Urologists' opinion on treating asymptomatic stones: Would we treat ourselves as we treat our patients? Survey from European Association of Urology, Young Academic Urologists, Endourology and Urolithiasis working party.

Background/aim: Management of asymptomatic kidney stones is an ongoing debate with follow-up and treatment guidelines based on low-level evidence. Our aim was to evaluate current management of asymptomatic urinary stones. Materials and methods: A 70-question survey was designed in collaboration with European Association of Urology, Young Academic Urologists, Section of Uro-Technology and Section of Urolithiasis groups and distributed. Responders filled out hypothetical scenarios from 2 perspectives, either as treating physicians, or as patients themselves. Results: A total of 212 (40.01%) responses were obtained. Median responder age was 39 years. 75% of responders were interested in "urolithiasis". 82.5% had never experienced a renal colic, 89.6% had never undergone urolithiasis treatment.Overall, as the kidney stone scenarios got more complicated, the invasiveness of the treatment preference increased. As "the physician", responders preferred the conservative option in all situations more than they would choose as "the patient". For ureteral stones, conservative approach was most preferred for small stones and ureteroscopy became more preferred as the stone size increased.For smaller kidney stones, the most preferred follow-up schedule was 4-6 monthly, whereas for larger and complicated stones it was 0-3 monthly from both perspectives respectively. For all ureteral stone scenarios, 0-4 weekly follow-up was mostly preferred.Interestingly, having had a renal colic was an independent predictor of an interventional approach, whereas having had an intervention was an independent predictor of a conservative approach. Conclusion: Current treatment and follow-up patterns of asymptomatic urinary stones are in agreement with international guidelines on symptomatic stones.In most of the urolithiasis situations urologists chose a conservative approach for their patients compared to what they would prefer for themselves. Conversely, urologists, in the scenarios as "the patient", would like to have a more frequent follow-up schedule for their stones compared to how they would follow-up their patients.

Predictive Value of the Mayo Adhesive Probability (MAP) Score in Laparoscopic Partial Nephrectomies: A Systematic Review from the EAU Section of Uro-Technology (ESUT).

The Mayo Adhesive Probability (MAP) score is a radiographic scoring system that predicts the presence of adherent perinephric fat (APF) during partial nephrectomies (PNs). The purpose of this systematic review is to summarize the current literature on the application of the MAP score for predicting intraoperative difficulties related to APF and complications in laparoscopic PNs. Three databases, PubMed, Scopus and Cochrane, were screened, from inception to 29 October 2023, taking into consideration the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. All the inclusion criteria were met by eight studies. The total operative time was around two hours in most studies, while the warm ischemia time was <30 min in all studies and <20 min in four studies. Positive surgical margins, conversion and transfusion rates ranged from 0% to 6.3%, from 0% to 5.0% and from 0.7% to 7.5%, respectively. Finally, the majority of the complications were classified as Grade I-II, according to the Clavien-Dindo Classification System. The MAP score is a useful tool for predicting not only the presence of APF during laparoscopic PNs but also various intraoperative and postoperative characteristics. It was found to be significantly associated with an increased operative time, estimated blood loss and intraoperative and postoperative complication rates.

Experts' recommendations in laser use for the treatment of bladder cancer: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training and Research in Urological Surgery and Technology (TRUST)-Group.

