Propensity-matched Analysis of Open Versus Robotic Primary Retroperitoneal Lymph Node Dissection for Clinical Stage II Testicular Cancer.

BACKGROUND: Open retroperitoneal lymph node dissection (O-RPLND) is the accepted standard surgical approach to treat retroperitoneal nodal disease in testis cancer. Increasingly, robotic RPLND (R-RPLND) is being performed due to the potential for lower blood loss, shorter length of stay, and accelerated recovery. OBJECTIVE: We have performed a propensity score matching (PSM) analysis comparing the survival and perioperative outcomes of O- and R-RPLND. DESIGN, SETTING, AND PARTICIPANTS: Analyzing the data from all patients who underwent primary RPLND at our center between 1990 and 2022, we used PSM to create a 2:1 (O-RPLND:R-RPLND) matched cohort. INTERVENTION: Primary O-RPLND versus R-RPLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was time to relapse. The secondary endpoints included operating time, length of stay, estimated blood loss (EBL), and surgical complications. Relapse-free survival rates were calculated using the Kaplan-Meier method, and log-rank tests were used to compare perioperative outcomes of O-RPLND versus R-RPLND. KEY FINDINGS AND LIMITATIONS: A total of 178 patients underwent primary RPLND: 137 O-RPLND and 41 R-RPLND. After PSM, 26 patients in the R-RPLND group were matched with 38 in the O-RPLND group. After matching, no significant baseline differences were noted. After a median follow-up of 23.5 mo (interquartile range 4.4-59.2), one (3.8%) relapse was noted in the R-RPLND group versus three (7.8%) in the O-RPLND group; however, this was not significant (hazard ratio 0.65, 95% confidence interval 0.07-6.31, p = 0.7097). No in-field relapses occurred in either cohort. R-RPLND was associated with a shorter length of stay (1 vs 5 d, p < 0.0001) and lower EBL (200 vs 300 ml, p = 0.032), but longer operative time (8.8 vs 4.3 h, p < 0.0001). CONCLUSIONS: R-RPLND offers low morbidity and improved perioperative outcomes, while maintaining oncologic efficacy of the open approach. PATIENT SUMMARY: To the best of our knowledge, this is the first study to compare open and robotic retroperitoneal lymph node dissection (R-RPLND) using a propensity score-matched system. We encourage the discussion and inclusion of primary R-RPLND into the standard of care algorithm for patients with de novo clinical stage (CS) II and relapsed CS I with CS II equivalent disease.

Long-term outcomes and cost savings of office fulguration of papillary Ta low-grade bladder cancer.

OBJECTIVES: To assess whether office-based fulguration (OF) under local anaesthesia for small, recurrent, pathological Ta low-grade (LG) non-muscle-invasive bladder cancer (NMIBC) is an effective alternative to transurethral resection of bladder tumour (TURBT), avoiding the costs and risks of procedure, and anesthesia. PATIENTS AND METHODS: Of 521 patients with primary TaLG NMIBC, this retrospective study included 270 patients who underwent OF during follow-up for recurrent, small, papillary LG-appearing tumours at a university centre (University Health Network, University of Toronto, Canada). We assessed the cumulative incidence of cancer-specific mortality (CSM) and disease progression (to MIBC or metastases), as well as possible direct cost savings. RESULTS: In the 270 patients with recurrent TaLG NMIBC treated with OF, the mean (sd) age was 64.9 (13.3) years, 70.8% were men, and 60.3% had single tumours. The mean (sd, range) number of OF procedures per patient was 3.1 (3.2, 1-22). The median (interquartile range) follow-up was 10.1 (5.8-16.2) years. Patients also underwent a mean (sd) of 3.6 (3.0) TURBTs during follow-up in case of numerous or bulkier recurrence. In all, 44.4% of patients never received intravesical therapy. The 10-year incidence of CSM and progression were 0% and 3.1% (95% confidence interval 0.8-5.4%), respectively. Direct cost savings in Ontario were estimated at $6994.14 (Canadian dollars) per patient over the study follow-up. CONCLUSIONS: This study supports that properly selected patients with recurrent, apparent TaLG NMIBC can be safely managed with OF under local anaesthesia with occasional TURBT for larger or numerous recurrent tumours, without compromising long-term oncological outcomes. This approach could generate substantial cost-saving to healthcare systems, is patient-friendly, and could be adopted more widely.

