Impact of COVID-19 on surgical residency training programs in Mexico City: The third victim of the pandemic. A resident's perspective.

OBJECTIVE: The aim of this study is to assess the perceptions of the impact of health-care disruption due to COVID-19 on the academic training and skills of surgical trainees. MATERIAL AND METHODS: We developed a 32-question survey assessing the clinical and surgical impact of COVID-19 on surgical training programs and proposals to compensate for the decrease in surgical education. We got 453 responses of surgical trainees in Mexico City. RESULTS: Sixty-six percent of the respondents answered that their centers had converted to the exclusive attention of COVID-19 patients. Ninety-five percent reported a decrease in surgical skills learning and 91.8% reported a decrease to clinical exposure. On proposals, 75.6% reported that it is essential to take the necessary measures to recover the clinical and surgical milestones lost. In the binary logistic regression analysis, we found that the postgraduate year (≥ PG-Y3) was statistically significant factor (p ≤ 0.000) related to a favorable opinion to developing an academic contingency plan and postponing the end of the academic residency year. CONCLUSION: More than 90% of the survey respondents reported having been affected by COVID-19 mitigation strategies. Our data calls for urgent training adjustments by hospital and university program leaders to mitigate downstream educational repercussions.

OBJETIVO: Evaluar las percepciones del impacto de la interrupción de la atención médica por COVID-19 en la formación académica y las habilidades de los residentes quirúrgicos. MATERIAL Y MÉTODOS: Realizamos una encuesta de 32 preguntas, evaluando el impacto clínico y quirúrgico del COVID-19 en los programas de entrenamiento quirúrgico y propuestas para compensar la disminución de la educación quirúrgica. Obtuvimos 453 respuestas de residentes quirúrgicos en la Ciudad de México. RESULTADOS: El 66% respondió que sus centros se convirtieron en atención exclusiva de pacientes con COVID-19. El 95% presentó una disminución en el aprendizaje de habilidades quirúrgicas y el 91. 8% presentó una disminución de la exposición clínica. El 75.6% consideró fundamental tomar las medidas necesarias para recuperar las destrezas clínicas perdidas. En el análisis de regresión logística binaria, encontramos que el año de posgrado (> PG-Y3) fue un factor estadísticamente significativo (p <0,000) relacionado con una opinión favorable para desarrollar un plan de contingencia académica y posponer el final del año de residencia académica. CONCLUSIÓN: Más del 90% de los encuestados fueron afectados por las estrategias de mitigación de COVID-19. Nuestros datos exigen ajustes urgentes por parte de los líderes de programas de hospitales y universidades para mitigar las repercusiones educativas posteriores.

Are All Stent Bearers Equal? Ureteral Stent Symptoms in Kidney Transplant Patients: A Case-Control Prospective Study.

Purpose: The aim of this study is to conduct a prospective, controlled single-center study to determine the prevalence and types of ureteral stent symptoms in kidney transplant (KTx) recipients and compare them with nontransplant subjects. Materials and Methods: From December 2012 to June 2019, a total of 102 patients having undergone a KTx and Double-J stent (DJS) placement and 88 patients having undergone endourological lithotripsy and DJS placement were enrolled. The Ureteral Stent Symptom Questionnaire (USSQ) was administered to patients with a median of 25 (KTx) and 31 (urolithiasis) days after stent placement. USSQ scores were used to compare symptoms between the two groups. Results: Of the 190 patients enrolled, 88 belonged to the lithotripsy group (control group) and 102 to the KTx recipients' group. Mean score for urinary symptoms was 21.42 for KTx patients vs 27.53 for control patients with statistical significance (p < 0.001, CI -7.792 to -4.433). The visual analog scale, overall bother, pain at voiding, flank pain at voiding, and frequency of painkiller use scores were significantly higher for control patients than for KTx patients (p = 0.024, <0.001, <0.001, <0.001, and 0.014, respectively). Frequency of rest, changes in work duration, work domain score, suspicion of urinary tract infection (UTI), and need for professional assistance scores were significantly lower for KTx patients than the control. There were no significant differences in general health and sexual domains between groups. Conclusions: KTx recipients have significantly fewer urinary symptoms, pain, work-related disturbances, suspected UTIs, and hospitalizations associated with stent placement than urolithiasis patients.

