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PURPOSE: To determine the cost-effectiveness of Contrast-Enhanced Ultrasound (ceUS) for the active surveillance of complex renal masses compared to the more established imaging modalities of CT and MRI. METHODS: A decision-analytic Markov state microsimulation model was constructed in TreeAge Pro. We simulated independent cohorts of 100,000 60-year-old individuals with either a Bosniak IIF or Bosniak III complex renal mass who were followed for 10 years or until death. The model compared three imaging strategies: (1) ceUS, (2) contrast-enhanced magnetic-resonance imaging (ceMRI), and (3) contrast-enhanced computed tomography (ceCT) for active surveillance of a complex renal mass. RESULTS: For 60-year-old patients with either Bosniak IIF or III renal masses, ceUS was the most cost-effective strategy even after varying rates of active surveillance from 10–100%. CONCLUSION: ceUS is a viable and cost-effective option in the active surveillance of Bosniak class IIF and III renal cysts. Even after varying the rates of active surveillance usage, ceUS was robust and remained the most dominant strategy. For patients who have impaired kidney functions, ceUS is can be a safer alternative than non-contrast enhanced CT or MRI in the management of patients with Bosniak III renal cysts.

Reporting surgical, interventional, and anesthesiologic complications is essential to improve the quality of healthcare delivery and to standardize and reproduce outcomes data. To address underlying issues in the reporting of complications and adverse events, it may be necessary to provide education and training, establish standardized definitions and reporting requirements, and create incentives for healthcare providers to report complications. Complications, a new international peer-reviewed open access journal, aims to provide best practice and expert opinion recommendations on the prevention, diagnosis, pathogenesis, and management of complications in basic, translational, and clinical research, as well as epidemiology. The journal invites authors to address four components of perioperative adverse events: assessment, reporting, the analysis of anticipatable factors, and management. The usability and practical implications of this information can have significant implications for academic and clinical practice. Priority lies in the assessment and reporting of adverse events, in order to standardize their management and improve the understanding of their impacts on patients’ peri-operative course.

Background: Lymph node invasion (LNI) represents a poor prognostic factor after primary radical prostatectomy (RP) for prostate cancer (PCa). However, the impact of LNI on oncologic outcomes in salvage radical prostatectomy (SRP) patients is unknown. Objective: To investigate the impact of lymph node dissection (LND) and pathological lymph node status (pNX vs. pN0 vs. pN1) on long-term oncologic outcomes of SRP patients. Patients and methods: Patients who underwent SRP for recurrent PCa between 2000 and 2021 were identified from 12 high-volume centers. Kaplan–Meier analyses and multivariable Cox regression models were used. Endpoints were biochemical recurrence (BCR), overall survival (OS), and cancer-specific survival (CSS). Results: Of 853 SRP patients, 87% (n = 727) underwent LND, and 21% (n = 151) harbored LNI. The median follow-up was 27 months. The mean number of removed lymph nodes was 13 in the LND cohort. At 72 months after SRP, BCR-free survival was 54% vs. 47% vs. 7.2% for patients with pNX vs. pN0 vs. pN1 (p < 0.001), respectively. At 120 months after SRP, OS rates were 89% vs. 81% vs. 41% (p < 0.001), and CSS rates were 94% vs. 96% vs. 82% (p = 0.02) for patients with pNX vs. pN0 vs. pN1, respectively. In multivariable Cox regression analyses, pN1 status was independently associated with BCR (HR: 1.77, p < 0.001) and death (HR: 2.89, p < 0.001). Conclusions: In SRP patients, LNI represents an independent poor prognostic factor. However, the oncologic benefit of LND in SRP remains debatable. These findings underline the need for a cautious LND indication in SRP patients as well as strict postoperative monitoring of SRP patients with LNI.

