Trends in the diffusion of robotic surgery in prostate, uterus, and colorectal procedures: a retrospective population-based study.

This study aimed to propose quantifiable metrics on the adoption lifecycle of robotic-assisted surgery (RAS) within and across prostate, hysterectomy, and colorectal procedures. This was a retrospective population-based cohort study of commonly performed RAS procedures in the US conducted from July 2001 to July 2015. The patients were identified from the Premier Hospital Database using International Classification of Diseases, 9th revision, Clinical Modification codes denoting prostate, uterus, and colorectal procedures. The Diffusion of Innovations theory was applied to percent RAS utilization to determine discrete eras of technology adoption. Overall and by-era patient baseline characteristics were compared between robotic and non-robotic groups. This study included a total of 2,098,440 RAS procedures comprising prostate (n = 155,342), uterus (n = 1,300,046), and colorectal (n = 643,052) procedures. Prostate (76.7%) and uterus (28.9%) procedures had the highest robotic utilization by the end of the study period and appear to be in the last adoption era (Laggard). However, robotic utilization in colorectal procedures (7.5%) was low and remained in the first era (Innovator) for a longer time (15 vs 60 vs 135 months). Whites, privately insured, patients with fewer comorbidities, and those admitted in large teaching hospitals were more likely to undergo RAS in the early study period. AS-associated patient and hospital profiles changed over time, suggesting that selected patient cohorts should be contextualized by overall adoption of a novel medical technology. The time-discretized analysis may also inform patient selection criteria and appropriate timing for clinical study stages proposed by the Idea, Development, Exploration, Assessment, Long-term study-Devices framework.

Retrospective analysis of the changes in the surgical treatment of benign prostatic hyperplasia during an 11-year period: a single-center experience.

The present study aimed to determine whether the number of patients with symptomatic benign prostatic hyperplasia (BPH) who preferred surgery decreased during the past 11 years at our center (West China Hospital, Chengdu, China), and whether this change affected the timing of surgery and the physical condition of surgical patients. This retrospective study included 57 557 patients with BPH treated from January 2008 to December 2018. Of these, 5427 patients were treated surgically. Surgical patients were divided into two groups based on the time of treatment (groups 8-13 and groups 13-18). The collected data comprised the percentage of all patients with BPH who underwent surgery, baseline characteristics of surgical patients, rehabilitation time, adverse events, and hospitalization costs. The surgery rates in groups 8-13 and groups 13-18 were 10.5% and 8.5% (P < 0.001), respectively. The two groups did not clinically differ regarding patient age and prostate volume. The rates of acute urinary retention and renal failure decreased from 15.0% to 10.6% (P < 0.001) and from 5.2% to 3.1% (P < 0.001), respectively. In groups 8-13 and groups 13-18, the mean catheterization times were 4.0 ± 1.7 days and 3.3 ± 1.6 days (P < 0.001), respectively, and the mean postoperative hospitalization times were 5.1 ± 2.4 days and 4.2 ± 1.8 days (P < 0.001), respectively. The incidences of unplanned second surgery and death reduced during the study period. The surgery rate decreased over time, which suggests that medication was chosen over surgery. However, the percentage of late complications of BPH also decreased over time, which indicates that the timing of surgery was not delayed.

Surgeon-Team Separation in Robotic Theaters: A Qualitative Observational and Interview Study.

BACKGROUND: The rapid uptake of robotic surgery has largely been driven by the improved technical aspects of minimally invasive surgery including improved ergonomics, wristed instruments, and 3-dimensional vision. However, little attention has been given to the effect of physical separation of the surgeon from the rest of the operating team. PURPOSE: The aim of this study was to examine in depth how this separation affected team dynamics and staff emotions. METHODS: Robotic procedures were observed in 2 tertiary hospitals, and laparoscopic/open procedures were added for comparison; field notes were taken instantaneously. One-to-one interviews with theater team members were audio recorded and transcribed verbatim. Qualitative analysis was conducted via grounded theory approach using NVIVO11. RESULTS: Twenty-nine participants (26 interviewed) were recruited to the study (11 females) and 134 (109 robotic) hours of observation were completed across gynecology, urology, and colorectal surgery.The following 3 main themes emerged with compounding factors identified: (a) communication challenge, (b) immersion versus distraction, and (c) emotional impact. Compounding factors included the following: individual and team experience, staffing levels, and the physical theater environment. CONCLUSIONS: Our emergent theory is that "surgeon-team separation in robotic theaters poses communication challenges which impacts on situational awareness and staff emotions." These can be ameliorated by staff training, increased experience, and team/procedure consistency.

