Incidence, risk factors, and outcome of Clostridioides difficile infection following urological surgeries.

PURPOSE: To assess the incidence, risk factors, and clinical outcomes associated with (Clostridioides difficile infection) CDI following urological surgery, which is the leading cause of nosocomial diarrhea and a growing public health burden. METHODS: We queried the National Surgical Quality Improvement Program (NSQIP) to identify patients undergoing urological surgery in 2015-2016. We evaluated the 30-day incidence and factors associated with postoperative CDI and 30-day hospital readmission and length of stay as secondary outcomes. Among the subset of patients undergoing radical cystectomy with urinary diversion (surgery with highest CDI incidence) we used multivariable logistic regression analysis to evaluate independent clinical and demographic factors associated with postoperative CDI. RESULTS: We identified 98,463 patients during the study period. The overall 30-day incidence of CDI was 0.31%, but varied considerably across surgery type. The risk of CDI was greatest following radical cystectomy with urinary diversion (2.72%) compared to all other urologic procedures (0.19%) and was associated with increased risk of hospital readmission (p < 0.0001), re-operation (p < 0.0001), and longer mean length of stay (p < 0.0001) in this cohort. Among patients undergoing radical cystectomy with urinary diversion, multivariable logistic regression revealed that preoperative renal failure (OR: 5.30, 95% CI 1.13-24.9, p = 0.035) and blood loss requiring transfusion (OR: 1.67, 95% CI 1.15-2.44, p = 0.0075) were independently associated with CDI. CONCLUSIONS: In a nationally representative cohort, the incidence of CDI was low but varied substantially across surgery types. CDI was most common following radical cystectomy and associated with potentially modifiable factors such as blood transfusion and significantly longer length of stay.

Overlapping Urological Surgeries at a Tertiary Academic Center.

OBJECTIVE: To evaluate whether the practice of procedure-time overlapping surgery (OS) is associated with inferior outcomes compared to nonoverlapping surgery (NOS) in urology, to address the paucity of data surrounding urologic surgeries to support or refute this practice. MATERIALS AND METHODS: We performed a retrospective review of all urological surgeries at a single tertiary-level academic center, Emory University Hospital, from July 2016 to July 2018. Patients who received OS were matched 1:2 to patients who had NOS. The primary outcomes were perioperative and postoperative complications and mortality. RESULTS: We reviewed 8535 urological surgeries. In-room time overlap was seen in 50.5% of cases and procedure-time overlap in 7.4%. Eleven out of the 13 attending urologists performed OS. The average time in the operating room was greater for OS by an average of 14 minutes. The average operative time was greater for OS than NOS by 11 minutes, but this did not reach statistical significance. There was no significant difference between the cohorts for rate of blood transfusions, ICU stay, need for postoperative invasive procedures, length of postoperative hospital stay, discharge location, Emergency Room visits, hospital readmission rate, 30 and 90-day rates of postoperative complications, and mortality. CONCLUSION: Procedure-time overlapping surgeries constituted a minority of urological cases. OS were associated with greater in-room time. We found no increased risk of perioperative or postoperative adverse outcomes in OS compared to matched NOS.

Clinical outcomes of 28 cats 12-24 months after urethrostomy.

OBJECTIVES: The aim of this study was to evaluate and compare the long-term clinical outcomes and quality of life of cats having undergone perineal urethrostomy (PU) or prepubic urethrostomy (PPU). METHODS: This clinical study followed 28 cats (PU, n = 22; PPU, n = 6) that underwent a urethrostomy, with a minimum of 1 year postoperative follow-up. Medical records, pet owner surveys and urologic laboratory tests were used for assessment. Urologic laboratory tests included serum symmetric dimethylarginine (SDMA), serum creatinine, urinalysis, urine specific gravity (USG), urine protein:creatinine (UPC) ratio and urine culture. RESULTS: The main indications for urethrostomy were multiple catheterizations and PU stricture. The overall complication rates of PU and PPU were 31.8% and 83.3%, respectively. Recurrent urinary tract infection (UTI) and urine scald dermatitis were less frequent in PU than in PPU cats (UTI 22.7% vs 66.6%; dermatitis 4.5% vs 83.3%). Bacteriuria was present in 77.2% and 100% of PU and PPU cats, respectively. Owner satisfaction rates were excellent in 81.8% of PU and 33.3% of PPU cases. CONCLUSIONS AND RELEVANCE: A proportion of cats that underwent urethrostomy showed bacteriuria, recurrent UTIs and increased levels of SDMA. PPU is important as a salvage procedure; however, it should be limited to cases in which standard techniques for PU cannot be performed, owing to the potential for recurrent complications and lower owner satisfaction.

Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis.

PURPOSE: The primary rationale for antimicrobial prophylaxis (AP) is to decrease the incidence of surgical site infection (SSI) and other preventable periprocedural infections, with the secondary goal of reducing antibiotic overuse. This Best Practice Statement (BPS) updates the prior American Urological Association (AUA) BPS and creates a comprehensive and user-friendly reference for clinicians caring for adult patients who are undergoing urologic procedures. MATERIALS AND METHODS: Recommendations are based on a review of English language peer-reviewed literature from 2006 through October 2018 and were made by consensus by a multidisciplinary panel. The search parameters included timing, re-dosing, and duration of AP across urologic procedures where there was the possibility of SSI. Excluded from the search were the management of infections outside the genitourinary (GU) tract and pediatric procedures. RESULTS: Single-dose AP is recommended for most urologic cases and antimicrobials should only be used when medically necessary, for the shortest duration possible, and not beyond case completion. Surgeons are the most accurate discerners of an SSI, and should use standard definitions to make better calculations of patient risk. The risk classification developed is dependent on the likelihood of developing SSI, and not the associated consequences of SSI. CONCLUSIONS: The AUA developed a multi-disciplinary BPS to guide clinicians on the proper usage of AP across urologic procedures and wound classifications. It is recommended that the lowest dose of antimicrobials be administered to decrease the risk of infection and to minimize the risk of drug-resistant organisms.

[Place of partial nephrectomy assisted by robot: Review of the literature at the time of a request for a specific nomenclature]. / Place de la néphrectomie partielle assistée par robot : revue de la littérature à l'heure d'une demande de nomenclature spécifique.

INTRODUCTION: Robot-assisted surgery is practiced more and more frequently in urology. Besides its place in prostatectomy for cancer, it also concerns partial nephrectomy (NP), in the treatment of renal tumors. The objective of this review is to compare the robot-assisted approach with laparoscopic or open approaches in partial nephrectomy in terms of functional or oncological outcomes and per- and postoperative complications. MATERIAL AND METHODS: A systematic review of the literature published from 2009 was carried out on PubMed. Clinical studies or meta-analyzes comparing robot-assisted surgery versus laparoscopic or open surgery in the NP domain were used. RESULTS: The clinical data presented in this review of the literature are based mainly on meta-analyzes of comparative studies. Patients operated with robotic assistance (NPAR) had significantly fewer postoperative complications than patients operated by open (RR 0.61; P=0.0002) or laparoscopic surgery (RR 0.84; P=0.007). Positive margins, at equivalent pathological stages, are comparable to the open and appear to be lower than the laparoscopic surgery (RR 0.53; P<0.001). After NP, the change in postoperative glomerular filtration rate (GFR) appears to be identical between the 3 pathways. Hot ischemia time is significantly shorter for NPAR compared to NPL. Finally, the estimated blood loss and length of stay are less severe in patients operated by NPAR compared to those operated by open surgery. CONCLUSION: Robot-assisted surgery offers the same oncological results (in the short and medium term) and appears to improve functional outcomes and morbidity. However, these findings need to be carefully analyzed, due to the low level of evidence from the studies presented and included in the meta-analyzes, and the lack of randomized clinical studies.