Frequency and risk factors for antegrade ureteral stone migration after percutaneous nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is the minimally invasive procedure of choice for the treatment of large and/or complex nephrolithiasis. Migration of residual fragments (RFs) into the ureter after PCNL is presumed to be uncommon. However, should associated stone-related events (SREs) occur, ancillary procedures may be required. The objective of this study was to describe the frequency and to analyze predictors of antegrade migration of RFs after PCNL. MATERIAL AND METHODS: A case-control study of patients who underwent PCNL for nephrolithiasis and had a postoperative computed tomography available within 48 hours was performed. Descriptive statistics and logistic regression analysis were carried out. RESULTS: The final sample included 169 interventions. Mean age was 49 ±13 years, median maximum stone size was 26 (7 to 87) mm and mean stone density was 835 (70 to 2022) Hounsfield Units (HUs). 7.1% of the patients experienced migration of RFs into the ureter after PCNL, of whom 41.6% suffered SREs. Lithotripsy was performed using ultrasonic (67.5%), laser (23.7%), and pneumatic (14.8%) technologies. Univariate analysis found female gender (OR 4.1, p = 0.02) height ≥1.68 m (OR 5.52, p = 0.009), middle (OR 6.71, p = 0.01) and upper (OR 3.59, p = 0.04) caliceal location, staghorn calculi (OR 4.72, p = 0.02), stone area (OR 1.001, p = 0.03), lasertripsy (OR 3.61, p = 0.03) and operative time (OR 1.007, p = 0.02) statistically significant for migration of SFs into the ureter after PCNL. Of these, only height ≥1.68 m (OR 7.17, p = 0.01) and staghorn nephrolithiasis (OR 13.27, p = 0.02) remained independent predictors in the multivariate analysis with an area under the curve of 0.69. CONCLUSIONS: 71.% of patients undergoing PCNL had a SF migrating to the ureter. Of these 41% suffered a SRE that required ancilliary interventions. Staghorn nephrolithiasis and ≥1.68 mts of height were found to predict this event.

Current practices in percutaneous nephrolithotomy in Mexico: results of a nation-wide electronic survey.

Practice patterns and choice of technological instruments in PCNL are not always standardized. There are no previous reports on the PCNL practice tendencies and patterns in Latin America. The aim of the study is to describe the current practice patterns of PCNL among the members of the Mexican Society of Urology ("Sociedad Mexicana de Urologia"). Observational and descriptive study. A 9-item closed questionnaire on PCNL practice patterns was answered by members of the Mexican Society of Urology in a secure website hosted survey after e-mail invitation. A descriptive numerical and graphical analysis was performed. A total of 90 contestants were registered out of 492 potential participants. PCNL is performed by 80% of the participants, with an average of 16 procedures per year. Percutaneous tracts are commonly obtained by urologists on the same day of the procedure. Sequential and telescopic dilators are equally preferred over balloons. The pneumatic litotriptor is the most common choice and CT scan and X-ray are equally used as follow-up. The practice patterns of PCNL from Mexican urologists are different from other international reports. Influence of socio-economic circumstances is inferred.

Emphysematous pyelonephritis: multicenter clinical and therapeutic experience in Mexico.

