Iatrogenic ureteric injury during abdominal or pelvic surgery: a meta-analysis.

OBJECTIVE: To assess the incidence of ureteric injuries, clinical value of prophylactic ureteric stenting and impact of intra- or postoperative detection of ureteric injuries in patients treated with gynaecological or colorectal surgery. METHODS: Multiple databases were searched for articles published before September 2021 according to the Preferred Reporting Items for Systematic Review and Meta-Analyses statement. Studies were deemed eligible if they evaluated the differences in the rate of ureteric injuries between laparoscopic and open surgery, prophylactic ureteric stenting or not, and those of final treatment success between intra- and postoperative detection in patients who underwent gynaecological or colorectal surgery. RESULTS: Overall, 46 studies were eligible for this meta-analysis. Compared to open surgery, laparoscopic hysterectomy was associated with a higher incidence of ureteric injuries (pooled odds ratio [OR] 2.12, 95% confidence interval [CI] 1.71-2.62), but there was no statistically significant difference in colectomy (pooled OR 0.89, 95% CI 0.77-1.03). Prophylactic ureteric stenting was associated with a lower incidence of ureteric injuries during gynaecological surgery (pooled OR 0.61, 95% CI 0.39-0.96). The number needed to perform ureteric stenting to prevent one ureteric injury was 224 in gynaecological surgery. On the other hand, prophylactic ureteric stenting did not reduce the risk of ureteric injuries during colorectal surgery. Intraoperative detection of a ureteric injury was associated with a lower rate of complication management failure compared to postoperative detection (pooled OR 0.22, 95% CI 0.12-0.41). CONCLUSIONS: Laparoscopic hysterectomy seems to be associated with a higher rate of ureteric injuries compared to an open approach. Prophylactic ureteric stenting seems to reduce this risk during gynaecological surgery. Intraoperative detection of a ureteric injury during abdominal/pelvic surgery improves outcomes, suggesting the need for awareness and proactive problem identification. Further well-designed studies assessing the candidates who are more likely to benefit from prophylactic ureteric stenting including cost analysis are needed.

[The use of "Fast-Track" in pediatric urology].

BACKGROUND: Current trends in the anesthesiology require a change in the perioperative management of patients, with a consideration of new approaches to anesthesia and the introduction of methods that reduce the stress response to surgery. AIM: To introduce the "fast-track" concept with the analysis of systemic hemodynamics and stress markers at the perioperative stage in children with urological diseases. MATERIALS AND METHODS: A prospective and retrospective analysis of the results of 42 children with urological disorders treated from 09.2016 to 04.2021 under spinal anesthesia (SA) was carried out. In each case, perioperative parameters were evaluated, including central hemodynamics and biochemical markers of stress response. RESULTS: Hemodynamic stability under SA in young children has an evidence base and a physiological explanation. Changes in stress response markers in various anesthesia methods revealed a more pronounced stress-protective effect in SA than in general anesthesia. CONCLUSIONS: Our data have shown that combined SA for urological procedures in children allows to more effectively and reliably prevent and block the manifestations of stress-induced reactions of hemodynamics and metabolism than general anesthesia. The introduction of fast-track approach in pediatric urology resulted in the faster postoperative recovery and shorter length of stay.

[Urological problems related to coloproctology. Part 1].

The aim of this review was to characterize the possible urological manifestations of rectal disorders in case of the involvement of the genitourinary system, as well as the symptoms of urological diseases involving the distal part of the large bowel. In urological and coloproctological practice, the anatomical and physiological proximity of the distal part of the intestine and the urogenital organs is of importance (for example, the common innervation of the pelvic organs, the synergy of the pelvic floor muscles, etc.), since it results in similar clinical manifestations, making it difficult to make a diagnosis. The most relevant and common urological and proctological diseases, including prostatitis, intestinovesical and rectourethral fistulas, damage to the ureter and bladder during colorectal surgery are discussed in the article. Particular attention is paid to the interdisciplinary cooperation of urologists and proctologists and the frequent need for their joint participation in the diagnosis and treatment of the pelvic organs disorders.

Clinical use and complications of percutaneous cystostomy pigtail catheters in 25 cats.

OBJECTIVES: The aims of this study were to describe the indications for percutaneous pigtail catheter placement in cats requiring urine diversion, and to report the associated intra- and postoperative complications. METHODS: The medical records of cats that underwent percutaneous pigtail catheter placement for urine diversion between January 2011 and May 2021 were retrospectively reviewed. RESULTS: Twenty-five cats were included. Indications for pigtail catheter placement were medical management of obstructive urinary tract disease (n = 12), urinary tract damage after traumatic injury (n = 8) and neurological bladder dysfunction (n = 5). Catheters were in place for a median time of 8.28 days (range 3-27), and the duration of the catheter placement was not different between the medical, traumatic and neurological groups. Ten cats (40%) developed pigtail catheter complications including dislodgement, urine leakage, urinary tract infection and bladder rupture. The majority of complications were easily resolved and did not require surgical intervention. CONCLUSIONS AND RELEVANCE: The results suggest that percutaneous pigtail catheter placement can facilitate urine diversion in both the emergency setting and in the long-term management of urine retention without many complications.

