Prevention and Management Following Complications from Endourology Procedures

Delayed hematuria after prostatic photovaporization: risk factors to know

OBJECTIVE

characterize delayed hematuria (DH) after photoselective vaporization of the prostate (PVP) and identify its associated risk factors.

METHODS

1014 patients who underwent PVP at an expert center, from September 2005 through December 2021, were prospectively enrolled in a database registry. Risk factors of DH included age, prostate volume, ASA score, history of BPH surgery, history of prostate cancer, use of anticoagulation or 5ARIs, concomitant procedure, operative factors, and the duration of follow-up.

RESULTS

The median operating time was 60 ± 11 min. The median specific applied energy was 318,500 Joules ± 101,347. After PVP, the mean catheterization duration was 1.6 days with a postoperative hospitalization time of 1.8 days. The median follow-up was 52 months (range 2-95 months). Hematuria occurred in 206 patients (20.3%), with 10% requiring an ER visit and 8.3% requiring hospital admission, transfusion or endoscopic clot removal. Almost 80% of hematuria episodes occurred within the first 3 months. The overall retreatment rate for clot retention was 3.7% after a mean time of 50 months. Hematuria-free survival was 97.2% after 1 year, and 89.3% after 4 years. Delayed hematuria occurred in 32 patients (3.1%). In the multivariate analysis, age, preoperative prostate volume, anticoagulant use, total applied energy, lasing time and operative time were identified as risk factors for delayed hematuria after PVP.

CONCLUSION

Larger prostate volume, longer operative time, longer lasing time, and use of oral anticoagulation increase the odds of delayed hematuria after PVP, while older age is protective.

Adherence to Antimicrobial Prophylaxis Guidelines in Endourologic Procedures: Frequency and Related Outcomes

Background: Surgical antimicrobial prophylaxis (SAP), when used appropriately based on evidence-based guidelines, can reduce the rate of infectious complications following endourologic procedures without compromising patient outcomes. Objectives: To investigate the appropriateness of the current SAP used in endourologic surgeries based on international guidelines and report their associated outcomes (urinary tract infection [UTI] and blood stream infection [BSI]). Design: Prospective cross-sectional study. Methodology: The medical records of patients undergoing endourologic procedures were reviewed to assess healthcare providers' adherence to international guideline recommendations. Assessed parameters included indication, duration, choice, and dose of the antibiotics used in endourologic procedures in two medical centers in Amman/Jordan. Furthermore, patients were asked to conduct laboratory urine tests to determine the rate of infectious complications within one month post-procedure. Results: Three hundred and sixty-one patients were recruited for the study. The adherence rates to guidelines regarding indication, choice, and dose of pre-operative antibiotics were 90.3%, 2.8%, and 77.8%, respectively. The duration was concordant with guidelines in only 3.4% of participants. A total of 41.8% of patients completed follow-up. Among those, 4.6% developed bacterial UTIs, and 0.7% developed BSI. Conclusion: Adherence to SAP guidelines in endourologic procedures was far from optimal. Primary deviations in the implementation of guidelines' recommendations were pinpointed. These results are crucial for planning interventions that optimize SAP utilization.

Incidence of Surgical Reintervention for Benign Prostatic Hyperplasia Following Prostatic Urethral Lift, Transurethral Resection of the Prostate, and Photoselective Vaporization of the Prostate: A TriNetX Analysis

Background

Prostatic urethral lift, or UroLift, has gained popularity as a treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). Surgical reintervention rates are a reliable indicator for treatment durability.

Objective

The objective of this study was to utilize TriNetX, a third-party database, to investigate the incidence of surgical reintervention following UroLift, transurethral resection of the prostate (TURP), and photoselective vaporization of the prostate (PVP) procedures for BPH from 2015 to 2018.

Design setting and participants

Male patients aged 18-100 yr diagnosed with BPH were identified in the TriNetX Diamond Network database between January 2015 and December 2018. Cohorts of individuals undergoing their first UroLift procedure were built using Current Procedural Terminology and International Classification of Diseases 10th Revision codes. TURP and PVP cohorts were built as comparison groups. The cohorts were then queried for subsequent BPH-related procedures.

Outcome measurements and statistical analysis

Reprocedure rates were assessed and descriptive statistics were used.

Results and limitations

The mean age at first-time UroLift was 70.1 ± 9.4 yr (n = 14 343). Cumulative reprocedure rates collected after first-time UroLift included 1 yr after UroLift (5.1%, n = 14 343) and 4 yr after UroLift (16.1%, n = 710), with an average annual increase of +3.6% per year following 1 yr after the procedure. Comparatively, TURP (n = 22 071) and PVP (n = 14 110) had 4-yr reprocedure rates of 7.5% and 7.8%, respectively, during the same timeframe. Limitations include a lack of clinical data and loss of follow-up data outside the Diamond Network.

