Impact of Mannitol Bladder Distension in the Intraoperative Detection of Ureteral Kinking During Pelvic Floor Surgery.

INTRODUCTION AND HYPOTHESIS: Ureteral injuries are the most feared complications of gynecological surgery and therefore intraoperative recognition is of the utmost importance. Intraoperative cystoscopy represents the diagnostics of choice to investigate ureteral patency thanks to the direct visualization of ureteral flows after administration of infusion mediums. In this study, we aimed to compare the diagnostic performance of saline versus mannitol intraoperative cystoscopy in terms of false negatives in a large cohort of patients. METHODS: We retrospectively analyzed data of patients who underwent vaginal hysterectomy and high uterosacral ligament suspension for POP. Patients were divided in two groups based on the use of saline or mannitol medium for intraoperative cystoscopy. Postoperative daily control of serum creatinine was performed until discharge, as well as urinary tract imaging, in symptomatic patients. RESULTS: A total of 925 patients underwent vaginal hysterectomy followed by high USL suspension for POP. Saline and mannitol medium were used in 545 patients and 380 patients respectively. Postoperative ureteral injuries were identified in 12 patients, specifically in 2% of the saline group and in 0.3% of the mannitol group. CONCLUSIONS: The use of mannitol instead of saline as a bladder distension medium was able to significantly reduce the occurrence of postoperative ureteral sequelae.

Thulium fiber laser vs. holmium laser enucleation of the prostate: results of a prospective randomized non-inferiority trial.

PURPOSE: Holmium laser enucleation of the prostate (HoLEP) represents the current standard procedure for size-independent surgical therapy of benign prostatic obstruction (BPO). With advent of the novel laser technology thulium fiber laser (TFL), we hypothesized that the functional outcome of TFL enucleation of the prostate (ThuFLEP) is non-inferior compared to HoLEP. METHODS: From October 2021 to October 2022, 150 patients with BPO were recruited for the prospective randomized trial in accordance with CONSORT. Stratified randomization into the arms ThuFLEP (n = 74) or HoLEP (n = 76) was carried out. The primary endpoint was non-inferior international prostate symptom score (IPSS) and quality of life (QoL) at three months after treatment. Secondary endpoints were rates of complications, peak flow, residual urine and operation times. RESULTS: Preoperative characteristics showed no significant differences. Overall IPSS and QoL improved from 21 to 8 and 4 to 1.5, respectively, after three months of follow-up. No statistically significant differences between ThuFLEP and HoLEP were observed regarding median postoperative IPSS (8.5 vs. 7, p > 0.9), QoL (1 vs. 2, p = 0.6), residual urine (48 vs. 30ml, p = 0.065) and peak flow (19 vs. 17ml/s, p > 0.9). Similarly, safety profile was comparable with no statistically significant differences regarding rate of major complications (5.3 vs. 5.4%, p = 0.5), laser hemostasis time (3 vs. 2min, p = 0.2), use of additive electric coagulation (74 vs. 87%, p = 0.06) or electric coagulation time (8 vs. 8min, p = 0.4). CONCLUSIONS: In this prospective, randomized trial ThuFLEP showed non-inferior results compared to HoLEP in terms of functional outcomes measured by IPSS and QoL as primary endpoint. TRIAL REGISTRATION NUMBER: DRKS00032699 (18.09.2023, retrospectively registered).

Rezum water vaporization therapy versus transurethral resection of the prostate in the management of refractory urine retention: matched pair comparative multicenter experience.