Limitations of Prostate Biopsy in Detection of Cribriform and Intraductal Prostate Cancer.

BACKGROUND: The presence of cribriform morphology and intraductal carcinoma (IDC) in prostate biopsies and radical prostatectomy specimens is an adverse prognostic feature that can be used to guide treatment decisions. OBJECTIVE: To assess how accurately biopsies can detect cribriform morphology and IDC cancer by examining matched biopsy and prostatectomy samples. DESIGN, SETTING, AND PARTICIPANTS: Patients who underwent radical prostatectomy at The Princess Margaret Cancer Centre between January 2015 and December 2022 and had cribriform morphology and/or IDC in the surgical specimen were included in the study. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We used detection sensitivity to evaluate the level of agreement between biopsy and prostatectomy samples regarding the presence of cribriform morphology and IDC. RESULTS AND LIMITATIONS: Of the 287 men who underwent radical prostatectomy, 241 (84%) had cribriform morphology and 161 (56%) had IDC on final pathology. The sensitivity of prostate biopsy, using radical prostatectomy as the reference, was 42.4% (95% confidence interval [CI] 36-49%) for detection of cribriform morphology and 44.1% (95% CI 36-52%) for detection of IDC. The sensitivity of prostate biopsy for detection of either IDC or cribriform morphology was 52.5% (95% CI 47-58%). Among patients who underwent multiparametric magnetic resonance imaging-guided biopsies, the sensitivity was 54% (95% CI 39-68%) for detection of cribriform morphology and 37% (95% CI 19-58%) for detection of IDC. CONCLUSIONS: Biopsy has low sensitivity for detecting cribriform morphology and IDC. These limitations should be incorporated into clinical decision-making. Biomarkers for better detection of these histological patterns are needed. PATIENT SUMMARY: Prostate biopsy is not an accurate method for detecting two specific types of prostate cancer cells, called cribriform pattern and intraductal prostate cancer, which are associated with unfavorable prognosis.

Poly(adenosine diphosphate-ribose) polymerase inhibitor combinations in first-line metastatic castrate-resistant prostate cancer setting: a systematic review and meta-analysis.

OBJECTIVES: To compare radiographic progression-free survival (rPFS), overall survival (OS), and treatment-emergent adverse events (TEAEs) among patients with metastatic castrate-resistant prostate cancer (mCRPC) receiving a combination of first-line poly(adenosine diphosphate-ribose) polymerase inhibitors (PARPi) plus androgen receptor axis-targeted agents (ARAT) vs placebo/ARAT. MATERIALS AND METHODS: We conducted a systematic review/meta-analysis of all published Phase III randomised controlled trials using EMBASE, MEDLINE, and Cochrane (inception until 6 June 2023). Published full-text manuscripts and conference abstracts were inclusion eligible. Study selection/data extraction were independently performed by two authors. The Cochrane Risk-of-Bias 2 Tool was used, and certainty of evidence assessed using the Grading of Recommendations, Assessment, Development, and Evaluations framework. Pooled hazard ratios (HRs) and relative risks, with corresponding confidence intervals (CIs), were generated using random-effects models. RESULTS: Three trials were identified: PROpel, MAGNITUDE, and TALAPRO-2. Compared to placebo/ARAT, the PARPi/ARAT combination was associated with a 35% rPFS improvement in the overall cohort (HR 0.65, 95% CI 0.56-0.76), with 68%, 45%, and 26% improvements in the BReast CAncer gene 1/gene 2 (BRCA1/2)-mutated (BRCA1/2m; P < 0.001), homologous recombination repair-mutated (HRRm; P < 0.001), and non-HRRm cohorts (P = 0.003), respectively. OS data maturity ranged from 31% to 48%, with overall cohort OS data unavailable from MAGNITUDE. The PROpel/TALAPRO-2 pooled analysis demonstrated a 16% OS improvement in the overall cohort (HR 0.84, 95 CI 0.72-0.98; P = 0.02). OS in the HRRm (HR 0.76, 95% CI 0.61-0.95) and the BRCA1/2m cohorts (HR 0.53, 95% CI 0.18-1.56) were improved, with a higher effect magnitude compared to the overall cohort. This combination was associated with a 45% relative risk increase in Grade ≥3 TEAEs, including 6.22-fold for Grade ≥3 anaemia (31.9% vs 4.9%). CONCLUSIONS: The addition of PARPi to ARAT in the first-line mCRPC setting is associated with rPFS benefits across subgroups, with the greatest magnitude of benefit in BRCA1/2m patients. OS benefits remain inconsistent irrespective of HRRm status, with significant increases in Grade ≥3 TEAEs, particularly anaemia. Currently, we suggest this combined approach be selectively offered to HRRm patients, preferentially BRCA1/2m.

