Robot-assisted simple prostatectomy for treatment of large prostatic adenomas: surgical technique and outcomes from a high-volume robotic centre.

PURPOSE: Aim of the present study is to describe our robot-assisted simple prostatectomy technique and to report 6-month surgical and clinical outcomes. METHODS: Eighty men were consecutively submitted to robot-assisted simple prostatectomy in our institution from October 2019 to October 2020. All procedures were performed by the same surgical team. Diagnostic preoperative assessment was based on history, symptoms evaluation by International Prostate Symptom Score, digital rectal examination, flowmetry with post-void residual volume measurement by abdominal ultrasound, prostatic volume estimation by MRI, PSA dosage. Under combined general and subarachnoid anesthesia, surgery was performed via a transperitoneal approach using a Da Vinci Si system in the four-arm configuration. Operative time, blood loss, hospital stay, catheterization time, intraoperative and postoperative complications were assessed. Clinical postoperative 6 months of evaluation was based on physical examination, flowmetry with post-void residual volume measurement, PSA dosage, and International Prostate Symptom Score. RESULTS: Mean operative time was 105.29 min, mean hospital staying 5.4 days. Blood loss was low in all cases and only 2 patients received transfusion. Catheterization time was 7 days. According to the Clavien-Dindo classification, only minor (grade I and grade II) intraoperative and postoperative complications were observed. At 6-month postoperative assessment, a statistically significant increase of urinary flow indexes and bladder capacity was recorded, as a significant reduction of urinary residual volume. No patient experienced stress urinary incontinence and the mean postoperative IPSS score was significantly reduced to 4.3. Two patients were diagnosed with incidental prostatic cancer at the histopathological examination. CONCLUSIONS: Data collected in our experience on a large cohort confirm efficacy and safety of Robot-Assisted Simple Prostatectomy. This procedure allows both short operative time and hospital staying, with low incidence of perioperative complications. This surgical technique can therefore be considered a valid alternative to other procedures for the surgical treatment of large volume prostates. Randomized prospective and comparative studies are warranted in the future to assess if different RASP techniques provide similar surgical and functional outcomes.

Patients' perceptions of quality of care delivery by urology residents: A nationwide study.

OBJECTIVE: To present the results of a nationwide survey among urological patients to evaluate their perception of the quality of care provided by residents. METHODS: An anonymous survey was distributed to patients who were referred to 22 Italian academic institutions. The survey aimed to investigate the professional figure of the urology resident as perceived by the patient. RESULTS: A total of 2587 patients were enrolled in this study. In all, 51.6% of patients were able to correctly identify a urology resident; however, almost 40% of respondents discriminated residents from fully trained urologists based exclusively on their young age. Overall, 98.2% patients rated the service provided by the resident as at least sufficient. Urology trainees were considered by more than 50% of the patients interviewed to have good communication skills, expertise and willingness. Overall, patients showed an excellent willingness to be managed by urology residents. The percentage of patients not available for this purpose showed an increasing trend that directly correlated with the difficulty of the procedure. Approximately 5-10% of patients were not willing to be managed by residents for simple procedures such as clinical visits, cystoscopy or sonography, and up to a third of patients were not prepared to undergo any surgical procedure performed by residents during steps in major surgery, even if the residents were adequately tutored. CONCLUSIONS: Our data showed that patients have a good willingness to be managed by residents during their training, especially for medium- to low-difficulty procedures. Furthermore, the majority of patients interviewed rated the residents' care delivery as sufficient. Urology trainees were considered to have good communication skills, expertise and willingness.

Current status of urology surgical training in Europe: an ESRU-ESU-ESUT collaborative study.

PURPOSE: To determine the current status of surgical training amongst European Urology Residents, including their satisfaction with training and their confidence in performing procedures. METHODS: A 23-item survey was distributed to the 15th European Urology Residents Education Programme (EUREP) 2017 participants. An analysis of demographics, workload, training resources, surgical exposure, surgical caseload, satisfaction and confidence in performing each procedure was performed. RESULTS: A total of 152/350 participants completed the survey (response rate 43%), of which 14% think they perform enough surgeries during their training, and 83% would like to continue training with a fellowship. Confidence in performing procedures without supervision and satisfaction with training was associated with higher surgical caseloads. Confidence in all laparoscopic/robotic procedures (except for laparoscopic/robotic partial nephrectomy) was associated with laparoscopic and robotics training, participation in practical courses and having training resources in hospitals. Satisfaction with surgical training was statistically associated with working ≤  50 h per week, laparoscopic training and having laparoscopic training boxes. CONCLUSIONS: Surgical exposure of European Urology residents for major/minimally invasive procedures, confidence in performing these procedures, and overall satisfaction with training is low. A higher volume of cases, as well as resources for training are associated with higher individual confidence and satisfaction with training.

