A novel mortality risk score for emphysematous pyelonephritis: A multicenter study of the Global Research in the Emphysematous Pyelonephritis group.

Background: Emphysematous pyelonephritis (EPN) is a necrotizing infection of the kidney and the surrounding tissues associated with considerable mortality. We aimed to formulate a score that classifies the risk of mortality in patients with EPN at hospital admission. Materials and methods: Patients diagnosed with EPN between 2013 and 2020 were retrospectively included. Data from 15 centers (70%) were used to develop the scoring system, and data from 7 centers (30%) were used to validate it. Univariable and multivariable logistic regression analyses were performed to identify independent factors related to mortality. Receiver operating characteristic curve analysis was performed to construct the scoring system and calculate the risk of mortality. A standardized regression coefficient was used to quantify the discriminating power of each factor to convert the individual coefficients into points. The area under the curve was used to quantify the scoring system performance. An 8-point scoring system for the mortality risk was created (range, 0-7). Results: In total, 570 patients were included (400 in the test group and 170 in the validation group). Independent predictors of mortality in the multivariable logistic regression were included in the scoring system: quick Sepsis-related Organ Failure Assessment score ≥2 (2 points), anemia, paranephric gas extension, leukocyte count >22,000/µL, thrombocytopenia, and hyperglycemia (1 point each). The mortality rate was <5% for scores ≤3, 83.3% for scores 6, and 100% for scores 7. The area under the curve was 0.90 (95% confidence interval, 0.84-0.95) for test and 0.91 (95% confidence interval, 0.84-0.97) for the validation group. Conclusions: Our score predicts the risk of mortality in patients with EPN at presentation and may help clinicians identify patients at a higher risk of death.

Prognosis of Extended-Spectrum-Beta-Lactamase-Producing Agents in Emphysematous Pyelonephritis-Results from a Large, Multicenter Series.

BACKGROUND: Emphysematous pyelonephritis (EPN) is a necrotizing infection of the kidney and surrounding tissues with significant mortality. We aimed to assess the clinical factors and their influence on prognosis in patients being managed for EPN with and without ESBL-producing bacteria and to identify if those with EPN due to ESBL infections fared any different. METHODS: A retrospective analysis was performed on patients with EPN diagnosis from 22 centers across 11 countries (between 2013 and 2020). Demographics, clinical presentation, biochemical parameters, radiological features, microbiological characteristics, and therapeutic management were assessed. Univariable and multivariable analyses were performed to determine the independent variables associated with ESBL pathogens. A comparison of ESBL and non-ESBL mortality was performed evaluating treatment modality. RESULTS: A total of 570 patients were included. Median (IQR) age was 57 (47-65) years. Among urine cultures, the most common isolated pathogen was Escherichia coli (62.2%). ESBL-producing agents were present in 291/556 urine cultures (52.3%). In multivariable analysis, thrombocytopenia (OR 1.616 95% CI 1.081-2.413, p = 0.019), and Huang-Tseng type 4 (OR 1.948 95% CI 1.005-3.778, p= 0.048) were independent predictors of ESBL pathogens. Patients with Huang-Tseng Scale type 1 had 55% less chance of having ESBL-producing pathogens (OR 1.616 95% CI 1.081-2.413, p = 0.019). Early nephrectomy (OR 2.3, p = 0.029) and delayed nephrectomy (OR 2.4, p = 0.015) were associated with increased mortality in patients with ESBL infections. Conservative/minimally invasive management reported an inverse association with mortality (OR 0.314, p = 0.001). CONCLUSIONS: ESBL bacteria in EPN were not significantly associated with mortality in EPN. However, ESBL infections were associated with poor prognosis when patients underwent nephrectomy compared conservative/minimally invasive management.

Small renal masses in Latin-American population: characteristics and prognostic factors for survival, recurrence and metastasis - a multi-institutional study from LARCG database.

