The impact of single-use digital flexible cystoscope for double J removal on hospital costs and work organization: A multicentric evaluation.

BACKGROUND: Isiris-α® is a single-use digital flexible cystoscope with an integrated grasper designed for double J (DJ) stent removal. Aim of this study was to conduct a multicentric evaluation of the costs and criticalities of stent removals performed with Isiris®-α in different hospitals and health systems, as compared to other DJ removal procedures. METHODS: After gathering 10 institutions worldwide with experience on Isiris-α®, we performed an analysis of the reported costs of DJ removal with Isiris-α®, as compared to the traditional reusable equipment used in each institution. The cost evaluation included instrument purchase, Endoscopic Room (EnR)/ Operatory Room (OR) occupancy, medical staff, instrument disposal, maintenance, repairs, decontamination or sterilization of reusable devices. RESULTS: The main factor affecting the costs of the procedure was OR/EnR occupancy. Decontamination and sterilization accounted for a less important part of total costs. Isiris-α® was more profitable in institutions where DJ removal is usually performed in the EnR/OR, allowing to transfer the procedure to outpatient clinic, with a significant cost saving and EnR/OR time saving to be allocated to other activities. In the only institution where DJ removal was already performed in outpatient clinics, there is a slight cost difference in favor of reusable instruments in high-volume institutions, given a sufficient number to guarantee the turnover. CONCLUSION: Isiris-α® leads to significant cost benefit in the institutions where DJ removal is routinely performed in EnR/OR, and brings significant improvement in organization, cost impact and turnover.

Cross-continental comparison of safety and protection measures amongst urologists during COVID-19.

OBJECTIVES: To determine the well-being of urologists worldwide during the coronavirus disease 2019 pandemic, and whether they have adequate personal protective equipment knowledge and supplies appropriate to their clinical setting. METHODS: Urologists worldwide completed a Société Internationale d'Urologie online survey from 16 April 2020 until 1 May 2020. Analysis was carried out to evaluate their knowledge about protecting themselves and others in the workplace, including their confidence in their ability to remain safe at work, and any regional differences. RESULTS: There were 3488 respondents from 109 countries. Urologists who stated they were moderately comfortable that their work environment offers good protection against coronavirus disease 2019 showed a total mean satisfaction level of 5.99 (on a "0 = not at all" to "10 = very" scale). A large majority (86.33%) were confident about protecting themselves from coronavirus disease 2019 at work. However, only about one-third reported their institution provided the required personal protective equipment (35.78%), and nearly half indicated their hospital has or had limited personal protective equipment availability (48.08%). Worldwide, a large majority of respondents answered affirmatively for testing the healthcare team (83.09%). Approximately half of the respondents (52.85%) across all regions indicated that all surgical team members face an equal risk of contracting coronavirus disease 2019 (52.85%). Nearly one-third of respondents reported that they had experienced social avoidance (28.97%). CONCLUSIONS: Our results show that urologists lack up-to-date knowledge of preferred protocols for personal protective equipment selection and use, social distancing, and coronavirus disease 2019 testing. These data can provide insights into functional domains from which other specialties could also benefit.

Comparison of retropubic, laparoscopic and robotic radical prostatectomy: who is the winner?

PURPOSE: This study is a systematic analysis of the evidence regarding oncological, perioperative and postoperative outcomes and the cost of open retropubic radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALP). METHODS: Summary data was abstracted from 104 original research articles representing 227,400 patients. PubMed/Medline, Scopus, Google Scholar, EMBASE and the Cochrane Library were reviewed in December 2016. A total of 104 publications were selected for inclusion. The primary outcomes were positive surgical margin (PSM) and major complication rate according to Clavien classifications. Secondary outcomes were operative time, length of hospital stay, estimated blood loss, transfusions, conversions, rate of post-operative erectile dysfunction and incontinence and total cost of procedure. RESULTS: ORP had a significantly higher rate than RALP for PSM (OR: 1.18; 95% CI 1.05-1.32; p = 0.004), but the rate of PSM was not significantly different between ORP versus LRP (OR: 1.37; 95% CI 0.88-2.14; p = 0.17) and RALP versus LRP (OR: 0.83; 95% CI 0.40-1.72; p = 0.62). The major Clavien complication rate was significantly different between ORP and RALP (OR: 2.14; 95% CI 1.24-3.68; p = 0.006). Estimated blood loss, transfusions and length of hospital stay were low for RALP, moderate for LRP and high for ORP. The rate of erectile dysfunction (OR: 2.58; 95% CI 1.77-3.75; p < 0.001) and incontinence (OR: 3.57; 95% CI 2.28-5.58; p < 0.001) were significantly lower after RALP than LRP and equivalent for other comparisons. Total cost was highest for RALP, followed by LRP and ORP. CONCLUSIONS: For PSM and peri- and post-operative complications, RALP showed better results than ORP and LRP. In the context of the biases between the studies, one should interpret the results with caution.

