Intrarenal pressure with hand-pump or pressurized-bag irrigation: randomized clinical trial at retrograde intrarenal surgery.

BACKGROUND: The aim was to ascertain the impact of irrigation technique on human intrarenal pressure during retrograde intrarenal surgery. METHODS: A parallel randomized trial recruited patients across three hospital sites. Patients undergoing retrograde intrarenal surgery for renal stone treatment with an 11/13-Fr ureteral access sheath were allocated randomly to 100 mmHg pressurized-bag (PB) or manual hand-pump (HP) irrigation. The primary outcome was mean procedural intrarenal pressure. Secondary outcomes included maximum intrarenal pressure, variance, visualization, HP force of usage, procedure duration, stone clearance, and clinical outcomes. Live intrarenal pressure monitoring was performed using a COMETTMII pressure guidewire, deployed cystoscopically to the renal pelvis. The operating team was blinded to the intrarenal pressure. RESULTS: Thirty-eight patients were randomized between July and November 2023 (trial closure). The final analysis included 34 patients (PB 16; HP 18). Compared with PB irrigation, HP irrigation resulted in significantly higher mean intrarenal pressure (mean(s.d.) 62.29(27.45) versus 38.16(16.84) mmHg; 95% c.i. for difference in means (MD) 7.97 to 40.29 mmHg; P = 0.005) and maximum intrarenal pressure (192.71(106.23) versus 68.04(24.16) mmHg; 95% c.i. for MD 70.76 to 178.59 mmHg; P < 0.001), along with greater variance in intrarenal pressure (log transformed) (6.23(1.59) versus 4.60(1.30); 95% c.i. for MD 0.62 to 2.66; P = 0.001). Surgeon satisfaction with procedural vision reported on a scale of 10 was higher with PB compared with HP irrigation (mean(s.d.) 8.75(0.58) versus 6.28(1.27); 95% c.i. for MD 1.79 to 3.16; P < 0.001). Subjective HP usage force did not correlate significantly with transmitted intrarenal pressure (Pearson R = -0.15, P = 0.57). One patient (HP arm) developed urosepsis. CONCLUSION: Manual HP irrigation resulted in higher and more fluctuant intrarenal pressure trace (with inferior visual clarity) than 100-mmHg PB irrigation. REGISTRATION NUMBER: osf.io/jmg2h (https://osf.io/).

Human in vivo baseline intrarenal pressure, peristaltic activity and response to ureteric stenting.

OBJECTIVES: To assess human in vivo intrarenal pressure (IRP) and peristaltic activity at baseline and after ureteric stent placement, using a narrow calibre pressure guidewire placed retrogradely in the renal pelvis. PATIENTS AND METHODS: A prospective, multi-institutional study recruiting consenting patients undergoing ureteroscopy was designed with ethical approval. Prior to ureteroscopy, the urinary bladder was emptied and the COMET™ II pressure guidewire (Boston Scientific) was advanced retrogradely via the ureteric orifice to the renal pelvis. Baseline IRPs were recorded for 1-2 min. At procedure completion, following ureteric stent insertion, IRPs were recorded for another 1-2 min. Statistical analysis of mean baseline IRP, peristaltic waveforms and frequency of peristaltic contractions was performed, thereby analysing the influence of patient variables and ureteric stenting. RESULTS: A total of 100 patients were included. Baseline mean (±SD) IRP was 16.76 (6.4) mmHg in the renal pelvis, with maximum peristaltic IRP peaks reaching a mean (SD) of 25.75 (17.9) mmHg. Peristaltic activity generally occurred in a rhythmic, coordinated fashion, with a mean (SD) interval of 5.63 (3.08) s between peaks. On univariate analysis, higher baseline IRP was observed with male sex, preoperative hydronephrosis, and preoperative ureteric stenting. On linear regression, male sex was no longer statistically significant, whilst the latter two variables remained significant (P = 0.004; P < 0.001). The mean (SD) baseline IRP in the non-hydronephrotic, unstented cohort was 14.19 (4.39) mmHg. Age, α-blockers and calcium channel blockers did not significantly influence IRP, and no measured variables influenced peristaltic activity. Immediately after ureteric stent insertion, IRP decreased (mean [SD] 15.18 [5.28] vs 16.76 [6.4] mmHg, P = 0.004), whilst peristaltic activity was maintained. CONCLUSIONS: Human in vivo mean (SD) baseline IRP is 14.19 (4.39) mmHg in normal kidneys and increases with both hydronephrosis and preoperative ureteric stenting. Mean (SD) peristaltic peak IRP values of 25.75 (17.9) mmHg are reached in the renal pelvis every 3-7 s and maintained in the early post-stent period.