Guideline of guidelines: follow-up after orchidectomy for clinical stage 1 testicular cancer.

Several medical organisations have developed evidence-based guidelines for the diagnosis, management, and follow-up of testicular cancer. This article aimed to review, compare, and summarise the most updated international guidelines and surveillance protocols for clinical stage 1 (CS1) testicular cancer. We reviewed a total of 46 articles on proposed follow-up strategies for testicular cancer, and six clinical practice guidelines including four guidelines published by urological scientific associations and two guidelines published by medical oncology associations. Most of these guidelines have been developed by panels of experts with different backgrounds in clinical training, and geographic practise patterns, which explains the considerable variability between published schedules, and recommended follow-up intensity. We present you with a comprehensive review of the most important clinical practice guidelines and propose unifying recommendations based on the most up to date evidence to help standardise follow-up schedules based on patterns and risk of disease relapse.

Small Renal Masses: The Evolving Histologic, Imaging, and Genomic Landscapes.

According to the American Cancer Society, it is currently estimated that approximately 81,800 new cases of kidney cancer will be diagnosed in the United States in 2023 [...].

Small Testicular Masses: Contemporary Diagnostic and Treatment Strategies, Future Directions, and Knowledge Gaps.

The incidental discovery of small masses in the testicles of young men is becoming an increasing clinical dilemma. We are learning that the malignancy rate in masses ≤ 2 cm is much lower than traditionally thought and could be as low as 13% to 21%. The challenge remains in identifying which of these patients harbor malignant tumors that need to be treated, and benign lesions that could be safely surveilled. The aim of this narrative review is to discuss the current scientific evidence, diagnostic work-up, and treatment strategies for small testicular masses. We also discuss selection criteria, follow-up schedules and triggers for intervention for the surveillance of these small testis masses. Furthermore, we give a set of recommendations for assessing and treating these patients, based on the available literature and our experience at a dedicated testicular cancer clinic.

Combined Reporting of Surgical Quality and Cancer Control after Surgical Treatment for Penile Tumors with Inguinal Lymph Node Dissection: The Tetrafecta Achievement.