Unusual case of infectious endocarditis in a patient subjected to transurethral resection of the prostate (TURP) without cardiovascular risk factors. / Endocarditis en un paciente sujeto a RTU de próstata sin factores de riesgo cardiovascular.

OBJECTIVE: Transurethral resection of the prostate (TURP) is the gold standard for the treatment of obstructive prostatic hyperplasia. A bacteremia leading to infectious endocarditis (IE) can be the result of urological procedures. IE post TURP is rare. METHODS: We report an unusual case of an infectious endocarditis complicating TURP for benign prostatic hyperplasiain absence of known previous cardiovascular risk factors or conditions. RESULTS AND CONCLUSIONS: The patient developed intermittent episodes of fever lasting more than two months starting 3 weeks from hospital discharge, and he was never referred to the hospital by his general practitioner, until he was evaluated by his Surgeon, admitted to the Emergency Department and diagnosed with infectious endocarditis, later dying for cardiac arrest before getting a cardiac valve replacement. This report aims to be a reminder of how invasive procedures can trigger secondary distant complications that should be taken into account while assessing a post-operative patient.

OBJETIVO: La resección transuretral de próstata es el gold estándar en el tratamiento de la hiperplasia benigna de próstata. Una bacteriemia que comporta endocarditis infecciosa (EI) puede ser como resultado de procedimientos urológicos. La EI post RTU próstata es rara. METODOS: Describimos un caso inusual de endocarditis infecciosa complicada post RTU de próstata por hiperplasia benigna de próstata en ausencia de factores de riesgo cardiovascular conocidos u otras patológicas. RESULTADOS Y CONCLUSIONES: El paciente desarrolló episodios intermitentes de fiebre por más de 2 meses iniciándose a las 3 semanas del alta hospitalaria. El paciente nunca fué mandado al hospital por el medico de familia hasta que fue evaluado por su cirujano, ingresado en el servicio de urgencias y diagnosticado de endocarditis infecciosa. Finalmente murió de parada cardiorespiratoria antes de someterse a cirugía de sustitución valvular. Este caso pretende recordar lo invasivo que es el procedimiento y que puede desencadenar complicaciones secundarias que deben tenerse en consideración en el contexto postoperatorio del paciente.

Exploratory analysis on the usage of Pi-score algorithm over endoscopic stone treatment step 1 protocol.

BACKGROUND: The Performance Improvement score (Pi-score) has been proven to be reliable to measure performance improvement during E-BLUS hands-on training sessions. Our study is aimed to adapt and test the score to EST s1 (Endoscopic Stone Treatment step 1) protocol, in consideration of its worldwide adoption for practical training. METHODS: The Pi-score algorithm considers time measurement and number of errors from two different repetitions (first and fifth) of the same training task and compares them to the relative task goals, to produce an objective score. Data were obtained from the first edition of 'ART in Flexible Course', during four courses in Barcelona and Milan. Collected data were independently analyzed by the experts for Pi assessment. Their scores were compared for inter-rater reliability. The average scores from all tutors were then compared to the PI-score provided by our algorithm for each participant, in order to verify their statistical correlation. Kappa statistics were used for comparison analysis. RESULTS: Sixteen hands-on training expert tutors and 47 3rd-year residents in Urology were involved. Concordance found between the 16 proctors' scores was the following: Task 1=0.30 ("fair"); Task 2=0.18 ("slight"); Task 3=0.10 ("slight"); Task 4=0.20, ("slight"). Concordance between Pi-score results and proctor average scores per-participant was the following: Task 1=0.74 ("substantial"); Task 2=0.71 ("substantial"); Task 3=0.46 ("moderate"); Task 4=0.49 ("moderate"). CONCLUSIONS: Our exploratory study demonstrates that Pi-score can be effectively adapted to EST s1. Our algorithm successfully provided an objective score that equals the average performance improvement scores assigned by of a cohort of experts, in relation to a small amount of training attempts.

