Are the Complication Rates for the Open Approach in the Surgical Treatment of Bladder Stones Higher Than Rates for Endoscopic Approaches? A Comparative Multivariate Analysis Study

Objective:To compare the effectiveness, safety and complication rates of open vs endoscopic approach for bladder stone surgery and investigate the predictive factor for success and complication rate in patients with bladder stone.Materials and Methods:The records of 128 patients, who underwent stone surgery between November 2010 and June 2017, were analyzed. The patients were divided into two groups according to surgical approach as endoscopic or open group. Duration of surgery and catheterization and length of hospital stay were recorded. Multivariate analyses were done using logistic regression test to determine the risk factors for complications.Results:A total of 130 procedures were performed in 128 patients included in the study. Of them, 93 were treated via endoscopic approach and 37 via open approach. The overall success rate in endoscopic and open groups was 92.5% and 100%, respectively (p=0.44). Increased age, type of surgical approach and using lithotripsy were found to be risk factors for complications in univariate analysis. Only the type of surgery was found to be an independent risk factor for complications in multivariate analysis (p=0.006).Conclusion:Open and endoscopic approaches showed similar effectiveness in patients with bladder stone. The only significant risk factor for complications was the type of surgical approach

Bipolar Endoscopic Enucleation of Big Benign Prostate Enlargement

Large benign prostatic enlargement (BPE) has been a major health problem and the surgical management could be technically challenging to urologists due to the limitation of conventional monopolar transurethral resection of prostate. Bipolar endoscopic enucleation of prostate aimed to remove the adenoma of BPE by stepwise adenoma devascularization and maximal adenoma removal through minimally invasive surgery. In this chapter we described the general principle, the surgical techniques of bipolar endoscopic enucleation and the related modifications of the technique in the recent years. As compared with open prostatectomy, bipolar endoscopic enucleation avoided the wound complications but achieved similar functional outcome. Bipolar endoscopic enucleation also allowed much more adenoma removal comparing with transurethral resection of the prostate. Unlike Holmium laser or thulium laser enucleation of the prostate, the required instruments for bipolar endoscopic enucleation of the prostate were familiar and more readily available to most urologists

Comparison of Stone Retrieval Basket, Stone Cone and Holmium Laser: Which One Is Better in Retropulsion and Stone-Free Status for Patients with Upper Ureteral Calculi?

Introduction: Transurethral lithotripsy (TUL) is an appropriate treatment for ureteral stones and is usually used for stones in the middle and lower part of the ureter. Different devices such as Holmium laser, stone basket and stone cone exist to prevent any fragments from retropulsion during TUL. The present study aims to compare the advantages and disadvantages of the Holmium laser, stone basket and stone cone. Methods: A retrospective study was conducted from September 2016 to January 2018 comparing various TUL methods in 88 subjects with proximal ureteral calculi. The study participants were devided into four matched groups. The first one included 20 patients undergoing TUL with no device (Group 1), the second group included 22 patients undergoing TUL while using the stone retrieval basket, the third group included 18 patients undergoing TUL while utilizing the stone cone and the fourth group included 28 patients undergoing TUL while using Hol-YAG laser. Results: A residual stone ≥ 3 mm was recorded in 15.9% of the patients. stone free rate were seen in 100%, 90.9, 83.3%and 55% in Holmium laser group, retrieval basket group, stone cone group and no device group respectively(p:0.001). Lowest rate of surgery complications including ureteral perforation, Post-operative fever and mucosal damage between 4 groups (p: 0.003) and highest time of surgery (p: 0.001) belong to laser group. If we want to ignore the laser group, success rate for lithotripsy was better in both groups with stone retrieval device compared to the no device group, but no advantage existed between stone basket and stone cone. Conclusion:We can safely conclude that laser significantly help to prevent stone migration during TUL. If we want to ignore the laser group, success rate for lithotripsy was significantly better in both groups with stone retrieval device compared to the no device group, but no advantage existed between stone basket and stone cone