PURPOSE: To compare the efficacy of Rezum with a matched cohort of patients undergoing transurethral resection of the prostate (TURP) for catheter-dependent urine retention secondary to benign prostate hyperplasia (BPH). METHODS: A retrospective review was performed for consecutive catheter-dependent patients who underwent Rezum for BPH. Patients were matched and compared with a similar cohort undergoing TURP, using non-inferiority analysis on propensity score-matched patient pairs. Patients were followed up at 1, 3, 6 and 12 months by international prostate symptoms score (IPSS), quality of life (QoL) index, peak flow rate (Qmax) and postvoid residual urine (PVR). RESULTS: Eighty-one patients undergoing Rezum were compared with equal number of matched patients who undergoing TURP. Patients undergoing Rezum experienced significantly shorter operation time (25.5 ± 8.7 vs. 103.4 ± 12.6 min; p < 0.001), lower intraoperative bleeding (2.4% vs. 20.7%, p < 0.001), shorter hospital stay (1.2 ± 0.9 vs. 2.4 ± 1.3 d, p < 0.001) and longer catheter time (12.6 ± 6.0 vs. 2.3 ± 1.2 d, p < 0.001), with no need for transfusion. Successful postoperative voiding was comparable between both arms (90.2% vs. 92.7%, p = 0.78), respectively. Despite patients undergoing TURP had significantly better voiding outcomes after 1 and 3 months, both groups were comparable after six and 12 months in terms of mean IPSS (11.1 ± 6.4 vs. 10.8 ± 3.4, p = 0.71), QoL indices (2.4 ± 1.6 vs. 2.1 ± 2.3, p = 0.33) and Qmax (22.0 ± 7.7 v. 19.8 ± 6.9 ml/sec, p = 0.06). CONCLUSION: This study supports the safety and efficacy of Rezum in the management of catheter-dependent patients secondary to BPH, with comparable functional outcomes to TURP. Until a randomized clinical comparison is available, long-term data are crucially recommended to compare the recurrence and reoperation rates.

Nascent myoma as a cause of urinary retention.

We present the case of a 47-year-old woman with a bulky, nascent necrotic myoma, which at first glance appeared to be a malignant process in the cervix. It caused significant retention of urine due to compression of the bladder and ureters, hydronephrosis and deterioration of renal function. A fully developed picture of the "bulge syndrome" dominated - lymphedema of the lower limbs and lower abdomen, pain in the lower abdomen, constipation, secondary secondary urinary infection, and paradoxical ischuria. During a gynecological examination in a specula, a strong-smelling, necrotic tumour was visualized reaching half of the vagina, which was causing a bloody discharge, which brought the patient to the examination. A biopsy was taken from the tumour. A permanent urinary catheter was inserted into the urinary bladder with gradual adjustment of renal functions. Due to the difficulties and the benign histological findings from the biopsy, a simple abdominal hysterectomy with bilateral salpingectomy from a lower midline incision was indicated. The operation was complicated by an extensive adhesive process and blood loss of 1,200 mL, with a decrease in hemoglobin in the blood count from 128 g/L to 79 g/L and the need for three blood transfusions. In the postoperative period, there is a prompt recovery of spontaneous micturition with normalization of bladder function, subsidence of lymphedema and subjective complaints of the patient.

The influence of preoperative urodynamic parameters on clinical results in patients with benign prostatic hyperplasia after transurethral resection of the prostate.

PURPOSE: To identify the urodynamic parameters affecting the clinical outcomes of transurethral resection of the prostate(TURP) surgery for patients with benign prostatic hyperplasia(BPH) by multifactor analysis and establish a regression model with diagnostic values. METHODS: The medical records of patients who underwent TURP surgery for BPH between December 2018 and September 2021 were collected from the urology department of the Second Affiliated Hospital of Kunming Medical University, Kunming, China. The patients' clinical data and urodynamic parameters were collected before surgery. The urodynamic parameters affecting surgical efficacy were identified by multifactor analysis, and a regression model with diagnostic values was established and evaluated. RESULTS: A total of 201 patients underwent TURP, of whom 144 had complete preoperative urodynamic data. Each urodynamic factor was subjected to multifactor analysis, and the bladder contractility index (BCI), bladder outflow obstruction index (BOOI), bladder residual urine, and bladder compliance (BC) were found to be independent influence factors on the efficacy of TURP in patients with BPH. The diagnostic value of the regression model was analyzed by receiver operating characteristics (ROC) analysis, and it was found that the AUC = 0.939 (95% CI 0.886-0.972), for which the sensitivity and specificity were 95.19% and 80%, respectively. CONCLUSIONS: The regression model had high diagnostic sensitivity and specificity in predicting the efficacy of surgery, and the diagnostic value was higher than that of individual urodynamic factors. Therefore, BCI, BOOI, bladder residual urine, and BC should be considered as independent influence factors on the efficacy of TURP surgery for BPH.

The Diagnostic Accuracy of a Retrograde Voiding Trial for Restoration of Spontaneous Voiding Function after Prolapse and Urinary Incontinence Surgery.

