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Background: The standard artificial urinary sphincter (AUS) is an implantable device for the treatment of urinary incontinence by applying a pressure loading around the urethra through an inflatable cuff, often inducing no‐physiological stimulation up to tissue degenerative phenomena. A novel in silico approach is proposed to fill the gap of the traditional procedures by providing tools to quantitatively assess AUS reliability and performance based on AUS‐urethra interaction. Methods: The approach requires the development of 3D numerical models of AUS and urethra, and experimental investigations to define their mechanical behaviors. Computational analyses are performed to simulate the urethral lumen occlusion by AUS inflation under different pressures, and the lumen opening by applying an intraluminal pressure progressively increased under the AUS action (Abaqus Explicit solver). The AUS reliability is evaluated in terms of tissue stimulation by the mechanical fields potentially responsible for vasoconstriction and tissue damage, while the performance by the intraluminal pressure that causes the lumen opening for a specific occlusive pressure, showing the maximum urethral pressure for which continence is guaranteed. Results: The present study implemented the procedure considering the gold standard AMS 800 and a novel patented AUS. Results provided the comparison between two sphincteric devices and the evaluation of the influence of different building materials and geometrical features on the AUS functionality. Conclusions: The approach was developed for the AUS, but it could be adapted also to artificial sphincters for the treatment of other anatomical dysfunctions, widening the analyzable device configurations and reducing experimental and ethical efforts. [ABSTRACT FROM AUTHOR]

The multidisciplinary nature of artificial intelligence (AI) has allowed for rapid growth of its application in medical imaging. Artificial intelligence algorithms can augment various imaging modalities, such as X-rays, CT, and MRI, to improve image quality and generate high-resolution three-dimensional images. AI reconstruction of three-dimensional models of patient anatomy from CT or MRI scans can better enable urologists to visualize structures and accurately plan surgical approaches. AI can also be optimized to create virtual reality simulations of surgical procedures based on patient-specific data, giving urologists more hands-on experience and preparation. Recent development of artificial intelligence modalities, such as TeraRecon and Ceevra, offer rapid and efficient medical imaging analyses aimed at enhancing the provision of urologic care, notably for intraoperative guidance during robot-assisted radical prostatectomy (RARP) and partial nephrectomy. [ABSTRACT FROM AUTHOR]

Introduction: Urologic complications are thought to be the most common surgical complication of renal transplantation. Ureteral pathology, including stenosis, urine leak, and vesicoureteral reflux, predominates. Although endourologic and interventional radiological management may be utilized, failure rates remain relatively high and surgical reconstruction remains the definitive management. Robotic ureteral reconstruction has been demonstrated to provide patient benefit in nontransplant populations, but the literature on transplant reconstruction is very limited. This study reports an additional series of patients with a focus on surgical technique, as well as reviews the available evidence for robotic reconstruction for post-transplant ureteral complications. Methods: All institutional patients undergoing robotic-assisted reconstruction for post-transplant ureteral complications for the years 2019–2022 were included. Intra- and postoperative variables, patient demographics, and follow-up data were obtained retrospectively from parsing of patient records. Statistics were tabulated descriptively. Results: Eleven patients underwent ureteral reconstruction. Of the 11, 9 (81%) were male with a mean age of 51.9 years (16–70) and BMI of 33.8 (24.3–49.1). The most common (10/11) indication for reconstruction was stricture; the most common (10/11) technique used was Lich-Gregoir reimplantation. Mean operative time was 288 minutes (143–500). There were no intra- or immediate postoperative complications. Median length of stay was 2 days (1–22). There were two incidences of mortality at 2 and 5 months postoperatively unrelated to surgery. There were four readmissions within 30 days, three for urinary tract infection (UTI) and one for a pelvic abscess which required washout. The remainder of the cohort has been followed for a mean of 14.6 months (6–41) without any incidences of graft loss or recurrence of ureteral pathology. Conclusions: Robotic-assisted ureteral reconstruction is a technically challenging but highly feasible technique that may provide the benefits of minimally invasive surgery while still allowing definitive reconstruction. Centers with extensive robotic capabilities should consider the technique. [ABSTRACT FROM AUTHOR]

Objective：To compare the accuracy of end - tidal carbon dioxide partial pressure（PETCO2）and transcutaneous carbon dioxide partial pressure（PTCCO2）in predicting arterial carbon dioxide pressure（PaCO2）in patients undergoing retroperitoneoscopic urologic surgery. Methods：Fifty patients undergoing retroperitoneoscopic urologic surgery under general anesthesia were included. Values of PaCO2，PETCO2，and PTCCO2 were measured before and 30，60，90 min after insufflation. The differences between PaCO2-PETCO2 and PaCO2-PTCCO2 were calculated. Correlation and regression analysis were conducted between PaCO2 and PETCO2，as well as between PaCO2 and PTCCO2. Bland-Altman analysis was used to assess the agreement between PaCO2 and the other two variables. Results：The absolute differences of PaCO2-PETCO2 and PaCO2-PTCCO2were（13.20 ± 4.43）mmHg and（4.35 ± 2.56）mmHg，respectively（P ＜ 0.05）. The correlation coefficient between PaCO2 and PETCO2was 0.79（r 2 =0.62，P ＜ 0.001），and between PaCO2 and PTCCO2 was 0.91（r 2 =0.83， P ＜ 0.001）. The 95% limits of agreement between PaCO2 and PETCO2 were 4.53 to 21.88 mmHg and between PaCO2 and PTCCO2 were -3.18 to 10.48 mmHg. Conclusion：PTCCO2 monitoring improves the accuracy of estimating PaCO2 in patients undergoing retroperitoneoscopic urologic surgery. [ABSTRACT FROM AUTHOR]