Retrospective audit for preoperative factors and clinical outcomes in patients undergoing bladder

BACKGROUND: Five percent of urinary tract stones are found in the urinary bladder. Bladder stones are responsible for 8% of urolithiasis related mortalities. We have conducted a study and evaluated the effectiveness, safety and the outcome of transurethral cystolithotripsy using a rigid cystoscope under general anaesthesia.METHODS: A retrospective study conducted at Mater Dei Hospital in Malta, from 2004 until 2020. Information obtained from medical records, information technology hospital system and department theatre list. 201 patients were included who all underwent cystolithotripsy with or without transurethral resection of prostate (TURP) or bladder neck incision (BNI). Approval to conduct the study was obtained after fulfilling all requirements requested by the University Research Ethics Committee of Malta, as well as obtaining approval of the CEO of Mater Dei Hospital in line with applicable hospital protocols.RESULTS: The mean age was 65 years, ranging between 21 and 89. Overall, the procedure was well tolerated and there were no major peri-operative complications. The hospital stay ranged between 1 to 33 days with an average of 3 days. Follow up average was 4.3 years. The maximum period with bladder catheter was 18 days before a successful trial without catheter. The majority of patients remained catheter free in the long term with a minority still requiring conservative measures for the relief of lower urinary tract symptoms.CONCLUSIONS: Transurethral cystolithotripsy using a rigid cystoscope under general anaesthesia is a safe and effective technique for the treatment of different sizes of bladder calculi.peer-reviewe

Complications of Vaginal Synthetic Sling Surgeries in Women: Population Based Cohort Study

Synthetic sling surgery is the procedure of choice for surgical correction of stress urinary incontinence (SUI) in females. However, complications are recognized, with surgical intervention to treat them in some instances. In a retrospective study we identified and analyzed those complication to determine their incidence and associated predictive factors. A total of 59,887 women who had synthetic sling procedure were included. Incidence of surgically treated complications was 2.2 % ((95% CI 2.07- 2.30) and on 10 years follow up cumulative incident rate was 3.3% (95% CI 3.0- 3.5). There was no significant difference in complication rate between urologists versus gynecologists. A significant reduction in complications was noted with high surgical volume providers (HR 0.73, 95% CI 0.65-0.83). Patients’ factors like age and simultaneous surgeries had significant effect. Results address and supports Food and Drug recommendation about use of synthetic meshes and slings in vaginal surgery

