Clinical Efficacy and Safety Meta-Analysis of Different Surgical Approaches for Female Stress Urinary Incontinence.

OBJECTIVE: Meta-analysis was conducted to compare and evaluate the efficacy and safety of tension-free vaginal tape (TVT), outside-in trans-obturator tape (TOT), inside-out tension-free vaginal tape-obturator (TVT-O) and transvaginal tension-free urethral sling surgery (TVT-S) in the treatment of female stress urinary incontinence (SUI). METHODS: A computer-based systematic search of the PubMed, The Cochrane Library, Medline, Embase, Web of Science and ScienceDirect databases for randomised controlled trials (RCTs) comparing TVT, TOT, TVT-O and TVT-S for the treatment of SUI was performed from the time of library construction to November 2023. Two investigators performed data extraction and quality evaluation of the included RCTs, extracting information including the follows: First author, time of publication, intervention, sample size, age, duration of follow-up and objective cure rate, subjective cure rate, dyspareunia, vaginal mucosal perforation, urinary tract infection, sling exposure and postoperative thigh pain/groin pain. Review Manager (RevMan) 5.4 was used for data processing. RESULTS: A total of 14 RCTs with 2665 patients were included. Meta-analysis showed no statistically significant differences in objective cure rate, urinary tract infection, sling exposure and postoperative thigh pain/groin pain. The subjective cure rate of TVT was higher than that of TOT (odds ratio (OR), 95% confidence interval (CI) = 1.37 (1.02, 1.84), p = 0.03); The incidence of TVT-O voiding difficulty was lower than that of TVT (OR, 95% CI = 2.94 (1.20, 7.20), p = 0.02); And the incidence of vaginal mucosal perforation of TOT was lower than that of TVT (OR, 95% CI = 0.11 (0.02, 0.61), p = 0.01). CONCLUSIONS: The four surgical procedures, TVT, TOT, TVT-O and TVT-S, were relatively similar in terms of SUI outcomes. TVT had a higher subjective cure rate than TOT and a higher incidence of postoperative dyspareunia and vaginal mucosal perforation.

Application of the ERAS guidelines in pediatric urological surgery: a systematic review.

INTRODUCTION: Consensus for Enhanced Recovery After Surgery (ERAS) in pediatrics has been achieved in neonatal intestinal surgery, yet it is not widely utilized in pediatric urology. We investigated the application of ERAS guidelines in pediatric urology, and determined its effects given the available level of evidence supporting the ERAS protocol in children. EVIDENCE ACQUISITION: A systematic literature review including series providing adoption of fast-track recovery protocols for pediatric urology procedures was carried out. Main outcome measures were study characteristics, adherence to the 19 ERAS items, complication rates and length of hospital stay. Sub-group analysis by surgery type (hypospadias versus major surgery) was performed. EVIDENCE SYNTHESIS: Nine series with data from 1272 surgical pediatric cases were included. An enhanced recovery pathway was applied in 67.3% of the reports. Two series included patients undergoing hypospadias repair and ERAS items were insufficiently reported. Studies including children undergoing major procedures mentioned a median of 15 ERAS items, yet applied a median of 11 items. Median compliance rate was 88.9% (range 50-100). More ERAS guideline items were reported (applied or mentioned) in the most recently published studies. CONCLUSIONS: There is limited reporting and use of the ERAS guidelines in urologic surgery particularly in hypospadias repair; whilst in major surgery in children, adherence and compliance rates vary widely. In more recent series there was an increase in ERAS items that have been mentioned and applied. Future research is needed to identify barriers and to overcome them in order to fully adopt and benefit from the ERAS pathway.

Complications: The Experience of the Urologic Surgeon.