Simple Summary: Robot-assisted surgery facilitates the examination and improvement of artificial intelligence (AI) integration in surgical processes through the provision of comprehensive telemetry data and an advanced viewing interface. Machine learning (ML) techniques enhance the feedback on the development of surgical abilities, the efficacy of the surgical operation, surgical guiding, and predicted results. By incorporating tension sensors on the robotic arms and employing augmented reality techniques, the surgical experience can be greatly improved. This enables the continuous monitoring of organ movements in real time, resulting in enhanced precision and accuracy. The integration of artificial intelligence (AI) into robotic surgery is anticipated to have a substantial influence on the education of upcoming surgeons and improve the entire surgical process. Both endeavours strive for ultimate accuracy in order to enhance the quality of surgical care. With the rapid increase in computer processing capacity over the past two decades, machine learning techniques have been applied in many sectors of daily life. Machine learning in therapeutic settings is also gaining popularity. We analysed current studies on machine learning in robotic urologic surgery. We searched PubMed/Medline and Google Scholar up to December 2023. Search terms included "urologic surgery", "artificial intelligence", "machine learning", "neural network", "automation", and "robotic surgery". Automatic preoperative imaging, intraoperative anatomy matching, and bleeding prediction has been a major focus. Early artificial intelligence (AI) therapeutic outcomes are promising. Robot-assisted surgery provides precise telemetry data and a cutting-edge viewing console to analyse and improve AI integration in surgery. Machine learning enhances surgical skill feedback, procedure effectiveness, surgical guidance, and postoperative prediction. Tension-sensors on robotic arms and augmented reality can improve surgery. This provides real-time organ motion monitoring, improving precision and accuracy. As datasets develop and electronic health records are used more and more, these technologies will become more effective and useful. AI in robotic surgery is intended to improve surgical training and experience. Both seek precision to improve surgical care. AI in ''master–slave" robotic surgery offers the detailed, step-by-step examination of autonomous robotic treatments. [ABSTRACT FROM AUTHOR]

No previous works have analyzed whether the order in which surgical teams see patients on morning rounds affects discharge efficiency at teaching hospitals. We obtained perioperative urologic surgery timing data at our academic institution from 2014 to 2019. We limited the analysis to routine postoperative day 1 discharges. Univariate and multivariate analyses were performed to determine whether various hospital and patient factors were associated with discharge timing. We analyzed 1,494 patients. Average discharge order time was 11:22 a.m. and hospital discharge 1:24 p.m. Univariate regression revealed earlier discharge order time for patients seen later in rounds by 4 minutes per sequential room cluster (p = .013) and by 12 minutes per cluster when excluding short-stay patients. Multivariate analysis revealed discharge order placement did not vary significantly by rounding order. However, time of hospital discharge did (p < .001), likely due to speed of discharge in the designated short-stay units. Attending physician was the most consistent predictor in variations of discharge timing, with statistical significance across all measured outcomes. Patients seen later in rounding progression received earlier discharge orders, but this relationship does not remain in multivariate modeling or translate to earlier discharge. These findings have helped guide quality improvement efforts focused on discharge efficiency. [ABSTRACT FROM AUTHOR]

Post-operative acute kidney injury (PO-AKI) is a serious complication that may occur after major abdominal surgery. The administration of intravenous perioperative amino acids (AAs) has been proven to increase kidney function and has some beneficial effects to prevent PO-AKI. The aim of this study was to establish if the perioperative infusion of AAs may reduce the incidence of PO-AKI in patients undergoing major urological minimally invasive surgery. From a total of 331 patients, the first 169 received perioperative crystalloid fluids and the following 162 received perioperative AA infusions. PO-AKIs were much higher in the crystalloid group compared to the AA group (34 vs. 17, p = 0.022) due to a lower incidence of KDIGO I and II in the AA group (14 vs. 30 p = 0.016). The AA group patients who developed a PO-AKI presented more risk factors compared to those who did not (2 (2-4) vs. 1 (1-2), p = 0.031) with a cut-off of 3 risk factors in the ROC curve (p = 0.007, sensitivity 47%, specificity 83%). The hospital length of stay was higher in the crystalloid group (p < 0.05) with a consequent saving in hospital costs. Perioperative AA infusion may help reduce the incidence of PO-AKI after major urological minimally invasive surgery. [ABSTRACT FROM AUTHOR]

Robotic surgery continues to revolutionize the field of urologic surgery, and thus it is crucial that graduating urologic surgery residents demonstrate proficiency with this technology. The large learning curve of utilizing robotic technology limits resident immediate participation in real-life robotic surgery, and skill acquisition is further challenged by variable case volume. Robotic simulation offers an invaluable opportunity for urologic trainees to cultivate strong foundational skills in a non-clinical setting, ultimately leading to both competence and operative confidence. Several different simulation technologies and robotic assessment protocols have been developed and demonstrate validity in several domains. However, despite their demonstrable utility, there is no formal robotic curricula within US urologic surgery residencies. In this article, we will review the current state of robotic simulation training in urologic surgery and highlight the importance of its widespread utilization in urologic surgery residency training programs. [ABSTRACT FROM AUTHOR]

Point-of-care ultrasonography (POCUS) with concomitant venous and arterial Doppler assessment enables clinicians to assess organ-specific blood supply. To date, no studies have investigated the usefulness of including a comprehensive perioperative POCUS assessment of patients undergoing major laparoscopic surgery. The primary aim of the present study was to evaluate whether the combined venous and arterial renal flow evaluation, measured at different time points of perioperative period, may represent a clinically useful non-invasive method to predict postoperative acute kidney injury (AKI) after major laparoscopic urologic surgery. The secondary outcome was represented by the development of any postoperative complication at day 7. We included 173 patients, subsequently divided for analysis depending on whether they did (n = 55) or did not (n = 118) develop postoperative AKI or any complications within the first 7 days. The main results of the present study were that: (1) the combination of arterial hypoperfusion and moderate-to-severe venous congestion inferred by POCUS were associated with worst outcomes (respectively, HR: 2.993, 95% CI: 1.522–5.884 and HR: 8.124, 95% CI: 3.542–18, p < 0.001); (2) high intra-operative abdominal pressure represents the only independent determinant of postoperative severe venous congestion (OR: 1.354, 95% CI: 1.017–1.804, p = 0.038); (3) the overall number of complications relies on the balance between arterial inflow and venous outflow in order to ensure the adequacy of peripheral perfusion; and (4) the overall reliability of splanchnic perfusion assessment by Doppler is high with a strong inter-rater reliability (ICC: 0.844, 95% CI: 0.792–0.844). The concomitant assessment of arterial and venous Doppler patterns predicts postoperative complications after major laparoscopic urologic surgery and may be considered a useful ultrasonographic biomarker to stratify vulnerable patients at risk for development of postoperative complications. [ABSTRACT FROM AUTHOR]