PURPOSE: To identify laser settings and limits applied by experts during laser vaporization (vapBT) and laser en-bloc resection of bladder tumors (ERBT) and to identify preventive measures to reduce complications. METHODS: After a focused literature search to identify relevant questions, we conducted a survey (57 questions) which was sent to laser experts. The expert selection was based on clinical experience and scientific contribution. Participants were asked for used laser types, typical laser settings during specific scenarios, and preventive measures applied during surgery. Settings for a maximum of 2 different lasers for each scenario were possible. Responses and settings were compared among the reported laser types. RESULTS: Twenty-three of 29 (79.3%) invited experts completed the survey. Thulium fiber laser (TFL) is the most common laser (57%), followed by Holmium:Yttrium-Aluminium-Garnet (Ho:YAG) (48%), continuous wave (cw) Thulium:Yttrium-Aluminium-Garnet (Tm:YAG) (26%), and pulsed Tm:YAG (13%). Experts prefer ERBT (91.3%) to vapBT (8.7%); however, relevant limitations such as tumor size, number, and anatomical tumor location exist. Laser settings were generally comparable; however, we could find significant differences between the laser sources for lateral wall ERBT (p = 0.028) and standard ERBT (p = 0.033), with cwTm:YAG and pulsed Tm:YAG being operated in higher power modes when compared to TFL and Ho:YAG. Experts prefer long pulse modes for Ho:YAG and short pulse modes for TFL lasers. CONCLUSION: TFL seems to have replaced Ho:YAG and Tm:YAG. Most laser settings do not differ significantly among laser sources. For experts, continuous flow irrigation is the most commonly applied measure to reduce complications.

Experts' recommendations in laser use for the treatment of urolithiasis: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group.

PURPOSE: To identify laser lithotripsy settings used by experts for specific clinical scenarios and to identify preventive measures to reduce complications. METHODS: After literature research to identify relevant questions, a survey was conducted and sent to laser experts. Participants were asked for preferred laser settings during specific clinical lithotripsy scenarios. Different settings were compared for the reported laser types, and common settings and preventive measures were identified. RESULTS: Twenty-six laser experts fully returned the survey. Holmium-yttrium-aluminum-garnet (Ho:YAG) was the primary laser used (88%), followed by thulium fiber laser (TFL) (42%) and pulsed thulium-yttrium-aluminum-garnet (Tm:YAG) (23%). For most scenarios, we could not identify relevant differences among laser settings. However, the laser power was significantly different for middle-ureteral (p = 0.027), pelvic (p = 0.047), and lower pole stone (p = 0.018) lithotripsy. Fragmentation or a combined fragmentation with dusting was more common for Ho:YAG and pulsed Tm:YAG lasers, whereas dusting or a combination of dusting and fragmentation was more common for TFL lasers. Experts prefer long pulse modes for Ho:YAG lasers to short pulse modes for TFL lasers. Thermal injury due to temperature development during lithotripsy is seriously considered by experts, with preventive measures applied routinely. CONCLUSIONS: Laser settings do not vary significantly between commonly used lasers for lithotripsy. Lithotripsy techniques and settings mainly depend on the generated laser pulse's and generator settings' physical characteristics. Preventive measures such as maximum power limits, intermittent laser activation, and ureteral access sheaths are commonly used by experts to decrease thermal injury-caused complications.

Preperitoneal vas deferens infiltration in high-risk prostate cancer.

Objectives: The objective of this study is to evaluate the prevalence and the importance of preperitoneal vas deferens (VD) infiltration in high-risk prostate cancer (PCa). Patients and Methods: In this prospectively designed study, we included 332 high-risk PCa patients with a Briganti score >5%, who were treated by robot-assisted radical prostatectomy between July 2017 and February 2022 at the Urology Department, SLK Kliniken Heilbronn. In addition to the standard histological analysis of the distal VD, which was attached to the prostate specimen, we analysed the infiltration status of preperitoneal VD in this cohort. The preperitoneal VD, which represents the middle part of ductus deferens and extends between the internal inguinal ring and obturator fossa, was resected during extended pelvic lymphadenectomy. Distal and preperitoneal VD status was registered together with preoperative and postoperative disease characteristics. Descriptive analysis methods and logistic regression analysis were used. Results: Briganti score of the target cohort had a median value of 19%, while 235 patients (70.8%) of the group demonstrated a locally advanced disease. The Grade Group at prostatectomy specimen was at least 3 for 286 patients (86.1%). Distal VD infiltration was found in 20 patients (6%) and preperitoneal VD infiltration in two patients (0.6%). Distal VD infiltration was not associated with an increased possibility for positive surgical margins or nodal status among pT3b patients, while both patients with preperitoneal VD infiltration were characterized by highly aggressive disease in locally advanced stage and bilateral distal VD infiltration. Conclusions: PCa extension along VD may reach a more proximal point of VD than the reported from the existing data infiltration of VD adjacent to seminal vesicles. This rare manifestation of PCa local extension may be the intermediate step to the rare cases of recurrence in the testicles. However, more robust data are needed to confirm the aforementioned hypothesis. Distal VD infiltration seems to have no additional prognostic value among patients with infiltrated seminal vesicles.

