Laparoscopic repair of acquired rectourethral fistula by vesical peritoneal flap.

INTRODUCTION: A rectourethral fistula (RUF) is an infrequent complication that can be iatrogenic in most cases. Multiple surgical interventions were described for RUF repair including transsphincteric, transanal, transperineal, and transabdominal approaches. To this day, there is no consensus on a standardized surgery of choice for acquired RUF. MATERIALS AND SURGICAL TECHNIQUE: Our patient was diagnosed with RUF 4 weeks after undergoing laparoscopic low anterior resection for midrectum adenocarcinoma, with failure of conservative treatment. A three-port transabdominal approach was used to dissect the rectoprostatic space and close the fistula orifice on the anterior rectal wall. With the technical impossibility to develop an omental flap, the peritoneum on the posterior vesical wall was carefully dissected to form a rectangular flap pedicled by its inferior aspect. The harvested peritoneal flap was then anchored between the prostate and the rectum. Follow-up imaging showed the absence of RUF, concurrently with total remission of RUF symptomatology. DISCUSSION: Management of acquired RUF can be challenging, especially after failure of conservative treatment. Laparoscopic repair of acquired RUF by vesical peritoneal flap is a valid option for a minimally invasive approach for the treatment of RUF.

Virtual reality for healthcare: A scoping review of commercially available applications for head-mounted displays.

Objective: This scoping review aimed to describe the scope of commercially available virtual reality (VR) healthcare applications for mainstream head-mounted displays (HMD)s. Methods: A search was conducted during late April and early May 2022 over five major VR app stores using "health," "healthcare," "medicine," and "medical" as keywords. Apps were screened based on their title and description sections. Metadata collected included: title, description, release date, price (free or paid), multilingual support, VR app store availability, and HMD support. Results: The search yielded 1995 apps, out of which 60 met the inclusion criteria. The analysis showed that the number of healthcare VR apps has been steadily increasing since 2016, but no developer has released more than two apps so far. Most of the reviewed apps can run on HTC Vive, Oculus Quest, and Valve Index. Thirty-four (56.7%) apps had a free version, and 12 (20%) apps were multilingual, i.e., supported languages other than English. The reviewed apps fell into eight major themes: life science education (3D anatomy, physiology and pathology, biochemistry, and genetics); rehabilitation (physical, mental, and phobia therapy); public health training (safety, life-saving skills, and management); medical training (surgical and patient simulators); role-playing as a patient; 3D medical imagery viewing; children's health; and online health communities. Conclusions: Although commercial healthcare VR is still in its early phases, end-users can already access a broad range of healthcare VR apps on mainstream HMDs. Further research is needed to assess the usefulness and usability of existing apps.

Cost of bladder cancer in Lebanon before and after the economic collapse: a probabilistic modeling study.

BACKGROUND AND OBJECTIVES: Lebanon has one of the highest incidence rates of bladder cancer (BC) in the world. In 2019, Lebanon's economy collapsed which majorly impacted healthcare costs and coverage. This study assesses the overall direct costs of urothelial BC in Lebanon, from the perspective of public and private third-party payers (TPP) and households, and evaluates the impact of the economic collapse on these costs. METHODS: This was a quantitative, incidence-based cost-of-illness study, conducted using a macro-costing approach. Costs of medical procedures were obtained from the records of various TPPs and the Ministry of Public Health. We modeled the clinical management processes for each stage of BC, and conducted probabilistic sensitivity analyses to estimate and compare the cost of each stage, pre-and post-collapse, and for each payer category. RESULTS: Before the collapse, the total annual cost of BC in Lebanon was estimated at LBP 19,676,494,000 (USD 13,117,662). Post-collapse, the total annual cost of BC in Lebanon increased by 768% and was estimated at LBP 170,727,187,000 (USD 7,422,921). TPP payments increased by 61% whereas out-of-pocket (OOP) payments increased by 2,745% resulting in a decrease in TPP coverage to only 17% of total costs. CONCLUSION: Our study shows that BC in Lebanon constitutes a significant economic burden costing 0.32% of total health expenditures. The economic collapse induced an increase of 768% in the total annual cost, and a catastrophic increase in OOP payments.