A Prospective Multi-institutional Study Using a Novel Safety Valve for the Prevention of Catheter Balloon Inflation Injury of the Urethra.

PURPOSE: We prospectively assessed the ability of a novel transurethral catheterization safety valve to prevent urethral catheter balloon injury in a multi-institutional clinical setting. MATERIALS AND METHODS: A prospective, multi-institution study was conducted. The safety valve was introduced for urinary catheterization in 6 hospital groups (4 in Ireland; 2 in the UK). The safety valve allows fluid in the catheter system to vent through a pressure relief valve if attempted intraurethral inflation of the catheter's anchoring balloon occurs. Device usage was studied over a 12-month period, with data recorded using a 7-item data sticker containing a scannable QR code. "Venting" through the safety valve during catheterization was indicative of prevention of a urethral injury. An embedded 3-month study was conducted in 3 centers, with any catheter balloon injuries occurring during catheterization without safety valve use referred to the on-call urology team recorded. Health economic analyses were also performed. RESULTS: During the overall 12-month device study phase, 994 urethral catheterizations were performed across study sites. Twenty-two (2.2%) episodes of safety valve venting were recorded. No urethral injuries occurred in these patients. In the embedded 3-month study, 18 catheter balloon injuries were recorded in association with catheterizations performed without the safety valve. Based on confirmed and device-prevented urethral injuries, the injury rate for urethral catheterization without safety valve use was calculated to be 5.5/1,000 catheterizations. CONCLUSIONS: The safety valve has the potential to eliminate catheter balloon injury if widely adopted. It represents a simple, effective, and innovative solution to this recurring problem applicable to all patient cohorts.

Upper urinary tract pressures in endourology: a systematic review of range, variables and implications.

OBJECTIVES: To systematically review the literature to ascertain the upper tract pressures generated during endourology, the relevant influencing variables and clinical implications. MATERIALS AND METHODS: A systematic review of the MEDLINE, Scopus and Cochrane databases was performed by two authors independently (S.C., N.D.). Studies reporting ureteric or intrarenal pressures (IRP) during semi-rigid ureteroscopy (URS)/flexible ureterorenoscopy (fURS)/percutaneous nephrolithotomy (PCNL)/miniaturized PCNL (mPCNL) in the period 1950-2021 were identified. Both in vitro and in vivo studies were considered for inclusion. Findings were independently screened for eligibility based on content, with disagreements resolved by author consensus. Data were assessed for bias and compiled based on predefined variables. RESULTS: Fifty-two studies met the inclusion criteria. Mean IRP appeared to frequently exceed a previously proposed threshold of 40 cmH2 O. Semi-rigid URS with low-pressure irrigation (gravity <1 m) resulted in a wide mean IRP range (lowest reported 6.9 cmH2 O, highest mean 149.5 ± 6.2 cmH2 O; animal models). The lowest mean observed with fURS without a ureteric access sheath (UAS) was 47.6 ± 4.1 cmH2 O, with the maximum peak IRP being 557.4 cmH2 O (in vivo human data). UAS placement significantly reduced IRP during fURS, but did not guarantee pressure control with hand-operated pump/syringe irrigation. Miniaturization of PCNL sheaths was associated with increased IRP; however, a wide mean human IRP range has been recorded with both mPCNL (lowest -6.8 ± 2.2 cmH2 O [suction sheath]; highest 41.2 ± 5.3 cmH2 O) and standard PCNL (lowest 6.5 cmH2 O; highest 41.2 cmH2 O). Use of continuous suction in mPCNL results in greater control of mean IRP, although short pressure peaks >40 cmH2 O are not entirely prevented. Definitive conclusions are limited by heterogeneity in study design and results. Postoperative pain and pyrexia may be correlated with increased IRP, however, few in vivo studies correlate clinical outcome with measured IRP. CONCLUSIONS: Intrarenal pressure generated during upper tract endoscopy often exceeds 40 cmH2 O. IRP is multifactorial in origin, with contributory variables discussed. Larger prospective human in vivo studies are required to further our understanding of IRP thresholds and clinical sequelae.

In vivo ureteroscopic intrarenal pressures and clinical outcomes: a multi-institutional analysis of 120 consecutive patients.