OBJECTIVE: To analyze the outcomes of emphysematous pyelonephritis (EPN), the impact of different treatment modalities, and to determine risk factors associated with mortality. METHODS: We retrospectively reviewed cases of EPN from 3 tertiary care institutions in Mexico. The diagnosis was confirmed with computed tomographic scan. Treatment was classified as follows: medical management (MM), minimally invasive, and surgical. Demographic, clinical, biochemical, and radiological characteristics were assessed and compared between survivors and nonsurvivors. Comparison was assessed using 1-way analysis of variance and chi-square. Univariate and multivariate logistic regression analyses were performed to determine prognostic factors. Main end point was mortality. RESULTS: A total of 62 patients were included (49 women and 13 men), with a mean age of 53.9 years. The most common comorbidities were diabetes (69.3%) and hypertension (40.3%). Escherichia coli was the most common isolated microorganism (62.7%). MM was provided to 24.2%, minimally invasive treatment to 51.6%, open drainage to 19.3%, and emergency nephrectomy to 4.8%. Overall mortality was 14.5% and was similar among different treatment modalities (P=.06). Survivors were younger (P=.004), had lower creatinine (P=.002), and better estimated glomerular filtration rate (P=.007). In univariate analysis, age (P=.009), creatinine (P=.009), and need for nephrectomy (P=.03) were associated with mortality. In multivariate logistic regression analysis, creatinine (odds ratio 1.56, 95% confidence interval 1.03-2.35, P=.03) and nephrectomy (odds ratio 9.7, 95% confidence interval 1.007-93.51, P=.049) remained significant predictors of mortality. CONCLUSION: EPN needs an aggressive MM and stepwise approach; nephrectomy should be the last resort of treatment. Creatinine level and need for nephrectomy are the strongest predictors of mortality according our analysis.

Urinary expression of novel tissue markers of kidney injury after ureteroscopy, shockwave lithotripsy, and in normal healthy controls.

BACKGROUND AND PURPOSE: Shockwave lithotripsy (SWL) and ureteroscopy (URS) are minimally invasive treatment alternatives for kidney stones. Although less invasive, SWL subjects the renal parenchyma to a high level of energy and the potential to cause renal injury. The ability to detect renal injury post-SWL in a reliable and noninvasive way would be clinically beneficial. Kidney injury molecule 1 (KIM-1) and N-acetyl-ß-D-glucosaminidase (NAG) are two proteins secreted by the kidney into the urine and have been found to be sensitive markers of acute kidney injury in transplant patients. The aim of this work was to measure urinary levels of KIM-1 and NAG in patients with kidney stone who were treated by SWL or URS and in nonstone volunteers. PATIENTS AND METHODS: Patients with kidney stones who were treated by SWL (n = 50) or URS (n = 10) were recruited. Voided urine samples were collected before and 2 to 3 hours after URS and SWL. In addition, further urinary specimens were collected 2 days and 2 weeks post-SWL treatment. Voided urine samples from healthy volunteers were also collected. RESULTS: Mean KIM-1 values were increased in patients with kidney stones when compared with volunteers. KIM-1 and NAG levels significantly increased post-SWL and returned to baseline within 2 weeks post-SWL. Poor kidney function was significantly associated with increased biomarker activity both in baseline and post-SWL measurements. There was no significant change in urinary KIM-1 and NAG concentrations before and after URS. CONCLUSIONS: Kim-1 and NAG levels significantly increased post-SWL treatment suggesting a potential role for these urinary markers in identifying patients at higher risk of tissue injury.

Risk factors for perinephric hematoma formation after shockwave lithotripsy: a matched case-control analysis.

PURPOSE: To determine the incidence of and evaluate the potential risk of a symptomatic perinephric hematoma (PNH) after shockwave lithotripsy (SWL) with the Storz Modulith SLX-F2 device. PATIENTS AND METHODS: Patient and treatment-related data from 6172 SWL treatments for proximal ureteral and kidney stones were collected prospectively from April 2006 to August 2010. Patients in whom signs or symptoms of a PNH developed after SWL were investigated with imaging studies. Each patient identified with a PNH was matched with four controls using sex, age (±5 years), shockwave rate, energy and number, and no SWL within the previous 6 months as the matching variables. The baseline characteristics of the 21 cases and 84 controls were compared using the Student t test. The independent variables of hypertension (intraoperative value >140/90 mm Hg), anticoagulant/antiplatelet drugs, obesity (body mass index ≥30), and diabetes were compared using a conditional logistic regression analysis. The dependent variable was hematoma. RESULTS: A PNH developed after SWL with the Storz Modulith SLX-F2 device in 21 (0.34%) adult patients (19 men, 2 women) with a mean age of 55.2 years. Significant risk factors identified included intraoperative hypertension (hazard ratio [HR] 3.302, 1.066-10.230, P=0.0384) and anticoagulant/antiplatelet medications (HR 4.198, 1.103-15.984, P=0.0355). Diabetes (P=0.1043) and obesity (P=0.1021) were not associated with PNH. CONCLUSIONS: A clinical PNH occurred in less than 1% of our population. This is consistent with reports from earlier generation devices. Risk factors identified for hematoma formation were intraoperative hypertension and the use of anticoagulant/antiplatelet drugs.