Conclusions

The reprocedure rate of UroLift at 4 yr is double the rate of TURP and PVP. In appropriately selected patients, UroLift might be a suitable option for those who desire symptomatic relief from BPH with minimal erectile and ejaculatory side effects. However, the risk of secondary surgical intervention should be considered when considering BPH treatments.

Patient summary

We compared the reintervention rates of prostatic urethral lift (PUL), transurethral resection of the prostate (TURP), and photoselective vaporization of the prostate (PVP) using the TriNetX database, and have found that the highest reintervention rates were for PUL of 16% at 4 yr of follow-up, compared with about 8% for those who had TURP and PVP. Interestingly, the most common reintervention was the same operation at 1 yr. This has important implications when counseling patients about the durability of these various outlet procedures for BPH.

The DEpth of Endoscopic Perforation scale to assess intraoperative perforations during transurethral resection of bladder tumor: subgroup analysis of a randomized controlled trial

PURPOSE

Bladder perforation (BP) is the most important intraoperative adverse event of transurethral resection of bladder tumor (TURBT). It is frequently underreported despite its impact on the postoperative course. There is no standardized classification of BP. The study aims to develop a classification of the depth of endoscopic bladder perforation during TURBT.

METHODS

This is a sub-analysis of a prospective randomized trial enrolling 248 patients submitted to en-bloc vs conventional TURBT from 03/2018 to 06/2021. The DEpth of Endoscopic Perforation (DEEP) scale is as follows: "0" visible muscular layer with no perivesical fat; "1" visible muscle fibers with spotted perivesical fat; "2" exposition of perivesical fat; "3" intraperitoneal perforation. Logistic and linear regression models were used to investigate predictors of high-grade perforations (DEEP 2-3) and to assess whether the DEEP scale independently predicted patients' postoperative outcomes.

RESULTS

A total of 146/248 (58.9%), 56/248 (22.6%), 41/248 (16.5%), 5/248 (2.0%) patients presented DEEP grade 0, 1, 2, and 3, respectively. Female gender [B coeff. 0.255 (95% CI 0.001-0.513); p = 0.05], tumor location [B coeff. 0.188 (0.026-0.339); p = 0.015], and obturator-nerve reflex [B coeff. 0.503 (0.148-0.857); p = 0.006] were independent predictors of DEEP. The scale predicted independently major complications [Odd Ratio (OR) 2.221 (1.098-4.495); p = 0.026], no post-operative chemotherapy intravesical instillation [OR 9.387 (2.434-36.200); p = 0.001], longer irrigation time [B coeff. 0.299 (0.166-0.441); p < 0.001] and hospital stay [B coeff. 0.315 (0.111-0.519); p = 0.003].

CONCLUSION

The DEEP scale provides a visual tool for grading bladder perforation during TURBT, which can help physicians standardize complication reporting and plan postoperative management accordingly.

Comparison of Emergency Room Visits and Rehospitalization for Bleeding Complications following Transurethral Procedures for the Treatment of Benign Prostatic Hyperplasia: A Population-Based Retrospective Cohort Study

Background: The postoperative bleeding complications associated with laser surgery of the prostate and transurethral resection of the prostate (TURP) were compared. Methods: We used the Taiwan National Health Insurance Research Database to conduct an observational population-based cohort study. All eligible patients who received transurethral procedures between January 2015 and September 2018 were enrolled. Patients who received laser surgery or TURP were matched at a ratio of 1:1 by using propensity score matching, and the association of these procedures with bleeding events was evaluated. Results: A total of 3302 patients who underwent elective transurethral procedures were included. The multivariable Cox regression analysis revealed that diode laser enucleation of the prostate (DiLEP) resulted in significantly higher emergency room risks within 90 days after surgery due to clot retention than the Monopolar transurethral resection of the prostate (M-TURP) (Hazard Ratio: 1.52; 95% Confidence Interval [CI], 1.06–2.16, p = 0.022). Moreover, GreenLight photovaporization of the prostate (PVP) (0.61; 95% CI, 0.38–1.00 p = 0.050) and thulium laser vaporesection of the prostate (ThuVARP) (0.67; 95% CI, 0.47–0.95, p = 0.024) resulted in significantly fewer rehospitalization due to clot retention than did M-TURP. No significant increase in blood clots were observed in patients using comedications and those with different demographic characteristics and comorbidities. Conclusions: Among the investigated six transurethral procedures for Benign prostatic hyperplasia, PVP and ThuVARP were safer than M-TURP because bleeding events and clot retention were less likely to occur, even in patients receiving anticoagulant or antiplatelet therapy. However, DiLEP and holmium laser enucleation of the prostate (HoLEP) did not result in fewer bleeding events than M-TURP.

