Robotic YV plasty outcomes for bladder neck contracture vs. vesico-urethral anastomotic stricture.

PURPOSE: To compare the outcomes of patients undergoing robotic YV plasty for bladder neck contracture (BNC) vs. vesico-urethral anastomotic stricture (VUAS). METHODS: A retrospective study included male patients who underwent robotic YV plasty for BNC after endoscopic treatment of BPH or VUAS between August 2019 and March 2023 at a single academic center. The primary assessed was the patency rate at 1 month post-YV plasty and during the last follow-up visit. RESULTS: A total of 21 patients were analyzed, comprising 6 in the VUAS group and 15 in the BNC group. Patients with VUAS had significantly longer operative times (277.5 vs. 146.7 min; p = 0.008) and hospital stay (3.2 vs. 1.7 days; p = 0.03). Postoperative complications were more common in the VUAS group (66.7% vs. 26.7%; p = 0.14). All patients resumed spontaneous voiding postoperatively. Five patients (23.8%) who developed de novo stress urinary incontinence had already an AUS (n = 1) or required concomitant AUS implantation (n = 3), all of whom were in the VUAS group (83.3% vs. 0%; p < 0.0001). The proportion of patients improved was similar in both groups (PGII = 1 or 2: 83.3% vs. 80%; p = 0.31). Stricture recurrence occurred in 9.5% of patients in the whole cohort, with no significant difference between the groups (p = 0.50). Long-term reoperation was required in three VUAS patients, showing a statistically significant difference between the groups (p = 0.05). CONCLUSION: Robotic YV plasty is feasible for both VUAS and BNC. While functional outcomes and stricture-free survival may be similar for both conditions, the perioperative outcomes were less favorable for VUAS patients.

Cut-off time for surgery and prediction of orchiectomy in spermatic cord torsion: a retrospective multicentric study over 15 years.

PURPOSE: Cut-off time to avoid orchiectomy relies on small series of patients. The objective was to determine the cut-off time to avoid orchiectomy in torsion of the spermatic cord in a large cohort. METHODS: We performed a retrospective multicenter study (TORSAFUF cohort) of patients with suspected spermatic cord torsion between 2005 and 2019. All patients aged > 12 years who were suspected of having a torsion of the spermatic cord in 14 University Hospitals in France were included (n = 2986). Patients for whom data on pain duration were not available (n = 923) or for whom the final diagnosis was not torsion of the spermatic cord (n = 807) were excluded. The primary outcome was orchiectomy. The secondary outcomes were testicular survival time and the prediction of orchiectomy with the duration of pain. RESULTS: 1266 patients were included with an orchiectomy rate of 12% (150 patients). The mean age was 21.5 years old in the salvage group and 23.7 years old in the orchiectomy group (p = 0.01), respectively. The median time from the onset of pain to surgery was 5.5 (IQR = 5) hours in the salvage group and 51.1 (IQR = 70) hours in the orchiectomy group (p < 0.0001). The risk of orchiectomy increased after a time cut-off of 6 h 30. A delay of 15 h 30 in pain duration was found to predict orchiectomy (sensitivity: 0.81; specificity: 0.87). CONCLUSIONS: Pain duration can predict the probability of salvaging the testicles and performing orchiectomy. Rapid intervention should be recommended, regardless of the time elapsed from the onset of pain.

A New Surgical Technique for Female-to-Male Top Surgery: The Posterioinferior Pedicle (PIPe) Approach.

