Functional and safety outcomes after benign prostatic enlargement surgeries in men with detrusor underactivity compared with normal detrusor contractility: Systematic review and meta-analysis.

INTRODUCTION: Men with detrusor underactivity (DUA) and concomitant bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) may present poorer functional outcomes after surgical desobstruction. This study aimed to evaluate the safety and efficacy of BPE surgery in men with DUA compared with those with normal detrusor contractility (NC). MATERIALS AND METHODS: This review was performed according to the 2020 PRISMA framework. A comprehensive literature search was performed until May 7, 2023, using MEDLINE, EMBASE, and Cochrane Database. No date limits were imposed. Only comparative studies were accepted. The primary endpoint was to assess if there was any difference in short- and long-term functional outcomes after BPE surgery in men with DUA and NC. The secondary endpoint was to evaluate the differences in perioperative outcomes and postoperative complications between the two groups. Meta-analysis was performed using Review Manager (RevMan) software. RESULTS: There were 5 prospective nonrandomized studies and 12 retrospective studies, including 1701 DUA and 1993 NC patients. Regarding surgical procedures, there were eight TURP (transurethral resection of the prostate) studies, four GreenLight PVP (photoselective vaporization of the prostate) studies, two HoLEP (Holmium laser enucleation of the prostate) studies, one GreenLight PVP/HoLEP study, one Holmium laser incision of the prostate study, and one study did not report the type of surgery. We did not find a statistically significant difference between the two groups in terms of perioperative outcomes, including postoperative catheterization time, hospitalization time, urinary retention, need to recatheterization, transfusion rate, or urinary tract infections. Also, we found no significant differences in long-term complications, such as bladder neck stenosis or urethral stenosis. Posttreatment bladder recatheterization and retreatment rate for BPE regrowth could not be evaluated properly, because only one study reported these findings. When we analyzed functional outcomes at 3 months, those with NC had lower International Prostatic Symptom Score (IPSS), lower quality-of-life (QoL) score, better maximum flow rate (Qmax), and lower post-voiding residual (PVR) of urine. These results were maintained at 6 months postoperatively, with exception of PVR that showed no difference. However, at 12 and more than 12 months the functional outcomes became similar regarding IPSS and QoL. There were few data about Qmax and PVR at longer follow-up. CONCLUSION: In this meta-analysis, data suggest that BOO surgical treatment in patients with concomitant BPE and DUA appears to be safe. Despite patients with DUA may present worse functional outcomes in the short postoperative term compared with the NC population, IPSS and QoL scores become comparable again after a longer follow-up period after surgery.

Psychological Health of Surgeons in a Time of COVID-19: A Global Survey.

OBJECTIVE: To assess the degree of psychological impact among surgical providers during the COVID-19 pandemic. SUMMARY OF BACKGROUND DATA: The COVID-19 pandemic has extensively impacted global healthcare systems. We hypothesized that the degree of psychological impact would be higher for surgical providers deployed for COVID-19 work, certain surgical specialties, and for those who knew of someone diagnosed with, or who died, of COVID-19. METHODS: We conducted a global web-based survey to investigate the psychological impact of COVID-19. The primary outcomes were the depression anxiety stress scale-21 and Impact of Event Scale-Revised scores. RESULTS: A total of 4283 participants from 101 countries responded. 32.8%, 30.8%, 25.9%, and 24.0% screened positive for depression, anxiety, stress, and PTSD respectively. Respondents who knew someone who died of COVID-19 were more likely to screen positive for depression, anxiety, stress, and PTSD (OR 1.3, 1.6, 1.4, 1.7 respectively, all P < 0.05). Respondents who knew of someone diagnosed with COVID-19 were more likely to screen positive for depression, stress, and PTSD (OR 1.2, 1.2, and 1.3 respectively, all P < 0.05). Surgical specialties that operated in the head and neck region had higher psychological distress among its surgeons. Deployment for COVID- 19-related work was not associated with increased psychological distress. CONCLUSIONS: The COVID-19 pandemic may have a mental health legacy outlasting its course. The long-term impact of this ongoing traumatic event underscores the importance of longitudinal mental health care for healthcare personnel, with particular attention to those who know of someone diagnosed with, or who died of COVID-19.

Perioperative outcomes and risk factors for major complications associated with nephrectomy for Xanthogranulomatous pyelonephritis: a multicenter study.

