Adherence to Antimicrobial Prophylaxis Guidelines in Endourologic Procedures: Frequency and Related Outcomes.

Background: Surgical antimicrobial prophylaxis (SAP), when used appropriately based on evidence-based guidelines, can reduce the rate of infectious complications following endourologic procedures without compromising patient outcomes. Objectives: To investigate the appropriateness of the current SAP used in endourologic surgeries based on international guidelines and report their associated outcomes (urinary tract infection [UTI] and blood stream infection [BSI]). Design: Prospective cross-sectional study. Methodology: The medical records of patients undergoing endourologic procedures were reviewed to assess healthcare providers' adherence to international guideline recommendations. Assessed parameters included indication, duration, choice, and dose of the antibiotics used in endourologic procedures in two medical centers in Amman/Jordan. Furthermore, patients were asked to conduct laboratory urine tests to determine the rate of infectious complications within one month post-procedure. Results: Three hundred and sixty-one patients were recruited for the study. The adherence rates to guidelines regarding indication, choice, and dose of pre-operative antibiotics were 90.3%, 2.8%, and 77.8%, respectively. The duration was concordant with guidelines in only 3.4% of participants. A total of 41.8% of patients completed follow-up. Among those, 4.6% developed bacterial UTIs, and 0.7% developed BSI. Conclusion: Adherence to SAP guidelines in endourologic procedures was far from optimal. Primary deviations in the implementation of guidelines' recommendations were pinpointed. These results are crucial for planning interventions that optimize SAP utilization.

Endourological Management of Ureteral Stricture in Patients with Renal Transplant: A Systematic Review of Literature.

Purpose: To analyze the utility and outcomes of available endourologic options to treat ureteral stricture after kidney transplantation (KT). Methods: A systematic review was carried out for all English language articles from 2000 to 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standards using EMBASE, MEDLINE, SCOPUS, Google scholar, and Cochrane library. The search term combination for the string was follows: [(Ureteral stricture) OR (ureter stenosis) OR (ureteral stenosis) OR (Stricture ureter) OR (Narrowing ureter) OR (Ureter restriction) OR (ureteral restriction) OR (ureteral narrowing) OR (ureteral obstruction) OR (ureter obstruction) OR (obstructing ureter) OR (obstructive ureter) OR (narrow ureter) OR (ureteral narrow)] AND [(kidney transplant) OR (transplanted kidney) OR (transplant) OR (transplantation)] AND [(management) OR (Robotic) OR (laser) OR (stent) OR (dilatation) OR (dilation) OR (endoscopic) OR (endourological) OR (Urologic) OR (laparoscopic) OR (surgery) OR (treatment)]. Case reports, review articles, animal and laboratory studies were excluded. Risk of bias assessment was conducted using the RoB 2 and ROBINS-I tools. Results: A total of 1102 relevant articles published from 2000 to 2023 were found. After screening of titles and abstracts, a total of 19 articles were included in our systematic review. Ureteral stent/nephrostomy placement, balloon dilatation (ureteroplasty) with or without laser was used as initial approaches whereas follow-up and success rate were analyzed among other parameters. Conclusions: The management of ureteral strictures after KT is challenging and selecting the most appropriate treatment is crucial for successful outcomes. Our review suggests that, an endourologic management is a safe option with good long-term outcomes, especially in short and early strictures.

Ureteroscopy in the elderly: safety and functional results.