INTRODUCTION: Most of the time, female-to-male (FtoM) chest surgery involves mastectomy techniques and free transplantation of the nipple-areola complex. With the increasing prevalence of gender dysphoria and the demand for female-to-male gender reassignment surgery, the need for FtM top surgery is also rising. To meet this demand, we present a new approach: the PIPe technique, based on a fasciocutaneous flap with a posteroinferior pedicle. MATERIALS AND METHODS: All patients with FtoM gender dysphoria undergoing surgery using the posteroinferior pedicle flap technique in the Plastic Surgery Department at Rennes University Hospital Center were included. The procedure involved extensive liposuction of the lower internal and external mammary quadrants, followed by liposuction of deep tissues in the upper quadrants, except in the pedicle area. After removing skin from the lower quadrants down to the dermis and de-epithelializing the posteroinferior pedicle flap, the thoracic flap was lowered and the areola transposed. RESULTS: From July 2022 to March 2023, fifteen patients underwent surgery, and their results were collected prospectively. The average age was 25 years, the mean weight was 76.6 kg, and the average BMI was 28.1 kg/m2. The average operating time was 102 min, and the mean weight excised was 459.5 g. The average length of hospital stay was 3.3 days, and the drainage duration was 2.4 days. No major complications were reported, and there were no cases of reintervention or recurrence. CONCLUSIONS: Our study presents a novel surgical approach utilizing the posteroinferior pedicle technique. Its key benefit lies in the preservation of neurovascular function, which makes it an attractive option for patients seeking to retain nipple sensitivity. This procedure is reliable, reproducible, and recommended as a first-line treatment for grade II and III gynecomastia due to its low rate of major complications and favorable functional and aesthetic outcomes. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Torsion of the spermatic cord in adults: a multicenter experience in adults with surgical exploration for acute scrotal pain with suspected testicular torsion.

Acute scrotal pain (ASP) requiring surgical exploration is common in the pediatric population, but little has been reported on this subject with regard to the adult population. The aim of this study was to investigate the demographic and clinical characteristics and outcomes of scrotal explorations performed on adult patients. Patients over 21 years of age who underwent surgical exploration for ASP with suspected testicular torsion (TT) at 14 French hospitals between January 2005 and December 2019 were included in this study. The main outcome measures were demographic characteristics, pathology found during scrotal exploration, and perioperative outcomes. Logistic regression was used to perform univariate and multivariate analyses to identify predictors of TT. Data for 1329 men were analyzed. The median age was 30 (interquartile range [IQR]: 25-35; range: 21-89) years. Regarding the clinical examination, 867 (65.2%) patients presented with an elevation of the testicle, 613 (46.1%) patients with scrotal edema or erythema, and 211 (15.9%) patients with nausea or vomiting. Operative findings identified TT in only 684 (51.5%) patients, epididymo-orchitis in 112 (8.4%) patients, a tumor in 16 (1.2%) patients, and no causes in 475 (35.7%) patients. Orchiectomy for nonviable testes was required in 101 (7.6%) patients. In multivariate analysis, an elevation of the testicle, erythema/swelling, and the presence of nausea/vomiting were found to be associated with the occurrence of TT. Testicular torsion is not exclusive to children and adolescents, so must be considered in males of any age with acute scrotal findings. However, one-third of scrotal explorations in adults did not lead to a diagnosis.

The Use of Doppler Ultrasound for Suspected Testicular Torsion: Lessons Learned from a 15-Year Multicentre Retrospective Study of 2922 Patients.