BACKGROUND: To evaluate demographic, clinical and pathological characteristics of small renal masses (SRM) (≤ 4 cm) in a Latin-American population provided by LARCG (Latin-American Renal Cancer Group) and analyze predictors of survival, recurrence and metastasis. METHODS: A multi-institutional retrospective cohort study of 1523 patients submitted to surgical treatment for non-metastatic SRM from 1979 to 2016. Comparisons between radical (RN) or partial nephrectomy (PN) and young or elderly patients were performed. Kaplan-Meier curves and log-rank tests estimated 10-year overall survival. Predictors of local recurrence or metastasis were analyzed by a multivariable logistic regression model. RESULTS: PN and RN were performed in 897 (66%) and 461 (34%) patients. A proportional increase of PN cases from 48.5% (1979-2009) to 75% (after 2009) was evidenced. Stratifying by age, elderly patients (≥ 65 years) had better 10-year OS rates when submitted to PN (83.5%), than RN (54.5%), p = 0.044. This disparity was not evidenced in younger patients. On multivariable model, bilaterality, extracapsular extension and ASA (American Society of Anesthesiologists) classification ≥3 were predictors of local recurrence. We did not identify significant predictors for distant metastasis in our series. CONCLUSIONS: PN is performed in Latin-America in a similar proportion to developed areas and it has been increasing in the last years. Even in elderly individuals, if good functional status, sufficiently fit to surgery, and favorable tumor characteristics, they should be encouraged to perform PN. Intending to an earlier diagnosis of recurrence or distant metastasis, SRM cases with unfavorable characteristics should have a more rigorous follow-up routine.

Robotic-assisted radical prostatectomy: The teaching. / Formación del personal en la prostatectomía radical laparoscópica asistida por robot.

OBJECTIVE OF THE REVIEW: Robot assisted Radical prostatectomy (RARP) has generated a new trend in the binomial teaching/learning, grouping these techniques in training modules such as theoretical learning, practice, personalized counseling, and modern tools like simulation and practice in virtual models. This review summarizes the current trend in the teaching process of RARP. RECENT FINDINGS: Current trends in the acquisition of the RARP learning curve is to provide the Urologist with a well-structured teaching process, implementing gradual training modules, which make possible to understand all aspects of the development of prostate surgery with a robotic system. This process consists in analyzing the theoretical aspects, perform training with high quality simulators and proctorization, in both cases in vivo and as assistant, until completion of the advanced phase in console with haptic training and proctor's direct advice, while the learning curve is being completed. The evidence shows that student and proctor feedback with the use of virtual models, immediately post-procedure video analysis, and a high-volume center are able to shorten the teaching process. The learning process never culminates, in other words, the final phase of the student, is when he is prepared to teaching the multiplier effect of his learning curve. CONCLUSIONS: Virtual models in Robotic surgery has changed the perspective teaching process of medicine. Theoretical knowledge, virtual training and Proctor's advice are essential steps in the learning curve. Future directions,evolution of virtual models in a similar fashion to the real scenario.

OBJETIVO: La Prostatectomía Radical asistida por Robot (PRAR) ha generado una nueva tendencia en el binomio enseñanza/aprendizaje agrupando estastécnicas en módulos de entrenamiento como aprendizaje teórico, practico, asesoramiento personalizado y herramientas modernas como simulación y práctica en modelos virtuales. Esta revisión resume la tendencia actual en el proceso de enseñanza de la PRAR. HALLAZGOS RECIENTES: La tendencia actual en la adquisición de la curva de la PRAR es proporcionar al urólogo un proceso de enseñanza bien estructurado,implementando módulos de entrenamiento graduales, que le permitan comprender en todos los aspectos el desenvolvimiento de la cirugía radical de próstata con un sistema robótico. Dicho proceso consiste en analizarlas bases teóricas, realizar entrenamiento con simulado res de alta calidad, interactuar con él supervisor tanto en casos in vivo como en ayudantía de cirugías, hasta completar la fase avanzada en consola con entrenamientoháptico y asesoramiento directo del supervisor, mientras se adquiere la curva de aprendizaje. La evidencia demuestra que la retroalimentación del alumno yproctor supervisor con el uso de modelos virtuales, análisis de videos inmediatamente posterior al procedimiento y un centro de alto volumen logran acortar el proceso de enseñanza. La formación en cirugía robótica nunca culmina, por el contrario, la fase final del alumno, es cuando se encuentra preparado para realizar el efecto multiplicador de su curva de aprendizaje.CONCLUSIÓN: La Cirugía Robótica ha cambiado la perspectiva de la  enseñanza de la Medicina, mediante el uso de modelos virtuales. Conocimientos teóricos, entrenamiento virtual y el asesoramiento del supervisor son pasos necesarios en la curva de aprendizaje. Direccionesfuturas esperadas son la evolución de los modelos virtuales similares al escenario real.