An international delphi survey and consensus meeting to define the risk factors for ureteral stricture after endoscopic treatment for urolithiasis.

PURPOSE: Iatrogenic ureteral strictures (US) after endoscopic treatment for urolithiasis represent a significant healthcare concern. However, high-quality evidence on the risk factors associated with US is currently lacking. We aimed to develop a consensus statement addressing the definition, risk factors, and follow-up management of iatrogenic US after endoscopic treatment for urolithiasis. METHODS: Utilizing a modified Delphi method, a steering committee developed survey statements based on a systematic literature review. Then, a two-round online survey was submitted to 25 experts, offering voting options to assess agreement levels. A consensus panel meeting was held for unresolved statements. The predetermined consensus threshold was set at 70%. RESULTS: The steering committee formulated 73 statements. In the initial survey, consensus was reached on 56 (77%) statements. Following in-depth discussions and refinement of 17 (23%) statements in a consensus meeting, the second survey achieved consensus on 63 (86%) statements. This process underscored agreement on pivotal factors influencing US in endoscopic urolithiasis treatments. CONCLUSIONS: This study provides a comprehensive list of categorized risk factors for US following endoscopic urolithiasis treatments. The objectives include enhancing uniformity in research, minimizing redundancy in outcome assessments, and effectively addressing risk factors associated with US. These findings are crucial for designing future clinical trials and guiding endoscopic surgeons in mitigating the risk of US.

[Urinary diversion in old patients (80+ years)]. / Harnableitung beim alten Patienten (80+).

With increasing life expectancy there is also an increased need for the management of older (≥ 80 years) patients with the diagnosis of muscle-invasive bladder cancer. Radical cystectomy with urinary diversion is the state of the art treatment (with neoadjuvant chemotherapy, as long as the patient is fit enough). Choosing the best urinary diversion with respect to morbidity compared to functionality and quality of life remains a challenge in these patients. Physical age alone is not decisive for making a decision. A thorough preoperative assessment of medical features, physical and cognitive impairments is more important. Older patients are generally provided with an ileal conduit as an incontinent urinary diversion, as the intervention involves reduced operating times and complexity compared to continent urinary diversions; however, in the case of good health status with an adequate life expectancy and sufficient compliance, continent diversions may be considered even in aged candidates. In the case of multimorbid patients with a high perioperative risk, ureterostomy with permanent ureteric stents is an important alternative. Most importantly, a thorough preoperative counselling enables patients to reach an informed decision.

Ureteral stricture rate after endoscopic treatments for urolithiasis and related risk factors: systematic review and meta-analysis.

PURPOSE: We aimed to accurately determine ureteral stricture (US) rates following urolithiasis treatments and their related risk factors. METHODS: We conducted a systematic review and meta-analysis following the PRISMA guidelines using databases from inception to November 2023. Studies were deemed eligible for analysis if they included ≥ 18 years old patients with urinary lithiasis (Patients) who were subjected to endoscopic treatment (Intervention) with ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), or shock wave lithotripsy (SWL) (Comparator) to assess the incidence of US (Outcome) in prospective and retrospective studies (Study design). RESULTS: A total of 43 studies were included. The pooled US rate was 1.3% post-SWL and 2.1% post-PCNL. The pooled rate of US post-URS was 1.9% but raised to 2.7% considering the last five years' studies and 4.9% if the stone was impacted. Moreover, the pooled US rate differed if follow-ups were under or over six months. Patients with proximal ureteral stone, preoperative hydronephrosis, intraoperative ureteral perforation, and impacted stones showed higher US risk post-endoscopic intervention with odds ratio of 1.6 (P = 0.05), 2.6 (P = 0.009), 7.1 (P < 0.001), and 7.47 (P = 0.003), respectively. CONCLUSIONS: The overall US rate ranges from 0.3 to 4.9%, with an increasing trend in the last few years. It is influenced by type of treatment, stone location and impaction, preoperative hydronephrosis and intraoperative perforation. Future standardized reporting and prospective and more extended follow-up studies might contribute to a better understanding of US risks related to calculi treatment.

[Processing of medical products in the urological practice]. / Aufbereitung von Medizinprodukten in der urologischen Praxis.