PURPOSE: To determine the risk factors associated with major complications in patients with histologically confirmed Xanthogranulomatous pyelonephritis (XGP) who underwent nephrectomy. METHODS: A multicenter retrospective study was performed including patients who underwent nephrectomy between 2018 and 2022 with histopathological diagnosis of XGP. Clinical and laboratory parameters at the initial presentation were evaluated. Data on extension of XGP was recorded as per the Malek clinical-radiological classification. Characteristics of nephrectomy and perioperative outcomes were obtained. The primary outcome was major complications, defined as a CD ≥ grade 3 and the need for intensive care unit (ICU) admission. Secondary outcomes included the comparison of complications evaluating the nephrectomy approach (transperitoneal, retroperitoneal, and laparoscopic). A sub-analysis stratifying patients who needed ICU admission and Malek classification was performed. RESULTS: A total of 403 patients from 10 centers were included. Major complications were reported in 98 cases (24.3%), and organ injuries were reported in 58 patients (14.4%), being vascular injuries the most frequent (6.2%). Mortality was reported in 5 cases (1.2%). A quick Sepsis-related Organ Failure Assessment (qSOFA) score ≥ 2, increased creatinine, paranephric extension of disease (Malek stage 3), a positive urine culture, and retroperitoneal approach were independent factors associated with major complications. CONCLUSION: Counseling patients on factors associated with higher surgical complications is quintessential when managing this disease. Clinical-radiological staging, such as the Malek classification may predict the risk of major complications in patients with XGP who will undergo nephrectomy. A transperitoneal open approach may be the next best option when laparoscopic approach is not feasible.

Laparoscopic Pyelolithotomy for treating urolithiasis in ectopic pelvic kidneys.

INTRODUCTION: The management of urolithiasis ectopic pelvic kidneys (EPK) can be challenging because of the aberrant anatomy (1-4). We demonstrate the step-by-step technique of the laparoscopic approach for treating urolithiasis in EPK. PATIENTS AND METHODS: Three men with EPK (2 left, 1 right) underwent laparoscopic pyelolithotomy through a transperitoneal approach. After establishing the pneumoperitoneum, the parietal peritoneum was opened at the parietal colic sulcus and the bowel displaced medially. The kidney was identified in the retroperitoneum and the renal pelvis exposed after removal of the perirenal adipose tissue. The renal pelvis was opened, and the stones were identified and retrieved with forceps in 2 cases and with a flexible nephroscope in 1 case. The renal pelvis was closed with a 3/0 running barbed suture. A DJ stent was placed in all patients. RESULTS: For the first time, a laparoscopic technique for treating stones in the ectopic kidney is demonstrated in detail. Mean patient age was 52.6 years (44-58). The mean stone size was 22.3 mm (20-24 mm). Stones were in the renal pelvis in 2 cases and in the inferior calyx in 1 case. Mean operative time was 146 minutes (135-155 min). Mean estimated blood loss was 116 ml (60-140 ml). No complications were observed. The mean hospital stay was 3 days. The DJ stents were removed after 3 weeks. All patients were stone free at the postoperative CT scan with a mean follow-up of 3.3 months (1-6 months). CONCLUSIONS: Laparoscopic pyelolithotomy can be an effective and reproducible minimally invasive technique for treating urolithiasis in EPK.

Infection Rate after Transperineal Prostate Biopsy with and without Prophylactic Antibiotics: Results from a Systematic Review and Meta-Analysis of Comparative Studies.