Impact of COVID-19 pandemic on functional urology procedures in France: a prospective study.

PURPOSE: To evaluate the impact of COVID-19 pandemic on functional urology procedures in France. METHODS: A prospective study was conducted within 11 secondary and tertiary referral centers in France. Patients aged > 18 years who were diagnosed with a functional urology disease before the national lockdown (March 17th, 2020) and who required a surgery were included. Study period went from March 17th to September 30th 2020. The included interventions were listed according to the guidelines for functional urology enacted by the French Association of Urology and delay of reoperation was compared to the guidelines' delay. The primary outcome was the number of procedures left unscheduled at the end of the study period. Descriptive statistics were performed. RESULTS: From March 17th 2020 to September 3 rd 2020, 1246 patients with a previous diagnosis of a functional urological disease requiring a surgery were included. The mean follow-up was 140.4 days (± 53.4). Overall, 316 interventions (25.4%) were maintained whereas 74 (5.9%) were canceled, 848 (68.1%) postponed and 8 patients (0.6%) died. At the end of the follow-up, 184 patients (21.7%) were still not rescheduled. If the intervention was postponed, the mean delay between the initial and final date was 85.7 days (± 64.4). CONCLUSION: Overall, more than two thirds of interventions had to be postponed and the mean delay between the initial and final date was about three months.

[Outcomes following the triage of patients for urological cancer and non-cancer surgery during Covid-19 pandemic peak]. / Évaluation des mesures de triages de la première vague pandémique Covid-19 pour sélectionner les patients à opérer pour cancers et urgences urologiques.

INTRODUCTION: Faced with the first wave of Covid-19 pandemic, guidelines for surgical triage were developed to free up healthcare resources. The aim of our study was to assess clinical characteristics and surgical outcomes of triaged patients during the first Covid-19 crisis. METHOD: We conducted a cohort-controlled, non-randomized, study in a University Hospital of south-eastern France. Data were collected prospectively from consecutive patients after triage during the period from March 15th to May 1st and compared with control data from outside pandemic period. Primary endpoint was intensive care unit (ICU) admissions for surgery-related complications. Rates of surgery-specific death, postponed operations, positive PCR testing and Clavien-Dindo complications and data from cancer and non- cancer subgroups were assessed. RESULTS: After triage, 96 of 142 elective surgeries were postponed. Altogether, 71 patients, median age 68 y.o (IQR: 56-75 y.o), sex ratio M/F of 4/1, had surgery, among whom, 48 (68%) had uro-oncological surgery. No patients developed Covid-19 pneumonia in the post-surgery period. Three (4%) were admitted to the ICU, one of whom died from multi-organ failure due to septic shock caused by klebsiella pneumonia following a delay in treatment. Three Covid-19 RT-PCR were done and all were negative. There was no difference in mortality rates or ICU admission rates between control and Covid- era patients. CONCLUSIONS: Surgery after triage during the first Covid-19 pandemic was not associated with worse short-term outcomes. Urological cancers could be operated on safely in our context but delays in care for aggressive genitourinary diseases could be life threatening. LEVEL OF EVIDENCE: 3.

[Impact of COVID-19 outbreak on urology surgical waiting lists and waiting lists prioritization strategies in the Post-COVID-19 era]. / Impacto del brote de COVID-19 en las listas de espera de cirugía urológica y estrategias de priorización en la era post-COVID-19.

Introduction: The suspension of most elective surgeries during COVID-19 pandemic caused the lengthening of urology surgical waiting lists. The objective of this study is to evaluate the impact of COVID-19 pandemic on urology surgical waiting list in a high-volume hospital. Methods: An observational descriptive study was designed. All patients included in the urology surgical waiting list of our high-volume center on May 1st 2020 (46 days after the suspension of elective surgery) were analyzed. Baseline variables, priority on the waiting list, main urological disease, type of scheduled surgery, and waiting time were recorded. Other variables recorded were the presence of a urinary catheter, number of accesses to the emergency department, evidence of COVID-19 infection, number of deaths and their cause. The waiting time for each disease was compared with the time to surgery in 2019. Results: A total of 350 patients were included. The mean (SD) time on the waiting list was 97.33 (55.47) days. Priority 1 patients, who normally should undergo surgery within 30 days, were on the waiting list for a mean (SD) time of 60.51 (20.14) days. They were mainly patients with ureteral lithiasis (25.6%), high-risk or muscle-invasive bladder cancer (20.9%) and high-risk prostate cancer (13.9%). The mean waiting time had already significantly exceeded the mean time to surgery in 2019 for radical cystectomy (p = 0.04) and URS (p = 0.003). Conclusions: The suspension of most elective surgeries due to COVID-19 had a significant impact on urology surgical waiting list of our high-volume center, especially in priority 1 group.