The reprocessing of medical products is an important topic both in urological practices and in hospitals. The complexity is caused by the increasing variety of medical instruments and also by the increasing demands on the legally required quality of the reprocessing. The Robert Koch Institute (RKI) and the Federal Institute for Drugs and Medical Devices (BfArM) have published recommendations for the processing of MD and last updated them in 2012. This article summarizes the legal framework for the reprocessing of medical devices, how medical devices are categorized before the appropriate procedure for reprocessing can be selected and the various steps in the reprocessing. A special focus is placed on medical products that are typically found in urological practices or outpatient departments and are processed there. Furthermore, the necessity of validating the processing method and the required training (expertise) of the personnel are discussed.

[Safety and efficacy of en bloc vs. conventional transurethral resection of bladder tumors: a meta-analysis and systematic review]. / Sicherheit und Effizienz der en bloc vs. konventionellen transurethralen Resektion von Blasentumoren: eine Metaanalyse und systematic Review.

BACKGROUND: En bloc tumor resection of bladder tumors (ERBT) is a novel alternative procedure to conventional resection of bladder tumor (cTURBT), which might help to address common problems of the standard method, such as inadequate detrusor muscle in specimens, high re-resection rates and high recurrence rates. OBJECTIVE: To analyze current data on ERBT in efficacy and safety compared to cTURBT. DATA SOURCES: PubMed. STUDY SELECTION: Two independent authors identified trials based on keywords and inclusion criteria. A third author was consulted in case of discrepancies. Screening keywords: ERBT, en bloc transurethral resection of bladder tumor, TURBT en bloc. A meta-analysis of 13 studies was performed. The effect size was estimated based on odds ratios and mean differences including their corresponding two-sided 95% confidence intervals. DATA SYNTHESIS: The analyzed studies comprised a homogenous collective in terms of tumor size, tumor multiplicity and tumor stage. Operation time did not significantly differ between the methods. Differences were observed in hospitalization and catheterization time in favor of ERBT. Reported complications did not show clear differences. There was significantly more detrusor muscle in the specimens in the ERBT group. No significant differences were found in recurrence up to 2 years of follow-up. CONCLUSION: ERBT is a safe alternative to conventional TURBT with promising features regarding effective resection of detrusor muscle. More standardized data on recurrence rates, different resection modalities and resection margin results are needed.

[Transurethral resection of bladder tumors (TURBT)]. / Transurethrale Resektion von Blasentumoren (TUR-B).

Transurethral resection of bladder tumors (TURBT) is the standard of care for the diagnostics and primary treatment of bladder tumors. These are removed by fragmentation using loop diathermy. The resection area is coagulated for hemostasis. An important aspect is always a complete resection with an adequate amount of detrusor muscle in the specimen. Postoperative intravesical instillation of single-shot chemotherapy has been proven to reduce recurrence rates. Methods for improved tumor visualization (particularly photodynamic diagnostics) are used to enhance tumor detection rates particularly in multifocal tumors or carcinoma in situ (CIS). Thus, recurrence and progression rates can be reduced. Depending on the histological examination of the TURBT specimen, follow-up treatment for non-muscle invasive bladder tumors are adjuvant instillation treatment using chemotherapy or Bacillus Calmette-Guérin (BCG), second look TURBT and early cystectomy or for muscle invasive bladder tumors, radical cystectomy or (oncologically subordinate) trimodal treatment with renewed TURBT, radiotherapy and chemotherapy are indicated. Possible complications of TURBT include bleeding with bladder tamponade, extraperitoneal or intraperitoneal bladder perforation and infections of the urogenital tract.

Reasons to go for thulium-based anatomical endoscopic enucleation of the prostate.

PURPOSE: To summarize the current evidence and the reasons to go for thulium-based anatomical endoscopic enucleation of the prostate (AEEP). METHODS: This review discusses the available literature on thulium-based AEEP. RESULTS: Thulium lasers operate at a wavelength between 1940 and 2013 nm. This wavelength, which has a low penetration depth in water, allows to perform smooth cuts in the prostatic tissue and allows urologists to perform various procedures: resection, vaporization, enucleation, or vapoenucleation of the prostate. Depending on the type of thulium laser, it can be used either in a continuous, or pulsed mode. CONCLUSION: In recent years, an increasing amount of evidence has described the thulium laser as a minimally invasive and size-independent treatment option for benign prostatic enlargement with excellent long-term results.

Endoscopic enucleation of the prostate (EEP). The same but different-a systematic review.

