Outcomes of urethral meatal preservation ventral urethroplasty for female urethral stricture: a series of cases.

Objective: To present a series of cases with our initial experience and short-term outcomes of a modified vaginal mucosal flap urethroplasty. Methods: Patients diagnosed with urethral stricture and operated by the same operative technique between January 2012 and January 2018 were followed for at least 6 months. Uroflowmetry and clinical outcomes were evaluated. Results: Nineteen patients were included with an average age of 56.4 years, mean preoperative Qmax of 5.3 ml/s, and PVR of 101.4 mL. After 6 months of the procedure, the mean Qmax improved to 14.7 mL/s (p<0.05), PVR decreased to 47.3 mL (p<0.05), and 84.2% of all patients reported improvement in clinical self-reported symptoms. There was an improvement in symptoms such as voiding effort in 84.2% of patients, weak stream (89.5%), and recurrent urinary tract infection (85.7%). The success rate (absence of symptoms and normal Qmax with no significant PVR) of the procedure was 84.2%. Conclusion: The described technique was considered effective for the treatment of female urethra stricture, with a high clinical success rate and an objective improvement of Qmax and decrease in PVR after 6 months of the procedure.

Catheter-associated meatal pressure injuries (CAMPI) in patients with long-term urethral catheters-a cross-sectional study of 200 patients.

Background: Indwelling urethral catheters (IDC) are ubiquitous to healthcare settings, and are associated with many familiar risks like haematuria, infections, bladder spasms and stones. However, a less known complication is catheter-associated meatal pressure injury (CAMPI), especially in those with long-term IDCs. The objective of this study was to explore the prevalence, associated features and management of CAMPI in adults with a long-term IDC. Methods: A cross-sectional multi-centre study was undertaken of 200 adults with a long-term IDC across regional south-west Queensland, Australia between June 2019 to June 2021. The prevalence of CAMPI was determined by clinical examination, voluntary surveys completed by participants and documentation in medical records. Key IDC statistics included total duration of IDC, location of IDC changes, IDC size, type and fixation. Results: Out of 200 adults with a long-term IDC, 9% (18/200) had a CAMPI. There was a higher prevalence of male CAMPI (17/169, 10%) compared to female CAMPI (1/31, 3%). The median time to identification of a CAMPI after initial IDC insertion was 12 weeks (2-136 weeks), but occurred as soon as 2 weeks. CAMPI formation was associated with IDC changes in the community, impaired mobility and congestive cardiac failure (CCF). CAMPI were mostly treated by conservative means given the frailty of the population. Conclusions: Poor mobility, community-managed IDCs, and CCF were all found to have statistically significant associations with the development of CAMPI. CAMPI represents an important and underserved iatrogenic complication within urology practice, and greater awareness is needed to prevent it in vulnerable patients with long-term IDCs.

Is It Worth the Sweat? Prehabilitation in Uro-oncology: A Mini Review.

In several surgical specialities, exercise as part of a prehabilitation program enhances recovery. However, for uro-oncological patients, evidence up to 2020 did not demonstrate significant benefits in terms of postoperative complications or hospital length of stay (LOS). We reviewed the literature from 2020 to 2023 and screened 205 reports, of which four full texts were included. Two retrospective cohort studies, despite having potential confounding risks, indicated that preoperative exercise might reduce LOS. One of these studies also suggested a lower likelihood of complications. Present evidence hints at the potential benefits of embedding exercise in prehabilitation for uro-oncological patients, particularly for short-term functional results. However, evidence on a direct effect on postoperative complications and LOS is still inconclusive. Future research should prioritise identification of specific exercises (eg, anaerobic vs aerobic, strength training, endurance, or respiratory exercises) that yield the most cost-effective benefits. PATIENT SUMMARY: Recent studies suggest that exercising before surgery might help people with urological cancers to improve their short-term fitness. More research is needed to see if exercise before surgery shortens hospital stays or reduces complications.

Influence of tract location on the outcomes of endoscopic combined intrarenal surgery: A retrospective analysis of 1000 cases.

