Retrograde intrarenal surgery for asymptomatic incidental renal stones: a retrospective, real-world data analysis.

OBJECTIVE: To determine surgical outcomes and stone-free rates (SFRs) when offering upfront retrograde intrarenal surgery (RIRS) to patients with asymptomatic incidental renal stones (AIRS), as active surveillance, shockwave lithotripsy or upfront intervention in patients with AIRS is still a debate among urologists. PATIENTS AND METHODS: This retrospective FLEXible Ureteroscopy Outcomes Registry (FLEXOR), supported by the Team of Worldwide Endourological Researchers (TOWER), examines adult patients who underwent RIRS. We analysed a subset of asymptomatic patients with renal stones on imaging who were treated with RIRS. Data includes patient characteristics, stone specifications, anaesthesia type, perioperative details, complications, and SFR. A multivariable logistic regression analysis was performed to assess factors associated with the SFR. RESULTS: Among 679 patients with AIRS, 640 met the inclusion criteria. The median age was 55 years, with 33.4% being female. In all, 22.1% had positive urine cultures. The median stone diameter was 12 mm, commonly in lower and interpolar locations. RIRS was preferentially performed under general anaesthesia using a reusable scope in 443 cases. Prophylactic antibiotics were administered to 314 patients. The median operation time was 58 min and the median laser time was 24 min. The SFR was 68.8%. The use of holmium laser (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.06-0.63; P < 0.01) and multiple stones (OR 0.38, 95% CI 0.19-0.76; P < 0.01) were factors associated with lower odds of being stone free. Overall complications were minimal, with sepsis in 1.6% of patients. Re-interventions were performed in 76 cases (11.8%), with RIRS being the most common in 67 cases (10.6%). CONCLUSION: Our multicentre real-world study is the first of its kind that highlights the pros and cons of offering RIRS to patients with AIRS and demonstrates a favourable SFR with acceptable complications. Pre-emptively discussing potential re-intervention helps patients make informed decisions, particularly in cases involving large and multiple stones.

Early outcomes of short-course low intensity shockwave therapy (LiSWT) for erectile dysfunction: A prospective, randomized, double-blinded, sham-controlled study in Malaysia.

Low-intensity shockwave therapy (LiSWT) has emerged as a promising non-invasive treatment modality for erectile dysfunction (ED) yet the well-designed randomized clinical trials are still lacking to prove its claimed benefits. A randomized, prospective, double-blinded sham-controlled study was conducted to evaluate the effectiveness and safety profile of short course LiSWT on vasculogenic ED patients. The International Index of Erectile Function-5 (IIEF-5) and Erection Hardness Score (EHS) questionnaires were used for evaluation. Patients underwent weekly sessions for 4 weeks and were re-assessed at 1, 3 and 6 months post therapy. Fifty one patients were recruited and randomized into sham and treatment arms. The mean IIEF-5 scores were significantly improved in the treatment arm compared to worsening of scores in the sham arm after 1 month (14.1 vs. 9.3 p < 0.001), 3 months (14.9 vs. 8.6, p < 0.001) and 6 months (14.2 vs. 7.9, p < 0.001) post treatment. A significant improvement of EHS was demonstrated at 1 month (2.4 vs. 1.8, p = 0.001, 3 months 2.7 vs. 1.7, p < 0.001) and 6 months (2.7 vs. 1.6, p < 0.001) in the treatment arm compared to sham arm. The success rate based on IIEF score increment more than five points was 26% in treatment arm and 0% in sham arm. Improvement in EHS score ≥3 in the treatment versus sham arm was 63% and 4%, respectively. There was no adverse effect reported. This 4-week LiSWT protocol reflects better treatment compliance, and it prevents further deterioration of erectile function among this cohort of patients. This study proves that LiSWT is a well-tolerated treatment with modest improvements in erectile function and hardness, among patients with vasculogenic ED.