The Evolving Role of Retrograde Intrarenal Surgery in the Treatment of Urolithiasis.

CONTEXT: Retrograde intrarenal surgery has gained substantial popularity worldwide thanks to continuous improvements in technology and techniques, and is now considered one of the first-line treatment options for active removal of renal stones. OBJECTIVE: To provide a comprehensive synthesis of the main evidences in literature on the current management of kidney stones by means of retrograde intrarenal surgery (RIRS). EVIDENCE ACQUISITION: A review of literature has been conducted using search string "retrograde intrarenal surgery OR flexible ureteroscop* OR ureterorenoscop*", without any language restriction; PubMed, Embase, and Scopus databases were searched in November 2016. Exclusion criteria involved manuscripts dealing with paediatric patients, and RIRS for proximal ureteric stones and for upper tract urothelial tumours. Fifty-seven papers were finally included in the analysis. EVIDENCE SYNTHESIS: Technological progress focuses on the miniaturisation of disposables and scopes, as well as on the increase of durability and improvement of the quality of image provided by these instruments. The technique has been in continuous development following the progress in technology. Currently, the main target of RIRS are renal stones 1-2cm in size, even though tertiary centres are pushing the boundaries to the treatment of larger stones. Nomograms predicting surgical outcomes and improving preoperative surgical planning have been developed. RIRS has been shown to be safe and effective in patients with specific conditions such as bleeding diathesis, anatomical malformation, or pregnancy. Cost effectiveness of the approach is still a matter of controversy when compared with other treatment modalities. CONCLUSIONS: RIRS is a well-established procedure under constant evolution with advances in technique and technology. It has gained worldwide popularity due to its minimal invasiveness and satisfactory outcomes. Future developments are needed to increase its cost effectiveness and extend its use to a wider range of indications. PATIENT SUMMARY: In this collaborative review, we have summarised the best evidence in literature with respect to current management of renal stones by means of retrograde intrarenal surgery (RIRS) with flexible ureteroscopy. RIRS has been shown to be a safe and effective treatment modality in a wide spectrum of clinical scenarios; technology and technique are continuously evolving to further push boundaries of its indications and efficacy.

'Mini, ultra, micro' - nomenclature and cost of these new minimally invasive percutaneous nephrolithotomy (PCNL) techniques.

New minimally invasive percutaneous nephrolithotomy (PCNL) techniques have changed the management of renal stones. We discuss the technological advances in PCNL and explain the meaning, requirements and set up costs for each of these 'newer' techniques.

Focal therapy in the management of small renal masses.

PURPOSE OF REVIEW: Focal therapy has gained attention in the treatment of small renal masses. However its use is encased by scarce data on long-term outcomes and low evidence regarding perioperative complications. Our purpose is to review the emerging data in the past 18 months. RECENT FINDINGS: Population US-based studies show steady increase in the use of thermal ablation. Clinical series and comprehensive reviews support safety and mid/long-term efficacy. Comparative studies and meta-analysis outlined oncological inferiority against partial nephrectomy in local tumor control. There are profound demographic and tumor differences between patients treated by one or another. Complication rate is lower after ablation but the lack of standard reporting weakens conclusions on this point. Generalizable cost-benefit studies are yet missed. Clinical and basic research aims to diminish radiological associated burden, improving lesion targeting and developing new energy-based technologies. SUMMARY: Data confirm acceptable outcomes of focal therapy in the small renal masses treatment.Although these are inferior in terms of local control compared with partial nephrectomy, patients and tumor characteristics differ between treatments.Current data remain of low evidence but for some meta-analysis. Preliminary reports suggest the possibility to decrease radiation burden and bipolar radiofrequency and photodynamic therapy as focus of future interest.