Objective: The da Vinci single-port (SP) platform represents the latest innovation in minimally invasive urologic surgery, and the adoption of this technology by urologists is increasing. In this article, we briefly describe the evolution of minimally invasive and single-site surgery, and offer a comprehensive review of the current literature on the SP platform. Materials and Methods: For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until August 15, 2022. The published literature to date within SP robotic surgery in urology will be discussed. Evidence Synthesis: There are relatively few high-quality studies on the SP system, but there are multiple case series describing unique indications and surgical approaches with the SP robot, demonstrating safety and feasibility in the hands of experienced robotic surgeons. There also are an increasing number of prospective, larger cohort studies comparing outcomes between SP and multiport (MP) approaches that show benefits of the SP system regarding improved cosmesis, postoperative pain control, and decreased length of stay. Conclusions: Multiple prospective studies have shown benefits regarding cost and pain control for SP platform procedures compared to the traditional MP robotic approach. While its high cost and learning curve represent barriers to adoption, the SP platform represents a critical development in minimally invasive surgery. As this technology is further implemented at more institutions, long-term, high-quality data should accrue that will demonstrate its true value. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the cost-effectiveness of obtaining a preoperative type and screen (T/S) for common urologic procedures. Methods: A decision tree model was constructed to track surgical patients undergoing two preoperative blood ordering strategies as follows: obtaining a preoperative T/S versus not doing so. The model was applied to the National (Nationwide) Inpatient Sample (NIS) data, from January 1, 2006 to September 30, 2015. Cost estimates for the model were created from combined patient-level data with published costs of a T/S, type and crossmatch (T/C), a unit of pRBC, and one unit of emergency-release transfusion (ERT). The primary outcome was the incremental cost per ERT prevented, expressed as an incremental cost-effectiveness ratio (ICER) between the two preoperative blood ordering strategies. A cost-effectiveness analysis determined the ICER of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500.00. Results: A total of 4,113,144 surgical admissions from 2006 to 2015 were reviewed. The overall transfusion rate was 10.54% (95% CI, 10.17–10.91) for all procedures. The ICER of preoperative T/S was $1500.00 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S. Conclusion: Routine preoperative T/S for radical prostatectomy (rate = 3.88%) and penile implants (rate =.91%) does not represent a cost-effective practice for these surgeries. It is important for urologists to review their institution T/S policy to reduce inefficiencies within the preoperative setting. [ABSTRACT FROM AUTHOR]

When the outcomes are equivalent to the open technique, conventional laparoscopy is a preferred surgical approach because of its minimal invasiveness. However, outcomes following laparoscopy depend on the surgeon’s expertise, and there is a significant learning curve to attain efficiency in complex reconstructing laparoscopic procedures. Robotic assistance bridges the gap between open and laparoscopic procedures and allows surgeons with limited laparoscopy experience to offer the benefits of minimally invasive surgery to their patients. While existing data do not show better outcomes with robot assistance compared with laparoscopy for most procedures, these studies are based on data from high-volume surgeons and centers. In reality, a significant number of surgeries are performed by low-volume centers and surgeons, and robotic assistance may enable them to offer benefits of minimally invasive surgery equivalent to those of higher volume centers since robotic assistance is associated with a shorter learning curve than laparoscopy. We review the data on the outcomes of robotic surgery for low-volume surgeons with a focus on centers and surgeons in Asia.

Introduction: This study aimed to assess patient compliance with a newly established electronic patient-reported outcome measure (ePROM) system after urologic surgery and to identify influencing factors. Methods: Digital surveys were provided to patients undergoing cystectomy, radical or partial nephrectomy, or transurethral resection of bladder tumor via a newly established ePROM system. Participants received a baseline survey preoperatively and several follow-up surveys postoperatively. Multivariable regression analysis was performed to identify factors predicting compliance. Results: Of N = 435 eligible patients, n = 338 completed the baseline survey (78.0%). Patients who did not participate were significantly more likely male (p = 0.004) and older than 70 years (p = 0.005). Overall, 206/337 patients (61.3%) completed the survey at 1-month, 167/312 (53.5%) at 3-month, and 142/276 (51.4%) at 6-month follow-up. Lower baseline quality of life (odds ratio: 2.27; p = 0.004) was a significant predictor for dropout at 1-month follow-up. Low educational level was significantly associated with low compliance at 3- (OR: 1.92; p = 0.01) and 6-month follow-up (OR: 2.88; p < 0.001). Conclusion: Acceptable compliance rates can be achieved with ePROMs following urologic surgery. Several factors influence compliance and should be considered when setting-up ePROM surveys. [ABSTRACT FROM AUTHOR]

Purpose of Review: This paper aims to discuss the various work-related musculoskeletal disorders (WRMDs) among urologists and provide an overview of the latest recommendations to improve awareness of ergonomic principles that can be applied in the operating room, with special consideration of challenges faced during pregnancy. Recent Findings: Urologists suffer from a large burden of WRMDs. The main drivers of pain associated with the various surgical approaches include repetitive movements, static and awkward body positions, and the use of burdensome equipment. Pregnant surgeons are at an even greater risk of WRMDs and face high rates of pregnancy complications. Summary: Laparoscopy, endoscopy, robot-assisted surgeries, and open surgeries present unique ergonomic challenges for the practicing urologist. Proper posture and equipment use, optimal operating room setup, intraoperative stretching breaks, and an emphasis on teaching ergonomic principles can reduce the risk of WRMDs. Surgeons are also at increased risk of WRMDs during pregnancy but may continue to operate while taking measures to limit physical exertion and fatigue. Improving awareness of and incorporating ergonomic principles early in a urologist's career may reduce the risk of injury and improve operative performance and longevity. [ABSTRACT FROM AUTHOR]

