Defining minimal invasive surgical therapy for benign prostatic obstruction surgery: Perspectives from a global knowledge, attitude, and practice survey.

Objective: To scrutinize the definitions of minimal invasive surgical therapy (MIST) and to investigate urologists' knowledge, attitudes, and practices for benign prostatic obstruction surgeries. Methods: A 36-item survey was developed with a Delphi method. Questions on definitions of MIST and attitudes and practices of benign prostatic obstruction surgeries were included. Urologists were invited globally to complete the online survey. Consensus was achieved when more than or equal to 70% responses were "agree or strongly agree" and less than or equal to 15% responses were "disagree or strongly disagree" (consensus agree), or when more than or equal to 70% responses were "disagree or strongly disagree" and less than or equal to 15% responses were "agree or strongly agree" (consensus disagree). Results: The top three qualities for defining MIST were minimal blood loss (n=466, 80.3%), fast post-operative recovery (n=431, 74.3%), and short hospital stay (n=425, 73.3%). The top three surgeries that were regarded as MIST were Urolift® (n=361, 62.2%), Rezum® (n=351, 60.5%), and endoscopic enucleation of the prostate (EEP) (n=332, 57.2%). Consensus in the knowledge section was achieved for the superiority of Urolift®, Rezum®, and iTIND® over transurethral resection of the prostate with regard to blood loss, recovery, day surgery feasibility, and post-operative continence. Consensus in the attitudes section was achieved for the superiority of Urolift®, Rezum®, and iTIND® over transurethral resection of the prostate with regard to blood loss, recovery, and day surgery feasibility. Consensus on both sections was achieved for EEP as the option with the better symptoms and flow improvement, lower retreatment rate, and better suitable for prostate more than 80 mL. Conclusion: Minimal blood loss, fast post-operative recovery, and short hospital stay were the most important qualities for defining MIST. Urolift®, Rezum®, and EEP were regarded as MIST by most urologists.

Cardiovascular risks of androgen receptor targeted agents in prostate cancer: a systematic review and meta-analysis.

INTRODUCTION: Androgen receptor targeted agents (ARTA) have increasingly been incorporated into treatment regimens for various stages of prostate cancer. Patients are living longer with prostate cancer, and thus have a higher cumulative exposure to the treatment and its accompanying side effects, especially those of cardiovascular disease. We aim to assess the differences in the incidence of cardiac-related adverse events after treatment of prostate cancer with ARTA versus placebo. METHODS: Three databases were thoroughly searched for relevant articles. The PICOS model was used to frame our clinical question, with which 2 independent authors went through several rounds of screening to select the final included studies. Meta-analysis was done using the Cochran-Mantel-Haenszel Method. Quality assessment was carried out with the Cochrane Risk of Bias tool RoB 2. RESULTS: The use of ARTA in prostate cancer increases the incidence of cardiac-related adverse events (RR: 1.56, 95% CI: 1.29-1.90, p < 0.00001), such as hypertension (RR: 1.69, 95% CI: 1.46-1.97, p < 0.00001), ischaemic heart disease (RR: 1.84, 95% CI: 1.36-2.50, p < 0.0001), and arrhythmia (RR: 1.38, 95% CI: 1.11-1.71, p = 0.004), although this did not manifest in an increased incidence of cardiac arrests/deaths (RR: 1.28, 95% CI: 0.87-1.88, p = 0.21). DISCUSSION: ARTA increases the risk of cardiac-related adverse events, hypertension, ischaemic heart disease and arrhythmia. Armed with this knowledge, we will be better poised to manage cardiac risks accordingly and involve a cardiologist as required when starting patients on ARTA.

Predicting new-baseline glomerular filtration rate (NBGFR) after donor nephrectomy: validation of a split renal function (SRF)-based formula.