On the Epidemiology, Diagnosis and Treatment of Upper Tract Urothelial Carcinoma

Aims: The overall aim of this thesis was to increase our knowledge about the epidemiology, diagnostics and treatment of upper tract urothelial carcinoma (UTUC). For paper 1, the aim was to obtain contemporary knowledge about UTUC incidence, UTUC tumour and patient characteristics, and possible changes over time using national, population based data. For paper 2 and 3, the aim was to evaluate current standard diagnostics before radical nephroureterectomy (RNU), and see if our findings could be used for selecting patients for intensified treatment. Further, we aimed to evaluate a previously published diagnostic model through an external validation. For paper 4, we aimed to evaluate the outcomes of endoscopic treatment for UTUC given at our hospital with particular emphasis on tumour grade. Materials and methods: For paper 1, the study population included all patients registered with an International Classification of Diseases tenth version (ICD-10) diagnosis code C65 (cancer of the renal pelvis) and C66 (cancer of the ureter) at the Norwegian Cancer Registry (NCR) during 1999-2018. After an inclusion/exclusion process, 3096 cases of verified UTUC in 2818 patients were included in the study. For purpose of comparisons with other urothelial cancers and renal cell carcinoma (RCC), 24467 cases of bladder cancer (BC), 287 cases of urethral cancer, and 13619 cases of RCC were drawn from the same main database during the same time period. Statistical analyses were performed to calculate UTUC age standardized rates (ASR), UTUC incidence rates compared to other urothelial cancers and RCC, and to look for possible changes over time regarding incidence rates, epidemiological variables and survival. For paper 2 and 3, all patients treated with a RNU for UTUC at Haukeland University Hospital and Vestfold Hospital Trust during 2005-2017 were evaluated. After an inclusion/exclusion process, 179 patients were included in the study. For paper 2, all available preoperative features regarding the patients, the CT scan and the ureteroscopy (URS) were analysed regarding their abilities to predict tumour stage and survival. Further analyses were performed to evaluate if our findings could be used to select patients for intensified treatment. For paper 3, 162 of the 179 patients had complete dataset needed for external validation of the published Margulis nomogram and were included in the study. An external validation assessing both model calibration and discrimination was performed. For paper 4, 43 patients treated endoscopically with curative intent at Haukeland University Hospital 2001-2012 were included. Statistical analyses were performed regarding survival, kidney protections rates and recurrence both for the whole cohort and stratified by indication for treatment and tumour grade. Results: Paper 1. The ASR according to the European standard population was 3.88 for the whole period, increasing significantly from 3.21 to 4.70 from the first to last five-year period, corresponding to an estimated annual increase of 2.5%. The proportion of UTUC compared to all urothelial cancers and RCC significantly increased. UTUC constituted 12.6% of all urothelial cancers in Norway during 2014-2018. Mean age at diagnosis increased from 71.8 to 73.9 years during the study period. The 5-year overall survival (OS) increased moderately over time from 44.3% to 51.7% comparing last decade with the first. In paper 2, we found that local invasion and the presence of pathological lymph nodes at CT predicted both tumour stage at final pathology and survival in uni-and multivariate regression analyses. These variables can be used when selecting patients for intensified treatment. Diagnostic URS has a limited role in preoperative tumour staging. In paper 3, we found an overall high concordance between predicted risk of non-organ confined disease using the Margulis nomogram, and the observed risk in our cohort. The accuracies of both the predicted and observed risks were 0.83 to indicate adequate model discrimination. The calibration was assessed in a scatter plot where the overall concordance was high, quantified with a Cronbach Alpha of 0.96. There seems to be a mis-calibration at the low-risk levels. In paper 4 we found that the five –year disease specific survival (DSS) of patients treated endoscopically with an elective indication or for a low grade tumour (according to the World Health organization (WHO) classification from 2004) was high (DSS 94% and 96% respectively). The survival of patients treated with an imperative indication or for a high-grade tumour were significantly lower (DSS 41% and 39% respectively). 25 of 43 patients were assessed as tumour free at one point during follow-up, and the five-year recurrence free survival among these patients were 76%. The five-year kidney protection rate (KPR) for patients with low-grade tumours was 60%. The KPR for patients tumour free at first follow-up (14 of 43), was 90%. Conclusions: The incidence of UTUC in Norway was higher than expected, and increasing. Patient age at diagnosis is increasing. Local invasion and pathological lymph nodes at CT can predict tumour stage and survival after RNU, and can be used when selecting patients for intensified treatment. The Margulis nomogram is considered validated for clinical use. Tumour grade according to the WHO classification from 2004 is a strong predictor of outcomes after endoscopic treatment for UTUC, and should be considered when selecting patients for this treatment modality.Doktorgradsavhandlin

Guideline Adherence of Paediatric Urolithiasis:An EAU Members’ Survey and Expert Panel Roundtable Discussion

Background: Paediatric nephrolithiasis has increased globally, requiring standardized recommendations. This study aims to assess the paediatric urolithiasis care between EAU members along with the statements of three experts in this field. Methods: The results of an electronic survey among EAU members comparing the guideline recommendations to their current practice managing paediatric nephrolithiasis in 74 centres are contrasted with insights from an expert-panel. The survey consisted of 20 questions in four main sections: demographics, instrument availability, surgical preferences and follow-up preferences. Experts were asked to give insights on the same topics. Results: A total of 74 responses were received. Computerised Tomography was predominantly used as the main imaging modality over ultrasound. Lack of gonadal protection during operations was identified as an issue. Adult instruments were used frequently instead of paediatric instruments. Stone and metabolic analysis were performed by 83% and 63% of the respondents respectively. Conclusions: Percutaneous Nephrolithotomy is the recommended standard treatment for stones > 20 mm, 12% of respondents were still performing shockwave lithotripsy despite PNL, mini and micro-PNL being available. Children have a high risk for recurrence yet stone and metabolic analysis was not performed in all patients. Expert recommendations may guide clinicians towards best practice