This study aimed to present a comprehensive literature review of the efforts of a spinal cord injury workgroup in Taiwan regarding urologic surgery for neurogenic lower urinary tract dysfunction (NLUTD) in patients with chronic spinal cord injury (SCI). Surgical procedures should be viewed as a final option for managing patients with SCI who have persistent symptoms and complications that cannot be resolved by other means. Surgeries can be grouped according to their purpose: reducing bladder pressures, reducing urethra resistance, increasing urethra resistance, and urinary diversion. The choice of surgery depends on the type of LUTD based on urodynamic tests. Additionally, cognitive function, hand motility, comorbidities, efficacy of surgery, and related complications should be considered. [ABSTRACT FROM AUTHOR]

Yuanyuan Mao, Jin Guo, Jingjing Yuan, Erxian Zhao, Jianjun Yang Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People’s Republic of ChinaCorrespondence: Jianjun Yang, Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, Zhengzhou, Henan, 450052, People’s Republic of China, Tel/Fax +8613783537619, Email Jianjunyang1971@163.comBackground: Remimazolam is a new medication with sedative and hypnotic effects. It has been demonstrated non-inferior to propofol in general anesthesia with regard to efficacy and safety. However, whether general anesthesia with remimazolam is better than propofol in terms of patients’ recovery quality remains unknown.Patients and Methods: Patients enrolled in this study were randomized to remimazolam or propofol group. In remimazolam group, general anesthesia was induced with remimazolam and sufentanil and maintained with remimazolam and remifentanil. In propofol group, general anesthesia was induced with propofol and sufentanil and maintained with propofol and remifentanil. Neuromuscular blocking agent cisatracurium was also injected during anesthesia. Sedation level was monitored by bispectral index (BIS). Our primary outcome was the quality of patients’ postoperative recovery, using the Quality of Recovery-15 (QoR-15) scale. Secondary outcomes included SpO2, HR, MBP and frequency of application of vasoactive drugs during anesthesia, as well as incidences of adverse events in the post anesthesia care unit (PACU).Results: The global scores of QoR-15 scale were lower in remimazolam group at postoperative day 1 and day 3 compared to propofol group, but differences between the two groups only had clinical significance at postoperative day 1. Among the five dimensions of QoR-15 scale, scores for physical comfort and emotional state were lower in remimazolam group than propofol group. MBP and HR were higher in remimazolam group than propofol group after anesthesia induction. SpO2 was similar in the two groups. The frequency of application of vasoactive drugs during anesthesia was higher in propofol group than remimazolam group. There was no statistical difference in the incidences of adverse events between the two groups.Conclusion: General anesthesia with remimazolam can provide more stable hemodynamics but also cause temporary reduction in the quality of recovery in patients undergoing urologic surgery, compared to propofol.Keywords: remimazolam, propofol, quality of recovery, urologic surgery

Abstract Objectives The aim of this study is to assess the course and management of poorly differentiated bladder urothelial carcinoma (UC), including plasmacytoid UC (PUC), in our local area. Although bladder cancer is relatively common, PUC is a rare and aggressive subtype with a poor prognosis that is still poorly understood. Materials and Methods A retrospective assessment of all poorly differentiated high‐grade UC over the last 15 years (2005–2020) in the Hunter New England area was completed. In total, 37 patients were included, and PUC variant was compared with the remaining poorly differentiated UC. Results Of the included cases, eight were PUC, nine squamous variant, two neuroendocrine, and one sarcomatoid. Overall, 23 cases proceeded to cystectomy, 15 had chemotherapy (six neoadjuvant), and 11 had radiation therapy. In the PUC subgroup, three had metastatic disease at diagnosis (37.5%). Of the three PUC patients who underwent cystectomy, all were upstaged. Two PUC cases had adjuvant chemotherapy, and one case had radiation. Within the follow‐up period, the PUC group had a cause‐specific mortality of 50% with a mean survival in these patients of 202 days, compared with 37.9% cause‐specific mortality with survival of 671.55 days (p = 0.23) in all other undifferentiated UC cases; 5‐year cause‐specific mortality with Kaplan–Meier analysis was estimated at 26% compared with 59%, respectively (p = 0.058). Conclusion Poorly differentiated UC is demonstrated to have a poor prognosis with a high mortality rate, particularly when PUC is present. Given the rarity of these variants, further studies are necessary to explore the impact of current treatment options.

Objective: This study aims to evaluate the ability of stroke volume variation (SVV), pulse pressure variation (PPV), and change in PVV and SVV after tidal volume challenge testing (ΔPPV and ΔSVV) aiming to predict fluid responsiveness in patients undergoing laparoscopic urologic surgery. Material and Methods: A prospective interventional study was performed with 23 patients undergoing urologic surgery while they were placed in Trendelenburg positions. A Vigileo/FloTrac system was used for the analysis. Hemodynamic data such as: arterial pressure (MAP), heart rate (HR), peak airway pressure (PIP), stroke volume (SV), cardiac output (CO), SVV, and PPV were recorded at the tidal volume settings of 8 mL/kg and 12 mL/kg before, and after a fluid challenge (FC). Fluid responsiveness was defined as an increase in SV(ΔSV) ≥15.0%. Results: After tidal volume challenge tests, there were significant increases in PIP in both groups. PPV increased only in the responders, as opposed to SVV, which increased significantly only in non-responders after tidal volume challenge test. After fluid challenge, PVV and SVV decreased gradually and significantly in both groups. The area under the ROC curves of patients undergoing laparoscopic urologic surgery was 0.872 (95% CI: 0.57-0.96) for ΔPPV, this change was the highest compared to other parameters. The threshold of the ΔPPV of patients undergoing laparoscopic urologic surgery was 4% with a sensitivity at 0.75 and specificity at 0.93. Conclusion: Change in PPV after the tidal volume challenge test from 8 mL/kg to 12 mL/kg can be used as an effective indicator to monitor fluid responsiveness in regards to patients undergoing urologic surgery.

