Validation of the Clavien-Dindo Grading System in Urology by the European Association of Urology Guidelines Ad Hoc Panel

Robotic sacrocolpopexy for the treatment of pelvic organ prolapse in elderly women: comparative analysis of safety and efficacy versus younger women

INTRODUCTION

Pelvic organ prolapse is a condition with high prevalence in elderly women. With increasing life expectancy and a desire for improved quality of life, a rise in the frequency of surgical treatments for these women is anticipated. The aim is to compare complication, success, and satisfaction rates among elderly patients (aged >70 years) in comparison to younger women undergoing robotic sacrocolpopexy, thereby assessing the safety and efficacy of this surgery in this group of patients.

METHOD

A prospective observational comparative study of 123 robotic sacrocolpopexies conducted between December 2016 and June 2022. Patients were stratified by age (cutoff point: 70 years). Baseline characteristics, type, and grade of prolapse, intra and postoperative data, complications, functional and anatomical outcomes, and satisfaction levels were collected.

RESULTS

Among the 123 patients, 62.6% were under 70 years old, while 37.4% were 70 years or older, exhibiting similar baseline characteristics, prolapse grade, and type. The percentages of intraoperative (6.5%) and postoperative complications (4.4-9%) were comparable in both age groups. Furthermore, success and satisfaction rates exceeded 90%, with no significant differences between women under and over 70 years during a two-year follow-up.

CONCLUSION

Robotic sacrocolpopexy is at least as effective and safe in women aged 70 years or older as in younger individuals, with no higher rates of intra and postoperative complications and similar rates of anatomical and subjective success.

Feasibility and Outcomes of Same-Day Discharge after Multiport Robot-Assisted Radical Prostatectomy

Introduction: Robot-assisted radical prostatectomy (RARP) provides much quicker recovery for men than open prostatectomy. In most centers, discharge is planned the morning after operation. However, after several years, we observed that no routine intervention was required for a majority of men over the first evening. Here, we detail our institution's outcomes for multiport RARP (MP-RARP) with same-day discharge (SDD). Methods: After excluding patients with single-port RARP (n = 25) and overnight stays (n = 30), data from 224 patients (n = 224/279, 88.2%) who underwent MP-RARP from May 2021 to September 2023 were collected. All patients were placed on an Enhanced Recovery After Surgery protocol and were given instructions regarding SDD. Patients were considered as SDD if they were discharged on the day of operation. Data regarding messages and phone calls to health care providers, urology clinic, and emergency department visits were recorded for analysis in the week postoperation. Results: The mean (±standard deviation [SD]) operative time was 142.5 ± 25.2 minutes, with a mean (±SD) console time of 95.1 ± 25.6 minutes. The median (interquartile range [IQR]) estimated blood loss was 50 (50-100) mL, and the mean (±SD) length of hospitalization was 163.2 ± 64.6 minutes. No intraoperative complications occurred in this cohort. The median (IQR) patient-reported pain score at 1 hour after operation was 3.5 (0-7), compared with 2 (0-4) at discharge. Of the 145 (64.7%) patients who reported their postoperative pain management, only 50 (34.4%) endorsed using opioids, and of those, 8 (16%) were known chronic opioid users. In the week after operation, 14 (6.3%) patients had unplanned visits to the health care facility. Additionally, 56 (25%) of patients contacted the clinic regarding the postoperative course during the same time frame. Conclusions: SDD after RARP is predictable and safe. SDD helps reduce the costs associated with inpatient stays without compromising surgical outcomes for patients.

Comparing open and robot-assisted partial nephrectomy - a single institution report

BACKGROUND

Open partial nephrectomy (OPN) has previously been considered the gold standard procedure for treatment of T1 localized renal tumors. After introduction of robot assisted partial nephrectomy (RAPN) as an alternative method to OPN, OPN was gradually abandoned at our department. The aim of the study was to retrospectively compare the results of patients treated with either OPN or RAPN for suspected renal carcinoma.

METHODS

Patients who underwent either open or robotic assisted partial nephrectomy between January 1st 2010 and December 31st 2020 were retrospectively included in the study. Each tumor subjected to surgery was scored preoperatively by the RENAL nephrometry score. Complications within 30 days were assessed according to the Clavien-Dindo classification system.

RESULTS

A total of 197 patients who underwent partial nephrectomy were identified; 75 were subjected to OPN and 122 were treated with RAPN. There were no significant differences between the groups with respect to age (OPN: 63 years ± 11, RAPN: 62 years ± 10), gender (OPN: 71/29%, RAPN: 67/33%), body mass index (OPN: 28 ± 5, RAPN: 28 ± 5), ASA score (OPN: 2.4 ± 0.6, RAPN: 2.2 ± 0.5), or nephrometry score (OPN: 6.6 ± 1.7, RAPN: 6.9 ± 1.7, p = 0.2). The operative time was significantly shorter in the OPN group (81 min) compared to the RAPN group (144.5 min, p < 0.001). Mean perioperative blood loss was 227 ± 162 ml in the OPN group compared to 189 ± 152 ml in the RAPN group (p = 0.1). Mean length of stay was shorter in the RAPN group (3 days) compared to the OPN group (6, days, p < 0.001). Positive surgical margin rate was significantly higher in the OPN group (21.6%) compared to the RAPN group (4.2%, p < 0.001). There were no differences in the number of Clavien-Dindo graded complications between the groups (p = 0.6).

CONCLUSIONS

The introduction of RAPN at our department resulted in shorter length of stay and fewer positive surgical margins, without increasing complications.

Validation of the Clavien-Madadi Classification for Unexpected Events in Pediatric Surgery: A Collaborative ERNICA Project

BACKGROUND

The Clavien-Madadi classification is a novel instrument for the assessment and grading of unexpected events in pediatric surgery, based on the Clavien-Dindo classification. The system has been adjusted to better fit the pediatric population in a prospective single-center study. There is a need now to validate the Clavien-Madadi classification within an international expert network.

METHODS

A pediatric surgical working group created 19 case scenarios with unexpected events in a multi-staged process. Those were circulated within the European Reference Network of Inherited and Congenital Anomalies (ERNICA) and surgeons were instructed to rate the scenarios according to the Clavien-Madadi vs. Clavien-Dindo classification.

RESULTS

59 surgeons from 12 European countries completed the questionnaire. Based on ratings of the case scenarios, the Clavien-Madadi classification showed significantly superior agreement rates of the respondents (85.9% vs 76.2%; p < 0.05) and was less frequently considered inaccurate for rating the pediatric population compared to Clavien-Dindo (2.1% vs 11.1%; p = 0.05). Fleiss' kappa analysis showed slightly higher strength of agreement using the Clavien-Madadi classification (0.74 vs 0.69). Additionally, intraclass correlation coefficient was slightly higher for the Clavien-Madadi compared to the Clavien-Dindo classification (ICCjust 0.93 vs 0.89; ICCunjust 0.93 vs 0.89). More pediatric surgeons preferred the Clavien-Madadi classification for the case scenarios (43.0% vs 11.8%; p = 0.002) and advantages of the Clavien-Madadi were confirmed by 81.4% of the surgeons.

CONCLUSION

The Clavien-Madadi classification is an accurate and reliable instrument for the grading of unexpected events in pediatric surgery. We therefore recommend its application in clinical and academic pediatric surgical practice.

LEVEL OF EVIDENCE

III.

Investigating the clinical reasoning abilities of large language model GPT-4: an analysis of postoperative complications from renal surgeries

PURPOSE

Large language models, a subset of artificial intelligence, have immense potential to support human tasks. The role of these models in science and medicine is unclear, requiring strong critical thinking and analysis skills. The objective of our study was to evaluate GPT-4's abilities to assess postoperative complications after renal surgeries.

MATERIALS AND METHODS

Discharge summaries were compiled, and patient information was deidentified in a Python-based program. Prompts were engineered in GPT-4 to assess for the presence of postoperative complications. GPT-4 was further asked to interpret each complication's Clavien-Dindo classification and institutional-specific category. GPT-4's database was compared to a human-curated database. Discrepancies were manually reviewed to calculate match and accuracy rates.

RESULTS

Approximately 944 renal surgeries were conducted from August 2005 to March 2022. There was a 79.6% match rate between GPT-4 and human-curated data in detecting postoperative complications. Accuracy rates were 86.7% for GPT-4 and 92.9% for human-curated. A subgroup of 139 patients had a complication detected by both GPT-4 and human with available Clavien-Dindo classification and category information. There was a 37.4% overall match rate for Clavien-Dindo grade and 55.4% match rate for category.

CONCLUSIONS

GPT-4 was able to accurately detect if there were any postoperative complications. It struggled with the complex task of further analyzing complications, especially with Clavien-Dindo classification, which requires more critical thinking and interpretation. While GPT-4 is not yet ready for advanced postoperative complication analysis, it can still be used to support clinicians in this endeavor.

Propensity Score Matching Analysis of Differential Outcomes in Holmium Laser Enucleation of the Prostate vs. Robotic-Assisted Simple Prostatectomy

Background & Objectives: Patients with bladder outlet obstruction (BOO) due to massive prostate enlargement have several surgical treatment options, such as robot-assisted simple prostatectomy (RASP) and holmium laser enucleation of the prostate (HoLEP). Postoperative outcomes may differ between those undergoing RASP and HoLEP. RASP has been associated with a lower incidence of transient stress urinary incontinence (SUI), while HoLEP allows for shorter catheterization times. Here, we report on our experience with both surgical modalities. Methods: Data were collected from prospectively maintained databases for 37 RASP patients and 181 HoLEP patients treated from July 2021 to November 2023. To control for selection bias, propensity score matching (PSM) was utilized based on age and prostate size. We compared patients' preoperative, perioperative, and postoperative outcomes both before and after applying PSM. Results: Before the PSM, the median prostate size was significantly lower in the HoLEP group (p < 0.001). The HoLEP group also had significantly shorter operative times (p ≤ 0.001) and lower weights of resected adenoma (p ≤ 0.001). After the PSM of 31 RASP and 31 HoLEP patients, all baseline patient characteristics were comparable. No significant differences were observed in operation time (p = 0.140) or in the weight of resected adenoma (p = 0.394) between the modalities. The median (IQR) length of catheterization was significantly shorter in the HoLEP group (1 [1-4] days) compared to the RASP group (7 [7-8] days), in both pre- and post-matching analyses (p ≤ 0.001 for both), reflecting the standard of practice. In contrast, in both pre- and post-PSM analyses, the average hospital stay was significantly shorter in the RASP cohort, as same-day discharge is standard in our center, whereas the HoLEP cohort required overnight stays due to routine continuous bladder irrigation before discharge (p < 0.001 for all). Notably, the SUI rates and American Urological Association (AUA) symptom scores were comparable at 3 months within both matched and unmatched cohorts (pre-PSM: p = 0.668, p = 0.083; post-PSM: p = 1, p = 0.152, respectively). Conclusions: Our comparative analysis indicates that both RASP and HoLEP yield similar outcomes, including SUI rates, at 3 months. While HoLEP provided shorter durations of postoperative catheterization, RASP offered shorter hospital stays.