STUDY OBJECTIVE: To assess the diagnostic accuracy of a retrograde voiding trial for the restoration of spontaneous voiding function after prolapse and urinary incontinence surgery and thereby determine whether the retrograde method can be a reliable alternative to the spontaneous voiding trial. DESIGN: A retrospective cohort study. SETTING: A single tertiary hospital in South Korea. PATIENTS: Women who underwent operations for prolapse, urinary incontinence, or both. INTERVENTION: Sequential voiding trials on postoperative day 1 or 2-retrograde voiding trial followed by spontaneous voiding trial. MEASUREMENTS AND MAIN RESULTS: Of the 408 women analyzed, 278 (68.1%) passed the spontaneous voiding trial on the first day of assessment and none experienced urinary retention after a successful voiding trial. Receiver operating characteristic analyses of retrograde voiding trials evaluating voided volume (VV), postvoid residual (PVR), and voiding efficiency (VE) all demonstrated high diagnostic accuracy for restoration of spontaneous voiding function, whereas measuring PVR and VE had better discriminative ability than VV (area under the curve [95% confidence interval] = 0.93 [0.90-0.95] for PVR, 0.94 [0.91-0.96] for VE, and 0.88 [0.85-0.91] for VV; DeLong's test between PVR/VE and VV p < .01). The optimal cutoffs determined by the Youden index were 200 mL for VV (sensitivity 85.0%, specificity 78.0%), 100 mL for PVR (sensitivity 84.0%, specificity 87.0%), and 66.7% for VE (sensitivity 86.0%, specificity 88.0%). CONCLUSIONS: The retrograde voiding trial is an accurate predictor for restoration of spontaneous voiding function after prolapse and incontinence surgery and can be a useful alternative to the spontaneous voiding trial.

Global Incidence and Risk Factors Associated With Postoperative Urinary Retention Following Elective Inguinal Hernia Repair: The Retention of Urine After Inguinal Hernia Elective Repair (RETAINER I) Study.

Importance: Postoperative urinary retention (POUR) is a well-recognized complication of inguinal hernia repair (IHR). A variable incidence of POUR has previously been reported in this context, and contradictory evidence surrounds potential risk factors. Objective: To ascertain the incidence of, explore risk factors for, and determine the health service outcomes of POUR following elective IHR. Design, Setting, and Participants: The Retention of Urine After Inguinal Hernia Elective Repair (RETAINER I) study, an international, prospective cohort study, recruited participants between March 1 and October 31, 2021. This study was conducted across 209 centers in 32 countries in a consecutive sample of adult patients undergoing elective IHR. Exposure: Open or minimally invasive IHR by any surgical technique, under local, neuraxial regional, or general anesthesia. Main Outcomes and Measures: The primary outcome was the incidence of POUR following elective IHR. Secondary outcomes were perioperative risk factors, management, clinical consequences, and health service outcomes of POUR. A preoperative International Prostate Symptom Score was measured in male patients. Results: In total, 4151 patients (3882 male and 269 female; median [IQR] age, 56 [43-68] years) were studied. Inguinal hernia repair was commenced via an open surgical approach in 82.2% of patients (n = 3414) and minimally invasive surgery in 17.8% (n = 737). The primary form of anesthesia was general in 40.9% of patients (n = 1696), neuraxial regional in 45.8% (n = 1902), and local in 10.7% (n = 446). Postoperative urinary retention occurred in 5.8% of male patients (n = 224), 2.97% of female patients (n = 8), and 9.5% (119 of 1252) of male patients aged 65 years or older. Risk factors for POUR after adjusted analyses included increasing age, anticholinergic medication, history of urinary retention, constipation, out-of-hours surgery, involvement of urinary bladder within the hernia, temporary intraoperative urethral catheterization, and increasing operative duration. Postoperative urinary retention was the primary reason for 27.8% of unplanned day-case surgery admissions (n = 74) and 51.8% of 30-day readmissions (n = 72). Conclusions: The findings of this cohort study suggest that 1 in 17 male patients, 1 in 11 male patients aged 65 years or older, and 1 in 34 female patients may develop POUR following IHR. These findings could inform preoperative patient counseling. In addition, awareness of modifiable risk factors may help to identify patients at increased risk of POUR who may benefit from perioperative risk mitigation strategies.

A systematic review and meta-analysis of efficacy and safety comparing greenlight laser vaporization with transurethral resection of the prostate for benign prostatic hyperplasia with prostate volume less than 80 ml.