Delayed surgery for localised and metastatic renal cell carcinoma: a systematic review and meta-analysis for the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic has led to the cancellation or deferment of many elective cancer surgeries. We performed a systematic review on the oncological effects of delayed surgery for patients with localised or metastatic renal cell carcinoma (RCC) in the targeted therapy (TT) era. METHOD: The protocol of this review is registered on PROSPERO(CRD42020190882). A comprehensive literature search was performed on Medline, Embase and Cochrane CENTRAL using MeSH terms and keywords for randomised controlled trials and observational studies on the topic. Risks of biases were assessed using the Cochrane RoB tool and the Newcastle-Ottawa Scale. For localised RCC, immediate surgery [including partial nephrectomy (PN) and radical nephrectomy (RN)] and delayed surgery [including active surveillance (AS) and delayed intervention (DI)] were compared. For metastatic RCC, upfront versus deferred cytoreductive nephrectomy (CN) were compared. RESULTS: Eleven studies were included for quantitative analysis. Delayed surgery was significantly associated with worse cancer-specific survival (HR 1.67, 95% CI 1.23-2.27, p < 0.01) in T1a RCC, but no significant difference was noted for overall survival. For localised ≥ T1b RCC, there were insufficient data for meta-analysis and the results from the individual reports were contradictory. For metastatic RCC, upfront TT followed by deferred CN was associated with better overall survival when compared to upfront CN followed by deferred TT (HR 0.61, 95% CI 0.43-0.86, p < 0.001). CONCLUSION: Noting potential selection bias, there is insufficient evidence to support the notion that delayed surgery is safe in localised RCC. For metastatic RCC, upfront TT followed by deferred CN should be considered.

Comparing Same-Sitting Bilateral vs Unilateral Retrograde Intrarenal Surgery in the Elderly.

OBJECTIVE: To compare same-sitting bilateral vs unilateral retrograde intrarenal surgery (RIRS) in elderly patients, focusing on postoperative complications and stone-free rates (SFR). METHODS: Data from 2 multicenter databases, FLEXible ureteroscopy Outcomes Registry (FLEXOR) (unilateral RIRS) and same sitting bilateral-retrograde intrarenal surgery (SSB-RIRS) (bilateral RIRS), were analyzed, considering only patients aged 70+ with preoperative computed tomography. Patients were categorized into Group 1 (bilateral RIRS) and Group 2 (unilateral RIRS). Follow-up included imaging assessments and secondary treatments as needed. RESULTS: Group 1 included 146 patients, while group 2 had 495. Group 1's patients were slightly older and had a higher prevalence of recurrent stone formation. Group 2 often underwent RIRS for incidental stones. Group 1 had larger and more pelvic stones. Laser lithotripsy and total operation times were significantly longer in Group 1. Group 2 had significantly higher overall stone-free rates, although there were no significant differences in ancillary procedures for residual fragments. Group 1 experienced more pelvicalyceal injuries needing stenting, postoperative fever, and post-op hematuria not requiring transfusion. CONCLUSION: In conclusion, bilateral RIRS can be carefully considered in elderly patients. Preoperative counseling is essential for both primary and repeat RIRS procedures, and further research is needed to optimize instrument and laser strategies for better outcomes in elderly RIRS patients.

Intravesical Chemohyperthermia vs. Bacillus Calmette-Guerin Instillation for Intermediate- and High-Risk Non-muscle Invasive Bladder Cancer: A Systematic Review and Meta-Analysis.