The use of triclosan eluting stents effectively reduces ureteral stent symptoms: a prospective randomized trial.

UNLABELLED: What's known on the subject? and What does the study add? Infection, encrustation and ureteral-stent-related symptoms (USRS) including pain, urgency and frequency are all major problems associated with stent use. No current ureteral stent or exogenously applied therapy adequately deals with these problems and antibiotic use is ineffective once a bacterial biofilm forms on the device. Triclosan is a broad spectrum antibacterial agent widely used in numerous healthcare products and has been previously shown to reduce inflammation on the skin and in the oral cavity. This study tested a triclosan-impregnated ureteral stent for its ability to reduce infection, encrustation and USRS. This study shows that while a triclosan-impregnated ureteral stent cannot reduce infection rates alone compared with antibiotic use, the stent can reduce several USRS including pain during indwelling. This study suggests that the triclosan eluting stent may have a role in treating patients, perhaps in combination with standard antibiotic therapy. OBJECTIVE: To evaluate the capacity of triclosan-loaded ureteral stents to reduce stent-associated bacterial attachment, biofilm formation and encrustation, thereby potentially reducing infection development and other device-related sequelae. PATIENTS AND METHODS: Twenty subjects requiring short-term stenting (7-15 days) were randomized to receive either a Percuflex Plus(®) non-eluting stent (control) or a Triumph(®) triclosan eluting stent. Control-stented subjects received 3 days of levofloxacin prophylaxis (500 mg once daily) while Triumph(®)-stented subjects did not. All subjects were assessed for positive urine and stent cultures, stent biofilm development and encrustation. Following device removal, each subject completed an analogue-scale symptom assessment questionnaire. RESULTS: Ureteral stenting was performed after nine ureteroscopic and one extracorporeal shock wave lithotripsy procedure in the control group and eight ureteroscopic and two shock wave lithotripsy procedures in the triclosan group. No significant differences were observed for culture, biofilm and encrustation between the two groups. Subjects in the triclosan group reported significant reductions in lower flank pain scores during activity (58.1% reduction, P = 0.017) and urination (42.6%, P = 0.041), abdominal pain during activity (42.1%, P = 0.042) and urethral pain during urination (31.7%, P = 0.049). CONCLUSIONS: In this study, the use of the Triumph(®) triclosan eluting stent had no marked impact on biofilm formation, encrustation or infection development in short-term stented patients. The Triumph(®) device led to significant reductions in several common ureteral-stent-related symptoms, supporting its use in this patient population.

A multicentre single-blind randomized controlled trial comparing bipolar and monopolar transurethral resection of the prostate.

INTRODUCTION: Monopolar transurethral resection of the prostate (TURP) is the gold standard surgical therapy for men with lower urinary tract symptoms due to benign prostatic hyperplasia. Although generally considered safer, TURP experience is limited in Canada. METHODS: Forty-three patients from 5 Canadian centres were randomized to TURP with either bipolar or monopolar platforms. Patients underwent baseline determinations of American Urological Association (AUA) symptom score, peak urinary flow rate, post-void residual bladder volume and transrectal ultrasound prostate volume. Primary outcome measures were improvement in AUA symptom score, quality of life assessment and bother assessment. Secondary outcomes included procedural times, duration of catheterization, length of hospitalization, complications and the degree of thermal artifact in tissue specimens. Patients were followed for 6 months. RESULTS: Twenty-two patients were treated with bipolar and 21 with monopolar TURP. Preoperative demographics were not statistically different between groups. Postoperative data collection times were equivalent in AUA symptom, quality of life, bother and sexual function assessments. No differences were observed in the procedure time (60.7 min, bipolar vs. 47.4, monopolar) or the duration of urethral catheterization (1.5 days, bipolar vs. 1.1, monopolar). More patients in the bipolar group were discharged on the same day of surgery. There were no differences in the degree of tissue thermal artifact or complication rate. CONCLUSION: This trial suggests equivalent short-term outcomes for men undergoing monopolar or bipolar TURP.