INTRODUCTION: Most urologic surgeons will experience surgical complications during their career. These complications can traumatize the surgeon. A national survey of AUA members was conducted to better understand the impact of surgical complications on mental, emotional, and physical health. METHODS: An anonymous survey was distributed to a random sample of 4528 AUA members (US urologists and trainees). Survey items were designed to identify the prevalence of surgical complications, and consequential mental, emotional, and physical impact on the surgeon. Also assessed was the support infrastructure available to urologists who experienced complications. RESULTS: The survey was completed by 467 urologists (10.3% response rate), 432 (95%) of whom reported having experienced a serious complication. The most common mental/emotional experiences were anxiety (85%), guilt/shame (81%), and grief/sadness/depression (71%). The most common physical symptoms reported were insomnia (62%), loss of appetite (23%), and headache (13%). Approximately 94% of respondents reported that they did not receive any counseling, and 69% reported not receiving any emotional support following the incident. Urologists reported that shame, lack of administrative time, fear, stigma, and guilt were barriers to seeking support. CONCLUSIONS: The overwhelming majority of urologists experience significant complications. These complications are associated with a high incidence of physical and emotional distress, and there is poor access to support. There is an opportunity for the AUA and other agencies to address barriers to seeking and accessing care for urologists who experience mental, emotional, and physical distress after experiencing surgical complications.

Diagnosis and Management of Ureteropelvic Obstruction in Kidney Transplant Recipients and Outcomes of Foley Y-V Pyeloplasty.

OBJECTIVES: To evaluate the etiology and diagnostic tools for ureteropelvic obstruction in kidney transplant recipients, we investigated the short-term and long-term outcomes of Foley Y-V pyeloplasty. MATERIALS AND METHODS: We retrospectively reviewed 10 patients who underwent kidney transplant followed by additional interventions to treat obstructive ureteral pathologies between 2016 and 2020. We enrolled 4 patients who had received intervention to treat ureteropelvic obstruction. For these 4 patients, serum creatinine and estimated glomerular filtration rate levels were recorded at baseline, during the symptomatic period, and long-term. In this single center study, we investigated diagnostic tools and management strategies for ureteropelvic obstruction and assessed performance of Foley Y-V nondismembered pyeloplasty in kidney transplant recipients. RESULTS: Among 4 patients, graft function (assessed by serum creatinine and estimated glomerular filtration rate) worsened significantly (P = .03) in the symptomatic period of ureteropelvic obstruction in all patients; however, graft function levels improved rapidly to levels similar to baseline (P = .07) after Y-V pyeloplasty. In addition, no statistically significant difference was detected between baseline and longterm graft functions afterY-V pyeloplasty in follow-up (P = .28). CONCLUSIONS: Diagnosis and management of ureteropelvic obstruction in kidney transplant recipients are challenging due to rarity and lack of an ideal management algorithm.There is no specific diagnostic tool to discriminate this pathology from other ureteral pathologies; therefore, a regimen of conventional imaging modalities and diuretic renogram combined with endoscopic evaluation is more reliable. Moreover, nondismembered Foley Y-V pyeloplasty is effective and safe for graft function in the short-term and long-term.

Systematic review and meta-analysis of the incidence of incisional hernia in urological surgery.

PURPOSE: To evaluate the incidence of incisional hernia in patients undergoing direct access to the abdominal cavity in urological surgery. METHODS: We conducted a systematic review in Pubmed, Embase, and Cochrane Central from 1980 to the present according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Eighty-four studies were selected for inclusion in this analysis, and meta-analysis and meta-regression were performed. RESULTS: The total incidence in the 84 studies was 4.8% (95% CI 3.7% - 6.2%) I2 93.84%. Depending on the type of incision, it was higher in the open medial approach: 7.1% (95% CI 4.3%-11.8%) I2 92.45% and lower in laparoscopic surgery: 1.9% (95% CI 1%-3.4%) I2 71, 85% According to access, it was lower in retroperitoneal: 0.9% (95% CI 0.2%-4.8%) I2 76.96% and off-midline: 4.7% (95% CI 3.5%-6.4%) I2 91.59%. Regarding the location of the hernia, parastomal hernias were more frequent: 15.1% (95% CI 9.6% - 23%) I2 77.39%. Meta-regression shows a significant effect in reducing the proportion of hernias in open lateral, laparoscopic and hand-assisted compared to medial open access. CONCLUSION: The present review finds the access through the midline and stomas as the ones with the highest incidence of incisional hernia. The use of the lateral approach or minimally invasive techniques is preferable. More prospective studies are warranted to obtain the real incidence of incisional hernias and evaluate the role of better techniques to close the abdomen.