Background: The efficacy of intravesical chemotherapy maintenance for patients with non-muscle invasive bladder cancer (NMIBC) is inferior compared to intravesical bacillus Calmette-Guerin (BCG). How intravesical chemohyperthermia (CHT) compares with BCG is under investigation. Objective: To compare the oncological outcomes and safety profile between intravesical CHT and BCG treatment for intermediate- and high-risk NMIBC. Methods: We performed a systematic review and meta-analysis of clinical studies comparing CHT with BCG for intermediate- and high-risk NMIBC patients. A comprehensive literature search on OVID MEDLINE, EMBASE, and Cochrane Library was conducted. Risk of bias was assessed by the Cochrane RoB tool and ROBINS-I. Certainty of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Results: A total of 2,375 articles were identified and five studies were finally included. Among them, four randomised trials comprising 327 patients (CHT group: 156 patients; BCG group: 171 patients) were included in the meta-analysis. There were no significant differences in the 24-36 months recurrence rates (CHT: 29.5%, BCG: 37.4%; RR: 0.83, 95% CI 0.61-1.13; moderate certainty of evidence) and the 24-36 months progression rates (CHT: 4.4%, BCG: 7.6%, RR = 0.62, 95% CI 0.26-1.49; low certainty of evidence). There were also no significant differences in grade 1-2 adverse events (CHT group: 59.9%, BCG group 54.5%; RR = 1.10, 95% CI 0.93-1.30; moderate certainty of evidence) and grade 3 or above adverse events (CHT group: 23.2%, BCG group 22.5%; RR = 0.99, 95% CI 0.69-1.43; low certainty of evidence). Conclusions: Intravesical CHT had equivalent oncological outcomes and similar safety profile when compared to BCG maintenance therapy for patients with intermediate- and high-risk NMIBC. CHT is a possible alternative treatment in the times of BCG shortage.

A Global Survey on the Impact of COVID-19 on Urological Services.

BACKGROUND: The World Health Organization (WHO) declared coronavirus disease-19 (COVID-19) as a pandemic on March 11, 2020. The impact of COVID-19 on urological services in different geographical areas is unknown. OBJECTIVE: To investigate the global impact of COVID-19 on urological providers and the provision of urological patient care. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional, web-based survey was conducted from March 30, 2020 to April 7, 2020. A 55-item questionnaire was developed to investigate the impact of COVID-19 on various aspects of urological services. Target respondents were practising urologists, urology trainees, and urology nurses/advanced practice providers. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the degree of reduction in urological services, which was further stratified by the geographical location, degree of outbreak, and nature and urgency of urological conditions. The secondary outcome was the duration of delay in urological services. RESULTS AND LIMITATIONS: A total of 1004 participants responded to our survey, and they were mostly based in Asia, Europe, North America, and South America. Worldwide, 41% of the respondents reported that their hospital staff members had been diagnosed with COVID-19 infection, 27% reported personnel shortage, and 26% had to be deployed to take care of COVID-19 patients. Globally, only 33% of the respondents felt that they were given adequate personal protective equipment, and many providers expressed fear of going to work (47%). It was of concerning that 13% of the respondents were advised not to wear a surgical face mask for the fear of scaring their patients, and 21% of the respondents were advised not to discuss COVID-19 issues or concerns on media. COVID-19 had a global impact on the cut-down of urological services, including outpatient clinic appointments, outpatient investigations and procedures, and urological surgeries. The degree of cut-down of urological services increased with the degree of COVID-19 outbreak. On average, 28% of outpatient clinics, 30% of outpatient investigations and procedures, and 31% of urological surgeries had a delay of >8 wk. Urological services for benign conditions were more affected than those for malignant conditions. Finally, 47% of the respondents believed that the accumulated workload could be dealt with in a timely manner after the COVID-19 outbreak, but 50% thought the postponement of urological services would affect the treatment and survival outcomes of their patients. One of the limitations of this study is that Africa, Australia, and New Zealand were under-represented. CONCLUSIONS: COVID-19 had a profound global impact on urological care and urology providers. The degree of cut-down of urological services increased with the degree of COVID-19 outbreak and was greater for benign than for malignant conditions. One-fourth of urological providers were deployed to assist with COVID-19 care. Many providers reported insufficient personal protective equipment and support from hospital administration. PATIENT SUMMARY: Coronavirus disease-19 (COVID-19) has led to significant delay in outpatient care and surgery in urology, particularly in regions with the most COVID-19 cases. A considerable proportion of urology health care professionals have been deployed to assist in COVID-19 care, despite the perception of insufficient training and protective equipment.