Tip bendable suction ureteral access sheath versus traditional sheath in retrograde intrarenal stone surgery: an international multicentre, randomized, parallel group, superiority study

Background

Retrograde intrarenal surgery (RIRS) is the main treatments for upper urinary tract stones. The Ureteral Access Sheath (UAS) serves as a supplementary tool, facilitating direct kidney access during RIRS. High quality of evidence comparing tip bendable suction ureteral access sheath (S-UAS) with traditional UAS in RIRS for the treatment of renal and ureteral stones is lacking. The purpose of the study is to compare the efficacy and safety of S-UAS with traditional UAS in RIRS for the treatment of renal or ureteral stones ≤30 mm.

Methods

An international, multicenter, and superiority randomized controlled trial included 320 intention-to-treat patients across 8 medical centers in China, the Philippines, Malaysia and Turkey from August 2023 to February 2024. The inclusion criteria were patients ≥18 years old with renal or ureteral stones ≤30 mm. RIRS was performed using either S-UAS or traditional UAS. The primary outcome was the immediately stone-free rate (SFR). Secondary outcomes included SFR 3 months after operation, operating time, hospital stay, auxiliary procedures, complications (using the Clavien-Dindo grading system), and improvement in the Quality of Life (QoL) score. Differences between proportions [risk difference (RD)]/means [mean difference (MD)] and 95% confidence intervals (CI) were presented. This study is registered at ClinicalTrials.gov: NCT05952635.

Findings

The S-UAS group demonstrated a significantly higher immediately SFR (81.3% versus 49.4%; RD 31.9%; 95% CI 22.5%-41.7%; p = 0.004) compared to the traditional UAS group, as determined by the one-side superiority test. Additionally, the S-UAS group exhibited a higher SFR at 3 months post-operation (87.5% versus 70.0%; RD 17.5%; 95% CI 8.7%-26.3%; p < 0.001), lower postoperative fever rate (RD -11.9%; 95% CI -18.7% to -4.9%; p < 0.001), reduced use of stone baskets (RD -70.6%; 95% CI -77.8% to -63.5%; p < 0.001), and better QoL improvement (MD 7.25; 95% CI 2.21-12.29; p = 0.005). No statistically significant differences were observed in operation time, hospital stay, or the need for second-stage RIRS.

Interpretation

In RIRS for upper urinary tract stones ≤30 mm, S-UAS exhibited superior performance compared to traditional UAS, demonstrating higher SFR, reduced postoperative fever rate, and improved QoL outcomes. S-UAS emerges as a prudent and advantageous alternative to traditional UAS for RIRS.

Funding

National Natural Science Foundation of China and Guangdong Province, and Zhejiang Medicine and Health Program.

The Soleymani and Collins Obstetric morbidity score (SaCOMS): A quantitative tool for measuring maternal morbidity from complex obstetric surgery such as placenta accreta spectrum (PAS)

It is currently very difficult to compare different management strategies for complex obstetric surgery, such as hysterectomy for severe Placenta Accreta Spectrum (PAS), as there is no widely accepted consensus for the classification of maternal surgical morbidity. Many studies focus on the amount of blood products transfused or admission to intensive care units (ICU). However, these are dependent on local policies and available resources. It also gives an incomplete representation of the entire 'patient journey' after they leave the operating room. Subsequent repeat procedures for lower urinary track damage is arguably worse from the woman's perspective than a short stay on an intensive care unit (ICU) for observation. We suggest a version of the Clavien-Dindo morbidity classification specific to obstetrics. Then employ it to build a quantitative morbidity score which aims to reflect the whole 'patient experience' including the post-operative pathway. We then demonstrate the utility of this system in a cohort of women with Placenta Accreta Spectrum (PAS). The Clavien-Dindo classification was modified to reflect obstetric procedures and a quantitative morbidity measure, the Soleymani and Collins Obstetric Morbidity Score (SaCOMS), was developed based on this. Both were then validated using a survey-based consultation of a panel of experts in PAS and retrospectively applied to a cohort of 54 women who underwent caesarean hysterectomy for PAS. Clinicians with expertise in PAS believe that the Modified Obstetric Clavien-Dindo classification system and the novel SaCOMS tool can improve assessment of maternal morbidity, and better reflect the 'patient experience'. Application of the classification system to a single-centre PAS cohort suggested that surgery by gynecologic-oncology surgeons may be associated with decreased incidence and cumulative morbidity outcomes for women with PAS, especially those with the most severe presentation. This study presents a clinically useful obstetric-specific classification system for surgical morbidity. SaCOMS also provides a quantitative reflection of the full patient- journey experienced as a result of surgical complications enabling a more patient-centered representation of morbidity.

Early postoperative pain and 30-day complications following major abdominal surgery: a retrospective cohort study

BACKGROUND

Increasing evidence supports a positive relationship between the intensity of early postoperative pain, and the risk of 30-day postoperative complications. Higher pain levels may hamper recovery and contribute to immunosuppression after surgery. This leaves patients at risk of postoperative complications.

METHODS

One thousand patients who underwent major abdominal surgery (cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, esophageal, liver, or pancreas surgery) at the Radboud university medical center were randomly selected from eligible patients between 2014 and 2020. Pain scores on day 1, the independent variable of interest, were extracted from the electronic patient files. Outcome measures were 30-day postoperative complications (infectious, non-infectious, total complications and classification according to Clavien-Dindo).

RESULTS

Seven hundred ninety complications occurred in 572 patients within 30 days after surgery, of which 289 (36.7%) were of infectious origin, and 501 (63.4%) complications were non-infectious. The mean duration from the end of surgery to the occurrence of infectious complications was 6.5 days (SD 5.6) and 4.1 days (SD 4.7) for non-infectious complications (p<0.001). Logistic regression analysis revealed that pain scores on postoperative day 1 (POD1) were significantly positively associated with 30-day total complications after surgery (OR=1.132, 95% CI (1.076 to 1.190)), Clavien-Dindo classification (OR=1.131, 95% CI (1.071 to 1.193)), infectious complications (OR=1.126, 95% CI (1.059 to 1.196)), and non-infectious complications (OR=1.079, 95% CI (1.022 to 1.140)).

CONCLUSIONS

After major abdominal surgery, higher postoperative pain scores on day 1 are associated with an increased risk of 30-day postoperative complications. Further studies should pursue whether optimization of perioperative analgesia can improve immune homeostasis, reduce complications after surgery and enhance postoperative recovery.

Cumulative morbidity of ureteroscopy for upper tract urothelial carcinoma

OBJECTIVE

To assess complications after ureteroscopy (URS) for upper tract urothelial carcinoma (UTUC) management and to assess its postoperative cumulative morbidity burden using the Comprehensive Complication Index (CCI).

MATERIALS AND METHODS

Single center retrospective study including patients submitted to URS for UTUC suspicion. URSs were both diagnostic and operative. Postoperative complications were recorded according to the EAU Guidelines and graded according to Clavien-Dindo Classification (CDC). The cumulative postoperative morbidity burden developed by patients experiencing multiple events was assessed using the CCI. Multivariable logistic regression (MLR) analyses identified factors independently associated with the development of any grade and major postoperative complications.

RESULTS

Overall, 360 patients with UTUC suspicion were included with a total of 575 URSs performed. The cumulative number of all postoperative complications recorded was 111. In 86 (15%) procedures, patients experienced at least one postoperative complication, while 25 (4.3%) experienced more than one complication. Of these, 16 (14%) were severe (CDC ≥ IIIa). The most frequent type of complications were urinary (34%), bleeding (30%) and infectious (30%). The higher the CDC grade, the higher the median CCI, with a statistically significant increase in median CCI from CDC II to major complications. Patients who experienced intraoperative complications were at higher risk of developing any grade and major postoperative complications at MLR.

CONCLUSIONS

Complications after ureteroscopy for UTUC are relatively uncommon events. Patients who experience intraoperative complications are at higher risk of developing postoperative complications. The comprehensive complication index appeared more representative of the cumulative postoperative morbidity rather than the Clavien-Dindo classification.

The Prognostic Value of Perioperative Platelet and Leukocyte Values in Patients Undergoing Radical Cystectomy: A Prospective Long-Term Cohort Study

INTRODUCTION

Studies assessing the impact of preoperative and first-day postoperative values of leukocytes, thrombocytes, and platelet/leukocyte ratio (PLR) after radical cystectomy (RC) are sparse. We aimed to assess the impact of these factors on long-term survival after RC.

METHODS

An analysis of patients undergoing open RC from 2004 to 2023 at our center was performed. Leukocytosis was defined as ≥8,000 leukocytes/μL and thrombocytosis as ≥400,000 thrombocytes/μL. Similarly, the cutoff for PLR was set at 28. A multivariable Cox regression analysis was performed to assess the role of leukocytosis, thrombocytosis, and PLR on long-term survival after RC. For all analyses, hazard ratios (HRs) with the corresponding 95% confidence intervals (CIs) were estimated.

RESULTS

A total of 1,817 patients with a median age of 70 years (interquartile range [IQR]: 62-77) were included. Overall, 804 (44%), 175 (10%), and 1,296 (71%) patients presented with leukocytosis, thrombocytosis, and PLR ≥28 preoperatively. Accordingly, 1,414 (78%), 37 (2%), and 249 (14%) patients presented with leukocytosis, thrombocytosis, and PLR ≥28 on the first day after RC. At a median follow-up of 26 months (IQR: 8-68) after RC, 896 (49%) patients died. In the multivariate Cox regression analysis after adjusting for major perioperative risk factors, only preoperative leukocytosis (HR: 1.3, 95% CI: 1.1-1.6, p = 0.01), as well as both preoperative and first-day thrombocytosis (HR: 2.1, 95% CI: 1.5-2.9, and HR: 2.8, 95% CI: 1.6-5.1, p < 0.001, accordingly) were associated with worse overall survival.

CONCLUSION

PLR should not be used as a prognostic marker for survival after RC. On the contrary, preoperative leukocytosis, as well as preoperative and first-day thrombocytosis should raise awareness among clinicians performing RC since they were independently associated with worse survival after RC.