Context Live surgical broadcast (LSB), also known as live surgery, has become a popular format for many types of surgical education meetings. However, concerns have been raised in relation to patient safety, ethical issues, and the actual educational value of LSB. Objective To summarize current evidence on LSB with a focus on the risks of complications and the educational impact. Evidence acquisition We performed a systematic review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies up to December 2020. We identified original articles reporting on patient outcomes, educational value, current use, and development of LSB. We also interrogated surgical society guidelines for position statements on LSB. Evidence synthesis Our literature search identified 46 studies spanning six surgical specialties, with urology being the most frequent. Approximately half of the studies reported on outcomes of surgical procedures during LSB. In urology, the few comparative studies available did not suggest higher complication rates in LSB, whereas data for other surgical fields highlighted evidence of worse outcomes. Four studies assessed the educational value of LSB via survey administration, for which the evidence is limited and of low quality. Thirteen guidelines and position statements on live surgery were identified among major surgical societies, including the European Association of Urology (EAU). Some surgical societies have expressly prohibited the use of LSB at their major meetings. The perspective of surgeons performing and/or attending live surgical sessions was evaluated in six studies, and four studies looked at urologists’ perception of LSB compared to semi-LSB. Limitations of this systematic review include the limited number of studies available, the low quality of the evidence, and data heterogeneity. Conclusions Evidence regarding outcomes of LSB is limited. Almost all the studies do not show a higher risk of complications or worse outcomes for patients undergoing a procedure during LSB. Only one study on gastrointestinal surgery reported that LSB outcomes were worse. Ongoing concerns have led to specific guidelines by several scientific societies, including the EAU, with the ultimate aim of minimizing surgical risks and maximizing patient safety. Patient summary Live surgery events are often part of surgical conferences. Data in the literature show mixed outcomes for operations performed during live surgery events, but with no increase in complication rates. Safety and ethical concerns remain. Other educational tools, such as prerecorded videos and live surgery transmission from the home institution of the operating surgeon might become preferred options in the future. This review was prospectively registered on the PROSPERO website ( www.crd.york.ac.uk/PROSPERO , registration number CRD42020194023).

The growth and adoption of artificial intelligence has led to impressive results in urology. As artificial intelligence grows more ubiquitous, it is important to establish artificial intelligence literacy in the workforce. To this end, we present a narrative review of the literature of artificial intelligence and machine learning in urology and propose a checklist of reporting standards to improve readability and evaluate the current state of the literature. The listed article demonstrated heterogeneous reporting of methodologies and outcomes, limiting generalizability of research. We hope that this review serves as a foundation for future evaluation of medical research in artificial intelligence.

Background Postoperative renal function impairment represents a main limitation for delivering adjuvant chemotherapy after radical nephroureterectomy (RNU). Objective To create a model predicting renal function decline after minimally invasive RNU. Design, setting, and participants A total of 490 patients with nonmetastatic UTUC who underwent minimally invasive RNU were identified from a collaborative database including 17 institutions worldwide (February 2006 to March 2020). Renal function insufficiency for cisplatin-based regimen was defined as estimated glomerular filtration rate (eGFR) 50 ml/min/1.73 m2 (n = 361) were geographically divided into a training set (n = 226) and an independent external validation set (n = 135) for further analysis. Outcome measurements and statistical analysis Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, a nomogram to predict postoperative eGFR Results and limitations The model that incorporated age, body mass index, preoperative eGFR, and hydroureteronephrosis was developed with an area under the curve of 0.771, which was confirmed to be 0.773 in the external validation set. The calibration curve demonstrated good agreement. Besides, the model was converted into a risk score with a cutoff value of 0.583, and the difference between the low- and high-risk groups both in overall death risk (hazard ratio [HR]: 4.59, p Conclusions A nomogram incorporating immediately available clinical variables can accurately predict renal insufficiency for cisplatin-based adjuvant chemotherapy after minimally invasive RNU and may serve as a tool facilitating patient selection. Patient summary We have developed a model for the prediction of renal function loss after radical nephroureterectomy to facilitate patient selection for perioperative chemotherapy.

The association between tobacco use and urothelial cancer of the bladder is well known. Given the worsening tobacco epidemic, here we make the case for systematic targeted points of intervention for urologists and other professionals to intervene against bladder cancer. Awareness of contemporary checkpoints where we can intervene for counseling patients may help medical education in a tobacco-pandemic difficult setting.

Objective To evaluate the impact of the “Movember” awareness campaign (men’s health campaign that takes place every November) on internet search trends for information online about prostate cancer and to compare the results with those for “Pinktober” (the breast cancer awareness campaign that takes place in October) in the Spanish language as an indirect measure of its effectiveness. Methods Google Trends was used to evaluate the monthly relative search volumes (RSV) of the terms “cáncer de próstata” (prostate cancer), “cáncer de mama” (breast cancer), and “Movember” from January 2009 to December 2019 both in Spain and worldwide (in the Spanish language). Breast cancer was used as a comparator of the campaign impact. Mean increase in RSV on-campaign and off-campaign was calculated and compared using the Mann-Whitney U test and Joinpoint regression analysis to assess loss or gain of interest. Results The term “cáncer de próstata” showed a statistically significant increase during the campaign months both in Spain (17.4%; P < 0.001) and worldwide (35.4%; P < 0.001). Both “cáncer de próstata” and Movember showed a decreasing trend worldwide and in Spain, while “cáncer de mama” showed an increasing trend. Conclusion The Movember campaign generates a statistically significant increase in the search trends on “cancer de próstata” (prostate cancer) during the month of November (both in Spain and worldwide); when compared with the breast cancer campaign “Pinktober” these increases are of a lesser magnitude but still significant, suggesting that the campaign is effective beyond the English language, although the interest has been decreasing throughout the years.