Laparoscopic intracorporeal ileal ureter replacement: multi-institutional data from 102 patients.

OBJECTIVE: To present long-term results of our laparoscopic intracorporeal ileal ureter replacement (LIUR) cohort, including more complex cases of laparoscopic ileocalycostomy. MATERIAL AND METHODS: We collected records of patients undergoing LIUR. Follow-up included a chemical profile and urine cultures. Imaging consisted of renal ultrasonography, excretory urography, cystography, and computer tomographic or magnetic resonance urography. RESULTS: One hundred and two patients were included. Stricture location was left (46.1%), right (39.2%), or bilateral (14.7%). No open conversion was performed. Seventy-four patients (72.5%) underwent a total ureteral unit removal. The mean operative time was 289.4 (120 - 680) minutes. The estimated blood loss was 185.2 (10-400) mL. Three patients had intraoperative complications, and fifteen had early postoperative complications. The mean postoperative hospital stay was 12.2 (7-35) days. The mean follow-up duration period was 37.7 (12-162) months. Most patients' follow-up was uneventful (88%), and seven patients presented with Grade 2 late complications. CONCLUSIONS: Intracorporeal laparoscopic ileal ureteral replacement in cases of extensive ureteral lesions offers optimal long-term outcomes and a low complication rate. Ileocalycostomy constitutes a viable option in the small group of patients with long proximal ureteral strictures and intrarenal pelvis.

Experts' recommendations in laser use for the treatment of upper tract urothelial carcinoma: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training Research in Urological Surgery and Technology (T.R.U.S.T.) group.

PURPOSE: To highlight and compare experts' laser settings during endoscopic laser treatment of upper tract urothelial carcinoma (UTUC), to identify measures to reduce complications, and to propose guidance for endourologists. METHODS: Following a focused literature search to identify relevant questions, a survey was sent to laser experts. We asked participants for typical settings during specific scenarios (ureteroscopy (URS), retrograde intrarenal surgery (RIRS), and percutaneous treatment). These settings were compared among the reported laser types to find common settings and limits. Additionally, we identified preventive measures commonly applied during surgery. RESULTS: Twenty experts completed the survey, needing a mean time of 12.7 min. Overall, most common laser type was Holmium-Yttrium-Aluminum-Garnet (Ho:YAG) (70%, 14/20) followed by Thulium fiber laser (TFL) (45%, 9/20), pulsed Thulium-Yttrium-Aluminum-Garnet (Tm:YAG) (3/20, 15%), and continuous wave (cw)Tm:YAG (1/20, 5%). Pulse energy for the treatment of distal ureteral tumors was significantly different with median settings of 0.9 J, 1 J and 0.45 J for Ho:YAG, TFL and pulsed Tm:YAG, respectively (p = 0.048). During URS and RIRS, pulse shapes were significantly different, with Ho:YAG being used in long pulse and TFL in short pulse mode (all p < 0.05). We did not find further disparities. CONCLUSION: Ho:YAG is used by most experts, while TFL is the most promising alternative. Laser settings largely do not vary significantly. However, further research with novel lasers is necessary to define the optimal approach. With the recent introduction of small caliber and more flexible scopes, minimal-invasive UTUC treatment is further undergoing an extension of applicability in appropriately selected patients.

