Improving Patient Information and Enhanced Consent in Urology: The Impact of Simulation and Multimedia Tools. A Systematic Literature Review from the European Association of Urology Patient Office.

BACKGROUND AND OBJECTIVE: Discussions surrounding urological diagnoses and planned procedures can be challenging, and patients might experience difficulty in understanding the medical language, even when shown radiological imaging or drawings. With the introduction of virtual reality and simulation, informed consent could be enhanced by audiovisual content and interactive platforms. Our aim was to assess the role of enhanced consent in the field of urology. METHODS: A systematic review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, using informed consent, simulation, and virtual reality in urology as the search terms. All original articles were screened. KEY FINDINGS AND LIMITATIONS: Thirteen original studies were included in the review. The overall quality of these studies was deemed good according to the Newcastle-Ottawa Scale. The studies analysed the application of different modalities for enhanced consent: 3D printed or digital models, audio visual multimedia contents, virtual simulation of procedures and interactive navigable apps. Published studies agreed upon a significantly improved effect on patient understanding of the diagnosis, including basic anatomical details, and surgery-related issues such as the aim, steps and the risks connected to the planned intervention. Patient satisfaction was unanimously reported as improved as a result of enhanced consent. CONCLUSIONS AND CLINICAL IMPLICATIONS: Simulation and multimedia tools are extremely valuable for improving patients' understanding of and satisfaction with urological procedures. Widespread application of enhanced consent would represent a milestone for patient-urologist communication. PATIENT SUMMARY: Several multimedia tools can be used to improve patients' understanding of urological conditions and procedures, such as simulation and models. Use of these tools for preoperative discussion enhances knowledge and patient satisfaction, resulting in more realistic patient expectations and better informed consent.

Current Standards for Training in Robot-assisted Surgery and Endourology: A Systematic Review.

BACKGROUND AND OBJECTIVE: Different training programs have been developed to improve trainee outcomes in urology. However, evidence on the optimal training methodology is sparse. Our aim was to provide a comprehensive description of the training programs available for urological robotic surgery and endourology, assess their validity, and highlight the fundamental elements of future training pathways. METHODS: We systematically reviewed the literature using PubMed/Medline, Embase, and Web of Science databases. The validity of each training model was assessed. The methodological quality of studies on metrics and curricula was graded using the MERSQI scale. The level of evidence (LoE) and level of recommendation for surgical curricula were awarded using the educational Oxford Centre for Evidence-Based Medicine classification. KEY FINDINGS AND LIMITATIONS: A total of 75 studies were identified. Many simulators have been developed to aid trainees in mastering skills required for both robotic and endourology procedures, but only four demonstrated predictive validity. For assessment of trainee proficiency, we identified 18 in robotics training and six in endourology training; however, the majority are Likert-type scales. Although proficiency-based progression (PBP) curricula demonstrated superior outcomes to traditional training in preclinical settings, only four of six (67%) in robotics and three of nine (33%) in endourology are PBP-based. Among these, the Fundamentals of Robotic Surgery and the SIMULATE curricula have the highest LoE (level 1b). The lack of a quantitative synthesis is the main limitation of our study. CONCLUSIONS AND CLINICAL IMPLICATIONS: Training curricula that integrate simulators and PBP methodology have been introduced to standardize trainee outcomes in robotics and endourology. However, evidence regarding their educational impact remains restricted to preclinical studies. Efforts should be made to expand these training programs to different surgical procedures and assess their clinical impact. PATIENT SUMMARY: Simulation-based training and programs in which progression is based on proficiency represent the new standard of quality for achieving surgical proficiency in urology. Studies have demonstrated the educational impact of these approaches. However, there are still no standardized training pathways for several urology procedures.

Percutaneous antegrade management of large proximal ureteral stones using non-papillary puncture.

