Urologic Surgery in Digital Era: Foresights and Futuristic Approach.

The new scientific developments and technological opportunities that have led to significant changes all build up the digital era. In medicine, the use of new technologies in patient diagnosis and treatment processes has opened new horizons for physicians and patients. As considering for the medical training, 3-dimensional modeling opportunities, virtual reality, augmented reality, and various simulators offered by the new technologies of the digital era have become a new hope. The 3-dimensional scanning and modeling, 3-dimensional medical printing, virtual reality technologies applications and simulators in urology are very recent and valuable. Besides, the exoscope-assisted 3-dimensional open surgery provides high-resolution 3-dimensional images to surgeons with high comfort as compared with old-fashioned operating microscopes. New modalities that tried to be integrated in robotic surgery are 3-dimensional reconstruction, usage of indocyanine green, augmented reality, contrast ultrasound, haptic feedback, and availability of single port. Some new companies announced their new robotic systems in the market. The use of these new technological applications during medical training, especially at the beginning of the education curve for various surgical interventions, may be beneficial in terms of reducing possible complications that may be encountered due to inexperience at the beginning of the education process and increasing patient safety. Urology will also stay at the futuristic approach in medicine, while 3-dimensional technologies used more widely in this field.

Impact of the COVID-19 Pandemic on Urological Care Delivery in the United States.

PURPOSE: We examined changes in urological care delivery due to COVID-19 in the U.S. based on patient, practice, and local/regional demographic and pandemic response features. MATERIALS AND METHODS: We analyzed real-world data from the American Urological Association Quality (AQUA) Registry collected from electronic health record systems. Data represented 157 outpatient urological practices and 3,165 providers across 48 U.S. states and territories, including 3,297,721 unique patients, 12,488,831 total outpatient visits and 2,194,456 procedures. The primary outcome measure was the number of outpatient visits and procedures performed (inpatient or outpatient) per practice per week, measured from January 2019 to February 2021. RESULTS: We found large (>50%) declines in outpatient visits from March 2020 to April 2020 across patient demographic groups and states, regardless of timing of state stay-at-home orders. Nonurgent outpatient visits decreased more across various nonurgent procedures (49%-59%) than for procedures performed for potentially urgent diagnoses (38%-52%); surgical procedures for nonurgent conditions also decreased more (43%-79%) than those for potentially urgent conditions (43%-53%). African American patients had similar decreases in outpatient visits compared with Asians and Caucasians, but also slower recoveries back to baseline. Medicare-insured patients had the steepest declines (55%), while those on Medicaid and government insurance had the lowest percentage of recovery to baseline (73% and 69%, respectively). CONCLUSIONS: This study provides real-world evidence on the decline in urological care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urological health services by demographics and procedure type.

Artificial intelligence in urological oncology: An update and future applications.

There continues to be rapid developments and research in the field of Artificial Intelligence (AI) in Urological Oncology worldwide. In this review we discuss the basics of AI, application of AI per tumour group (Renal, Prostate and Bladder Cancer) and application of AI in Robotic Urological Surgery. We also discuss future applications of AI being developed with the benefits to patients with Urological Oncology.

What a mesh! An Australian experience using national female continence surgery trends over 20 years.

PURPOSE: To review the evolution of female continence surgical practice in Australia over the last 20 years and observe whether vaginal mesh controversies impacted these trends. MATERIALS AND METHODS: From January 2000 to December 2019, medicare benefit schedule codes for female continence procedures were identified and extracted for: mesh sling, fascial sling, bulking agent, female urethral prosthesis, colposuspension, and removal of sling. Population-adjusted incidences per 100,000 persons were calculated using publicly available demographic data. Three discrete phases were defined over the study time frame for analysis: 2000-2006; 2006-2017, and 2017-2019. Interrupted time-series analyses were conducted to assess for impact on incidence at 2006 and 2017. RESULTS: There were 119,832 continence procedures performed in Australia from 2000 to 2019, with the mid-urethral sling (MUS) the most common (72%). The majority of mesh (n = 63,668, 73%) and fascial sling (n = 1864, 70%) procedures were in women aged < 65 years. Rates of mesh-related procedures steeply declined after 2017 (initial change: -21 cases per 100,000; subsequent rate change: -12 per 100,000, p < 0.001). Non-mesh related/bulking agents increased from + 0.34 during 2006-2017 to + 2.1 per 100,000 after 2017 (p < 0.001). No significant change in mesh extraction was observed over 2006-2017 (+ 0.06 per 100,000, p = 0.192). There was a significant increase in mesh extraction procedures after 2017 (0.83 per 100,000, p < 0.001). CONCLUSION: Worldwide, controversy surrounding vaginal mesh had a significant impact on Australian continence surgery trends. The most standout trends were observed after the 2017 Australian class-action lawsuit and Senate Inquiry.