OBJECTIVES: This study aimed to investigate the influence of tract location on surgical outcomes in endoscopic combined intrarenal surgery (ECIRS), considering the location of residual stones. METHODS: From January 2015 to December 2021, 1417 consecutive patients underwent ECIRS in three hospitals. After excluding patients with preoperative percutaneous nephrostomy, intended multi-stage procedures, those with a tract in the renal pelvis, and those with multiple tracts, 1000 patients were retrospectively analysed by comparing three groups based on tract location: group 1 (upper calyx), group 2 (middle calyx), and group 3 (lower calyx). A multivariate logistic regression model was implemented to assess whether the tract location independently affected the stone-free status. RESULTS: Patient characteristics were significantly different among the groups in terms of age, stone laterality, presence of calyceal stones, and hydronephrosis. There were no differences in stone-free rate (SFR) among the three groups. Multivariate analysis indicated that the tract location (group 1 or 2 compared with group 3) did not significantly affect the stone-free status (odds ratio = 1.4, 0.9-1.9, p = 0.066). Surgical duration significantly varied among the groups, with the shortest time observed in group 1. Organ injury was observed exclusively in group 1 (1.13%). Residual fragments were predominantly found in the lower calyx, with the calyx associated with the tract being the second most common location. CONCLUSIONS: Tract location does not significantly affect SFR. To improve the SFR, observation of the lower calyx and tract placement is important.

Outcomes of urethral meatal preservation ventral urethroplasty for female urethral stricture: a series of cases

Abstract Objective: To present a series of cases with our initial experience and short-term outcomes of a modified vaginal mucosal flap urethroplasty. Methods: Patients diagnosed with urethral stricture and operated by the same operative technique between January 2012 and January 2018 were followed for at least 6 months. Uroflowmetry and clinical outcomes were evaluated. Results: Nineteen patients were included with an average age of 56.4 years, mean preoperative Qmax of 5.3 ml/s, and PVR of 101.4 mL. After 6 months of the procedure, the mean Qmax improved to 14.7 mL/s (p<0.05), PVR decreased to 47.3 mL (p<0.05), and 84.2% of all patients reported improvement in clinical self-reported symptoms. There was an improvement in symptoms such as voiding effort in 84.2% of patients, weak stream (89.5%), and recurrent urinary tract infection (85.7%). The success rate (absence of symptoms and normal Qmax with no significant PVR) of the procedure was 84.2%. Conclusion: The described technique was considered effective for the treatment of female urethra stricture, with a high clinical success rate and an objective improvement of Qmax and decrease in PVR after 6 months of the procedure.

Preclinical evaluation of the Versius surgical system: A next-generation surgical robot for use in minimal access prostate surgery.

Objectives: To evaluate the Versius surgical system for robot-assisted prostatectomy in a preclinical cadaveric model using varying system setups and collect surgeon feedback on the performance of the system and instruments, in line with IDEAL-D recommendations. Materials and methods: Procedures were performed in cadaveric specimens by consultant urological surgeons to evaluate system performance in completing the surgical steps required for a prostatectomy. Procedures were conducted using either a 3-arm or 4-arm bedside unit (BSU) setup. Optimal port placements and BSU layouts were determined and surgeon feedback collected. Procedure success was defined as the satisfactory completion of all steps of the procedure, according to the operating surgeon. Results: All four prostatectomies were successfully completed; two were completed with a 3-arm BSU setup and two using a 4-arm BSU setup. Small adjustments were made to the port and BSU positioning, according to surgeon preference, in order to complete the surgical steps. The surgeons noted some instrument difficulties with the Monopolar Curved Scissor tip and the Needle Holders, which were subsequently refined between the first and second sessions of the study, in line with surgeon feedback. Three cystectomies were also successfully completed, demonstrating the capability of the system to perform additional urological procedures. Conclusions: This study provides a preclinical assessment of a next-generation surgical robot for prostatectomies. All procedures were completed successfully, and port and BSU positions were validated, thus supporting the progression of the system to further clinical development according to the IDEAL-D framework.