BACKGROUND: To optimize results reporting after penile cancer (PC) surgery, we proposed a Tetrafecta and assessed its ability to predict overall survival (OS) probabilities. METHODS: A purpose-built multicenter, multi-national database was queried for stage I-IIIB PC, requiring inguinal lymphadenectomy (ILND), from 2015 onwards. Kaplan-Meier (KM) method assessed differences in OS between patients achieving Tetrafecta or not. Univariable and multivariable regression analyses identified its predictors. RESULTS: A total of 154 patients were included in the analysis. The 45 patients (29%) that achieved the Tetrafecta were younger (59 vs. 62 years; p = 0.01) and presented with fewer comorbidities (ASA score ≥ 3: 0% vs. 24%; p < 0.001). Although indicated, ILND was omitted in 8 cases (5%), while in 16, a modified template was properly used. Although median LNs yield was 17 (IQR: 11-27), 35% of the patients had <7 nodes retrieved from the groin. At Kaplan-Maier analysis, the Tetrafecta cohort displayed significantly higher OS probabilities (Log Rank = 0.01). Uni- and multivariable logistic regression analyses identified age as the only independent predictor of Tetrafecta achievement (OR: 0.97; 95%CI: 0.94-0.99; p = 0.04). CONCLUSIONS: Our Tetrafecta is the first combined outcome to comprehensively report results after PC surgery. It is widely applicable, based on standardized and reproducible variables and it predicts all-cause mortality.

Do We Need a Urine Culture Before Cystoscopy? Time to Shift Away from Routine Testing.

OBJECTIVE: To determine if cystoscopy could be safely performed without a urine culture by analyzing 2 prospectively cohorts of patients undergoing outpatient cystoscopy, 1 without urine culture and the other cohort screened and treated for ASB as per protocol. We aim to report the rate of symptomatic UTI and the rate of urinary sepsis within 30 days of cystoscopy. METHODS: All patients who underwent cystoscopy between 2021 and 2022 were invited to participate. Patients were prospectively recruited in a 2:1 ratio. Cohort A: patients who did not require urine culture before cystoscopy. Cohort B: patients who were required to have sterile urine before the procedure. Primary endpoint was the occurrence of symptomatic UTI ≤ 30 days after cystoscopy. RESULTS: A total of 461 patients were recruited, 316 for cohort A and 145 for cohort B. Fifteen patients had symptomatic UTIs between both groups, 8 in Cohort A and 7 in Cohort B. The overall rate of symptomatic UTI was 3.2%, 2.5% for Cohort A and 4.8% for Cohort B. We had only 1 case of urinary sepsis in Cohort B. The RR for developing UTI in cohort B was 1.91 in the univariate model and 1.74 in the multivariate analysis. CONCLUSION: Routine urine culture before outpatient cystoscopy is unnecessary. In asymptomatic patients, subsequent UTIs are rare and can be easily treated. Avoiding routine urine culture helps prevent misuse of antibiotics, reduce cancellation rates, and ease the burden of patients that get cancelled because of ASB. The low risk of symptomatic UTI after the procedure must be discussed with the patient.

miRNAs for testicular germ cell tumours: Contemporary indications for diagnosis, surveillance and follow-up.

Despite excellent outcomes with modern multidisciplinary care, clinicians caring for patients with testicular germ cell tumour (TGCTs) face clinical dilemmas across the spectrum of disease. Wrong treatment choices can lead to undertreatment or overtreatment of these young men. Unfortunately the currently available biomarkers alpha-fetoprotein and human chorionic gonadotropin, lack sufficient sensitivity and specificity to reliably aid in these clinical dilemmas. Thus, a sensitive and specific biomarker is desperately needed. Serum or plasma miRNA, in particular, miR-371a-3p, has shown great promise in discriminating the presence of TGCT and may represent a breakthrough for this disease. In this review, we discuss the potential role of miRNA across clinical states of TGCTs. We review their discovery, methods of assay, limitations and future potential.

Metastatic renal cell carcinoma of the native kidney in a renal transplant recipient: Revisiting the era of tyrosine kinase inhibitors - Case report.

Patients who receive solid organ transplants are at higher risk for developing cancer, which is attributable to chronic immune suppression. Less than 8 cases of metastatic RCC (mRCC) have been reported until now. The aim of this article is to present the case of a 77-year-old male with mRCC of the native kidney and discuss treatment options including targeted therapy, which appears to be the treatment of choice, even in the era of immunotherapy.

Inverted urethral flap reconstruction after partial penectomy: Long-term oncological and functional outcomes.

