and authorship. Results: A total of 4142 publications were retrieved from our search, of which 874 articles remained after applying eligibility criteria. Trends show a steady increase in prostate cancer research in the Arab world. Most studies were focussed on diagnosis and treatment, whereas a lack in studies concerning screening and prevention, as well as epidemiological data, was evident. Most studies were not funded and had no female author. Country gross domestic product and population were positively correlated with its research output. The USA had the highest number of corresponding authors. The majority of Arab-based studies did not involve collaborations with other countries. Most research conducted was basic or clinical studies with a low level of evidence. Conclusion: Our present review identified significant gaps and limitations in prostate cancer research in Arab countries. Priority areas for research investment have also been highlighted as a first step towards context-specific health policies. Abbreviations: ASR: age-standardised rate; COVID-19: coronavirus disease 2019; GDP: gross domestic product; HDI: Human Development Index; KSA: Kingdom of Saudi Arabia; UAE: United Arab Emirates.