PURPOSE: We performed a systematic review comparing the incidence of infectious complications following transperineal ultrasound-guided prostate biopsy (TPB) in cases utilizing antibiotic prophylaxis (AP) vs cases not utilizing antibiotic prophylaxis (NAP). MATERIALS AND METHODS: The incidences of complications were pooled using the Cochran-Mantel-Haenszel method with the random effect model and expressed as risk ratio (RR). RR higher than 1 indicates an increased risk of complication in patients undergoing TPB without antibiotics. Statistical significance was set at p <0.05 and 95% CI. RESULTS: A total of 1,748 papers were retrieved. After the screening process, 8 studies were included in the quantitative analysis (4 retrospective, and 4 prospective and nonrandomized), reporting on 3,662 patients. A total of 2,368 patients underwent TPB utilizing AP and 1,294 underwent TPB utilizing NAP. The pooled rates of post-biopsy fever from 6 available studies reporting this parameter were 0.69% in the AP group and 0.47% in the NAP group (RR: 1.02, 95% CI: 0.02-44.55, p=0.99). The pooled rates of post-biopsy genitourinary infections from 8 available studies reporting this parameter were 0.11% in the AP group and 0.31% in the NAP group (RR: 2.09, 95% CI: 0.54-8.10, p=0.29). The pooled rates of post-biopsy sepsis over 8 studies reporting this parameter were 0.13% in the AP group and 0.09% in the NAP group (RR: 1.09, 95% CI: 0.21-5.61, p=0.92). The pooled rates of post-biopsy readmission for infections over 8 studies reporting this parameter were 0.13% in the AP group and 0.23% in the NAP group (RR: 1.29, 95% CI: 0.31-5.29, p=0.73). Death due to post-biopsy sepsis did not occur in any study. CONCLUSIONS: This systematic review found no significant difference in infection rate, fever, sepsis or readmission rate after TPB between those cases utilizing AP and those cases without AP.

Urethral stricture following endoscopic prostate surgery: a systematic review and meta-analysis of prospective, randomized trials.

INTRODUCTION AND OBJECTIVES: This systematic review aims to evaluate the incidence and influencing factors of urethral stricture (US) in relation to different BPH endoscopic techniques. MATERIALS AND METHODS: We performed a systematic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. The incidence of US was estimated through comparative studies between different endoscopic techniques. Patients were assigned into groups according to the type of surgery (enucleation, ablation and resection group). Incidences of US were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and reported as Risk Ratio (RR), 95% Confidence Intervals (CI), and p-values. RESULTS: A total of 80 studies were included for meta-analysis. The pooled incidence of US was 1.7% after enucleation, 2.1% after ablation, 3.8% after monopolar (M)-TURP and 2.1% after bipolar (B)-TURP. The incidence of US was significantly lower after Enucleation than after TURP (RR 0.58 95% CI 0.39-0.84, p = 0.004). US incidence was lower for Ablation procedures than TURP, but the difference did not reach significance (RR 0.79 95% CI 0.61-1.3, p = 0.08). However, this was significant in the subgroup of M-TURP studies (RR 0.67, 95% CI, 0.49-0.91, p = 0.01). Sub-analysis showed that the risk of US was significantly lower after Enucleation than after TURP within 12 months after surgery (RR 0.51 95% CI 0.33-0.81, p = 0.004). CONCLUSION: The study shows an increased incidence of US after TURP compared to enucleation and ablation procedures. The main factors related to increased US incidence are the use of monopolar energy, instrument caliber and duration of postoperative catheterization.

Incidence, predictive factors and oncological outcomes of incidental prostate cancer after endoscopic enucleation of the prostate: a systematic review and meta-analysis.

INTRODUCTION: This systematic review aims at reporting the incidence, predictive factors, and the oncological outcomes of incidental prostate cancer (IPCa) in men who underwent endoscopic enucleation of prostate (EEP). METHODS: A literature search was performed using the following Medical Subject Heading (MeSH) terms and keywords: "Prostatic Neoplasms", "Prostate Cancer", "Transurethral Resection of Prostate", "Prostate resection", "Prostate enucleation". Meta-analysis was performed if there were two or more studies reporting the same outcome under the same definition. In case of insufficient data, results were presented in a narrative manner. RESULTS: Sixty-one studies were included in qualitative synthesis and 55 were included in meta-analysis. The pooled IPCa rate was 0.08 (95% CI 0.073-0.088). Increasing age, higher preoperative serum prostate-specific antigen (PSA) level, higher preoperative PSA density (PSAD), smaller prostate volume, higher postoperative PSA velocity and lower enucleated prostate weight, were reported to have significant correlation with IPCa. In BPH patients, the mean pre-operative and post-operative PSA levels were 5.58 ± 1.48 ng/dL and 1.06 ± 0.27 ng/dL, respectively. In patients with IPCa, the mean pre-operative and post-operative PSA levels were 7.72 ± 2.90 ng/dL and 2.77 ± 1.66 ng/dL, respectively. The mean percentage PSA reduction was 82.0% ± 1.8% for BPH patients and 68.2% ± 12.1% for IPCa patients. IPCa was most commonly managed by active surveillance (68.7%). CONCLUSIONS: The pooled incidence of IPCa after EEP was 8%. An absolute post-operative PSA level of < 2.0 and a percentage PSA reduction of > 70% should be expected in BPH patients after EEP.