BACKGROUND: Use of Doppler ultrasonography (DUS) for patients with suspected testicular torsion (TT) is highly controversial and remains debated, as it can delay surgery and its performance may vary. OBJECTIVE: To assess the role, impact, safety, and performance of DUS in the management of patients with suspected TT before scrotal exploration. DESIGN, SETTING, AND PARTICIPANTS: The TORSAFUF cohort retrospectively included patients older than 12 yr who underwent surgery for suspected TT in 14 academic hospitals between 2005 and 2019. Perioperative data and surgical and DUS reports were collected. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Clinical factors influencing DUS utilisation were analysed using multivariate logistic regression. The orchidectomy rate and delay to surgery were compared by group with and without DUS receipt using one-to-one propensity score (PS) matching to assess imaging safety. For the group with preoperative imaging, DUS performance was evaluated using a contingency table. RESULTS AND LIMITATIONS: Overall, 2922 patients were included, of whom 956 (32.7%) underwent DUS before surgery. DUS was more likely to be performed in older patients (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.1-1.2), those who experienced progressive onset of pain (OR 1.5, 95% CI 1.1-2), and patients who presented at the emergency department more than 6 h after their first scrotal symptoms (OR 2.3, 95% CI 1.9-2.8). After PS matching, DUS receipt was not significantly associated with orchidectomy but the delay to surgery was 1 h longer. DUS demonstrated strong sensitivity of 85.2% (95% CI 82.1-88.3%) and specificity of 52.7% (95% CI 48.8-56.6%). The performance was better for younger patients and for those with time since onset of pain of >6 h. CONCLUSIONS: In this large retrospective study, DUS before surgery was safe, feasible, and useful in selected cases with suspected TT, but it should not delay or replace surgery in cases with a strong clinical suspicion. PATIENT SUMMARY: We analysed the performance and safety of an ultrasound scan of the scrotum before surgery for patients with a suspected twisted testicle (TT). This scan before surgery was not associated with a higher risk of negative outcomes but was only moderate in accurately diagnosing TT. Surgery to correct TT should not be delayed.

Factors Predictive of Selective Angioembolization Failure for Moderate- to High-grade Renal Trauma: A French Multi-institutional Study.

BACKGROUND: Angiography with selective angioembolization (SAE) is safe and effective in addressing bleeding in patients with renal trauma. However, there are no validated criteria to predict SAE efficacy. OBJECTIVE: To evaluate factors predictive of SAE failure after moderate- to high-grade renal trauma. DESIGN, SETTING, AND PARTICIPANTS: TRAUMAFUF was a retrospective multi-institutional study including all patients who underwent upfront SAE for renal trauma in 17 French hospitals between 2005 and 2015. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was SAE efficacy, defined as the absence of repeat SAE, salvage nephrectomy, and/or death for each patient. RESULTS AND LIMITATIONS: Out of 1770 consecutive patients with renal trauma, 170 (9.6%) with moderate- to high-grade renal trauma underwent SAE. Overall upfront SAE was successful in 131 patients (77%) and failed in 39 patients: six patients died after the embolization, ten underwent repeat SAE, 22 underwent open nephrectomy, and one underwent open surgical exploration. In multivariate logistic regression analysis, gross hematuria (odds ratio [OR] 3.16, 95% confidence interval [CI] 1.29-8.49; p=0.015), hemodynamic instability (OR 3.29, 95% CI 1.37-8.22; p=0.009), grade V trauma (OR 2.86, 95% CI 1.06-7.72; p=0.036), and urinary extravasation (OR 3.49, 95% CI 1.42-8.83; p=0.007) were predictors of SAE failure. The success rate was 64.7% (22/34) for patients with grade V trauma and 59.6% (31/52) for those with hemodynamic instability. The study was limited by its retrospective design and the lack of a control group managed with either surgery or surveillance. CONCLUSIONS: We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure. However, success rates in these subgroups remained relatively high, suggesting that SAE might be appropriate for those patients as well. PATIENT SUMMARY: Selective angioembolization (SAE) is a useful alternative to nephrectomy to address bleeding in patients with renal trauma. Currently, there are no validated criteria to predict SAE efficacy. We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure.

Cystectomy and ileal conduit for neurogenic bladder: Comparison of the open, laparoscopic and robotic approaches.