Medical expulsive therapy for distal ureteral stones.

Although minimally invasive treatments for ureteral stones are efficacious, they are not free of complications and are associated with high cost. Medical expulsive therapy (MET) has recently emerged as an alternative strategy for the initial management of small distal ureteral stones. A MEDLINE search was undertaken to evaluate all currently available data on efficacy and safety of MET therapy in such patients. The specific mechanism of action on the ureteral smooth muscle and the emerging evidence of the efficacy (defined as either an increase in expulsion rate or a decrease in time to expulsion) and low-risk profile suggest that alpha-adrenergic receptor antagonists (alpha-blockers) and calcium channel antagonists should be the initial medical treatment in patients amenable to conservative therapy. NSAIDs and anticholinergics have not shown efficacy as single agents or in combination with alpha-blockers or nifedipine. Corticosteroids may provide a small additive effect when combined with either alpha-blockers or nifedipine.

Intraurethral lubricants: a critical literature review and recommendations.

In current clinical practice, lidocaine gel is widely used as a local anesthetic lubricant before various forms of transurethral instrumentation. Over the past few years, the value of local anesthesia during urethral catheterization and flexible or rigid cystoscopy has been questioned. Strong data are lacking, and the results from the different studies are contradictory. As a result, the correct use of the intraurethral gels is, for the most part, left to individual preference. The purpose of this review is to provide an overview of the characteristics of the intraurethral gels, to assess the effectiveness, and to define evidence-based indications for their use.

EAU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines).

OBJECTIVE: To provide the first update of the EAU guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO). METHODS: A systematic literature review was conducted based on the results of a MEDLINE search concentrating on the years 1999-2003. In combination with expert opinions recommendations were made on the usefulness of diagnostic tests, therapeutic options and follow-up. RESULTS: During initial assessment the following tests are recommended: medical history, physical examination including digital-rectal examination, International Prostate Symptom Score, urinalysis, serum creatinine and prostate specific antigen measurement, uroflowmetry and post-void residual volume. All other tests are optional or not recommended. Aim of treatment is to improve LUTS and quality of life and to prevent severe BPE-related complications. Development of a 5alpha-reductase type I and II inhibitor and the data of the MTOPS trial providing scientific evidence for a combination therapy were the most significant innovations since the first version. Finally a more detailed knowledge on the natural history with identification of several risk factors for progression is the basis for a risk-profile orientated (preventive) therapy. CONCLUSIONS: Updated recommendations for assessment, treatment, and follow-up of patients with LUTS due to BPO are presented.

Application of external microwave thermotherapy in urology: past, present, and future.

The excellent clinical results of transurethral microwave thermotherapy (TUMT) for the treatment of symptomatic benign prostatic hyperplasia (BPH) gave to TUMT the leading position among the microwave thermotherapy modalities available for the treatment of different urologic conditions. Research in TUMT has focused on operating software, temperature monitoring, intraprostatic heat distribution, cell-kill calculations, and correlations with clinical variables. Randomized comparisons of TUMT with other established therapies for BPH, including transurethral resection, have facilitated the evaluation of the clinical outcome, durability, morbidity, and costs of the treatment. The applications of microwave thermotherapy in other urologic diseases are also presented in this review.

Transurethral microwave thermotherapy: the gold standard for minimally invasive therapies for patients with benign prostatic hyperplasia?

From all available minimally invasive methods for the treatment of symptomatic benign prostatic hyperplasia (BPH), transurethral microwave thermotherapy (TUMT) has gained a firm position as the most attractive option. Recent research has produced innovations in high-energy TUMT, including new treatment protocols, refined selection criteria, and monitoring of intraprostatic temperature. Furthermore, long-term results from randomized studies comparing TUMT with transurethral resection of the prostate (TURP) or medical treatment are now available. All these data indicate that more durable clinical outcomes and less morbidity can be achieved with TUMT, strengthening its position as a standard treatment for BPH. This paper describes the status of TUMT in the treatment of lower urinary tract symptoms related to BPH, focusing on variations in the outcomes with different devices, the durability of treatment outcomes, morbidity, selection criteria, and cost. The relation of TUMT to medical management and TURP also is addressed.