Theoretical and experimental evaluation of the distance dependence of fiber-based fluorescence and reflection measurements for laser lithotripsy

OBJECTIVES

In laser lithotripsy, a green aiming beam overlying the infrared (IR) treatment radiation gives rise to reflection and fluorescence signals that can be measured via the treatment fiber. While stone autofluorescence is used for target detection, the condition of the fiber can be assessed based on its Fresnel reflection. For good applicability, fluorescence detection of stones should work even when the stone and fiber are not in direct contact. Fiber breakage detection, on the other hand, can be falsified if surfaces located in front of the fiber reflect light from the aiming laser back into it. For both applications, therefore, a fundamental investigation of the dependence of the signal amplitude on the distance between fiber and surface is important.

METHODS

Calculations of the signal drop of fluorescence or diffuse and specular reflection with increasing fiber distance were performed using ray tracing based on a simple geometric model for different fiber core diameters. Reflection signals from a mirror, diffuse reflector, human calculi, and porcine renal tissue placed in water were measured at varying distances (0 - 5 mm). For human calculi, fluorescence signals were recorded simultaneously.

RESULTS

The calculations showed a linear signal decrease down to ~60% of the maximum signal (fiber in contact). The distance z at which the signal drops to for example 50% depends linearly on the diameter of the fiber core. For fibers used in lithotripsy and positioned in water,z_50%ranges from 0.55 mm (200 µm core diameter) to 2.73 mm (1 mm core diameter). The calculations were in good agreement with the experimental results.

CONCLUSIONS

The autofluorescence signals of stones can be measured in non-contact mode. Evaluating the Fresnel signal of the end face of the fiber to detect breakage is possible unless the fiber is situated less than some millimeters to reflecting surfaces.

Which are the commonest sites and characteristics of post- transurethral prostate surgery (TPS) strictures in a high-volume reconstructive center?

BACKGROUND

Urethral stricture is a well-known complication after transurethral prostate surgery (TPS) and it is usually considered an easy-to-treat condition. We aimed to examine characteristics of post-TPS urethral stricture cases that were referred for urethroplasty at our tertiary center.

METHODS

We identified 201 patients with TPS-induced stricture treated with urethroplasty at our institution from 2017-2021. First, stricture length and location were evaluated during preoperative assessment. Second, multiple sets of multivariable logistic regression (MLR) analyses were run to assess whether clinical variables were associated with the location of the stricture.

RESULTS

Median stricture length was 5 cm (4-7). 141 (70.1%) patients received previous no-invasive treatments (dilatation and/or DVIU). Proximal bulbar urethra was the commonest site for stricture, while panurethral stricture (≥10cm) was diagnosed in 41 (20.4%) patients. Lichen sclerosus was more common in patients with penile stricture location, compared to patients with other involved segments (26% vs 19%, p=0.03), and it was the only predictor of penile and mid bulbar urethra location at MLR. Surgical approaches were augmented urethroplasty in 94% of patients, especially for patients with previous treatment including urethroplasty (95.8% vs 82.5% for naïve, p=0.004). Dorsal onlay was the preferred approach for bulbar (53.4%) and penile urethra (90.7%), while ventral onlay (38.2%) and double face augmentation (20.6%) were the preferred approach in membranous strictures.

CONCLUSIONS

The majority of patients that were referred for TPS-induced stricture attempted previous non-invasive managements. Referred TPS-induced urethral stricture were long and frequently involving multiple segments of urethra. Augmentation urethroplasty was our preferred surgical approach due to the characteristics and complexity of these strictures. The presence of lichen may increase the risk of post-TPS stricture in specific segment of urethra, namely the penile and mid-bulbar urethra.

Risk Factors of Emergency Room Visits for Bleeding Complications Following Transurethral Procedures in the Treatment of Benign Prostatic Hyperplasia: A Retrospective Cohort Study

Purpose

Transurethral procedures, including transurethral resection of the prostate (TURP) and laser prostatectomy, are often linked to emergency room (ER) visits for postoperative bleeding. Although some studies have been conducted, the risk factors associated with these ER visits are not completely understood. This retrospective cohort study identified potential risk factors associated with ER visits for postoperative bleeding.

Patients and Methods

Preoperative assessment data and operational and postoperational parameters recorded at Chang Gung Memorial Hospital, Taiwan between December 2015 and January 2017 for patients who underwent elective transurethral procedures were analyzed to identify potential risk factors. The primary endpoint was ER visits for gross hematuria within three months following operation, and the secondary endpoint was ER visits for blood clot-induced urinary retention (clot retention) within three months following operation.