OBJECTIVES: To evaluate the pressure range generated in the human renal collecting system during ureteroscopy (URS), in a large patient sample, and to investigate a relationship between intrarenal pressure (IRP) and outcome. PATIENTS AND METHODS: A prospective multi-institutional study was conducted, with ethics board approval; February 2022-March 2023. Recruitment was of 120 consecutive consenting adult patients undergoing semi-rigid URS and/or flexible ureterorenoscopy (FURS) for urolithiasis or diagnostic purposes. Retrograde, fluoroscopy-guided insertion of a 0.036-cm (0.014″) pressure guidewire (COMET™ II, Boston Scientific, Marlborough, MA, USA) to the renal pelvis was performed. Baseline and continuous ureteroscopic IRP was recorded, alongside relevant operative variables. A 30-day follow-up was completed. Descriptive statistics were applied to IRP traces, with mean (sd) and maximum values and variance reported. Relationships between IRP and technical variables, and IRP and clinical outcome were interrogated using the chi-square test and independent samples t-test. RESULTS: A total of 430 pressure traces were analysed from 120 patient episodes. The mean (sd) baseline IRP was 16.45 (5.99) mmHg and the intraoperative IRP varied by technique. The mean (sd) IRP during semi-rigid URS with gravity irrigation was 34.93 (11.66) mmHg. FURS resulted in variable IRP values: from a mean (sd) of 26.78 (5.84) mmHg (gravity irrigation; 12/14-F ureteric access sheath [UAS]) to 87.27 (66.85) mmHg (200 mmHg pressurised-bag irrigation; 11/13-F UAS). The highest single pressure peak was 334.2 mmHg, during retrograde pyelography. Six patients (5%) developed postoperative urosepsis; these patients had significantly higher IRPs during FURS (mean [sd] 81.7 [49.52] mmHg) than controls (38.53 [22.6] mmHg; P < 0.001). CONCLUSIONS: A dynamic IRP profile is observed during human in vivo URS, with IRP frequently exceeding expected thresholds. A relationship appears to exist between elevated IRP and postoperative urosepsis.

The recurrent urinary tract infection health and functional impact questionnaire (RUHFI-Q): design and feasibility assessment of a new evaluation scale.

INTRODUCTION: We aim to design a tool to assess the impact of recurrent urinary tract infection (rUTI) on quality of life (QoL) in adult women, given the notable absence of an established instrument for this purpose. MATERIALS AND METHODS: Best practice guidelines in health-related survey design were reviewed. A literature review informed creation of an interview guide. Following ethical approval, 10 female patients (23-38 years) with rUTI were invited to participate in phase 1 of questionnaire design; all agreed. Individual semi-structured interviews were conducted exploring the impact of rUTI on patients' QoL. Interviews were repeated with 5 staff members (3 urology nurses and 2 consultant urologists). Responses were recorded and thematic analysis performed, to inform the design of a new questionnaire. A further 10 patients were recruited to assess feasibility of completion. RESULTS: All participants found available questionnaires unfit for assessment of rUTI-related QoL. Multiple themes emerged as integral to an rUTI questionnaire, including: frequency of UTIs, duration of symptoms, time to full recovery, specific symptoms of UTI, constitutional symptoms, impact on work/education, impact on leisure activities, impact on interpersonal relationships, impact on sexual relationships, psychological aspects and implications of treatment. Data saturation was reached. Based on responses, the Recurrent Urinary tract infection Health and Functional Impact Questionnaire (RUHFI-Q) was drafted, comprising 10 domains and 16 items. CONCLUSIONS: We propose a novel self-administered questionnaire, the RUHFI-Q, as an instrument to standardize evaluation of the QoL impact of rUTI in a population of premenopausal women. Further validation studies are in progress.

The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections.