We conducted a meta-analysis to evaluate the efficacy and safety of photo selective vaporisation of the prostate (PVP) with the GreenLight Laser versus transurethral resection of the prostate (TURP) for the treatment of small-volume benign prostatic hyperplasia (BPH). As of July 2022, relevant literature in online databases such as Cochrane Library, PubMed, and Embase was searched, including studies published on or before that date, and there were 9 studies in total, including 5 RCTs and 4 non-RCTs. In total 1525 patients were included to compare the efficacy of PVP and TURP in treating BPH. The Cochrane Collaboration criteria were used to evaluate the risk of bias. The software was used for random effect meta-analysis with RevMan 5.3. Data extraction included: clinical baseline characteristics, perioperative parameters, complication rates, International Prostate Symptom Score (IPSS), prostate specific antigen (PSA), post-void residual urine (PVR), maximum flow rate (Qmax), and quality of life (QoL). The pooled analysis showed that PVP was associated with reduced blood loss, blood transfusion, clot retention, catheterization time, definitive catheter removal, and hospital stay, but was associated with longer operative time and more severe dysuria (all p < 0.05). The results of this meta-analysis show that PVP as a technique for the treatment of benign prostatic hyperplasia with a volume of less than 80 cc has similar efficacy to standard TURP in IPSS, PSA, PVR, Qmax and QoL, and is an effective alternative. It outperformed TURP in terms of blood transfusion, catheterization time and hospital stay, while TURP is superior to PVP in terms of operation time.

Early vs Delayed Transurethral Surgery in Acute Urinary Retention: Does Timing Make a Difference?

PURPOSE: Our goal was to compare outcomes of early vs delayed transurethral surgery for benign prostatic hyperplasia after an episode of acute urinary retention compared to men without preoperative acute retention. MATERIALS AND METHODS: We conducted a retrospective cohort analysis using data from the New York Statewide Planning and Research Cooperative System from 2002-2016. We identified men ≥40 years old who underwent primary ambulatory transurethral resection or photoselective vaporization of the prostate, assessing surgical failure as time to reoperation or recatheterization. We categorized presurgical acute urinary retention by number of episodes: none (reference), 1, or ≥2 precatheterizations, and time from first retention episode to surgery: none (reference), 0-6 months, and >6 months. We used Fine-Gray competing-risk models to predict surgical failure at 10 years, with presurgical acute retention as the primary predictor, adjusted for age, race, insurance, Charlson Comorbidity Index score, preoperative urinary infection, and procedure type, with death as the competing risk. RESULTS: Among 17,474 patients undergoing transurethral surgery, 10% had preoperative acute retention with a median time to surgery of 2.4 months (IQR: 1-18). Among men with preoperative retention, 37% had ≥6 months of delay to surgery. The 10-year cumulative treatment failure rate was 17.2% among catheter naïve men vs 34.0% with ≥2 precatheterizations and 32.9% with ≥6 months delay to surgery. Delays from catheterization to surgery were associated with higher rates of treatment failure (<6 months SHR 1.49, P < .001; ≥6 months SHR 2.11, P < .001) vs catheter naïve men. CONCLUSIONS: Preoperative acute urinary retention and delay to surgery once catheterized are associated with poorer long-term postoperative outcomes after surgery for benign prostatic hyperplasia.

Intradetrusor OnabotulinumtoxinA Injections at the Time of Holmium Laser Enucleation of the Prostate for Men with Severe Storage Symptoms.

Introduction: Intradetrusor onabotulinumtoxinA (OTA) injection is a well-established treatment option for refractory overactive bladder; however, its use at the time of holmium laser enucleation of the prostate (HoLEP) for men with bladder outlet obstruction (BOO) and severe storage symptoms has not been previously reported. Materials and Methods: We retrospectively identified men with BOO and severe storage symptoms who underwent treatment with 200 U of intradetrusor OTA (Botox®) at the time of HoLEP. Patients were propensity score matched to a cohort of HoLEP-only patients based on age, Michigan Incontinence Symptom Index (M-ISI) score, preoperative urinary retention, urge incontinence, and prostate size. Perioperative, postoperative, and patient-reported outcomes were examined between groups. Results: We identified 82 men who underwent HoLEP, including 41 patients in the OTA group and 41 patients in the control group. There was no difference in operative times (59 minutes OTA vs 55 minutes control, p = 0.2), rates of same-day trial of void (TOV) (92% OTA vs 94% control, p = 0.7), or rates of same-day discharge (88% OTA vs 85% control, p = 0.6) between groups. There was no difference in temporary postoperative urinary retention (7% OTA vs 2% control, p = 0.3) between groups. Patients who received OTA injections had a significant reduction in their incontinence scores at 3-month follow-up (M-ISI -8, interquartile range [IQR]: -13 to 0, p < 0.001), whereas control patients did not (M-ISI -5, IQR: -8 to -1, p = 0.2). There was no difference in rates of 90-day complications between groups (OTA 10% vs control 5%, p = 0.7). Conclusions: Intradetrusor OTA at the time of HoLEP is safe and is associated with improved urinary incontinence scores and AUA Symptom Score. Rates of same-day discharge and same-day TOV after HoLEP were not affected by OTA. These findings support the role of OTA as an adjunct to surgical intervention in men with incontinence in the presence of BOO.