Safety and oncological outcome of early intraoperative intravesicle mitomycin C vs. deferred instillation in patients receiving robot-assisted radical nephroureterectomy

Introduction

Radical nephroureterectomy with concurrent bladder cuff excision (RNUBCE) is the gold standard surgical approach for high-risk primary upper tract urothelial carcinoma (UTUC). Given the notably high incidence of bladder tumor recurrence following this procedure, this study aimed to evaluate the effect and safety of intraoperative mitomycin-C (MMC) instillation vs. deferred instillation on overall oncological outcomes following robot-assisted RNUBCE.

Methods

This is a retrospective chart review study. Patients with non-invasive (N0, not T3/T4) UTUC who underwent robotic RNUBCE combined an intraoperative MMC instillation or a deferred MMC instillation after surgery at a medical center in Taiwan between November 2013 and June 2020 were eligible for inclusion. Patients with prior bladder UC, carcinomas of other origins, received neoadjuvant chemotherapy, and had undergone kidney transplantation were excluded. All surgeries were executed by a single surgical team under the guidance of the same surgeon. The primary outcomes was the risk of bladder tumor recurrence between patients received intraoperative (IO) vs. deferred MMC instillation postoperatively (PO) during one-year follow-up. The secondary outcome was postoperative adverse events assessed by the Clavien-Dindo classification. Univariate and multivariable Cox regression analyses were performed to determine the associations between study variables and the outcomes.

Results

A total of 54 patients were included in the analysis. 12 (22.2%) patients experienced a bladder tumor recurrence during follow-up (IO: 7.7%, PO: 35.7%, p < 0.021). After adjustment in the multivariable, intraoperative MMC instillation was significantly associated with lower risk of bladder recurrence [adjusted hazard ratio (aHR) = 0.15, 95% CI: 0.03-0.81, p = 0.028]. No MMC-related Clavien-Dindo Grade III-IV adverse events were found in either group.

Conclusion

IIntraoperative MMC instillation is safe and associated with a lower bladder tumor recurrence risk in patients undergoing robotic RNUBCE for UTUC than deferred instillation. Future large, prospective studies are still warranted to confirm the findings.

Real-world experience of water vapour therapy (Rezum) in patients with benign prostatic enlargement: a retrospective single-center study

BACKGROUND

Water vapor thermal therapy (Rezum) is a minimally invasive treatment for benign prostatic enlargement (BPE). Studies reporting urodynamic results regarding the procedure are rare. Our study aimed to assess the effectiveness of Rezum on urinary outcome parameters in a consecutive series of patients and compare urodynamic data before and after treatment.

METHODS

We retrospectively evaluated all the patients treated with Rezum between 07/2017 and 12/2023 at our institution. Patients who had more than one Rezum intervention, those who were unable to void (i.e., catheter-dependent patients), and those with insufficient data were excluded from the data analysis. Descriptive outcomes, such as symptom scores (IPSS, IPSS-QoL), peak flow in uroflowmetry (Qmax), post-micturition residual urine volume (PVR), and prostate volume (PVol), were analyzed. If available, preoperative and postoperative urodynamic results were evaluated.

RESULTS

In total, 250 Rezum procedures were performed during the observational period. After applying the exclusion criteria, the data from 193 patients were included in the analysis. Patients achieved significant symptom relief as measured using the IPSS (46% reduction) and IPSS-QoL scores (41% reduction). Qmax improved by 4.8 ml/s, as the mean PVR significantly decreased by 50%. PVol and PSA values decreased by 30% and 27.5%, respectively. In 19/193 patients with a urodynamic evaluation, pre- and postoperative data analysis showed a significant reduction in the bladder outlet obstruction index (BOOI) by approximately 70%.

CONCLUSIONS

Rezum is effective and can improve urinary symptoms. In appropriate patients, Rezum can significantly reduce the bladder outlet obstruction (BOO).

Open versus robotic partial nephrectomy in obese patients: a multi-institutional propensity score-matched analysis (UroCCR 43-Robese study)

INTRODUCTION

There is limited evidence on the outcomes of robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN) in obese patients (BMI ≥ 30 kg/m2). In this study, we aimed to compare perioperative and oncological outcomes of RPN and OPN.

METHODS

We relied on data from patients who underwent PN from 2009 to 2017 at 16 departments of urology participating in the UroCCR network, which were collected prospectively. In an effort to adjust for potential confounders, a propensity-score matching was performed. Perioperative outcomes were compared between OPN and RPN patients. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

Overall, 1277 obese patients (932 robotic and 345 open were included. After propensity score matching, 166 OPN and 166 RPN individuals were considered for the study purposes; no statistically significant difference among baseline demographic or tumor-specific characteristics was present. A higher overall complication rate and major complications rate were recorded in the OPN group (37 vs. 25%, p = 0.01 and 21 vs. 10%, p = 0.007; respectively). The length of stay was also significantly longer in the OPN group, before and after propensity-score matching (p < 0.001). There were no significant differences in Warm ischemia time (p = 0.66), absolute change in eGFR (p = 0.45) and positive surgical margins (p = 0.12). At a median postoperative follow-up period of 24 (8-40) months, DFS and OS were similar in the two groups (all p > 0.05).

CONCLUSIONS

In this study, RPN was associated with better perioperative outcomes (improvement of major complications rate and LOS) than OPN. The oncological outcomes were found to be similar between the two approaches.

Assessing the Impact of Percutaneous Nephrostomy Presence on Neoadjuvant Treatment Quality in Patients With Muscle Invasive Bladder Cancer

INTRODUCTION

Symptomatic hydronephrosis associated with muscle invasive bladder cancer (MIBC) necessitates percutaneous nephrostomy (PCN) insertion before neoadjuvant chemotherapy (NAC). This study assesses the impact of PCN presence on standard intended NAC quality, its related complications and outcome after radical cystectomy (RC).

MATERIALS AND METHODS

The study comprises a retrospective, multicenter cohort of 193 consecutive RCs performed between 2016 and 2019. Eighty (42%) of these patients received NAC and were divided in 2 comparison groups by presence (n = 26; 33%) or absence (n = 54; 67%) of PCN. Endpoints included completion of adequate NAC treatment (cisplatin-based chemotherapy for at least 4 courses), complications during NAC, post-RC complications and hospital stay.

RESULTS

Overall, patients with PCN (45/193; 23%) featured a higher referral rate to NAC (58% vs. 36%, P = .01), worse glomerular filtration rates (P < .001) and more adverse events (P = .04), in comparison to non-PCN patients. In the NAC cohort, PCN patients had less adequate treatment rates (54% vs. 85%, P = .005), and more infections (35% vs, 7%; P = .008) and hospitalizations (58% vs. 13%; P < .001) during chemotherapy. Post-RC outcome was similar for both comparison groups. PCN was an independent risk factor for inadequate NAC (OR = 3.9, P = .04), and infections (OR = 11.3, P = .01) and hospitalizations (OR = 7.5, P = .004) during NAC.

CONCLUSIONS

PCN in MIBC patients is a significant risk factor for inadequate NAC and adverse events during treatment. This finding may quire the rationale of NAC, potentially leading to consideration of NAC avoidance and upfront RC in PCN patients. Further survival studies with long follow-up are needed for elucidating this issue.

Percutaneous Image-Guided Cryoablation of Endophytic Renal Cell Carcinoma

PURPOSE

Endophytic renal cancer treatment is a challenge. Due to difficulties in endophytic tumor visualization during surgical extirpation, image-guided percutaneous cryoablation (PCA) is an attractive alternative. The minimally invasive nature of PCA makes it favorable for comorbid patients as well as patients in which surgery is contraindicated. Oncological outcomes and complications after PCA of endophytic biopsy-proven renal cell carcinoma (RCC) were reviewed in this study.

MATERIALS AND METHODS

Patients were included after a multidisciplinary team conference from January 2015 to November 2021. Inclusion criteria were endophytic biopsy-proven T1 RCC treated with PCA with one year of follow-up. Complications were reported according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system and the Clavien-Dindo classification (CDC) system. Major complications were defined as a grade ≥ 3 according to the CDC.

RESULTS

Fifty-six patients were included with a total of 56 endophytic tumors treated during 61 PCA sessions. The median RENAL nephrometry score was 9 (IQR 2), and the mean tumor size was 25.7 mm (SD ± 8.9 mm). Mean hospitalization time was 0.39 (SD ± 1.1) days. At a mean follow-up of 996 days (SD ± 559), 86% of tumors were recurrence free after one PCA. No patients progressed to metastatic disease. According to the CIRSE classification, 10.7% (n = 6) had grade 3 complications, and 5.4% (n = 3) had CDC major complications.

CONCLUSION

This study demonstrates that PCA of endophytic biopsy-proven T1 RCC is safe with few major complications and excellent local tumor control rates at almost three-year mean follow-up. LEVEL OF EVIDENCE 3: Retrospective cohort study.

Robotic or open superficial inguinal lymph node dissection as staging procedures for clinically node negative high risk penile cancer

OBJECTIVE

To evaluate perioperative and oncologic outcomes of a cohort of clinically node negative high-risk penile cancer patients undergoing robotic assisted inguinal lymph node dissection (RAIL) compared to patients undergoing open superficial inguinal lymph node dissection (OSILND).

PATIENTS AND METHODS

We retrospectively reviewed the clinical characteristics and outcomes of clinically node negative high-risk penile cancer patients undergoing RAIL at MDACC from 2013-2019. We sought to compare this to a contemporary open cohort of clinically node negative patients treated from 1999 to 2019 at MDACC and Moffit Cancer Center (MCC) with an OSILND. Descriptive statistics were used to characterize the study cohorts. Comparison analysis between operative variables was performed using Fisher's exact test and Wilcoxon's rank-sum test. The Kaplan-Meier method was used to estimate survival endpoints.

RESULTS

There were 24 patients in the RAIL cohort, and 35 in the OSILND cohort. Among the surgical variables, operative time (348.5 minutes vs. 239.0 minutes, P < 0.01) and the duration of operative drain (37 vs. 22 days P = 0.017) were both significantly longer in the RAIL cohort. Complication incidences were similar for both cohorts (34.3% for OSILND vs. 33.3% for RAIL), with wound complications making up 33% of all complications for RAIL and 31% of complications for OSILND. No inguinal recurrences were noted in either cohort. The median follow-up was 40 months for RAIL and 33 months for OSILND.