Is intraoperative ultrasonography necessary in laparoscopic partial nephrectomy for exophytic tumours?

INTRODUCTION: The value of IOUS has been proven especially for endophytic kidney tumours, but has not been assessed critically for exophytic kidney tumours. We aimed to evaluate the value of IOUS for exophytic kidney tumours. MATERIAL AND METHODS: The data of LPN cases were collected prospectively between 2000 and 2022. Thirty-two of 535 patients who underwent laparoscopic retroperitoneal partial nephrectomy without IOUS were matched with the IOUS applied cases according to tumour size, tumour localization and PADUA score. RESULTS: There were no differences between the two groups in terms of the matching parameters. The average warm ischemia time was 14 min for the IOUS group (range 9-32 min) and 20 min for the non-IOUS group (range 7-52 min) (p = 0.01). Also, the average cutting time was shorter in the IOUS group (6 min vs 9 min) (p = 0.046). There was no difference between the two groups in terms of suturing times (8 min vs 8.5 min) (p = 0.66). The average tumour size was 3.5 cm and pathologically-proven residual tumour was detected in one patient in each group. CONCLUSION: The use of IOUS in laparoscopic retroperitoneal partial nephrectomy for exophytic kidney tumours may shorten the warm ischemia time by reducing the cutting time.

Experts' recommendations in laser use for the endoscopic treatment of prostate hypertrophy: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group.

PURPOSE: To identify expert laser settings for BPH treatment and evaluate the application of preventive measures to reduce complications. METHODS: A survey was conducted after narrative literature research to identify relevant questions regarding laser use for BPH treatment (59 questions). Experts were asked for laser settings during specific clinical scenarios. Settings were compared for the reported laser types, and common settings and preventive measures were identified. RESULTS: Twenty-two experts completed the survey with a mean filling time of 12.9 min. Ho:YAG, Thulium fiber laser (TFL), continuous wave (cw) Tm:YAG, pulsed Tm:YAG and Greenlight™ lasers are used by 73% (16/22), 50% (11/22), 23% (5/22), 13.6% (3/22) and 9.1% (2/22) of experts, respectively. All experts use anatomical enucleation of the prostate (EEP), preferentially in one- or two-lobe technique. Laser settings differ significantly between laser types, with median laser power for apical/main gland EEP of 75/94 W, 60/60 W, 100/100 W, 100/100 W, and 80/80 W for Ho:YAG, TFL, cwTm:YAG, pulsed Tm:YAG and Greenlight™ lasers, respectively (p = 0.02 and p = 0.005). However, power settings within the same laser source are similar. Pulse shapes for main gland EEP significantly differ between lasers with long and pulse shape modified (e.g., Moses, Virtual Basket) modes preferred for Ho:YAG and short pulse modes for TFL (p = 0.031). CONCLUSION: Ho:YAG lasers no longer seem to be the mainstay of EEP. TFL lasers are generally used in pulsed mode though clinical applicability for quasi-continuous settings has recently been demonstrated. One and two-lobe techniques are beneficial regarding operative time and are used by most experts.

Estimated Radiation Dose to the Lens During Endourologic Procedures: The Role of Leaded Glasses and the ALARA Protocol-An ESU/ESUT-YAU Endourology Group Collaboration.