AIM: The objective of the present study was to compare the outcomes of open versus laparoscopic versus robotic cystectomy and ileal conduit for neurogenic lower urinary tract dysfunction (NLUTD). METHODS: The charts of all patients who underwent cystectomy and ileal conduit for NLUTD between January 2004 and November 2020 in an academic center were retrospectively reviewed. The approach was either open, laparoscopic or robot-assisted depending on the period (i.e., three consecutive era). For the robotic approach, the diversion was done either intracorporeally or extracorporeally. We compared the perioperative and late postoperative outcomes between the three groups. RESULTS: After exclusion of 10 patients with non-neurogenic benign conditions, 126 patients were included over the study period. The most frequent neurological conditions were multiple sclerosis (36.5%) and spinal cord injury (25.4%). The approach was open, laparoscopic or robot-assisted in 31 (24.6%), 26 (20.6%) and 69 (54.7%) cases respectively. Seventy-two patients experienced a 90-day postoperative complication (57.1%) of which 22 had a major complication (Clavien 3 or higher, 17.5%) including one death (0.8%). The rate of major postoperative complications was significantly lower in the robotic group (23% vs. 23% vs. 10%; p = 0.049) while the rate of overall complications was comparable across the three groups (58.1% vs. 53.9% vs. 60.6%; p = 0.84). After a median follow-up of 23 months, 22 patients presented a late complication (17.6%), mainly incisional hernia (5; 4%) and uretero-ileal stricture (9; 7.2%). The rate of late complications did not differ significantly between the three approaches. CONCLUSION: Cystectomy and ileal conduit for neurogenic bladder is associated with a relatively high perioperative morbidity. The robot-assisted approach may decrease the risk of major postoperative complications.

What Is Better for Predicting Morbidity of Robotic Partial Nephrectomy-A Score or Your Clinical Judgement?

BACKGROUND: Little is known about the predictive value of surgeon's judgement to estimate perioperative outcomes following robotic partial nephrectomy (RPN). OBJECTIVE: To evaluate the accuracy of surgeon's intuition to estimate perioperative outcomes of patients undergoing RPN and compare its predictive value with that of objective scoring systems. DESIGN, SETTING, AND PARTICIPANTS: We prospectively analysed 100 consecutive patients who underwent RPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: RENAL, PADUA, and MAP scores were calculated based on preoperative imaging. The surgeon gave a subjective estimation of the technical difficulty and the risk of postoperative complications of RPN immediately before and after surgery using a visual analogue scale (VAS). Correlation between scores, VAS, estimated blood loss (EBL), operative time (OT), and warm ischaemia time (WIT) were examined. Logistic regression analyses were performed to identify the best predictors of overall complications. Receiver operating characteristic (ROC) curve analysis was used to assess the accuracy of VAS and scoring systems to predict trifecta achievement. RESULTS AND LIMITATIONS: RENAL, PADUA, and MAP scores significantly correlated with surgeon's pre- and postoperative VAS evaluation, with the RENAL score showing the strongest correlation (r=0.49 and r=0.34, respectively). Pre- and postoperative VAS scores had the strongest correlation with EBL (r=0.48 and r=0.59, respectively), OT (r=0.44 and r=0.65, respectively), and WIT (r=0.37 and r=0.47, respectively). In multivariate analysis adjusted for anticoagulant/antiplatelet treatment, body mass index, surgeon's experience, and Charlson comorbidity index, only surgeon's prediction could significantly predict overall complications (odds ratio=5.42, p <0.001). Finally, surgeon's intuition was better to predict trifecta accomplishment than all radiological scores (ROC areas under the curves were 0.76 and 0.77 for pre- and postoperative VAS scores, respectively). CONCLUSIONS: Surgeon's clinical assessment is a good predictor of perioperative outcomes of RPN and seems to perform better than conventional scores. PATIENT SUMMARY: In this report, we found that surgeon's clinical feeling can better predict perioperative morbidity of robotic partial nephrectomy than conventional radiological scores.

Diagnosis and treatment of urinary and sexual dysfunction in hereditary TTR amyloidosis.