Knowledge, attitudes, and practices of active surveillance in prostate cancer among urologists: a real-life survey from Brazil.

BACKGROUND: Active surveillance (AS) is the preferred treatment for patients with very low-and low-risk prostate cancer (PCa), but it is underperformed worldwide. This study aimed to report knowledge, attitudes, and practices (KAP) of AS for PCa among urologists in Brazil. METHODS: This cross-sectional study used a questionnaire with 50 questions divided into participant characteristics, knowledge regarding inclusion criteria for AS, follow-up, intervention triggers, acceptance, and practice for an index patient. Data analysis comprises absolute and relative frequencies of the variables. After that, a logistic regression was performed in order to verify possible patterns of answers provided by the respondents in the index patient questionnaire. RESULTS: Questionnaires were sent through the SurveyMonkey® platform to 5,015 urologists using email addresses and through social media. A total of 600 (12%) questionnaires returned and 413 (8.2%) were completed and included in the analysis. Only 53% of urologists adopt AS for low- and very-low-risk PCa. Inclusion criteria were patients with age > 50 years (32.2%), prostate specific antigen (PSA) < 10 ng/mL (87.2%), T1 clinical stage (80.4%), Biopsy Gleason score ≤ 6, positive cores ≤ 2 (44.3%), positive core involvement < 50% (45.3%), and magnetic resonance imaging findings (38.7%). The PSA doubling time was still used by 60.3%. Confirmatory biopsy (55.9%), PSA level (36.6%), and digital rectal examination (34.4%) were considered by most urologists for follow-ups. Patient preference (85.7%), upgrade of Gleason score (73.4%), and increased number of positive cores (66.8%) were associated with conversion to definitive treatment. In an index patient, non-acceptance and active treatment request were the most cited reasons for not performing AS. CONCLUSION: There is significant variability in the KAP of AS in Brazil, which indicates the need to reinforce AS, its inclusion and follow-up criteria, and the benefits for physicians and the general population. TRIAL REGISTRATION: Not applicable.

Nephrostomy tube versus double J ureteral stent in patients with malignant ureteric obstruction. A systematic review and meta-analysis of comparative studies.

PURPOSE: We aimed to perform a systematic review to assess perioperative outcomes, complications, and survival in studies comparing ureteral stent and percutaneous nephrostomy in malignant ureteral obstruction. MATERIALS AND METHODS: This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Meta-analyses were performed on procedural data; outcomes; complications (device-related, accidental dislodgement, febrile episodes, unplanned device replacement), dislodgment, and overall survival. Continuous variables were pooled using the inverse variance of the mean difference (MD) with a fixed effect, and 95% confidence interval (CI). The incidences of complications were pooled using the Cochran-Mantel-Haenszel method with the random effect model and reported as Odds Ratio (OR), and 95% CI. Statistical significance was set two-tail p-value < 0.05 Results: Ten studies were included. Procedure time (MD -10.26 minutes 95%CI -12.40-8.02, p< 0.00001), hospital stay (MD -1.30 days 95%CI -1.69 - -0.92, p< 0.0001), number of accidental tube dislodgments (OR 0.25 95% CI 0.13 - 0.48, p< 0.0001) were significantly lower in the stent group. No difference was found in mean fluoroscopy time, decrease in creatinine level post procedure, overall number of complications, interval time between the change of tubes, number of febrile episodes after diversion, unplanned device substitution, and overall survival. CONCLUSION: Our meta-analysis favors stents as the preferred choice as these are easier to maintain and ureteral stent placement should be recommended whenever feasible. If the malignant obstruction precludes a stent placement, then PCN is a safe alternative.

Shedding light on polypragmasy of pain after transurethral prostate surgery procedures: a systematic review and meta-analysis.