INTRODUCTION: Penile aesthetics after partial penectomy (PP) for penile cancer (PC), significantly affect a patient's health-related quality of life (HRQoL), self-esteem, and sexual function. Satisfactory reconstruction has become a major milestone in the treatment of these patients. METHODS: Clinical charts of all patients that underwent PP and reconstruction with an inverted urethral flap (IUF) were reviewed. The primary endpoints were recurrence-free survival (RFS), overall survival (OS), and progression-free survival (PFS) which were graphically represented by Kaplan-Meier estimates. The key secondary endpoints were Health-related quality of life (HRQoL), erectile function, and lower urinary tract symptoms. RESULTS: Between May 2007 and December 2019, 74 patients with PC underwent PP and IUF reconstruction. The median age was 62 years (IQR 52-76), median follow-up was 72 months (IQR 38-121). Twenty-nine patients (39.2%) underwent inguinal lymph node dissection, 62 (83.8%) underwent dynamic sentinel lymph node biopsy. Kaplan-Meier estimates of OS, RFS, and PFS showed a 6-year OS of 86.5%, 6-year RFS of 90.5%, and a 6-year PFS of 85.1%. Regarding functional outcomes, we found a mean global health score of 84.6% ± 10.4 at the EQ-5D-3L-VAS. The mean Voiding score of the ICIQ-MLUTS was 1.7 ± 3.2 and a mean IIEF-5 score of 17.3 ± 7. CONCLUSIONS: To the best of our knowledge, we report the largest cohort in the literature of PP with IUF reconstruction. These results are important since early-stage PC is the most common stage at diagnosis. In carefully selected patients' preservation of a longer urethral stump to allow for the inverted flap is safe and does not compromise oncological outcomes while preserving HRQoL.

MicroRNAs as Potential Liquid Biopsy Biomarker for Patients with Castration-Resistant Prostate Cancer.

Purpose: To identify micro-RNAs (miRNAs) expression profiles in peripheral blood plasma that could play a role as potential biomarkers in patients who progressed to castration-resistant prostate cancer (CRPC). Liquid biopsy analysis of miRNAs is a fast-developing field with a considerable likelihood to predict tumor progression and metastasis by targeting genes involved in oncogenesis. Patients and Methods: Differential expression analysis of miRNAs profile in CRPC patients was performed by creating small RNA libraries of circulating miRNAs using HiSeq2500 Illumina platform. A secondary analysis of aligned reads with miRNA identification and quantification was performed using miARmaSeq. Using the Bowtie algorithm, the selected variants were compared to reference nucleotide sequence GRCh38 and miRbase. Novel miRNA sequences were structurally analyzed using mirDeep2®. Results: A total of 16 patients with CRPC were included for analysis. Identified circulating miRNAs were hsa-miR-885-3p, hsa-miR-4467, hsa-miR-4686, hsa-miR-146a-3p, hsa-miR-6514-5p. Genes identified as regulated by these miRNAs were GPR56, BDNF, CTNND1, C17orf62, and DTNA. Conclusion: We explored the miRNA expression profile in patients with CRPC, identifying five miRNAs implicated in the regulation of genes involved in prostate cancer (PCa) oncogenesis and progression. We also found miRNA 855-3p in peripheral blood for the first time, which has a critical role in tumor growth mechanisms and higher expression profile than in healthy individuals.

Outpatient 180 W XPS GreenLight Laser Photoselective Vaporization of the Prostate: 7-Year Experience.