Stray electrical currents in laparoscopic instruments used in da Vinci® robot-assisted surgery: an in vitro study.

BACKGROUND AND PURPOSE: The da Vinci(®) surgical system requires the use of electrosurgical instruments. The re-use of such instruments creates the potential for stray electrical currents from capacitive coupling and/or insulation failure. We used objective measures to report the prevalence and magnitude of such stray currents. MATERIALS AND METHODS: Thirty-seven robotic instruments were tested using an electrosurgical unit (ESU) at pure coagulation and cut waveforms at four different settings. Conductive gel-coated instruments were tested at 40W, 80W, and maximum ESU output (coagulation 120W, cut 300W). The magnitude of stray currents was measured by an electrosurgical analyzer. RESULTS: At coagulation waveform in open air, 86% of instruments leaked a mean of 0.4W. In the presence of gel-coated instruments, stray currents were detected in all instruments with means (and standard deviation) of 3.4W (± 2), 4.1W (± 2.3), and 4.1W (± 2.3) at 40W, 80W, and 120W, respectively. At cut waveform in open air, none of the instruments leaked current, while gel-coated instruments leaked a mean of 2.2W (± 1.3), 2.2W (± 1.9) and 3.2W (± 1.9) at 40W, 80W, and 300W, respectively. CONCLUSIONS: All tested instruments in our study demonstrated energy leakage. Stray currents were higher during coagulation (high voltage) waveforms, and the magnitude was not always proportionate to the ESU settings. Stray currents have the potential to cause electrical burns. We support the programmed end of life of da Vinci instruments on the basis of safety. Consideration should be given to alternate energy sources or the adoption of active electrode monitoring technology to all monopolar instruments.

Third prize: the impact of fluid environment manipulation on shockwave lithotripsy artificial calculi fragmentation rates.

BACKGROUND AND PURPOSE: Studies have suggested that shockwave lithotripsy (SWL) stone fragmentation rates can be affected by characteristics of the fluid media surrounding the stone, although evidence to implicate the impact of urine specific gravity (SG) is limited and inconclusive. Our aim is to further explore the impact fluid media and SGs have on stone fragmentation using a variable focus lithotripter. MATERIALS AND METHODS: Artificial stones were presoaked for 24 hours in urine and then shocked in various fluid media including artificial urine (SG 1.010 control, 1.020, and 1.07), human pooled urine (HPU), degassed HPU, Pentastarch, 100% and 30% contrast, degassed 30% contrast, 100% ethanol, deionized water (dH(2)O), degassed dH(2)O, 5% glucose, Ringer lactate, 0.9% saline, glycerol, whole blood, and lubricating gel. After soaking, SWL using the Modulith SLX-F2 electromagnetic lithotripter was performed. Fragments were dried and sieved using a 4-mm diameter opening grid. Fragments >4 mm were weighed and fragmentation coefficients (FCs) calculated (pre-SWL weight - post-SWL weight)/(pre-SWL weight) × 100. Fifteen stones were shocked for each fluid group. RESULTS: Fluid type, viscosity, and degassing all significantly impacted stone fragmentation. While the solutions' SG, per se, did not appear to affect stone fragmentation, the use of degassed 30% contrast significantly improved stone destruction over the SG 1.010 artificial urine control (95.3% vs 71.4, P < 0.01). Furthermore, degassing improved comminution rates by increasing the number of completely fragmented stones (FC = 100%). Using degassed 30% contrast, 12/15 stones were completely fragmented, compared with only 2/15 in the control group (P = 0.007). Among the whole blood, glycerol, and lubricating gel groups, only 1/15, 0/15, and 1/15 stones reached 100% FC respectively in the narrow focus, possibly because of the detrimental impact of increased viscosity. CONCLUSIONS: Different fluid media can significantly affect FC in vitro. Among the various fluids tested, degassed 30% contrast significantly increased the FC and total number of completely fragmented stones.