Physician eye contact in telemedicine video consultations: A cross-cultural experiment.

INTRODUCTION: Eye contact is generally considered a beneficial non-verbal behavior in patient-physician communication. Physicians are advised to simulate eye contact during video consultations by gazing at the camera, although we lack evidence that doing so is beneficial. This work is a cross-cultural experiment that aims to answer: "Are physicians who gaze at the camera during video consultations perceived as making eye contact, and are their communication skills rated higher?" METHODS: 43 Japanese and 61 Lebanese participants watched videos of physicians providing the same video consultations while gazing at the camera and screen. After watching each video, they rated the physicians' communication skills using six items from the GCRS and the MAAS-G scales. They also picked and justified their preferred physician gaze direction. RESULTS: When physicians gazed at the camera, they were perceived as making more eye contact and received higher communication and interpersonal skills ratings, both in Japan and Lebanon. The effect of gazing at the camera was consistently positive but varied by country and consultation content. In Japan, simulating eye contact improved the ratings of the attentive and caring physician, whereas in Lebanon, it improved the ratings of the tired and inattentive physician. When asked to choose their preferred gaze direction, 88.4% of Japanese and 90.2% of Lebanese participants chose camera gaze over screen gaze due to its positive effect on patient feelings and physician perception. Participants who chose screen gaze noted the unnaturalness of gazing at the camera and its potential negative impact on care quality. CONCLUSION: Physicians providing video consultations can simulate eye contact by gazing at the camera. Doing so improves their communication and interpersonal skills ratings and could potentially enhance their communication with their patients. Mainstream video conferencing platforms could implement gaze correction methods to simulate eye contact without affecting the physicians' experience and capacity to provide quality care.

Data Protection in Healthcare Research: Medical Students' Knowledge and Behavior.

Healthcare research involves handling personal health information. Information security policies are implemented in research institutions to ensure data subjects' rights but are not always respected due to researchers' neglect or unawareness. This paper is part of an action research project at Saint Joseph University in Lebanon aiming to increase researchers' compliance with the university's information security policy. An anonymous online questionnaire was administered to medical students to evaluate their knowledge and behavior regarding patient data handling in research projects. 38 responses were collected. Results show that most students collect patient data for research, and are frequently not aware of, and do not comply with, the existing information security policy. We also found correlations between low knowledge and non-compliant behaviors including clicking on links from unknown senders, leaving computers unattended, and sharing data insecurely. To address these issues, we plan to implement various Information Security Awareness interventions and compare their effectiveness.

Physician Communication Skills in Telemedicine: The Role of Eye Contact.

Gaze is an important non-verbal behavior in patient-physician communication. We examine the effect of the physician's gaze direction in video consultations on their communication and interpersonal skills ratings. 51 subjects watched videos of a physician providing the same teleconsultations while (a) looking directly at the camera and (b) looking at the computer screen. After each video, the participants rated the physician's skills. The results showed that looking at the camera is perceived as making eye contact and is associated with higher ratings on two communication skill items: (1) using empathy to communicate appreciation of the patient's feelings, and (2) providing support by expressing concern, understanding, and willingness to help. The effect of eye contact depended on the content of the consultation and on the general attitude of the physician. These results highlight the role of eye contact in video consultations and its dependency on other verbal and non-verbal behaviors.

Ensuring Care Continuity in Extreme Crises: A Participatory Action Research Approach.

The Lebanese healthcare system has been facing major challenges due to an unprecedented financial crisis, socio-political instability, and the COVID-19 pandemic. This study aims to examine the impact of overlapping major crises on care continuity and to propose IT-based solutions to address current challenges and build future resilience. To this end, we adopted a participatory action research approach and conducted a two-phase qualitative study - six semi-structured interviews followed by three future workshops with local stakeholders including physicians and interns practicing in Lebanon. Through the interviews, we identified the primary consequences of the crises and the ways they impacted the continuity of care. We also identified adaptation mechanisms used by physicians and patients to ensure continuity of care. Through the future workshops, we identified various IT-based solutions that could be implemented to tackle existing challenges and support local adaptation attempts.