Controversial issues and new trends in elective laparoscopic cholecystectomy

Aims: The incidence of bile duct injuries (BDI) and symptomatic residual bile duct stones in patients undergoing elective laparoscopic cholecystectomy (LC) without routine use of intraoperative cholangiography (IOC) were studied. The appropriateness and long-term results of elective LC in the treatment of gallstone disease in the elderly patients were analyzed. The rate of abdominal symptom persistence after elective LC along with its dependence from preoperative symptom severity in uncomplicated gallstone patients was clarified. In addition, the feasibility and applicability of single incision laparoscopic cholecystectomy (SILC) in small-volume community hospitals were assessed. Patients and methods: Patient records of all 1,101 patients (mean age 53 years, range 15 - 89 years, 874 females and 227 males) who had elective LC for gallstone disease in Turku City Hospital for Surgery between 1992 - 2001 were retrospectively studied. Data concerning long-term outcomes were obtained with questionnaire sent to the available patients in 2004. Short- and long-term results of elderly patients (age ≥ 75 years, n = 80) were compared with the two younger age groups (< 65 years and 65 - 74 years, n = 80 in each). Recurrence rates of abdominal symptoms in patients who have had uncomplicated gallstone disease with severe (n = 380) and mild (n = 287) preoperative symptoms, were compared. The details and outcome of SILC in 51 consecutive patients were recorded and analyzed. Results: The incidence of BDIs was 0.5% (n = 5) and symptomatic residual bile duct stones 0.9% (n = 10). The mean hospitalization time and the rate of complications increased with the age of the patients. Eighty percent of patients aged ≥ 75 years were satisfied or very satisfied with the long-term results of the procedure. Thirty-seven percent of patients continued to have abdominal symptoms postoperatively (41% of patients with mild preoperative symptoms and 33% with severe symptoms, p = 0.052). Eighty-two percent of SILCs succeeded without conversion to multi-port or open surgery. No major intra- or postoperative complications occurred in SILC patients, but 10% of patients had postoperative wound infection. Conclusions: Both the incidence of BDIs and symptomatic postoperative bile duct stones remain low without the routine use of IOC. Also in elderly, elective LC seems safe and feasible operation with good long-term results. More than one third of the patients with uncomplicated gallstone disease experienced persistent symptoms after elective LC. Patients with mild preoperative symptoms may have more recurrences. SILC can be adopted without major complications in small-volume hospitals but the rate of wound infections seems to increase with the introduction of SILC.Kiistanalaisia kysymyksiä ja uusia suuntauksia elektiivisessä sappirakon tähystysleikkauksessa Tavoitteet: Tutkimuksessa selvitettiin sappitievaurioiden ja oireisten sappitiehyeiden jäännöskivien esiintyvyyttä potilailla, joille elektiivinen laparoskooppinen kolekystektomia oli tehty ilman rutiininomaista leikkauksenaikaista kolangiografiaa. Tutkimuksessa analysoitiin myös elektiivisen laparoskooppisen kolekystektomian soveltuvuutta ja pitkäaikaistuloksia iäkkäiden potilaiden