Results

A total of 665 patients who underwent elective transurethral procedures were enrolled. The transurethral procedures included monopolar transurethral resection of the prostate (M-TURP), bipolar TURP (B-TURP), greenlight photoselective vaporization of the prostate (PVP), thulium laser enucleation of the prostate (ThuLEP) and thulium laser transurethral vaporesection of the prostate (ThuVARP). Regarding ER visits for clot retention within three months, multivariable logistic regression revealed significantly lower rates of clot retention in patients who received B-TURP than in those who underwent ThuVARP (AOR, 0.18; 95% confidence interval [CI], 0.04–0.82, p = 0.027). Moreover, significantly higher clot retention was observed in patients who underwent two or more rounds of manual irrigation (AOR, 9.51; 95% CI, 1.66–54.43, p = 0.011).

Conclusion

Multiple manual irrigations shortly after operation can be considered a novel predictor of postoperative clot retention-related ER visits. Among the transurethral procedures, ThuVARP was associated with a higher risk of clot retention-related ER visits than was B-TURP.

Transurethral Resection of Bladder Tumor: Electrosurgical and Laser

Transurethral resection of bladder tumor (TURBT) is still the gold standard for the diagnosis, treatment, and staging of nonmuscle invasive bladder cancer. En bloc resection of bladder tumor (EBRT) has been recently introduced to overcome the limitations of conventional TURBT. EBRT potential advantages are (1) complete resection, (2) a more precise and controlled resection (potentially fewer complications), (3) better sample orientation for histopathology analysis, (4) presence of detrusor in the specimen, and (5) less tumor seeding on normal urothelium by tumor fragments. This article aimed to present a step-by-step technique of conventional TURBT and EBRT with thulium laser support. We also aimed to provide tips and tricks for a correct surgical procedure and postoperative patient care. Finally, clinical outcomes of TURBT versus EBRT were reviewed.

Bladder perforation during transurethral resection of the bladder: a comprehensive algorithm for diagnosis, management and follow up

INTRODUCTION

Despite bladder perforation (BP) is a frequent complication during transurethral resection of bladder (TURB) for bladder cancer (BCa), literature lacks systematic reviews focusing on this issue. We aimed to investigate incidence, diagnosis, therapy, and prognosis after BP during TURB for BCa; therapy was distinguished between conservative (without the need for bladder repair) and surgical management (requiring bladder wall closure).

EVIDENCE ACQUISITION

A systematic search was conducted up to April 2021 using PubMed, Scopus, Cochrane Database of Systematic Reviews, and Web of Science to identify articles focusing on incidence, detection, management, or survival outcomes after iatrogenic BP. The selection of articles followed the Preferred Reporting Items for Systematic Review and Meta-Analyses process.

EVIDENCE SYNTHESIS

We included 41 studies, involving 21,174 patients. Overall, 521 patients experienced BP during TURB for BCa, with a mean incidence of 2.4%, up to 58.3% when post-operative cystography is routinely performed after all TURB procedures. Risk factors were low body mass index (BMI) (p=0.01), resection depth (p=0.006 and p=0.03), and low surgical experience (p=0.006). Extraperitoneal BP (68.5%) were treated conservatively in 97.5% of patients; intraperitoneal BP were managed with surgical bladder closure in 56% of cases. Overall, three immediate BP-related deaths were recorded due to septic complications. Extravesical tumour seeding was observed after 6 intraperitoneal and 1 extraperitoneal BP (median time: 6.2 months). Intraperitoneal BP (p=0.0003) and bladder closure (p<0.001) were found as independent predictors of extravesical tumour recurrence.

CONCLUSIONS

BP is more frequent than expected when proper diagnosis is routinely performed after all TURB procedures. Risk factors include low BMI, resection depth, and unexperienced surgeon. The risk of sepsis after BP suggests empirical antibiotic prophylaxis after BP.

Iatrogenic Ureteral Injury Treatment with Biodegradable Antireflux Heparin-Coated Ureteral Stent-Animal Model Comparative Study