Determinants of pyelonephritis onset in patients with obstructive urolithiasis.

BACKGROUND: Acute obstructive pyelonephritis due to urolithiasis represents a medico-surgical emergency that can lead to life-threatening complications. There are still no established factors that reliably predict progression toward acute pyelonephritis in patients presenting with a simple renal colic. OBJECTIVE: To investigate clinical and paraclinical factors that are associated with the onset of acute obstructive pyelonephritis. METHODS: Patients presenting to the emergency department for renal colic with obstructive urolithiasis on imaging were enrolled in the study. Demographic data, vital signs, medical comorbidities, blood test results, urinalysis, and radiological findings were recorded. Obstructive pyelonephritis was defined by the presence of two or more of the following criteria: fever, flank pain or costovertebral angle tenderness, and a positive urine culture. RESULTS: Seventeen patients out of 120 presenting with renal colic, were diagnosed with acute obstructive pyelonephritis (14%). Parameters that were associated with the onset of obstructive pyelonephritis were: diabetes (p = 0.03), elevated CRP (p = 0.01), stone size (>5 mm) (p = 0.03), dilatation of renal pelvis (p = 0.01), peri-renal fat stranding (p = 0.02), and positive nitrites on urinalysis (p < 0.01). Hyperleukocytosis, acute kidney injury, multiple stones, pyuria (>10/mm3), hypertension, and were not associated with the onset of obstructive pyelonephritis. CONCLUSION: This study showed that known diabetic status, elevated CRP, positive urine nitrites, stone size (>5 mm), pyelic dilatation, and peri-renal fat stranding were associated with the onset of pyelonephritis in patients presenting to the emergency department with obstructive urolithiasis.

Factors Related to Personal Health Data Sharing: Data Usefulness, Sensitivity and Anonymity.

Using an online survey, we examined the relationships between the perceived usefulness, sensitivity, and anonymity of personal health data and people's willingness to share it with researchers. An analysis of 112 responses showed that people's willingness and perceptions are related to the type of the data, their trust in the data's anonymity, and their personal sociodemographic characteristics. In general, we found that people do not completely trust that their identities remain anonymous when sharing data anonymously with researchers. We also found that they are more willing to share personal health data with researchers if they perceive it as useful for public health research, not sensitive, and if they trust that their identity will remain anonymous after sharing it. We also found that people's age, gender, occupation, and region of residence may be related to their perceptions regarding the sharing of personal health data.

Mobile sonouroflowmetry using voiding sound and volume.

Uroflowmetry (UF) is a common clinic-based non-invasive test to diagnose Lower Urinary Tract Dysfunction (LUTD). Accurate home-based uroflowmetry methods are needed to conveniently conduct repeated uroflowmetries when patients are physiologically ready to urinate. To this end, we propose and evaluate a novel mobile sonouroflowmetry (SUF) method that estimates the urinary flow rate from a sound signal recorded using a mobile phone. By linearly mapping the total sound energy to the total voided volume, the sound energy curve is transformed to a flow rate curve allowing the estimation of the flow rate over time. An evaluation using data from 44 healthy young men showed high similarity between the UF and SUF flow rates with a mixed-effects model correlation coefficient of 0.993 and a mean root mean square error of 2.37 ml/s. Maximum flow rates were estimated with an average absolute error of 2.41 ml/s. Future work on mobile uroflowmetry can use these results as an initial benchmark for flow rate estimation accuracy.

Automatic Classification of Screen Gaze and Dialogue in Doctor-Patient-Computer Interactions: Computational Ethnography Algorithm Development and Validation.