Objective: To evaluate the feasibility and the safety of medial non-papillary percutaneous nephrolithotomy (npPCNL) for the management of large proximal ureteral stones. Methods: We evaluated prospectively collected data of 37 patients with large proximal ureteral stones more than 1.5 cm in diameter treated by prone npPCNL. Depending on stone size, in-toto stone removal or lithotripsy using the Lithoclast® Trilogy (EMS Medical, Nyon, Switzerland) was performed. Perioperative parameters including operative time (from start of puncture to the skin suturing), stone extraction time (from the first insertion of the nephroscope to the extraction of all stone fragments), and the stone-free rate were evaluated. Results: Twenty-one males and 16 females underwent npPCNL for the management of large upper ureteral calculi. The median age and stone size of treated patients were 58 (interquartile range [IQR]: 51-69) years and 19.3 (IQR: 18.0-22.0) mm, respectively. The median operative time and stone extraction time were 25 (IQR: 21-29) min and 8 (IQR: 7-10) min, respectively. One case (2.7%) of postoperative bleeding and two cases (5.4%) of prolonged fever were managed conservatively. The stone-free rate at a 1-month follow-up was 94.6%. Conclusion: The npPCNL provides a straight route to the ureteropelvic junction and proximal ureter. Approaching from a dilated portion of the ureter under low irrigation pressure with larger diameter instruments results in effective and safe stone extraction within a few minutes.

Transurethral resection of bladder tumor: A systematic review of simulator-based training courses and curricula.

Objective: Transurethral resection of bladder tumor is one of the most common everyday urological procedures. This kind of surgery demands a set of skills that need training and experience. In this review, we aimed to investigate the current literature to find out if simulators, phantoms, and other training models could be used as a tool for teaching urologists. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement and the recommendations of the European Association of Urology guidelines for conducting systematic reviews. Fifteen out of 932 studies met our inclusion criteria and are presented in the current review. Results: The UroTrainer (Karl Storz GmbH, Tuttlingen, Germany), a virtual reality training simulator, achieved positive feedback and an excellent face and construct validity by the participants. The inspection of bladder mucosa, blood loss, tumor resection, and procedural time was improved after the training, especially for inexperienced urologists and medical students. The construct validity of UroSim® (VirtaMed, Zurich, Switzerland) was established. SIMBLA simulator (Samed GmbH, Dresden, Germany) was found to be a realistic and useful tool by experts and urologists with intermediate experience. The test objective competency model based on SIMBLA simulator could be used for evaluating urologists. The porcine model of the Asian Urological Surgery Training and Education Group also received positive feedback by the participants that tried it. The Simulation and Technology Enhanced Learning Initiative Project had an extraordinary face and content validity, and 60% of participants would like to use the simulators in the future. The 5-day multimodal training curriculum "Boot Camp" in the United Kingdom achieved an increase of the level of confidence of the participants that lasted months after the project. Conclusion: Simulators and courses or curricula based on a simulator training could be a valuable learning tool for any surgeon, and there is no doubt that they should be a part of every urologist's technical education.

Endoscopic enucleation of the prostate with Thulium Fiber Laser (ThuFLEP). A retrospective single-center study.

PURPOSE: The aim of the present, retrospective study was to describe our initial experience and early outcomes of Thulium Fiber Laser enucleation of the prostate (ThuFLEP) with the use of the FiberDust™ (Quanta System, Samarate, Italy) in patients with benign prostate hyperplasia. METHODS: From June 2022 to April 2023, all patients who underwent endoscopic enucleation of the prostate at Urology Department of the University Hospital of Patras were included. A single surgeon utilizing the same standardized operative technique performed all the surgeries. The primary endpoints included the uneventful completion of the operation, the surgical time and any minor or major complication observed intra- or post-operatively. RESULTS: Twenty patients with benign prostate hyperplasia were treated with ThuFLEP. All the surgeries were completed successfully and uneventfully. The enucleation phase of the operation was completed in a mean time of 45±9.1 min, while the average time needed for the morcellation was 17.65±3.42 min. No significant complications were observed intra- or post-operatively. The average hemoglobin drop was calculated to be 0.94±0.71 g/dL. CONCLUSIONS: All the operations were successfully and efficiently completed with the use of the FiberDust™ (Quanta System, Samarate, Italy) in ThuFLEP. Significant blood loss or major complications were not observed.

Minimal invasive treatment of urethral strictures: An experimental study of the effect of paclitaxel coated balloons in the wall of strictured rabbit's urethra.