Purpose: GreenLight XPS Laser System (GL-XPS) photoselective vaporization of the prostate (PVP) is not only noninferior to transurethral resection of the prostate, but also with shorter rates of hospital stay and length of catheterization. Scarce literature has been published about the feasibility and safety of performing GL-XPS PVP in an outpatient setting. Our aim is to report our 7-year experience with outpatient GL-XPS PVP. Methods: Medical charts of all patients who underwent GL-XPS PVP between 2013 and 2020 were reviewed. Patients were discharged after careful monitoring in the recovery room and the catheter was removed either at home or at a scheduled hospital visit. We used the Shapiro-Wilk test to assess for normal distribution, and the evaluation of homoscedasticity was performed with the SD test. For qualitative variables, the comparison between groups was carried using the chi-square test and for the quantitative variables we used the nonparametric Mann-Whitney U test. Results: A total of 537 patients were treated, 517 in an outpatient basis. Median age was 68 years (interquartile range [IQR] 62-76), median prostate volume 50 cc (IQR 40-70). 22.8% were on anticoagulants or antiplatelet therapy. Median operative time was 100 minutes (IQR 75-125), length of hospital stay 5 hours (IQR 4-6.45), mean length of catheterization 48 hours (SD 14.92). Readmission rate within 90 days of surgery was 11.7%, 58 (10.8%) for surgical-related complications. Median time for readmission was 4 days (IQR 2-24). Immediate readmission (within 10 days) was recorded in 7.6% of patients, urinary retention was the main cause. No significant differences were found trying to find perioperative predictors for readmission. Conclusions: Our experience suggests that outpatient GL-XPS PVP could be performed safely with a predefined outpatient pathway, with a low readmission and complication rate. (IRB number CEI-521).

Ionizing Radiation Exposure in Children with Vesicoureteral Reflux: Should We Be Alarmed? / Exposición a radiacion ionizante en niños con reflujo vesicoureteral: Debemos preocuparnos?

Objectives Ionizing radiation imaging is commonly used for diagnosis and follow up in children with vesicoureteral reflux (VUR). We aim to measure the effective dose (mSv) in patients with VUR. Methods We reviewed our electronic database of patients under 8-years-old with VUR. Primary endpoint was to calculate the effective radiation dose (ED). Absolute frequencies and percentages were reported for global qualitative variables. This study conducted a logistic regression model to calculate the odds ratio for radiation exposure. Analysis was performed using STATA version 14.0 (StataCorp LLC, College Station, TX, EEUU). Results A total of 140 patients were found, 97 were assessed for eligibility. We included 59 patients in the final analysis. Mean age was 20 ± 17.9 months, 66% were females. Most cases of VUR were bilateral (44%) and high grade (93.4%). The lowest number of studies per patient was two, with a minimum radiation of 5.7 mSv. The highest radiation was estimated at 20.7 mSv corresponding to a total of five studies. Logistic regression showed that highest grades of VUR and age of first UTI episode were associated with higher ED (OR, 1.7; 95% CI, 0.87-3.31), (OR 1.02; 95% CI 0.97-1.07) respectively. A mean ED for children with VUR was estimated of 5.5 ± 3 mSv/year. Conclusion In our study, the children with VUR were exposed to 5.5 mSv/year without counting the natural background radiation, which is alarming, and we believe should raise awareness worldwide in how we are unnecessarily diagnosing indolent VUR cases and following patients.