Most urological interventions are now performed with minimally invasive surgery techniques such as laparoscopic surgery. Combining ERAS protocols with minimally invasive surgery techniques may be the best option to reduce hospital length-of-stay and post-operative complications. We designed this study to test the hypothesis that using low intra-abdominal pressures (IAP) during laparoscopy may reduce post-operative complications, especially those related to reduced intra-operative splanchnic perfusion or increased splanchnic congestion. We applied a complete neuromuscular blockade (NMB) to maintain an optimal space and surgical view. We compared 115 patients treated with standard IAP and moderate NMB with 148 patients treated with low IAP and complete NMB undergoing major urologic surgery. Low IAP in combination with complete NMB was associated with fewer total post-operative complications than standard IAP with moderate NMB (22.3% vs. 41.2%, p < 0.001), with a reduction in all medical post-operative complications (17 vs. 34, p < 0.001). The post-operative complications mostly reduced were acute kidney injury (15.5% vs. 30.4%, p = 0.004), anemia (6.8% vs. 16.5%, p = 0.049) and reoperation (2% vs. 7.8%, p = 0.035). The intra-operative management of laparoscopic interventions for major urologic surgeries with low IAP and complete NMB is feasible without hindering surgical conditions and might reduce most medical post-operative complications. [ABSTRACT FROM AUTHOR]

A shortage of inpatient beds and nurses during the coronavirus disease 2019 pandemic has lent priority to safe same-day discharge after surgery. The minimally invasive nature of robotic surgery has allowed an increasing number of procedures to be done on an outpatient basis. Anesthetic management should be designed to complement the technical advantages of robotic surgery in facilitating early discharge. [ABSTRACT FROM AUTHOR]

The Hem-o-lok Weck clip is part of a polymer locking ligation system often employed for hemostasis in surgical practices. Its use is routine in a wide array of surgical subspecialties. Surgeons have limited options in removing these clips when they are aberrantly positioned. Herein, we describe a novel, cost-effective approach for removing a Hem-o-lok clip using standard robotic instruments. This simple approach will allow surgeons to remove a Hem-o-lok clip precisely and quickly if it is not adequately placed. During a routine robotic-assisted laparoscopic prostatectomy a Hem-o-lok Weck clip was noted to be in juxtaposition to the rectal wall, and it was deemed appropriate to remove it. Ultimately, the indwelling Prograsp forceps was moved from the right fourth arm position to the left arm position. This allowed the Prograsp forceps to compress the scissors in the right hand port, which was insufficient in cutting the hinge of the clip. This provided sufficient force to cut through the clip at its hinge with ease. The Hem-o-lok Weck clip is used in various surgical specialties. It is occasionally placed suboptimally and requires removal. Given the challenge of finding and using the clip removal device, surgeons should be aware of this simple and cost-effective way of removing a Hem-o-lok clip if desired.

Background: Despite the superiority of minimal access surgery (MAS) over open surgery, MAS is difficult to perform and has a demanding learning curve. Robot-assisted surgery is an advanced form of MAS. The Versius® surgical robot system was developed with the aim of overcoming some of the challenges associated with existing surgical robots. The present study was designed to investigate the feasibility, clinical safety, and effectiveness of the Versius system in MAS. Materials and Methods: A comprehensive search was carried out in the Medline, Web of Science Core Collection (Indexes = SCI-EXPANDED, SSCI, A & HCI Timespan), and Scopus databases for articles published until February 2022. The keywords used were Versius robot, visceral, colorectal, gynecology, and urologic surgeries. Articles on the use of the Versius robot in minimal access surgery (MAS) were included in the review. Results: Seventeen articles were reviewed for the study. The investigation comprised a total of 328 patients who had been operated on with this robot system, of which 48.3%, 14.2%, and 37.5% underwent colorectal, visceral, and gynecological procedures, respectively. Postoperative and major complications within 30 days varied from 7.4% to 39%. No major complications and no readmissions or reoperations were reported in visceral and gynecological surgeries. Readmission and reoperation rates in colorectal surgeries were 0–9%. Some procedures required conversion to conventional laparoscopic surgery (CLS) or open surgery, and all procedures were completed successfully. Based on the studies reviewed in the present report, we conclude that the Versius robot can be used safely and effectively in MAS. Conclusions: A review of the published literature revealed that the Versius system is safe and effective in minimal access surgery. However, the data should be viewed with caution until randomized controlled trials (RCTs) have been performed. Studies on the use of this robotic system in oncological surgery must include survival as one of the addressed outcomes. [ABSTRACT FROM AUTHOR]

Several studies have shown the consequences of COVID-19 pandemic on perceived stress of different populations, but none of them analyzed urological patients who underwent elective surgery.

Three-dimensional (3D) printing technologies have been increasingly utilized in medicine over the past several years and can greatly facilitate surgical planning thereby improving patient outcomes. Although still much less utilized compared to computed tomography (CT), magnetic resonance imaging (MRI) is gaining traction in medical 3D printing. The purpose of this study was two-fold: 1) to determine the prevalence in the existing literature of using MRI to create 3D printed anatomic models for surgical planning and 2) to provide image acquisition recommendations for appropriate clinical scenarios where MRI is the most suitable imaging modality. The workflow for creating 3D printed anatomic models from medical imaging data is complex and involves image segmentation of the regions of interest and conversion of that data into 3D surface meshes, which are compatible with printing technologies. CT is most commonly used to create 3D printed anatomic models due to the high image quality and relative ease of performing image segmentation from CT data. As compared to CT datasets, 3D printing using MRI data offers advantages since it provides exquisite soft tissue contrast needed for accurate organ segmentation and it does not expose patients to unnecessary ionizing radiation. MRI, however, often requires complicated imaging techniques and time-consuming postprocessing procedures to generate high-resolution 3D anatomic models needed for 3D printing. Despite these challenges, 3D modeling and printing from MRI data holds great clinical promises thanks to emerging innovations in both advanced MRI imaging and postprocessing techniques. EVIDENCE LEVEL: 2 TECHNICAL EFFICATCY: 5. [ABSTRACT FROM AUTHOR]

