The impact of COVID-19 in medical practice. A review focused on Urology

ABSTRACT COVID-19 pandemic is a rapidly spreading virus that is changing the World and the way doctors are practicing medicine. The huge number of patients searching for medical care and needing intensive care beds led the health care system to a burnout status especially in places where the care system was already overloaded. In this setting, and also due to the absence of a specific treatment for the disease, health authorities had to opt for recommending or imposing social distancing to relieve the health system and reduce deaths. All other medical specialties nondirectly related to the treatment of COVID-19 had to interrupt or strongly reduce their activities in order to give room to seriously ill patients, since no one knows so far the real extent of the virus damage on human body and the consequences of doing non deferrable procedures in this pandemic era. Despite not been a urological disease, the urologist needs to be updated on how to deal with these patients and how to take care of himself and of the medical team he works with. The aim of this article is to review briefly some practical aspects of COVID-19 and its implications in the urological practice in our country.

Bilateral simultaneous percutaneous nephrolithotomy versus staged approach: a critical analysis of complications and renal function

SUMMARY INTRODUCTION: Patients with bilateral kidney stones and burdened by large stones are challenging cases for endourologists. Simultaneous bilateral percutaneous nephrolithotomy (sbPCNL) is an option; however, it may be accompanied by important morbidity. An alternative is a staged PCNL, operating one side each time. Herein, we compare the impact of sbPCNL and staged PCNL on complication rates and renal function. METHODS: Patients who underwent sbPCNL or staged bilateral PCNL with a frame time of 6 months were searched in our prospectively collected kidney stone database. Groups were compared for age, gender, body mass index (BMI), comorbidities (classification by the American Society of Anesthesiology - ASA), stone size, Guy's score, stone-free status, renal function, blood loss, blood transfusion rate, complication rate, and length of hospital stay. RESULTS: Twenty-six patients and 52 kidney units were enrolled. The mean operative time was 134.7 min. Only 11.3% of cases had complications, all of them minor (Clavien ≤ 2). Overall, the stone-free rate was 61.50%. Comparing the groups, there was a significantly longer operative time in the sbPCNL group (172.5 vs. 126.3 min; p=0.016), as well as a higher transfusion rate (12.5% vs. 5.6%; p=0.036). There was no statistically significant difference in creatinine levels between the groups. Regarding the stone-free rate, there was a significantly higher proportion of patients in the staged PCNL group (64.9% vs. 43.8%; p=0.012). CONCLUSION: sbPCNL is a safe procedure; however, when compared to staged procedures it has a higher transfusion and lower stone-free rate.

RESUMO INTRODUÇÃO: Paciente com cálculos renais bilaterais e de grande volume são casos desafiadores para os endourologistas. A nefrolitotripsia percutânea bilateral simultânea (NLPbs) é um opção, entretanto esse procedimento pode ser acompanhado de morbidade importante. Uma alternativa é a NLP estagiada, operando um lado de cada vez. Aqui, nós comparamos o impacto da NLPbs e da NLP estagiada nas taxas de complicações e função renal. MÉTODOS: Pacientes que foram submetidos a NLPsb ou NLP stagiada com intervalo de até 6 meses foram pesquisados em nossa base de dados de cálculos renais prospectivamente coletada. Os grupos foram comparados em idade, gênero, índice de massa corpórea (IMC), comorbidades (classificação da Sociedade Americana de Anestesiologia - ASA), tamanho do cálculo, Classificação de Guys, taxa de pacientes livres de cálculos, função renal, perda sanguínea, taxa de transfusão, taxa de complicações e tempo de internação hospitalar. RESULTADOS: Vinte e seis paciente e 52 unidades renais foram incluídas. O tempo operatório médio foi de 134,7 min. Apenas 11.3% dos casos tiveram complicações, sendo todas menores (Clavien ≤ 2). No geral, a taxa de pacientes livres de cálculos foi de 61,5%. Comparando os grupos houve um tempo operatório significativamente maior no grupo NLPbs(172,5 vs. 126,3 min; p=0,016), assim como uma maior taxa de transfusão (12,5% vs. 5,6%; p=0.036). Não houve diferença significante nos níveis de creatinina entre os grupos. Em relação a taxa de doentes livre de cálculos houve uma proporção significativamente maior de pacientes livres de cálculos na NLP estagiada (64,9% vs. 43,8%; p=0,012). CONCLUSÃO: A NLPsb é um procedimento seguro, entretando quando comparada ao procedimento estagiado apresenta uma maior taxa de transfusão e uma menor taxa de pacientes livres de cálculos.