Minimal-invasive management of urological complications after kidney transplantation.

Kidney transplantation represents the gold standard treatment option for patients with end-stage renal disease. Improvements in surgical technique and pharmacologic treatment have continuously prolonged allograft survival in recent years. However, urological complications are frequently observed, leading to both postoperative morbidity and putative deterioration of allograft function. While open redo surgery in these patients is often accompanied by elevated surgical risk, endoscopic management of urological complications is an alternative, minimal-invasive option. In the present article, we reviewed the literature on relevant urological postoperative complications after kidney transplantation and describe preventive approaches during the pre-transplantation assessment and their management using minimal-invasive approaches.

Management of the Transitional Urology Patient: the Role of the Adult Reconstructive Urologist.

PURPOSE OF REVIEW: Patients with congenital urologic conditions present unique challenges as adults. Herein, we review the literature relevant to the adult reconstructive urologist confronted with complex surgical concerns affecting their patients with a history of hypospadias, spina bifida, and other syndromes affecting the genitourinary tract. RECENT FINDINGS: Urethral stricture disease related to hypospadias is complex, but successful urethroplasty and penile curvature correction can be achieved with an anatomically minded approach. Multiple urinary diversion techniques can be considered in a patient-centered approach to bladder management in the adult spina bifida patient, but complications are common and revision surgeries are frequently required. Strong evidence is lacking for most surgical techniques in this population, but experiences reported by pediatric and adult urologists with genitourinary reconstruction training can help foster consensus in decision-making. Urologists trained in genitourinary reconstruction may be uniquely positioned to care for the transitional urology patient as they enter adolescence and adulthood.

Risk-based stratification triaging system in pediatric urology: what COVID-19 pandemic has taught us.

INTRODUCTION AND OBJECTIVE: SARS-COV-2 pandemic has affected the population worldwide requiring social distancing, quarantine and isolation as strategies to control virus propagation. Initial measures to reduce the burden to the health care system during the pandemic included deferring elective surgery. These damage control measures did not take into account the mid- and long-term implications. Management of congenital anomalies can be time sensitive with delays resulting in permanent disability, morbidity and increased costs to the healthcare system. This study reports the results of using a novel scoring system that enables triage of time sensitive congenital anomalies and pediatric surgical conditions and how implementation of Enhanced Recovery After Surgery (ERAS®) principles allowed optimization of resources and reduced the burden to the system while allowing for appropriate care of pediatric patients with urgent urologic surgical conditions. METHODS: We present a prospective case series of patients with congenital urological conditions scheduled and taken to surgery during COVID-19 pandemic. All pediatric urology cases that were pending and or scheduled for surgery at the moment the pandemic struck as well as all cases that presented to the emergency department with urological conditions were triaged and included for analysis using a modified Medically Necessary, Time-Sensitive Procedures: Scoring System (MeNTS). A modified MeNTS was implemented for pediatric patients, giving more priority to the impact of deferring surgical intervention on patient's prognosis. An individualized evaluation using this scoring system was applied to each patient. Intra- and postoperative ERAS® principles were applied to all cases operated during the pandemic between March 20th and April 24th to reduce the burden to the healthcare system. RESULTS: A total of 49 patients were triaged and included for analysis with a mean age of 6.47 years of age. Adjusted MeNTS showed that all clinically emergent cases had a score of 12 or less. Cases that could be postponed for 2 weeks but no longer had a score between 13 and 15. The ones that could wait 6 weeks or longer had scores higher than 16. Score results were not the same for similar procedures and individualized assessments resulted in scores based on an individual patient's conditions. From the total cases, implementation of ERAS® principles increased outpatient procedures from 68 to 90.4%. CONCLUSION: Our results provide a novel triaging method to rank pediatric urological surgical management based on individualized patient's clinical conditions. Cutoff values of 12 and 16 allowed appropriate triage preventing the postponement of urgent urologic cases during the COVID-19 pandemic. Implementation of ERAS® principles allowed for these procedures to be done in the outpatient setting, preserving valuable healthcare resources. TYPE OF STUDY: Prospective cohort study. LEVEL OF EVIDENCE: IV.

Single Port Robotic Surgery in Urology.