Objective: The aim is to assess the effectiveness of a biodegradable antireflux ureteral stent with heparin coating in a comparative study (BraidStent^®-H) in an animal model for the treatment of iatrogenic ureteral perforation. Materials and Methods: A total of 24 female pigs underwent initial endoscopic, nephrosonographic, and contrast fluoroscopy assessment of the urinary tract. Afterward, unilateral iatrogenic perforation in proximal ureter model was performed. Then the animals were randomly assigned to Group-I, in which a double-pigtail stent was placed for 6 weeks, or Group-II, in which a BraidStent-H a biodegradable heparin-coated stent was placed. Follow-up assessments were performed at 1 and 6 weeks and 5 months. Results: In terms of therapeutic effectiveness, complete resolution was observed in 95.8% of Group-I animals and 87.5% in Group-II. No animals in Group-II showed vesicoureteral reflux (VUR) during the study; statistical significance was observed at 1 and 6 weeks versus Group-I. All stents in Group-II degraded without producing obstructive fragments and allowed distal ureteral peristalsis. Heparin coating was not efficient to reduce asymptomatic bacteriuria between groups. Pathologic assessment did not show any significance in the global score, but did in the "fibrosis in muscular layer" parameter, at the ureteral perforation healing area; Group-II showed higher healing quality. Conclusions: The biodegradable intraureteral BraidStent^®-H is highly effective for the minimally invasive treatment of ureteral perforation, since it displays controlled and predictable degradation, avoiding the development of VUR as well as irritation of the bladder trigone. Unfortunately, heparin coating was not effective in avoiding stent-associated bacteriuria.

The Comprehensive Complication Index for Advanced Monitoring of Complications Following Endoscopic Surgery of the Lower Urinary Tract

Purpose: To evaluate the Comprehensive Complication Index (CCI) for reporting complications in lower urinary tract transurethral procedures and compare it with the Clavien-Dindo classification (CDC). Materials and Methods: A total of 450 consecutive patients were included into the analyses [150 each of transurethral resection of bladder tumors (TURBT), transurethral resection of the prostate (TURP), and transurethral enucleation of the prostate using Tm:YAG, (ThuLEP)]. Complications were assessed according to the modified CDC. The CCI was calculated using a freely accessible online tool. Descriptive statistics and correlation analyses were applied to quantify operational differences and length of stay (LOS) between CDC and CCI. Sample size calculations for hypothetical clinical trials were contrasted for CDC and CCI application. Results: Overall n = 150 patients with complications (33.3%) within the first 60 days after operation were identified. Of these, n = 125 (83.4%) were minor complications up to CDC grade IIIa. Of patients with complications, n = 57 patients (12.6%) experienced more than one complication. Here, the cumulative CCI led to an upgrade of at least one CDC grade in 33 patients. Hence, in 22.0% of cases, the highest CDC grade underestimated the degree of complications. CCI showed higher correlation with LOS compared with CDC (all r > 0.2, all p-values ≤0.0001). Using CCI instead of CDC for sample calculation resulted in a strong reduction of the required number of patients for all three interventions (percentage of patient number decrease: -93.2% for TURBT, -71.8% for TURP, and -81.1% for ThuLEP). Conclusion: The CCI gives a more precise interpretation of the postinterventional complications of TURBT, TURP, and ThuLEP. CCI application may reduce the required sample size for clinical trials and will relieve their recruitment in the future.

Which Anatomic Structures Should Be Preserved During Aquablation Contour Planning to Optimize Ejaculatory Function? A Case-control Study Using Ultrasound Video Recordings to Identify Surgical Predictors of Postoperative Anejaculation

OBJECTIVE

To identify key anatomic structures that should be preserved to decrease postoperative anejaculation after Aquablation.

METHODS

We conducted a case-control study design using patient data and operative video logs from Aquablation clinical trials. Cases were sexually active participants with functional baseline ejaculation and postoperative anejaculation. Controls were sexually active participants with functional baseline ejaculation and no postoperative decline in sexual function. Each case was matched to 1 or 2 controls. Video logs from the procedure were scored for: verumontanum cut coverage, penetration of ejaculatory ducts, depth of cut below the verumontanum, angle offset of verumontanum to centerline of protection zone, number of passes, and intraprostatic calcifications. Conditional logistic regression was used to calculate univariate odds ratios relating anatomic findings to case/control status.

RESULTS

We identified 24 cases and 27 controls. In univariate analysis, predictors of postoperative anejaculation were: penetration of the ejaculatory ducts (odds ratio [OR] 8.6 [95% CI 1.09-67.5], P = .041) and depth below the verumontanum (OR 1.92 [1.1-3.3], P = .015).

CONCLUSION

Violation of anatomic structures involved in ejaculation during the Aquablation procedure increases the risk of postoperative anejaculation. More careful attention to these structures during contour planning may further improve ejaculatory function after Aquablation.

Perioperative Hypothermia after Transurethral Surgeries: Is it Necessary to Heat the Irrigation Fluids?

Objective

To investigate the role of heated irrigation fluids in the risk of hypothermia and related complications in patients undergoing transurethral procedures.

Methods

The medical records of all patients who underwent transurethral procedures between 2000 and 2016 at the VA Hospital were reviewed. Irrigation fluids have been heated to 42°C since 2013, as per the institutional policy (Group II). Prior to this date, room temperature solutions were used (Group I). The perioperative body temperature, use of warming devices, procedure length, and anaesthesia type were extracted from records and compared for both groups. In addition, demographic and anthropometric data, preoperative comorbidities, laboratory data, admission information and postoperative complications were obtained from the quality improvement database.