BACKGROUND: Accurate prediction of post-donor nephrectomy (DN) glomerular filtration rate is potentially useful for evaluating and counselling living kidney donors. Currently, there are limited tools to evaluate post-operative new-baseline glomerular filtration rate (NBGFR) in kidney donors. We aim to validate a conceptually simple formula based on split renal function (SRF) previously developed for radical nephrectomy patients. METHODS: Eighty-three consecutive patients who underwent DN from 2010 to 2016 were included. Pre-operative CT imaging and functional data including pre-DN baseline Global GFR (108.2 ± 13.2 mL/min/1.73m2) were included. Observed NBGFR was defined as the latest eGFR 3-12 months post-DN. SRF, defined as volume of the contralateral non-resected kidney normalised by total volume of kidneys, was determined from pre-operative cross-sectional imaging (49.2 ± 2.36%). The equation derived from Rathi et al. is as detailed: Predicted NBGFR = 1.24 × (Global GFR Pre-DN) x (SRF). RESULTS: The relationship between predicted NBGFR (66.0 ± 8.29 mL/min/1.73m2) and observed NBGFR (74.9 ± 16.4 mL/min/1.73m2) was assessed by evaluating correlation coefficients, bias, precision, accuracy, and concordance. The new SRF-based formula for NBGFR prediction correlated strongly with observed post-operative NBGFR (Pearson's r = 0.729) demonstrating minimal bias (median difference = 7.190 mL/min/1.73m2) with good accuracy (96.4% within ± 30%, 62.7% within ± 15%) and precision (IQR of bias = - 0.094 to 16.227). CONCLUSION: The SRF-based formula was also able to accurately discriminate all but one patient to an NBGFR of > 45 mL/min/1.73m2. We utilised the newly developed SRF-based formula for predicting NBGFR in a living kidney donor population. Counselling of donor post-operative renal outcomes may then be optimised pre-operatively.

Near-Infrared Fluorescence Imaging with Indocyanine Green for Robot-Assisted Partial Nephrectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: We aimed to analyze the influence of near-infrared fluorescence (NIRF) using indocyanine green (ICG) with standard robot-assisted partial nephrectomy (RAPN) in patients with a kidney tumor (KT). METHODS: We performed a literature search on 12 September 2023 through PubMed, EMBASE, and Scopus. The analysis included observational studies that examined the perioperative and long-term outcomes of patients with a KT who underwent RAPN with NIRF. RESULTS: Overall, eight prospective studies, involving 535 patients, were eligible for this meta-analysis, with 212 participants in the ICG group and 323 in the No ICG group. For warm ischemia time, the ICG group showed a lower duration (weighted Mean difference (WMD) = -2.05, 95% confidence interval (CI) = -3.30--0.80, p = 0.011). The postoperative eGFR also favored the ICG group (WMD = 7.67, 95% CI = 2.88-12.46, p = 0.002). No difference emerged for the other perioperative outcomes between the two groups. In terms of oncological radicality, the positive surgical margins and tumor recurrence rates were similar among the two groups. CONCLUSIONS: Our meta-analysis showed that NIRF with ICG during RAPN yields a favorable impact on functional outcomes, whereas it exerts no such influence on oncological aspects. Therefore, NIRF should be adopted when preserving nephron function is a paramount concern.

Laparoscopic retroperitoneal heminephrectomy for renal cell carcinoma in horseshoe kidney: a case report and review of the literature.

INTRODUCTION: In this case report, we demonstrate our technique of a retroperitoneal laparoscopic heminephrectomy for a T1b right hilar tumor in a horseshoe kidney. CASE PRESENTATION: A 77-year-old Vietnamese woman presented to the hospital because of right flank pain. On presentation, her serum creatinine was 0.86 mg/dL and glomerular filtration rate was 65.2 mL/minute/1.73 m2. According to her renal scintigraphy, glomerular filtration rates of the right and left moieties were 24.2 and 35.5 mL/minute, respectively. Computed tomography imaging demonstrated a 5.5 × 5.0 cm solid hilar mass with a cT1bN0M0 tumor stage was in the right moiety. After discussion, the patient elected a minimally invasive surgery to treat her malignancy. The patient was placed in a flank position. We used Gaur's balloon technique to create the retroperitoneal working space, and four trocar ports were planned for operation. Three arteries were dissected, including two arteries feeding the right moiety, one artery feeding the isthmus, and one vein, which was clipped and divided by Hem-o-lok. The isthmusectomy was performed with an Endostapler. Consequently, the ureter was clipped and divided. Finally, the whole right segment of the horseshoe kidney was mobilized and taken out via the flank incision. RESULTS: The total operative time was 250 min with an estimated blood loss of 200 mL. The patient's serum creatinine after surgery was 1.08 mg/dL, and glomerular filtration rate was 49.47 mL/minute/1.73 m2. The patient was discharged on postoperative day #4 without complication. Final pathologic examination of the tumor specimen revealed a Fuhrman grade II clear cell renal cell carcinoma, capsular invasion, with negative surgical margins. After a three-month follow-up, the serum creatinine was 0.95 mg/dL, and glomerular filtration rate was 57.7 mL/minute/1.73 m2. Local recurrence or metastasis was not detected by follow-up computed tomography imaging. CONCLUSIONS: Retroperitoneal laparoscopic heminephrectomy is a safe and feasible technique for patients with renal cell carcinoma in a horseshoe kidney and may be particularly useful in low income settings without access to robotic technology.

