The Novel and Minimally Invasive Treatment Modalities for Female Pelvic Floor Muscle Dysfunction; Beyond the Traditional

Pelvic floor dysfunction is a clinical entity that is prevalent among female patients. Determining the exact underlying cause of pelvic floor dysfunction is difficult, and surgical intervention for this clinical entity may be challenging. Pelvic floor dysfunction can affect the quality of life of the patient by causing stress urinary incontinence, pelvic organ prolapse, or both. Well-defined surgical treatment options, minimally invasive approaches, and novel techniques for the treatment of pelvic floor dysfunction have been recently introduced. Here, we evaluated the management options available for patients with stress urinary incontinence and pelvic organ prolapse. We searched Medline and EMBASE databases for relevant articles by using the keywords "pelvic floor dysfunction," "minimally invasive procedures," "stress urinary incontinence," "pelvic organ prolapse," and "novel techniques". Traditional treatment options for stress urinary incontinence and pelvic organ prolapse are beyond the scope of our review. Laparoscopic and robotic surgical treatments for pelvic floor dysfunction continue to evolve and develop. These minimally invasive techniques will soon replace open procedures. Alternative novel treatment modalities have also been developed from novel human-compatible materials and are emerging as successful treatments for stress urinary incontinence. The development of these various treatment options has implications for future surgical practice in the field of uro-gynecology.

Role of Minimally Invasive (Micro and Ultra-mini) PCNL for Adult Urinary Stone Disease in the Modern Era: Evidence from a Systematic Review.

PURPOSE OF REVIEW: The role of PCNL and the expertise surrounding it has expanded in recent decades. Miniaturisation of equipment and instrument size has formed a part of this innovation. Although an increasing number of studies have been performed on miniaturised PCNL (Mi-PCNL) recently, a critical appraisal on these is lacking. We therefore conducted a systematic review of the literature to evaluate the efficacy, safety and feasibility of Mi-PCNL techniques (< 15 Fr). RECENT FINDINGS: A systematic review was conducted from 1990 to March 2017 on outcomes of Mi-PCNL [micro PCNL (m-PCNL) and ultra-mini PCNL (UMP)] in adult patients. Ten studies (three on m-PCNL and seven on UMP) were included in our study. Across the three studies, 118 patients (mean age 42.2 years, male to female ratio 1.3:1) underwent m-PCNL (4.8 Fr). For a mean stone size of 13.9 mm, a mean stone-free rate (SFR) was 89% and an overall complication rate was 15.2% [Clavien classification I (44%), II (28%), III (28%)], with no Clavien IV or V complications. Across the seven studies, 262 patients (mean age 49.4 years, male to female ratio 1.5:1) underwent UMP (13-14 Fr). For a mean stone size of 18.6 mm, a mean SFR was 88.3% and an overall complication rate was 6.2% [Clavien classification I (57%), II (36%), III (7%)], with no Clavien IV or V complications. While the transfusion rates for m-PCNL was 0.85%, only one case each in m-PCNL and UMP needed conversion to mini PCNL. Our review shows that for small- to medium-sized renal stones, Mi-PCNL can yield good stone-free rates whilst maintaining a low morbidity associated with it. There were no Clavien > III complications and no mortality with only one transfusion reported from this minimally invasive technique.

Correlation between organ-specific co-morbidities and complications in bladder cancer patients undergoing radical cystectomy.

OBJECTIVE: To evaluate the association between patients' organ-specific co-morbidities and post-operative complications following radical cystectomy for bladder cancer. PATIENTS AND METHODS: All patients who underwent radical cystectomy at Aarhus University Hospital during the period from January 2006 to February 2014 were included retrospectively. A total of 40 comorbidities and 59 complications were registered meticulously. Univariate and multivariate analyses were used to detect associations between the individual comorbidities and specific post-operative complications. RESULTS: Ninety-two per cent (575/625) of patients experienced one or more complications following radical cystectomy. Clavien-Dindo grade 3-5 complications were observed in 40.8% of patients, and 6.2% had severe complications (Clavien-Dindo grade 4-5). The mortality rate was 2.2%. High BM, previous myocardial infarction and chronic obstructive pulmonary disease were noted to be associated with moderate-to-severe post-operative complications (Clavien-Dindo grade 3-5), while diabetes and lymphoproliferative disorders were significantly associated with severe complications (Clavien-Dindo grade 4-5). CONCLUSION: This study demonstrates that overall complications to radical cystectomy are high (92%). The associations between specific comorbidities and complications need to be further investigated in order to evaluate whether pre-operative assessment can be more optimally used in a prevention strategy tailored to the individual patient.

Radical cystectomy in the elderly - Is this a safe treatment option?