Current status of urological training in Europe.

Modern urological training has changed drastically in the past years, due to the global surgical training trends, advances in technology, subspecialization of the field and, working hour regulations for doctors. The lack of a standardized curriculum across Europe, puts in evidence the great difference in the requirements in every country, from the start of the residency, to obtaining the accreditation. We sought to identify problems related to medical, scientific and surgical activity during urological training, and summarize data obtained from surveys realized during the European Urology Residents Education Programme (EUREP) in 2013, and from countries such as Germany, Italy and Spain. Data from surveys reveals an evident lack of surgical confidence across all participants for major procedures, a general non-compliance with the working hour regulations, and a worrisome risk for burnout and negative consequences in resident's personal lives. Possible solutions are discussed, involving an early preference for a particular practice, and a standardized simulation-based training. The European Association of Urology (EAU) and the European School of Urology (ESU) offer a wide range of working groups, educational and scientific activities for improving the acquisition of competencies (surgical and scientific) of residents and urologists at any point of their career. We describe a brief description of the most important EAU and ESU opportunities.

Perceived Role of Social Media in Urologic Knowledge Acquisition Among Young Urologists: A European Survey.

BACKGROUND: Social media (SoMe) are increasingly being integrated into personal and professional life, with urology being a leading medical specialty in SoMe adoption. OBJECTIVE: We aimed to assess the perceived role of SoMe in urologic knowledge acquisition among young urologists across Europe. DESIGN, SETTING, AND PARTICIPANTS: Members of the European Society of Residents in Urology designed a 20-item online survey via surveymonkey.com. The survey was designed in accordance with Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines and was distributed via e-mail and social media in 23 European countries to urology residents and young urologists. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Statistical Package for the Social Sciences (SPSS) software was used for descriptive statistics and statistical analysis. For comparative analysis the Mann-Whitney U test was used. RESULTS AND LIMITATIONS: A total of 316 young urologists with a mean age of 31.2±3.9 yr responded to the survey. Of the respondents, 99% use SoMe in a personal and/or professional way. YouTube and LinkedIn are the most frequently used platforms for professional use. SoMe were ranked in third place as an information source for urologic news/updates, lying behind journals and websites but ahead of congresses and books. Video content from YouTube or other sources was ranked as a preferred tool to see/understand surgical techniques ahead of websites and reference books. 61% follow urologic associations, 47% follow urologic events, 44% follow urologic journals, and 39% follow urologic experts on SoMe. The perceived influence of SoMe on urology knowledge was rated as moderate to high by 63% and as low to none by 37% of young urologists. Of the respondents, 44% apply guidelines on the appropriate use of SoMe in urology. CONCLUSIONS: SoMe play a significant role in knowledge acquisition by young urologists in Europe. Physicians, organizations, and institutions should strive to spread and provide valuable educational content through SoMe. PATIENT SUMMARY: Social media can be valuable for education in urology because it is useful to keep abreast of new developments in this field of medicine.

Urology Residency Training in Italy: Results of the First National Survey.

BACKGROUND: Numerous surveys have been performed to determine the competence and the confidence of residents. However, there is no data available on the condition of Italian residents in urology. OBJECTIVE: To investigate the status of training among Italian residents in urology regarding scientific activity and surgical exposure. DESIGN, SETTING, AND PARTICIPANTS: A web-based survey that included 445 residents from all of the 25 Italian Residency Programmes was conducted between September 2015 and November 2015. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The main outcomes were represented by scientific activity, involvement in surgical procedures, and overall satisfaction. RESULTS AND LIMITATIONS: In total, 324 out of 445 (72.8%) residents completed the survey. Overall, 104 (32%) residents had not published any scientific manuscripts, 148 (46%) published ≤5, 38 (12%) ≤10, 26 (8%) ≤15, four (1%) ≤20, and four (1%) >20 manuscripts, respectively. We did not observe any differences when residents were stratified by sex (p=0.5). Stent positioning (45.7%), extracorporeal shock wave lithotripsy (30.9%), transurethral resection of bladder tumor (33.0%), hydrocelectomy (24.7%), varicocelectomy (17%), ureterolithotripsy (14.5%), and orchiectomy (12.3%) were the surgical procedures more frequently performed by residents. Overall, 272 residents (84%) expressed a good satisfaction for urology specialty, while 178 (54.9%) expressed a good satisfaction for their own residency programme. We observed a statistically decreased trend for good satisfaction for urology specialty according to the postgraduate year (p=0.02). CONCLUSIONS: Italian Urology Residency Programmes feature some heavy limitations regarding scientific activity and surgical exposure. Nonetheless, satisfaction rate for urology specialty remains high. Further improvements in Residency Programmes should be made in order to align our schools to others that are actually more challenging. PATIENT SUMMARY: In this web-based survey, Italian residents in urology showed limited scientific productivity and low involvement in surgical procedures. Satisfaction for urology specialty remains high, demonstrating continuous interest in this field of study from residents.