PURPOSE: The aim of this study is the evaluation of the distribution of paclitaxel (PTX) released by a coated balloon in the layers of rabbit's urethra. METHODS: 18 rabbits were included. A laser device was used for the stricture formation. After two weeks, dilation of the strictured urethra was performed by using Advance 35LP PTA balloons and Advance 18 PTX PTA balloons. The experimental models were divided into 3 groups. The group Α included two rabbits without any intervention except for the stenosis procedure. Group B compromised six rabbits that underwent dilation with Advance 35LP PTA balloons. Group C consisted of 10 rabbits to which dilation with both Advance 35LP PTA balloons and Advance 18 PTX PTA balloons was applied. Histological evaluation and Immunohistochemistry were performed on all specimens. RESULTS: Inflammation, fibrosis and ruptures were detected in the specimens of the study. In specimens of Group C the decrease of inflammation and fibrosis rate was greater. Anti-PTX antibody was detected in the epithelium, lamina propria and smooth muscle layer of all specimens of urethras that have been harvested immediately and 1 day after the dilation with Advance 18 PTX PTA balloon and it was not observed in any layer of the urethral wall of the rest of the examined specimens of Group C. CONCLUSIONS: PTX's enrichment was detected in the smooth muscle layer of all specimens that have been harvested immediately and 24h after the dilation with Advance 18 PTX PTA balloons. PTX may play an inhibitive role in the recurrence of the stenosis.

Use of artificial stones in training and laboratory studies, have we found the right material? Outcomes of a systematic review from the European School of Urology.

Objective: In this review, we investigated the current literature to find out which artificial stones (AS) are available in endourology, and in which experimental and training schemes they are used. Materials and Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Twenty-one out of 346 studies met our inclusion criteria and are presented in the current review. The inclusion criteria were the existence of AS and their use for laboratory and training studies. Results: There is a wide variety of materials used for the creation of AS. BegoStone powder (BEGO USA, Lincoln, Rhode Island) and plaster of Paris™ were used in most of the studies. In addition, Ultracal-30 (U. S. Gypsum, Chicago, IL) was also used. Other materials that were used as phantoms were AS created from plaster (Limbs and Things, UK), standardized artificial polygonal stone material (Chaton 1028, PP13, Jet 280; Swarovski), model stones consisting of spheres of activated aluminum (BASF SE, Ludwigshafen am Rhein, Deutschland), Orthoprint (Zhermack, Badia Polesine, Italy), and a combination of plaster of Paris, Portland cement, and Velmix (calcium sulfate powder). Many experimental settings have been conducted with the use of AS. Our research demonstrated nine studies regarding testing and comparison of holmium: yttrium-aluminum-garnet laser devices, techniques, and settings. Six studies were about extracorporeal shock wave lithotripsy testing and settings. Three experiments looked into treatment with percutaneous nephrolithotomy. Additionally, one study each investigated imaging perioperatively for endourological interventions, stone bacterial burden, and obstructive uropathy. Conclusion: AS have been used in a plethora of laboratory experimental studies. Independent of their similarity to real urinary tract stones, they present a tremendous potential for testing and training for endourological interventions.

ESRU-ESU-YAU_UROTECH Survey on Urology Residents Surgical Training: Are We Ready for Simulation and a Standardized Program?

Background: Currently, the landscape of surgical training is undergoing rapid evolution, marked by the initial implementation of standardized surgical training programs, which are further facilitated by the emergence of new technologies. However, this proliferation is uneven across various countries and hospitals. Objective: To offer a comprehensive overview of the existing surgical training programs throughout Europe, with a specific focus on the accessibility of simulation resources and standardized surgical programs. Design setting and participants: A dedicated survey was designed and spread in May 2022 via the European Association of Urology (EAU) mail list, to Young Urologist Office (YUO), Junior membership, European Urology Residents Education Program participants between 2014 and 2022, and other urologists under 40 yr, and via the EAU Newsletter. Intervention: A 64-item, online-based survey in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) using the platform of Survey Monkey (Portland, OR, USA) was realized. Outcome measurements and statistical analysis: The study involved an assessment of the demographic characteristics. Additionally, it explored the type of center, availability of various surgical approaches, presence of training infrastructure, participation in courses, organization of training, and participants' satisfaction with the training program. The level of satisfaction was evaluated using a Likert-5 scale. The subsequent sections delved into surgical training within the realms of open, laparoscopic, robotic, and endoscopic surgery, each explored separately. Finally, the investigation encompassed the presence of a structured training course and the availability of a duly validated final evaluation process. Results and limitations: There were 375 responders with a completion rate of 82%. Among them, 75% were identified as male, 50.6% were young urologists, 31.7% were senior residents, and 17.6% were junior residents. A significant majority of participants (69.6%) were affiliated with academic centers. Regarding the presence of dry lab training facilities, only 50.3% of respondents indicated its availability. Among these centers, 46.7% were primarily focused on laparoscopy training. The availability of virtual and wet lab training centers was even more limited, with rates of 31.5% and 16.2%, respectively. Direct patient involvement was reported in 80.5% of cases for open surgery, 58.8% for laparoscopy, 25.0% for robotics, and 78.6% for endourology. It is worth noting that in <25% of instances, training followed a well-defined standardized program comprising both preclinical and clinical modular phases. Finally, the analysis of participant feedback showed that 49.7% of respondents expressed a satisfaction rating of either 4 or 5 points with respect to the training program. The limitations of our study include the low response rate, predominance of participants from academic centers, and absence of responses from individuals not affiliated with the EAU network. Conclusions: The current distribution of surgical training centers falls short of ensuring widespread access to standardized training programs. Although dry lab facilities are relatively well spread, the availability of wet lab resources remains restricted. Additionally, it appears that many trainees' initial exposure to surgery occurs directly with patients. There is a pressing need for continued endeavors to establish uniform training routes and assessment techniques across various surgical methodologies. Patient summary: Nowadays, the surgical training landscape is heterogeneous across different countries. The implementation of a standardized training methodology to enhance the overall quality of surgical training and thereby improving patient outcomes is needed.