CONCLUSIONS

We observed similar complication rates and surgical variable outcomes in our analysis apart from operative time and operative drain duration. Oncological outcomes were similar between the two cohorts. RAIL was a reliable staging and potentially therapeutic procedure among clinically node negative patients with penile squamous cell carcinoma with comparable outcomes to an OSILND cohort.

Safety and feasability of ureteroscopy for pediatric stone, in children under 5 Years (SFUPA 5): A French multicentric study

INTRODUCTION

Ureteroscopy (URS) can be proposed as first-line therapy for the management of pelvic stones from 10 to 20 mm and for lower ureteric stones in children. However, little is known about the success and the morbidity of URS in young children. Ureteroscopic treatment may present matters in young children because of the small size of the pediatric kidney and the small size of the collecting system.

OBJECTIVE

To assess safety and efficacy of URS for the treatment of urinary stones in children aged of 5 years or less.

STUDY DESIGN

After the institutional ethical board approval was obtained, we conducted a retrospective, analytic, multicentric study that included all URS performed between January 2016 and April 2022 in children aged of 5 years or less. In this non-comparative case series, anonymized pooled data were collected from 7 tertiary care centers of pediatric patients. Endpoints were the one-session SFR at 3 months and per and postoperatives complications. Descriptive statistics were applied to describe the cohort.

RESULTS

Eighty-three patients were included. For them, 96 procedures were performed at the median age of 3.5 years (IQR: 0.8-5) and median weight of 14 Kg (6.3-23). Median stone size was 13 mm (4-45). There were 65 (67 %) renal stones treated with flexible URS, most of which were in the renal pelvis (30 %) and in the lower calix (33 %). A ureteral access sheath was used in 91 % procedures. Preoperative ureteral stent was placed in 52 (54 %) of patients. None of patients had ureteral dilatation. The single-session SFR was 67.4 % (56.3 and 89.2 % for flexible URS and semi-rigid URS respectively) and children require 1.4 procedures to achieve complete stone clearance. The overall complication rate was 18.7 %, most of them were minor (Clavien I-II). Intraoperative perirenal extravasation (Clavien IIIb) due to forniceal rupture was documented in 6.2 % of cases, related to an increased intrapelvic pressure (IPP) performed in a closed pelvicalyceal system.

DISCUSSION

Pediatric urologists should be aware of forniceal rupture based on the presence of extravasation of contrast during endourological procedures especially when they have difficulties to reach lower caliceal stone in small patient.

CONCLUSION

URS in patients aged of 5 years or less, is a complex minimally invasive procedure with reasonable efficacy and low morbidity. Intrarenal stones treated by RIRS in young children carries the risk of additional procedures to complete stone clearance.

Iatrogenic or recurrent bladder neck contracture treated by the Palminteri-Ferrari technique: a new way to approach a frustrating condition

PURPOSE

Bladder neck stricture (BNS) is a bothersome disease which may affect patients after trauma or prostatic surgery. It is frustrating due to the low durable success rate of currently available surgical techniques. The aim of the study is to explore the efficacy of a novel technique.

MATERIALS & METHODS

The surgical protocol was developed by two high case-volume surgeons. The technique consists of Holmium laser incisions at 3-6-9-12 o'clock. Subsequently, triamcinolone acetonide 40 mg is injected. Two months later, the BNS is endoscopically checked in operatory room and re-procedure take place, if necessary (max 3 times). Failure was defined as the need of definitive urinary diversion. Subjective satisfaction was measured through PGI-I Questionnaire.

RESULTS

A total of 45 patients were enrolled. Median age was 63 (IQR 59-69) years and BNS developed by different causes. Naïve BNS procedure patients were 12 (26.7%), others 33 (73.3%) underwent median 2 (IQR 1-4) previous urethrotomies, including 16 other surgeries. Suprapubic bladder catheter was present in 34 patients (75.6%). No complications were registered. Re-procedure at control was necessary in 24 patients (53.3%) for a median of 1 (IQR 1-3) procedures. At median follow-up of 18 months, failures were 4 (8.9%) and urinary incontinence was reported in 2 patients (4.5%) who required incontinence surgery. Median PGI-I was 2.

CONCLUSIONS

Our technique of BNS treatment allows good outcomes and high rate of subjective improvement amongst patients. Moreover, naïve patients seem to have better results. However, longer follow-up and higher sample size are mandatory to further assess these data.

The impact of perioperative risk factors on long-term survival after radical cystectomy: a prospective, high-volume cohort study

INTRODUCTION

Radical cystectomy (RC) is the gold standard for muscle-invasive bladder cancer. Nevertheless, RC is associated with substantial perioperative morbidity and mortality. We aimed to evaluate the role of important perioperative risk factors in predicting long-term survival after RC.

METHODS

An analysis of the prospective cohort of patients undergoing open RC from 2004 to 2023 at our center was performed. Patients who died within one month after RC were excluded from the study. A univariate and multivariable Cox regression analysis was performed to assess the role of sex, age, urinary diversion, preoperative values of creatinine and hemoglobin, first-day postoperative values of CRP, leucocytes, and thrombocytes, perioperative Clavien-Dindo complications, perioperative chemotherapy, admission to the intensive or intermediate care unit, as well as type of histology, pathologic T-stage, positive lymph nodes, and positive surgical margins on predicting the long-term overall survival after RC. For all analyses hazard ratios (HRs) with the corresponding 95% confidence intervals (CIs) were estimated.

RESULTS

A total of 1,750 patients with a median age of 70 years (IQR: 62-76) were included. Of them, 1,069 (61%) received ileal conduit and 650 (37%) neobladder. Overall, 1,016 (58%) perioperative complications occurred. At a median follow-up of 31 months (IQR: 12-71), 884 (51%) deaths were recorded. In the multivariable Cox regression analysis, increasing age (HR: 1.03, 95%CI: 1.02-1.04, p < 0.001), higher preoperative creatinine values (HR: 1.27, 95%CI: 1.12-1.44, p < 0.001), lower preoperative hemoglobin values (HR: 0.93, 95%CI: 0.89-0.97, p = 0.002), higher postoperative thrombocyte values (HR: 1.01, 95%CI: 1.01-1.02, p = 0.02), Clavien-Dindo 1-2 complications (HR: 1.26, 95%CI: 1.03-1.53, p = 0.02), Clavien-Dindo 3-4 complications (HR: 1.55, 95%CI: 1.22-1.96, p < 0.001), locally advanced bladder cancer (HR: 1.29, 95%CI: 1.06-1.55, p = 0.009), positive lymph nodes (HR: 1.74, 95%CI: 1.45-2.11, p < 0.001), and positive surgical margins (HR: 1.61, 95%CI: 1.29-2.01, p < 0.001) negatively affected long-term survival.

CONCLUSION

Beside increased age and worse oncological status, impaired renal function, lower preoperative hemoglobin values, higher postoperative thrombocyte values, and perioperative complications are independent risk factors for mortality in the long term in patients undergoing open RC.

Has fluoroless endourology (URS and PCNL) come of age? Evidence from a comprehensive literature review

INTRODUCTION

Radiation via the use of imaging is a key tool in management of kidney stones. Simple measures are largely taken by the endourologists to implement the 'As Low As Reasonably Achievable' (ALARA) principle, including the use of fluoroless technique. We performed a scoping literature review to investigate the success and safety of fluoroless ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) procedures for the treatment of KSD.

METHODS

A literature review was performed searching bibliographic databases PubMed, EMBASE and Cochrane library, and 14 full papers were included in the review in accordance with the PRISMA guidelines.

RESULTS

Of the 2535 total procedures analysed, 823 were fluoroless URS vs. 556 fluoroscopic URS; and 734 fluoroless PCNL vs. 277 fluoroscopic PCNL. The SFR for fluoroless vs. fluoroscopic guided URS was 85.3% and 77%, respectively (p=0.2), while for fluoroless PCNL vs. fluoroscopic group was 83.8% and 84.6%, respectively (p=0.9). The overall Clavien-Dindo I/II and III/IV complications for fluoroless and fluoroscopic guided procedures were 3.1% (n=71) and 8.5% (n=131), and 1.7% (n=23) and 3% (n=47) respectively. Only 5 studies reported a failure of the fluoroscopic approach with a total of 30 (1.3%) failed procedures.

CONCLUSION

The ALARA protocol has been implemented in endourology in numerous ways to protect both patients and healthcare workers during recent years. Fluoroless procedures for treatment of KSD are safe and effective with outcomes comparable to standard procedures and could become the new frontier of endourology in selected cases.

Transurethral versus open enucleation of the prostate in Sweden - a retrospective comparative cohort study

OBJECTIVE

To investigate if treatment with transurethral enucleation of the prostate (TUEP) during the learning curve is as efficient and safe in the short term as transvesical open prostate enucleation (OPE), in patients with benign prostatic obstruction (BPO) > 80 ml in a population in Sweden.  Methods: 54 patients with ultrasound verified BPO > 80 ml and indication for surgery underwent TUEP or OPE between 2013 and 2019. Peri- and postoperative outcome variables regarding voiding efficiency and morbidity from 20 OPE at Skåne University Hospital (SUS) and from the first 34 TUEP performed at SUS and Ystad Hospital were retrospectively assembled. Follow-up data from the first 6 postoperative months were collected by chart review.

RESULTS

Intraoperative bleeding during TUEP was less than in OPE (225 ml vs. 1,000 ml). TUEP took longer surgery time than OPE (210 vs. 150 min.). Within 30 days postoperatively, bleeding occurred less often after TUEP (23% vs. 40%), requiring one fourth of the blood transfusions given after OPE. After TUEP, patients had shorter hospitalisation (3 days vs. 7 days) and catheterisation time (3 days vs. 12 days). During the 6-month follow-up period, incontinence and UTI defined as symtomatic significant bacteriuria (urinary culture) were observed as main complications after TUEP and OPE. Functional outcome data availability (International Prostate Symptom Score [IPSS] questionnaire, uroflowmetry, residual urine) were limited.

CONCLUSIONS

Treatment with TUEP during the learning curve led to less bleeding, shorter hospitalisation- and catheterisation time than treatment with OPE. However, surgery time was shorter with OPE. There were no major differences between the groups concerning mid-term functional outcomes, with the reservation of an inconsistent follow-up.

11-item modified frailty index and outcomes after radical cystectomy

INTRODUCTION

To investigate the association between modified frailty index (mFI) scores and radical cystectomy outcomes.