Effective and Economical Option of Anesthesia in Retrograde Intrarenal Surgery.

Background: There is only limited data in the literature showing the effect of anesthesia methods on the success of retrograd intrarenal surgery. The aim of this study was to compare and evaluate retrograd intrarenal surgery cases performed under spinal and general anesthesia in terms of effectiveness, cost, hospitalization time and complications. Methods: A total of 337 patients who underwent retrograd intrarenal surgery due to kidney stones between 2014 and 2019 were retrospectively evaluated. In our study, the patients were divided into two groups according to the anesthesia method administered: Group 1 consisted of 172 patients who received spinal anesthesia and Group 2 comprised 165 patients administered general anesthesia. Both groups were compared in terms of demographic data, localization and size of stone, radiographic stone density, operation time, complications, need for postoperative analgesia, length of hospitalization, and stone free rate. Results: The cost of general anesthesia was significantly higher compared to that of spinal anesthesia (p < 0.001). The analgesia application administered within the first six postoperative hours was significantly higher in the general anesthesia group (p < 0.001). In other findings, there was no statistically significant difference between the two groups. Conclusion: Retrograd intrarenal surgery can be performed with similar safety and effectiveness under both general and spinal anesthesia. However, spinal anesthesia seems to be more advantageous due to the patients' lower need for analgesics in the early postoperative period and the lower cost of the anesthetics used.

Reconstrução total da cobertura cutânea do pênis com retalho miocutâneo: relato de caso / Total reconstruction of the skin coverage of the penis with myocutaneous flap: case report

Introdução: O pênis é uma importante estrutura do corpo masculino, sendo sua reconstrução um desafio. Existem diversas doenças e deformidades que acometem este órgão, sendo necessário, em certos casos, a reconstrução total da cobertura cutânea do pênis, tendo já sido descritas na literatura diversas técnicas, tais como o uso de enxertos totais, retalho escrotal, retalhos miocutâneos da fáscia lata e outros. Relato de Caso: Neste relato é apresentada uma reconstrução da cobertura total do pênis por meio do uso de retalho miocutâneo do músculo cremaster com pele da bolsa escrotal, conseguindo prover uma boa vascularização e mantendo a permeabilidade uretral. Conclusão: Tal técnica não foi encontrada em nenhuma das bases de dados pesquisadas no trabalho, apenas semelhantes, e mostrouse como uma boa opção para a reconstrução total da cobertura cutânea peniana.

Introduction: The penis is an important structure of the male body, and its reconstruction is a challenge. Several diseases and deformities affect this organ, being necessary, in certain cases, for the total reconstruction of the cutaneous coverage of the penis, having already been described in the literature several techniques, such as the use of total grafts, scrotal flap, myocutaneous flaps of the fasciae latae and others. Case Report: In this report, a reconstruction of the total coverage of the penis is presented using a myocutaneous flap of the cremaster muscle with skin from the scrotum, achieving good vascularization and maintaining urethral permeability. Conclusion: This technique was not found in any of the databases researched in this study, only similar ones, and it proved to be a good option for the total reconstruction of penile skin coverage.

Ultrashort anisoperistaltic end-to-side ureteroureterostomy in renal transplantation / Anastomose uretero-ureteral término-lateral anisoperistáltica ultracurta no transplante renal

ABSTRACT The improvement of surgical techniques in kidney transplantation aims to reduce the incidence of post-transplant complications, contributing to the reduction of hospital stay, related costs, morbidity and mortality, in addition to improving the quality of life of patients. The choice of the best technique is influenced by several factors and the most common technique for urinary tract reconstruction in transplants is performed with implantation of the ureter of the graft in the caudal position, with the anastomosis performed in the bladder. However, the kidney pole can be inverted and the graft ureter anastomosis can be performed directly on the recipient's ureter, facilitating venous and ureteral anastomoses and reducing urological complications.