Time to recurrence after nephrectomy as a predictor of cancer-specific survival in localized clear-cell renal cell carcinoma.

OBJECTIVE: To evaluate the prognostic impact of early recurrence (within 12 months) after surgery on cancer-specific survival (CSS) of patients with localized clear-cell renal cell carcinoma (ccRCC). METHODS: Patients with surgically treated localized ccRCC were studied. Using the Kaplan-Meier method, we calculated CSS; by univariate and multivariate models we analyzed the association of early recurrence with cancer-related mortality. RESULTS: We identified 259 patients with pT1-4/NX/0M0 ccRCC treated between February 1981 and September 2009; of 66 (25.5%) with disease recurrence, 29 (43.9%) had early relapse. Overall, 43 patients (16.6%) died from ccRCC. The 5- and 10-year CSS for those without, late and early recurrence was 98.5 and 96.5%, 53 and 39.8%, and 23 and 23%, respectively (p < 0.0001). In the multivariate Cox model, pT stage (p = 0.01) and early recurrence (p < 0.0001) independently predicted CSS. CONCLUSIONS: Recurrent disease after localized ccRCC confers a poor prognosis, especially if detected within 12 months after surgery. Thus, this criterion should be included as an independent risk factor for cancer-related mortality.

Impact of lymph node invasion and sarcomatoid differentiation on the survival of patients with locally advanced renal cell carcinoma.

INTRODUCTION: The application of current prognosticators in locally advanced nonmetastatic renal cell carcinoma (RCC) is controversial. We analyzed the impact of clinical and pathological variables on the survival of this subset of patients. PATIENTS AND METHODS: We studied patients with RCC in stages III and IV without metastases, treated surgically between 1980 and 2009. We calculated disease-free (DFS) and cancer-specific survival (CSS), and the relation of clinical and pathological variables with these end-points. RESULTS: We identified 126 patients with locally advanced RCC; 8.7% had sarcomatoid differentiation. Tumor stage was pT3a in 48% and pT3b in 42%; 11.9% had lymph node invasion (N+). Patients with N- and N+ had a 10-year DFS of 49.0 and 23.4%, respectively (p = 0.0001). In multivariate analysis N+ (p = 0.0002) was the strongest predictor of DFS. The 10-year CSS of patients without sarcomatoid differentiation was 53.1% while those with sarcomatoid differentiation did not reach the median time to death (p < 0.0001). In multivariate analysis, sarcomatoid differentiation (p = 0.01) was the strongest predictor of CSS. CONCLUSIONS: Locally advanced RCC portends poor prognosis. Preoperatively, weight loss and Eastern Cooperative Oncology Group performance status are predictors of recurrence and mortality, respectively. However, the most powerful predictors of DFS and CSS in our cohort were lymph node status and sarcomatoid differentiation.

Current status of ureteral stent technologies: comfort and antimicrobial resistance.

The placement of a ureteral stent is one of the most commonly performed urologic procedures. Indwelling ureteral stents are often accompanied by significant patient morbidity, including lower urinary tract symptoms, flank pain, and urinary tract infections. This article reviews the current state of ureteral stent technology developed to address the problem of stent discomfort and infection.

Fusion of the seminal vesicles discovered at the time of robot-assisted laparoscopic radical prostatectomy.

The reported incidence of seminal vesicle anomalies is low, and it usually occurs in association with other genitourinary anomalies, thus frequently diagnosed by a cluster of fertility, pain or obstructive symptoms. We present a case of a clinically silent seminal vesicle fusion encountered during a robotic assisted radical prostatectomy. Awareness of potential congenital anomalies is crucial for surgeons, to prevent surgical complications or adverse outcomes as a result of the altered anatomy.

Preoperative indications for percutaneous nephrolithotripsy in 2009.

Abstract Since the first description of percutaneous nephrolithotripsy (PNL) over 30 years ago, the indications for this procedure in the management of upper tract urinary stones has greatly expanded. Despite recent advances in shock wave lithotripsy and ureteroscopic technologies, PNL maintains a dominant role in the management of complex and large volume upper tract stones. The contemporary indications for PNL are reviewed herein.