Staghorn renal stones: what the urologist needs to know

ABSTRACT Patients with staghorn renal stones are challenging cases, requiring careful preoperative evaluation and close follow-up to avoid stone recurrence. In this article we aim to discuss the main topics related to staghorn renal stones with focus on surgical approach. Most of staghorn renal stones are composed of struvite (magnesium ammonium phosphate) and are linked to urinary tract infection by urease-producing pathogens. Preoperative computed tomography scan and careful evaluation of all urine cultures made prior surgery are essential for a well-planning surgical approach and a right antibiotics choice. Gold standard surgical technique is the percutaneous nephrolithotomy (PCNL). In cases of impossible percutaneous renal access, anatrophic nephrolithotomy is an alternative. Shockwave lithotripsy and flexible ureteroscopy are useful tools to treat residual fragments that can be left after treatment of complete staghorn renal stone. PCNL can be performed in supine or prone position according to surgeon's experience. Tranexamic acid can be used to avoid bleeding. To check postoperative stone-free status, computed tomography is the most accurate imaging exam, but ultrasound combined to KUB is an option. Intra-operative high-resolution fluoroscopy and flexible nephroscopy have been described as an alternative for looking at residual fragments and save radiation exposure. The main goals of treatment are stone-free status, infection eradication, and recurrence prevention. Long-term or short-term antibiotic therapy is recommended and regular control imaging exams and urine culture should be done.

Renal manifestations of sarcoidosis: from accurate diagnosis to specific treatment

ABSTRACT Sarcoidosis is a multisystem granulomatous disease characterized by epithelioid noncaseating granulomas associated with clinical and radiologic findings. The cause of this disease is still uncertain. Sarcoidosis affects mostly lungs and lymph nodes and is not usually considered a urological disease, therefore, this etiology may be overlooked in several urological disorders, such as hypercalcemia, hypercalciuria and nephrolithiasis. It affects all races and genders. This review aims to describe the urological manifestations of sarcoidosis and to elucidate how the disease may affect the management of numerous urological conditions.

A comprehensive literature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices

ABSTRACT Purpose to critically review all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes. Materials and Methods A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. All factors potentially affecting surgical costs or clinical outcomes were considered. Prospective assessments, case control and case series studies were included. Results 741 studies were found. Of those, 18 were duplicated and 77 were not related to urology procedures. Of the remaining 646 studies, 59 were considered of relevance and selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. Operative time was in average 20% shorter with digital scopes, single-use or not. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Longer scope longevity is achieved with Cidex and if a dedicated nurse takes care of the sterilization process. The main surgical factors that negatively impact device longevity are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. We have built a comprehensive financial cost-effective decision model to flexible ureteroscope acquisition. Conclusions The cost-effectiveness of a flexible ureteroscopy program is dependent of several aspects. We have developed a equation to allow a literature-based and adaptable decision model to every interested stakeholder. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls.

Robot - assisted laparoscopic local recurrence resection after radical prostatectomy

ABSTRACT Introduction and objective: Local prostate cancer recurrence is usually treated with salvage radiation (sRDT) with or without adjuvant therapy. However, surgical resection could be an option. We aim to present the surgical technique for robot - assisted laparoscopic resection prostate cancer local recurrence after radical prostatectomy (RP) and sRDT in 2 cases. Patients and method: First case depicts a 70 year - old man who underwent RP in 2001 and sRDT in 2004. Following adjuvant therapy, patient had biochemical recurrence. MRI showed a solid mass in the prostatic fossa close to vesicourethral anastomosis, measuring 2.1 cm and PET / CT revealed hyper caption significant uptake in the prostatic fossa. Second case is a 59 year - old man who underwent RP in 2010 and sRDT in 2011. Again, patient presented with biochemical recurrence. PET / CT showed hyper caption in the prostatic fossa. Biopsy conformed a prostate adenocarcinoma. Both patients underwent robot - assisted extended pelvic lymph nodes dissection and local recurrence resection. A standard 4 robotic arms port placement was utilized. Results: Both procedures were uneventfully performed in less than 3 hours and there were no complications. Pathological examination showed a prostate adenocarcinoma Gleason 7 and 8 in the first and second case, respectively; surgical margins and lymph nodes were negative. After 6 months of follow-up, continence was not affected and both patients presented with PSA < 0.15 ng / mL. Conclusion: Robot - assisted laparoscopic resection of prostate cancer local recurrence after RP and sRDT detected by PSMA PET / CT seems to be safe in experienced hands. It may postpone adjuvant therapy in selected cases.