How long do we need to reach sufficient expertise with the avatera® robotic system?

PURPOSE: To investigate the learning curve in four basic surgical skills in laparoscopic and robotic surgeries, and evaluate the approximate time needed to reach sufficient expertise in performing these tasks with the avatera® system. METHODS: Twenty urology residents with no previous experience in dry-lab and robotic surgery were asked to complete four basic laparoscopic tasks (peg transfer, circle cutting, needle guidance, and suturing) laparoscopically and robotically. All participants were asked to complete the tasks first after watching the Uroweb educational material and, second, after undertaking a 2-hour training in robotic and laparoscopic dry-lab. Thereafter, all trainees continued to undertake 2-hour training programs until being able to complete the tasks with the avatera® robot at the desired time. Paired t test and one-way ANOVA test were used to analyze time differences between the groups. RESULTS: Time needed to complete all tasks either robotically or laparoscopically was significantly less in the second compared to the first attempt for all Groups in each Task. In the robotic dry-lab, time needed to complete the tasks was significantly less than in the laparoscopic dry-lab. A significant effect of previous laparoscopic experience of the participants on the training time needed to achieve most of the goal times was detected. CONCLUSION: The results of the study highlight the role of previous laparoscopic experience in the training time needed to achieve the performance time goals and demonstrate that the learning curve of basic surgical skills using the avatera® system is steeper than the laparoscopic one.

Experts' recommendations in laser use for the treatment of urolithiasis: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group.

PURPOSE: To identify laser lithotripsy settings used by experts for specific clinical scenarios and to identify preventive measures to reduce complications. METHODS: After literature research to identify relevant questions, a survey was conducted and sent to laser experts. Participants were asked for preferred laser settings during specific clinical lithotripsy scenarios. Different settings were compared for the reported laser types, and common settings and preventive measures were identified. RESULTS: Twenty-six laser experts fully returned the survey. Holmium-yttrium-aluminum-garnet (Ho:YAG) was the primary laser used (88%), followed by thulium fiber laser (TFL) (42%) and pulsed thulium-yttrium-aluminum-garnet (Tm:YAG) (23%). For most scenarios, we could not identify relevant differences among laser settings. However, the laser power was significantly different for middle-ureteral (p = 0.027), pelvic (p = 0.047), and lower pole stone (p = 0.018) lithotripsy. Fragmentation or a combined fragmentation with dusting was more common for Ho:YAG and pulsed Tm:YAG lasers, whereas dusting or a combination of dusting and fragmentation was more common for TFL lasers. Experts prefer long pulse modes for Ho:YAG lasers to short pulse modes for TFL lasers. Thermal injury due to temperature development during lithotripsy is seriously considered by experts, with preventive measures applied routinely. CONCLUSIONS: Laser settings do not vary significantly between commonly used lasers for lithotripsy. Lithotripsy techniques and settings mainly depend on the generated laser pulse's and generator settings' physical characteristics. Preventive measures such as maximum power limits, intermittent laser activation, and ureteral access sheaths are commonly used by experts to decrease thermal injury-caused complications.

Grafts in Peyronie's surgery without the use of prostheses: a systematic review and meta-analysis.