Retrograde intrarenal surgery: Past, present, and future.

With the recent technological advancements in endourology, retrograde intrarenal surgery has become a more popular procedure for treatment of urolithiasis. Furthermore, since the introduction of new laser systems and advanced flexible ureteroscopy with miniaturized ureteroscopes, the treatment indications for retrograde intrarenal surgery have expanded to include not only larger renal stones of >2 cm but also upper urinary tract urothelial carcinoma, ureteral stricture, and idiopathic renal hematuria. Clinicians must keep up with these trends and make good use of these technologies in the rapidly changing field of endourology. Simultaneously, we must consider the risk of various complications including thermal injury due to laser use, ureteral injury caused by the ureteral access sheath, and radiation exposure during retrograde intrarenal surgery with fluoroscopic guidance. This review focuses on the past, present, and future of retrograde intrarenal surgery and provides many topics and clinical options for urologists to consider.

Single Port Robotic Surgery in Urology.

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

How the COVID-19 Wave Changed Emergency Urology: Results From an Academic Tertiary Referral Hospital in the Epicentre of the Italian Red Zone.

OBJECTIVE: To quantify and characterize the burden of urological patients admitted to emergency department (ED) in Lombardy during Italian COVID-19 outbreak, comparing it to a reference population from 2019. METHODS: We retrospectively analysed all consecutive admissions to ED from 1 January to 9 April in both 2019 and 2020. According to the ED discharge ICD-9-CM code, patients were grouped in urological and respiratory patients. We evaluated the type of access (self-presented/ambulance), discharge priority code, ED discharge (hospitalization, home), need for urological consultation or urgent surgery. RESULTS: The number of urological diagnoses in ED was inversely associated to COVID-19 diagnoses (95% confidence interval -0.41/-0.19; Beta = -0.8; P < .0001). The average access per day was significantly lower after 10 March 2020 (1.5 ± 1.1 vs 6.5 ± 2.6; P < .0001), compared to reference period. From 11 March 2020, the inappropriate admissions to ED were reduced (10/45 vs 96/195; P = .001). Consequently, the patients admitted were generally more demanding, requiring a higher rate of urgent surgeries (4/45 vs 4/195; P = .02). This reflected in an increase of the hospitalization rate from 12.7% to 17.8% (Beta = 0.88; P < .0001) during 2020. CONCLUSION: Urological admissions to ED during lockdown differed from the same period of 2019 both qualitatively and quantitatively. The spectrum of patients seems to be relatively more critical, often requiring an urgent management. These patients may represent a challenge due to the difficult circumstances caused by the pandemic.

Trends in the surgical management of vesicoureteral reflux in Finland in 2004-2014.

OBJECTIVES: Previous data on the trends of surgical treatment of vesicoureteral reflux outside USA are scarce. The aim of this study was to clarify the national trends of operative treatment of vesicoureteral reflux (VUR) in Finland. METHODS: We analyzed national data from Finnish Care Register for Health Care on children (<16 years of age) surgically treated for VUR in 2004-2014. RESULTS: Endoscopic injections of the ureteral orifices were primarily performed for 1212 and open ureteral reimplantation for 272 children. The use of both types of surgery decreased during the study period (p = 0.0043 and p < 0.001, respectively). The median age at surgery for VUR was lower in those treated with open ureteral reimplantation than those with endoscopic injections of the ureteral orifices [3 and 4 years, respectively] (p = 0.0001). The length of hospital stay was significantly longer (median 9.9 days) with open ureteral reimplantation compared to that (median 1.3 days) with endoscopic injections (p < 0.0001) and did not change during the study period. Reoperations were significantly more common in patients who were primarily treated with endoscopic injections (n = 146/1072, 14%) than with ureteral reimplantation (n = 7/230, 3%) (p < 0.0001). CONCLUSIONS: While the best treatment options for VUR remain debatable, operative treatment of VUR has become less common in Finland. HIGHLIGHTS Recent data on the trends of treatment of vesicoureteral reflux outside USA are scarce. Surgical treatment for vesicoureteral reflux decreased in Finland during the study period. The length of stay was longer but reoperations were needed less often with ureteral reimplantation compared to endoscopic injections.

Robotics in Pediatric Urology: Evolution and the Future.