PURPOSE: To provide a comprehensive review on the new da Vinci SP (single port) robotic surgical system. The published literature to date within urology and a description of the new system will be discussed. FINDINGS: There are currently no high-quality published studies with the SP robotic system. All studies are case series, many with 10 or fewer patients. However, all studies have found the SP system to be safe and feasible in performing most urological procedures. Renal and pelvic surgery using the SP robotic system is safe and feasible in the hands of expert robotic surgeons. Long-term, high-quality data is lacking. While the current high price and the learning curve will limit the SP systems' use in many health care systems, new updates and the release of robotic surgical systems from other developers may help drive down costs and encourage uptake.

The dramatic COVID 19 outbreak in Italy is responsible of a huge drop of urological surgical activity: a multicenter observational study.

OBJECTIVE: To describe the trend in surgical volume in urology in Italy during the coronavirus disease 2019 (COVID-19) outbreak, as a result of the abrupt reorganisation of the Italian national health system to augment care provision to symptomatic patients with COVID-19. METHODS: A total of 33 urological units with physicians affiliated to the AGILE consortium (Italian Group for Advanced Laparo-Endoscopic Surgery; www.agilegroup.it) were surveyed. Urologists were asked to report the amount of surgical elective procedures week-by-week, from the beginning of the emergency to the following month. RESULTS: The 33 hospitals involved in the study account overall for 22 945 beds and are distributed in 13/20 Italian regions. Before the outbreak, the involved urology units performed overall 1213 procedures/week, half of which were oncological. A month later, the number of surgeries had declined by 78%. Lombardy, the first region with positive COVID-19 cases, experienced a 94% reduction. The decrease in oncological and non-oncological surgical activity was 35.9% and 89%, respectively. The trend of the decline showed a delay of roughly 2 weeks for the other regions. CONCLUSION: Italy, a country with a high fatality rate from COVID-19, experienced a sudden decline in surgical activity. This decline was inversely related to the increase in COVID-19 care, with potential harm particularly in the oncological field. The Italian experience may be helpful for future surgical pre-planning in other countries not so drastically affected by the disease to date.

A Critical Appraisal of the American College of Surgeons Medically Necessary, Time Sensitive Procedures (MeNTS) Scoring System, Urology Consensus Recommendations and Individual Surgeon Case Prioritization for Resumption of Elective Urological Surgery During the COVID-19 Pandemic.

PURPOSE: Resumption of elective urology cases postponed due to the COVID-19 pandemic requires a systematic approach to case prioritization, which may be based on detailed cross-specialty questionnaires, specialty specific published expert opinion or by individual (operating) surgeon review. We evaluated whether each of these systems effectively stratifies cases and for agreement between approaches in order to inform departmental policy. MATERIALS AND METHODS: We evaluated triage of elective cases postponed within our department due to the COVID-19 pandemic (March 9, 2020 to May 22, 2020) using questionnaire based surgical prioritization (American College of Surgeons Medically Necessary, Time Sensitive Procedures [MeNTS] instrument), consensus/expert opinion based surgical prioritization (based on published urological recommendations) and individual surgeon based surgical prioritization scoring (developed and managed within our department). Lower scores represented greater urgency. MeNTS scores were compared across consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores. RESULTS: A total of 204 cases were evaluated. Median MeNTS score was 50 (IQR 44, 55), and mean consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores were 2.6±0.6 and 2.2±0.8, respectively. Median MeNTS scores were 52 (46.5, 57.5), 50 (44.5, 54.5) and 48 (43.5, 54) for individual surgeon based surgical prioritization priority 1, 2 and 3 cases (p=0.129), and 55 (51.5, 57), 47.5 (42, 56) and 49 (44, 54) for consensus/expert opinion based surgical prioritization priority scores 1, 2, and 3 (p=0.002). There was none to slight agreement between consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores (Kappa 0.131, p=0.002). CONCLUSIONS: Questionnaire based, expert opinion based and individual surgeon based approaches to case prioritization result in significantly different case prioritization. Questionnaire based surgical prioritization did not meaningfully stratify urological cases, and consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization frequently disagreed. The strengths and weaknesses of each of these systems should be considered in future disaster planning scenarios.

Nonobstetrical Robotic-Assisted Laparoscopic Surgery in Pregnancy: A Systematic Literature Review.

Urologic and gynecologic surgeons are the top utilizers of robotic surgery; however, nonobstetrical robotic-assisted laparoscopic surgery (RALS) in pregnant patients is infrequent. A systematic literature review was performed to ascertain the frequency, indication and complications of RALS in pregnancy. Results showed 38 pregnancies from eleven publications between 2008 and 2020. Five cases were for urologic indication and 33 for gynecologic indication. Minimal surgical alterations were required. Although no adverse maternal-fetal outcomes were reported, there are not enough cases published to determine safety. This review demonstrates the feasibility of RALS for the pregnant population in the hands of competent robotic surgeons.