ABSTRACT: Peyronie's disease (PD) is characterized by abnormal penile curvature, and various surgical methods have been developed using different graft materials. However, there is currently no universal agreement on which type of graft is the best. The objective of this review was to evaluate the available literature and identify the most effective graft material for penile curvature correction in PD. A literature search was conducted using electronic databases, including PubMed, Scopus, and the Cochrane Library. The patients, intervention, comparison, and outcome (PICO) approach was used to define the eligibility of studies. Two authors independently selected studies, evaluated them, and extracted data. Random-effect models using the DerSimonian-Laird method were used. Most studies were single-arm studies and had a high risk of bias. Buccal mucosa grafts (BMG) were found to result in the highest penile straightening rates and were associated with the least de novo erectile dysfunction. TachoSil grafts demonstrated a high success rate in straightening despite a higher mean preoperative curvature, while Tutoplast grafts had a higher incidence of postoperative erectile dysfunction. BMG had the highest percentage of postoperative penile straightening. Overall, the TachoSil graft showed the best performance when preoperative curvature is taken into account. Based on the available literature, BMG appear to be the most effective for penile curvature correction in PD, but this is offset by the requirement for low preoperative curvature. The TachoSil graft shows the best overall performance when preoperative curvature is considered. Comparative randomized clinical trials are still needed to determine graft superiority.

Nonpapillary Prone Endoscopic Combined Intrarenal Surgery (ECIRS): Five-Year Experience and Outcomes from a High-Volume Center.

Endoscopic combined intrarenal surgery (ECIRS) provides simultaneous retrograde and percutaneous access to the upper urinary tract. The purpose of this study is to present revised data, tips and tricks, and technique modifications arising from our five-year experience with ECIRS. The data of 62 patients who underwent nonpapillary prone ECIRS from January 2019 to November 2023 were prospectively collected. All cases were performed in the prone position. Inclusion criteria were complex stone cases with stones in multiple calyces requiring either multiple accesses or multiple sessions to achieve stone-free status. Patients' mean age was 54.4 ± 12.39 years, while the mean stone size was 39.03 ± 13.93 mm. The mean operative time was 51.23 ± 17.75 min. Primary and final stone-free rates were 83.8% and 90.3%, respectively. In total, nine patients presented with postoperative complications, which were all Grade II ones. The holmium-YAG laser type during retrograde lithotripsy was associated with significantly shorter operative times compared to the thulium fiber laser. Nonpapillary prone ECIRS is a feasible, safe, and efficient approach for patients with specific stone and anatomy characteristics. The implementation of more, higher-evidence studies is of utmost importance so that safer conclusions can be drawn.

Replicating Florence Intracorporeal Neobladder Technique in Laparoscopic Radical Cystectomy: A Retrospective Study.

OBJECTIVE: To evaluate retrospectively the feasibility of Florence robotic intracorporeal neobladder technique in laparoscopic radical cystectomy. METHODS: Fourteen patients with muscle-invasive bladder cancer underwent laparoscopic radical cystectomy and Florence robotic intracorporeal neobladder between September 2021 and February 2023. Patients' characteristics, pathology data, perioperative outcomes, postoperative complications, and follow-up data were collected. RESULTS: All operations were successfully completed laparoscopically. The median total operative time was 343 minutes, and the median estimated blood loss was 169.5 mL. No intraoperative complications were observed. The median hospitalization time was 7days, while the median time to regular diet was 3days. Clavien Dindo Grade < III complications appeared in five patients within 30days postoperation. No other complications were noted over the 90days follow-up. Organ-confined disease was confirmed in 11 patients and locally advanced disease in three patients. At 3months follow-up, eight and four patients were daytime and night-time continent, respectively. CONCLUSION: Replicating Florence robotic intracorporeal neobladder in laparoscopic radical cystectomy is safe, feasible, and repeatable, based on the encouraging perioperative, oncological, and functional outcomes of our study. However, further prospective studies on a larger scale are required to prove its long-term results.

Robot-assisted radical prostatectomy using the avatera system™: a prospective pilot study.