Surgical Outcomes for Elderly Patients Undergoing Transurethral Resection of the Prostate for Chronic Urinary Retention and Proposal of a Management Algorithm.

Introduction: Chronic urinary retention (CUR) is a major problem in elderly patients and leads to high levels of morbidity. CUR can be treated surgically with transurethral resection of the prostate (TURP), but surgery is frequently avoided in elderly patients due to increased perioperative risks and the presence of detrusor underactivity, which can lead to surgical failure. We report on contemporary outcomes for catheterized elderly patients undergoing TURP from a high-volume university teaching hospital. Patients and Methods: Catheterized patients 80 years of age and older undergoing TURP for CUR at a university teaching hospital between 2012 and 2020 (9 years) were eligible. Those with neurogenic bladder, urethral stricture, or prior TURP were excluded. Surgical success was defined as being catheter free at 3- and 12-month follow-up. Statistical analysis was performed using the Chi-squared test for grouped data and logistic regression modeling for continuous data. Results: A total of 147 patients were included and underwent TURP. Of these, 118 (80.3%) were completely catheter free or using intermittent self-catheterization at initial 3-month follow-up. One hundred seventeen (79.6%) remained catheter free at 1-year follow-up. Postvoid residual >1500 mL before TURP (p = 0.017); age ≥90 (p = 0.0067); and World Health Organization performance status ≥3 (p < 0.00001) were all identified as independent risk factors for surgical failure. A selected subset of patients excluding these risk factors showed overall catheter-free rates of 88.8% at 3-month follow-up. Early and late complications were noted in 6.8% and 2.7% of patients. Conclusion: Our contemporary series demonstrate high rates of successful postoperative voiding for selected elderly patients after TURP, with catheter-free rates at 12 months of 88.8%. Overall complication rate was 9.5%, which may be justified given the alternative morbidity of long-term catheterization. TURP remains an efficacious and cost-effective treatment for selected elderly patients who are catheterized for CUR.

Effect of urinary retention on the surgical outcome of holmium laser enucleation of the benign prostatic hyperplasia.

PURPOSE: To evaluate the effect of urinary retention (UR) on holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms. MATERIALS AND METHODS: A retrospective analysis of a prospective cohort of patients who underwent HoLEP between January 2010 and December 2016 was performed. The perioperative factors, including the International Prostate Symptom Score, Overactive Bladder Symptom Score, prostate-specific antigen, urodynamic study results, uroflowmetry results, transrectal ultrasound prostate volume, operative time, morcellation time, enucleation weight, and complications, were evaluated. Postoperative evaluation was performed at 2, 3, and 6 months. RESULTS: Overall, 903 patients were identified. The mean age and follow-up were 68.3 years and 6 months, respectively. Among the patients, 135 (15.0%) patients had a history of acute UR (AUR), and 36 patients (4.0%) had chronic UR (CUR). The mean detrusor pressures at maximum flow were 64.4, 74.3, and 77.7 cmH2O (p<0.001). The mean maximum flow rates (Qmax) were 7.6, 6.6, and 4.8 mL/s (p<0.001). Additionally, the mean bladder outlet obstruction indices were 49.5, 61.1, and 69.4 (p<0.001). The postoperative Qmax improved in all three groups. The mean postvoid residual volumes (PVRs) were 55, 75, and 333 mL preoperatively; 20, 29, and 66 mL at 2 weeks; 16, 23, and 45 mL at 3 months; and 15, 22, and 52 mL at 6 months (p<0.001). CONCLUSIONS: Voiding symptoms, PVR, and Qmax of BPH patients with preoperative AUR and CUR significantly improved after Ho-LEP, similar to those without preoperative UR.