PURPOSE AND OBJECTIVE: To evaluate and compare the incidences of post-operative pelvic pain (PPP) in patients undergoing ablation, enucleation and conventional transurethral resection of the prostate (TURP). METHODS: A systematic review and meta-analysis was conducted according to the PRISMA guidelines. Using MEDLINE via PubMed and Cochrane CENTRAL, randomised control trials (RCTs) and observational studies reporting PPP rates post-ablation, enucleation or TURP were identified. The risk of biases (RoB) in RCTs and observation studies were assessed using the Cochrane RoB1.0 tool and the Newcastle-Ottawa Scale, respectively. RESULTS: 62 studies were included for qualitative analysis, while 51 of them reported number of patients with PPP post-intervention. Three observational studies and 13 RCTs compared the rates of PPP in patients undergoing ablation, enucleation or TURP. The most reported types of PPP are dysuria, abdominal pain and irritative symptoms. The pooled incidence of PPP at 1-month follow-up in patients undergoing ablation, enucleation and TURP were 0.15 (95% CI 0.10-0.22), 0.09 (95% CI 0.04-0.19 and 0.10 (95% CI 0.06-0.15), respectively. PPP is no longer prevalent at 3-months and onwards post-operatively. Ablation is associated with a higher risk of PPP than enucleation (RR 2.19, 95% CI 1.04-4.62) and TURP (RR 2.40, 95% CI 1.03-5.62) in observational studies but not RCTs; and there were no significant differences in the rates of PPP upon comparison of other modalities. CONCLUSION: PPP is common after transurethral benign prostatic hyperplasia surgery. Patients undergoing ablation had a higher rate of post-intervention PPP than those undergoing enucleation and TURP in observational studies.

Bladder neck stenosis after transurethral prostate surgery: a systematic review and meta-analysis.

PURPOSE: Bladder neck stenosis (BNS) is a long-term complication of surgical procedures for benign prostatic hyperplasia (BPH). We performed a systematic literature review and a meta-analysis of the incidence of BNS after transurethral procedures for BPH. METHODS: We performed a systemic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. We accepted only randomized trials comparing transurethral resection of the prostate (TURP) vs. other transurethral surgery for BPH that were grouped in Ablation vs. Enucleation modalities. The incidences of BNS were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and expressed as Risk Ratios, 95% Confidence Intervals, and p values. Study heterogeneity was assessed utilizing the I2 value. RESULTS: 72 studies were identified for meta-analysis, 46 comparing TURP vs. Ablation and 26 TURP vs. Enucleation. The pooled incidence of BNS was 1.3% after TURP, 0.66% after enucleation and 1.2% after Ablation. The incidence of BNS was higher after TURP than after Enucleation but the difference was not statistically significant (RR 1.75 95% CI 0.81-3.79, p = 0.16). There was no significant heterogeneity among the studies (I2 0%, Chi2 4.11, p = 0.90). The incidence of BNS was higher after TURP than after Ablation, but the difference was not statistically significant (RR 1.31, 95% CI 0.82-2.11, p = 0.26) with no significant heterogeneity (I2 0%, Chi2 21.1, p = 0.51). CONCLUSION: Our study showed no difference in the rate of BNS incidence among randomized trials comparing TURP vs. Ablation vs. Enucleation and can be used as a reference to counsel patients undergoing BPH surgery.

Delayed surgery for localised and metastatic renal cell carcinoma: a systematic review and meta-analysis for the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic has led to the cancellation or deferment of many elective cancer surgeries. We performed a systematic review on the oncological effects of delayed surgery for patients with localised or metastatic renal cell carcinoma (RCC) in the targeted therapy (TT) era. METHOD: The protocol of this review is registered on PROSPERO(CRD42020190882). A comprehensive literature search was performed on Medline, Embase and Cochrane CENTRAL using MeSH terms and keywords for randomised controlled trials and observational studies on the topic. Risks of biases were assessed using the Cochrane RoB tool and the Newcastle-Ottawa Scale. For localised RCC, immediate surgery [including partial nephrectomy (PN) and radical nephrectomy (RN)] and delayed surgery [including active surveillance (AS) and delayed intervention (DI)] were compared. For metastatic RCC, upfront versus deferred cytoreductive nephrectomy (CN) were compared. RESULTS: Eleven studies were included for quantitative analysis. Delayed surgery was significantly associated with worse cancer-specific survival (HR 1.67, 95% CI 1.23-2.27, p < 0.01) in T1a RCC, but no significant difference was noted for overall survival. For localised ≥ T1b RCC, there were insufficient data for meta-analysis and the results from the individual reports were contradictory. For metastatic RCC, upfront TT followed by deferred CN was associated with better overall survival when compared to upfront CN followed by deferred TT (HR 0.61, 95% CI 0.43-0.86, p < 0.001). CONCLUSION: Noting potential selection bias, there is insufficient evidence to support the notion that delayed surgery is safe in localised RCC. For metastatic RCC, upfront TT followed by deferred CN should be considered.