Nonmuscular Invasive Urothelial Carcinoma of the Bladder in Pediatric and Young Adult Patients: Age-related Outcomes.

OBJECTIVE: To report 2 pediatric urology referral centers' experience on transitional cell carcinoma of the bladder (TCCB) in patients younger than 30 years, focusing on age-related prognostic factors. MATERIALS AND METHODS: Patients younger than 30 years affected by TCCB from January 1999 to December 2011 were investigated. Spearman's rank test and Kruskal-Wallis test were adopted for statistical analysis. RESULTS: Eighteen patients were identified (8 females, 10 males) and stratified by age at presentation: 5 in group A (12 years old and younger), 7 in group B (13-19 years), and 6 in group C (20-29 years). Females were predominant in groups A and B, whereas males were predominant in group C. Pathological grading revealed low-grade papillary urothelial carcinoma in 7, papillary urothelial neoplasm of low malignant potential in 7, and high-grade urothelial papillary carcinoma in 4 patients. At a mean follow-up of 6.5 years, recurrence was observed in 2 cases. Statistical analysis showed a positive correlation between age and grading. There was no statistical significance based on gender. Staging was significant between the age groups; older patients had more advanced tumors. CONCLUSION: TCCB is rarely observed in the first 3 decades of life. The prognosis is good in early-age presentation. Sex distribution, pathological grading, and prognosis were found different according to age. Patients younger than 19 years behave in a more favorable manner than those older, and should be followed up like adults.

Robotic assisted laparoscopic radical prostatectomy following transrectal compared to transperineal prostate biopsy: surgical, oncological and functional outcomes.

BACKGROUND: To assess if transperineal prostate (TP) biopsy affects th e outcome of robotic-assisted laparoscopic prostatectomy (RALP), with particular reference to perioperative complications, oncological results and functional outcomes in the early postoperative setting. METHODS: We identified 61 men who had undergone RALP after TP biopsies, from June 2012 to June 2014 and a control group of 120 men who had undergone RALP after conventional TRUS biopsy in the same period. Data was compared from the pre-operative biopsy, peri- and postoperative period, procedural outcomes including histological, oncological and functional outcomes between the groups. RESULTS: The groups had comparable demographics, with matched median ages and PSA levels. There was a higher incidence of Gleason 6 disease detected in the TRUS group (P=0.01). Mean operative time (146 minutes TRUS vs. 158 minutes TP, P=0.133), blood loss (250 mL TRUS vs. 288 mL TP, P=0.462) and intraoperative complications were not significantly different between groups. Median length of stay (1 day) and median catheter duration (7 days) were identical in both cohorts. PSA failure rate at 6 months was similar (11.7% TRUS vs. 9.8% TP, P=0.904). There were no differences in functional outcomes (potency or continence) between groups at 6 month s follow-up. CONCLUSIONS: RALP is safe after TP biopsy with no adverse impact on oncological or short-term functional outcomes.

Magnetic Resonance and Ultrasound Image Fusion Supported Transperineal Prostate Biopsy Using the Ginsburg Protocol: Technique, Learning Points, and Biopsy Results.