Purpose: On February 6, 2018, the European Atomic Energy Community reduced the annual equivalent dose limit for the lens from 150 to 20 mSv/year, because of its association with cataracts at low radiation doses. Our aim was to estimate the radiation doses received by the lens during endourologic procedures that require fluoroscopy. Materials and Methods: Multicenter study including prospective data of annual eye dosimeters between 2017 and 2020. Four endourologists used an eye dosimeter in endourologic procedures that require fluoroscopy (ureteroscopy, retrograde intrarenal surgery, and percutaneous nephrolithotomy). Surgeons 1 and 2 wore leaded glasses; surgeon 1 also used the as low as reasonably achievable (ALARA) protocol. Descriptive statistical analysis using SPSS 25.0 was conducted. Results: Surgeons 1, 2, 3, and 4 performed a median of 159, 586, 102, and 129 endourologic procedures per year, respectively, for a total of 641, 2340, 413, and 350 procedures between 2017 and 2020. The median annual dose of lens radiation exposure was 0.16, 1.18, 3.79, and 1.42 mSv per year, respectively, which corresponds to 0.001, 0.009, 0.024, and 0.012 mSv per procedure. The two surgeons who used leaded glasses registered a lower radiation dose per procedure (0.001 vs 0.027). Similarly, the urologist who used the ALARA protocol registered the lowest lens radiation dose compared with the three surgeons who did not use it (0.001 vs 0.023). Conclusions: The endourologists who participated in this study effectively comply with current guidelines on radiation exposure to the lens. Registered eye lens radiation does not seem to be related to the number of procedures but rather to the use of leaded glasses and the ALARA protocol.

How do endoscopic bladder tumor resection techniques affect pathology practice? EAU Section of Uro-Technology (ESUT) and Uropathology (ESUP) survey.

PURPOSE: We aimed to examine how different endoscopic bladder tumor resection techniques affect pathologists' clinical practice patterns. METHODS: An online survey including 28 questions clustered in four main sections was prepared by the ESUT ERBT Working Group and released to the pathologists working in the institutions of experts of the ESUT Board and the working groups and experts in the uropathology working group. A descriptive analysis was performed using the collected data. RESULTS: Sixty-eight pathologists from 23 countries responded to the survey. 37.3% of the participants stated that they always report the T1 sub-staging. Of those who gave sub-staging, 61.3% used T1a, b. 85.2% think that en bloc samples provide spatial orientation faster than piecemeal samples, and 60% think en bloc samples are timesaving during an inspection. 55.7% stated that whether the tissue sample is en bloc or piecemeal is essential. 57.4% think en bloc sample reduces turnaround time and is cost-effective for 44.1%. A large number of pathologists find that the pathology examination of piecemeal samples has a longer learning curve. CONCLUSION: The survey shows that pathologists think that they can diagnose faster, accurately, and cost-effectively with ERBT samples, but they do not often encounter them in practice. Moreover, en bloc samples may be a better choice in pathology resident training. Evidence from real-life observational pathology practice and clinical research can reveal the current situation more clearly and increase awareness on proper treatment in endoscopic management of bladder tumors.

Laparoscopic totally intracorporeal ileal ureter replacement: a multi-institutional study.

OBJECTIVE: To prove the feasibility, as well as the reproducibility of laparoscopic totally intracorporeal ileal ureter replacement (LIUR), by presenting a multicenter patient cohort with a long follow-up. MATERIAL AND METHODS: Records of patients undergoing different types of ureteral replacements have been collected. Follow-up included a chemical profile and urine cultures. Imaging consisted of renal ultrasonography and excretory urography, as well as a cystography or an isotopic renography when indicated. RESULTS: Forty patients were included in the study. Twelve underwent a right, 20 a left, and eight a bilateral laparoscopic ureteral replacement. The mean procedure time was 335 (150-680) minutes and the mean estimated blood loss was 221 (50-400) mL. Only three patients presented intraoperative complications, which were managed immediately, and three patients presented a Clavien III postoperative complication. Abdominal drains and nephrostomy tubes were removed after 24-36 h and 7-10 days, respectively. The mean hospital stay was 13.5 (10-35) days. Follow-up was at least six months. CONCLUSIONS: LIUR constitutes a feasible and reproducible method for the restoration of long ureteral defects.

Effect of Simulation-based Training on Surgical Proficiency and Patient Outcomes: A Randomised Controlled Clinical and Educational Trial.