Reproductive surgery: glimpses into the past and thoughts for the future (part 2).

This month's Views and Reviews continues with part two of the series regarding reproductive surgery. The roles of reproductive surgery in müllerian anomalies, tubal and pelvic disease, fertility preservation, and male reproductive surgery are included. Augmenting each contribution, authors have added images and videos to their reflections.

Reproductive surgery for müllerian anomalies: a review of progress in the last decade.

Disorders of development, fusion, or resorption of paired müllerian ducts and urogenital sinus may cause various congenital malformations of the corpus uteri, cervix, vagina, and fallopian tubes. Classification systems have been developed to better characterize these anomalies, and each has advantages and disadvantages. Clinical correlation of classification of anomalies with pre- and postsurgical outcomes is needed to better direct treatment. Methods to evaluate these anomalies are primarily radiologic studies, with diagnostic surgery rarely used. Treatment of müllerian anomalies used to focus on relief of symptoms. Now, as diagnostic and surgical options have expanded, preservation or improvement of reproductive potential is a primary goal. As a consequence, controversies in surgical management have also developed. Future directions in this field include better-quality studies with the use of consistent diagnostic criteria to evaluate impacts of treatment on clinical outcomes.

Surgery of Anomalies of Gonadal and Genital Development in the "Post-Truth Era".

This article aims to examine the current issues of debate concerning the management of atypical gonadal and genital development (AGD). Understanding this complex subject begins with defining the distinct AGD conditions, the aims and nature of surgical treatments, and the perceptions of affected individuals and their families. The evolving societal and medical contexts in this field are confronting facts and opinions, leading to a significant change in attitudes and approaches.

Changes in practice patterns in male infertility cases in the United States: the trend toward subspecialization.

OBJECTIVE: To assess changes in the practice patterns of urologists performing male infertility procedures (vasal reconstruction, sperm retrieval, varicocelectomy) from 2004 to 2015 in the United States. DESIGN: Examination of self-reported procedural volumes from urologists undergoing certification and recertification using case log data provided by the American Board of Urology. The study period was stratified into early (2004-2007) and recent (2012-2015) time periods. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOMES MEASURE(S): Temporal variations in male infertility practice patterns among different urologic subspecialties between the early and recent time periods. RESULT(S): The overall proportion of total male infertility procedures performed by andrologists significantly increased between the early and recent groups (23% to 26%). This growth was driven by a significant increase in the proportion of varicocele repairs being performed by andrologists between the early and recent periods (19% to 25%). Most notably, an assessment of total number of male infertility procedures performed by newly certifying urologists showed that there was a significant increase in the overall proportion of all male infertility procedures being performed by recently trained andrologists (24% to 35%). This significant increase was seen individually among all three types of male infertility procedures. CONCLUSION(S): With the increased trend in urologists obtaining fellowship training, male infertility surgical volume is beginning to shift from general urologists to subspecialized andrologists.

[Urogynecology: from past to future].

Over the last decade, the field of urogynecologic surgery has been subject to deep changes. A thorough understanding of the injury mechanisms responsible for pelvic organ prolapse (POP) and urinary incontinence in women, greatly contributed to the development of innovative surgical techniques and changing therapeutic approaches. The variety of treatment options to correct POP and incontinence has greatly expanded, partly thanks to the development of several advanced surgical kits by biotechnology companies. This review describes the evolution of surgical techniques in the field of pelvic floor reconstruction during the last century and raises questions regarding the safety and efficacy of the various techniques available in this field. This paper summarizes the "state of the art" for POP and the incontinence surgery approach in Western countries. It also provides a number of general recommendations based on the authors personal experience [expert opinion]. Such recommendations with slight variations appear in position statements of professional societies worldwide.

Aspectos citológicos, histológicos e morfológicos de neovaginas de mulheres e transmulleres / Cytological, histological and morphological aspects of women and transwomen

O estudo das neovaginas em mulheres e principalmente em transexuais masculinos operados inclui pequeno número de casos e conta com pouco detalhamento sobre o assunto. Algumas perguntas ainda estão por ser respondidas: é necessária a colpocitologia oncoparasitária? Se necessária, em que espaço de tempo? Devemos nos preocupar com a infecção pelo HPV? Quanto tempo é necessário para haver a completa metaplasia do epitélio utilizado? A flora bacteriana é semelhante? Com o objetivo de chamar a atenção para o tema, realizamos uma revisão bibliográfica, abordando aspectos cirúrgicos, oncocitopatológicos, histológicos e morfológicos de neovaginas de mulheres biológicas e transmulheres (transexuais masculinos).