Discriminatory ability of perioperative heart rate variability in predicting postoperative complications in major urologic surgery: a prospective cohort study.

We aimed to determine if continuous perioperative heart rate variability (HRV) monitoring could improve risk stratification compared to a short preoperative measurement in radical cystectomy patients. Electrocardiography (ECG) recordings were collected continuously preoperatively to discharge in 83 patients. Two, 5-min ECG signal segments (preoperative and at 24-h post ECG placement) were analyzed offline to extract HRV metrics. HRV metric discriminatory ability to identify patients with 30-day postoperative complications were analyzed using receiver operating characteristics curves. Sixty participants were included for analysis of which 27 (45%) developed a complication within 30 days postoperative. HRV was reduced in patients with complications. Postoperative standard deviation NN intervals and root mean square of successive differences had area under the curves (AUC) of 0.67 (95% CI 0.54 to 0.81) and 0.68 (95% CI 0.54 to 0.82), respectively. Significant discriminatory abilities were also reported for postoperative frequency metrics of absolute low frequency (LF) [AUC = 0.65 (95% CI 0.51 to 0.79)] and high frequency (HF) powers [AUC = 0.69 (95% CI 0.55 to 0.83)] and total power [AUC = 0.66 (95% CI 0.53 to 0.80)]. Postoperative acquired HRV metrics demonstrated improved discriminatory ability. Our findings suggest that longer-term perioperative HRV monitoring presents with superior ability to stratify complication risk.

Comparison of efficacy and safety of open and laparoscopic proximal ureterolithotomy for ureteral stone management: A systematic review and meta-analysis.

Despite advances in non-invasive and minimally invasive techniques, some proximal ureteral stones with impaction require open or laparoscopic surgery. No systematic reviews or meta-analyses have compared the efficacy and safety of open proximal ureterolithotomy and laparoscopic approaches. The aim of this study was to compare the efficacy and safety between open and laparoscopic proximal ureterolithotomy for ureteral stone management. Following the PRISMA guidelines, systematic searches were conducted in five databases (PubMed, Scopus, ScienceDirect, Web of Science, and ProQuest) to identify articles comparing those two surgical approaches. Operative time, blood loss, pain score, hospital stay, recovery time, and complications were collected and compared. Heterogeneity-based meta-analysis with random-effects or fixed-effects models were conducted. Two randomized controlled trials and four observational cohort studies with 386 participants met the criteria. Open surgery had significantly less time than laparoscopic ureterolithotomy (mean difference (MD): 26.63 minutes, 95%CI: 14.32, 38.94; p<0.0001). Intraoperative blood loss (MD: -1.27 ml; 95%CI: -6.64, 4.09; p=0.64) and overall complications (OR: 0.68; 95%CI: 0.41, 1.15; p=0.16) were not significantly different between two approaches. Laparoscopic ureterolithotomy reduced visual analogue scale (VAS) pain scores (MD: -2.53; 95%CI: -3.47, -2.03; p<0.00001), hospital stays (MD: -2.40 days; 95%CI: -3.42 to -1.38 days; p=0.03), and recovery time (MD: -9.67 days; 95%CI: -10.81 to -8.53 days; p<0.00001). In conclusion, open proximal ureterolithotomy had less time, but laparoscopic surgery reduced postoperative pain, hospital stay, and recovery time. Both methods had comparable intraoperative bleeding and complications.

Retrospective analysis of urethral anastomosis with ancillary maneuvers and intraoperative biaxial defect measurements to achieve a tension free guidance system for redo PFUDD treatment.