PURPOSE: Various techniques for EEP exist. They differ by surgical steps and the source of energy. It is assumed that the latter is of minor importance, whereas adherence to the anatomical enucleation template determines the postoperative result. So far, no systematic review highlights the differences between the energy sources in use for anatomical EEP. This study will address selfsame topic. METHODS: A systematic review of the literature was completed on September 1st, 2020. Studies comparing HoLEP, ThuLEP, DiLEP, or BipolEP with TUR-P providing 12 months of postoperative follow-up were included. Two frequentist network meta-analyses were created to compare the techniques of EEP indirectly. RESULTS: 31 studies, including 4466 patients, were found eligible for our meta-analysis. Indirect pairwise comparison showed differences in surgery time between BipolEP and HolEP (MD - 16.72 min., 95% CI - 27.75 to - 5.69) and DiLEP and HoLEP (MD - 22.41 min., 95% CI - 39.43 to - 5.39). No differences in the amount of resected prostatic tissue, major and minor complications and postoperative catheterization time were found. The odds for blood transfusions were threefold higher for BipolEP than for HoLEP (OR 3.27, 95% CI 1.02-10.5). The difference was not statistically significant when comparing prospective trials and matched-pair analysis only (OR 3.25, 95% CI 0.94-11.18). The Qmax 12 months after surgery was 2 ml/sec. higher for BipolEP than for DiLEP (MD 2.00, 95% CI 0.17-3.84) and 1.94 ml/sec. lower for DiLEP than for HoLEP (MD - 1.94, 95% CI - 3.65 to - 0.22). CONCLUSION: The energy source used for EEP has an impact on the intervention itself. BipolEP promotes surgical efficiency; laser techniques lower the risk of bleeding. REGISTRY: This meta-analysis is registered in the PROSPERO international prospective register registry with the registration number CRD42020205836.

Recent evidence for anatomic endoscopic enucleation of the prostate (AEEP) in patients with benign prostatic obstruction on antiplatelet or anticoagulant therapy.

INTRODUCTION: Due to demographic changes in today's society, the number of patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) is increasing. Similarly, the proportion of patients with cardiovascular risk factors undergoing antiplatelet (AP) or anticoagulation (AC) therapy is growing as well. METHODS: This review discusses the current literature on various techniques used for anatomic endoscopic enucleation of the prostate (AEEP) in patients on AC/AP therapy. RESULTS: The large number of energy sources used for AEEP makes it difficult to compare them. Overall, fewer bleeding-associated complications arise in patients under AP compared to AC or bridging therapy with low molecular weight heparin. However, perioperatively both AP and AC therapy lead to a higher risk of bleeding complications compared to patients not taking anticoagulants. CONCLUSIONS: The literature shows that AEEP is possible and efficacious in patients under AC/AP therapy, with only slight differences compared to patients not taking AC/AP drugs, on a short and long-term basis. Nevertheless, the sparse data, the retrospective nature of many studies and the inclusion of prostate sizes between 50 and 110 ml only, make it difficult to come to strong conclusions.

[Urological infections and antibiotic management in geriatric patients]. / Urologische Infektionen und Antibiotikamanagement bei geriatrischen Patienten.

Both the demographic shift and progress in medicine are resulting in an increasingly longer life expectancy. It is presumed that a mean age of 90 years will be achieved within the next decade in many countries. Thus, geriatric medicine, which is committed to the specific needs of older, often frail and frequently comorbid patients, is becoming increasingly more important. The prevalence of infections of the genitourinary tract increases with age, simultaneously, a critical and conscious use of antibiotics is required in terms of antimicrobial treatment. The intention of the present review is to make the reader aware of the specific characteristics of urinary tract infections and asymptomatic bacteriuria in the older patient population in terms of epidemiology, spectrum of pathogens and resistance as well as the indications for and performance of antimicrobial treatment.

[Surgical treatment of benign prostatic hyperplasia-resection, vaporization or enucleation?] / Operative Therapie des benignen Prostatasyndroms ­ resezieren, vaporisieren oder enukleieren?

BACKGROUND: Benign prostatic hyperplasia (BPH) is the most common condition affecting the male lower urinary tract. Besides transurethral resection of the prostate (TURP), vaporization of the prostate and endoscopic enucleation of the prostate are available. OBJECTIVES: To provide an overview of the current status of surgical therapies for BPH. MATERIALS AND METHODS: Narrative review of the literature on the surgical treatment of BPH. RESULTS: Besides TURP, which still can be regarded as the reference technique for surgical treatment of BPH in men with a prostate volume <80 cc, greenlight laser vaporization of the prostate (GLV) and endoscopic enucleation of the prostate (EEP) are established and evidence-based alternatives. A multitude of prospective randomized trials could show comparable functional outcomes of GLV or EEP in comparison to TURP. Based on lower comorbidity and comparable outcomes, bipolar TURP rather than monopolar TURP should be regarded as the surgical reference technique. In patients with ongoing oral anticoagulation of thrombocyte aggregation inhibition, GLV provides high intra- und postoperative safety. Endoscopic enucleation of the prostate is the only transurethral surgical method which provides high level evidence concerning safety and efficacy in patients with prostates >80 cc. CONCLUSIONS: Choice of surgical treatment of BPH should be individualized and based on prostate size, comorbidities and surgical experience.