RESUMO O aprimoramento das técnicas cirúrgicas no transplante renal tem o objetivo de reduzir a incidência de complicações pós-transplante, contribuindo com a redução do tempo de internamento hospitalar, os custos relacionados, a morbidade e a mortalidade, além de melhorar a qualidade de vida dos pacientes. A escolha da melhor técnica é influenciada por diversos fatores e a técnica mais comum de reconstrução do trato urinário nos transplantes é a realizada com implante do ureter do enxerto na posição caudal, com a anastomose feita na bexiga. No entanto, pode-se inverter o polo do rim, posicionando o polo inferior cranialmente e realizar a anastomose do ureter do enxerto diretamente no ureter do receptor, facilitando a anastomose ureteral e diminuindo as complicações urológicas.

Listening to Music during Outpatient Cystoscopy Reduces Pain and Anxiety and Increases Satisfaction: Results from a Prospective Randomized Study.

BACKGROUND: This study investigates the effect of classical music, music of patients' own choice, or no music on pain reduction during elective cystoscopy. OBJECTIVES: The aim of the study was to describe the effect of listening to classical music, music of patients' own choice, or no music on patient's pain and satisfaction rates when carrying out an elective cystoscopy and the effect on the assessment capability of the performing urologist. DESIGN, SETTING, AND PARTICIPANTS: This randomized trial included 127 patients undergoing elective cystoscopy at the Urological Department of the University Clinic of Munich between June 2019 and March 2020. Outcome Measurements and Statistical Analysis: Patients were assigned randomly to 3 groups: group I: listening to standardized classical music (n = 35), group II: listening to music according to the patients' choice (n = 34), and control group III: no music (n = 44). Prior to cystoscopy, anxiety levels were assessed by the Beck Anxiety Inventory (BAI). The Visual Analog Scale (VAS, range 1-100) was used for a self-assessment of pain, discomfort, and satisfaction. Statistical analysis was done with Spearman's rank correlation and t-tests. RESULTS AND LIMITATIONS: The median age was 63 (range 27-91) years. The duration of cystoscopy was 5.7 (1-30) min. Patients had undergone a median of 2.3 cystoscopies in the past. Between giving informed consent and cystoscopy, patients had to wait for a median of 64 (0-260) min. The median VAS pain score was significantly lower in group I at 1.7 and group II at 2.3 versus 5.2 in the control group III (p < 0.001). The control group III had significantly worse pain and patient satisfaction rates compared with groups I and II. Group I had a significant lower VAS pain score than groups II and III (p < 0.001). Classical music also increased the assessment capability of the preforming urologist. CONCLUSIONS: Listening to music during elective cystoscopy significantly reduces pain and distress and leads to higher patient and surgeon satisfaction. We recommend listening to classical music or music chosen by the patients during outpatient flexible/rigid cystoscopy in daily clinical routine. Patient Summary: In this study, we found that patients who listened to classical music or music of their own choice while undergoing a cystoscopy showed significant reduction of pain and distress.

Shedding light on polypragmasy of pain after transurethral prostate surgery procedures: a systematic review and meta-analysis.

PURPOSE AND OBJECTIVE: To evaluate and compare the incidences of post-operative pelvic pain (PPP) in patients undergoing ablation, enucleation and conventional transurethral resection of the prostate (TURP). METHODS: A systematic review and meta-analysis was conducted according to the PRISMA guidelines. Using MEDLINE via PubMed and Cochrane CENTRAL, randomised control trials (RCTs) and observational studies reporting PPP rates post-ablation, enucleation or TURP were identified. The risk of biases (RoB) in RCTs and observation studies were assessed using the Cochrane RoB1.0 tool and the Newcastle-Ottawa Scale, respectively. RESULTS: 62 studies were included for qualitative analysis, while 51 of them reported number of patients with PPP post-intervention. Three observational studies and 13 RCTs compared the rates of PPP in patients undergoing ablation, enucleation or TURP. The most reported types of PPP are dysuria, abdominal pain and irritative symptoms. The pooled incidence of PPP at 1-month follow-up in patients undergoing ablation, enucleation and TURP were 0.15 (95% CI 0.10-0.22), 0.09 (95% CI 0.04-0.19 and 0.10 (95% CI 0.06-0.15), respectively. PPP is no longer prevalent at 3-months and onwards post-operatively. Ablation is associated with a higher risk of PPP than enucleation (RR 2.19, 95% CI 1.04-4.62) and TURP (RR 2.40, 95% CI 1.03-5.62) in observational studies but not RCTs; and there were no significant differences in the rates of PPP upon comparison of other modalities. CONCLUSION: PPP is common after transurethral benign prostatic hyperplasia surgery. Patients undergoing ablation had a higher rate of post-intervention PPP than those undergoing enucleation and TURP in observational studies.