What is the quickest scoring system to predict percutaneous nephrolithotomy outcomes? A comparative study among S. T. O. N. E score, guy's stone ccore and croes nomogram

ABSTRACT Objective: To compare the application time and the capacity of the nomograms to predict the success of Guy's Stone Score (GSS), S.T.O.N.E. Nephrolithometry (STONE) and Clinical Research Office of the Endourological Society nephrolithometric nomogram (CROES) of percutaneous nephrolithotomy (PCNL), evaluating the most efficient one for clinical use. Materials and Methods: We studied 48 patients who underwent PCNL by the same surgeon between 2010 and 2011. We calculated GSS, STONE and CROES based on pre-operative non-contrast computed tomography (CT) images and clinical data. A single observer, blinded to the outcomes, reviewed all images and assigned scores. We compared the application time of each nomogram. We used an analysis of variance for repeated measures and multiple comparisons by the Tukey test. We compared the area under the ROC curve (AUC) of the three nomograms two by two to determine the most predictive scoring system. Results: The immediate success rate was 66.7% and complications occurred in 16.7% of cases. The average operative time was 122 minutes. Mean application time was significantly lower for the GSS (27.5 seconds) when compared to 300.6 seconds for STONE and 213.4 seconds for CROES (p<0.001). There was no significant difference among the GSS (AUC=0.653), STONE (AUC=0.563) and CROES (AUC=0.641) in the ability to predict immediate success of PCNL. Conclusions: All three nomograms showed similar ability to predict success of PCNL, however the GSS was the quickest to be applied, what is an important issue for routine clinical use when counseling patients who are candidates to PCNL.

The challenge of cystine and struvite stone formers: clinical, metabolic and surgical assessment

ABSTRACT Purpose: To compare the clinical, metabolic, and calculi characteristics of cystine and struvite stone patients after percutaneous nephrolithotripsy (PCNL). Material and Methods: Between January/2006-July/2013, 11 cystine stone patients were treated in our clinic. Of those, 3 were excluded due to incomplete follow-up. Eight cystine stone patients (2 with bilateral disease; 10 renal units-RU) were considered for further analysis. A cohort of 8 struvite stone formers (10RU) was matched having the same age, gender, body mass index (BMI) and Guys stone score. Analyzed parameters comprised demographic data, serum/urinary metabolic evaluation and surgical outcomes. Results: Both groups had 6 female patients. Groups were similar in regards to age, gender, BMI, stone burden, and serum creatinine (p=NS). All patients had PCNL as the first surgical treatment modality. Stone free rate (SFR) after the first PCNL tended to be lower (0%) in the cystine compared to the struvite group (40%)(p=0.08). Final SFR after secondary procedures increased to 70% in cystine and 80% in struvite patients (p=1.0); mean number of procedures to achieve stone free status was higher in the first group (3.57 vs. 2.0;p=0.028). Hypocitraturia was found in all patients, but struvite cases presented with lower mean urinary citrate levels (p=0.016). Other common abnormalities were elevated urinary pH (cystine 75% and struvite 62.5%;p=1.0) and low urinary volume (62.5%,37.5%;p=0.63). Conclusion: Multiple interventions and suboptimal stone free rates are trait of the significant stone burden of struvite and cystine patients. Underlying metabolic abnormalities characterized by increased urinary pH, hypocitraturia and low urinary volume are often encountered in both populations.

Semi-rigid ureteroscopic lithotripsy versus laparoscopic ureterolithotomy for large upper ureteral stones: a meta - analysis of randomized controlled trials

ABSTRACT Introduction: To provide a systematic review and meta-analysis of randomized controlled trials (RCT) comparing semi-rigid ureteroscopic lithotripsy (URS) with laparoscopic ureterolithotomy (LU) for the treatment of the large proximal ureteral stone. Materials and methods: A systematic literature review was performed in June 2015 using the PubMed, Scopus, and Web of Science databases to identify relevant studies. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. Results: Six RCT including 646 patients were analyzed, 325 URS cases (50.3%) and 321 LU cases (49.7%). URS provided a significantly shorter operative time (weighted mean difference [WMD] = −31.26 min; 95%CI −46.88 to −15.64; p<0.0001) and length of hospital stay (WMD = −1.48 days; 95%CI −2.78 to −0.18; p=0.03) than LU. There were no significant differences in terms of overall complications (OR = 0.78; 95%CI 0.21-2.92; p=0.71) and major complications – Clavien ≥3 – (OR = 1.79; 95%CI 0.59-5.42; p=0.30). LU led to a significantly higher initial stone-free rate (OR = 8.65; 95%CI 4.18-17.91; p<0.00001) and final stone-free rate (OR = 6.41; 95%CI 2.24-18.32; p=0.0005) than URS. There was a significantly higher need for auxiliary procedures in URS cases (OR = 6.58; 95%CI 3.42-12.68; p<0.00001). Conclusions: Outcomes with LU for larger proximal ureteral calculi are favorable compared to semi-rigid URS and should be considered as a first-line alternative if flexible ureteroscopy is not available. Utilization of flexible ureteroscopy in conjunction with semi-rigid ureteroscopy may impact these outcomes, and deserves further systematic evaluation.