[Endoscopic enucleation of the prostate]. / Endoskopische Enukleation der Prostata.

The spectrum of surgical procedures for the minimally invasive treatment of benign prostatic hyperplasia (BPH) has significantly increased over the last two decades. The simple suprapubic prostatectomy (subtotal prostatectomy, SP) has largely lost relevance in current practice. On the other hand, transurethral resection of the prostate (TURP) has been further standardized and potentially made safer by the introduction of the bipolar technique and low-pressure systems.Transurethral (endoscopic) enucleation techniques (endoscopic enucleation of the prostate, EEP) are increasingly competing with the current gold standard TURP and are replacing SP for treatment of larger adenomas. This approach is especially related to the rapid development of laser technology, which has sustainably changed the face of modern BPH treatment in a similar way to stone therapy. This has been incorporated in the clinical patient management, clinical studies and standardization of numerous surgical techniques that are systematically described in this article. Additionally, efforts have also been made to use other energy sources, such as bipolar current in EEP. With respect to scientific objectivity, high-quality clinical trials are regularly published which further strengthen the position of EEP.

Aquablation of the prostate: single-center results of a non-selected, consecutive patient cohort.

PURPOSE: Aquablation of the prostate using the AquaBeam™ system promises equivalent functional outcomes, reduced learning curve, and improved sexual function compared to transurethral prostate resection as shown in prospective randomized trials. This prospective cohort study aims to evaluate if published results can be transferred into the clinical routine in a non-selected patient collective. METHODS: This study includes all patients treated between September 2017 and June 2018 with Aquablation of the prostate. Patients have been evaluated prospectively for the perioperative course and early follow-up. Besides voiding parameter and symptom score, TRUS-volume change, ejaculatory function, and adverse events have been recorded. RESULTS: 118 consecutive patients have been treated in the given time. Aquablation could be carried out successfully in all patients. IPSS, QoL, Qmax, and PVR improved significantly after the procedure and continued to improve during 3-month follow-up. Mean OR time was 20 min, TRUS volume decreased by 65%, and 73% of the patients retained antegrade ejaculation. Thirteen adverse events (> Clavien-Dindo I) occurred in 10 patients. CONCLUSION: The surgical ablation of the prostate using Aquablation achieved significant and immediate improvement of functional voiding parameters Qmax and PVR as well as symptomatic improvement of IPSS and QoL. Aquablation seems to be safe and effective with a low perioperative complication profile even in a non-selected group of patients.

Thulium vapoenucleation of the prostate versus holmium laser enucleation of the prostate for the treatment of large volume prostates: preliminary 6-month safety and efficacy results of a prospective randomized trial.

PURPOSE: We compared the perioperative and postoperative characteristics of thulium vapoenucleation and holmium laser enucleation of the prostate for the treatment of large volume benign prostatic hyperplasia. MATERIALS AND METHODS: A total of 94 patients with benign prostatic hyperplasia and a median prostate size of 80 (IQR 46.75-100) cc were either randomized to thulium vapoenucleation or holmium laser enucleation of the prostate. Patients were assessed preoperatively, 1 and 6 months postoperatively. RESULTS: The median operative time was 60 (IQR 41-79) min without significant differences between the groups. There were no significant differences between the groups regarding catheter time [2 (IQR 2-2) days] and postoperative stay [2 (IQR 2-3) days]. Clavien 1 (13.8%), 2 (3.2%), 3a (2.1%), and Clavien 3b (4.3%) complications occurred without significant differences between the groups. At 6-month follow-up, median maximum flow rate (10.7 vs. 25.9 ml/s), post-void residual urine (100 vs. 6.5 ml), I-PSS (20 vs. 5), quality of life (4 vs. 1), PSA (4.14 vs. 0.71 µg/l), and prostate volume (80 vs. 16 ml) had improved significantly (p < 0.001) compared to baseline without significant differences between the groups. Median PSA decrease was 79.7% (58.8-90.6%) and prostate volume reduction was 74.5% (68.57-87.63%) without differences between the groups. The reoperation rate was zero at 6-month follow-up. CONCLUSIONS: Thulium vapoenucleation and holmium laser enucleation of the prostate are safe and effective procedures for the treatment of large volume benign prostatic hyperplasia. Both procedures give satisfactory micturition improvement with low morbidity and sufficient prostate volume reduction at 6-month follow-up.