BACKGROUND: Prostate biopsy supported by transperineal image fusion has recently been developed as a new method to the improve accuracy of prostate cancer detection. OBJECTIVE: To describe the Ginsburg protocol for transperineal prostate biopsy supported by multiparametric magnetic resonance imaging (mpMRI) and transrectal ultrasound (TRUS) image fusion, provide learning points for its application, and report biopsy results. The article is supplemented by a Surgery in Motion video. DESIGN, SETTING, AND PARTICIPANTS: This single-centre retrospective outcome study included 534 patients from March 2012 to October 2015. A total of 107 had no previous prostate biopsy, 295 had benign TRUS-guided biopsies, and 159 were on active surveillance for low-risk cancer. SURGICAL PROCEDURE: A Likert scale reported mpMRI for suspicion of cancer from 1 (no suspicion) to 5 (cancer highly likely). Transperineal biopsies were obtained under general anaesthesia using BiopSee fusion software (Medcom, Darmstadt, Germany). All patients had systematic biopsies, two cores from each of 12 anatomic sectors. Likert 3-5 lesions were targeted with a further two cores per lesion. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Any cancer and Gleason score 7-10 cancer on biopsy were noted. Descriptive statistics and positive predictive values (PPVs) and negative predictive values (NPVs) were calculated. RESULTS AND LIMITATIONS: The detection rate of Gleason score 7-10 cancer was similar across clinical groups. Likert scale 3-5 MRI lesions were reported in 378 (71%) of the patients. Cancer was detected in 249 (66%) and Gleason score 7-10 cancer was noted in 157 (42%) of these patients. PPV for detecting 7-10 cancer was 0.15 for Likert score 3, 0.43 for score 4, and 0.63 for score 5. NPV of Likert 1-2 findings was 0.87 for Gleason score 7-10 and 0.97 for Gleason score ≥4+3=7 cancer. Limitations include lack of data on complications. CONCLUSIONS: Transperineal prostate biopsy supported by MRI/TRUS image fusion using the Ginsburg protocol yielded high detection rates of Gleason score 7-10 cancer. Because the NPV for excluding Gleason score 7-10 cancer was very high, prostate biopsies may not be needed for all men with elevated prostate-specific antigen values and nonsuspicious mpMRI. PATIENT SUMMARY: We present our technique to sample (biopsy) the prostate by the transperineal route (the area between the scrotum and the anus) to detect prostate cancer using a fusion of magnetic resonance and ultrasound images to guide the sampling.

Current status of urological training in Europe / Estado actual de la formación urológica en Europa

Modern urological training has changed drastically in the past years, due to the global surgical training trends, advances in technology, subspecialization of the field and, working hour regulations for doctors. The lack of a standardized curriculum across Europe, puts in evidence the great difference in the requirements in every country, from the start of the residency, to obtaining the accreditation. We sought to identify problems related to medical, scientific and surgical activity during urological training, and summarize data obtained from surveys realized during the European Urology Residents Education Programme (EUREP) in 2013, and from countries such as Germany, Italy and Spain. Data from surveys reveals an evident lack of surgical confidence across all participants for major procedures, a general non-compliance with the working hour regulations, and a worrisome risk for burnout and negative consequences in resident’s personal lives. Possible solutions are discussed, involving an early preference for a particular practice, and a standardized simulation-based training. The European Association of Urology (EAU) and the European School of Urology (ESU) offer a wide range of working groups, educational and scientific activities for improving the acquisition of competencies (surgical and scientific) of residents and urologists at any point of their career. We describe a brief description of the most important EAU and ESU opportunities (AU)

El entrenamiento de los residentes en urología ha sufrido cambios dramáticos en los últimos años, principalmente debido a los cambios globales en la enseñanza quirúrgica, a los avances en tecnología, a la subespecilización de la urología, y a las regulaciones de horas de trabajo para médicos. La falta de un curriculum estandarizado en Europa, pone en manifiesto las diferencias entre cada país, desde el momento de acceder a una plaza de formación hasta obtener la certificación como urólogo. Buscamos identificar los problemas relacionados con la formación médica, científica y quirúrgica, y resumir la información obtenida en encuestas durante el European Urology Residents Education Programme (EUREP) de 2013 y de países como Alemania, Italia, y España. La información de las encuestas nos revela una carencia en la confianza de realizar procedimientos quirúrgicos mayores, un incumplimiento general de las regulaciones de horarios de trabajo, y un preocupante riesgo de "burnout" y de consecuencias negativas en la vida personal de los residentes. Se discuten posibles soluciones, que involucran las preferencias en la práctica urológica personal, y el aprendizaje estandarizado con simulación. La Asociación Europea de Urología (EAU) y la Escuela Europea de Urología (ESU) ofrecen una amplia gama de grupos de trabajo, y actividades educativas y científicas para aumentar el nivel de las competencias (quirúrgicas y científicas) de residentes y urólogos en cualquier punto de su carrera. Describimos brevemente las oportunidades formativas más destacadas de la EAU y la ESU (AU)