A Systematic Review on Guidelines and Recommendations for Urology Standard of Care During the COVID-19 Pandemic.

CONTEXT: The first case of the new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), was identified in Wuhan, China, in late 2019. Since then, the coronavirus disease 2019 (COVID-19) outbreak was reclassified as a pandemic, and health systems around the world have faced an unprecedented challenge. OBJECTIVE: To summarize guidelines and recommendations on the urology standard of care during the COVID-19 pandemic. EVIDENCE ACQUISITION: Guidelines and recommendations published between November 2019 and April 17, 2020 were retrieved using MEDLINE, EMBASE, and CINAHL. This was supplemented by searching the web pages of international urology societies. Our inclusion criteria were guidelines, recommendations, or best practice statements by international urology organizations and reference centers about urological care in different phases of the COVID-19 pandemic. Our systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Of 366 titles identified, 15 guidelines met our criteria. EVIDENCE SYNTHESIS: Of the 15 guidelines, 14 addressed emergency situations and 12 reported on assessment of elective uro-oncology procedures. There was consensus on postponing radical prostatectomy except for high-risk prostate cancer, and delaying treatment for low-grade bladder cancer, small renal masses up to T2, and stage I seminoma. According to nine guidelines that addressed endourology, obstructed or infected kidneys should be decompressed, whereas nonobstructing stones and stent removal should be rescheduled. Five guidelines/recommendations discussed laparoscopic and robotic surgery, while the remaining recommendations focused on outpatient procedures and consultations. All recommendations represented expert opinions, with three specifically endorsed by professional societies. Only the European Association of Urology guidelines provided evidence-based levels of evidence (mostly level 3 evidence). CONCLUSIONS: To make informed decisions during the COVID-19 pandemic, there are multiple national and international guidelines and recommendations for urologists to prioritize the provision of care. Differences among the guidelines were minimal. PATIENT SUMMARY: We performed a systematic review of published recommendations on urological practice during the coronavirus disease 2019 (COVID-19) pandemic, which provide guidance on prioritizing the timing for different types of urological care.

Opioid Stewardship in Urology: Quality Improvement Summit 2018.

INTRODUCTION: We summarize the 2018 AUA (American Urological Association) Quality Improvement Summit, Opioid Stewardship in Urology, highlighting appropriate urological opioid use as well as reviewing programs that have been successful in reducing opioid prescribing. The AUA brought together nearly 100 attendees from across the United States, including clinicians who specialize in urology and other specialties, as well as researchers, government officials and others. METHODS: The 2018 AUA Quality Improvement Summit was a 1-day meeting held at AUA headquarters in Linthicum, Maryland. Talks and panels highlighted opioid stewardship programs and emphasized research on the nature and management of postoperative pain. RESULTS: The impact of the opioid epidemic is profound and the contribution of postoperative prescribing is noteworthy (eg 6% of opioid naïve patients demonstrate new persistent use habits after surgery and up to 70% of opioid pills prescribed after surgery go unused). Speakers raised awareness of these facts and detailed opportunities to improve, including prudent prescribing, opioid reclamation, use of nonopioid alternatives, and outreach and education. CONCLUSIONS: The 2018 AUA Quality Improvement Summit provided a platform for urologists to discuss the opioid epidemic and to learn strategies for combatting this issue from multidisciplinary experts. Physician led opioid stewardship and research, facilitated by this Summit, may enhance the quality and safety of medical care and improve the lives of patients, their families and their communities.