BACKGROUND: It is hypothesised that simulation enhances progression along the initial phase of the surgical learning curve. OBJECTIVE: To evaluate whether residents undergoing additional simulation, compared to conventional training, are able to achieve proficiency sooner with better patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: This international, multicentre, randomised controlled trial recruited 94 urology residents with experience of zero to ten procedures and no prior exposure to simulation in ureterorenoscopy, selected as an index procedure. INTERVENTION: Participants were randomised to simulation or conventional operating room training, as is the current standard globally, and followed for 25 procedures or over 18 mo. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The number of procedures required to achieve proficiency, defined as achieving a score of ≥28 on the Objective Structured Assessment of Technical Skill (OSATS) scale over three consecutive operations, was measured. Surgical complications were evaluated as a key secondary outcome. This trial is registered at www.isrctn.com as ISCRTN 12260261. RESULTS AND LIMITATIONS: A total of 1140 cases were performed by 65 participants, with proficiency achieved by 21 simulation and 18 conventional participants over a median of eight and nine procedures, respectively (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.72-2.75). More participants reached proficiency in the simulation arm in flexible ureterorenoscopy, requiring a lower number of procedures (HR 0.89, 95% CI 0.39-2.02). Significant differences were observed in overall comparison of OSATS scores between the groups (mean difference 1.42, 95% CI 0.91-1.92; p < 0.001), with fewer total complications (15 vs 37; p = 0.003) and ureteric injuries (3 vs 9; p < 0.001) in the simulation group. CONCLUSIONS: Although the number of procedures required to reach proficiency was similar, simulation-based training led to higher overall proficiency scores than for conventional training. Fewer procedures were required to achieve proficiency in the complex form of the index procedure, with fewer serious complications overall. PATIENT SUMMARY: This study investigated the effect of simulation training in junior surgeons and found that it may improve performance in real operating settings and reduce surgical complications for complex procedures.

Simulation training in transurethral resection/laser vaporization of the prostate; evidence from a systematic review by the European Section of Uro-Technology.

PURPOSE: Transurethral resection (TURP) and photoselective vaporization of the prostate (PVP) constitute established surgical options to treat benign prostate hyperplasia. We investigated the current literature for simulators that could be used as a tool for teaching urologists alone or within the boundaries of a course or a curriculum. METHODS: A literature search was performed using PubMed, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials-CENTRAL. Search terms included: Simulat*, train*, curricull*, transurethral, TUR*, vaporesect*, laser. The efficacy of different simulators and the impact of different devices, curricula and courses in training and trainee learning curves were the primary endpoints. RESULTS: Thirty-one studies are selected and presented. Validated virtual reality TURP simulators are the UW VR, PelvicVision, Uro-Trainer, and TURPsim™. Validated synthetic TURP models are Dr. K. Forke's TURP trainer, Bristol TURP trainer, different tissue prostate models, and 3D-printed phantoms. The Myo Sim PVP and the GreenLightTM are sufficiently validated PVP simulators. Several TURP and PVP training curricula have been developed and judged as applicable. Finally, the TURP modules of the European Urology Residents Education Programme (EUREP) Hands-on Training course and the Urology Simulation Bootcamp Course (USBC) are the most basic annual TURP courses identified in the international literature. CONCLUSIONS: Simulators and courses or curricula are valuable learning and training TURP/PVP tools. The existent models seem efficient, are not always adequately evaluated and accepted. As part of training curricula and training courses, the use of training simulators can significantly improve quality for young urologists' education and clinical practice.

Is 'Omega Sign' anatomical endoscopic enucleation of the prostate technique reproducible?