The neovagina studies in women and mainly in operated male transsexuals (transwomen) are few and with few cases specified. Their follow-up is also difficult. Some questions have not been answered yet: is the oncologic colpocytology necessary? If it is necessary, what would the best time to do it? Shall we be worried about HPV infection? What is the necessary time to completely metaplasia? Is the bacterial flora similar? With the purpose of calling attention to this subject, we made a bibliography revision approaching cytological, histological and morphologic aspects of women and transwomen neovaginas (male-to-female transsexual).

Valoración de la satisfacción del paciente a medio plazo tras reparación del prolapso urogenital con malla de polipropileno / Evaluation of medium-term patient satisfaction after repair of urogenital prolapse using polypropylene mesh

Objetivo: Evaluar la tasa de satisfacción de las pacientes sometidas a cirugía de corrección del prolapso urogenital con malla de polipropileno. Material y método: Estudio retrospectivo, no aleatorizado, con 106 pacientes que, desde abril de 2005 a enero de 2007, se sometieron a corrección de diferentes tipos de prolapso urogenital mediante malla de polipropileno. El seguimiento se realizó mediante visitas en consulta a los 2 y 6 meses. Posteriormente se realizó un análisis descriptivo de los datos. Resultados: La edad media fue de 64,4 años. El 91,51% era multípara y el 92,45% había pasado la menopausia. La intervención mayoritaria fue la colocación de una malla anterior con banda libre de tensión para la corrección de la incontinencia urinaria asociada, que representó un 34,90% del total. Se obtuvo una tasa global de complicaciones intraoperatorias del 2,83%, inmediatas del 37,73% y tardías del 21,69%. La tasa de éxito del procedimiento a los 6 meses estuvo entre el 80 y el 100%. La tasa de satisfacción de las pacientes a los 2 y 6 meses varió entre el 50 y el 100%, según el procedimiento realizado. Conclusiones: A pesar de la baja tasa de complicaciones intraoperatorias y a medio plazo en las cirugías de reparación del suelo pélvico en los prolapsos urogenitales con la malla de polipropileno, la tasa de satisfacción de las pacientes dependió mucho del procedimiento realizado, que fue menor en las mallas posteriores y cuando se asociaba cirugía de corrección de la incontinencia urinaria (AU)

Objective: To evaluate the satisfaction rate among women who underwent repair of urogenital prolapse using polypropylene meshes. Material and method: We performed a retrospective, non-randomized study in 106 patients who had undergone different kinds of urogenital prolapse repairs using polypropylene meshes between April 2005 and January 2007. Follow-up consisted of 2 visits to the hospital, 2 and 6 months after surgery. Subsequently, the information was analyzed descriptively. Results: The mean age was 64.4 years. The rate of multiparous and postmenopausal women was 91.51% and 92.45%, respectively. The most frequently used surgical technique was anterior mesh placement with a tension-free band (34.90%) to correct associated urinary incontinence. The complications rates were as follows: intraoperative complications (2.83%), immediate complications (37.73%), and late complications (21.69%). The success rate after 6 months was 80%-100%, depending on the technique. The satisfaction rate varied between 50%-100% and also depended on the technique. Conclusions: Despite the low rate of intraoperative and medium-term complications in the reconstructive surgery of pelvic floor for urogenital prolapses using polypropylene meshes, the satisfaction rate depended heavily on the kind of mesh use. The lowest rates were found in posterior meshes and when surgery for urinary incontinence was associated (AU)

[Burch procedure: experience of 45 years of history]. / Operación de Burch: experiencia a 45 años de historia.

It has been 45 years since John C. Burch first described his "colposuspension of the Cooper's ligament" technique for the surgical management of stress urinary incontinence. Half a century later, his legacy remains alive. His technique, and its further modifications, still occupies a privileged place among the surgical options for the management of the stress urinary incontinence. Even now, Burch procedure is considered the gold standard with which all the other new techniques must be compared in order to measure their effectiveness. In the past few years, there have been important advances in the knowledge and standardization of the female urodynamics. This has increased the accuracy of the medical assessments to have a better selection for this surgical procedure. Then, with the technique focused on such cases, the results of the procedure have been optimized, considering that its complications are not serious and they are relatively infrequent. The success rates of this technique are up to approximately 90% in 5 to 10 years follow-ups and 69% in 10 to 20 years follow-ups. Therefore, it is believed that Burch's urethropexia continues contributing greatly to the management of the stress urinary incontinence. This revision includes 33 articles, all of them related with this matter from Ovid database.