OBJECTIVES: Redo surgery for pelvic fracture urethral distraction defects (PFUDDs) is still a challenge. the long urethral defect makes it difficult while the high tension increase the recurrence rate. Although certain ancillary maneuvers can relieve tension, there is no consensus or guidelines for the prediction/planning of the selection. In this study, we present our experience with developing an intraoperative guidance system to achieve tension-free urethral anastomosis. PATIENTS AND METHODS: A total of 91 recurrent PFUDD patients managed at our center between 2020 and 2022 were retrospectively analyzed. The patients underwent scar removing and urethral anastomosis. For the long defect and high-tension cases, 6 kinds of tension-relieving maneuvers were used respectively during the process of urethral anastomosis. Preoperative assessment of the urethrogram was done before surgery, while biaxial (vertical and horizontal) defect measurements were performed intraoperatively. The patients were followed-up for 12 months (8.9 ± 4.2), furthermore, recurrence and complications were analyzed. RESULTS: The overall success rate was 86.81%. The mean defect in urethrogram was 2.9 ± 1.1 cm. 27 simple anastomosis was performed when the vertical plus horizontal defect was less than 2 cm with 11.11% recurrence. 24 cavernous septum splittings were performed when the horizontal defect was greater than 2 cm with 8.33% recurrence. 21 inferior pubectomies were performed when the horizontal defect was greater than 3 cm with 19.05% recurrence. 15 ancillary distal urethra manipulations (fully distal urethral mobilization, urethral suspension and corpus cavernosa folding) were performed when the vertical defect was 3 to 4 cm with 13.33 recurrence. 4 reroutings were performed when the vertical defect was greater than 4 cm with 25.00% recurrence. CONCLUSIONS: Ancillary maneuvers are effective for reducing tension in redo urethral anastomosis. Measurement of divergent vertical and horizontal urethral defects could guide the selection of ancillary maneuvers. Combined tension-relieving maneuvers is recommended according to the defect direction and length to achieve a tension-free anastomosis.

Multi-Institutional Bladder Exstrophy Consortium After 8 Years: The Short- and Intermediate-Term Outcomes.

PURPOSE: Bladder exstrophy (BE) poses challenges both during the surgical repair and throughout follow-up. In 2013, a multi-institutional BE consortium was initiated, which included utilization of unified surgical principles for the complete primary repair of exstrophy (CPRE), real-time coaching, ongoing video capture and review of video footage, prospective data collection, and routine patient data analysis, with the goal of optimizing the surgical procedure to minimize devastating complications such as glans ischemia and bladder dehiscence while maximizing the rate of volitional voiding with continence and long-term protection of the upper tracts. This study reports on our short-term complications and intermediate-term continence outcomes. MATERIALS AND METHODS: A single prospective database for all patients undergoing surgery with a BE epispadias complex diagnosis at 3 institutions since February 2013 was used. For this study, data for children with a diagnosis of classic BE who underwent primary CPRE from February 2013 to February 2021 were collected. Data recorded included sex, age at CPRE, adjunct surgeries including ureteral reimplantations and hernia repairs at the time of CPRE, osteotomies, and immobilization techniques, and subsequent surgeries. Data on short-term postoperative outcomes, defined as those occurring within the first 90 days after surgery, were abstracted. In addition, intermediate-term outcomes were obtained for patients operated on between February 2013 and February 2017 to maintain a minimum follow-up of 4 years. Outcomes included upper tract dilation on renal and bladder ultrasound, presence of vesicoureteral reflux, cortical defects on nuclear scintigraphy, and continence status. Bladder emptying was assessed with respect to spontaneous voiding ability, need for clean intermittent catheterization, and duration of dry intervals. All operating room encounters that occurred subsequent to initial CPRE were recorded. RESULTS: CPRE was performed in 92 classic BE patients in the first 8 years of the collaboration (62 boys), including 46 (29 boys) during the first 4 years. In the complete cohort, the median (interquartile range) age at CPRE was 79 (50.3) days. Bilateral iliac osteotomies were performed in 89 (97%) patients (42 anterior and 47 posterior). Of those undergoing osteotomies 84 were immobilized in a spica cast (including the 3 patients who did not have an osteotomy), 6 in modified Bryant's traction, and 2 in external fixation with Buck's traction. Sixteen (17%) patients underwent bilateral ureteral reimplantations at the time of CPRE. Nineteen (21%) underwent hernia repair at the time of CPRE, 6 of which were associated with orchiopexy. Short-term complications within 90 days occurred in 31 (34%), and there were 13 subsequent surgeries within the first 90 days. Intermediate-term outcomes were available for 40 of the 46 patients, who have between 4 and 8 years of follow-up, at a median of 5.7 year old. Thirty-three patients void volitionally, with variable dry intervals. CONCLUSIONS: Cumulative efforts of prospective data collection have provided granular data for evaluation. Short-term outcomes demonstrate no devastating complications, that is, penile injury or bladder dehiscence, but there were other significant complications requiring further surgeries. Intermediate-term data show that boys in particular show encouraging spontaneous voiding and continence status post CPRE, while girls have required modification of the surgical technique over time to address concerns with urinary retention. Overall, 40% of children with at least 4 years of follow-up are voiding with dry intervals of > 1 hour.