PURPOSE: We aimed to review the current knowledge on the epidemiology, diagnosis, and management of urinary and sexual dysfunction in patients with TTR amyloidosis (ATTR). METHODS: We performed a review of the literature, screening for randomized controlled trials, prospective and retrospective series, position papers, and guidelines on urinary and sexual dysfunction in ATTR patients published in PubMed and Embase. RESULTS: Lower urinary tract dysfunction is present in up to 83% of patients with ATTR. Voiding symptoms are the most common, reported in 34.8-87.5% of patients, while urinary tract infections are reported in up to 50%. Urinary incontinence is observed in 16.7-37.5% of the ATTR population, mostly due to decreased urethral resistance. Sexual dysfunction affects over 40% of ATTR patients, with erectile dysfunction and sexual arousal disorder being the most common symptoms in male and female patients, respectively. In addition to a thorough clinical examination, invasive pressure-flow urodynamic testing is a cornerstone in the assessment of ATTR lower urinary tract dysfunction. The most common finding is detrusor underactivity and intrinsic sphincter deficiency. Poor bladder compliance can also be observed in patients, due to amyloid deposits on the bladder wall. Urinary tract imaging may be of interest to rule out upper urinary tract deterioration. Given the paucity of data in the ATTR population, treatment should be tailored to the individual patient. CONCLUSION: Urinary and sexual dysfunction are highly prevalent in ATTR patients. Comprehensive assessment and multidisciplinary management are keys to avoiding upper urinary tract damage and improving patients' quality of life.

Prospective Assessment of the Sexual Function After Greenlight Endoscopic Enucleation and Greenlight 180W XPS Photoselective Vaporization of the Prostate.

OBJECTIVE: To evaluate the impact of Greenlight 180W photoselective vaporization of the prostate (PVP) and endoscopic enucleation of the prostate (GreenLEP) on ejaculatory and erectile functions. MATERIALS AND METHODS: Between January 2014 and September 2016, 440 men with low urinary tract symptoms or complications related to benign prostate obstruction with prostate >80 g and sexually active, underwent a PVP or GreenLEP performed by experienced surgeons at a single institution. Patients were matched in a 1:1 fashion according to preoperative transrectal ultrasonography prostatic volume and cardiovascular risk factors (smoking, diabetes, and hypertension). RESULTS: One hundred patients in each group were included. Mean prostatic volume were 110 g (95%CI: 101-118) and 107 g (95%CI: 99-115) in the GreenLEP and PVP groups, respectively (P = .68). Mean total energy delivered in the PVP group was 4.42 kJ/g (4.2-4.6). Surgical retreatment was required in 9 patients (10.1%) in the PVP group and none in the GreenLEP group (log rank test: P = .002). Mean prostate specific antigen level and International Prostate Symptom Score score were significantly lower in the GreenLEP group than in the PVP group at 3, 12, and 24 months (P <.001). Preserved antegrade ejaculation was reported in 24 patients (26.9%) in the PVP group vs 1 patient (1.2%) in the GreenLEP group at 12 months (P <.001). In multivariate analysis, age, history of coronary artery disease, and surgical treatment with PVP were independent factors of IIEF-5 decline. CONCLUSION: Despite a poor rate of preserved antegrade ejaculation, GreenLEP was associated with better erectile function outcomes possibly due to greater improvement of low urinary tract symptoms.

Comparison of adjustable continence therapy periurethral balloons and artificial urinary sphincter in female patients with stress urinary incontinence due to intrinsic sphincter deficiency.

INTRODUCTION AND HYPOTHESIS: The objective was to compare the outcomes of the ACT® device with those of the artificial urinary sphincter (AUS) AMS 800 in the treatment of stress urinary incontinence (SUI) due to sphincter deficiency in women. METHODS: All the women who underwent surgical treatment for SUI due to intrinsic sphincter deficiency from 2007 to 2017 were included in a single-center retrospective study. The primary endpoint was the functional outcome. Perioperative functional parameters of the two groups were compared. RESULTS: Twenty-five patients underwent an ACT® implantation and 36 an AUS implantation. Patients in the AUS group were younger (62.9 vs 70.4 years; p = 0.03) with less comorbidity (ASA Score = 3 in 12.1% vs 33.3%; p = 0.005). Operative time and hospital stay were shorter in the ACT® group (45.7 vs 206.1 min; p < 0.001; 1.7 vs 7 days; p < 0.001 respectively). There was a higher rate of intraoperative complications in the AUS group (47% vs 8%; p < 0.001) but the rates of postoperative complications were similar between both groups. The ACT® was associated with an increased risk of urinary retention (20% vs 2.8%; p = 0.04). Results were in favor of AUS for: decrease in USP stress incontinence subscore (-7.6 vs -3.2; p < 0.001), number of pads per 24 h (- 4.6 vs -2.3; p = 0.002), PGII scale (PGII = 1: 61.1% vs 12%; p < 0.001), and cure rate (71.4% vs 21.7%; p < 0.001). CONCLUSIONS: In the present series, keeping in mind the significantly different baseline characteristics, AUS implantation was associated with better functional outcomes than the ACT® in female patients with SUI due to intrinsic sphincter deficiency, but with a higher intraoperative complications rate, longer operative time, and a longer stay.