Purpose: Preoperative deep vein thrombosis (pre-DVT) is a risk of symptomatic venous thromboembolism (VTE) and a serious postoperative surgical complication. However, little is known about pre-DVT in patients undergoing surgery. This study aimed to investigate the incidence and screening criteria of pre-DVT in patients undergoing urological surgery. Materials and Methods: Between 2015 and 2017, 320 patients admitted to our hospital for urological surgery were included in this retrospective study. All patients underwent preoperative D-dimer testing. Patients with elevated D-dimer (≥1.0 µg/mL) levels underwent lower-limb compression ultrasonography (CUS). Clinical parameters were analyzed as predictors of pre-DVT, and modest cutoff value of D-dimer to predict pre-DVT were evaluated. Results: Of 320 patients, preoperative elevated D-dimer levels and DVT were found in 81 (25.3%) and 20 (6.3%) patients, respectively. The positive predictive value (PPV) was 24.7% (20/81). ROC curve analysis revealed a cutoff D-dimer level of 1.8 µg/mL, yielding a PPV of 40.7% for pre-DVT among patients with elevated D-dimer levels. Preoperative DVT was detected in 16 (7.6%, n=210) patients with malignancy, 3 (5.7%, n=53) with adrenal tumors, and in 1 (1.8%, n=57) kidney donor. An age of >70 years was significantly associated with risk for pre-DVT (odds ratio, 2.81; 95% confidence interval, 1.12–7.19; p=0.0270). During a postoperative follow-up period of 90 days, no patient developed symptomatic VTE. Conclusions: The incidence of pre-DVT was 6.3% in patients undergoing urological surgery. Elderly patients and/or a cutoff D-dimer level of 1.8 µg/mL might be good indications for pre-DVT screening by CUS.

Purpose: As computational power has improved over the past 20 years, the daily application of machine learning methods has become more prevalent in daily life. Additionally, there is increasing interest in the clinical application of machine learning techniques. We sought to review the current literature regarding machine learning applications for patient-specific urologic surgical care. Methods: We performed a broad search of the current literature via the PubMed-Medline and Google Scholar databases up to Dec 2020. The search terms "urologic surgery" as well as "artificial intelligence", "machine learning", "neural network", and "automation" were used. Results: The focus of machine learning applications for patient counseling is disease-specific. For stone disease, multiple studies focused on the prediction of stone-free rate based on preoperative characteristics of clinical and imaging data. For kidney cancer, many studies focused on advanced imaging analysis to predict renal mass pathology preoperatively. Machine learning applications in prostate cancer could provide for treatment counseling as well as prediction of disease-specific outcomes. Furthermore, for bladder cancer, the reviewed studies focus on staging via imaging, to better counsel patients towards neoadjuvant chemotherapy. Additionally, there have been many efforts on automatically segmenting and matching preoperative imaging with intraoperative anatomy. Conclusion: Machine learning techniques can be implemented to assist patient-centered surgical care and increase patient engagement within their decision-making processes. As data sets improve and expand, especially with the transition to large-scale EHR usage, these tools will improve in efficacy and be utilized more frequently. [ABSTRACT FROM AUTHOR]

Urologic surgeries are widely performed, and the cases have increased owing to the fact that the elderly population is growing. The narrow and limited surgical space is a challenge in performing most urologic surgeries. Additionally, the elderly population is exposed to the risk of perioperative complications; therefore, a comprehensive understanding and approach are required to provide optimized anesthesia during surgery. We have searched the literature on anesthesia for urologic surgeries and summarized the anesthetic considerations for urologic surgeries.

Objectives: We aimed to evaluate the association between scores on each item of the SARC-F questionnaire and life expectancy in patients undergoing major surgery for urologic cancer., Methods: This retrospective study included 1018 patients undergoing elective major urologic cancer surgery. All patients completed the SARC-F questionnaire preoperatively. Demographic and clinical data were collected. The primary endpoint was an association between SARC-F scores and overall survival (OS)., Results: Of the 1018 patients, the median age was 72 years and 920 (90%) were male. Multivariate analysis revealed four factors significantly and independently associated with shorter OS: assistance with walking score ≥1 (Hazard ratio: HR=2.18, P =0.044), cancer stages ≥ III (HR=7.98, P <0.001), high blood loss ≥78 ml or blood transfusion during surgery (HR=4.53, P =0.007 and HR=2.41, P =0.037, respectively)., Conclusions: This study found that among the items of the SARC-F questionnaire, assistance with walking was a strong predictor of life expectancy. Incorporating such a simple screening tool into the preoperative assessment would help to ensure more appropriate perioperative care for urologic cancer patients., (Copyright: © 2024 Hylonome Publications.)

Introduction:  Baclofen, a clinically available GABA B receptor agonist, produces nonopioid analgesia in multiple models of pain but has had limited studies related to perioperative pain control. The present study seeks to study effects of baclofen on postoperative pain measures and opioid use in adult patients subjected to percutaneous nephrolithotomy (PCNL)., Methods: Using a placebo-controlled, double-blind methodology, a single 10 mg oral dose of baclofen or placebo was given prior to a surgery in 34 patients undergoing PCNL. Standardized intraoperative and postoperative protocols related to opioid use were followed. Use of postoperative opioids in the post-anesthesia care unit and for the first 24 hours following surgery were recorded as were pain scores and other medication use., Results: There was a significant positive correlation in the use of postoperative opioids in patients who had a preceding history of opioid use. However, there were no significant differences in opioid use which could be attributed to baclofen. There were also no differences in postoperative vital signs, side effects or other medication use., Conclusions:  Analgesic benefits of preoperative baclofen were not observed at the dose employed. Safety of the drug was observed., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. University of Alabama at Birmingham Institutional Review Board for Human Studies issued approval IRB-300002466. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mandabach et al.)