BACKGROUND: The study of doctor-patient-computer interactions is a key research area for examining doctor-patient relationships; however, studying these interactions is costly and obtrusive as researchers usually set up complex mechanisms or intrude on consultations to collect, then manually analyze the data. OBJECTIVE: We aimed to facilitate human-computer and human-human interaction research in clinics by providing a computational ethnography tool: an unobtrusive automatic classifier of screen gaze and dialogue combinations in doctor-patient-computer interactions. METHODS: The classifier's input is video taken by doctors using their computers' internal camera and microphone. By estimating the key points of the doctor's face and the presence of voice activity, we estimate the type of interaction that is taking place. The classification output of each video segment is 1 of 4 interaction classes: (1) screen gaze and dialogue, wherein the doctor is gazing at the computer screen while conversing with the patient; (2) dialogue, wherein the doctor is gazing away from the computer screen while conversing with the patient; (3) screen gaze, wherein the doctor is gazing at the computer screen without conversing with the patient; and (4) other, wherein no screen gaze or dialogue are detected. We evaluated the classifier using 30 minutes of video provided by 5 doctors simulating consultations in their clinics both in semi- and fully inclusive layouts. RESULTS: The classifier achieved an overall accuracy of 0.83, a performance similar to that of a human coder. Similar to the human coder, the classifier was more accurate in fully inclusive layouts than in semi-inclusive layouts. CONCLUSIONS: The proposed classifier can be used by researchers, care providers, designers, medical educators, and others who are interested in exploring and answering questions related to screen gaze and dialogue in doctor-patient-computer interactions.

Urodynamics in patients with multiple sclerosis: is it necessary? A randomized-controlled trial.

BACKGROUND: The need for complete urodynamic evaluation in Multiple Sclerosis (MS) patients with Lower Urinary Tract Symptoms (LUTS) is not fully established in the literature. The objective was to evaluate the effect of urodynamics in MS patients with LUTS on treatment outcomes. METHODS: MS patients with LUTS were recruited. On their first visit, urinary symptoms, symptom bother and urologic quality-of-life were evaluated using standardized questionnaires. On their second visit, patients were randomized into two groups: Group A underwent uroflowmetry, and Group B underwent a urodynamic study. Patients received treatment based on the whole evaluation and then were evaluated at 1, 3 and 6 months. RESULTS: Fifty MS patients with LUTS were randomized to 25 patients in each group. All scores decreased significantly after 6 months of treatment in both groups (p < 0.05). However, no differences were found between the two groups at baseline and at 1, 3 and 6 months of treatment (p > 0.05) concerning treatment outcomes. CONCLUSION: A detailed clinical and non-invasive evaluation of MS patients with LUTS seems to be sufficient for prescribing an effective treatment. A urodynamic study does not influence the response to the prescribed treatment in terms of LUTS severity, bother or urologic quality-of-life.

The Effect of the COVID-19 Pandemic on Physicians' Use and Perception of Telehealth: The Case of Lebanon.

The COVID-19 pandemic forced physicians to quickly adapt and find ways to provide their usual offline services by using online tools. We aimed to understand how physicians adapted to the sudden need for telehealth and if their perception of telehealth changed due to their experience during the COVID-19 pandemic. We conducted an exploratory sequential mixed-methods study. We interviewed five Lebanese physicians and thematically analyzed the interviews. We developed a questionnaire based on the analysis results and administered it online to physicians in Lebanon. In total, 140 responses were collected. We found that, during the COVID-19 pandemic, physicians engaged in more telehealth activities in the realms of telemedicine, public awareness, continuing medical education, research, administration, and teaching. They also expanded their repertoire of information-technology tools. Our results also show that there was a significant shift in the physicians' perceptions, indicating greater openness and willingness to adopt telehealth services. However, a significant amount of skepticism and uncertainty regarding telemedicine remains, especially concerning its efficiency, safety, and the adequacy of existing regulations. Based on our findings, we offer recommendations for health IT policy makers, developers, and researchers, to sustain the continuity of telehealth activities beyond the COVID-19 pandemic.