PURPOSE: 'Prophylactic' ureteric stents potentially reduce rates, and facilitate intraoperative recognition, of iatrogenic ureteric injury (IUI) during colorectal resections. A lack of consensus surrounds the risk-benefit equation of this practice, and we aimed to assess the evidence base. METHODS: A systematic review was performed according to PRISMA guidelines. MEDLINE, Scopus, EMBASE and Cochrane databases were searched using terms 'ureteric/ureteral/JJ/Double J stent' or 'ureteric/ureteral catheter' and 'colorectal/prophylactic/resection/diverticular disease/diverticulitis/iatrogenic injury'. Primary outcomes were rates of ureteric injuries and their intraoperative identification. Secondary outcomes included stent complication rates. RESULTS: We identified 987 publications; 22 papers met the inclusion criteria. No randomised controlled trials were found. The total number of patients pooled for evaluation was 869,603 (102,370 with ureteric stents/catheters, 767,233 controls). The most frequent indications for prophylactic stents were diverticular disease (45.38%), neoplasia (33.45%) and inflammatory bowel disease (9.37%). Pooled results saw IUI in 1521/102,370 (1.49%) with, and in 1333/767,233 (0.17%) without, prophylactic ureteric stents. Intraoperative recognition of IUIs occurred in 10/16 injuries (62.5%) with prophylactic stents, versus 9/17 (52.94%) without stents (p = 0.579). The most serious complications of prophylactic stent use were ureteric injury (2/1716, 0.12%) and transient ureteric obstruction following stent removal (13/666, 1.95%). CONCLUSIONS: Placement of prophylactic ureteric stents has a low complication rate. There is insufficient evidence to conclude that stents decrease ureteric injury or increase intraoperative detection of IUIs. Apparently higher rates of IUI in stented patients likely reflect use in higher risk resections. A prospective registry with harmonised data collection points and stratification of intraoperative risk is needed.

Design and utilisation of a novel, high-fidelity, low-cost, hybrid-tissue simulation model to facilitate training in robot-assisted partial nephrectomy.

Robot-assisted partial nephrectomy (RAPN) has rapidly evolved as the standard of care for appropriately selected renal tumours, offering key patient benefits over radical nephrectomy or open surgical approaches. Accordingly, RAPN is a key competency that urology trainees wishing to treat kidney cancer must master. Training in robotic surgery is subject to numerous challenges, and simulation has been established as valuable step in the robotic learning curve. However, simulation models are often both expensive and suboptimal in fidelity. This means that the number of practice repetitions for a trainee may limited by cost restraints, and that trainees may struggle to reconcile the skills obtained in the simulation laboratory with real-world practice in the operating room. We have developed a high-fidelity, low-cost, customizable model for RAPN simulation based on porcine tissue. The model has been utilised in teaching courses at our institution, confirming both feasibility of use and high user acceptability. We share the design of our model in this proof-of-concept report.

Diagnosis and management of indeterminate testicular lesions.

The sophistication and accessibility of modern-day imaging result in frequent detection of small or equivocal lesions of the testes. Traditionally, diagnosis of a testicular lesion with any possibility of malignancy would usually prompt radical orchidectomy. However, awareness is growing that a substantial proportion of these lesions might be benign and that universal application of radical orchidectomy risks frequent overtreatment. Given the potentially profound effects of radical orchidectomy on fertility, endocrine function and psychosexual well-being, particularly in scenarios of an abnormal contralateral testis or bilateral lesions, organ-preserving strategies for equivocal lesions should be considered. Image-based active surveillance can be applied for indeterminate lesions measuring ≤15 mm with a low conversion rate to surgical treatment. However, these outcomes are early and from relatively small, selected cohorts, and concerns prevail regarding the metastatic potential of even small undiagnosed germ cell tumours. No consensus exists on optimal surveillance (short interval (<3 months) ultrasonography is generally adopted); histological sampling is a widespread alternative, involving inguinal delivery of the testis and excisional biopsy of the lesion, with preoperative marking or intraoperative ultrasonographic localization when necessary. Frozen section analysis in this context demonstrates excellent diagnostic accuracy. Histological results support that approximately two-thirds of marker-negative indeterminate solitary testicular lesions measuring ≤25 mm overall are benign. In summary, modern imaging detects many small indeterminate testicular lesions, of which the majority are benign. Awareness is growing of surveillance and organ-sparing diagnostic and treatment strategies with the aim of minimizing rates of overtreatment with radical orchidectomy.

Cost-effectiveness of a novel urethral catheter safety device in preventing catheterization injuries in the UK.