We aimed to evaluate the learning curve of the surgically standardised 'Omega Sign' anatomical endoscopic enucleation (AEEP) of the prostate surgery technique for junior surgeons. This study is a retrospective comparison of cases that underwent AEEP by a mentor surgeon and three junior surgeons who have completed their learning curve. A video-based laser enucleation of the prostate assessment tool (LEAT) composed of 8 steps of the technique was used to assess a senior surgeon and junior surgeons' surgical compatibility and consistency. The surgeon who defined Omega Sign technique was determined as group 1, and cases by three junior surgeons were identified as group 2. The end points were to assess the reproducibility and repeatability and operative post-operative outcomes of the technique. 55 patients' videos were rated by five experienced endourologists. There was no significant difference in LEAT scores between the groups among all steps. The most symmetry was found in the 1st and 3rd steps. Inter-rater consistency was also high for each step, with no statistically significant difference between the evaluators. The standardised anatomical 'Omega Sign' technique is reproducible for the junior surgeons. The operative steps can be performed with high consistency, and the functional and perioperative outcomes are comparable with the senior surgeon.

Evaluation of a remote-controlled laparoscopic camera holder for basic laparoscopic skills acquisition: a randomized controlled trial.

BACKGROUND: Unsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH. METHODS: Novices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants. RESULTS: Forty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n = 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P = 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P = 0.0004). No significance differences were achieved in the circle cutting (P = 0.18) or needle guidance tasks (P = 0.32). The RCH group experienced significantly lower workload (P = 0.014) due to lower levels of distraction (P = 0.047). CONCLUSIONS: Remote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice. TRIAL REGISTRATION: ISRCTN 83733979.

Comparison of synchronous bilateral transperitoneal and posterior retroperitoneal laparoscopic adrenalectomy: results of a multicenter study.

BACKGROUND: Different techniques for laparoscopic adrenalectomy have been proposed with the lateral transperitoneal approach and posterior retroperitoneal approach being the two more frequently minimally invasive surgeries in most of the clinics. There are no sufficient studies in which the results of lateral transperitoneal and posterior retroperitoneal approaches in synchronous bilateral laparoscopic adrenalectomy have been compared. In the current study, we aimed to report our multicenter results of the lateral transperitoneal and posterior retroperitoneal synchronous bilateral laparoscopic adrenalectomy experience in patients who had different bilateral adrenal pathologies and to compare the outcomes of these two different operative procedures. METHODS: Between 2012 and 2018, a total of 52 patients with a mean age of 43.5 years underwent simultaneous bilateral laparoscopic adrenalectomy at 6 different centers. Twenty-seven and 25 patients underwent bilateral lateral transperitoneal and posterior retroperitoneal laparoscopic adrenalectomy, respectively. Patients' age, gender, body max index, operative indications, mass size, operation time, blood loss, length of hospitalization, intraoperative and postoperative complications and pathology reports were analyzed. RESULTS: Synchronous bilateral transperitoneal group was younger than synchronous posterior retroperitoneal group (37 years vs. 50.4 years.) (p: 0.001). Posterior retroperitoneal group had significantly decreased operating time and less blood loss than transperitoneal group. No significant difference was found with regard to postoperative hospital stay, perioperative and postoperative complications between two groups. Majority of the histopathological results were adrenal hyperplasia associated with Cushing's disease (61.5%). Less frequent pathological results were adrenal adenoma and pheochromocytoma (15.4% and 13.5%, respectively). During the follow-up period, no recurrence or disease-related mortality was observed in the patients. CONCLUSION: Our results shows that shorter operative time and less bleeding can be achieved with posterior retroperitoneal approach in synchronous bilateral laparoscopic adrenalectomy. In our series, intraoperative and postoperative complication rates were similar between both surgical approaches.

Role of sparing of puboprostatic ligaments on continence recovery after radical prostatectomy: a randomized controlled trial.