Thermotherapy and thermoablation for benign prostatic hyperplasia.

PURPOSE OF REVIEW: From all the available thermoablative methods for the treatment of symptomatic benign prostatic hyperplasia, transurethral microwave thermotherapy is considered as standard in minimally invasive management. The literature is enriched by several new studies on transurethral microwave thermotherapy, and thus this review presents up-to-date information about thermotherapy. RECENT FINDINGS: New studies have provided significant information regarding differences in outcome for devices with different protocols and selection criteria, confirming the superiority of high-energy programmes. Furthermore, monitoring of the intraprostatic temperature promises better clinical results by means of individualization of the treatment. Long-term results have been available and allow the evaluation of the fundamental issue of treatment durability. Improvement after high-energy transurethral microwave thermotherapy remains durable for more than 2.5 years. Randomized studies comparing this treatment with other established therapies for benign prostatic hyperplasia, including medical treatment and transurethral resection of the prostate, have also contributed to an evaluation of the morbidity, and costs of treatment. Clinical outcomes with transurethral microwave thermotherapy are in the range of those obtained with transurethral resection of the prostate and are superior to those of medical management. Retreatment after transurethral resection of the prostate emerges because of complications following the procedure, whereas retreatment after transurethral microwave thermotherapy is as a result of treatment failure. In addition, the rate of failure of medical management is almost seven times higher than that for transurethral microwave thermotherapy. Thus, the latter seems to play a dominant role in the economic models used to assess the cost-efficiency of different treatment modalities for benign prostatic hyperplasia. SUMMARY: The recent innovations in high-energy transurethral microwave thermotherapy provide better and more durable clinical outcomes and lower morbidity, and strengthen its position as an established treatment for benign prostatic hyperplasia. However, there is always room for improvement, so further research on therapeutic protocols, treatment monitoring and selection criteria are to be welcomed.

Computerised assessment of maximum urinary flow: an efficient, consistent and valid approach.

OBJECTIVES: To evaluate the relative accuracy of a computerised method to quantitatively assess maximum urinary flow. METHODS: A total of 1147 uroflows were evaluated by the computerised method and by three experts from different European countries. The sample consisted of uroflows from the respective visits by a 20% sample of randomly chosen patients (n = 223) with lower urinary tract symptoms with participation in two clinical trials in which the efficacy and safety of Permixon was evaluated. The proportions of automated maximum flow values included in the 10% extended range of experts (and their 95% confidence intervals) were assessed, as well as the concordance coefficients between experts and the computerised method and the paired Student's t-test for the average differences between experts and computer. RESULTS: The rate of agreement between experts and computer varied between about 95 and 100% over factor levels for visit, type of machine and country. Concordance coefficients indicated good agreement between experts and the automated method. When looking at average differences between experts and the computer, the smallest differences were observed between experts 2, 3 and the computer (differences not statistically significant). Statistically significant average differences were observed between expert 1 and the other experts as well as between expert 1 and the computer. CONCLUSIONS: The computerised assessment decreases the fraction of variability of maximum urinary flow caused by artifacts as well as intra- and inter-expert variation. The computerised assessment of maximum urinary flow is an efficient, consistent and valid approach to quantitatively assess maximum urinary flow in clinical trials.

Recent developments in guidelines on benign prostatic hyperplasia.

Guidelines within the healthcare system aim to rationalize the diagnosis, treatment and follow-up of a particular disease and can be applicable on an international scale or may be country specific. Specialists, who determine the clinical evidence for individual practices, prepare these guidelines, and the strength of these recommendations depends on available evidence. The assessment of patients includes a minimal number of non-invasive tests. Only in cases of abnormalities are additional (more invasive) tests recommended. Treatment decisions should be evidence-based but, despite guidelines, the choice of treatment is often highly dependent on the personal preference of the urologist. Patients' awareness of different treatment options and their involvement in choosing a treatment is also increasing. Economical aspects are becoming more and more important in making healthcare decisions. Data on durability of treatments, however, are limited and deserve special attention in order to provide the most cost-effective care for different patient groups.