Les événements thromboemboliques (ETE) sont parmi les complications non chirurgicales les plus fréquentes en urologie. Différentes stratégies de prophylaxie périopératoires existent pour en diminuer le risque de survenue. L'objectif de cette étude était de proposer une mise au point pratique sur les indications, les schémas et les résultats des différents protocoles réalisés de prévention des ETE en chirurgie urologique. Nous avons réalisé une revue de la littérature entre janvier 2000 et avril 2021 en utilisant les bases de données Medline et PubMed. Les mots clés suivants ou une combinaison de ces mots en français ou en anglais ont été utilisés : « Complications thromboemboliques, Thrombose veineuse profonde, Embolie pulmonaire, Thromboprophylaxie, Chirurgie urologique ». La définition, la physiopathologie, la prévalence des ETE, les indications des thromboprophylaxies, leurs complications, les protocoles et leur efficacité en termes de réduction de risque ont été analysés. Au total, l'étude a porté sur l'analyse de 34 articles. L'ETE était défini comme une thrombose veineuse profonde (TVP) ou une embolie pulmonaire (EP) symptomatique. La triade de Virchow était considérée par les différentes études comme la base physiopathologique expliquant les troubles de la coagulation et la thrombose veineuse. Les TVP représentaient 1 à 5 % des complications non chirurgicales en urologie. Ce taux est sensiblement équivalent à celui des ETE associés à une chirurgie abdominale majeure. Certaines situations de prise en charge spécifiques en urologie étaient plus propices à la survenue d'ETE notamment l'hormonothérapie et la chimiothérapie périopératoire. La prévention des ETE était recommandée par l'ensemble des études. Elle reposait sur l'évaluation du risque d'ETE appréciés sur la base de l'analyse des facteurs individuel et du contexte chirurgical envisagé. La néphrectomie, la transplantation rénale, la chirurgie ouverte du bas appareil urinaire et les curages ganglionnaires iliaques ou lomboaortiques étaient les interventions à risque élevé. Les héparines de bas poids moléculaire (HBPM), l'héparine non fractionnée (HNF) et le fondaparinux étaient les molécules les plus utilisées et pouvaient être utilisés en postopératoire. La durée recommandée de la thromboprophylaxie médicamenteuse variait de 4 à 6 semaines. Le recours à la contention veineuse était systématique en hospitalier ou en ambulatoire. Les différentes stratégies préventives étaient associées à une réduction significative du risque absolu de survenue d'ETE rapportée par la majorité des études. Les recommandations actuelles sur les schémas type de thromboprohylaxie différaient suivant les sociétés savantes, sans doute à l'origine d'une certaine hétérogénéité rapportée en pratique clinique à la fois au sein des pays et entre les pays. Tous les schémas de prescription pour prévenir le risque d'ETE postopératoire conduisaient à une réduction de survenue. Les recommandations pour la chirurgie urologique reposaient sur des assimilations à des études de cohorte plus importantes en chirurgie pelvienne et digestive. Ces recommandations soulignaient l'intérêt d'une décision collégiale. Elles reposaient sur l'évaluation multidisciplinaire partagée du risque d'ETE appréciés sur la base de l'analyse des facteurs individuel et du contexte chirurgical envisagé. Thromboembolic events (TEEs) are among the most common non-surgical complications in urology. Different perioperative prophylaxis strategies exist to reduce the risk of occurrence. The objective of this study was to provide a practical update on the indications, diagrams and results of the various protocols carried out to prevent TEEs in urological surgery. We performed a review of the literature between January 2000 and April 2021 using the Medline and PubMed databases. The following key words or a combination of these words in French or in English were used: "Thromboembolic complications, Deep vein thrombosis, Pulmonary embolism, Thromboprophylaxis, Urological surgery". The definition, pathophysiology, prevalence of TEEs, indications for thromboprophylaxis, their complications, protocols and their effectiveness in terms of risk reduction were analyzed. The study included the analysis of 34 articles. TEE was defined as symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE). The Virchow triad was considered by various studies as the pathophysiological basis explaining coagulation disorders and venous thrombosis. DVT accounted for 1 to 5 % of non-surgical complications in urology. This rate is roughly equivalent to that of TEEs associated with major abdominal surgery. Certain specific management situations in urology were more conducive to the onset of a TEE, in particular hormone therapy and perioperative chemotherapy. Prevention of TEEs was recommended by all of the studies. It was based on the assessment of the risk of ETA assessed on the basis of the analysis of individual factors and the planned surgical context. Nephrectomy, kidney transplantation, open lower urinary tract surgery, and iliac or lumboaortic lymph node dissection were the high-risk procedures. Low molecular weight heparins (LMWH), unfractionated heparin (UFH) and fondaparinux were the most widely used molecules and could be used postoperatively. The recommended duration of drug thromboprophylaxis ranged from 4 to 6 weeks. The use of venous retention was systematic in hospital or outpatient. The various preventive strategies were associated with a significant reduction in the absolute risk of the occurrence of a TEE reported by the majority of studies. Current recommendations on typical thromboprohylaxis regimens differed among learned societies, probably at the origin of a certain heterogeneity reported in clinical practice both within and between countries. All the strategies to prevent the risk of postoperative TEE led to a reduction in their occurrence. Recommendations for urologic surgery were based on assimilations to larger cohort studies in pelvic and digestive surgery. These recommendations highlighted the value of a collegial decision. They were based on a shared multidisciplinary assessment of the risk of TEE assessed on the basis of the analysis of individual factors and the envisaged surgical context. [ABSTRACT FROM AUTHOR]