Obstetrical and Gynecological Devices; Reclassification of Surgical Instrumentation for Use With Urogynecologic Surgical Mesh. Final order.

The Food and Drug Administration (FDA or the Agency) is reclassifying surgical instrumentation for use with urogynecologic surgical mesh from class I (general controls) exempt from premarket notification to class II (special controls) and subject to premarket notification, and identifying them as "specialized surgical instrumentation for use with urogynecologic surgical mesh." FDA is designating special controls that are necessary to provide a reasonable assurance of safety and effectiveness of the device. FDA is reclassifying this device on its own initiative based on new information.

ICD-10: are you ready?

With the signing of H.R. 4302 ( https://beta.congress.gov/bill/113th-congress/house-bill/4302 ), the implementation date for using ICD-0-CM codes for coding and billing medical encounters in the United States is now scheduled for October 1, 2015. This conversion from using ICD-9-CM codes will be a tremendous change in the way providers and practices deliver health care and could be financially devastating to those who are not properly prepared. Proper preparations will require educating virtually everyone involved in almost every aspect of patient care with a sufficient understanding of ICD-10 language, coding structure, and rules. Vital to this conversion is accurate documentation in the medical records by providers, knowledge of insurance coverage (local and national) rules, and acceptance of those codes by electronic health record systems, clearinghouses, and payors. Early preparation, appropriate education, and proper testing will minimize the financial impact.

Vias de acesso para tratamento de cálculos urinários: influência da introdução da videolaparoscopia / Access way for treatment of urinary calculi: impact of the introduction of laparoscopy

Avaliar a influência da laparoscopia na rotina cirúrgica do Serviço de Urologia do HC-UFMG. Métodos: Foi feita uma análise retrospectiva de todas as cirurgias, para tratamento de cálculos, realizadas no HC-UFMG entre janeiro de 2004 e outubro de 2008. Resultados: No total foram realizados 613 procedimentos e 4.850 litotripsias extracorpóreas (LECOs). Ao estratificarmos o tipo de procedimento cirúrgico realizado em função do tempo, temos que: no período inicial do estudo (2004), houve apenas seis (4,7%) casos de litíase tratados pela via laparoscópica, já no ano de 2008, os procedimentos laparoscópicos corresponderam a 17 (15,2%) casos. Conclusões: As principais modalidades no tratamento de cálculos urinários são os procedimentos endoscópicos e a LECO. A laparoscopia, apesar de ter indicações limitadas, vem ganhando espaço frente à cirurgia aberta, principalmente nos casos refratários a tratamentos menos invasivos.

This paper aims to determine the influence of the laparoscopy in the treatment of urinary stones in a tertiary hospital (HC-UFMG). Methods: We reviewed our data from January 2004 to October 2008. All patients, who underwent surgery in our institution for the treatment of urinary calculi, were enrolled. Results: Six hundred and thirteen procedures and 4,850 shock wave lithotripsy (SWL) were performed. In the first year of the study (2004), only six (4.7%) cases were done by laparoscopic approach, whereas in the last year (2008) a total of 17 (15.2%) cases were performed using the laparoscopic technique. Conclusion: The SWL and the endoscopic surgery remained as the first line treatment of urinary stones, during the whole period studied. The laparoscopic technique, despite its limitations, is getting acceptance (over the traditional open procedure) and is indicated in those cases where minimally invasive techniques have failed.

Nomenclature of natural orifice translumenal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) procedures in urology.