Mesorectal excision with or without lateral lymph node dissection for elderly patients with mid-low rectal cancer: safety and feasibility analysis.

OBJECTIVE: The perioperative safety and survival benefits of lateral lymph node dissection in elderly patients have been less reported. This study aimed to compare short-term and survival outcomes of total mesorectal excision and total mesorectal excision + lateral lymph node dissection in elderly patients. METHODS: A total of 444 elderly patients (≥65 years) with middle-low rectal cancer were enrolled in three institutions and divided into the total mesorectal excision + lateral lymph node dissection group (n = 110) and the total mesorectal excision group (n = 334). Eighty-three matched pairs were selected for evaluation after propensity matching. Data of 297 patients (age <65 years) with middle-low rectal cancer who underwent total mesorectal excision + lateral lymph node dissection were also collected and reviewed. Clinical and pathological features, postoperative outcomes and survival data were collected and analyzed. RESULTS: Compared with the total mesorectal excision group, the operation time of patients in the total mesorectal excision + lateral lymph node dissection group was significantly longer (277.6 vs. 171.4 min, P < 0.001), and the estimated blood loss was significantly more (119.6 vs. 57.5 ml, P = 0.014). Although there was no significant difference in overall complications (24.1% vs. 14.4%, P = 0.115) and grade 3-5 complications (9.6% vs. 7.2%, P = 0.576) between the two groups, the incidence of urinary retention (10.8% vs. 2.4%, P = 0.029) was higher in the total mesorectal excision + lateral lymph node dissection group. Two groups of patients achieve a similar 3-year overall survival (92.8% vs. 85.4%, P = 0.195) and 3-year disease-free survival (81.5% vs. 73.0%, P = 0.625). In addition, we compared long-term outcomes in 110 elderly patients with total mesorectal excision + lateral lymph node dissection and 297 non-elderly patients with total mesorectal excision + lateral lymph node dissection, and the results showed that 3-year (89.2% vs. 80.9%, P = 0.546) and disease-free survival (76.4% vs. 70.4%, P = 0.346) were similar between elderly and non-elderly patients. CONCLUSIONS: Although urinary retention is closely related to the implementation of lateral lymph node dissection in elderly patients, total mesorectal excision with lateral lymph node dissection could be performed safely with accepted overall and grade 3-5 postoperative complications in elderly patients with rectal cancer. Moreover, elderly patients with clinical lateral lymph node metastasis can also benefit from lateral lymph node dissection as well as younger patients. Prospective studies with large sample sizes are needed to verify our results further.

Robotic approach to vesicourethral anastomotic stenosis and resection of remaining prostate after radical prostatectomy.

OBJECTIVE: To show a total transabdominal robotic approach to an extensive recalcitrant vesicourethral anastomotic stenosis (VUAS) after open radical prostatectomy (ORP) with end-to-end anastomosis. While there is very little literature on the matter and even fewer videos showing the actual surgical view with a step-by-step explanation in complex cases, VUAS robotic transabdominal surgery provides better view and reach, with potentially better continence results, without the need for pubectomy. METHODS: A 72-year-old male was submitted to a failed ORP for Gleason 3+4 localized cancer 2 years before, where the wrong plane of dissection left behind prostate remnants and the seminal vesicles, which evolved with a complex stenosis and recurrent episodes of acute urinary retention (AUR) that started two weeks after the first catheter removal. Five endoscopic procedures in total were unsuccessful and AUR reoccurred. A vesico-urethral cystography (VUC) and multiparametric prostate and urethral MRI found the seminal vesicles with prostate remnants, two centimeters urethral stenosis from bladder neck to bulbar urethra and periurethral fibrosis with no evidence of residual tumor. PSA was 1.2 and prostate biopsy showed no tumor on prostate remnant. A transabdominal robotic approach was chosen. RESULTS: Prostate residue, bladder neck and periurethral fibrosis were excised, with healthy mucosa found on both ends. End-to-end anastomosis was successful. Drain and catheter were removed on the 1st and 14th post-operative day, respectively, with good urinary stream. A VUC at 30 days showed a patent bladder neck. Incontinence was 3 pads/day after catheter removal and decreased to 1 pad/day after 180 days. CONCLUSION: VUAS may reach 15% (1, 2) and endourologic therapies are first-line choices, however, recalcitrant cases require reconstruction (3-6). The most common approach is perineal, with high incontinence rates, reaching >90% (7, 8). The retropubic alternative has better but also discouraging numbers of up to 58% incontinence rates (9). Though with 100% social continence results, the 2021 European guidelines still could not recommend the robotic procedure as standard of care due to evidence limited to anecdotal reports (10-12).