sappikivitaudin hoidossa. Sen lisäksi selvitettiin vatsan alueen oireiden uusiutumista komplisoitumatonta sappikivitautia sairastavilla potilailla elektiivisen laparoskooppisen kolekystektomian jälkeen. Lisäksi, tutkimuksessa arvioitiin yhden portin kautta tehtävän laparoskooppisen kolekystektomian käyttökelpoisuutta ja sovellettavuutta aluesairaaloissa. Aineisto ja menetelmät: Tähän retrospektiiviseen tutkimukseen otettiin mukaan kaikki 1101 potilasta (keski-ikä 53 vuotta, vaihteluväli 15 - 89 vuotta, 874 naista ja 227 miestä), joiden sappikivitautia oli hoidettu elektiivisellä laparoskooppisella kolekystektomialla Turun kaupungin Kirurgisessa sairaalassa vuosina 1992 - 2001. Toimenpiteen pitkäaikaistuloksia selvitettiin vuonna 2004 lähetetyllä kyselyllä. Iäkkäämpien potilaiden (ikä ≥ 75 vuotta, n = 80) lyhyt- ja pitkäaikaistuloksia verrattiin kahteen nuorempaan ikäryhmään (ikä < 65 vuotta ja ikä 65 - 74 vuotta, n = 80 molemmissa ryhmissä). Komplisoitumatonta sappikivitautia sairastaneiden potilaiden vatsaoireiden uusiutumista sappileikkauksen jälkeen selvitettiin vertaamalla kahta potilasryhmää, joista toisessa ryhmässä leikkausta edeltäneet oireet olivat olleet voimakkaita (n = 380) ja toisessa lieviä (n = 278). Yhden portin kautta tehtävän laparoskooppisen kolekystektomian hoitotuloksia selvitettiin yksityiskohtaisesti 51:n peräkkäisen potilaan otoksella. Tulokset: Sappitievaurioiden esiintyvyys tutkimusryhmässä oli 0.5% (n = 5) ja oireisten sappitiehyeiden jäännöskivien esiintyvyys oli 0.9% (n = 10). Iäkkäämmillä potilailla keskimääräinen sairaalassaoloaika oli pidempi sekä komplikaatioiden määrä suurempi. Kuitenkin 75 vuoden ikäisistä tai sitä vanhemmista potilaista 80% oli tyytyväisiä tai erittäin tyytyväisiä toimenpiteen pitkäaikaistulokseen. Komplisoitumatonta sappikivitautia sairastaneilla potilailla vatsaoireet jatkuivat sappileikkauksen jälkeen 37%:lla potilaista (leikkausta edeltävästi lieviä tai voimakkaita oireita kokeneiden potilasryhmien välillä ei ollut tilastollista eroa). Yhden portin tekniikalla aloitetuista leikkauksista 82% onnistuttiin toteuttamaan ilman lisäporttien laittamista tai konversiota avoleikkaukseksi. Yhden portin menetelmällä hoidetuilla potilailla ei esiintynyt vakavia leikkauksenaikaisia tai leikkauksen jälkeisiä komplikaatioita, mutta 10%:lla näistä potilaista todettiin leikkauksen jälkeinen haavainfektio. Johtopäätökset: Sekä sappitievaurioiden että leikkauksen jälkeisten oireisten sappitiehyeiden jäännöskivien esiintyvyys pysyvät alhaisina ilman rutiininomaista leikkauksenaikaista kolangiografiaa. Iäkkäillä potilailla laparoskooppinen kolekystektomia vaikuttaa turvalliselta ja käyttökelpoiselta toimenpiteeltä, jolla saavutetaan myös hyvät pitkäaikaistulokset. Komplisoitumatonta sappikivitautia sairastavista yli kolmasosalla vatsaoireet eivät häviä elektiivisen sappileikkauksen jälkeen. Pysyviä oireita saattaa esiintyä enemmän potilailla, joilla leikkausta edeltävät vatsaoireet ovat olleet enimmäkseen lieviä. Yhden portin kautta tehtävä laparoskooppinen kolekystektomia soveltuu käytettäväksi aluesairaaloissa, eikä menetelmän käyttöönottoon liity vaikeita komplikaatioita vaikkakin haavainfektioiden määrä tuntui yhden portin tekniikka käytettäessä kasvavan.Siirretty Doriast

Urology

УЧЕБНО-МЕТОДИЧЕСКИЕ ПОСОБИЯУРОЛОГИЯУРОЛОГИЧЕСКИЕ БОЛЕЗН