Outcomes of Localized Renal Cell Carcinoma Across Different Races.

Introduction: Epidemiological outcomes of renal cell carcinoma (RCC) remain sparse. This study aims to compare preoperative characteristics, surgical outcomes, and oncological outcomes of RCC patients at a urology unit in Singapore.Methods: A retrospective cohort analysis of 137 RCC patients in the National University Hospital of Singapore who had undergone partial nephrectomy between 2009 and 2020 was conducted. χ2 tests (Chi-Square Test, Fisher's Exact Test) and one-way analysis of variance (ANOVA) were used for comparing categorical and continuous variables respectively. Kaplan-Meier estimates were used for survival analysis.Results: In total, 137 patients were identified (Chinese [n=82], Malay [n=19], Indian [n=15], Others [n=21]). Indian patients were diagnosed at an earlier age (52.13±10.52 years, P=0.018). A larger percentage of Malay patients (78.9%, P<0.001) were operated on before 2016, prior to the center's adoption of the robotic surgical technique. More Malay and Indian patients underwent laparoscopic surgery (36.8% and 46.7%, P=0.008), experiencing higher rates of intra-operative conversions compared to the Chinese and other ethnicities (5.3% and 13.3% vs. 0%, P=0.011). They also had longer post-operative stays compared to Chinese (7.42±6.46 days; 7.40±7.69 days vs. 4.88±2.87 days, P=0.036). Malays were much less likely to undergo robotic partial nephrectomy compared to Chinese patients (OR=0.295, 95% CI=0.102-0.856) and had the highest rate of metastatic recurrence (10.5%, P=0.023).

A cross-sectional quality assessment of TikTok content on benign prostatic hyperplasia.

BACKGROUND: With an increasing reliance on online sources for medical information, we studied the quality and completeness of health literacy videos on TikTok regarding BPH. METHODS: A cross-sectional systematic evaluation of TikTok videos using the search term "Benign Prostatic Hyperplasia" was performed on 14th April 2023, and included 49 patient information and educational videos. The videos were then analysed by two reviewers and scored using two instruments: the DISCERN instrument and a completeness analysis. RESULTS: Of the 49 videos, 38 were created by healthcare professionals (HCPs). The average length of each video was 62.7 ± 59.3 s, with a large average number of total views (24,990.1 ± 109,534.9 views). The DISCERN score trended higher in every category in videos published by HCPs compared to non-HCPs, with HCPs providing a statistically significant increase in reliability (19.0,14.6, p < 0.05) and total score (29.4,23, p < 0.05). Majority of videos were deemed as poor or worse (91.8%) in quality. The completeness of the videos' content was also evaluated across five categories with an average score of 2.53 ± 2.1 out of the maximum 12. The DISCERN scores did not correlate with the degree of completeness of the videos (r = 0.226). CONCLUSION: BPH videos on TikTok have a wide reach, but the videos are mostly of low quality and completeness. Future videos should be made with quality and completeness in mind given the large viewership and more can be done to evaluate the extent of BPH misinformation and its impact on patients.