Objetivos La imagenología por radiación ionizante es una herramienta usada frecuentemente para el diagnóstico y seguimiento de pacientes con reflujo vesicoureteral (RVU). El objetivo del presente trabajo es calcular la dosis estimada en milisieverts (mSv) de pacientes con RVU. Métodos Se realizó una revisión retrospectiva de todos los pacientes menores de 8 años con RVU. El objetivo principal fue calcular la dosis de radiación efectiva recibida por los pacientes con base en los estudios imagenológicos realizados hasta el momento de la revisión de la base de datos. Las frecuencias y porcentajes fueron reportados para las variables cualitativas. Se realizó una regresión logística para calcular la asociación de factores de riesgo con la exposición a radiación. El análisis estadístico fue realizado con el programa STATA versión 14.0 (StataCorp LLC, College Station, TX, EEUU). Resultados Se identificaron 140 patientes, de los cuales 97 fueron evaluados para coprobar su elegibilidad. En total, 59 pacientes fueron incluidos para el análisis final. La edad promedio de los pacientes fue de 20 ± 1,.9 meses, y 66% eran mujeres. La mayoría de casos fueron bilaterales (44%) y de alto grado (93,4%). El menor número de estudios realizados por paciente fue 2, con una dosis mínima de radiación acumulada de 5,7 mSv. La máxima radiación acumulada fue de 20,7 mSv, correspondiente a un total de 5 estudios. La regresión logística demostró que altos grados de reflujo y la edad a la cual tuvieron la primera infección se asociaban con mayores dosis de radiación efectiva (razón de probabilidades [RP]: 1.7; intervalo de confianza del 95% [IC95%]: 0,87­3,31), (RP: 1,02; IC95%: 0,97­1,07), respectivamente. Estimamos una dosis efectiva de radiación de 5,5 ± 3 mSv/año en nuestra población. Conclusión Nuestro estudio demuestra que pacientes con reflujo son expuestos a un promedio de 5,5 mSv/año sin contar la radiación de base a la que se exponen todos los humanos anualmente, lo cual resulta alarmante. Esto debe generar introspección al momento de evaluar pacientes con reflujo y evitar efectos a largo y mediano plazos.

Turning Problems into Opportunities: How to Resume Urological Elective Surgery Using a Scoring System during COVID-19 Outbreak / Convirtiendo problemas en oportunidades: como reanudar la cirugía urológica electiva utilizando un sistema de puntaje durante la pandemia por COVID-19

Objective Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which is the largest pandemic in the last century and has created a health care crisis worldwide. Contingency plans have led to put on hold all urological elective surgeries. The aim of the present article is to report the adaptation of theMedically Necessary Time-Sensitive (MeNTS) scoring systemto triage patients who were awaiting urological elective surgery during the COVID-19 pandemic. Methods The present study was conducted as a part of a necessary transition of care delivery at a tertiary care institution in order to re-establish urological elective surgery. We triaged all urological elective surgeries with the MeNTS instrument and proposed a cutoff value of 45 points to avoid complications in the COVID-19 crisis while resuming elective procedures. Results A total of 91 patients awaiting elective urological surgery pending to be rescheduled were identified. Their median age was 60.5 years old (interquartile range [IQR]: 46­93). Twenty-five patients were American Society of Anesthesiologists (ASA) class I, 51 (56%) were class II, and 12 (13%) were class III. The median MeNTS score was 42 points (IQR: 36­59). Twenty-nine patients had aMeNTS score>45 and were advised to postpone their surgery. Sixty-two had a score 45 and were gradually rescheduled. Conclusions The present study may have practical implications regarding the selection of urological elective surgeries in the challenging health care situation caused by the COVID-19 pandemic. Our real-life data showed us that 32% of our procedures must be postponed, and 68% could be carefully considered and gradually rescheduled for surgery.

Introducción El coronavirus del síndrome de dificultad respiratoria aguda 2 (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2, en inglés) causa la llamada enfermedad por coronavirus 2019 (coronavirus disease 2019, COVID-19, en inglés) que ha generado la pandemia más grande en el último siglo, y ha llevado a una crisis en el sistema de salud a nivel mundial. El objetivo de este artículo es reportar la utilización del sistema médicamente necesario, sensible al tiempo (medically necessary, time-sensitive, MeNTS, en inglés) para gradualmente reanudar la cirugía urológica programada durante la pandemia. Metodos Este estudio se llevó a cabo como parte de una transición necesaria en la atención en salud para restablecer la cirugía urológica programada. Clasificamos a todos los pacientes utilizando el instrumento MeNTS, y arbitrariamente propusimos un punto de corte de 45 puntos, dinámico de acuerdo con el momento y la situación de la pandemia. Resultados Un total de 91 pacientes en espera de cirugía urológica programada fueron identificados. La mediana de edad fue de 60.5 años (rango intercuartil [RIC]: 46 a 93 años). En total, 25 (27.4%) pacientes eran clase I en la clasificación de la Sociedad Americana de Anestesiólogos (American Society of Anesthesiologists, ASA), 51 (56%) eran ASA II, y 12 (13%), ASA III. La mediana del puntaje del MeNTS fue de 42 puntos (RIC: 36 a 59). En total, 29 pacientes tuvieron un puntaje de MeNTS mayor a 45 puntos, y se les recomendó posponer su cirugía electiva; 62 (68%) tuvieron un puntaje ≤ 45 puntos, y se reprogramaron gradualmente a partir del 1ro de mayo de 2020. Conclusiones Este estudio puede tener varias implicaciones practicas a la hora de seleccionar pacientes para reprogramar su cirugía urológica electiva durante situaciones desafiantes para los sistemas de salud, como la pandemia por COVID-19. Nuestros datos de la práctica clínica real muestran que el 32% de los procedimientos se deben posponer, y el 68% pueden considerarse cuidadosamente para ser reprogramados gradualmente.