Long-term Renal Preservation and Complication Profile With Ileal Ureter Creation.

OBJECTIVE: To examine long-term ileal ureter replacement results at over 32 years at our institution. Long segment or proximal ureteral strictures pose a challenging reconstructive problem. Ureteroureterostomy, psoas hitch, Boari flap, buccal ureteroplasty, and autotransplantation are common reconstructive techniques. We show that ileal ureter remains a lasting option. METHODS: We performed a retrospective review of patients undergoing open ileal ureter creation from 1989-2021. Patient demographics, operative history, and complications were examined. All patients were followed for changes in renal function. Demographic data were analyzed and Cox proportional hazard models were performed. RESULTS: One hundred and fifty-eight patients were identified with median follow-up time of 40 months. Eighty-one percent had a unilateral ileal ureter creation. Fifty percent were female, median age was 53.3. Twenty-seven percent of patients had radiation-induced strictures. Preoperatively, 56.3% of patients were chronic kidney disease stage 1-2 and 43.7% were stage 3-5. Post-operatively, 54% were stage 1-2 and 46% were stage 3-5. Cox proportional hazard models demonstrated no significant correlation between worsening renal function and stricture cause, bilateral repair, complications, or sex (biologically male or female). Seventy-seven percent had no 30-day complications. Clavien complications included grade 1 (18), grade 2 (4), grade 3 (9), and grade 4 (5). Long-term complications included worsening renal function (3%), incisional hernia (8.2%), and small bowel obstruction (6.9%). Five (3.1%) patients ultimately required dialysis and 5 (3.1%) patients developed metabolic acidosis. CONCLUSION: Ileal ureteral reconstruction is often a last resort for patients with complex ureteral injuries. Clinicians can be reassured by our long-term data that ileal ureteral creation is a safe treatment with good preservation of renal function and low risk of hemodialysis and metabolic acidosis.

Assessing the Feasibility and Safety of the Toumai® Robotic System in Urologic Surgery: Initial Experience.

Introduction: Robotic surgery using da Vinci surgical system has gained prominence in urology; emerging robotic platforms are expanding its applications and increasing affordability. We assess the feasibility and safety of a novel system, the Toumai® robotic system in various urological surgeries. Methods: This prospective study was conducted at the first affiliated hospital of Zhengzhou university. Twenty consecutive patients underwent renal and prostatic surgery with the Toumai. The study assessed technical feasibility (conversion rate) and safety (perioperative complications) of the procedures as primary outcomes. Secondary endpoints included key surgical perioperative outcomes: functional and oncologic results. The Endoscopic Surgical System operates within a master-slave protocol, comprising a Surgeon Console, Patient Platform, and Vision Platform. Results: Seventeen patients underwent various nephrectomy procedures and three underwent radical prostatectomy (RP). There was no conversion to alternative surgical approach; a single (Clavien-Dindo grade ≥3b) complication occurred, and no readmission was recorded within 30 days. The median operative time was 120, 140, and 210 minutes for partial nephrectomy (PN), radical nephrectomy, and RP, respectively. Off-clamp PN was performed in one case, and the warm ischemia time in the remaining two case was 18 minutes. The median docking time was 22 minutes for nephrectomy and 20 minutes for RP; no major robotic malfunction was encountered. At 3-month follow-up, no tumor recurrence was recorded, renal function was well preserved, and the continence status was satisfactory. Conclusions: We present the initial clinical utilization of an innovative robotic platform. Complex urological surgeries were successfully completed without conversions and with minimal complications. Further investigations are warranted to confirm these initial findings.