The impact of body mass index on oncological and surgical outcomes of patients undergoing nephrectomy: a systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review and meta-analysis to evaluate the impact of body mass index (BMI) on oncological (primary) and surgical (secondary) outcomes of patients who underwent nephrectomy, as obesity or high BMI is a known risk factor for renal cell carcinoma (RCC) and predictor of poorer outcomes. METHODS: Studies were identified from four electronic databases from database inception to 2 June 2021, according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. The review protocol was registered in the International Prospective Register of Systematic Reviews with the identification number: CRD42021275124. RESULTS: A total of 18 studies containing 13 865 patients were identified for the final meta-analysis. Regarding oncological outcomes, higher BMI predicted higher overall survival (BMI >25 vs BMI <25 kg/m2 : hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.58-0.85), cancer-specific survival (BMI >25 vs BMI <25 kg/m2 : HR 0.60, 95% CI 0.50-0.73; BMI 25-30 vs BMI <25 kg/m2 : HR 0.46, 95% CI 0.23-0.95; BMI >30 vs BMI <25 kg/m2 : HR 0.50, 95% CI 0.36-0.69), and recurrence-free survival rates (BMI >25 vs BMI <25 kg/m2 : HR 0.72, 95% CI 0.63-0.82; BMI 25-30 vs BMI <25 kg/m2 : HR 0.59, 95% CI 0.42-0.82). Those with a lower BMI fared better in surgical outcomes, such as operation time and warm ischaemic time, although the absolute difference was minimal and unlikely to be clinically significant. There was no difference between groups for length of hospital stay, intraoperative or postoperative complications, blood transfusion requirements, and conversion to open surgery. CONCLUSION: Our study suggests that a higher BMI is associated with improved long-term oncological survival and similar perioperative outcomes as a lower BMI. More research into the underlying biological and physiological mechanisms will enable better understanding of the effect of BMI, beyond mere association, on post-nephrectomy outcomes.

Radiomics vs radiologist in bladder and renal cancer. Results from a systematic review.

Introduction: Radiomics in uro-oncology is a rapidly evolving science proving to be a novel approach for optimizing the analysis of massive data from medical images to provide auxiliary guidance in clinical issues. This scoping review aimed to identify key aspects wherein radiomics can potentially improve the accuracy of diagnosis, staging, and grading of renal and bladder cancer. Material and methods: A literature search was performed in June 2022 using PubMed, Embase, and Cochrane Central Controlled Register of Trials. Studies were included if radiomics were compared with radiological reports only. Results: Twenty-two papers were included, 4 were pertinent to bladder cancer, and 18 to renal cancer. Radiomics outperforms the visual assessment by radiologists in contrast-enhanced computed tomography (CECT) to predict muscle invasion but are equivalent to CT reporting by radiologists in predicting lymph node metastasis. Magnetic resonance imaging (MRI) radiomics outperforms radiological reporting for lymph node metastasis. Radiomics perform better than radiologists reporting the probability of renal cell carcinoma, improving interreader concordance and performance. Radiomics also helps to determine differences in types of renal pathology and between malignant lesions from their benign counterparts. Radiomics can be helpful to establish a model for differentiating low-grade from high-grade clear cell renal cancer with high accuracy just from contrast-enhanced CT scans. Conclusions: Our review shows that radiomic models outperform individual reports by radiologists by their ability to incorporate many more complex radiological features.

Radiomics vs radiologist in prostate cancer. Results from a systematic review.

PURPOSE: Radiomics in uro-oncology is a rapidly evolving science proving to be a novel approach for optimizing the analysis of massive data from medical images to provide auxiliary guidance in clinical issues. This scoping review aimed to identify key aspects wherein radiomics can potentially improve the accuracy of diagnosis, staging, and extraprostatic extension in prostate cancer (PCa). METHODS: The literature search was performed on June 2022 using PubMed, Embase, and Cochrane Central Controlled Register of Trials. Studies were included if radiomics were compared with radiological reports only. RESULTS: Seventeen papers were included. The combination of PIRADS and radiomics score models improves the PIRADS score reporting of 2 and 3 lesions even in the peripheral zone. Multiparametric MRI-based radiomics models suggest that by simply omitting diffusion contrast enhancement imaging in radiomics models can simplify the process of analysis of clinically significant PCa by PIRADS. Radiomics features correlated with the Gleason grade with excellent discriminative ability. Radiomics has higher accuracy in predicting not only the presence but also the side of extraprostatic extension. CONCLUSIONS: Radiomics research on PCa mainly uses MRI as an imaging modality and is focused on diagnosis and risk stratification and has the best future possibility of improving PIRADS reporting. Radiomics has established its superiority over radiologist-reported outcomes but the variability has to be taken into consideration before translating it to clinical practice.