AIMS: Intraurethral catheter balloon inflation is a substantial contributor to significant catheter-related urethral injury. A novel safety valve has been designed to prevent these balloon-inflation injuries. The purpose of this evaluation was to assess the cost-effectiveness of urethral catheterisation with the safety valve added to a Foley catheter versus the current standard of care (Foley catheter alone). MATERIALS AND METHODS: The analysis was conducted from the UK public payer perspective on a hypothetical cohort of adults requiring transurethral catheterization. A decision tree was used to capture outcomes in the first 30 days following transurethral catheterization, followed by a Markov model to estimate outcomes over a person's remaining lifetime. Clinical outcomes included catheter balloon injuries [CBIs], associated short-term complications, urethral stricture disease, life years and QALYs. Health-economic outcomes included total costs, incremental cost-effectiveness ratio, net monetary benefit (NMB) and net health benefit. RESULTS: Over a person's lifetime, the safety valve was predicted to reduce CBIs by 0.04 per person and CBI-related short-term complications by 0.03 per person, and nearly halve total costs. The safety valve was dominant, resulting in 0.02 QALYs gained and relative cost savings of £93.19 per person. Probabilistic sensitivity analysis indicated that the safety valve would be cost-saving in 97% of simulations run versus standard of care. CONCLUSIONS: The addition of a novel safety valve aiming to prevent CBIs during transurethral catheterization to current standard of care was estimated to bring both clinical benefits and cost savings.

Mechanical characteristics of the ureter and clinical implications.

The ureteric wall is a complex multi-layered structure. The ureter shows variation in passive mechanical properties, histological morphology and insertion forces along the anatomical length. Ureter mechanical properties also vary depending on the direction of tensile testing and the anatomical region tested. Compliance is greatest in the proximal ureter and lower in the distal ureter, which contributes to the role of the ureter as a high-resistance sphincter. Similar to other human tissues, the ureteric wall remodels with age, resulting in changes to the mechanical properties. The passive mechanical properties of the ureter vary between species, and variation in tissue storage and testing methods limits comparison across some studies. Knowledge of the morphological and mechanical properties of the ureteric wall can aid in understanding urine transport and safety thresholds in surgical techniques. Indeed, various factors alter the forces required to insert access sheaths or scopes into the ureter, including sheath diameter, safety wires and medications. Future studies on human ureteric tissue both in vivo and ex vivo are required to understand the mechanical properties of the ureter and how forces influence these properties. Testing of instrument insertion forces in humans with a focus on defining safe upper limits and techniques to reduce trauma are also needed. Last, evaluation of dilatation limits in the mid and proximal ureter and clarification of tensile strength anisotropy in human specimens are necessary.

Functional outcomes and health-related quality of life following penile cancer surgery: a comprehensive review.

INTRODUCTION: Organ-sparing surgery (OSS) in penile cancer management aspires to maintain organ form and function and preserve health-related quality of life (HRQoL), yet there is a lack of integrated evidence exploring these outcomes. OBJECTIVES: The aim sought to review HRQoL, functional, aesthetic, and psychological outcomes following OSS or radical penectomy for penile cancer. METHODS: A systematic review of MEDLINE and Cochrane databases included studies reporting on function (sexual, urinary or sensory), genital appearance or HRQoL/psychological well-being following surgical treatment of primary penile cancer. English-language reports (2000-2022), incorporating patient-reported or objective clinical outcome measures, were eligible. Studies of nonsurgical treatment strategies and those in the context of metastatic disease were excluded. Data were compiled and analyzed. RESULTS: Twenty-six studies were included. Sexual function was the most studied outcome (754 pooled respondents; 19 studies), most frequently with the original 15-item and abridged 5-item International Index of Erectile Function. Preservation of erectile function following OSS is generally described, with some reduction in overall sexual satisfaction cited. Heterogeneous assessment of voiding function with little preoperative evaluation render interstudy comparison difficult. Most patients appear able to void from a standing position following OSS, with spraying the most common symptom. Maintenance of some sensory function is described with both split-thickness skin grafting and urethral glanduloplasty following radical glansectomy. Limited studies suggest reasonable patient satisfaction with genital cosmesis post-OSS. A negative impact on HRQoL is described in most studies following penile cancer surgery, variably correlated with aggressiveness of penile surgery and addition of lymphadenectomy. Anxiety, depression, and reduced self-esteem have been reported in penile cancer survivors. Relationship well-being varies, with some survivors reporting this to be unchanged. CONCLUSION: OSS can preserve elements of sexual, urinary, and sensory function, supporting advantages over radical penectomy for eligible patients. However, a comprehensive understanding remains limited due to small, heterogeneous patient cohorts, challenges in obtaining premorbid data, and variability in outcome measures. Standardization of patient-reported outcomes following OSS is desirable.

Effect of obesity on perioperative outcomes following gastrointestinal surgery: meta-analysis.