Efficacy of Laparoscopic Totally Extraperitoneal Repair for Inguinal Hernia.

Objective: To assess the treatment efficacy of laparoscopic totally extraperitoneal repair for inguinal hernia. Methods: Between November 2018 and May 2020, 130 patients with inguinal hernias diagnosed and treated in our hospital were randomly recruited and assigned to receive either tension-free hernia repair (control group) or laparoscopic totally extraperitoneal repair (study group) at the random method. All patients received routine care including external traditional Chinese medicine (TCM) application. Outcome measures included surgical indices, numeric rating scale (NRS) scores, infections, and postoperative complications. Results: Laparoscopic surgery is associated with a shorter operation duration, time-lapse before postoperative off-bed activity, and hospital stay, as well as less intraoperative hemorrhage volume compared to tension-free hernia repair in the control group. Patients in the study group had considerably lower NRS ratings after therapy than those in the control group. (P < 0.05). After treatment, the levels of blood cell count (WBC), C-reactive protein (CRP), and procalcitonin (PCT) in the study group were lower than those in the control group (P < 0.05). In the control group, there were 0 cases of hematoma, 3 cases of subcutaneous effusion, 4 cases of urinary retention, 5 cases of scrotal effusion, and 1 case of bladder injury. In the study group, there were 0 cases of hematoma, 1 case of subcutaneous fluid, 1 case of urinary retention, 0 cases of scrotal fluid, and 0 cases of bladder injury. Laparoscopic surgery resulted in a lower incidence of postoperative complications versus traditional surgery (P <0.05). Conclusion: Laparoscopic totally extraperitoneal repair for inguinal hernia improves the intraoperative indices, mitigates postoperative pain, and reduces the risks of infections and complications, with the advantages of short operation duration, less hemorrhage volume, and shorter hospital stay. It shows great potential for clinical promotion.

The association between the parameters of uroflowmetry and lower urinary tract symptoms in prostate cancer patients after robot-assisted radical prostatectomy.

OBJECTIVE: To investigate changes in uroflowmetry parameters in men undergoing robot-assisted radical prostatectomy (RARP) for prostate cancer. MATERIALS AND METHODS: Four hundred and twenty-eight patients received uroflowmetry testing before and after RARP from November 2011 to December 2018. Clinicopathological data, including age, initial prostate-specific antigen (PSA), prostate volume, clinical stage, body mass index (BMI), uroflowmetry parameters, and core lower urinary tract symptom scores (CLSS) were retrospectively obtained from clinical records. Changes in uroflowmetry parameters were analyzed for statistical predictors and effects on post-operative outcomes. RESULTS: A significant increase in maximum flow rate (MFR) and decreases in voided volume (VV) and post-void residual urine (PVR) were seen. In multivariate analysis, age was a negative predictor of MFR increase, while prostate volume was a positive predictor of PVR decrease and MFR increase. VV decrease led to worse incontinence symptoms, while PVR decrease and MFR increase led to improvement in voiding symptoms such as slow stream and straining. Continence recovery curves showed that VV decrease were associated with a delay in continence recovery. CONCLUSIONS: Significant changes were seen in uroflowmetry results after RARP, each parameter directly related to urinary symptoms. In particular, VV decrease was associated with a worsening of incontinence symptoms and continence recovery.

The Effect and Safety of Rapid and Gradual Urinary Decompression in Urine Retention: A Systematic Review and Meta-Analysis.