Prospective Multicenter Open-Label One-Arm Trial Investigating a Pumpkin Seed, Isoflavonoids, and Cranberry Mix in Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia: A Pilot Study.

Phytotherapy for lower urinary tract symptoms (LUTSs) due to benign prostate hyperplasia (BPH) is progressively demanded by patients and trusted by physicians. The aim was to assess the efficacy of a mix of pumpkin seed extract, soy germ isoflavonoids, and cranberry (Novex®) in the management of mild to moderate LUTS in BPH patients. Male patients aged ≥40 years, who had had mild to moderate LUTS for >6 months at screening, with no previous therapy or who are still symptomatic despite current use of alpha-blockers, were recruited. Exclusion criteria were an IPSS >19 and an age >80 years. The mixed compound was administered orally, daily, for 3 months. Patients were evaluated by means of IPSS, urological quality of life (uQoL) index, and International Index of Erectile Function (IIEF-5) at 3 visits: baseline (visit 1), 30 days (visit 2), and 90 days after treatment (visit 3). Among 163 screened patients, 128 patients (61.8 ± 9.9 years) were recruited. IPSS improved from 15 (Q1 : 12-Q3 : 17) in visit 1, to 11 (Q1 : 8-Q3 : 14) in visit 2, and to 9 (Q1 : 6-Q3 : 12) in visit 3 (p < 0.001). uQoL improved from 4 (3-4) in visit 1, to 3 (2-3) in visit 2, and to 2 (1-2) in visit 3 (p < 0.001). The patients had an IIEF-5 score of 15 (12-18.7) in visit 1, 15 (12-18) in visit 2, and 17 (13-19) in visit 3 (p=0.99 visits 1 vs. 2, p=0.004 visits 2 vs. 3, and p=0.001 visits 1 vs. 3). Treating mild to moderate LUTS/BPH patients with Novex® might therefore relieve symptoms, improve the quality of life, and have a mild beneficial effect on erectile function.

Minimally invasive simple prostatectomy in the era of laser enucleation for high-volume prostates: A systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review and meta-analysis of available prospective and retrospective studies comparing the minimally invasive (laparoscopic or robot-assisted) simple prostatectomy (MISP) and laser enucleation of the prostate for treating male lower urinary tract symptoms in high-volume prostates, as laser enucleation of the prostate is the new trend for treating high-volume prostates (>80 mL) but many urologists now prefer MISP. METHODS: A systematic search was done using the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cochrane databases in June 2019, with research terms including: 'laser', 'laparoscopy', 'enucleation', 'BPH', 'simple prostatectomy', 'Millins', and 'adenomectomy'. The meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Of 38 screened articles, six were analysed and a total of 975 men were included. The average operative time, length of stay and catheterisation time were significantly shorter in the laser enucleation group (P = 0.006, P < 0.001 and P < 0.001, respectively). The amount of prostatic tissue removed during surgery was comparable between both the laser enucleation and MISP groups (P = 0.39). The International Prostate Symptom Score, prostate-specific antigen level, maximum urinary flow rate and post-void residual urine volume were also comparable at 3 months. Finally, similar transfusion rates and Clavien-Dindo complication rates were observed (P = 0.08 and P = 0.41, respectively). CONCLUSION: This systematic review of the literature and meta-analysis provide a further demonstration of the safety and effectiveness of both laser enucleation and MISP. While laser enucleation had a shorter catheterisation time and hospital stay than MISP, the latter still had unique and specific indications.Abbreviations: ELEP: eraser laser enucleation of the prostate; HoLEP: holmium laser enucleation of the prostate; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PVR: post-void residual urine volume; Qmax: maximum urinary flow rate; (L)(MI)(RA)SP: (laparoscopic) (minimally-invasive) (robot-assisted) simple prostatectomy.

The use of mirabegron in neurogenic bladder: a systematic review.