Context Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr. Objective To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezūm, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection. Evidence acquisition A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses. Evidence synthesis The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; −9.81 points, 95% confidence interval [CI] −11.37 to −8.25 at 1 mo; −13.13 points, 95% CI −14.98 to −11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8–4.5 to +4.14 ml/s, 95% CI 0.72–7.56 at 12 mo), and postvoid residual volume (−10.10 ml, 95% CI −27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34–2.42 at the start of follow-up; and 1.04, 95% CI 0.28–1.8 after 1 yr), or the IPSS-Quality of Life questionnaire. Conclusions Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezūm, UroLift, and PAE had a minimal impact on patients’ sexual function with respect to baseline, especially regarding preservation of ejaculation. Patient summary We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function. Take Home Message Novel ultra-minimally invasive treatments can yield fast and effective relief of lower urinary tract symptoms without affecting a patient’s quality of life.

Resumen Introduccion y objetivo La inteligencia artificial (IA) esta en pleno desarrollo, y su implementacion en la medicina ha supuesto una mejora en la practica clinica y quirurgica. Una de sus multiples aplicaciones es el entrenamiento quirurgico, con la creacion de programas que permiten evitar complicaciones y riesgos para el paciente. El objetivo de este articulo es analizar las ventajas de la IA aplicada al entrenamiento quirurgico en urologia. Material y metodos Se realiza una revision de la literatura de los articulos publicados en ingles sobre la IA aplicada a la medicina, especialmente a la cirugia y a la adquisicion de habilidades quirurgicas. Resultados El entrenamiento quirurgico ha evolucionado con el tiempo gracias a la IA. Se ha creado un modelo de aprendizaje quirurgico en el que las habilidades se adquieren de forma gradual, evitando complicaciones al paciente. El uso de simuladores permite un aprendizaje progresivo en el que la cantidad y la complejidad de los procedimientos aumentan progresivamente. Adicionalmente, la IA se utiliza en pruebas de imagen para planificar cirugias o tratamientos. Conclusion Actualmente el uso de la IA en la practica clinica diaria supone un avance en la medicina, y en particular en la formacion quirurgica.

Introduction and objective Artificial intelligence (AI) is in full development and its implementation in medicine has led to an improvement in clinical and surgical practice. One of its multiple applications is surgical training, with the creation of programs that allow avoiding complications and risks for the patient. The aim of this article is to analyze the advantages of AI applied to surgical training in urology. Material and methods A literary research is carried out to identify articles published in English regarding AI applied to medicine, especially in surgery and the acquisition of surgical skills. Results Surgical training has evolved over time thanks to AI. A model for surgical learning where skills are acquired in a progressive way while avoiding complications to the patient, has been created. The use of simulators allows a progressive learning, providing trainees with procedures that increase in number and complexity. On the other hand, AI is used in imaging tests for surgical or treatment planning. Conclusion Currently, the use of AI in daily clinical practice has led to progress in medicine, specifically in surgical training.

Prostate cancer is the most common cancer amongst men, and one of its treatments in the localized stage is radical prostatectomy (RP). This technique achieves a high success rate regarding oncological results, but one of its main drawbacks are sexual disorders, especially erectile dysfunction, ranging from 14-90% of the cases. Therefore, surgery advancements in the last decade have been focused on minimizing the impact on patient’s functioning. Now is time for a step forward in the recovery of functional outcomes after RP. Bioengineering solutions such as stem-cell therapy and tissue engineering hold great opportunities for the treatment of all tissues and organs dysfunctions, which may help in neuroprotection and neuro-regeneration. Specifically, the use of Dehydrated human amnion/chorion membrane (dHACM) allografts and chitosan membranes (ChiMe) aims at reconstructing damaged neurovascular plexuses of the urogenital system to support erectile function recovery. Some research is being done on this topic, and promising results are emerging.