MATERIALS AND METHODS

We conducted a multicenter retrospective analysis of 292 patients who underwent radical cystectomy between 2015 and 2019. The patients were stratified according to mFI scores (mFI 0-1 vs. mFI ≥2). Baseline characteristics were compared between groups. The primary endpoints were cancer-specific survival (CSS) and overall survival (OS), and the secondary endpoint was the 30-day postoperative complication rate.

RESULTS

One group included 164 patients with mFI 0-1 and the other included 128 patients with mFI ≥2. The cohort's median age was 69 years, and median follow-up for survivors was 33 months. Thirty-day major postoperative complication rate was 19%. Ninety patients (31%) died during the study period, 70 of them (24%) from bladder cancer. Older age, male sex, lower kidney function, and diversion to an ileal conduit were significantly more common in the mFI ≥2 group. The postoperative complication rates were comparable between groups, but the CSS and OS were significantly lower in the frailer group (p = 0.007 and p = 0.03, respectively). An mFI score ≥ 2 emerged as an independent risk factor for cancer-specific death (hazard ratio [HR] = 1.7, p = 0.03) and overall-mortality (HR = 1.8, p = 0.008).

DISCUSSION

High mFI scores are associated with shorter CSS and OS after radical cystectomy. Healthcare providers should be encouraged to calculate frailty preoperatively for judicious patient selection in light of the predicted outcomes.

Physicians' assessment of complications after gynecological surgery in Sweden: The GYNCOM survey

INTRODUCTION

Complications after gynecological surgery in Sweden are registered in the well-established Swedish National Quality Register of Gynecological Surgery, GynOp. The aim of this study was to analyze interrater reliability in assessing complications according to the methods in GynOp, and to explore physicians' perceptions of registering complications.

MATERIAL AND METHODS

A digital survey was sent to gynecologists and residents in gynecology in Sweden. Participating clinics were recruited through the Swedish network for national clinical studies in Obstetrics and Gynecology, SNAKS. Twenty fictional cases, intended to represent normal postoperative course, failure to cure, and varying degrees of complications, were developed by the research group. The clinical scenarios included abdominal and laparoscopic surgery of the uterus and adnexa, vaginal hysterectomies, as well as hysteroscopy. The respondents graded each case on the presence of a complication (yes/no). Type of complication, severity, and what action the complication required according to Clavien-Dindo was registered if a complication was acknowledged, according to the method in GynOp. Interrater reliability and the opinions of the respondents were presented descriptively. More than 80% of respondents making the same assessment was considered as agreement.

RESULTS

The response rate was 41%, with 104 responding physicians from 16 gynecological clinics. Type and severity of complication was considered relevant to register by 88% and 89% of respondents, respectively. Agreement on whether the case described a complication was >80% in 85% (17/20) of cases and agreement using the Clavien-Dindo classification was >90% in 80% (16/20) of cases. There was high agreement in assessments of classically severe complications, such as pulmonary embolism and ureteral damage, in both presence of complication and severity, as well as Clavien-Dindo (>90% for all methods). Cases with agreement <80% on whether the case described a complication were bordering between normal postoperative course and minor complication.

CONCLUSIONS

This study provides validation for the methods used to register complications after gynecological surgery according to the GynOp register, including the use of Clavien-Dindo in gynecology. However, the results indicate a need to define what should be considered symptoms inherent to each type of surgery.

Holographic 3D renal segments reconstruction protects renal function by promote choice of selective renal artery clamping during robot-assisted partial nephrectomy

OBJECTIVE

To investigate the impact of selective artery clamping (SAC) and main artery clamping (MAC) during robot-assisted partial nephrectomy (RAPN) on renal function and the influence of holographic three-dimensional (3D) reconstruction of renal segments on the selection between SAC and MAC.

METHODS

This retrospective observational study included patients who underwent RAPN at First Hospital Affiliated to the Army Medical University between December 2016 and July 2022. According to the clamping methods, the patients were divided into the SAC group and the MAC group. The primary outcome was renal function.

RESULTS

A total of 422 patients (194 in the SAC group and 228 in the MAC group) were included. The RAPN procedures were all completed successfully. The patients in SAC group had less glomerular filtration rate (GFR) decline in the affected kidney (8.6 ± 7.0 ml/min vs. 18.7 ± 10.9 ml/min, P < 0.001) and minor estimated glomerular filtration rate (eGFR) decrease (4.3 ± 10.5 ml/min vs. 12.6 ± 12.1 ml/min, P < 0.001) than those in MAC group. Among 37 patients with baseline renal insufficiency, the GFR decline of the affected kidney in the SAC subgroup was significantly lower than in the MAC subgroup (5.5 ± 6.5 ml/min vs. 14.3 ± 9.2 ml/min, P = 0.002). The proportion of patients who underwent 3D reconstruction was significant higher in the SAC group than in the MAC group. (65.46% vs. 28.07%, P < 0.001).

CONCLUSION

The SAC technique during RAPN may serve as a protective measure for renal function, while the implementation of holographic 3D renal segment reconstruction technique may facilitate optimal selection of SAC.

Discrepancy in Reporting of Perioperative Complications: A Retrospective Observational Study

OBJECTIVE

To assess the discrepancy between perioperative complications, prospectively recorded during a cohort study versus retrospectively from health records.

BACKGROUND

Perioperative adverse events are relevant for patient outcome, but incomplete reporting is common.

METHODS

Two physicians independently recorded all intraoperative adverse events according to ClassIntra and all postoperative complications according to the Clavien-Dindo classification based on all available health records. These retrospective assessments were compared with the number and severity of those prospectively assessed in the same patients during their inclusion in 1 center of a prospective multicenter cohort study.

RESULTS

Interrater agreement between both physicians for retrospective recording was high [intraclass correlation coefficient: 0.89 (95% CI, 0.86, 0.91) for intraoperative and 0.88 (95% CI, 0.85, 0.90) for postoperative complications]. In 320 patients, the incidence rate was higher retrospectively than prospectively for any intraoperative complication (incidence rate ratio: 1.79; 95% CI, 1.50, 2.13) and for any postoperative complication (incidence rate ratio: 2.21; 95% CI, 1.90, 2.56). In 71 patients, the severity of the most severe intraoperative complication was higher in the retrospective than in the prospective data collection, whereas in 69 the grading was lower. In 106 patients, the severity of the most severe postoperative complication was higher in the retrospective than in the prospective data collection, whereas in 19 the grading was lower.

CONCLUSIONS

There is a noticeable discrepancy in the number and severity of reported perioperative complications between these 2 data collection methods. On the basis of the double-blinded assessment of 2 independent raters, our study renders prospective underreporting more likely than retrospective overreporting.

A randomized controlled trial investigating rectus sheath catheters following radical cystectomy

OBJECTIVE

To evaluate whether rectus sheath catheter (RSC) insertion may be an alternative to thoracic epidural (TE).

PATIENTS AND METHODS

In a non-blinded, single-centre, non-inferiority study, patients undergoing open radical cystectomy were randomized 1:1 to receive either a TE or surgically placed RSC. The primary endpoint was cumulative opiate use (median oral morphine equivalent [OME]) in the first 72 h postoperatively. Secondary outcomes included visual analogue scale pain scores, measures of postoperative recovery including mobility and time to regular diet, and complications.

RESULTS

Ninety-seven patients were randomized (51 TE, 46 RSC). The median OME was 103 (77.5-132.5) mg in the TE arm and 161.75 (117.5-187.5) mg in the RSC arm. A Mann-Whitney U-test confirmed non-inferiority of RSC to TE at a threshold of 15 mg OME (P = 0.002). When comparing pain scores for the first three postoperative days, an early difference was observed that favoured the TE group during post-anaesthesia care unit stay, which was lost after postoperative day 1. Patient satisfaction with analgesia on the third postoperative day was similar in the two arms (P = 0.47). There were no statistically significant differences between arms with respect to the other secondary outcomes.

CONCLUSIONS

The outcomes from this prospective randomized trial demonstrated non-inferiority of RSC insertion compared to TE with respect to 72-h opiate use. Patient satisfaction with pain control on postoperative day 3 was the same for each group.

Complications After Radical Cystectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials with a Meta-regression Analysis

CONTEXT

Radical cystectomy is considered a procedure of high complexity with a relative high complication rate.

OBJECTIVE

To systematically summarize the literature regarding the complications of radical cystectomy and the factors that contribute to them.

EVIDENCE ACQUISITION

We searched MEDLINE/PubMed, ClinicalTrials.gov, and Cochrane Library, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for randomized controlled trials (RCTs) on complications related to radical cystectomy.

EVIDENCE SYNTHESIS

A total of 3766 studies were screened, and 44 studies were included in this systematic review and meta-analysis. Complications following radical cystectomy are quite common. The most common complications were gastrointestinal complications (20%), infectious complications (17%), and ileus (14%). The majority of complications occurring were Clavien I-II (45%). Specific measurable patient factors are related to certain complications and can be used to stratify risk and assist in preoperative counseling, while proper design of high-quality RCTs may better reflect real-life complication rates.

CONCLUSIONS

In our study, RCTs with a low risk of bias had higher complication rates than studies with a high risk of bias, underlining the need for further improvement on complication reporting in order to refine surgical outcomes.

PATIENT SUMMARY

Radical cystectomy is usually followed by high complication rates, which affect patients and are, in turn, strongly associated with patients' preoperative health status.

Benefits and Harms of Benign Prostatic Obstruction Treatments in Renal Transplanted Patients

CONTEXT

In an increasingly ageing transplant population, timely management of benign prostatic obstruction (BPO) is key to preventing complications that result in graft dysfunction or compromise survival.

OBJECTIVE

To evaluate benefits/harms of BPO treatments in transplant patients by reviewing current literature.

EVIDENCE ACQUISITION

A computerised bibliographic search of Medline, Embase, and Cochrane databases was performed for studies reporting outcomes on BPO treatments in transplanted patients.

EVIDENCE SYNTHESIS

A total of 5021 renal transplants (RTs) performed between 1990 and 2016 were evaluated. BPO incidence was 1.61 per 1000 population per year. Overall, 264 men underwent intervention. The mean age was 58.4 yr (27-73 yr). In all, 169 patients underwent surgery (n = 114 transurethral resection of the prostate [TURP]/n = 55 transurethral incision of the prostate [TUIP]) and 95 were treated with an un-named alpha-blocker (n = 46) or doxazosin (n = 49). There was no correlation between prostate volume and treatment modality (mean prostate size = 26 cc in the surgical group where reported and 48 cc in the medical group). The mean follow-up was 31.2 mo (2-192 mo). The time from RT to BPO treatment was reported in six studies (mean: 15.4 mo, range: 0-156 mo). The time on dialysis before RT was recorded in only three studies (mean: 47.3 mo, range: 0-288 mo). There was a mean improvement in creatinine after intervention from 2.17 to 1.77 mg/dl. A total of 157 men showed an improvement in the International Prostate Symptom Score (from 18.26 to 6.89), and there was a significant reduction in postvoid residual volume in 199 (mean fall 90.6 ml). Flow improved by a mean of 10 ml/s following intervention in 199 patients. Complications included acute urinary retention (4.1%), urinary tract infections (8.4%), bladder neck contracture (2.2%), and urethral strictures (6.9%). The mean reoperation rate was 1.4%.