Specific training for LESS surgery results from a prospective study in the animal model

ABSTRACT Objective to prospectively evaluate the ability of post-graduate students enrolled in a laparoscopy program of the Institute for Teaching and Research to complete single port total nephrectomies. Materials and Methods 15 post-graduate students were enrolled in the study, which was performed using the SILStm port system for single-port procedures. All participants were already proficient in total nephrectomies in animal models and performed a left followed by a right nephrectomy. Analyzed data comprised incision size, complications, and the time taken to complete each part of the procedure. Statistical significance was set at p<0.05. Results All students successfully finished the procedure using the single-port system. A total of 30 nephrectomies were analyzed. Mean incision size was 3.61 cm, mean time to trocar insertion was 9.61 min and to dissect the renal hilum was 25.3 min. Mean time to dissect the kidney was 5.18 min and to complete the whole procedure was 39.4 min. Total renal hilum and operative time was 45.8% (p<0.001) and 38% (p=0.001) faster in the second procedure, respectively. Complications included 3 renal vein lesions, 2 kidney lacerations and 1 lesion of a lumbar artery. All were immediately identified and corrected laparoscopically through the single-port system, except for one renal vein lesion, which required the introduction an auxiliary laparoscopic port. Conclusion Laparoscopic single-port nephrectomy in the experimental animal model is a feasible but relatively difficult procedure for those with intermediate laparoscopic experience. Intraoperative complications might be successfully treated with the single-port system. Training aids reducing surgical time and improves outcomes.

Percutaneous nephrolithotomy in patients with solitary kidney: a critical outcome analysis

To describe our experience with percutaneous nephrolithotomy (PCNL) in patients with solitary kidneys and analyze factors that can impact on intra-operative bleeding and postoperative complications.

Predicting calyceal access for percutaneous nephrolithotomy with computed tomography multiplanar reconstruction

OBJECTIVES: Objective parameters in computed tomography (CT) scans that could predict calyceal access during percutaneous nephrolithotomy have not been evaluated. These parameters could improve access planning for percutaneous nephrolithotomy. We aimed to determine which parameters extracted from a preoperative multiplanar reconstructed CT could predict renal calyceal access during a percutaneous nephrolithotomy. METHODS: From January 2009 through April 2011, 230 patients underwent 284 percutaneous nephrolithotomies at our institution. Sixteen patients presented with complete staghorn calculi, and 11 patients (13 renal units) were analyzed. Five parameters were extracted from a preoperative reconstructed CT and compared with the surgical results of percutaneous nephrolithotomy. RESULTS: Fifty-eight calyces were studied, with an average of 4.4 calyces per procedure. A rigid nephroscope was used to access a particular calyx, and a univariate analysis showed that the entrance calyx had a smaller length (2.7 vs. 3.98 cm, p = 0.018). The particular calyx to be accessed should have a smaller length (2.22 vs. 3.19 cm, p = 0.012), larger angles (117.6 vs. 67.96, p<0.001) and larger infundibula (0.86 vs. 0.61 cm, p = 0.002). In the multivariate analysis, the only independent predictive factor for accessing a particular calyx was the angle between the entrance calyx and the calyx to be reached (OR 1.15, 95% confidence interval [CI], 1.053-1.256, p = 0.002). CONCLUSION: The angle between calyces obtained by multiplanar CT reconstruction is the only predictor of calyx access. .

Laparoscopic skill laboratory in urological surgery: tools and methods for resident training

PURPOSE: Laparoscopy has certainly brought considerable benefits to patients, but laparoscopic surgery requires a set of skills different from open surgery, and learning in the operating room may increase surgical time, and even may be harmful to patients. Several training programs have been developed to decrease these potential prejudices. PURPOSES: to describe the laparoscopic training program for urological residents of the "Hospital das Clinicas" of the Sao Paulo Medical School, to report urological procedures that are feasible in dry and wet labs, and to perform a critical analysis of the cost-benefit relation of advanced laparoscopic skills laboratory. MATERIALS AND METHODS: The laparoscopic skill lab has two virtual simulators, three manual simulators, and four laparoscopic sets for study with a porcine model. The urology residents during their first year attend classes in the virtual and manual simulator and helps the senior urological resident in activities carried out with the laparoscopic sets. During the second year, the urological resident has six periods per week, each period lasting four hours, to perform laparoscopic procedures with a porcine model. Results: In a training program of ten weeks, one urological resident performs an average of 120 urological procedures. The most common procedures are total nephrectomy (30 percent), bladder suture (30 percent), partial nephrectomy (10 percent), pyeloplasty (10 percent), ureteral replacement or transuretero anastomosis (10 percent), and others like adrenalectomy, prostatectomy, and retroperitoneoscopy. These procedures are much quicker and caused less morbidity. CONCLUSION: Laparoscopic skills laboratory is a good method for achieving technical ability.