OBJECTIVE: To determine if significant differences exist in the perioperative outcomes of patients aged >75 years treated with radical cystectomy (RC) compared to younger patients, as RC is frequently not offered to 'elderly' patients with bladder cancer because of supposed increased risks of complications. PATIENTS AND METHODS: We retrospectively analysed prospectively collected data of all patients that underwent RC in our centre from May 2013 to June 2015. In all, 81 consecutive RCs were identified and included in our study. Patients were divided into two age groups: Group A, aged <75 years (51 patients) and Group B, aged ≥75 years (30). Co-morbidities and perioperative outcomes were compared between the groups. Fisher's exact test was used for statistical analysis. RESULTS: In 68 patients RC was performed laparoscopically and the remaining 13 patients underwent open RC. The mean (range) age was 70.7 (36-85) years. There were 37 patients with muscle-invasive disease and 42 had non-muscle-invasive disease. The median hospital stay was not significantly different between the two age groups (10 vs 11 days). There was no significant difference in the preoperative Charlson co-morbidity index. The 30-day mortality rate was 4% for those aged <75 years and 6.6% for those aged ≥75 years, with overall perioperative complication rates of 57% vs 66%, respectively. Most complications were minor (Clavien-Dindo Grade I-II) and there was no statistically significant difference between the two cohorts. There was also no statistically significant difference in blood transfusion rates. CONCLUSION: RC in patients aged ≥75 years has similar perioperative morbidity when compared with younger patients and can be offered in selected elderly patients. Thus, age should not be an absolute contraindication for RC.

Laser Endopyelotomy in the Management of Pelviureteric Junction Obstruction in Adults: A Systematic Review of the Literature.

Laser endopyelotomy (LEP) is considered as an option for the treatment of pelviureteric junction obstruction in adults. A comprehensive systematic search of the published literature was performed to assess the success rate and perioperative complications of LEP in the treatment of primary and secondary pelviureteric junction obstruction and to identify the factors that may have an impact on the success of LEP. The evidence available has significant limitations in terms of the heterogeneous study design and the definitions of outcomes. The average overall success rate of the pooled data was 75% with a mean follow-up of 29 months. Complications were predominately minor with an average rate of 12.5%.

Outcomes of haematuria referrals: two-year data from a single large university hospital in Denmark.

OBJECTIVE: The aim of this study was to review haematuria referrals to a large university hospital in Denmark, based on the previous Danish guidelines for haematuria referral (before January 2016), to evaluate the pattern of referrals and the cancer detection rates and compare these with the current guidelines. MATERIALS AND METHODS: A retrospective study was undertaken of all patients referred from primary care for the evaluation of haematuria from January 2013 to December 2014. All patients underwent cystoscopic examination and upper urinary tract evaluation using computed tomography. Patients' demographics, type of haematuria, presence of urinary symptoms and cancer detection rates were recorded. RESULTS: The study included 1577 patients, with a mean age of 63 years (range 16-96 years). Of these, 56.4% had visible haematuria (VH) and 43.6% were referred for non-visible haematuria (NVH). In total, 228 malignancies were detected (14.5% cancer detection rate). Overall, 11.2% of patients had bladder cancer, 1.8% renal cancer and 0.4% upper tract transitional cell carcinoma. In the VH group, 205 malignancies were detected (23% cancer detection rate). The detection rate was higher for those with asymptomatic VH (24.6%) than for those with symptomatic VH (15.4%). The cancer detection rate for symptomatic NVH was 9.1%, with only three cancers diagnosed in those younger than 60 years of age. For asymptomatic NVH, the cancer detection rate was only 1.5%, with a total of eight urological malignancies diagnosed in patients aged 60 years or older. CONCLUSIONS: The new Danish referral pathway has an acceptable capture rate for patients presenting with haematuria of all severities. The overall cancer detection rate of 14.5%, and 23% for patients with VH in this study, is an important validation of previous studies. A cancer detection rate of greater than 30% was shown in patients with VH over 70 years old.

Evaluation of the complications in laparoscopic retroperitoneal radical nephrectomy; An experience of high volume centre.