BACKGROUND: Obesity can pose perioperative challenges related to obesity-associated co-morbidities and technical factors. However, the true impact of obesity on postoperative outcomes is not well established and reports are conflicting. The aim was to perform a systematic review and meta-analysis to explore the effect of obesity on perioperative outcomes for general surgery procedures in distinct obesity subtypes. METHODS: A systematic review was performed for studies reporting postoperative outcomes in relation to BMI in upper gastrointestinal, hepatobiliary and colorectal based on an electronic search using the Cochrane Library, Science Direct, PubMed and Embase up to January 2022. The primary outcome was the incidence of 30-day postoperative mortality among patients with obesity undergoing general surgical procedures in comparison to patients with normal range BMI. RESULTS: Sixty-two studies, including 1 886 326 patients, were eligible for inclusion. Overall, patients with obesity (including class I/II/II) had lower 30-day mortality rates in comparison to patients with a normal BMI (odds ratio (OR) 0.75, 95 per cent c.i. 0.66 to 0.86, P < 0.0001, I2 = 71 per cent); this was also observed specifically in emergency general surgery (OR 0.83, 95 per cent c.i. 0.79 to 0.87, P < 0.0000001, I2 = 7 per cent). Compared with normal BMI, obesity was positively associated with an increased risk of 30-day postoperative morbidity (OR 1.11, 95 per cent c.i. 1.04 to 1.19, P = 0.002, I2 = 85 per cent). However, there was no significant difference in postoperative morbidity rates between the cohorts of patients with a normal BMI and class I/II obesity (OR 0.98, 95 per cent c.i. 0.92 to 1.04, P = 0.542, I2 = 92 per cent). Overall, the cohort with obesity had a higher rate of postoperative wound infections compared with the non-obese group (OR 1.40, 95 per cent c.i. 1.24 to 1.59, P < 0.0001, I2 = 82 per cent). CONCLUSION: These data suggest a possible 'obesity paradox' and challenge the assumption that patients with obesity have higher postoperative mortality compared with patients with normal range BMI. Increased BMI alone is not associated with increased perioperative mortality in general surgery, highlighting the importance of more accurate body composition assessment, such as computed tomography anthropometrics, to support perioperative risk stratification and decision-making. REGISTRATION NUMBER: CRD42022337442 (PROSPERO https://www.crd.york.ac.uk/prospero/).

Mechanical and morphological characterisation of porcine urethras for the assessment of paediatric urinary catheter safety.

Paediatric urinary catheters are often necessary in critical care settings or to address congenital anomalies affecting the urogenital system. Iatrogenic injuries can occur during the placement of such catheters, highlighting the need for a safety device that can function in paediatric settings. Despite successful efforts to develop devices that improve the safety of adult urinary catheters, no such devices are available for use with paediatric catheters. This study investigates the potential for utilising a pressure-controlled safety mechanism to limit the trauma experienced by paediatric patients during inadvertent inflation of a urinary catheter anchoring balloon in the urethra. Firstly, we establish a paediatric model of the human urethra using porcine tissue by characterising the mechanical and morphological properties of porcine tissue at increasing postnatal timepoints (8, 12, 16 and 30 weeks). We identified that porcine urethras harvested from pigs at postnatal week 8 and 12 exhibit morphological properties (diameter and thickness) that are statistically distinct from adult porcine urethras (postnatal week 30). We therefore utilise urethra tissue from postnatal week 8 and 12 pigs as a model to evaluate a pressure-controlled approach to paediatric urinary catheter balloon inflation intended to limit tissue trauma during inadvertent inflation in the urethra. Our results show that limiting catheter system pressure to 150 kPa avoided trauma in all tissue samples. Conversely, all of the tissue samples that underwent traditional uncontrolled urinary catheter inflation experienced complete rupture. The findings of this study pave the way for the development of a safety device for use with paediatric catheters, thereby alleviating the burden of catastrophic trauma and life changing injuries in children due to a preventable iatrogenic urogenital event.

Global Incidence and Risk Factors Associated With Postoperative Urinary Retention Following Elective Inguinal Hernia Repair: The Retention of Urine After Inguinal Hernia Elective Repair (RETAINER I) Study.