PURPOSE: To evaluate the use of mirabegron in patients with neurogenic bladder. METHODS: A systematic review of the literature was conducted using four databases (Medline via PubMed, Scopus, Cochrane, and EMBASE). Articles evaluating mirabegron in neurogenic bladder patients were collected, and assessment of the drug's efficacy was reviewed according to clinical and urodynamic parameters. RESULTS: Seven studies were selected and a total of 302 patients with NB were evaluated, ranging from 15 to 66 patients per study. All of the patients had received antimuscarinics as a previous treatment modality. Mirabegron was used as a second-line treatment after antimuscarinics lacked efficacy or caused adverse effects. The duration of the treatments ranged from 4 to 12 weeks. Reported in two studies each, bladder compliance and maximal cystometric capacity were the most commonly improved urodynamic parameters. In the majority of the studies, positive outcomes were reported for clinical scores. Additionally, analysis of the IPSS subscores revealed an improvement of storage symptoms as opposed to voiding symptoms. In all of the studies, mirabegron was well tolerated. CONCLUSION: Mirabegron appears to be an effective treatment in the management of neurogenic bladder unresponsive to antimuscarinics, particularly in patients presenting with storage symptoms. There is still no evidence concerning the use of mirabegron as a first-line therapy for neurogenic bladder.

Feasibility of robotic double Yang-Monti ileal conduit with bladder augmentation: surgical technique.

OBJECTIVE: To report the feasibility of a novel robotic technique for intracorporeal construction of a double Yang-Monti ileal conduit with bladder augmentation in an adult patient. METHODS: The Yang-Monti procedure can be considered as an alternative to Mitrofanoff appendicovesicostomy when the appendix is not available or in obese patients. To date, the robotic approach has not been described. We have described all the steps of our surgery, performed on a 35-year-old obese patient with post-traumatic paraplegia and a neurogenic bladder. We focused on the technical tips and highlighted all the differences with the standard open technique. RESULTS: Our technique provided satisfactory results. No intraoperative complications occurred. The operative time was 250 minutes, and the intraoperative blood loss was 200 mL. The clinical course was uneventful. CONCLUSION: We have shown that robotic intracorporeal realization of a double Yang-Monti ileal conduit with bladder augmentation is feasible, extending the potential indications of robot-assisted surgery. The evaluation of more cases is advised.

The learning curve of transrectal ultrasound-guided prostate biopsies: implications for training programs.

OBJECTIVE: To assess the quality of specimens obtained from prostate biopsies performed by urology residents and evaluate the number of procedures required to perform high-quality transrectal ultrasound (TRUS)-guided prostate biopsies. MATERIALS AND METHODS: Between 2006 and 2009, 770 patients underwent TRUS-guided prostate biopsies in our academic center. During the 6 semesters of this period, 24 residents (4 per semester) performed 1 session of 5.6±1.5 procedures each month for a total of 33.6±9 procedures during the study. The first session was performed with a senior urologist. Prostate cancer detection rate and standards of quality (average length of prostatic core biopsy specimens and absence of prostatic tissue) were retrospectively studied between the beginning and the end of each semester. RESULTS: A total of 12,760 biopsy cores were performed for 770 procedures. Mean patient age (64.5±6.1 years), and median prostate-specific antigen (8.7±3.7 ng/mL) were comparable between the study periods. The average length of biopsy cores significantly improved (+10%) from the first (12±2.7 mm) to the last month (13.2±2.1 mm) with a plateau after 12 procedures. Overall, cancer detection rate was 47% and was stable during the semester (41.3% the first month vs 44.1% the last month; P=.39). On univariate and multivariate analysis the mean length of biopsy specimens was associated with the number of procedures (P<.001) and the number of cores performed (P<.001). CONCLUSION: Twelve procedures are necessary to perform high-quality TRUS-guided prostate biopsies without compromising prostate cancer detection. In current training programs, we strongly recommend that residents have direct supervision for a minimum of 12 cases before they are allowed to perform TRUS-guided biopsies with indirect supervision.