An Update of In Vivo Application of Artificial Intelligence and Robotics for Percutaneous Nephrolithotripsy: Results from a Systematic Review.

PURPOSE OF REVIEW: Kidney puncture is a key step in percutaneous nephrolithotomy (PCNL). Ultrasound/fluoroscopic-guided access to the collecting systems is commonly used in PCNL. Performing a puncture is often challenging in kidneys with congenital malformations or complex staghorn stones. We aim to perform a systematic review to examine data on in vivo applications, outcomes, and limitations of using artificial intelligence and robotics for access in PCNL. RECENT FINDINGS: The literature search was performed on November 2, 2022, using Embase, PubMed, and Google Scholar. Twelve studies were included. 3D in PCNL is useful for image reconstruction but also in 3D printing with definite benefits seen in improving anatomical spatial understanding for preoperative and intraoperative planning. 3D model printing and virtual and mixed reality allow for an enhanced training experience and easier access which seems to translate into a shorter learning curve and better stone-free rate compared to standard puncture. Robotic access improves the accuracy of the puncture for ultrasound- and fluoroscopic-guided access in both supine and prone positions. The potential advantage robotics are using artificial intelligence to do remote access, reduced number of needle punctures, and less radiation exposure during renal access. Artificial intelligence, virtual and mixed reality, and robotics may play a key role in improving PCNL surgery by enhancing all aspects of a successful intervention from entry to exit. There is a gradual adoption of this newer technology into clinical practice but is yet limited to centers with access and the ability to afford this.

Use of metallic ureteric stents for chronic ureteric obstruction and its association with value-based care.

Introduction: We aimed to compare the real-world data and our clinical experience with metallic stents (MSs) and conventional polymeric stents (PSs) in the management of both malignant and benign chronic ureteric obstruction (CUO), in terms of clinical outcomes and costs. Methods: Clinical data from our institution, including outcomes for all ureteric stents inserted for long-term management of CUO from all causes from 2014 to 2017, were retrospectively reviewed and compared between the MS and PS episodes. Results: A total of 247 stents were placed in 63 patients with CUO over the 4-year study period. Of these, 45 stents were MSs. There was no significant difference in all baseline characteristics between the MS and PS groups, except for the aetiology of obstructive cause. Mean indwelling stent duration was significantly greater for MS than for PS (228.6 ± 147.0 vs. 146.1 ± 66.0 days, P < 0.001), thereby leading to lower average number of stent changes per year in the MS group compared to the PS group (1.4 vs. 6.3 times, respectively). Despite the higher unit cost of MS compared to PS, there was no significant mean cost difference overall (cost per dwelling day SGD 7.82 ± SGD 10.44 vs. SGD 8.23 ± SGD 20.50, P = 0.888). Conclusion: Resonance MS is a better option than PS to manage CUO from malignant and benign causes because its significantly longer indwelling time mitigates the higher unit cost of the stent. It potentially reduces the number of procedures and operations in patients. Thus, it should be considered for all patients with CUO requiring long-term ureteric drainage.

Single-port and multiport robot-assisted radical prostatectomy: A meta-analysis.

Objective: To compare the perioperative, oncological, and functional outcomes between single-port robot-assisted radical prostatectomy (SP-RARP) and multiport robot-assisted radical prostatectomy (MP-RARP) via a meta-analysis. Methods: For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until January 15, 2022. A meta-analysis has been reported in line with PRISMA 2020 and AMSTAR Guidelines. The risk ratio and weighted mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CI). Results: Of the 368 retrieved abstracts, 41 underwent full-text review, and seven studies were included in the final analysis, comprising a total cohort of 1,934 cases of RARP (355 SP-RARP cases and 1,579 MP-RARP cases). Compared to MP-RARP, the SP-RARP group had less postoperative pain score (MD = -0.7, 95% CI -1 to -0.4, P<0.001), morphine milligram equivalents usage (MD = -3.8, 95% CI -7.5 to -0.1, P=0.04), hospital stay (MD = -1, 95% CI -1.8 to -0.1, P=0.019), and urinary catheterization time (MD = -1.1, 95% CI -1.9 to -0.3, P=0.008). However, the SP-RARP group had a longer console time than the MP-RARP group (MD = 5.3, 95% CI 2.6 to 7.9, P<0.001). Conclusions: Our study demonstrated that early results were mostly equivalent with the single-port approach. This technology may help to reduce the hospital stay and postoperative pain for patients undergoing radical prostatectomy compared to MP-RARP, without compromising the functional and early oncological outcomes.