CONCLUSIONS

Current literature is heterogeneous and of low-level evidence. Despite this, alpha-blockers, TUIP, and TURP showed a beneficial increase in the peak urinary flow and reduced symptoms in transplants patients with BPO. Improvement in the mean graft creatinine was noted after intervention. Complications were under-reported. A multicentre comparative cohort study is needed to draw firm conclusions about the ideal treatment for BPO in RT patients.

PATIENT SUMMARY

In this report, we looked at the outcomes for transplant patients undergoing medical or surgical management of benign prostatic obstruction. Although the literature was very heterogeneous, we found that medical management and surgery with transurethral resection/incision of the prostate are beneficial for improving urinary flow and bothersome symptoms. We conclude that further prospective studies are required for better clarity about timing and modality of intervention in transplant patients.

Comparison of oral morbidity and mid-term efficacy of anterior urethroplasty using an autologous tissue-engineered graft (MukoCell®) versus native oral mucosa graft

OBJECTIVE

Our study aimed to compare surgical success rate (SR) and oral morbidity of augmentation urethroplasty for anterior urethral strictures using autologous tissue-engineered oral mucosa graft (TEOMG) named MukoCell® versus native oral mucosa graft (NOMG).

METHODS

We conducted a single-institution observational study on patients undergoing TEOMG and NOMG urethroplasty for anterior urethral strictures >2 cm in length from January 2016 to July 2020. SR, oral morbidity, and potential risk factors of recurrence were compared between groups were analyzed. A decrease of maximum uroflow rate < 15 mL/s or further instrumentation was considered a failure.

RESULTS

Overall, TEOMG (n = 77) and NOMG (n = 76) groups had comparable SR (68.8% vs. 78.9%, p = 0.155) after a median follow-up of 52 (interquartile range [IQR] 45-60) months for TEOMG and 53.5 (IQR 43-58) months for NOMG. Subgroup analysis revealed comparable SR according to surgical technique, stricture localization, and length. Only following repetitive urethral dilatations, TEOMG achieved lower SR (31.3% vs. 81.3%, p = 0.003). Surgical time was significantly shorter by TEOMG use (median 104 vs. 182 min, p < 0.001). Oral morbidity and the associated "burden" in patients' quality of life were significantly less at 3 weeks following the biopsy required for TEOMG manufacture, compared to NOMG harvesting and totally absent at 6 and 12 months postoperatively.

CONCLUSIONS

The SR of TEOMG urethroplasty appeared to be comparable to NOMG at a mid-term follow-up but taking into account the uneven distribution of stricture site and the surgical techniques used in both groups. Surgical time was significantly shortened, since no intraoperative mucosa harvesting was required, and oral complications were diminished through the preoperative biopsy for MukoCell® manufacture.

Bioengineered dermal matrix (Integra®) reduces donor site morbidity in total phallic construction with radial artery forearm free-flap

Total phallic construction with radial artery forearm free-flap (RAFFF) is widely regarded as the gold standard approach for phalloplasty. However, donor-site morbidity remains a significant concern, which is typically managed by using a full-thickness skin graft (FTSG) on the forearm. Split thickness skin grafts (STSG) have been proposed as an alternative, along with the use of an acellular dermal matrix substitute. A retrospective comparative analysis was performed to assess the differences in operative, functional and cosmetic outcomes between FTSG (Group A) and the combination of acellular dermal matrix with STSG (Group B). A retrospective cohort study was conducted on all patients who underwent total phallic construction with RAFFF, between 2016 and 2021. Post-operative surgical and functional outcomes were evaluated using validated tools. A total of 34 patients were included in the study, with 18 patients (52.9%) in Group A and 16 patients (47.1%) in Group B. Group B demonstrated a significant advantage in terms of healing time (24 days vs. 30 days, p = 0.003) and complete graft take (93.8% vs. 27.8%, p = 0.001). Group B also had significantly shorter operative times (310 min vs. 447 min, p = 0.001) and a reduced median hospital stay (8 days vs. 10 days, p = 0.001). Satisfaction with cosmesis was significantly higher in Group B (93.8% vs. 66.7%, p = 0.048).

Comparing Robotic-Assisted to Open Radical Cystectomy in the Management of Non-Muscle-Invasive Bladder Cancer: A Propensity Score Matched-Pair Analysis

BACKGROUND

For non-muscle-invasive bladder cancer (NMIBC) requiring radical surgery, limited data are available comparing robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) to open radical cystectomy (ORC). The objective of this study was to compare the two surgical techniques.

METHODS

A multicentric cohort of 593 patients with NMIBC undergoing iRARC or ORC between 2015 and 2020 was prospectively gathered. Perioperative and pathologic outcomes were compared.

RESULTS

A total of 143 patients operated on via iRARC were matched to 143 ORC patients. Operative time was longer in the iRARC group (p = 0.034). Blood loss was higher in the ORC group (p < 0.001), with a consequent increased post-operative transfusion rate in the ORC group (p = 0.003). Length of stay was longer in the ORC group (p = 0.007). Post-operative complications did not differ significantly (all p > 0.05). DFS at 60 months was 55.9% in ORC and 75.2% in iRARC with a statistically significant difference (p = 0.033) found in the univariate analysis.

CONCLUSION

We found that iRARC for patients with NMIBC is safe, associated with a lower blood loss, a lower transfusion rate and a shorter hospital stay compared to ORC. Complication rates were similar. No significant differences in survival analyses emerged across the two techniques.

Evaluation of the usefulness of the Clavien-Dindo classification of surgical complications

The Clavien-Dindo (CD) classification is widely used in the reporting of surgical complications in scientific literature. It groups complications based on the level of intervention required to resolve them, and benefits from simplicity and ease of use, both of which contribute its to high inter-rater reliability. It has been validated for use in many specialties due to strong correlation with key outcome measures including length of stay, postsurgical quality of life and case-related renumeration. Limitations of the classification include concerns over differentiating grade III and IV complications and not classifying intraoperative complications. The Comprehensive Complication Index is an adaptation of the CD classification which generates a morbidity score from 0 to 100. It has been proposed as a more effective method of assessing the morbidity burden of surgical procedures. However, it remains less popular as calculations of morbidity are complicated and time-consuming. In recent years there have been suggestions of adaptations to the CD classification such as the Clavien-Dindo-Sink classification, while in some specialties, completely new classifications have been proposed due to evidence the CD classification is not reliable. Similarly, the Surgical Expertise and Validity Evaluation project aims to determine benchmarks against which surgeons may compare their own practice.

Novel single-stage preputial spiral graft for panurethral stricture: a step-by-step description of the technique

PURPOSE

To report the 12-month results of a novel urethroplasty technique relying on a spiral preputial graft for panurethral stricture disease.

MATERIALS AND METHODS

Twenty consecutive patients were treated between May and October 2021 at our center. A spiral preputial mucocutaneous graft is a foreskin-based graft, developed from a 5-cm-wide preputial skin, which is harvested using a helicoidal shape and can reach up to 20 cm in length. Stricture characteristics were assessed through preoperative retrograde and voiding cystourethrogram and maximum uroflowmetry data (Qmax). Complications were collected up to 30 days after surgery and graded using the Clavien-Dindo (C-D) classification. The patients were followed up to 12 months.

RESULTS

Preoperative median Qmax was 6.5 ml/s [interquartile range (IQR): 4.0-8.7]. After a median follow-up of 12 months (IQR 12-13), six patients experienced at least one complication. Of them, two patients had grade 2 C-D complications, while only one developed a grade 3a C-D complication. The median postoperative Qmax was 16 ml/s (IQR: 13-18). Only one patient had early urethral stricture recurrence treated with dilatation after catheter removal. At one-year follow-up, no other patients had urethral stricture recurrence with an overall median Qmax of 15.1 ml/s (IQR 13.5-16.4).

CONCLUSIONS

Our novel single-stage spiral preputial graft urethroplasty for panurethral stricture treatment appears to be safe and could be used as a valid alternative to two-stage procedures or even to single-stage buccal mucosa graft augmentation.

Long-term survival after female pelvic organ-sparing radical cystectomy versus standard radical cystectomy: a multi-institutional propensity score-matched analysis

BACKGROUND

The application of pelvic organ preserving-radical cystectomy (POPRC) in female patients with bladder cancer has attracted more and more attention in recent years. In the current study, the authors aim to compare the long-term oncological outcomes of POPRC versus standard radical cystectomy (SRC) in a large multicenter retrospective cohort.

PATIENTS AND METHODS

Data on female patients with bladder cancer who underwent POPRC or SRC in January 2006 and April 2018 were included from three Chinese urological centers. The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival and recurrence-free survival. To decrease the effect of unmeasured confounders associated with treatment selection, 1:1 propensity score matching was performed.

RESULTS

Among the 273 enrolled patients, 158 underwent POPRC (57.9%), and 115 underwent SRC (42.1%). The median follow-up time was 38.6 (15.9-62.5) months. After propensity score matching, each cohort included 99 matched patients. The OS ( P =0.940), cancer-specific survival ( P =0.957), and recurrence-free survival ( P =0.476) did not differ significantly from the two matched cohorts. Subgroup analysis confirmed that the OS was similar between the patients treated with POPRC and SRC across all subgroups examined (all P > 0.05). In multivariable analysis, the surgical method (SRC vs. POPRC) was not an independent risk factor for OS (Hazard ratio 0.874, 95% CI 0.592-1.290; P =0.498).

CONCLUSIONS

The results showed that no significant difference in long-term survival was determined between female patients undergoing SRC and those undergoing POPRC.

Comparison of peri- and intraoperative outcomes of open vs robotic-assisted partial nephrectomy for renal cell carcinoma: a propensity-matched analysis

BACKGROUND

Partial nephrectomy (PN) is the gold standard surgical treatment for resectable renal cell carcinoma (RCC) tumors. However, the decision whether a robotic (RAPN) or open PN (OPN) approach is chosen is often based on the surgeon's individual experience and preference. To overcome the inherent selection bias when comparing peri- and postoperative outcomes of RAPN vs. OPN, a strict statistical methodology is needed.