PURPOSE: To evaluate the effectiveness and safety of ureteroscopy (URS) for urinary stones treatment in patients ≥ 80 years of age. METHODS: From 2012 to 2021, 96 patients ≥ 80 years underwent URS for urinary stone disease. Patients' demographics and surgical outcomes were examined. RESULTS: The median length of follow-up was 25 months. Median age was 84 years. Half of the patients (53%) were ASA score 3 and 16% ASA 4. Mean stone diameter (SD) was 10.6 mm, and mean procedure time was 78 min. Eighty-three patients underwent follow-up imaging (ultrasonography or computed tomography) with a median time of 31 days. Stone-free rate was 73.9%. Twenty patients (20.7%) experienced a minor complication [Clavien-Dindo (CD) I-II] whereas five (5.7%) experienced a major complication (CD III-V). SD ≥ 10 mm predicted CD III-V complications (OR 1.25, 95% CI 1.01-1.55, p = 0.03). Urinary drainage prior the procedure with double J stent, nephroureteral stent or percutaneous nephrostomy tube had no impact on patients' SFR [74.6% in the drained group versus 64.0% in the undrained group (p = 0.44)] nor on major complications (OR 4.68, 95% CI 0.25-87.77, p = 0.30). CONCLUSION: In elderly patients, URS for treatment of renal and ureteral stones is a relatively efficient and safe procedure. The risk of major complications is low, and the only associated risk factor found was SD ≥ 10 mm. Urinary drainage prior the procedure did not affect patients' outcomes.

Safety During Ureteroscopy: Radiation, Eyes, and Ergonomics.

It is known that urologic surgeons are at risk of work-place injury due to the physical requirements of operating and exposure to hazards. These hazards include radiation, exposure to body fluids, use of laser energy, and orthopedic injury due to the physical nature of operating. The risks that these hazards present can be mitigated by implementing several evidence-based safety measures. The methods to protect against radiation exposure include keeping radiation usage in the operating room as low as reasonably achievable, donning lead aprons, and wearing protective glasses. Additionally, protective glasses decrease the risk of eye injury from laser injury and exposure to body fluids. Finally, practicing sound surgical ergonomics is essential to minimize the risk of orthopedic injury and promote career longevity. The interventions discussed herein are simple and easy to implement in one's daily practice of urology.

[Benign prostatic hyperplasia management during COVID-19 pandemia.] / Manejo de la hiperplasia benigna de próstata durante la pandemia COVID-19.

OBJECTIVES: The pandemic caused by the new SARS / Cov-2 Coronavirus represents an unprecedented scenario in modern medicine that affects many aspects of daily healthcare. Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) has a high prevalence and is related to high consumption of health resources. For this reason, we performed a revision of the management of LUTS and HBP during and after COVID-19 pandemic. MATERIAL AND METHODS: A group of experts in benign prostatic hyperplasia from different regions of Spain were selected to design a strategy to reorganize the management of benign prostatic hyperplasia and lower urinary tract symptoms during the pandemic. A comprehensive review of the literature was undertaken and a set of recommendations are generated. RESULTS: Recommendations for the management of LUTS-BPH during and after the SARS/CoV2 coronavirus pandemic outbreak consist of promoting telemedicine and developing joint protocols with Primary Care Attention .Clear diagnostic and treatment criteria and referral criteria must be established. Referral of patients for risk complications such as kidney failure, recurrent hematuria and obstructive uropathy are a priority. Surgeries due to BPH are generally potentially delayed until phases I and II of the pandemic, in which the percentage of hospitalized patients with COVID-19 does not exceed 25%, and it is necessary to determine COVID19 negativity. The surgical technique that associates the least complications and the shortest stay should be selected. CONCLUSIONS: The diagnosis and prescription of treatment for BPH during the COVID-19 pandemic should be based on telemedicine and joint protocols for primary care attention and urology. Elective surgical treatment can be delayed until we are in phases I or II, individualizing the surgical and anaesthetic technique of choice to minimize risks.