A systematic review and meta-analysis of the safety and efficacy of endoscopic enucleation and non-enucleation procedures for benign prostatic enlargement.

INTRODUCTION AND OBJECTIVE: This study aims to evaluate safety and efficacy of different endoscopic enucleation of the prostate (EEP) techniques, by comparing laser (L-EEP) and non-laser (NL-EEP) procedures; and EEP versus other endoscopic non-enucleation (ENE) surgeries for benign prostatic enlargement (BPE). METHODS: A systematic literature review was performed for randomized clinical trials (RCT) that compared different endoscopic treatments for BPE, between 1982 and 2018. Two analyses were performed: (1) EEP versus ENE; and (2) L-EEP versus NL-EEP. Efficacy was assessed using perioperative data (removed tissue volume, operation time (OT), catheterization time, length of hospital stay); and functional outcomes [IPSS, IIEF-5, maximum flow rate (Qmax), postvoid residual volume (PVR), quality of life (QoL)]. Safety was assessed through complications (Hb and sodium decrease, transfusion rate). Meta-analyses were performed using RevMan® 5.3. RESULTS: Out of 35 RCTs (4066 patients), 31 (3909 patients) evaluated EEP versus ENE, and 4 (327 patients) evaluated L-EEP versus NL-EEP. EEP presented greater Qmax. Also, EEP presented less catheterization time, length of hospital stay, Hb decrease, transfusion rate. OT and bladder injury were greater with EEP. There were no significant differences between other items. L-EEP removed more tissue volume, with a smaller drop in serum Hb. There were no significant differences in other perioperative data, functional outcomes, complications. CONCLUSIONS: EEP and ENE are effective and safe for treating BPE. Perioperative data favors EEP. Statistical differences, with questionable clinical significance in functional outcomes and complication rates were encountered. L-EEP provides greater tissue removal and smaller Hb decrease then NL-EEP, with similar functional profiles.

Anatomical endoscopic enucleation of the prostate: The next gold standard? No! (or not yet!).

Most cases of lower urinary tract symptoms due to benign prostatic hyperplasia are initially managed through medical therapy. In cases that surgery is indicated, the anatomical endoscopic enucleation of the prostate (aEEP), first described in 1983, allegedly presents the same safety profile as the best endoscopic non-enucleating procedures and the same long-term functional outcomes as simple prostatectomy. Thus, why aEEP has not yet been consolidated as the gold-standard BPH surgical treatment? The main reasons are as follows: (a) Multiple energy sources and techniques; (b) High costs; (c) Steep learning curve; (d) Rare in-residency training; (e) Reimbursement issues; (f) Outcomes and (g) Complications. We do believe aEEP is an important advance and a "practice-changing" procedure that will play an important role in the BPH surgical options arsenal, especially for larger prostates. However, there is a need to start an in-residency training program, with a mentor guidance, and, over time, the cost will likely be reduced due to greater competition between companies and greater support from health insurers. Considering these points, in the future, EEP may be considered the gold-standard treatment for BPH… but not yet.

A global knowledge, attitudes and practices survey on anatomical endoscopic enucleation of prostate for benign prostatic hyperplasia among urologists.

There is an increasing use of the procedure, anatomical endoscopic enucleation of the prostate, as an alternative to conventional transurethral resection of prostate for surgical treatment of benign prostatic hyperplasia. However, barriers to adoption of this procedure remain and no prior studies explored this important aspect till date. The aim of this study is to identify the predictors and barriers of surgeon-related practices in this area. The study findings may also provide valuable insight into current practice trends worldwide. To achieve the objectives, we conducted an online, cross-sectional, questionnaire-based study between 1st September 2019 and 5th October 2019 to investigate the knowledge, attitudes and practices among urologists worldwide. Our findings showed that the main barriers for adoption of the procedure were lack of mentorship, a steep learning curve, and unavailability of morcellator, bipolar or laser energy sources. Fear of urinary incontinence, bleeding and bladder injury were not major hindrance to adoption of this technique. The results also demonstrated that there will be continued increase in utility of the procedure in the future.