Almost 30 years have passed since the inception of minimally invasive surgery in urology and specifically in pediatric urology. Laparoscopy has now become an essential tool in the pediatric urologic armamentarium. The application of robot-assisted surgery in pediatrics has allowed for widespread utilization for common reconstructive procedures such as pyeloplasty and ureteral reimplantation. Understanding the implementation, technical considerations, and outcomes are critical for continued success and adoption. This has allowed for increased use in more complex urologic procedures such as redo pyeloplasty, dismembered ureteral reimplantation, catheterizable channel creation, and bladder augmentation.

Robotic Surgery Training: Current Trends and Future Directions.

The use of robotic surgery in urology has grown exponentially in the past 2 decades, but robotic surgery training has lagged behind. Most graduating residents report a lack of comfort independently performing common robotic urologic surgeries, despite an abundance of available resources. There is a general consensus on the key components of a comprehensive robotics curriculum, and well-validated tools have been developed to assess trainee competency. However, no single curriculum has emerged as the gold standard on which individual programs can build their own robotics curricula.

Competing Robotic Systems: A Preview.

"The new frontier of robotic surgery is well under way. Current research and development is rapidly progressing, allowing for the creation of many new robotic companies. Each company has its own identity and platform for what their vision for the future entails. The competition generated between these companies will shortly be forcing newer, cheaper, more accessible robotic systems worldwide."

Current Trends in Artificial Intelligence Application for Endourology and Robotic Surgery.

With the advent of electronic medical records and digitalization of health care over the past 2 decades, artificial intelligence (AI) has emerged as an enabling tool to manage complex datasets and deliver streamlined data-driven patient care. AI algorithms have the ability to extract meaningful signal from complex datasets through an iterative process akin to human learning. Through advancements over the past decade in deep learning, AI-driven innovations have accelerated applications in health care. Herein, the authors explore the development of these emerging AI technologies, focusing on the application of AI to endourology and robotic surgery.

Cirugía urológica funcional y SARS-CoV-2: cómo y por qué hay que retomar ya la actividad quirúrgica adaptados a la nueva realidad / Functional urology surgery and SARS-CoV-2: how and why surgical activity should be resumed now, adapting to the new reality

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Autonomous surgery in the era of robotic urology: friend or foe of the future surgeon?

Despite advances in robotic-assisted surgery (RAS) in the past two decades, control of the robotic system currently remains under the command of a human surgeon. Historically, urology has pioneered new surgical techniques and technologies. Now, autonomous RAS is on the horizon and the first data from clinical trials of autonomous RAS in urology are being published. Automation takes control away from the surgeon but promises standardization of techniques, increased efficiency, potentially reduced complication rates and new ways of integrating intra-operative imaging. Preclinical and clinical evidence is emerging that supports the use of autonomous robotic-assisted urological surgery. Use of autonomous technologies in the operating theatre will directly affect the role of the urological surgeon. Integration of autonomous RAS can be viewed as a positive aid, but it might also be perceived as a threat to the future urological surgeon.

Recent Trends in Transurethral Surgeries and Urological Outpatient Procedures: a Nationwide Population-based Cohort Study.

BACKGROUND: Demographic change and advances in technology affect transurethral surgery and outpatient procedures in the urologic field. There are few population-based studies that accurately assess the trend of transurethral surgery and outpatient procedures including diagnostic tests. We investigated the recent epidemiologic trends in transurethral surgeries and urological outpatient procedures from 2009 to 2016 in Korea using the entire population-based cohort. METHODS: We analyzed medical service claim data of transurethral surgery, urological outpatient procedures submitted by medical service providers from the Health Insurance Review and Assessment Service from 2009 to 2016. RESULTS: Transurethral ureter surgery increased by 134.9% from 14,635 in 2009 to 34,382 in 2016 (B = 2,698; R² = 0.98; P < 0.001). The transurethral bladder surgery increased by 65.5% from 12,482 in 2009 to 20,658 in 2016 (B = 1,149; R² = 0.97; P < 0.001). Over the 8-years period, there were not significant changes in transurethral prostate (B = 43; R² = 0.04; P = 0.617) and urethral surgery (B =-12; R² = 0.18; P = 0.289). The significantly increasing trends in cystoscopy (B = 5,260; R² = 0.95; P < 0.001) and uroflowmetry (B = 53,942; R² = 0.99; P < 0.001) were observed during the 8-year period. There was no difference in bladder catheterization during the 8-year period. Urodynamic study (UDS: B =-2,156; R² = 0.77; P = 0.003) and electrical stimulation treatment (EST: B =-1,034; R² = 0.87; P < 0.001) significantly decreased. CONCLUSION: In Korea, transurethral ureter surgery and transurethral bladder surgery have been continuously increasing. Transurethral prostate surgery and transurethral urethral surgery remained constant with no increase or decrease. Cystoscopy and uroflowmetry continue to increase, while UDS and EST continue to decrease.