Background and objectives: Trials to evaluate the effect and safety of rapid and gradual urinary decompression have been published for decades. Due to inconclusive results, this study aimed to assess whether rapid bladder decompression increased complications in adults with acute urinary retention. Materials and Methods: We searched the Cochrane Library, EMBASE, Google Scholar, and PubMed databases for articles published from the database inception to 31 August 2021. Studies that compared the effects and complication rates of rapid and gradual urinary decompression in adults with acute urinary retention were included. The primary outcome was post-decompression hematuria, while the secondary outcome was circulatory collapse. Meta-analyses were conducted using random effects models. Sensitivity analyses, tests for publication bias, and trial sequential analyses were conducted. The PROSPERO registration number is CRD42021233457. Results: Overall, four articles were included in the comprehensive analysis, and 435 participants met all the eligibility criteria. In the primary meta-analysis of all four study groups, rapid urinary decompression did not increase the risk of post-decompression hematuria (RR = 0.91; 95% CI: 0.62 to 1.35; p = 0.642). The I2 statistic was 0.0% (p = 0.732), indicating no substantial heterogeneity. In the meta-analysis of randomized controlled studies, the result did not change (RR = 0.89; 95% CI: 0.31 to 2.52; p = 0.824). The Egger's test and Begg test (p = 0.339 and 0.497, respectively) indicated the absence of statistical evidence of publication bias. Leave-one-out sensitivity analysis was conducted and showed the pooled results were robust. In secondary outcome, there were no reported events of circulatory collapse in the current studies. Conclusions: The currently available data suggest that rapid urinary decompression is an effective and safe method with a complication rate similar to that of gradual decompression in an acute urinary retention population. Further large-scale randomized studies are required.

Treatment with CoreTherm in 570 patients with prostate volumes of 80-366 ml: an evaluation of short- and long-term retreatment risk.

INTRODUCTION: CoreTherm (ProstaLund AB, Lund, Sweden) is an outpatient treatment option in men with lower urinary tract symptoms and catheter-dependent men with chronic urinary retention caused by benign prostatic obstruction (BPO). CoreTherm is high-energy transurethral microwave thermotherapy with feedback technique. Modern treatment with CoreTherm includes transurethral intraprostatic injections of mepivacaine and adrenaline via the Schelin Catheter (ProstaLund AB, Lund, Sweden) and is often referred to as the CoreTherm Concept. OBJECTIVES: The aim of this study was to evaluate the short- and long-term retreatment risk in men with large prostates and BPO or chronic urinary retention, all primarily treated with CoreTherm. MATERIAL AND METHODS: All men from the same geographical area with prostate volumes ≥ 80 ml treated 1999-2015 with CoreTherm and having BPO or were catheter-dependent due to chronic urinary retention, were included. End of study period was defined as December 31, 2019. RESULTS: We identified and evaluated 570 men treated with CoreTherm, where 12% (71 patients) were surgically retreated during the follow-up. Mean follow-up was 11 years, and maximum follow-up was 20 years. The long-term retreatment rate in our study was 23%. A majority of these could be retreated with CoreTherm or TURP, with only 3% requiring open surgery. CONCLUSION: We conclude that CoreTherm is a suitable outpatient treatment option in patients with profoundly enlarged prostates, regardless of age, prostate size, and reason for treatment.

Long-term outcomes of Blocksom vesicostomy for elderly patients with chronic urinary retention.

PURPOSE: To report on the long-term outcomes of vesicostomy in elderly patients with chronic urinary retention. MATERIALS AND METHODS: We conducted a study of 16 elderly patients with chronic urinary retention who underwent Blocksom vesicostomy between April 2010 and March 2021. Postoperative follow-up was conducted every 3 months to check for abnormal findings, such as stoma outlet obstruction, infection, bleeding, bladder prolapse, and bladder stones. The incidence of these findings and the time until they occurred, as well as the rate of achieving a catheter-free status and the time until catheter reinsertion, were then calculated using the Kaplan-Meier curve. RESULTS: The mean age (±standard deviation) of patients whose cases were observed was 78.6 (±7.8) years; the oldest patient was 87 years of age. The study population included 14 male patients and 2 female patients, with a higher number of males. The causes of urinary retention included neurogenic bladder in 12 patients (including patients with 3 spinal cord injury), advanced prostate cancer in 2 patients, and iatrogenic urethral stricture in 2 patients. The average follow-up period was 55.7 months. During follow-up, 14 patients (87.5% of the total) achieved a catheter-free status under conditions that required no additional treatment. Complications were observed in 6 cases (37.5%); among them, two cases required reoperation. All complications were observed within 2 years after surgery. CONCLUSION: Blocksom vesicostomy may become a viable option in the treatment of elderly patients with chronic urinary retention whose symptoms do not improve with medical therapy.