INTRODUCTION: The twenty first century has witnessed some amazing advancements in surgery. In urology minimally invasive surgery has become the standard treatment for many disease processes and procedures. One of the newest innovations into this field has been the development of Natural Orifice Translumenal Endoscopic Surgery (NOTES) and Laparoendoscopic Single-site Surgery (LESS). While the practice and application of these new techniques are in their infancy, there has been a great deal of confusion regarding the nomenclature and terminology associated with these procedures. The aim of this publication is to attempt to define the many issues associated with the standardization of terminology for these procedures in order to promote effective scientific progress and communication. MATERIALS AND METHODS: A literature search using Medline and pubmed focusing on all terminology to describe NOTES and LESS from 1990 to 2008 was done. In addition, various acronyms were searched using four separate online acronym databases. The information was recorded by number of citations and by the number of citations specific to the urologic literature. Based on common usage, definitions and criteria were developed to describe these procedures for current scientific publication. These terms were then collectively reviewed and agreed upon by the Urologic NOTES Working Group as a platform for consensus to begin the arduous process of standardization. RESULTS: There is wide variation in the terminology and use of acronyms for natural orifice translumenal endoscopic surgery and laparo-endoscopic single-site surgery. The keyword literature search uncovered 8710 citations from MEDLINE and pubmed, with 363 citations specific to urology. There was significant overlap in the search of different terms. The search of established abbreviation and acronym databases revealed many citations, but relatively few specific to urology. CONCLUSION: Standardization of the nomenclature applied to natural orifice transluminal endoscopic surgery (NOTES) and laparo-endoscopic single-site surgery (LESS) is essential as the body of literature continues to grow in order to allow clear and precise scientific communication. As the techniques continue to evolve, we propose that NOTES and LESS be designated as the common terms to define these new procedures in urology.

Spectrum of urological procedures in University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria.

AIM: To determine the relative frequencies of types of operations, age and gender distribution of the patients and the indications for operation in the Urology Unit over a 10-year period between 1989 and 1998. SETTING: The Urology Unit of the University of Port Harcourt Teaching Hospital. TYPE OF STUDY: Retrospective. METHODS: Patients' demographic data were collected from the Main Theatre registers of the Hospital, the Medical Records Department ward records patients' and case note. Those operations done in the Urology Unit were analysed. RESULTS: Urological operations (total 1875) formed 22.6% of all surgical operations in the hospital during the decade under review. There were 1847 males (98.5%) and 28 females (1.5%). The age distribution showed two peaks in the first decade and in the seventh decade. Frequencies of operations were least in the 4th decade and after the 9th decade. Circumcisions, surgery for prostate disease, procedures for urethral strictures, urological trauma and paediatric reconstruction formed the majority of operations. Endoscopic urological procedures were limited to the occasional cystoscopy. Some 67.6% of the operations were performed in the first half of the decade and 32.4% in the second half. A rapid decrease in the number of operations was noticed which compared with the same pattern in the Department of Surgery as a whole. CONCLUSION: We recommend the establishment and development of human and material resources for Urological service for basic procedures and endo-urological practice in keeping with contemporary trends and the allocation of more theatre space and out-patient Clinic time to the urology service.

Minimally invasive surgical management of ureteropelvic junction obstruction: laparoscopic and robot-assisted laparoscopic pyeloplasty.

Ureteropelvic junction (UPJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by an intrinsic or extrinsic obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital in origin; however, acquired conditions at the level of the ureteropelvic junction may also present with symptoms and signs of obstruction. Until recently, open pyeloplasty and endoscopic techniques have been the main surgical options, with the intent of complete excision or incision of the obstruction. The introduction of laparoscopy and robot-assisted applications has allowed for minimally invasive reconstructive surgery that mirrors open surgical techniques. These techniques offer substantial benefits to patients by reducing morbidity, hastening postoperative recovery, and improving cosmetic outcome. During the last decade, laparoscopic pyeloplasty has garnered much interest. However, because of the technically challenging nature of this procedure, it is performed only at select medical centers by surgeons with advanced laparoscopic training. The recent introduction of robotics to the field of minimally invasive surgery may facilitate this procedure and allow for more widespread implementation by surgeons of varying skill levels. This review is limited primarily to the treatment of congenital or acquired UPJ obstruction via laparoscopic and robot-assisted laparoscopic pyeloplasty. Herein, we report the early results, ongoing evolution, and potential future role for these novel surgical procedures.