Urogynaecological research: current and future developments.

The massive introduction of new products from device and drug industries together with a scanty device approval process and a growing scepticism about the reliability of drug trials call for new improved strategies in urogynaecological research. Device companies and physicians have a mutual ethical responsibility of contributing to create clinical data based on the framework of trials in surgery before new surgical products are implemented and disseminated. In respect of the patients' altruism and confidence, which make drug trials possible, the industry and academia have an obligation to conduct and report clinical results in accordance with the highest standards of scientific and ethical integrity.

Birth prevalence of cryptorchidism and hypospadias in northern England, 1993-2000.

AIM: There is much debate as to whether the prevalence rates of cryptorchidism and hypospadias are increasing. To address this issue we investigated the birth prevalence of cryptorchidism and hypospadias in the northern region of England during the period 1993-2000. METHODS: Cases of cryptorchidism and hypospadias were identified from northern region hospital episodes statistics (HES). Trends in birth prevalence, based on the number of male live births, were assessed using linear regression. RESULTS: Prevalence was 7.6 per 1000 male live births for cryptorchidism and 3.1 per 1000 male live births for hypospadias. The orchidopexy rates for 0-4 year olds and 5-14 year olds were 1.8 and 0.8 per 1000 male population, respectively. The rates for hypospadias repair for 0-4 year olds and 5-14 year olds were 0.6 and 0.1 per 1000 male population, respectively. There was a statistically significant decreasing temporal trend for the corrective procedure in cryptorchidism of 0.1 per 1000 male population aged under 5 years per annum (95% confidence interval: -0.01 to -0.05, p<0.001), but no temporal change for the corrective procedure in hypospadias (p = 0.60). CONCLUSION: HES data were of high quality for the study period. There was no significant change in the prevalence of surgically corrected hypospadias. However, there was an apparent decline in the prevalence of surgically corrected cryptorchidism that may reflect a decrease in the prevalence of the condition or may be due to a decrease in the rate of surgical intervention.

Minitipóia com enxerto autógeno de mucosa vaginal para tratamento cirúrgico da incontinência urinária de esforço / Mini-sling with autogenous graft of vaginal mucous membrane for surgical treatment of stress urinary incontinence

O polipropileno monofilamentar, produto derivado do gás propano, comercializado como tela de Márlex, tem sido o tipo de prótese mais utilizada em nosso meio para correção dos defeitos herniários da parede abdominal. O produto estimula o crescimento de fibroblastos e essa fibroplasia induzida é a principal responsável pelo reforço desejado. Desde a década de 90, esse mesmo material, vem sendo utilizado também para o tratamento cirúrgico da incontinência urinária de esforço por varias técnicas. Dentre elas, uma utiliza instrumental que limita o uso aos ginecologistas e apresenta complicações, além do risco de infecção e erosão, que são complicações inerentes ao uso das telas. Tecidos autógenos como fascia lata e mucosa vaginal têm sido utilizados, mas com transfixação dos fios de sutura para via suprapúbica. Uma forma de se evitar os inconvenientes dessa via de acesso é a fixação do retalho de mucosa da vagina aos ligamentos pubovesicouretral por via baixa.

Tratamento cirúrgico do prolapso da parede vaginal anterior através da técnica de sling transobturatório / Surgical treatment of the anterior vaginal wall prolapse by the transobturator sling technique

A abordagem cirúrgica do prolapso genital, particularmente da parede vaginal anterior (cistocele), é realizada classicamente através de técnicas que envolvem tecidos pouco resistentes e suscetíveis à recidiva precoce, como a colporrafia anterior. Os princípios da biocirurgia introduzem o conceito de biomateriais para reforço tecidual, visando uma abordagem minimamente invasiva e resultados duradouros. Utilizando-se a via transobturatória, inicia-se por incisão da parede vaginal anterior seguida de dissecção lateral até o ramo ísquio-púbico. Após introdução das agulhas inferiores e superiores, coloca-se uma tela para correção do defeito vaginal central e quatro hastes auto-fixáveis para correção do defeito lateral, fazendo ajuste sem tensão. A correção transobturatória do prolapso da parede vaginal anterior é uma alternativa segura e de caracter minimamente invasivo para o tratamento do prolapso vaginal anterior, com significativa redução dos riscos de complicações intra e pós-operatória. Futuramente, havendo os bons resultados a longo prazo, poderá ser considerada opção de rotina nestes casos