OBJETIVOS: La pandemia causada por el nuevo Coronavirus SARS/Cov-2 supone un escenario sin precedentes en la medicina moderna que afecta de manera indirecta en numerosos aspectos de nuestra actividad diaria como sanitarios. La hiperplasia benigna de próstata (HBP) es una patología con una elevada prevalencia y consumo de recursos sanitarios. Por ello, es necesaria una revisión en el manejo de la misma con el fin de adecuarlo a las necesidades impuestas por los acontecimientos recientes.MATERIAL Y MÉTODOS: Un grupo de expertos en hiperplasia benigna de próstata de distintas comunidades autónomas de España fueron contactados para diseñar una estrategia para reorganizar el manejo de la hiperplasia benigna de próstata y los síntomas del tracto urinario inferior durante la pandemia. Se realiza una revisión narrativa de la literatura publicada y se generan una serie de recomendaciones de manejo. RESULTADOS: Entre las recomendaciones para el manejo de HBP en tiempos de pandemia por coronavirus SARS/CoV2 se incluyen la promoción de teleconsulta y la realización de protocolos conjuntos con Atención Primaria estableciendo criterios de diagnóstico, tratamiento y derivación claros y homogéneos. Deben priorizarse las derivaciones pacientes complicaciones de riesgo tales como insuficiencia renal, hematuria recidivante y uropatía obstructiva. Desde el punto de vista quirúrgico, se trata generalmente de cirugías potencialmente demorables hasta fases I y II de la pandemia, donde el porcentaje de pacientes hospitalizados con Covid-19 no supera el 25%, siendo preciso determinar negatividad de COVID19. Debe seleccionarse la técnica quirúrgica que asocie una menor tasa de complicaciones así como una estancia más baja. CONCLUSIONES: El diagnóstico y el inicio del tratamiento médico de la HBP durante la pandemia debe basarse en la instauración de la telemedicina y protocolos conjuntos con atención primaria y urología. El tratamiento quirúrgico electivo se puede demorar hasta encontrarnos en fases I o II, individualizando la técnica quirúrgica y anestésica de elección para minimizar riesgos.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America.

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

Management of Primary Obstructive Megaureter by Endoscopic High-Pressure Balloon Dilatation. IDEAL Framework Model as a New Tool for Systematic Review.

Introduction: Therapeutic management of primary obstructive megaureter (POM) requiring surgery has been under debate for the last 15 years especially regarding the outcomes of endoscopic techniques compared to most traditional approaches. This review aims to analyze endoscopic High-Pressure Balloon Dilatation (HPBD) using the IDEAL model, a five-stage framework that describes surgical innovations (Idea, Development, Exploration, Assessment, and Long-term Study) and provides recommendations for a rigorous stepwise surgical research pathway. This model has been developed and demonstrated its value in evaluating surgical innovations assessing data quality and providing relevant information for the optimal design and feasibility of research in surgery. Materials and Methods: A systematic review of the published series of endoscopic HPBD in patients with POM was done using the IDEAL model as a tool to assess evidence quality. Reported clinical outcomes are also analyzed and reviewed. Results: The analysis of the results of the systematic assessment of the reported cohort of patients treated with HPBD for POM that the technique up to date is in stage 2a and stage 2b, or development. Evidence quality among the reported cohorts of patients with POM treated with HPBD is adequate, although systematization and standardization should be improved. Clinical outcomes of HPBD in the management of POM consistently show a 87.7% success rate with a negligible operative complication rate once "learning curve" has been surpassed. Symptomatic vesicoureteral reflux (VUR) is the main reason for ureteric reimplantation, but asymptomatic VUR does not seem to influence clinical outcome. Conclusions: The IDEAL framework and recommendations have allowed a systematic analysis of the evidence quality of the reported experience in the management of children with POM with HPBD of the vesicoureteral junction. The available evidence demonstrates that HPBD is an effective treatment for patients with POM, with a long-term success rate of 87.7% with very low morbidity. Future research mandates a standardization of data reporting, "ideally" following IDEAL recommendations, that would be required for any intervention and facilitate comparative analysis.

Endourologic Treatment for Aggressive Angiomyxoma of the Bladder.

Background: Aggressive angiomyxoma (AA) is a rare tumor that usually appears in the female pelvic and perineal regions. It commonly has infiltrative behavior and high local recurrence risk. We report an unusual presentation of AA, originating in a female patient's bladder. Case Report: A 43-year-old female patient presented with recurrent urinary tract infection for 6 months; ultrasonography showed a bladder tumor that was diagnosed as AA by immunohistochemistry and treated with complete transurethral resection. Conclusion: Transurethral resection can be an effective approach for the treatment of AA.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America.

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

Wandering Double-J Stent in the Retroperitoneum: A Case Report.