BACKGROUND: Robot-assisted radical prostatectomy is a minimally invasive, safe procedure preferred in the management of localized prostate cancer. In this study, we present our initial experience with the avatera™ system (avateramedical GmbH, Jena, Germany) in robot-assisted radical prostatectomy. METHODS: A total of fourteen patients underwent robot-assisted radical prostatectomy using this newly introduced system in our department from June 2022 to October 2022. The primary endpoints of the study were the time and the successful completion of the operation, the hemoglobin drop and the presence of complications. The pathologic tumor stage and the presence of positive surgical margins were also recorded. Follow-up of the patients for the functional outcomes over a period of 3 months took place. RESULTS: The completion of all the surgeries was successful. The median draping and docking times were 9.5 minutes (7-13) and 10 minutes (5-40), respectively. The median console time was 103.5 minutes (90-121). No conversion to laparoscopic or open prostatectomy was necessary. The median hemoglobin drop was 1.95 g/dL (0.3-2.7), while positive surgical margins were present in two patients postoperatively. No major complications or need for transfusion were noticed. Six months after the procedure, 78.6% of the participants were continent while 77.7% of the nerve-sparing patients reported erections adequate for intercourse. CONCLUSIONS: All the operations were completed successfully without major complications or significant blood loss. The functional outcomes were acceptable according to the literature. Based on the early outcomes, robot-assisted radical prostatectomy with the avatera™ system (avateramedical GmbH) could be considered feasible, safe, and efficient.

Radiological Density, Atomic Numbers, and Stone Fragmentation of Bego Stones Used for Research in Endourology: Comparison to Real Urinary Stones.

Objective: The aim of the study was to characterize artificial stones used for research in endourology in terms of radiological properties and hardness, based on stone fragmentation, and to compare them with real stones. Materials and Methods: We built artificial stones using BegoStone Plus™ powder (BEGO, Lincoln, RI), with powder (g)-water (mL) ratios ranging from 15:03 to 15:12. The CT Gemstone Spectral Imaging Software® (GE Medical Systems, LLC, Waukesha, WI) was used to evaluate the radiological density in HU and spectral properties. Stone fragmentation was assessed in an in vitro experimental setting. These properties of artificial stones were compared with real urinary calculi. Results: Regarding radiological density in terms of HUs, 15:03 artificial calculi showed similar results when compared with real stones comprising calcium oxalate and calcium phosphate. The 15:03 and 15:04 artificial stones showed similar spectral property results to calcium pyrophosphate stones. The 15:11 artificial stones showed similar stone fragmentation results to real stones comprising uric acid, and 15:03 artificial calculi showed similar results to apatite and cystine stones. Conclusions: Artificial stones are useful for research in endourology. Stones with a powder (g)-water (mL) ratio of 15:03 proved to mimic real hard stones in terms of HUs, atomic number, and stone fragmentation in our study and could be used as artificial hard stones, and 15:11 stones showed similar stone fragmentation to uric acid stones. Our study might suggest that standard Bego stones are useful to investigate different areas in endourology, but not radiological properties because radiological homogeneity is not ensured unless more sophisticated mixing methods are used.

Salvage holmium laser enucleation of the prostate after previous interventions: a systematic review.

OBJECTIVE: To investigate the feasibility, safety and efficacy of holmium laser enucleation of the prostate (HoLEP) in the re-treatment setting (salvage HoLEP) and compare it to the primary HoLEP procedure that is commonly used for the treatment of benign prostate hyperplasia (BPH). MATERIALS AND METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, PubMed, Scopus, and Cochrane databases were systematically screened, from inception to 8 August 2022. Other potentially eligible studies were retrieved using the reference lists of the included studies. Retrospective and prospective studies, both comparative and non-comparative, were included. RESULTS: A total of 12 studies met the inclusion criteria and were included in the final qualitative synthesis. One study was prospective comparative (non-randomised), seven studies were retrospective comparative, and four studies were retrospective non-comparative or case series. In total, 831 patients were treated with salvage HoLEP in the above studies. Previous intervention before salvage HoLEP ranged among studies. The most commonly performed was transurethral resection of the prostate. Intraoperative parameters of salvage HoLEP were comparable with those reported during primary HoLEP, while all postoperative outcomes were significantly improved after salvage HoLEP and were similar with those observed after primary HoLEP. No major complications were noted after salvage HoLEP according to Clavien-Dindo classification. CONCLUSIONS: Salvage HoLEP after previous interventions for treating recurrent or residual BPH is a feasible, safe, and efficient procedure. Data presented in selected studies, along with the holmium laser's physical properties to resect more tissue and to dissect along the true anatomical plane of BPH, render HoLEP an ideal salvage treatment modality for recurrent or residual BPH symptoms.

Feasibility study of a novel robotic system for transperitoneal partial nephrectomy: An in vivo experimental animal study.