Reliability of urinary cytology and cystoscopy for the screening and diagnosis of bladder cancer in patients with neurogenic bladder: A systematic review.

AIMS: To assess the reliability of urinary cytology and cystoscopy to screen and diagnose bladder cancer in patients with NB. PATIENTS AND METHODS: A systematic literature search of the Medline and Embase databases was performed in April 2017. Data extraction was performed by two independent reviewers. A narrative synthesis was made. RESULTS: Out of 220 records assessed, 15 were included in this systematic review. All studies were prospective or retrospective series with no control group. Cystoscopy allowed the detection of asymptomatic bladder cancer in 0-10 patients, with a screening sensitivity (available in only one study) of 0%, a screening specificity ranging from 65% to 90%, and a yield in detecting asymptomatic bladder cancer of 0% in all series where it could be calculated. Urinary cytology allowed the detection of bladder cancer in asymptomatic patients in 0-12 patients, with a screening sensitivity of 71%, a screening specificity ranging from 92% to 97% and a yield ranging from 0% to 1.25%. Sensitivity of cystoscopy for diagnosis of bladder cancer ranged from 27% to 81% and specificity was 54% in the only study where it could be calculated. Sensitivity of urinary cytology for diagnosis of bladder cancer was 0-72% and specificity was 100%. CONCLUSION: There is currently insufficient data to support formal recommendations of using both tools in the screening of bladder cancer in patients with neurogenic bladder. Urinary cytology outperformed cystoscopy for screening and might be the best tool currently available.

Extracorporeal Shockwave Lithotripsy Versus Flexible Ureteroscopy for the Management of Upper Tract Urinary Stones in Children.

OBJECTIVE: To compare the efficacy and morbidity of extracorporeal shockwave lithotripsy (SWL) and flexible ureteroscopy (F-URS) for the management of upper tract urinary stones in children. METHODS: All SWL and F-URS performed in children in a single institution between 2000 and 2014 were reviewed retrospectively. Only procedures performed to treat upper tract urinary stones (upper ureter or kidney) were included in this study. Preoperative and perioperative outcomes were compared between the SWL and F-URS groups. Univariate and multivariate logistic regression analyses were used to evaluate predictors of stone-free (SF) status. RESULTS: Over the study period, 100 SWL and 46 F-URS were conducted in 69 children. The SWL and F-URS groups were comparable in terms of stone size (14.6 vs 13.2 mm, p = 0.32), but there were more multiple stones (31% vs 57%; p = 0.003) and lower pole calculi (14% vs 37%; p = 0.003) in the F-URS group. The SF rate after one procedure was almost two times higher in the F-URS group compared with the SWL group (37% vs 21%; p = 0.04) without increasing the complication rate (21.7% vs 16%; p = 0.31). Similar results were observed in the subgroup of single renal stones <20 mm (SF rates: 78.6% vs 50%; p = 0.06). In multivariate analysis, the use of F-URS vs SWL was a predictor of an SF status (odds ratio = 3.7; p = 0.02). CONCLUSION: F-URS provides a higher single-session SF rate, despite more complex urinary stones (multiple, lower pole, etc.) and without increasing morbidity.