The Utility and Safety of Ureteral Access Sheath During Retrograde Intrarenal Surgery in Children.

OBJECTIVE: To compare retrograde intrarenal surgery (RIRS) with and without ureteral access sheath (UAS) in different pediatric age groups. METHODS: The data of RIRS for kidney stone in children were obtained from 9 institutions. Demographic characteristics of patients and stones, intraoperative and postoperative results were recorded. While analyzing the data, patients who underwent RIRS without UAS (group 1) (n = 195) and RIRS with UAS (group 2) (n = 194) were compared. RESULTS: Group 1 was found to be young, thin, and short (P <.001, P = .021, P <.001), but there was no gender difference and similar symptoms were present except hematuria, which was predominant in group 2 (10.6% vs 17.3%, P <.001). Group 1 had smaller stone diameter (9.91 ± 4.46 vs 11.59 ± 4.85 mm, P = .001), shorter operation time (P = .040), less stenting (35.7% vs 72.7%, P = .003). Re-intervention rates and stone-free rates (SFR) were similar between groups (P = .5 and P = .374). However, group 1 had significantly high re-RIRS (P = .009). SFR had a positive correlation with smaller stone size and thulium fiber laser usage compared to holmium fiber laser (HFL) (P <.001 and P = .020), but multivariate analysis revealed only large stone size as a risk factor for residual fragments (P = .001). CONCLUSION: RIRS can be performed safely in children with and without UAS. In children of smaller size or younger age (<5 years), limited use of UAS was observed. UAS may be of greater utility in stones larger than 1 cm, regardless of the age, and using smaller diameter UAS and ureteroscopes can decrease the complications.

Retroperitoneoscopic Simple Nondismembered Pyeloplasty with Da Vinci Si Assistance to Prevent Alignment Shift.

Aims: Retroperitoneoscopic simple nondismembered pyeloplasty (SNDP) with da Vinci Si assistance was developed because of a possible risk for alignment shift after retroperitoneoscopic diamond-shaped bypass pyeloplasty (Diamond-Bypass; DP). Outcomes of SNDP and DP were compared. Materials and Methods: For SNDP, a small longitudinal incision is made on the border of the dilated pelvis and narrowed ureter at the ureteropelvic junction (UPJ). Extending this incision toward the pelvis allows identification of mucosa while maintaining the integrity of surrounding tissues that are so thin and fragile that they will not influence lumen alignment. Data for DP were obtained from a previously published article. Results: For SNDP (n = 3), mean age at surgery was 2.67 years (range: 1-4), mean operative time was 176 minutes. Mean postoperative Society of Fetal Urology (SFU) grades for hydronephrosis were 1.2, 0.7, and 0.6, 1, 2, and 3 months after stent removal, respectively. Postoperative diethylenetriaminepentaacetic acid (DTPA) was normal (n = 3). For DP (n = 5) mean age at surgery was 4.3 years (range: 1-14), mean operative time was 189 minutes. Mean postoperative SFU grades were 2.8, 2.2, and 1.6, respectively. Postoperative DTPA was normal (n = 4) and delayed (n = 1). All SNDP and DP were asymptomatic by 3 months after stent removal. Conclusion: Both SNDP and DP have favorable outcomes. If the UPJ is located at the lowest end of the renal pelvis, SNDP may improve hydronephrosis more quickly.

Outpatient vs Inpatient Single-Port Robotic Urologic Surgery: Perioperative Outcomes and Complications.