OBJECTIVE: Sparing of puboprostatic ligaments (PPLs) during radical prostatectomy was introduced as a technique to improve urinary continence. This study aims to study the effect of sparing of PPLs during laparoscopic radical prostatectomy in terms of continence during the first 3 months. METHODS: A total of 74 patients, diagnosed with clinically localized prostate cancer, were randomly assigned to two equal groups; PPLs division and sparing during LRP. Based on the number of daily used pads, both groups completed 3 months follow-up to assess continence recovery. The effects of age, preoperative total prostate-specific antigen (PSA) and clinical tumor stage on continence recovery were also studied. The study was registered and approved by the Ethics Committee of Alexandria University-Faculty of Medicine (Protocol No. 0201074). RESULTS: Seventy-four patients were enrolled, with a mean age of 63.8 years. Baseline characteristics were comparable, except significantly higher mean PSA in the division group. Sixty patients were continent (0-1 pad/day) at 3 months follow-up. Continence was significantly better in the sparing than division group at 1 week after catheter removal (67.6% vs 40.5%, p = 0.01), at 1 month (73% vs 45.9%, p = 0.009) and 2 months (89.2% vs 51.4%, p = 0.0001). At 3 months follow-up, there was no significant difference between both groups (83.3% vs 78.4% for sparing and division groups, respectively; p = 0.28). Moreover, continence was significantly improved at 3 months compared to 1 week in both groups. CONCLUSION: Sparing of puboprostatic ligaments during radical prostatectomy significantly improves postoperative early recovery of urinary continence.

Impact of three-dimensional vision in laparoscopic partial nephrectomy for renal tumors.

OBJECTIVE: To compare three-dimensional (3D) with standard two-dimensional (2D) laparoscopic partial nephrectomy (LPN) with respect to intra- and postoperative outcomes. MATERIAL AND METHODS: Data from 112 patients who underwent transperitoneal LPN from 2012 to 2014 by a single experienced surgeon were collected. Sixty patients (group 1) underwent conventional 2D LPN and 52 patients (group 2) 3D LPN. Perioperative patient, procedure, and tumor data were recorded. The follow-up period was 1-5 years. RESULTS: The two groups had similar patient age (p=0.834) and body mass index (p=0.141). The total laparoscopy time (LT) was shorter in group 2 (119.0 vs. 106.0 min; p=0.009). Warm ischemia times (WITs) were also shorter in group 2 (11.5 vs. 10.0 min; p=0.032). The estimated blood loss (EBL) (350.0 vs. 250.0 mL; p<0.001) and hemoglobin (Hb) decrease (1.55 vs. 1.35 g/dL; p=0.536) were lower in the 3D LPN group. Creatinine (0 vs. 0 g/dL; p=0.610) increase and estimated glomerular filtration rate (eGFR) decrease (0 vs. 0 mL/min/1.73 m2; p=0.553) did not demonstrate statistically significant differences. Duration of hospitalization (7 vs. 7 days; p=0.099) and complication rates (p=0.559) were similar between the two groups. CONCLUSION: The new-generation 3D laparoscope has a great impact on significant LPN intraoperative parameters, mainly LT, WIT, and EBL. Hb decrease is also in favor of 3D vision, although not dramatically altered. Therefore, 3D LPN appears to be superior to conventional 2D LPNs.

Transperitoneal and retroperitoneal approach in laparoscopic partial nephrectomy for posterior cT1 renal tumors: A retrospective, two-centers, comparative study.

OBJECTIVES: To compare perioperative, oncological and functional outcomes of Laparoscopic Transperitoneal Partial Nephrectomy (LTPN) and Retroperitoneal Laparoscopic Partial Nephrectomy (LRPN) for posterior, cT1 renal masses (RMs). MATERIALS AND METHODS: Databases of two urologic institutions applying different laparoscopic surgical approaches on posterior cT1 RMs between June 2016 and November 2018 were retrospectively evaluated. Data on patient demographics, perioperative data and tumor histology were collected and further analyzed statistically. RESULTS: Each group consisted of 15 patients. Baseline characteristics were comparable in each group. When compared to LTPN, LRPN was associated with significantly shorter operative time (OT) (115 min versus 199 min, p < 0.05). No significant differences were detected in the other outcomes. CONCLUSIONS: LRPN is associated with a significantly shorter OT compared to LTPN for posterior cT1 RMs. Both surgical approaches are safe, feasible and credible, demonstrating optimal results.