Results

There were 1,363 patients in Group I and 269 patients in Group II. Perioperative temperature was decreased by 0.10°C in Group I compared to a temperature gain of 0.32°C in Group II (p<0.001). Three hundred and forty-eight (21%) patients undergoing transurethral procedures developed hypothermia <36°C. There was no difference in the incidence of postoperative mortality or complications between the normothermic and hypothermic patients.

Conclusion

The replacement of room temperature solutions with warmed solutions for irrigation during transurethral procedures reduced the risk of temperature loss and hypothermia following these procedures. Available heating strategies effectively prevented the perioperative heat loss; however, such strategies did not affect the incidence of postoperative complications.

Consensus Definition and Prediction of Complexity in Transurethral Resection or Bladder Endoscopic Dissection of Bladder Tumours

Simple Summary

Transurethral resection of bladder tumours may be technically challenging. Complexity was defined by consensus from the literature by a panel of ten senior urologists as “any TURBT/En-bloc dissection that results in incomplete resection and/or prolonged surgery (>1 h) and/or significant (Clavien-Dindo ≥ 3) perioperative complications”. Patient and tumour’s characteristics that suggested to by the panel to relate to complex surgery were collected and then ranked by Delphi consensus. They were tested in the prediction of complexity in 150 clinical scenarios. After univariate and logistic regression analyses, significant characteristics were organized into a checklist that predicts complexity. Receiver operating characteristics (ROC) curves of the regression model and the corresponding calibration curve showed adequate discrimination (AUC = 0.916) and good calibration. The resulting Bladder Complexity Checklist can be used to deliver optimal preoperative information and personalise the organisation of surgery.

Abstract

Ten senior urologists were interrogated to develop a predictive model based on factors from which they could anticipate complex transurethral resection of bladder tumours (TURBT). Complexity was defined by consensus. Panel members then used a five-point Likert scale to grade those factors that, in their opinion, drove complexity. Consensual factors were highlighted through two Delphi rounds. Respective contributions to complexity were quantitated by the median values of their scores. Multivariate analysis with complexity as a dependent variable tested their independence in clinical scenarios obtained by random allocation of the factors. The consensus definition of complexity was “any TURBT/En-bloc dissection that results in incomplete resection and/or prolonged surgery (>1 h) and/or significant (Clavien-Dindo ≥ 3) perioperative complications”. Logistic regression highlighted five domains as independent predictors: patient’s history, tumour number, location, and size and access to the bladder. Receiver operating characteristic (ROC) analysis confirmed good discrimination (AUC = 0.92). The sum of the scores of the five domains adjusted to their regression coefficients or Bladder Complexity Score yielded comparable performance (AUC = 0.91, C-statistics, p = 0.94) and good calibration. As a whole, preoperative factors identified by expert judgement were organized to quantitate the risk of a complex TURBT, a crucial requisite to personalise patient information, adapt human and technical resources to individual situations and address TURBT variability in clinical trials.

Consultation on kidney stones, Copenhagen 2019: aspects of intracorporeal lithotripsy in flexible ureterorenoscopy

Purpose

To summarize current knowledge on intracorporeal laser lithotripsy in flexible ureterorenoscopy (fURS), regarding basics of laser lithotripsy, technical aspects, stone clearance, lithotripsy strategies, laser technologies, endoscopes, and safety.

Methods

A scoping review approach was applied to search literature in PubMed, EMBASE, and Web of Science. Consensus was reached through discussions at the Consultation on Kidney Stones held in September 2019 in Copenhagen, Denmark.

Results and conclusions

Lasers are widely used for lithotripsy during fURS. The Holmium laser is still the predominant technology, and specific settings for dusting and fragmenting have evolved, which has expanded the role of fURS in stone management. Pulse modulation can increase stone ablation efficacy, possibly by minimizing stone retropulsion. Thulium fibre laser was recently introduced, and this technology may improve laser lithotripsy efficiency. Small fibres give better irrigation, accessibility, and efficiency. To achieve optimal results, laser settings should be adjusted for the individual stone. There is no consensus whether the fragmentation and basketing strategy is preferable to the dusting strategy for increasing stone-free rate. On the contrary, different stone scenarios call for different lithotripsy approaches. Furthermore, for large stone burdens, all laser settings and lithotripsy strategies must be applied to achieve optimal results. Technology for removing dust from the kidney should be in focus in future research and development. Safety concerns about fURS laser lithotripsy include high intrarenal pressures and temperatures, and measures to reduce both those aspects must be taken to avoid complications. Technology to control these parameters should be targeted in further studies.