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

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

Comparison and outcomes of dusting versus stone fragmentation and extraction in retrograde intrarenal surgery: results of a systematic review and meta-analysis.

Introduction: Lithotripsy during retrograde intrarenal surgery (RIRS) can be achieved either by fragmentation and extraction or dusting with spontaneous passage. We aimed to perform a systematic review on the safety and stone-free rate after RIRS by comparing the techniques of dusting vs fragmentation/extraction. Material and methods: This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The inverse variance of the mean difference and 95% Confidence Interval (CI), Categorical variables were assessed using Cochran-Mantel-Haenszel Method with the random effect model and reported as Odds Ratio (OR) and 95% CI. Statistical significance was set at p <0.05. Results: There were 1141 patients included in 10 studies. Stone size was up to 2.5 cm All studies used holmium laser for lithotripsy. Meta-analysis showed no significant difference in surgical time (MD -5.39 minutes 95% CI -13.92-2.31, p = 0.16), postoperative length of stay (MD -0.19 days 95% CI -0.60 - -0.22, p=0.36), overall complications (OR 0.98 95% CI 0.58-1.66, p = 0.95), hematuria (OR 1.01 95% CI 0.30-3.42, p = 0.99), postoperative fever (OR 0.70 95% CI 0.41-1.19, p = 0.19) and sepsis (OR 1.03 95% CI 0.10-10.35, p = 0.98), immediate (OR 0.40 95% CI 0.13-1.24, p = 0.11) and overall stone-free rate (OR 0.76 95% CI 0.43-1.32, p = 0.33), and retreatment rate (OR 1.35 95% CI 0.57-3.20, p = 0.49) between the groups. Conclusions: This systematic review infers that urologists can safely use either option of fragmentation and basket extraction or dusting without extraction to achieve similar outcomes as both techniques are similar for efficacy and safety.

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

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

Prevalence and Risk Factors of Mortality in Emphysematous Pyelonephritis Patients: A Meta-Analysis.

BACKGROUND: Emphysematous pyelonephritis (EP) is a severe necrotizing infection of the renal parenchyma which is associated with significant case mortality. We sought to identify the incidence and predictive risk factors associated with EP mortality. METHODS: Two electronic databases, PubMed and Web of Science, were searched from their inception until June 06, 2021 for relevant articles. Two independent teams reviewed abstracts and extracted data from the selected manuscripts. A meta-analysis has been reported in line with PRISMA 2020 and AMSTAR Guidelines. RESULTS: Of the 1080 retrieved abstracts, 79 underwent full-text review and 45 studies were included in the final analysis, comprising a total cohort of 1303 patients and 177 mortalities. The pooled prevalence of mortality among the patients with EP disease was 13%. Our analysis found a significantly decreasing trend in mortality rates, an increasing trend in minimally invasive intervention and decreasing trends in emergency nephrectomy in the EP studies from 1985 to 2020. Significant risk factors that were associated with a negative impact on survival of EP patients included sepsis (OR = 15.99), shock (OR = 15.57), disturbance of consciousness (OR = 12.11), thrombocytopenia (OR 7.85), acute renal failure (OR = 5.41), Wan classification I (OR = 4.57), emergency nephrectomy (OR = 3.73), Huang-Tseng classification III-IV (OR = 2.4) and medical management alone (OR = 2.04). Female sex (OR = 0.52) and minimally invasive intervention (OR = 0.47) (percutaneous nephrostomy or ureteral stent placement) were associated with decreased mortality rates. CONCLUSIONS: Our study results demonstrated several significant risk factors that could help guide treatment to reduce the mortality risk of EP patients. Clinically, early treatment with a combination of minimally invasive intervention and appropriate medical management may be protective for reducing mortality risk in EP patients.