INTRODUCTION: The da Vinci Single Port (SP) robotic surgical system has minimized the impact of surgery on patients. Hence, outpatient robotic procedures are being explored to reduce costs and improve patient experience. Here, we evaluate the perioperative outcomes and safety of same-day discharge (SDD) after surgery compared to inpatient procedures using the SP. METHODS: A total of 374 patients underwent surgery with the da Vinci SP system between January 2019 and February 2023. Surgeries were performed in a single high-volume center. Patients were either managed with a standardized outpatient or inpatient protocol. SDD clinical pathway was implemented in June 2021. Patients were assessed for discharge eligibility based on specific guidelines. Detailed instructions were provided at discharge, and patients were followed postoperatively. Baseline characteristics, perioperative data, complications, time to complication, and readmissions were assessed. RESULTS: Two hundred eight patients underwent outpatient surgery and 166 underwent inpatient surgery (total = 374). Outpatient surgery was not associated with increased postoperative complications and readmission compared to inpatient surgery. Ninety percent and 74.6% of patients experienced no complications in the outpatient and inpatient populations, respectively (P =< .001). Time to first complication was also comparable between the 2 groups (3 days [IQR 1-8] vs 10 days [IQR 4-30] for outpatient vs inpatient; P = .3). The proportion of successful SDDs increased over time, reaching 88% in October 2022. CONCLUSIONS: Outpatient surgery using the da Vinci SP is safe and feasible, without increasing postoperative complications compared to standard inpatient surgery.

Procedure-Specific Thromboprophylaxis in Urological Surgeries: A Narrative Review.

PURPOSE: Postoperative pulmonary embolism is a leading cause of mortality in patients undergoing major urologic surgeries, presenting a complex challenge in balancing the risks of venous thromboembolism (VTE) and perioperative bleeding. This study examines the current evidence on thromboprophylaxis in urological procedures, focusing on procedure-specific considerations. METHODS: Literature on thromboprophylaxis in urological procedures was reviewed during the past decade. RESULTS: Various mechanical thromboprophylaxis methods, such as compression stockings, pneumatic compression devices, foot pumps, mobilization, and exercises, are available preventive measures. Additionally, unfractionated heparin (UFH) and low molecular weight heparin (LMWH) are commonly used pharmacological agents for VTE prevention, with the choice between mechanical, pharmacological, or combined approaches tailored to individual patient characteristics and surgical requirements. Patient risk stratification into low, medium, and highrisk categories based on age, BMI, and VTE history guides the selection of thromboprophylaxis strategies. Surgical procedures are categorized as oncological or non-oncological, with uro-oncological surgeries posing a higher VTE risk than non-oncological procedures. Consequently, a combination of pharmacological and mechanical prophylaxis is typically recommended for uro-oncological patients, while pharmacological prophylaxis is reserved for high-risk individuals undergoing non-oncological surgeries. Mechanical prophylaxis is advised for high-risk patients undergoing procedures with elevated VTE risk. CONCLUSION: This study summarized an optimal thromboprophylaxis protocol taking into account patient risk factors and the specific urological procedure.

Tunable tension tape versus transobturator tape in treatment of stress urinary incontinence in women: Randomized controlled trial.

INTRODUCTION: The synthetic mid-urethral slings are currently considered to be the most widely used technique for the surgical treatment of stress urinary incontinence (SUI). The most challenging aspect of the existing approaches is to achieve the optimal tension of the sling which treatment results are directly dependent on. To solve this problem, sling systems enabling an adjustment of the tension in the early postoperative period were created. A comparative study of the effectiveness and safety of such a system and a nonadjustable sling seems to be a relevant task. MATERIALS AND METHODS: A double-blind, randomized, multicenter trial enrolled 320 patients with a mean age of 55.2 ± 11.2 years and confirmed SUI. Patients were randomized into two groups: the first group underwent a standard synthetic suburethral sling (transobturator tape [TOT]) procedure and the second group underwent a tunable tension tape sling (TTT) procedure. All patients underwent stress test, uroflowmetry and ultrasound scan to determine the postvoid residual volume. Urinary Distress Inventory Short Form 6, International Consultation on Incontinence Questionnaire-Short Form, Pelvic Organ Prolapse Incontinence Sexual Questionnaire 12 questionnaires were used to assess subjective efficacy. RESULTS: Enhancement of prosthesis tension in the second group was required in 44 (28%) patients. Due to the possibility of tightening of the sling in the early postoperative period, the operation was effective in 143 (89%) patients in the adjustable sling group and in 109 (68%) patients in Group 1, p < 0.001. Loosening of the sling tension was performed in 25 (16%) patients in Group 2. The signs of obstructive voiding symptoms at the follow-up time of 36 months remained in Group 1 in 13 (8%) patients. Subjective satisfaction with treatment on the PGI-I scale was higher in Group 2: 100 (62%) versus 132 (82%), p < 0.001. CONCLUSION: A synthetic mid-urethral TTT is superior to a standard nonadjustable sling in long-term effectiveness and safety.