Diagnostic performance and predictive capacity of early urine cytology after transurethral resection of nonmuscle invasive bladder cancer: A prospective study

OBJECTIVES

To prospectively evaluate the value of early urine cytology (EUC) after the primary transurethral resection of bladder tumor (TURBT) of nonmuscle invasive bladder cancer (NMIBC) for the prediction of positive biopsy findings on repeat TURBT.

METHODS

After approval of institutional review board, patients who underwent TURBT for NMIBC between February 2014 and July 2018 were included in the study. Patients with concomitant Carcinoma in Situ (CIS), upper tract urothelial tumors, biopsy proven muscle invasion, or low-risk NMIBC (single, primary, Ta, and G1 tumor) were excluded. Forty-eight hours after primary TURBT, EUC was retrieved and patients were scheduled for repeat TURBT 2 to 6 weeks later according to the predetermined protocol. The primary outcome was to determine the role of positive EUC to predict positive biopsy findings on repeat TURBT.

RESULTS

During the study period, 198 patients fulfilled the study inclusion criteria of which 49 (25%) had recurrent NMIBC. Primary TURBT pathology results showed T1 stage in 195 (98.5%) patients and high-grade malignancy in 158 (79.8%). Intermediate- and high-risk NMIBC were defined in 49 (25%) and 149 (75%) patients, respectively. EUC was positive in 114 patients; of whom 78 (68.4%) showed positive biopsy findings on repeat TURBT (P = 0.001). The sensitivity, specificity, negative, and positive predictive values of EUC for biopsy findings at repeat TURBT were 90% (95%CI: 87-94), 75% (95%CI: 71-79), 89% (95%CI: 85-94), and 68% (95%CI: 62-74), respectively. On mean (±SD) follow-up of 42(±13) months, tumor recurrence was encountered in 101 (53%) patients. On multivariate Cox regression analysis, EUC was significantly associated with tumor recurrence (HR = 4.6, 95%CI: 2.37-8.9, P < 0.001).

CONCLUSIONS

Positive EUC after primary TURBT for NMIBC is significantly associated with positive repeat TURBT for malignancy. EUC is an independent predictor of tumor recurrence. EUC might be implemented after primary TURBT to help refining indications of repeat biopsy and planning of further intervention.

Shock wave lithotripsy, for the treatment of kidney stones, results in changes to routine blood tests and novel biomarkers: a prospective clinical pilot-study

Background

The number of patients undergoing shock wave lithotripsy (SWL) for kidney stones is increasing annually, and as such the development of post-operative complications, such as haematuria and acute kidney injury (AKI) following SWL, is likely to increase. The aim of the study was to evaluate changes in routine blood and novel biomarkers following SWL, for the treatment of kidney stones.

Methods

Twelve patients undergoing SWL for solitary unilateral kidney stones were recruited. From patients (8 males and 4 females) aged between 31 and 72 years (median 43 years), venous blood samples were collected pre-operatively (baseline), at 30, 120 and 240 min post-operatively. Routine blood tests were performed using a Sysmex XE-5000, and Beckman Coulter AU5800 and AU680 analysers. NGAL, IL-18, IL-6, TNF-α, IL-10 and IL-8 concentrations were determined using commercially available ELISA kits.

Results

Significant (p ≤ 0.05) changes were observed in several blood parameters following SWL. NGAL concentration significantly increased, with values peaking at 30 min post-treatment (p = 0.033). Although IL-18 concentration increased, these changes were not significant (p = 0.116). IL-6 revealed a statistically significant rise from pre-operative up to 4 h post-operatively (p < 0.001), whilst TNF-α significantly increased, peaking at 30 min post-SWL (p = 0.05). There were no significant changes to IL-10 and IL-8 concentrations post-SWL (p > 0.05).

Conclusions

Changes to routine blood tests and specific biomarkers, in the future, may be more useful for clinicians. In turn, identification of a panel of biomarkers could provide valuable data on “normal” physiological response after lithotripsy. Ultimately, studies could be expanded to identify or predict those patients at increased risk of developing post-operative complications, such as acute kidney injury or. These studies, however, need validating involving larger cohorts.

Complications of anatomical endoscopic enucleation of the prostate

Transurethral resection of the prostate (TURP) remains the 'gold standard' for surgical treatment of benign prostatic obstruction (BPO). Recently, anatomical endoscopic enucleation of the prostate (AEEP) using holmium laser, thulium laser and plasma, etc., is extensively applied in clinical practice. However, perioperative complications of AEEP are inevitable in spite of lower incidence compared with TURP. This study reviewed the literature related to the aetiology, prevention and treatment of common complications of AEEP, which would contribute to the diagnosis and treatment of BPO.