PURPOSE: To evaluate the safety and feasibility of partial nephrectomy with the use of the novel robotic system in an in vivo animal model. METHODS: Right partial nephrectomy was performed in female pigs by a surgical team consisting of one surgeon and one bedside assistant. Both were experienced in laparoscopic surgery and trained in the use of the novel robotic system. The partial nephrectomies were performed using four trocars (three trocars for the robotic arms and one as an assistant trocar). The completion of the operations, set-up time, operation time, warm ischemia time (WIT) and complication events were recorded. The decrease in all variables between the first and last operation was calculated. RESULTS: In total, eight partial nephrectomies were performed in eight female pigs. All operations were successfully completed. The median set-up time was 19.5 (range, 15-30) minutes, while the estimated median operative time was 80.5 minutes (range, 59-114). The median WIT was 23.5 minutes (range, 17-32) and intra- or postoperative complications were not observed. All variables decreased in consecutive operations. More precisely, the decrease in the set-up time was calculated to 15 minutes between the first and third attempts. The operative time was reduced by 55 minutes between the first and last operation, while the WIT was decreased by 15 minutes during the consecutive attempts. No complications were noticed in any operation. CONCLUSIONS: Using the newly introduced robotic system, all the advantages of robotic surgery are optimized and incorporated, and partial nephrectomies can be performed in a safe and effective manner.

A new era and future of education: the impact of pandemic on online learning - a study from the European School of Urology.

Introduction: In contemporary times, the online learning process has become indispensable for healthcare education. In this direction, the European School of Urology (ESU) has taken the challenge to implement new technologies to bring down knowledge barriers. Web-based seminars (webinars) are one of the tools that help us move towards such inclusivity, and in front-facing COVID-19 pandemic, when face-to-face meetings were forbidden. Material and methods: Data from ESU webinars was collected from 2016 to 2022. We described the trends through years of: a) number of webinars per year; b) number of oncological versus non-oncological webinars per year; c) number of registrations per year; d) attendance rate; e) YouTube visualisations. We also analysed audience demographics and COVID-19 impact. Results: We found a 60% increase in webinars launched per year with a trend towards more non-oncological webinars. A 94% rise in the number of registrations and an 85% increase in the attendance ratio from 2016 to 2022 was observed. The mean YouTube visualisations per webinar decreased over 200%. Among registrations, we had a 3:1 male: female ratio, 53% were older than 40, and a 51% were of European precedence. COVID-19 positively impacted webinars with a remarkable increase on the amount of webinars launched, number of registrations and attendance ratio. Conclusions: Webinars are a powerful tool to spread healthcare knowledge, bridging the gap in medical educational access. COVID-19 was a determinant that reinforced its implantation, but our data show that this new learning tool had a positive uptake, and has come to stay.

Location of ureteral access sheath in the ureter. Does it affect the fluid flow in different calyces?

Introduction: The aim of this study was to evaluate outflow variation in different locations of the pyelocaliceal system with the use of different ureteral access sheath (UAS) sizes and different UAS positioning. Material and methods: The experimental setup included an anaesthetised porcine model, a 7.5-Fr ureteroscope with a 200-µm laser fibre inserted in the working channel, a hand-held pumping irrigating system, and UAS of different sizes, namely: 9.5/11.5 Fr, 12/14 Fr, and 14/16 Fr. Each UAS was placed just below the ureteropelvic junction (UPJ) or in the mid-ureter. The ureteroscope was placed in the renal pelvis, upper and lower calyces, and outflow measurements were obtained with 3-second interval pumping for one minute in every experimental setup. Results: The UAS positioning in the mid-ureter was associated with significantly higher outflow rates in the lower calyx (p = 0.041). While the UAS was below the UPJ, we observed a trend of lower outflow rate in the lower calyx, which was completely inverted when the UAS was in the mid-ureter. Increasing the UAS size from 9.5/11.5 Fr to 12/14 Fr led to a significant increase in outflow in the renal pelvis and upper calyx (p = 0.007), but not in the lower calyx. A further increase to 14/16 Fr did not produce increased flow. Conclusions: Different locations of the pyelocaliceal system have different fluid mechanics during fURS. In the renal pelvis and upper calyx increasing the diameter of the UAS improved the outflow, whereas in the lower calyx the position of the UAS seems to be the most relevant factor. These variables should be considered when performing fURS, especially with high-power laser lithotripsy.