MATERIALS AND METHODS

We relied on an institutional tertiary-care database to identify RCC patients treated with RAPN and OPN between January 2003 and January 2021. Study endpoints were estimated blood loss (EBL), length of stay (LOS), rate of intraoperative and postoperative complications, and trifecta. In the first step of analyses, descriptive statistics and multivariable regression models (MVA) were applied. In the second step of analyses, to validate initial findings, MVA were applied after 2:1 propensity-score matching (PSM).

RESULTS

Of 615 RCC patients, 481 (78%) underwent OPN vs 134 (22%) RAPN. RAPN patients were younger and presented with a smaller tumor diameter and lower RENAL-Score sum, respectively. Median EBL was comparable, whereas LOS was shorter in RAPN vs. OPN. Both intraoperative (27 vs 6%) and Clavien-Dindo > 2 complications (11 vs 3%) were higher in OPN (both < 0.05), whereas achievement of trifecta was higher in RAPN (65 vs 54%; p = 0.028). In MVA, RAPN was a significant predictor for shorter LOS, lower rates of intraoperative and postoperative complications as well as higher trifecta rates. After 2:1 PSM with subsequent MVA, RAPN remained a statistical and clinical predictor for lower rates of intraoperative and postoperative complications and higher rates of trifecta achievement but not LOS.

CONCLUSIONS

Differences in baseline and outcome characteristics exist between RAPN vs. OPN, probably due to selection bias. However, after applying two sets of statistical analyses, RAPN seems to be associated with more favorable outcomes regarding complications and trifecta rates.

The role of malnutrition universal screening tool in predicting outcomes after radical cystectomy

PURPOSE

The Malnutrition Universal Screening Tool integrates body mass index, unintentional weight loss and present illness to assess risk for malnutrition. The predictive role of 'MUST' among patients undergoing radical cystectomy is unknown. We investigated the role of 'MUST' in predicting postoperative outcomes and prognosis among patients after RC.

MATERIALS AND METHODS

We conducted a multicenter retrospective analysis of 291 patients who underwent radical cystectomy in 6 medical centers between 2015 and 2019. Patients were stratified to risk groups according to the 'MUST' score [low risk (n = 242) vs. medium-to-high risk (n = 49)]. Baseline characteristics were compared between groups. Endpoints were 30-day postoperative complications rate, cancer-specific-survival and overall survival. Kaplan-Meier curves and Cox-regression analyses were used to evaluate survival and identify predictors of outcomes.

RESULTS

Median age of the study cohort was 69 years (IQR 63-74). Median duration of follow up for survivors was 33 months (IQR 20-43). Thirty-day major postoperative complications rate was 17%. Baseline characteristics were not different between the 'MUST' groups, and there was no difference in early post-operative complication rates. CSS and OS were significantly lower (p ≤ 0.02) in the medium-to-high-risk group ('MUST' score≥1) with estimated 3-year CSS and OS rates of 60% and 50% compared to 76% and 71% in the low-risk group, respectively. On multivariable analysis, 'MUST'≥1 was an independent predictor of overall- (HR = 1.95, p = 0.006) and cancer-specific-mortality (HR = 1.74, p = 0.05).

CONCLUSIONS

High 'MUST' scores are associated with decreased survival in patients after radical cystectomy. Thus, the 'MUST' score may serve as a preoperative tool for patient selection and nutritional intervention.

Development and Interrater Agreement of a Novel Classification System Combining Medical and Surgical Adverse Event Reporting

Importance

Categorization systems for adverse events are not standardized across care settings and specialties and do not always include near miss events (events where there was potential for patient harm, but where no actual harm occurred), making it difficult to effectively assess patient safety for quality improvement.

Objective

To develop and assess interrater agreement on a classification system for adverse events reporting that incorporates events in both inpatient and outpatient settings across medical and surgical subspecialties including near miss events.

Design, Setting, and Participants

A cross-sectional study in a tertiary care center including 174 patient cases occurring from 2018 to 2020 was carried out. Data were abstracted from a Department of Otorhinolaryngology-Head and Neck Surgery Quality Assurance database. The cases were comprised of near miss and adverse events occurring in adult and pediatric patients in inpatient, outpatient, and emergency department settings. The ratings took place in March and April of 2022.

Exposures

Four raters (2 attending physicians and 2 senior resident physicians) were recruited to classify these cases according to 3 classification systems: the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP), Clavien-Dindo, and our novel Quality Improvement Classification System (QICS).

Main Outcomes and Measures

The primary outcome was overall interrater agreements using Fleiss κ.

Results

Across all 4 raters grading 174 cases, the NCC-MERP, Clavien-Dindo, and QICS received a κ score. Fair-to-moderate interrater reliability was observed between the resident and attending physician groups across the 3 classification systems: NCC-MERP (κ = 0.33; 95% CI, 0.30-0.35), Clavien-Dindo (κ = 0.47; 95% CI, 0.43-0.50), and QICS (κ = 0.42; 95% CI, 0.39-0.44). Strong interrater concordance was observed for complications across all scenarios.

Conclusion and Relevance

This cross-sectional study found that the new QICS classification scheme was applicable to wide-ranging clinical scenarios with a focus on patient-centered outcomes including near miss events. In addition, QICS allowed for the comparison of patient outcome data in a multitude of settings.

Stone attenuation on computer tomography helps surgeons make decisions between miniaturized percutaneous nephrolithotomy or retrograde intrarenal surgery for lower pole stones: a retrospective study

A retrospective study was performed on 200 patients who underwent miniaturized percutaneous nephrolithotomy (mini-PCNL) or retrograde intrarenal surgery (RIRS) for 10-20 mm sized lower pole renal calculi to investigate the relationship between computed tomography (CT) attenuation of calculi and surgical outcomes. CT was used to examine the location, size, and CT attenuation values of the calculi. Additionally, the operation time, hospital stay, hemoglobin (Hb) reduction, stone-free rate (SFR), and complication rate were also meticulously documented and subjected to comparative analysis. Complications were assessed using the Clavien-Dindo grading system. We observed no significant differences in hospitalization data and follow-up outcomes, except for a longer hospital stay and higher Hb drops in patients receiving mini-PCNL. Statistical analysis revealed an association between CT attenuation and operation time. Compared with mini-PCNL, RIRS could reduce bleeding, hospital stay, surgery time, and complications for 10-20 mm sized lower pole kidney stones with CT values < 1000 HU. RIRS resulted in longer operation time and lower stone-free rates despite shorter hospital stays and less bleeding than mini-PCNL for stones with CT values > 1000 HU. Therefore, selecting an appropriate surgical method based on CT attenuation might improve outcomes. For patients with stone attenuation values < 1000 HU, RIRS is the recommended option. When stone attenuation values > 1000 HU, the surgical method should be chosen based on the patient's individual situation.

Impact of Preoperative Ureteral Stenting in Retrograde Intrarenal Surgery for Urolithiasis

Background and Objectives: Ureteral stent insertion passively dilates the ureter. Therefore, it is sometimes used preoperatively before flexible ureterorenoscopy to make the ureter more accessible and facilitate urolithiasis passage, especially when ureteroscopic access has failed or when the ureter is expected to be tight. However, it may cause stent-related discomfort and complications. This study aimed to assess the effect of ureteral stenting prior to retrograde intrarenal surgery (RIRS). Materials and Methods: Data from patients who underwent unilateral RIRS for renal stone with the use of a ureteral access sheath from January 2016 to May 2019 were retrospectively analyzed. Patient characteristics, including age, sex, BMI, presence of hydronephrosis, and treated side, were recorded. Stone characteristics in terms of maximal stone length, modified Seoul National University Renal Stone Complexity score, and stone composition were evaluated. Surgical outcomes, including operative time, complication rate, and stone-free rate, were compared between two groups divided by whether preoperative stenting was performed. Results: Of the 260 patients enrolled in this study, 106 patients had no preoperative stenting (stentless group), and 154 patients had stenting (stenting group). Patient characteristics except for the presence of hydronephrosis and stone composition were not statistically different between the two groups. In surgical outcomes, the stone-free rate was not statistically different between the two groups (p = 0.901); however, the operation time for the stenting group was longer than that of the stentless group (44.8 ± 24.2 vs. 36.1 ± 17.6 min; p = 0.001). There were no differences in the complication rate between the two groups (p = 0.523). Conclusions: Among surgical outcomes for RIRS with a ureteral access sheath, preoperative ureteral stenting does not provide a significant advantage over non-stenting with respect to the stone-free rate and complication rate.

Ureteroscopy in Patients with Urinary Diversion: Outcomes and Lessons Learned from Two European Centres

Background

Ureteroscopy (URS) in patients with urinary diversion is technically challenging. Common difficulties include anastomotic strictures, tortuosity, and failure to cannulate the ureteric orifice. There are few studies reporting outcomes in this special population.

Objective

Our aim was to report outcomes at two tertiary centres in Europe.

Design setting and participants

A multicentre retrospective cohort study was conducted between 2010 and 2022.

Intervention

URS (antegrade and retrograde) procedures carried out in patients with urinary diversions.

Outcome measurements and statistical analysis

Outcomes of interest included success at cannulating the ureteric orifice, stone-free rate (SFR), and complications. A logistic regression analysis was performed to identify potential predictors for success at cannulating the ureteric orifice and success at completing the intended procedure in a single session.

Results and limitations

Fifty patients underwent 72 URS procedures, with most (86%) undergoing a retrograde approach. The majority (82%) of patients had undergone ileal conduit. Wallace was the commonest anastomosis type (64%). Ureteric anastomosis was cannulated successfully in 81% of cases. The most common reason for cannulation failure was the inability to identify the ureteric orifice (11%). A multivariable analysis revealed that an endourologist performing the case was associated with a significantly greater likelihood of cannulation success compared with consultants (odds ratio 25.9, p < 0.001). The mean operative time and hospital stay were 49 min (range: 11-126) and 1 d (range: 0-10), respectively. SFRs were 75% (zero fragments) and 81% (residual fragments ≤2 mm). No intraoperative complications were recorded. The overall postoperative complication rate was 6%. This study is limited by its retrospective status.

Conclusions

Endourological experience increases the likelihood of successful ureteric cannulation and procedural success. A low complication rate can be achieved despite this being a population with often multiple comorbidities.

Patient summary

Patients with previous bladder reconstructive surgery can undergo ureteroscopy with good outcomes. Surgeon experience increases the likelihood of treatment success.