Our clinic's first experience with HoLEP

OBJECTIVE:

The present study reports a retrospective evaluation of the first Holmium laser prostate enucleation (HoLEP) cases and their results in our clinic.

METHODS:

Twenty four patients who underwent HoLEP surgery between April 2017 and November 2017 were evaluated for demographic characteristics, duration of operation, amount of hemorrhage, amount of energy used, tissue weight removed, catheterization time and complications. IPSS and uroflowmetry results were compared before and after the surgery.

RESULTS:

Patients with hemoglobin, IPSS, uroflowmetry, and voiding speeds (Qmean, Qmax) were compared before and after the surgery. There was a significant difference in IPSS, Qmean and hemoglobin values but not in Qmax, statistically. Our complications rates were correlated with the literature.

CONCLUSION:

HoLEP stands out as a surgical method that can be applied with high confidence in the treatment of benign prostatic hyperplasia and it has similar functional results to gold standard surgeries, causes fewer complications, improves patient comfort due to short catheterization and hospitalization and is more advantageous regarding cost.

A pilot study evaluating changes to haematological and biochemical tests after Flexible Ureterorenoscopy for the treatment of kidney stones

BACKGROUND

Currently there is limited research documenting the changes in blood parameters, following Flexible Ureterorenoscopy. This study aims to determine whether there are any changes in haematology and biochemistry parameters, following Flexible Ureterorenoscopy for the treatment of kidney stones.

METHODS

40 consecutive patients aged between 27-87 years (median 49 years) undergoing Flexible Ureterorenoscopy for the treatment of kidney stones were recruited (26 male, 14 female). Blood samples were collected from each patient at four time points: baseline (pre-operatively) followed by 30 minutes, 120 minutes and 240 minutes post-operatively. On these samples, routine haematological and biochemistry tests were carried out. In addition to the assessment of clinical parameters prospectively from the medical notes.

RESULTS

There was a significant decrease observed following Flexible Ureterorenoscopy in the following parameters: lymphocytes (p = 0.007), eosinophils (p = 0.001), basophils (p = 0.001), haemoglobin (p = 0.002), red blood cells (p = 0.001), platelet count (p = 0.001), fibrinogen concentration (p = 0.001), von Willebrand factor (p = 0.046), C reactive protein (p = 0.01), total protein (p = 0.001), albumin (p = 0.001), globulin (p = 0.001) and alkaline phosphatase (p = 0.001). In addition, there was a significant increase observed in the following parameters: white blood cells (p = 0.001), neutrophils (p = 0.001), activated partial thromboplastin time (p = 0.001), total bilirubin (p = 0.012), creatinine (p = 0.008), sodium (p = 0.002) and potassium (p = 0.001). Limiting factors for this study were the sample size, and restriction on the recruitment time points.

CONCLUSIONS

Significant changes were noted to occur in haematology and biochemistry parameters following Flexible Ureterorenoscopy. Some of the data presented in this study may represent the 'normal' post-operative response following FURS, as no major complications occurred, in the majority of our patients. This data on the 'normal response' will need to be validated but may ultimately aid clinicians in distinguishing patients at risk of complications, if reproduced in larger multi-centre studies.

[HoLEP learning curve: Toward a standardised formation and a team strategy]

AIM

Holmium laser enucleation of prostate (HoLEP) is renowned for the difficulty of its learning curve. Our aim was to evaluate the interest of a three-step tutorial in the HoLEP learning curve, in a university center.

METHODS

It is a retrospective, monocentric study of the 82 first procedures done consecutively by the same operator with a proctoring in early experience and after 40 procedures. For all patients were noted: enucleation efficiency (g/min), morcellation efficiency (g/min), percentage of enucleated tissue (enucleated tissue/adenome weigth evaluated by ultrasonography. g/g), perioperative morbidity (Clavien), length of hospital stay, length of urinary drainage, functional outcomes at short and middle term (Qmax, post-void residual volume [PVR], QOL scores and IPSS at 3 and 6months).

RESULTS

Enucleation and morcellation efficiency were significantly higher after the second proctoring (0.87 vs 0.44g/min; P<0.0001 and 4.2 vs 3.37g/min, P=0.038, respectively) so as the prostatic volume (43.5 vs 68.1mL, P=0.0001). Percentage of enucleated tissue was higher in the second group, however, the difference was not significant (69.5% vs 80.4%, P=0.03). Per- and postoperative complications, hospital length of stay, urinary drainage length and functional results at 3 and 6months were not significantly different.

CONCLUSION

The learning curve did not interfere with functional results. The second proctoring was essential to us in order to grasp the technique. These data underlined the necessity of a pedagogic reflexion in order to built a standardized formation technique to the HoLEP.

LEVEL OF EVIDENCE

4.