Open partial nephrectomy: current review.

Partial nephrectomy (PN) is increasingly considered the gold standard treatment for localized renal cell carcinomas (RCCs) where technically feasible. The advantage of nephron-sparing surgery lies in preservation of parenchyma and hence renal function. However, this advantage is counterbalanced with increased surgical risk. In recent years with the popularization of minimally invasive partial nephrectomy (laparoscopic and robotic), the contemporary role of open PN (OPN) has changed. OPN has several advantages, particularly in complex patients such as those with a solitary kidney, multi-focal tumors, and significant surgical history, as well as providing improved application of renoprotective measures. As such, it is a technique that remains relevant in current urology practice. In this article we discuss the evidence, indications, operative considerations and surgical technique, along with the role of OPN in contemporary nephron-sparing surgery.

Right atrium tumor extension through the inferior vena cava. considerations about nine cases operated under cardiopulmonary bypass

Abstract Introduction: Adrenocortical and renal cell carcinomas rarely invade the right atrium (RA). These neoplasms need surgical treatment, are very aggressive and have poor prognostic and surgical outcomes. Case series: We present a retrospective cohort of nine cases of RA invasion through the inferior vena cava (four adrenocortical carcinomas and five renal cell carcinomas). Over 13 years (2002-2014), nine patients were operated in collaboration with the team of urologists. Surgery was possible in all patients with different degrees of technical difficulty. All patients were operated considering the imaging examinations with the aid of CPB. In all reported cases (renal or suprarenal), the decision to use CPB with deep hypothermic circulatory arrest (DHCA) on surgical strategy was decided by the team of urological and cardiac surgeons. Conclusion: Data retrospectively collected from patients of public hospitals reaffirm: 1) Low incidence with small published series; 2) The selected cases did not represent the whole historical casuistry of the hospital, since they were selected after the adoption of electronic documentation; 3) Demographic data and references reported in the literature were presented as tables to avoid wordiness; 4) The series highlights the propensity to invade the venous system; 5) Possible surgical treatment with the aid of CPB in collaboration with the urology team; 6) CPB with DHCA is a safe and reliable option; 7) Poor prognosis with disappointing late results, even considering the adverse effects of CPB on cancer prognosis are expected but not confirmed.

Right Atrium Tumor Extension Through the Inferior Vena Cava. Considerations About Nine Cases Operated Under Cardiopulmonary Bypass.

INTRODUCTION: Adrenocortical and renal cell carcinomas rarely invade the right atrium (RA). These neoplasms need surgical treatment, are very aggressive and have poor prognostic and surgical outcomes. CASE SERIES: We present a retrospective cohort of nine cases of RA invasion through the inferior vena cava (four adrenocortical carcinomas and five renal cell carcinomas). Over 13 years (2002-2014), nine patients were operated in collaboration with the team of urologists. Surgery was possible in all patients with different degrees of technical difficulty. All patients were operated considering the imaging examinations with the aid of CPB. In all reported cases (renal or suprarenal), the decision to use CPB with deep hypothermic circulatory arrest (DHCA) on surgical strategy was decided by the team of urological and cardiac surgeons. CONCLUSION: Data retrospectively collected from patients of public hospitals reaffirm: 1) Low incidence with small published series; 2) The selected cases did not represent the whole historical casuistry of the hospital, since they were selected after the adoption of electronic documentation; 3) Demographic data and references reported in the literature were presented as tables to avoid wordiness; 4) The series highlights the propensity to invade the venous system; 5) Possible surgical treatment with the aid of CPB in collaboration with the urology team; 6) CPB with DHCA is a safe and reliable option; 7) Poor prognosis with disappointing late results, even considering the adverse effects of CPB on cancer prognosis are expected but not confirmed.

Factors associated with multidrug-resistant bacteria in a cohort of patients with asymptomatic bacteriuria who underwent urological surgery.