[En bloc resection and vaporization techniques for the treatment of bladder cancer]. / En-bloc-Resektion und Vaporisation von Harnblasenkarzinomen.

BACKGROUND: Modifications in resection techniques may overcome obvious limitations of conventionally performed transurethral resection (e. g., tumor fragmentation) of bladder tumors or provide an easier patient treatment algorithm (e. g., tumor vaporization). OBJECTIVES: The present review article summarizes the current literature in terms of en bloc resection techniques, histopathological quality, complication rates, and oncological outcomes. MATERIALS AND METHODS: A separate data search was performed for en bloc resection (ERBT, n = 27) and vaporization (n = 15) of bladder tumors. RESULTS: In most cases, ERBT is performed in a circumferential fashion. Alternatively, ERBT may be performed by undermining the tumor base via antegrade application of short energy impulses. Based on high rates of detrusor in specimens of ERBT (90-100%), a better histopathological quality is assumed. Significant differences in perioperative complication rates have not been observed, although obturator-nerve-based bladder perforations are not seen when laser energy is used. There is a nonstatistically significant trend towards lower recurrence rates in ERBT groups. Tumor vaporization may provide a less invasive technique for older patients with recurrences of low-risk bladder cancer. It can be performed in an outpatient setting. CONCLUSIONS: ERBT may provide better histopathological quality. Tumor vaporization is performed in health care systems where reimbursement is adequate.

[Extracorporeal shock wave lithotripsy]. / Extrakorporale Stoßwellenlithotripsie.

Interventional treatment of stones essentially consists of three treatment modalities. Extracorporeal shockwave lithotripsy (ESWL), in addition to uterorenoscopy (URS) and percutaneous nephrolitholapaxy (PCNL) is an essential treatment pillar and is the only noninvasive therapy option for the treatment of urinary stones. After a long period of ESWL being the leading choice in stone treatment, the number of SWL interventions diminished in recent years in favor of the other two treatment modalities (URS and PCNL). This article describes the indications, surgical technique and management of complications of SWL.

[Surgical positioning techniques in urology : Tips and tricks]. / Lagerungstechniken in der Urologie : Tipps und Tricks.

Correct positioning of patients during preoperative preparations is essential for success of the intervention to avoid any positioning trauma and to provide the best access to the targeted structures. The appropriate positioning (and optimal performance) means that complications are avoided and also makes an essential contribution to the smooth course of the surgical intervention. A correct position is essential particularly in urology because the organs assigned to the discipline of urology are anatomically mostly difficult to reach. A further important function of the correct positioning technique is the avoidance of injuries to the patient. This article summarizes the most common positioning techniques in urological interventions with special emphasis on the explanation of practical advice, helpful tips and possible complications that can enable even junior surgeons to correctly perform the appropriate positioning technique.

Implementation of minimally invasive percutaneous nephrolithotomy (MIP): comparison of the initial learning curve with the later on clinical routine in a tertiary centre.

OBJECTIVE: We report on the comparison of clinical results of the early phase of implementation of minimally invasive PNL (MIP) in a mentor-based approach with the later on clinical routine in a tertiary centre. PATIENTS AND METHODS: From January 2010 until January 2015 MIP was performed in 190 patients. Stone and patient characteristics were recorded in prospective manner. Perioperative complications were recorded within the Clavien-Classification. The first 120 consecutive patients undergoing MIP were evaluated and divided into three groups of 40 patients each. Mentor-based introduction of MIP was done within the first 40 patients (group A). Further patients were treated on routine clinical practice basis (group B and C). Treatment outcome was compared within the three groups. RESULTS: The groups did not significantly differ with regard to patient characteristics, operation time and decline in haemoglobin. In the mentor-based series mean stone size was 21.7 ± 12.6 vs. 15.6 ± 7.9 and 16.1 ± 8.4 mm in group B and C (p = 0.033). Primary stone-free rates were 65, 87.5 and 87.5% for the three groups (p = 0.015). Stone-free rate was higher in smaller and simple stones. Overall, complication rate was 41.7% including 36.7% Clavien grade I and II complications. CONCLUSIONS: MIP can be implemented safe and effectively with mentor-based approach. MIP has a high safety profile, which allows high safety and efficacy of MIP at the time of implementation.