Neoadjuvant pazopanib in nonrhabdomyosarcoma soft tissue sarcomas (ARST1321): A report of major wound complications from the Children's Oncology Group and NRG Oncology

BACKGROUND AND OBJECTIVES

The impact upon wound healing of targeted molecular therapies, when incorporated into neoadjuvant therapy of soft tissue sarcoma, is largely unknown. Here, we describe wound complications following addition of pazopanib, a tyrosine kinase inhibitor (TKI), to neoadjuvant radiotherapy (RT) +/- chemotherapy for soft tissue sarcoma.

METHODS

Wound complications were evaluated on dose-finding and randomized arms of ARST1321, a phase II/III study incorporating neoadjuvant RT, +/- pazopanib, +/- ifosfamide/doxorubicin (ID) for sarcoma therapy.

RESULTS

Of 85 evaluable patients, 35 (41%) experienced postoperative wound complications. Most (57%) were grade III. Randomization to pazopanib + RT + ID carried a 50% wound complication rate (17/34, with 47% grade III), compared to 22% (5/23) with ID + RT alone. In nonchemotherapy study arms, pazopanib + RT resulted in a 59% wound complication rate versus 25% for those receiving RT alone. Grade III wound complications occurred among 26% (15/58) of all patients receiving pazopanib. Wound complications occurred a median of 35 days postoperatively. Some occurred following diagnostic biopsies and at remote surgical sites.

CONCLUSION

The addition of pazopanib to neoadjuvant chemotherapy and RT resulted in a higher wound complication rate following therapy of soft tissue sarcoma. The rate of grade III complications remained comparable to that reported in contemporary literature.

Understanding Outcomes After Major Surgery

The global volume of surgery is increasing. Adverse outcomes after surgery have resource implications and long-term impact on quality of life and consequently represent a significant and underappreciated public health issue. Standardization of outcome reporting is essential for evidence synthesis, risk stratification, perioperative care planning, and to inform shared decision-making. The association between short- and long-term outcomes, which persists when corrected for base-line risk, has significant implications for patients and providers and warrants further investigation. Candidate mechanisms include sustained inflammation and reduced physician activity, which may, in the future, be mitigated by targeted interventions.

Evaluation of comprehensive complication index versus Clavien-Dindo classification in prediction of overall survival after radical cystectomy

PURPOSE

We aimed to evaluate the benefits of Comprehensive Complication Index (CCI) compared with the Clavien-Dindo Classification (CDC) in the reporting of radical cystectomy (RC) complications.

MATERIALS AND METHODS

We retrospectively analyzed post-operative complications of 251 consecutive RC patients between 2009 and 2021. Patient demographics and causes of mortality were noted. Oncologic outcomes included the recurrence, time to recurrence, cause of all deaths, and time to death. Each complication was graded with CDC and, corresponding and cumulative CCI calculated for each patient.

RESULTS

A total of 211 patients are included. Median patient age and follow-up time were 65 (IQR 60-70) years and 20 (IQR 9 - 53) months, respectively. The five-year recurrence and death rates were 39.3% (83/211) and 59.7% (126/211), respectively. Post-operative 521 complications were recorded. Patients with experienced any complication were 69.6% (147/211) and 45.0% (95/211) had > 1 complications. Thirty (14.2%) patients ended up with a cumulative CCI score that corresponded to a higher CDC grade. Severe complications calculated with CDC increased from 18.5% to 19.9% (p < 0.001) with cumulative CCI. Female gender, positive lymph node, and positive surgical margin, presence of severe CDC complication, and CCI score were significant independent predictive factors for overall survival (OS). The contribution of CCI to the multivariable model was 1.8% higher than CDC.

CONCLUSIONS

Cumulative morbidity reporting improved with the use of CCI compared to CDC. Both CDC and CCI are significant predictive factors for OS independent of oncologic predictive factors. Reporting the cumulative burden of complications with CCI is more predictive on oncologic survival than reporting complications with CDC.

Does the Polydimethylsiloxane Urethral Injection (Macroplastique®) Improve Sexual Function in Women, in Fertile Age, Affected by Stress Urinary Incontinence?

Background and Objectives: Stress urinary incontinence (SUI) negatively affects women’s quality of life, including sexual function. The aim of the current study was to evaluate the effect of polydimethylsiloxane (Macroplastique®) on sexual function in women of fertile age affected by SUI. Materials and Methods: Single-center prospective study. Sexually active women of fertile age with symptoms of pure SUI, which were urodynamically proven, were submitted to intraurethral Macroplastique® injection. At 6-months follow-up, their sexual function was evaluated with Female Sexual Function Index (FSFI), while the SUI cure rate was objectively assessed through a negative stress test and subjectively by a Patient Global Impression of Improvement (PGI-I) score < 3. The difference of coital incontinence prevalence was assessed between the baseline and the 6-month follow-up. Peri- and postoperative complications of Macroplastique® injection were recorded and classified according to the Clavien–Dindo system. Results: Twenty-one women fulfilled inclusion criteria and were submitted to Macroplastique® procedure. The concerning sexual function, desire, satisfaction, and overall FSFI score significantly improved. Since other domains were less impaired at the baseline, we could not assess significant improvement for all of them. We observed a complete regression of coital incontinence (0/21, 0%) in comparison with the baseline (5/21, 23.8%; p = 0.04). The objective SUI cure rate was 76% (16/21), while the subjective SUI cure rate was 80.9% (17/21). One woman developed de novo overactive bladder, and two women developed postoperative voiding dysfunction (self-solved in 24 h). Conclusions: The Macroplastique® urethral injection was demonstrated to be safe and effective in improving sexual function in sexually active women of fertile age affected by pure SUI, urodinamically proven at 6-months follow-up.

Sexual well-being and penile appearance in adolescents operated for distal hypospadias in childhood

BACKGROUND

The importance of patient-reported outcomes (PRO) in hypospadias is increasing. However, more knowledge is needed concerning genital self-perception on appearance and function in adolescents. The complication rates for distal hypospadias is different from that for severe hypospadias, and expected outcomes related to sexual well-being and cosmetics may also differ.

OBJECTIVE

To investigate 16-year-olds' self-reported outcomes on penile appearance, sexual well-being, and voiding function in distal hypospadias, and compare with that of healthy male adolescents and a surgeon's view.

STUDY DESIGN

Sixteen-year-old patients operated for distal hypospadias were included in this cross-sectional study and compared to a group of healthy adolescents. The assessment tools included the adolescents' self-perception on genital appearance and function measured by Pediatric Penile Perception Score (PPPS) and their responses to a structured interview. We also included information on clinical data from the electronic medical records, together with a physical examination and an uroflowmetry.

RESULTS

Seventy patients and 61 healthy adolescents participated. Patients and the comparison group reported no differences on sexual well-being. The patients were satisfied with penile appearance, however their overall PPPS was significantly lower (8.9), compared to the comparison group (9.6, p = 0.03). Thirty-nine percent of patients had complications leading to re-interventions and reported lower scores on genital self-perception on appearance and function compared to those who had not re-interventions. Voiding function was normal. The surgeon's score on appearance was comparable to the patients' score.

DISCUSSION

A key finding in our study is the patients' high satisfaction on sexual well-being, which was similar to healthy adolescents. The patients were also satisfied with penile appearance but scored significantly lower than the comparison group. Surgeons and patients had comparable scores on appearance; however, they seemed to emphasize different aspects of appearance. Our results on penile appearance and sexual well-being are comparable to those of other studies on distal hypospadias. In our study, re-interventions were associated with more negative genital self-perception on appearance and function, similar to findings in other studies.

CONCLUSION

Our results show overall positive satisfaction on sexual well-being, voiding function and penile appearance despite less satisfaction on penile appearance when compared with the comparison group. Satisfaction was reported to be good also in patients experiencing re-interventions.

Antegrade Percutaneous Retrieval of Upward Migrated Double-J Stent in Very Small Size Pediatric Patients Under Ultrasonic Guide

Purpose: To evaluate the safety of antegrade percutaneous retrieval migrated ureteral stent in very small size pediatric patients with ultramini instruments under ultrasonography guide. Materials and Methods: A total number of 10 out of 115 patients who were referred to our center with upward migrated Double-J (DJ) were candidates for antegrade approach from 2017 to 2020. The pyelocalyceal system was punctured in a prone position by using an 18-gauge disposable needle with Chiba tip and visualization of the upper tract by 3.5 MHz ultrasonic guidance. Then 0.038-inch J tipped guide wire was passed through the needle and the tract was dilated up to 6F under ultrasonographic guide. The 8F access sheath was positioned over the 6F dilator. The semirigid 6F ureteroscope was introduced through the sheath and DJ was removed with a grasper. Results: The mean age was 11.4 ± 5.48 months. The mean time from the previous surgery to DJ removal procedure was 6.4 ± 0.84 weeks. The mean operation time was 11.7 ± 1.76 minutes. All the patients were discharged from the hospital within the 1st day. There were no serious complications (grade 3, 4, or 5) according to Clavien-Dindo classification. Conclusion: The antegrade retrieval of upward migrated DJ with ultramini instrument under ultrasonographic guidance in failed cases of retrograde approach is a safe and effective approach in very small size pediatric patients.

Intraoperative complication of radical cystectomy for muscle-invasive bladder cancer: does the surgical approach matter? A retrospective multicenter study using the EAUiaiC classification

PURPOSE

Despite surgical and anesthetic progress, radical cystectomy for bladder cancer remains one of the most morbid surgeries in urology. The objective of our study was to describe intraoperative complications and to assess the impact of surgical approach on morbidity.

METHODS

We retrospectively reviewed medical records of patients treated by radical cystectomy for localized muscle invasive bladder cancer between 2015 and 2020, following the Martin et al. criteria for complications reports. All intraoperative adverse events were graded according to the EAUiaiC scores. Multivariate regression models were used to determine predicting factors of complications.

RESULTS

A total of 318 patients were included for analysis. Among them, 17 patients (5.4%) presented an intraoperative complication. No preoperative oncological or clinical factor was associated with the occurrence of an intraoperative complication. Surgical approach had no impact on morbidity. Both overall survival (HR 2.02; CI95% 0.87-4.68; p = 0.101) and recurrence-free survival (HR 1.856; CI95% 0.804-4.284; p = 0.147) were not associated with intraoperative complication.

CONCLUSION

Radical cystectomy remains a highly morbid surgery and surgical approach did not improve the complication rate. Perioperative morbidity has a significant impact on patient survival. The association between intraoperative and postoperative complications illustrates the cumulative effect of perioperative events that are associated with survival.