Large and complex renal stones are usually treated with percutaneous nephrolithotomy (PCNL). One of the crucial steps in this procedure is the access to the collecting system with the percutaneous puncture and this maneuver leads to a risk of vascular and neighboring organs’ injury. In the last years, the application of virtual image-guided surgery has gained wide diffusion even in this specific field. To provide a short overview of the most recent evidence on current applications of virtual imaging guidance for PCNL. A non-systematic review of the literature was performed. Medline, PubMed, the Cochrane Database and Embase were screened for studies regarding the use virtual imaging guidance for PCNL. 3D virtual navigation technology for PCNL was first used in urology with the purpose of surgical training and surgical planning; subsequently, the field of surgical navigation with different modalities (from cognitive to augmented reality or mixed reality) had been explored. Finally, anecdotal preliminary experiences explored the potential application of artificial intelligence guidance for percutaneous puncture. Nowadays, many experiences proved the potential benefit of virtual guidance for surgical simulation and training. Focusing on surgery, this tool revealed to be useful both for surgical planning, allowed to achieve a better surgical performance, and for surgical navigation by using augmented reality and mixed reality systems aimed to assist the surgeon in real time during the intervention.

CONTEXT Pelvic lymph node dissection (PLND) yields the most accurate staging in patients undergoing radical prostatectomy (RP) for prostate cancer (PCa), although it can be associated with morbidity. OBJECTIVE To systematically evaluate the impact of PLND extent on perioperative morbidity in patients undergoing RP. A new PLND-related complication assessment tool is proposed. EVIDENCE ACQUISITION A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) was conducted. MEDLINE/PubMed, Scopus, Embase and Web of Science databases were searched to yield studies discussing perioperative complications following RP and PLND. The extent of PLND was classified according to the European Association of Urology PCa guidelines. Studies were categorized according to the extent of PLND. Intra- and postoperative complications were classified as "strongly," "likely," or "unlikely" related to PLND. Anatomical site of perioperative complications was recorded. A cumulative meta-analysis of comparative studies was conducted using Review Manager 5.3 (Cochrane Collaboration, Oxford, UK). EVIDENCE SYNTHESIS Our search generated 3645 papers, with 176 studies meeting the inclusion criteria. Details of 77 303 patients were analyzed. Of these studies, 84 (47.7%), combining data on 28 428 patients, described intraoperative complications as an outcome of interest. Overall, 534 (1.8%) patients reported one or more intraoperative complications. Postoperative complications were reported in 151 (85.7%) studies, combining data on 73 629 patients. Overall, 10 401 (14.1%) patients reported one or more postoperative complication. The most reported postoperative complication strongly related to PLND was lymphocele (90.6%). The pooled meta-analysis revealed that RP���+���limited PLND/standard PLND had a significantly decreased risk of experiencing any intraoperative complication (risk ratio [RR]: 0.55; p���=��� 0.01) and postoperative complication strongly related to PLND (RR: 0.46; p���=���

Background Lombardy has been the first and one of the most affected European regions during the first and second waves of the novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]). Objective To evaluate the impact of coronavirus disease 2019 (COVID-19) on all urologic activities over a 17-wk period in the three largest public hospitals in Lombardy located in the worst hit area in Italy, and to assess the applicability of the authorities’ recommendations provided for reorganising urology practice. Design, setting, and participants A retrospective analysis of all urologic activities performed at three major public hospitals in Lombardy (Brescia, Bergamo, and Milan), from January 1 to April 28, 2020, was performed. Outcome measurements and statistical analysis Join-point regression was used to identify significant changes in trends for all urologic activities. Average weekly percentage changes (AWPCs) were estimated to summarise linear trends. Uro-oncologic surgeries performed during the pandemic were tabulated and stratified according to the first preliminary recommendations by Stensland et al (Stensland KD, Morgan TM, Moinzadeh A, et al. Considerations in the triage of urologic surgeries during the COVID-19 pandemic. Eur Urol 2020;77:663–6) and according to the level of priority recommended by European Association of Urology guidelines. Results and limitations The trend for 2020 urologic activities decreased constantly from weeks 8–9 up to weeks 11–13 (AWPC range –41%, –29.9%; p, Take Home Message Coronavirus disease 2019 (COVID-19) pandemic urologic recommendations redefined treatment options and timing of urological surgical activities to support urologists during this healthcare crisis to avoid delaying life-saving treatments. These recommendations should be adapted according to hospital resources and local incidence of the pandemic.