BACKGROUND: Although the factors associated to bacterial resistance in patients with asymptomatic bacteriuria (ASB) have been studied in pregnant, fertile age women, patients with spinal cord injury, and those with urogynecological disorders, nothing is known about the factors associated with multidrug-resistant (MDR) bacteria in patients with ASB and planned urological procedures. This study therefore sought to identify the sociodemographic and clinical factors associated with MDR bacteria in a cohort of patients with ASB scheduled for urological procedures. METHODS: We conducted a nested case-control study on a cohort of patients with ASB and planned urological procedures at 3 Colombian medical centers. Cases were patients with MDR bacteria and controls were patients without MDR bacteria. RESULTS: A total of 184 patients were included, 41.8% (n = 77) of whom presented ASB with MDR bacteria. The factors linking ASB with MDR bacteria were: advanced age (odds ratio, 1.03; 95% confidence interval, 1.01-1.06) and hospitalization within the 3-month period before surgery (odds ratio, 2.35; 95% confidence interval, 1.08-5.21). CONCLUSIONS: Bacterial resistance is frequent among patients with ASB and planned urological procedures. Advanced age and prior hospitalization should be borne in mind for patients with planned urological procedures because they are factors associated with the presence of MDR bacteria.

Multilevel Analysis of Readmissions After Radical Cystectomy for Bladder Cancer in the USA: Does the Hospital Make a Difference?

BACKGROUND: Hospitals are increasingly being held responsible for their readmissions rates. The contribution of hospital versus patient factors (eg, case mix) to hospital readmissions is unknown. OBJECTIVE: To estimate the relative contribution of hospital and patient factors to readmissions after radical cystectomy (RC) for bladder cancer. DESIGN, SETTING, AND PARTICIPANTS: We identified individuals who underwent RC in 2014 in the Nationwide Readmissions Database (NRD). The NRD is a nationally representative (USA), all-payer database that includes readmissions at index and nonindex hospitals. Survey weights were used to generate national estimates. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The main outcome was readmission within 30 d after RC. Using a multilevel mixed-effects model, we estimated the statistical association between patient and hospital characteristics and readmission. A hospital-level random-effects term was used to estimate hospital-level readmission rates while holding patient characteristics constant. RESULTS AND LIMITATIONS: We identified a weighted sample of 7095 individuals who underwent RC at 341 hospitals in the USA. The 30-d readmission rate was 29.5% (95% confidence interval [CI] 27.8-31.2%), ranging from 1.4% (95% CI 0.6-2.2%) in the bottom quartile to 73.6% (95% CI 68.4-78.7) in the top. In our multilevel model, female sex and comorbidity score were associated with a higher likelihood of readmission. The hospital random-effects term, encompassing both measured and unmeasured hospital characteristics, contributed minimally to the model for readmission when patient characteristics were held constant at population mean values (pseudo-R2<0.01% for hospital effects). Surgical volume, bed size, hospital ownership, and academic status were not significantly associated with readmission rates when these terms were added to the model. CONCLUSIONS: After adjusting for patient characteristics, hospital-level effects explained little of the large between-hospital variability in readmission rates. These findings underscore the limitations of using 30-d post-discharge readmissions as a hospital quality metric. PATIENT SUMMARY: The chance of being readmitted after radical cystectomy varies substantially between hospitals. Little of this variability can be explained by hospital-level characteristics, while far more can be explained by patient characteristics and random variability.

Cistite glandular associada à metaplasia intestinal com extravasamento de mucina: relato de caso / Glandular cystitis associated to intestinal type metaplasia with mucin extravasation: a case report