Importance: Postoperative urinary retention (POUR) is a well-recognized complication of inguinal hernia repair (IHR). A variable incidence of POUR has previously been reported in this context, and contradictory evidence surrounds potential risk factors. Objective: To ascertain the incidence of, explore risk factors for, and determine the health service outcomes of POUR following elective IHR. Design, Setting, and Participants: The Retention of Urine After Inguinal Hernia Elective Repair (RETAINER I) study, an international, prospective cohort study, recruited participants between March 1 and October 31, 2021. This study was conducted across 209 centers in 32 countries in a consecutive sample of adult patients undergoing elective IHR. Exposure: Open or minimally invasive IHR by any surgical technique, under local, neuraxial regional, or general anesthesia. Main Outcomes and Measures: The primary outcome was the incidence of POUR following elective IHR. Secondary outcomes were perioperative risk factors, management, clinical consequences, and health service outcomes of POUR. A preoperative International Prostate Symptom Score was measured in male patients. Results: In total, 4151 patients (3882 male and 269 female; median [IQR] age, 56 [43-68] years) were studied. Inguinal hernia repair was commenced via an open surgical approach in 82.2% of patients (n = 3414) and minimally invasive surgery in 17.8% (n = 737). The primary form of anesthesia was general in 40.9% of patients (n = 1696), neuraxial regional in 45.8% (n = 1902), and local in 10.7% (n = 446). Postoperative urinary retention occurred in 5.8% of male patients (n = 224), 2.97% of female patients (n = 8), and 9.5% (119 of 1252) of male patients aged 65 years or older. Risk factors for POUR after adjusted analyses included increasing age, anticholinergic medication, history of urinary retention, constipation, out-of-hours surgery, involvement of urinary bladder within the hernia, temporary intraoperative urethral catheterization, and increasing operative duration. Postoperative urinary retention was the primary reason for 27.8% of unplanned day-case surgery admissions (n = 74) and 51.8% of 30-day readmissions (n = 72). Conclusions: The findings of this cohort study suggest that 1 in 17 male patients, 1 in 11 male patients aged 65 years or older, and 1 in 34 female patients may develop POUR following IHR. These findings could inform preoperative patient counseling. In addition, awareness of modifiable risk factors may help to identify patients at increased risk of POUR who may benefit from perioperative risk mitigation strategies.

Perceptions and Practice Patterns of Urologists Relating to Intrarenal Pressure During Ureteroscopy: Findings from a Global Cross-Sectional Analysis.

Objectives: To explore beliefs and practice patterns of urologists regarding intrarenal pressure (IRP) during ureteroscopy (URS). Methods: A customized questionnaire was designed in a 4-step iterative process incorporating a systematic review of the literature and critical analysis of topics/questions by six endourologists. The 19-item questionnaire interrogated perceptions, practice patterns, and key areas of uncertainty regarding ureteroscopic IRP, and was disseminated via urologic societies, networks, and social media to the international urologic community. Consultants/attendings and trainees currently practicing urology were eligible to respond. Quantitative responses were compiled and analyzed using descriptive statistics and chi-square test, with subgroup analysis by procedure volume. Results: Responses were received from 522 urologists, practicing in six continents. The individual question response rate was >97%. Most (83.9%, 437/515) respondents were practicing at a consultant/attending level. An endourology fellowship incorporating stone management had been completed by 59.2% (307/519). The vast majority of respondents (85.4%, 446/520) scored the perceived clinical significance of IRP during URS ≥7/10 on a Likert scale. Concern was uniformly reported, with no difference between respondents with and without a high annual case volume (p = 0.16). Potential adverse outcomes respondents associated with elevated ureteroscopic IRP were urosepsis (96.2%, 501/520), collecting system rupture (80.8%, 421/520), postoperative pain (67%, 349/520), bleeding (63.72%, 332/520), and long-term renal damage (26.1%, 136/520). Almost all participants (96.2%, 501/520) used measures aiming to reduce IRP during URS. Regarding the perceived maximum acceptable threshold for mean IRP during URS, 30 mm Hg (40 cm H2O) was most frequently selected [23.2% (119/463)], with most participants (78.2%, 341/463) choosing a value ≤40 mm Hg. Conclusions: This is the first large-scale analysis of urologists' perceptions of ureteroscopic IRP. It identifies high levels of concern among the global urologic community, with almost unanimous agreement that elevated IRP is associated with adverse clinical outcomes. Equipoise remains regarding appropriate IRP limits intraoperatively and the most appropriate technical strategies to ensure adherence to these.

En bloc transurethral resection of bladder tumors: A review of current techniques.