Introduction: Perioperative complications, especially intraoperative adverse events (iAEs), carry significant potential for long-term sequelae in a patient’s postoperative course. These events represent a substantial gap in contemporary surgical literature, with only a fraction of publications reporting intraoperative complications as outcomes of interest. To date, there is no universal standard for comprehensively reporting intraoperative complications in surgical practice and literature beyond the systems developed for grading individual events. We aim to establish a set of best-practice criteria for iAE reporting known as the Intraoperative Complication Assessment and Reporting with Universal Standards (ICARUS) Guidelines. Methods and analysis: We will generate the ICARUS reporting guidelines using the EQUATOR Network development framework and the SQUIRE Guidelines. The initial step involves an umbrella review and meta-analysis of systemic reviews (SRs) assessing the perioperative adverse events of common surgeries. Measures for assessing, collecting, grading, and reporting the iAEs will be merged into a comprehensive list of criteria. Using a modified Delphi methodology, a team of expert surgeons (≥ 200 inpatient procedures/years) will contribute to and evaluate the proposed reporting guidelines. The panel will evaluate both the clinical usefulness and quality assessment and improvement utility of each criterion using a 5-point Likert. We expect multiple survey rounds until consensus regarding the utility of the guidelines is reached. Dissemination: We plan to share then validate the newly developed guidelines within each surgical field. Dissemination will involve publicly shared guidelines, simultaneous journal publications, conference presentations, encouragement for journal endorsement, and application for inclusion in the Equator Network database. The study team plans to continue collecting feedback for future extension of the intraoperative reporting guidelines. HIGHLIGHTS: Intraoperative adverse events are underreported and lack homogeneity in surgical literature We aim to use a modified Delphi methodology to develop the consensus-based, intraoperative complications assessment and reporting with universal standards (ICARUS) guidelines We will disseminate the ICARUS guidelines through journal publications and presentations at national and international meetings; journals and professional organizations will be encouraged to endorse the ICARUS guidelines

Prior literature has suggested that Propecia or finasteride may negatively impact men’s sexual health. In 2011, the Food and Drug Administration (FDA) provided a warning on finasteride drug labels to include decreased libido and erectile dysfunction. We sought to determine global online interest in finasteride sexual side effects, their penetrance and variation, and how they compared over time. We also sought to evaluate the influence of the FDA communications on internet searches for finasteride side effects. We utilized Google search engine from January 2004 to December 2020 to include trends from web searches of Propecia or finasteride and its side effects compared amongst the United States, United Kingdom, and Australia. We performed join-point regression analysis. We compared the annual relative search volume (ARSV), average annual percentage change (AAPC), and temporal patterns to evaluate for loss or gain of interest in the respective key terms. We determined that average ARSV for “finasteride” was 15% in 2004 and increased significantly to 57% in 2020 (APC: +9.25%, 95% CI 8 to 10.5, p

We sought to evaluate outcomes of lymph node dissection (LND) in patients with upper tract urothelial carcinoma.We performed a multicenter retrospective analysis utilizing the ROBUUST (for RObotic surgery for Upper Tract Urothelial Cancer Study) registry for patients who did not undergo LND (pNx), LND with negative lymph nodes (pN0) and LND with positive nodes (pN+). Primary and secondary outcomes were overall survival (OS) and recurrence-free survival (RFS). Multivariable analyses evaluated predictors of outcomes and pathological node positivity. Kaplan-Meier analyses (KMAs) compared survival outcomes.A total of 877 patients were analyzed (LND performed in 358 [40.8%]/pN+ in 73 [8.3%]). Median nodes obtained were 10.2 for pN+ and 9.8 for pN0. Multivariable analyses noted increasing age (OR 1.1, p0.001), pN+ (OR 3.1, p0.001) and pathological stage pTis/3/4 (OR 3.4, p0.001) as predictors for all-cause mortality. Clinical high-grade tumors (OR 11.74, p=0.015) and increasing tumor size (OR 1.14, p=0.001) were predictive for lymph node positivity. KMAs for pNx, pN0 and pN+ demonstrated 2-year OS of 80%, 86% and 42% (p0.001) and 2-year RFS of 53%, 61% and 35% (p0.001), respectively. KMAs comparing pNx, pN0 ≥10 nodes and pN010 nodes showed no significant difference in 2-year OS (82% vs 85% vs 84%, p=0.6) but elicited significantly higher 2-year RFS in the pN0 ≥10 group (60% vs 74% vs 54%, p=0.043).LND during nephroureterectomy in patients with positive lymph nodes provides prognostic data, but is not associated with improved OS. LND yields ≥10 in patients with clinical node negative disease were associated with improved RFS. In high-grade and large tumors, lymphadenectomy should be considered.