Background: Operative blood loss is associated with postoperative morbidity and mortality in surgery. Hemostatic agents are used as adjuncts for hemostasis during surgery and help to prevent postoperative bleeding. We evaluated the safety and efficacy of an investigational polysaccharide hemostatic (PH) topical product compared to a U.S. Food and Drug Administration (FDA)-approved control in clinical use comprising microporous polysaccharide hemospheres (MPH) to achieve hemostasis of bleeding surfaces during surgery., Study Design: This prospective multicenter trial enrolled patients undergoing open elective cardiac, general, or urologic surgery. Patients were stratified by bleeding severity and therapeutic area, then randomized 1:1 to receive PH or MPH. Bleeding assessments occurred intraoperatively using a novel bleeding assessment methodology. Primary endpoint was noninferiority as compared with control via effective hemostasis at 7 min. Patients were monitored and followed daily in the postoperative period until time of discharge and again at 6 weeks. Overall survival was assessed in oncology patients at 24 months. Safety of PH vs. MPH was determined by comparing relative incidence of adverse events., Results: Across 19 centers, 324 (161 PH, 163 MPH) patients were randomized (48 % general surgery, 27 % cardiac surgery, and 25 % urologic surgery). PH was noninferior to MPH and met the primary endpoint of hemostatic success at 7 min at a non-inferiority margin of 10 %. No significant differences were found in adverse event rates. Six deaths were reported within the 6-week follow-up period. No difference in overall survival was observed at 2 years (76 % PH vs. 74 % MPH, P  = .66) for patients undergoing cancer operations., Conclusion: Across three therapeutic areas, PH was noninferior to MPH at all hemostasis assessment time points with no safety concerns. PH is an effective alternative to MPH for hemostasis during surgery.ClinicalTrials.gov Identifier: NCT02359994., Competing Interests: As the study sponsor, CryoLife/Artivion provided financial support to conduct the study including project management, monitoring, data management, statistical analyses, and generation of the final study report for submission to the FDA. The authors have disclosed any conflicts of interest., (© 2024 The Authors.)

Purpose: To assess if the choice of acetaminophen formulation (intravenous vs oral) when administered preoperatively for ambulatory cystoscopy procedures is associated with differences in anesthetic outcomes.Methods: Medical records of adult patients undergoing ambulatory cystoscopy procedures at an outpatient procedural center from July 1, 2014, through November 30, 2017, were abstracted. The association between anesthetic outcomes (severe pain, rescue opioids, postoperative nausea, and vomiting) and acetaminophen formulation was assessed. Propensity-adjusted analyses were performed using inverse probability of treatment weighting to account for potential confounders.Results: During the study time frame, there were 611 intravenous and 2955 oral acetaminophen administrations for cystoscopy procedures. Postoperative bladder spasms were a major contributor to severe pain and complicated 1036 cases, with similar rates between intravenous (N = 183, 29.9%) and oral (N = 853, 28.9%) formulations, P = .625. After adjusting for bladder spasms, intravenous acetaminophen was associated with longer anesthesia recovery (estimate 5.2 [95% CI 0.5-9.9] minutes, P = .030), use of rescue opioids (odds ratio 1.33 [1.07-1.66], P = .012), and postoperative nausea and vomiting (1.40 [1.02-1.93], P = .037), but not severe pain (1.07 [0.81-1.40], P = .640).Conclusion: Preoperative intravenous acetaminophen compared to oral acetaminophen for ambulatory cystoscopy procedures was not associated with better anesthetic outcomes. Bladder spasms were a major contributor to postoperative pain. [ABSTRACT FROM AUTHOR]

Purpose: This study assessed the ability of the LACE + [Length of stay, Acuity of admission, Charlson Comorbidity Index (CCI) score, and Emergency department visits in the past 6 months] index to predict adverse outcomes after urologic surgery. Methods: LACE + scores were retrospectively calculated for all consecutive patients (n = 9824) who received urologic surgery at one multi-center health system over 2 years (2016–2018). Coarsened exact matching was employed to sort patient data before analysis; matching criteria included duration of surgery, BMI, and race among others. Outcomes including unplanned hospital readmission, emergency room visits, and reoperation were compared for patients with different LACE + quartiles. Results: 722 patients were matched between Q1 and Q4; 1120 patients were matched between Q2 and Q4; 2550 patients were matched between Q3 and Q4. Higher LACE + score significantly predicted readmission within 90 days (90D) of discharge for Q1 vs Q4 and Q2 vs Q4. Increased LACE + score also significantly predicted 90D emergency room visits for Q1 vs Q4, Q2 vs Q4, and Q3 vs Q4. LACE + score was also significantly predictive of 90D reoperation for Q1 vs Q4. LACE + score did not predict 90D reoperation for Q2 vs Q4 or Q3 vs Q4 or 90D readmission for Q3 vs. Q4. Conclusion: These results suggest that LACE + may be a suitable prediction model for important patient outcomes after urologic surgery. [ABSTRACT FROM AUTHOR]

Aging of population represents a new challenge for physicians who have to deal with the balance of risk and benefit in a population that is poorly represented in clinical trials. Frail patients need individualized treatments because of their high risk of developing complications in the course of therapies. Several studies have reported the effect of frailty on falls, hospitalization and mortality, but only few have focused on surgical patients and frailty is not included in the traditional surgical risk scales. Geriatric surgery patients have a physiologic vulnerability requiring assessment beyond the traditional preoperative evaluation of adults. Although single organ evaluation cannot be ignored in elderly population, recognition of frail patients during preoperative assessment may provide additional insight in predicting poor outcome; thus, aiding preoperative decision-making. We developed a Urological-Geriatric Integrated Diagnostic-Therapeutic Pathway in order to evaluate ≥65 years old patients affected by urogenital pathologies which require major surgery and to early identify frail subject.

Introduction: Andrology and urogenital reconstruction are emerging disciplines in French urology. The aim of our study was to evaluate the evolution of andrological surgical procedures over the period 2013-2022 using national data., Materials and Methods: We collected national common classification of medical acts (CCAM) coding data for all procedures involving andrological surgery from the Scansanté internet platform set up by the Technical Agency for Information on Hospitalisation, which collects prospectively from healthcare structures all procedures coded according to CCAM coding. All surgical procedures in andrology were selected. The inclusion period extended from 2013 to 2022., Results: In 10 years, the number of vasectomies has increased tenfold, with 29,890 cases in 2022. Vaso-vasostomies remain marginal, with 80 cases per year. Trans-identity surgeries are rising sharply. Vaginoplasties have multiplied by 4 (333 in 2022) and masculinising surgeries have multiplied by 10 (234 in 2022). Penile prosthesis surgery has increased slightly over 10 years. The number of testicular biopsies has remained stable over time, as has the number of surgeries for curvature of the penis., Conclusion: Two andrological surgeries are showing very strong growth: vasectomy and transgender surgery. The emergence of these 2 activities is linked to societal aspirations. Urologists need to be trained to meet this demand., Niveau De Preuve: Grade 4., (Copyright © 2024. Published by Elsevier Masson SAS.)