A mucosa vesical, na presença de agentes agressores, sofre alterações inicialmente benignas, mas com a cronicidade pode sofrer modificações potencialmente metaplásicas. A cistite glandular apresenta um quadro sintomático inespecífico, sendo necessária a realização de biópsia para seu diagnóstico e diferenciação histológica, podendo dividir-se em subtipos clássico e intestinal. Após análise de prontuário médico pertencente ao Hospital Santa Rita de Maringá, objetiva-se relatar o caso de um paciente masculino, de 32 anos, com disúria e dor em hipogástrico, apresentando em ultrassonografia lesão cística de 3,8 cm de diâmetro na bexiga. Após a retirada da lesão por ressecção transuretral, a análise histopatológica revelou presença de ninhos de Von Brunn, áreas de epitélio mucossecretor e mucina extracelular na mucosa vesical, propondo a existência de lesão glandular com metaplasia intestinal. Foi realizado estudo imunohistoquímico para diagnóstico diferencial de adenocarcinoma mucossecretor bem diferenciado. A cistite glandular, quando manifestada macroscopicamente, assemelha-se a uma neoplasia por apresentar um aspecto irregular, difuso e algumas vezes ulceroso. Seu diagnóstico e tratamento podem ser simultâneos, porém, nos casos mais graves, as opções terapêuticas são restritas. O diagnóstico diferencial é extremamente importante para afastar a possibilidade de adenocarcinoma vesical, portanto, é imprescindível o acompanhamento periódico dos pacientes após o tratamento com a realização de exames específicos. O uso de marcadores imunohistoquímicos tem se tornado relevante para o correto diagnóstico, pois genes relacionados ao ciclo celular, como o fator de transcrição homebox 2 do tipo caudal (CDX2), podem representar um vínculo entre o surgimento de metaplasia e sua possível progressão a adenocarcinoma. (AU)

The bladder's mucosa, in the presence of aggressive agents, undergoes initially benign changes, but with chronicity may undergo potentially metaplastic modifications. Glandular cystitis presents nonspecific symptoms and biopsy is necessary for diagnosis and histological differentiation, subdividing it into classic and intestinal subtypes. After analyzing a medical record belonging to the Santa Rita Hospital from Maringá, the objective of this study is to report the case of a 32-year-old male patient with dysuria and pain in the hypogastric region, presenting on ultrasonography cystic lesion of 3.8 cm of diameter in the bladder. After removal of the lesion by transurethral resection, the histopathological analysis revealed the presence of Von Brunn nests, areas of mucosecretory epithelium and extracellular mucin in the bladder's mucosa, suggesting the existence of a glandular lesion with intestinal metaplasia. It was performed an immunohistochemical study for differential diagnosis of well-differentiated mucosecretory adenocarcinoma. Glandular cystitis, when manifest-ed macroscopically, resembles a neoplasm, since it can present an irregular aspect, diffuse and sometimes ulcerous. The diagnosis and treatment can be simultaneous, but in severe cases, the therapeutic options are restricted. Differential diagnosis is extremely important to rule out the possibility of bladder adenocarcinoma, therefore it is essential to follow up patients after treatment with specific tests periodically. The use of immunohistochemical markers has become rele-vant for the correct diagnosis, since genes related to the cell cycle, such as caudal type homeobox transcription factor 2 (CDX2), may represent a link between the onset of metaplasia and its possible progression to adenocarcinoma (AU)

Surgical treatment of a penoscrotal massive localized lymphedema: Case report.

INTRODUCTION: Massive localized lymphedema is an aggressive type of lymphedema that causes great functional impairment for the patient, depriving from one's basic life activities. The treatment of this type of lesion is eminently surgical, requiring ablative surgery (complete surgical resection of the lesion), but the possible techniques not always provide a good functional result. PRESENTATION OF CASE: We reported a case of a penoscrotal massive lymphedema treated by our Body Contour Group/Plastic surgery department of our institute. We performed the resection of the giant penoscrotal lesion, used a posterior scrotal flap for defect's reconstruction and a split-thickness skin graft for penis' body reconstruction, closed with Z-plasty. DISCUSSION: Contrary to what the literature says, we prefer to use the split-thickness skin graft to reconstruct the penis' body in these cases, against local flaps. According to our experience with some similar cases, this technique provides a better functional result once it allows the penis to a better expansion during erection. The key maneuver to avoid contracture of the graft and retraction of the penis is to perform a broken line suture (Z-plasty) in the topography of the median raphe. CONCLUSION: In cases of penoscrotal massive lymphedema, the treatment's option with better results is the surgical one. The use of a scrotal flap associated with split-thickness skin graft for penis provides good aesthetic and functional outcomes.