OBJECTIVES: To provide a standardised report of complications after retroperitoneal laparoscopic radical nephrectomy (rLRN) in a high-volume centre using Clavien-Dindo classification. MATERIALS AND METHODS: We analysed records maintained in a prospective database of 330 consecutive patients that underwent rLRN between March 1995 and September 2016. All complications were graded according to the modified Clavien-Dindo classification. Three generations of surgeons were defined and the learning curve in rLRN was evaluated by comparing the first 100 cases (Group A) performed by firstgeneration surgeons with the last 100 cases (Group B) by thirdgeneration surgeons. RESULTS: The mean age of our cohort was 66 ± 11.9 years. The overall complication rate was 19.7%. The majority of complications (12.7%) were Clavien 1 (5.1%) and Clavien 2 (7.6%) and did not require any interventions; blood transfusion was the most frequently encountered intervention (4.8%). Half of which were because of major intraoperative bleeding. Mortality rate was 0.9%. We found a trend towards lower complication rate in group B (19%) compared to group A (23%); this was mainly because of the reduction in the incidence of Clavien 1 and 2 complications. The pathological stage varied significantly in the two groups while the rate of negative surgical margins was comparable. CONCLUSIONS: rLRN is a safe procedure with an acceptable rate of complications. The learning curve was shorter for the thirdgeneration surgeons (group B); although these surgeons operated on a significantly higher number of patients with more advanced diseases. The Clavien-Dindo classification is suitable for assessing rLRN complications. Adopting this standardised system can help in the evaluation and comparison of surgical quality of LRN series.

Enhanced recovery for non-colorectal surgery.

In recent years the advent of programs for enhanced recovery after major surgery (ERAS) has led to modifications of long-standing and well-established perioperative treatments. These programs are used to target factors that have been shown to delay postoperative recovery (pain, gut dysfunction, immobility) and combine a series of interventions to reduce perioperative stress and organ dysfunction. With due differences, the programs of enhanced recovery are generally based on the preoperative amelioration of the patient's clinical conditions with whom they present for the operation, on the intraoperative and postoperative avoidance of medications that could slow the resumption of physiological activities, and on the promotion of positive habits in the early postoperative period. Most of the studies were conducted on elective patients undergoing colorectal procedures (either laparotomic or laparoscopic surgery). Results showed that ERAS protocols significantly improved the lung function and reduced the time to resumption of oral diet, mobilization and passage of stool, hospital stay and return to normal activities. ERAS' acceptance is spreading quickly among major centers, as well as district hospitals. With this in mind, is there also a role for ERAS in non-colorectal operations?

Enhanced recovery for colorectal surgery: Practical hints, results and future challenges.

Enhanced recovery after surgery (ERAS) protocols are now achieving worldwide diffusion in both university and district hospitals with special interest in colorectal surgery. The optimization of the patient's preoperative clinical conditions, the careful intraoperative administration of fluids and drugs and the postoperative encouragement to resume the normal physiological functions as early as possible has produced results in a large amounts of studies. These approaches successfully challenged long-standing and well-established perioperative managements and finally achieved the status of gold standard treatments for the perioperative management of uncomplicated colorectal surgery. Even more important, it seems that the clinical improvement of the patient's clinical management through ERAS protocols is now reaching his best outcomes (length of stay of 4-6 d after the operation) and therefore any further measures add little to the results already established (i.e., the adjunct of laparoscopic surgery to ERAS). Still dedicated meetings and courses around the world are exploring new aspects including the improvement the preoperative nutrition status to provide the energy necessary to face the surgical stress, the preoperative individuation of special requirements that could be properly addressed before the date of surgery and therefore would reduce the number of unnecessary days spent in hospital once fully recovered (i.e., rehabilitation, social discharges), and finally the development of an important web of out-of-hours direct access in order to individuate alarm symptoms in those patients at risk of complications that could prompt an early readmission.

The role of a standardized 36 core template-assisted transperineal prostate biopsy technique in patients with previously negative transrectal ultrasonography-guided prostate biopsies.

OBJECTIVE: To determine the efficacy and safety of a standardized 36 core template-assisted transperineal biopsy technique for detecting prostate cancer in patients with previously negative transrectal ultrasonography-guided prostate biopsies and elevated prostate-specific antigen (PSA) levels. PATIENTS AND METHODS: Between April 2008 to September 2010, a total of 40 patients with a mean (range) age of 63 (49-73) years, a mean (range) elevated PSA level of 21.9 (4.7-87) ng/mL and two previous sets of negative TRUS-guided prostate biopsies underwent standardized 36 core template-assisted transperineal prostate biopsies under general anaesthetic as a day case procedure. The cancer detection rate and complications for all cases were evaluated. RESULTS: In total, 27 of 40 (68%) patients were found to have adenocarcinoma of the prostate, two patients (5.0%) had atypical small acinar proliferation, one had high-grade prostatic intraepithelial neoplasia (2.5%), four (10%) had chronic active inflammation and six (15%) had benign histology. Gleason scores were in the range 6-9, with a median Gleason score of 7. There were no cases of urosepsis, urinary tract infections or haematuria. A single patient experienced acute urinary retention, with a subsequent succesful trial without a catheter, and haematospermia was common, although minor. CONCLUSIONS: Our standardized 36 core template-assisted transperineal prostate biopsy technique is safe and associated with a high detection rate of prostate cancer. This technique should be considered in patients with elevated PSA levels and previously negative TRUS-guided prostate biopsies.