INTRODUCTION: Growing interest surrounds the concept of en bloc transurethral resection of bladder tumors (ERBT). Theoretical advantages include improved adherence to oncological principles and potential yield of superior pathological specimens. Multiple ERBT methods exist. This review summarizes the current evidence regarding application of differing techniques and technologies to ERBT. METHODS: A systematic review of MEDLINE/EMBASE/Scopus databases was performed, using terms "en bloc," "ERBT," "bladder," and "urinary bladder neoplasm." Template-based data extraction included technique of ERBT, feasibility, tumor size, activation of obturator nerve reflex, operative complications, detrusor muscle sampling rate, and recurrence data. RESULTS: Multiple approaches to ERBT have evolved, using a variety of energy sources. The feasibility of electrocautery, laser, combined waterjet/electrocautery, and polypectomy snare techniques have been confirmed in achieving ERBT. ERBT appears safe, with a low complication rate. The use of laser energy sources reduces the risk of activating the obturator nerve reflex during lateral wall resections. Otherwise, no energy source is unequivocally superior in achieving ERBT. The rate of detrusor muscle sampling is high with use of ERBT and appears superior to that achieved with conventional TURBT (cTURBT) in multiple comparative studies. A limited number of largely non-randomized trials assess bladder tumor recurrence; current evidence suggests this is similar between ERBT and cTURBT groups. CONCLUSIONS: ERBT using a variety of technologies is feasible and safe, with a high detrusor muscle sampling rate. Further research is required to determine whether rates of residual disease or recurrence can be reduced with ERBT vs. cTURBT.

Reconstruction of the male external genitalia in diverse disease processes: Our reconstructive algorithm, techniques, and experience.

Background: Male genital form and function may be rendered abnormal by a number of disease processes, with profound associated psychological and functional consequences. The aim of the study is to review our reconstructive experience with cases of genital loss or distortion due to nonmalignant diseases processes and atypical neoplasia. Materials and methods: A retrospective review of a prospectively maintained database was performed to identify reconstructive cases performed from 2018 to 2020 under the care of a single surgeon. Male patients 18 years or older with a disease diagnosis other than squamous cell carcinoma affecting genital form were included. Disease processes, patient factors, surgical techniques, and both functional and cosmetic outcomes were reviewed. Results: Fourteen cases were identified. The patients had a mean age of 52.2 years (range, 21-72 years). Acquired buried penis was present in 8 patients. Etiology of genital abnormality included balanitis xerotica obliterans (n = 6), excess skin loss at circumcision (n = 2), self-injection of petroleum jelly to penile shaft (n = 1), Fournier gangrene (n = 1), hidradenitis suppurativa (n = 1), extramammary Paget disease (n = 1), idiopathic lymphoedema (n = 1), and penoscrotal webbing (n = 1). Reconstructive techniques performed included penile debridement/shaft skin release, scrotectomy, suprapubic apronectomy, and division of penoscrotal webbing, in combination with split-thickness skin grafting where required. A penile implant was inserted in one patient. Reconstructive planning, techniques, and outcomes are described. Conclusions: A variety of reconstructive techniques in andrology can be used to improve the aesthetic and functional outcomes of multiple disease processes affecting the male external genitalia.

A Prospective Multi-Institutional Evaluation of Iatrogenic Urethral Catheterization Injuries.

OBJECTIVES: To perform a multi-institutional investigation of incidence and outcomes of urethral trauma sustained during attempted catheterization. PATIENTS & METHODS: A prospective, multi-center study was conducted over a designated 3-4 month period, incorporating seven academic hospitals across the UK and Ireland. Cases of urethral trauma arising from attempted catheterization were recorded. Variables included sites of injury, management strategies and short-term clinical outcomes. The catheterization injury rate was calculated based on the estimated total number of catheterizations occurring in each center per month. Anonymised data were collated, evaluated and described. RESULTS: Sixty-six urethral catheterization injuries were identified (7 centers; mean 3.43 months). The mean injury rate was 6.2 ± 3.8 per 1000 catheterizations (3.18-14.42/1000). All injured patients were male, mean age 76.1 ± 13.1 years. Urethral catheterization injuries occurred in multiple hospital/community settings, most commonly Emergency Departments (36%) and medical/surgical wards (30%). Urological intervention was required in 94.7% (54/57), with suprapubic catheterization required in 12.3% (n = 7). More than half of patients (55.56%) were discharged with an urethral catheter, fully or partially attributable to the urethral catheter injury. At least one further healthcare encounter on account of the injury was required for 90% of patients post-discharge. CONCLUSIONS: This is the largest study of its kind and confirms that iatrogenic urethral trauma is a recurring medical error seen universally across institutions, healthcare systems and countries. In addition, urethral catheter injury results in significant patient morbidity with a substantial financial burden to healthcare services. Future innovation to improve the safety of urinary catheterization is warranted.