Surgical Technique of Supine Percutaneous Nephrolithotomy in Children / Técnica quirúrgica de la nefrolitotomía percutánea en supino en niños

Percutaneous nephrolithotomy (PCNL) in children has becomemore widely used due to its high efficacy and safety and to the development of miniaturized instruments. A supine approach is promising due to advantages such as better ventilation, reproducibility, and ergonomics. The purpose of the present study is to describe our surgical technique with special considerations in the pediatric population. We used an oblique supine position supported by one silicone gel positioning pad under the hip and another under the ipsilateral flank. The anatomical landmarks used to guide the puncture were the 11th and 12th ribs, the posterior axillary line, and the iliac crest. Initially, a ureteral catheter was introduced endoscopically. A retrograde pyelography was performed to guide the puncture, which was performed using a biplanar technique. A hydrophilic guide wire was then advanced through the needle. Dilation was performed with Alken telescopic dilators until 14 Ch. Fragmentation was performed either with a 13 Ch semirigid cystoscope or a flexible ureteroscope using a holmium: yttrium aluminum garnet (Ho:Yag) laser.We left a double J catheter. Supine PCNL in the pediatric population has comparable efficacy in terms of stone free rate to that of the prone approach as well as less complications. Certain considerations in children are careful padding and placement of the patient close to the edge of the table. Puncture should be guided by ultrasound to reduce radiation exposure. Miniaturized equipment is not widely available, so adaptation of adult equipment for the pediatric population is sometimes necessary.

La nefrolitotomía percutánea en niños se ha vuelto ampliamente utilizada por su alta efectividad, seguridad, y por la miniaturización de los instrumentos endoscópicos. El abordaje en supino es prometedor por sus ventajas, como mejor ventilación, reproducibilidad, y ergonomía. El propósito es describir nuestra técnica quirúrgica con las consideraciones especiales a tener en cuenta en la población pediátrica. Todos nuestros pacientes han sido intervenidos bajo la siguiente técnica quirúrgica: en una posición oblicua en supino, utilizando soportes de silicona ubicados debajo de la cadera y del flanco ipsilateral, se marcan los reparos anatómicos: las costillas once y doce, la línea axilar posterior y la cresta ilíaca. Inicialmente se introduce un cateter ureteral por vía endoscópica, con el cual se realiza una pielografía retrógrada para guiar la punción con una técnica biplanar. Se avanza una guía hidrofílica y, sobre esta, los dilatadores telescopados de Alken hasta un tracto de 14 Ch. Se realiza la fragmentación con un cistoscopio semirígido de 13 Ch o con un ureteroscopio flexible utilizando el láser Ho:Yag. Se deja un cateter JJ. La nefrolitotomía percutánea en la población pediátrica es comparable en términos de tasa libre de cálculos al abordaje en prono, con menos complicaciones. Una consideración importante en niños es una adecuada posición, cerca al eje de la mesa. La punción debe ser guiada por ultrasonido para disminuir la exposición a radiación. La disponibilidad de equipos miniaturizados es limitada, por lo cual usualmente es necesario adaptar los equipos de adultos.