Background: Double-J (DJ) stent is an integral part of urologic practice. DJ stents can have numerous complications such as persistent irritative symptoms, encrustations, and up and down migrations within the pelvicaliceal system (PCS), but displacement outside the urinary tract is rare. We are presenting a unique case of DJ stent lying outside the PCS for more than a decade. Case Presentation: A 46-year-old female presented with left flank pain and dysuria. She had undergone percutaneous nephrolithotomy in the left side 11 years ago. Imaging studies revealed a forgotten DJ stent with proximal part lying in the PCS with dense encrustations and the distal coil in the retroperitoneum at the level of the contralateral sacroiliac joint with the shaft crossing the midline at fourth lumbar vertebral level. The malpositioned forgotten stent was removed intact using the multimodal endourologic technique. During follow-up, the patient had prompt relief of symptoms and a preserved renal unit. Conclusion: To the best of our knowledge, this is the first report of malpositioned and forgotten DJ stent for more than a decade with lower end lying near the opposite lower ureter managed effectively by an endourologic method.

The Effects of Propofol as s Sole Intravenous Anesthetics on Endourologic Transurethral Lithotripsy / 대한마취과학회지

BACKGROUND: Propofol is an intravenous anesthetic characterized by rapid induction and prompt recovery. Recently, its is used widely in clinical practice, especially when early discharge is advisable. We conducted this study for the evaluation of the effects of propofol as a sole intravenous anesthetic on the operation with minimal pain such as TUL(transurethral lithotripsy). METHODS: Patients were recruited for ASA class 1 and 2 from those who received TUL operation. Propofol was administered 2 mg/kg for induction and continuously infused at the rate of 1.2~1.4 mg/kg/hr after the loss of consciousness. With the stabilization of the vital signs, we reduced the dose of propofol to 1.0~1.2 mg/kg/hr. We checked the patients' movement, vital signs, recovery time and monitored the appearance of the symtoms such as nausea, vomiting postoperatively. RESULTS: 1) The average time of operation was 15+/-12 minutes. 2) The average recovery time was 15+/-9 minutes(range 2~30 min). 3) Blood pressure and peripheral oxygen saturation(SpO2) were declined during anesthesia, but SpO2 was normalized in the recovery room. 4) No significant complications were observed. 5) Mild movement of the patient was noticed in the begining of operation, but it did not affect the surgical procedure. CONCLUSIONS: Propofol was effective as a sole intravenous anesthetic to minimize postoperative complications such as nauea, vomiting for TUL with minimal pain.

Experience of Extracorporeal Shock Wave Lithotripsy with Northgate SD-3 in 2500 Patients of Urinary Calculi / 대한비뇨기과학회지

Extracorporeal shock wave lithotripsy (ESWL) has been established as the first line procedure of urinary stone treatment. To evaluate clinical efficacy and to identify the criteria of proper patient selection tempered by understanding of the limitations of the ESWL therapy available. We reviewed 2500 patients with urinary stone treated by ESWL using the Northgate SD-3 lithotriptor between June, 1989 and May, 1995. The results were obtained as follows: 1. The total average success rate of treatment was 92.6%. 2. The success rate according to stone locations were 88% in kidney (1074/1214 cases), 93.5% in ureter(1275/1323 cases) and 92.7% in bladder (38/41 cases). 3. The success rate according to stone size measured on the KUB film were 98.0% below 10mm, 91.0% in 11 - 20mm, 80.0% in 21 - 30mm and 68.7% over 31mm. 4. The average numbers of treatment were 2.3 sessions and the mean number of shock per treatment were 1940 +- 230. 5. Of the 2578 cases, 2178(84.5%) were treated by ESWL monotherapy. For auxiliary procedure, Double-J stents were placed in 64 cases and nephrostomy in 49 cases. Stone manipulation including push back, Dormia basket, Ureteroscopy were performed in 161 cases. We conclude that as a highly effective and minimally invasive treatment modality, ESWL has become to be the therapy of choice in 85.5% of urinary stones. When ESWL therapy is less effective for stone size larger than 3 cm(68.7%), staghorn calculi (65.5%) and presence of anatomical barriers, the additional endourologic procedures need to be indicated.