[Remarks on the introduction of the German Diagnosis-Related Groups (DRGs) for the specialty of urology]. / Anmerkungen zur Einführung der Deutschen Diagnosis-related Groups (G-DRGs) für das Fach Urologie.

In January 2003 a new system to charge inpatient treatment was established in Germany: the G-DRGs. This system is based on the thought that equal medical service causes equal costs all over Germany. Hospitals offering a broad spectrum of diagnostics and therapies and being unable to select their patients according to economical aspects are put at disadvantage: Despite a perfect documentation the G-DRGs reflect their medical service only in an insufficient way. Tools for an optimized coding must be a coding manual created for the specific needs of urologists and an infrastructure that allows a permanent quality control for all persons involved.

[Clinical study of surgical site infection following portless endoscopic urological surgery (PLES)].

We investigated the clinical risk factors and bacteriological examination for surgical site infection (SSI) in 144 portless endoscopic surgeries consisting of 66 clean and 78 clean-contaminated surgeries in urological diseases from April 2000 to December 2001. There were no cases of SSI in the clean surgeries. SSI occurred in 5 cases (3.5%) of clean-contaminated surgeries including total cystectomy and ileal conduit in 4 cases and total prostatectomy in 1 case. Multivariate statistical studies revealed that usage of ileum during operation and preoperative hypo-albuminemia were significant risk factors for SSI. Gram-negative rods and anaerobic bacteria were isolated from the operative wound in the total cystectomy and ileal conduit, suggesting that SSI in the operation with usage of the ileum was partially derived from contamination with endogenous bacteria, while, normal flora of the skin in the wound did not cause any post-operative SSI.

The 'top 10' urological procedures: a study of hospital episodes statistics 1998-99.

OBJECTIVE: To summarize the urological procedures recorded in Hospital Episodes Statistics (HES, 1998-99) and to examine the accuracy of coding and HES. MATERIALS AND METHODS: Data on the 10 commonest urological procedures from the Department of Health website (www.doh.gov.uk/hes) were extracted, summarized and presented. RESULTS: Urethral catheterization, endoscopic procedures on the bladder, prostate, urethra and ureter (excluding ureteric stone extraction), minor open procedures on the foreskin and the vas, bladder instillation, extracorporeal shockwave lithotripsy and prostatic biopsy are the 10 commonest procedures, according to finished consultant episodes. There is published evidence that the data from coding and HES are not completely accurate. CONCLUSION: This study highlights shortfalls in the HES data (1998-99) which may directly affect the funding of urological services.

Use of new technology in endourology and laparoscopy by american urologists: internet and postal survey.

OBJECTIVES: To assess the use of new technology by American urologists. METHODS: Using the American Urological Association directory, surveys were sent via the U.S. postal service to 1000 randomly selected American urologists and 3065 urologists who had an Internet address listed in the directory. RESULTS: Responses were received from 601 urologists (415 postal, 186 Internet). Overall, 81% of survey respondents reported performing fewer or the same number of percutaneous procedures as compared with 3 to 4 years ago and 84% reported carrying out more or the same number of ureteroscopic procedures in the treatment of patients with stone disease. Open dismembered pyeloplasty (43%) and Acucise endopyelotomy (42%) were most frequently reported as the preferred treatment for adult patients with symptomatic ureteropelvic junction obstruction. Although 60% of respondents reported that they have taken a laparoscopy course, 67% currently do not perform any laparoscopy in their practice. In addition, only 7% of urologists stated that laparoscopy comprises more than 5% of their practice. When stratified by the number of years in practice, those in practice less than 10 years were more likely than those in practice 10 to 20 years and those in practice longer than 20 years to have performed an endopyelotomy (77%, 60%, and 48%, respectively, P <0.001) and to be currently performing laparoscopy (49%, 36%, and 18%, respectively, P <0.001). CONCLUSIONS: Compared with 3 to 4 years ago, American urologists are performing more ureteroscopy and fewer percutaneous stone procedures. Although most urologists have taken laparoscopy courses, this modality has not been widely incorporated into their practices at present.