Impact of the COVID-19 Pandemic on the Urologist's clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.

This letter to the Editor aims to provide suggestions and recommendations for the management of urological conditions in times of COVID-19 crisis in Brazil and other low- and middle-income countries. It is important to highlight that one of the main characteristics of this pandemic is the oversaturation of the health system capacity, mostly due to a high demand for personal protective equipment (PPE), Hospital/ICU beds, as well as ventilators. In places with limited resources and where the health care systems are already saturated, such consideration is even more worrisome. Therefore, most worldwide authorities are recommending to avoid, as much as possible, patient's elective visits to hospitals, as well as a judicious use of the operating room in order to mitigate the strain put on the health system. While efforts should be directed to the care of COVID-19 patients, other conditions (especially urgencies and oncological cases) must continue to be assisted. Thus, through a panel of experts, we have prepared a practical guide for Thus, through a panel of experts, we have prepared a practical guide for urologists based on the recommendations from the main Urologic Associations, as well as data from the literature to support the suggested management. We will try to follow the standard guideline recommendations from the American Urological Association (AUA) and European Association of Urology (EAU), with the aim of pursuing the best outcomes possible. However, some recommendations were based on the consensus of the panel, taking into consideration the reality of developing countries and the unprecedented situation caused by the COVID-19 crisis. Most importantly, all recommendations on this manuscript are based on the expectancy of a maximum 3-month duration of the crisis. If this period shall extended, these recommendations will be revised and updated.

Robot-Assisted Nephropexy.

INTRODUCTION: Renal ptosis is defined as the renal descent when there is a change from supine to orthostatic position, usually with a change of two vertebral bodies or more than five cm apart. Although rare, it is one of the causes of chronic flank pain or of upper abdomen. The typical patient of renal ptosis is young, female, thin, with complaint of pain when in an upright position (1, 2). OBJECTIVE: Demonstrate a robot-assisted nephropexy technique in a young woman diagnosed with symptomatic renal ptosis on the right kidney, confirmed by imaging tests. MATERIALS AND METHODS: A 29-year-old female patient with a history of chronic right-sided pain and palpable renal mobility on physical examination. The diagnosis of renal ptosis was confirmed by ultrasound imaging, excretory urography (Figure -1), and renal scintigraphy with 99mTc-DTPA (Figure-2). She was submitted to a robotic-assisted right nephropexy with a polypropylene mesh fixing the right kidney to the ipsilateral psoas muscle fascia. RESULT: We reported a 96-minute surgical time. The patient was discharged in the first postoperative day. At the one-month follow-up, there was an important improvement of the symptoms, with normality renal function and imaging tests describing adequate renal positioning. CONCLUSIONS: Robotic-assisted nephropexy is feasible and can be an excellent minimally invasive alternative technique for the proposed surgery. We reported a shorter hospital stay and a faster postoperative recovery compared with the opened procedure.

Open suprapubic versus retropubic prostatectomy in the treatment of benign prostatic hyperplasia during resident's learning curve: a randomized controlled trial.

PURPOSE: This study compared the suprapubic (SP) versus retropubic (RP) prostatectomy for the treatment of large prostates and evaluated perioperative surgical morbidity and improvement of urinary symptoms. MATERIALS AND METHODS: In this single centre, prospective, randomised study, 65 consecutive patients with LUTS and surgical indication with prostate volume greater than 75g underwent open prostatectomy to compare the RP (32 patients) versus SP (33 patients) technique. RESULTS: The SP group exhibited a higher incidence of complications (p=0.002). Regarding voiding pattern analysis (IPSS and flowmetry), both were significantly effective compared to pre-treatment baseline. The RP group parameters were significantly better, with higher peak urinary flow (SP: 16.77 versus RP: 23.03mL/s, p=0.008) and a trend of lower IPSS score (SP: 6.67 versus RP 4.14, p=0.06). In a subgroup evaluation of patients with prostate volumes larger than 100g, blood loss was lower in those undergoing SP prostatectomy (p=0.003). Patients with prostates smaller than 100g in the SP group exhibited a higher incidence of low grade late complications (p=0.004). CONCLUSIONS: The SP technique was related to a higher incidence of minor complications in the late postoperative period. High volume prostates were associated with increased bleeding when the RP technique was utilized. The RP prostatectomy was associated with higher peak urinary flow and a trend of a lower IPSS Score.