Experience of Extracorporeal Shock Wave Lithotripsy with Northgate SD-3 in 2500 Patients of Urinary Calculi / 대한비뇨기과학회지

Extracorporeal shock wave lithotripsy (ESWL) has been established as the first line procedure of urinary stone treatment. To evaluate clinical efficacy and to identify the criteria of proper patient selection tempered by understanding of the limitations of the ESWL therapy available. We reviewed 2500 patients with urinary stone treated by ESWL using the Northgate SD-3 lithotriptor between June, 1989 and May, 1995. The results were obtained as follows: 1. The total average success rate of treatment was 92.6%. 2. The success rate according to stone locations were 88% in kidney (1074/1214 cases), 93.5% in ureter(1275/1323 cases) and 92.7% in bladder (38/41 cases). 3. The success rate according to stone size measured on the KUB film were 98.0% below 10mm, 91.0% in 11 - 20mm, 80.0% in 21 - 30mm and 68.7% over 31mm. 4. The average numbers of treatment were 2.3 sessions and the mean number of shock per treatment were 1940 +- 230. 5. Of the 2578 cases, 2178(84.5%) were treated by ESWL monotherapy. For auxiliary procedure, Double-J stents were placed in 64 cases and nephrostomy in 49 cases. Stone manipulation including push back, Dormia basket, Ureteroscopy were performed in 161 cases. We conclude that as a highly effective and minimally invasive treatment modality, ESWL has become to be the therapy of choice in 85.5% of urinary stones. When ESWL therapy is less effective for stone size larger than 3 cm(68.7%), staghorn calculi (65.5%) and presence of anatomical barriers, the additional endourologic procedures need to be indicated.

Treatment Options for Lower Ureteral Calculi: Expectancy or Endourologic manipulations / 대한비뇨기과학회지

To determine the optimal therapeutic approach for lower ureteral calculi at the hospitals which have not possessed ESWL, we reviewed 85 cases initially treated with expectancy for more than 7 days. Of 85 cases, 37 were treated with expectancy only and the remaining 48 cases received the endourologic manipulations such as stone basket and ureteroscopic removal. A total cumulative spontaneous passage rate at 3 weeks was about 52.9% and the possibility of spontaneous passage of remained stones at 3 weeks was not significant. The spontaneous passage rate was higher in the cases with the stones of small size (less than 6mm), smooth-round shape and without urinary tract obstruction than the other cases. 26 cases were treated with the stone basket and stone extraction rate was only 42.3%. The stone extraction rate was higher in the cases with the stones of smaller size (less than 4mm), irregular-speculated shape and with short duration of previous expectancy than the other cases. A total of 32 cases received the ureteroscopic manipulation and the success rate was 87.5%. Thus, we recommend initial expectancy for up to 3 weeks in the lower ureteral calculi smaller than 10 mm. And after this period, the positive and selective endourological manipulation considering the stone size, shape and expectant duration may be desirable in respect of treatment efficacy.

Endourologic Diversion / 대한비뇨기과학회지

Twenty three endourologic diversion for obstructed upper urinary tract were performed in 20 kidneys of 18 Patients at Seoul National University Hospital during one year period ending August, 1983. These procedures include 13 percutaneous nephrostomies, 3 antegrade internal ureteral splints and 7 retrograde Double-J stents. Underlying diseases of 13 patients were malignant and 5 patients were benign disease. Most common indications were hydronephrosis with uremia in debilitated patients whose surgical risks were too high. A palliative diversion was performed in 15 kidneys and temporary diversion in 5. Encourologic diversion resulted in clinical improvement in 15 of 20 kidneys. Complications occurred in 3 of 23 procedures. There was 1 morality secondary to sepsis 24 hours after insertion of catheter. Most common problem was catheter blockade which was managed conservatively with irrigation in the most instances. However in 7 instance, catheter had to be changed or discontinued because of. complete obstruction. average duration of functioning catheter until blockade was 34-51 days. We found endourologic diversion is effective and economic procedure for palliative or temporary diversion, which was conventionally carried out by surgical intervention.