An evaluation of three validated comorbidity indices to predict short-term postoperative outcomes after prosthetic urologic surgery.

PURPOSE: Commonly used comorbidity indices include the Charlson Comorbidity Index (CCI), Elixhauser/Van Walraven Index (VWI), and modified frailty index (mFI). This study evaluates whether these indices predict postoperative readmissions and complications after inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) placement. METHODS: We identified adult males who underwent IPP or AUS placement using the State Inpatient and State Ambulatory Surgery and Services Databases for Florida (2010-2015) and California (2010-2011). CCI, VWI, and mFI scores were calculated for each patient. We extracted 30-day emergency department services, 30-day readmissions, 90-day device complications (e.g., removal, replacement, or infection), and 90-day postoperative complications (excluding device complications). Receiver-operating characteristic curves were constructed and areas under the curve (AUC) were compared between the indices using the VWI as the reference model. We considered an AUC < 0.7 to represent poor predictive power. RESULTS: We identified 4242 IPP and 1190 AUS patients. All three indices had AUCs and 95% confidence intervals less than 0.70 for all outcomes following IPP and AUS placement making these indices poor predictors for postoperative outcomes. There were no significant differences in predicting 90-day postoperative complications between the VWI (AUC = 0.59, 95% CI [0.54-0.63]), CCI (AUC = 0.59, 95% CI [0.54-0.63], p = 0.99), and mFI (AUC = 0.60, 95% CI [0.55-0.66], p = 0.53) for IPPs and VWI (AUC = 0.54, 95% CI [0.47-0.61]), CCI (AUC = 0.50, 95% CI [0.43-0.57], p = 0.30), and mFI (AUC = 0.52, 95% CI [0.43-0.60], p = 0.56) for AUS placements. CONCLUSION: All three comorbidity indices were poor predictors of readmissions and complications following urologic prosthetic surgeries. A better comorbidity index is needed for risk-stratification of patients undergoing these surgeries.

Minimally invasive pyeloplasty versus open pyeloplasty for ureteropelvic junction obstruction in infants: a systematic review and meta-analysis.

Background: To compare the perioperative outcomes and success rates of minimally invasive pyeloplasty (MIP), including laparoscopic and robotic-assisted laparoscopic pyeloplasty, with open pyeloplasty (OP) in infants. Materials and Methods: In September 2022, a systematic search of PubMed, EMBASE, and the Cochrane Library databases was undertaken. The systematic review and meta-analysis were conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with the study registered prospectively in the PROSPERO database (CRD42022359475). Results: Eleven studies were included. Dichotomous and continuous variables were presented as odds ratios (OR) and standard mean differences (SMD), respectively, with their 95% confidence intervals (CI). Compared to OP, a longer operation time and shorter length of stay were associated with MIP (SMD: 0.96,95% CI: 0.30 to 1.62, p = 0.004, and SMD: -1.12, 95% CI: -1.82 to -0.43, p = 0.002, respectively). No significant differences were found between the MIP and OP in terms of overall postoperative complications (OR:0.84, 95% CI: 0.52 to 1.35, p = 0.47), minor complications (OR: 0.76, 95% CI: 0.40 to 1.42, p = 0.39), or major complications (OR: 1.10, 95% CI: 0.49 to 2.50, p = 0.81). In addition, a lower stent placement rate was related to MIP (OR: 0.09, 95% CI: 0.02 to 0.47, p = 0.004). There was no statistical difference for success rate between the MIP and OP (OR: 1.35, 95% CI: 0.59 to 3.07, p = 0.47). Finally, the results of subgroup analysis were consistent with the above. Conclusions: Our meta-analysis demonstrates that MIP is a feasible and safe alternative to OP for infants, presenting comparable perioperative outcomes and similar success rates, albeit requiring longer operation times. However, it is essential to consider the limitations of our study, including the inclusion of studies with small sample sizes and the combination of both prospective and retrospective research designs.