Clavien Classification System Research Articles

Comparison of Outcomes of Extracorporeal Shockwave Lithotripsy with Ureteroscopic Lasertripsy for Management of Proximal Ureteral Stones.

To compare the outcomes of extracorporeal shockwave lithotripsy with ureterorenoscopy and lasertripsy for managing upper ureteral stones of size 10mm to 15mm. Observational, cross-sectional study. Place and Duration of the Study: Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), from December 2020 to December 2021. A total of 168 patients with the diagnosis of proximal ureteric stone of size 1-1.5 cm were enrolled for this study. Patients were divided into two groups by simple random method. Group 1 patients underwent ureteroscopic lithotripsy (URS) and lasertripsy while Group 2 patients were subjected to extracorporeal shockwave lithotripsy (ESWL). Patients' demography, operative time, duration of hospitalisation, complication rate and stone-free rates, were recorded for both groups. Frequency and percentages were calculated for categorical variables and mean and standard deviation were calculated for continuous variables. For comparison of continuous variables, one-way ANOVA was applied, and Chi-square test was applied to compare the categorical variables. The p-value ≤0.05 was taken as significant. The mean age was of 39.55 ± 14.06 years, with the majority falling within the age group of 26 to 40 years. There were more males (116, 69%) than females (52, 31%). Most of the patients did not have a history of diabetes or hypertension. Sixty-two patients had previous history of stones. The average duration of ureteric stone disease was 3.18 ± 3.14 months. The mean size of the ureteric stone was 10.82 ± 3.19mm. The procedure duration was significantly shorter for URS, as compared to ESWL (33.81 ± 15.42 minutes vs. 45.00 ± 0.00 minutes, p=<0.01. The overall stone clearance rate was significantly higher after URS (83.3%) as compared to ESWL (64.2%, p=0.05). URS was a superior treatment option as compared to ESWL. However, the selection of the most appropriate procedure should be based on a tailored approach considering the patient's preference and the size of the stones. Extracorporeal shockwave lithotripsy (ESWL), Ureteroscopic lithotripsy (URS), Modified clavien classification system (MCCS), Ureteric stone.

Understanding ureteroscopy complications according to modified Clavien classification system.

To determine the complications of ureteric stone treatment with semi-rigid uretero-renoscopy in accordance with the modified Clavien classification system. The descriptive, prospective study was conducted at the Department of Urology, Sindh Institute of Urology and Transplantation, Karachi, from June 30, 2020, to December 29, 2021, and comprised patients of either gender aged 18-70 years having ureteric stones. All patients were subjected to ureterorenoscopy using a semi-rigid ureteroscope under general anaesthesia. The patients were followed up for 2 months. All complications were noted and graded in line with the Modified Clavien Complication System. Ultrasound and X-ray were used to determine the stone-free rate. Data was analysed using SPSS 23. Of the 414 patients, 304(73.4%) were males and 110(26.5%) were females. The overall mean age was 40.22±13.10 years. There were 106(25.6%) proximal, 134(32.3%) middle, and 174(42%) distal ureteric stones. Stent placement was done in 56(13.5%) cases. There were 260(62.8%) patients with no complication, 90(21.7%) with grade I complications, 34(8.2%) with grade II complications, 10(2.4%) with grade IIIa, 8(1.9%) with grade IIIb, and 12 (2.9%) with grade IVa complications. Uretero-renoscopy was found to be a safe procedure, as it had minimal associated complications with optimal stone clearance and great dexterity. The Modified Clavien classification system was found to be an easy way to classify surgical complications of uretero-renoscopy.

Risk factors for hemorrhagic complications following robotic-assisted partial nephrectomy.

The aim of this study was to analyze the risk factors for hemorrhagic complications in patients who underwent robotic-assisted partial nephrectomy. We retrospectively reviewed the records of 260 patients who underwent robotic-assisted partial nephrectomy. Hemorrhagic complications were defined as bleeding, hematoma, or arteriovenous fistula requiring hemostatic medication, blood transfusion, or therapeutic intervention. Hemorrhagic complications were graded according to the modified Clavien classification system, and the hemorrhagic complication group comprised only those complications with Clavien grade II or higher. Thereafter, we investigated the presence of any relevant association between perioperative factors and hemorrhagic complications. Of 260 patients included in the study, 32 (12.3%) had hemorrhagic complications. The postoperative hemoglobin level was significantly lower in the hemorrhagic complication group than in the group without complications. The hemorrhagic complication group had significantly more essential blood loss and a significantly longer length of hospital stay. In the univariate analysis, type 2 diabetes mellitus, Radius-scores tumor size as maximal diameter exophytic/endophytic properties of the tumor nearness of the deepest portion of the tumor to the collecting system or renal sinus anterior (a)/posterior (p) descriptor location relative to the polar line., sum of the renal size plus renal sinus involvement in the PADUA score is a simple anatomical system that can be used to predict the risk of surgical and medical perioperative complications in patients undergoing open NSS, prolonged console time (>180 minutes), prolonged warm ischemic time (>25 minutes), and method of pedicle control were statistically significant risk factors. In the multivariate logistic regression analysis, warm ischemic time >25 minutes was the only significant risk factor for hemorrhagic complications (odds ratio, 3.51; 95% confidence interval, 1.28-9.59; p = 0.01). Patients who undergo robotic-assisted partial nephrectomy with a warm ischemic time >25 minutes are significantly more likely to have hemorrhagic complications and should hence receive careful perioperative follow-up.

Inter-observer Reliability in Reporting Complications of Transurethral Resection of the Prostate with Clavien-Dindo Classification: A Retrospective Observational Study

Introduction: Transurethral Resection of the Prostate (TURP) is a gold standard treatment for Benign Prostatic Hyperplasia (BPH). The Clavien classification system was proposed in 1992 to grade complications of general surgery, which was then modified in 2004 by Dindo. In 2017, the European Association of Urology (EAU) endorsed its use for reporting complications in urological procedures. However, the system relies on observers to grade complications, and different observers may assign different grades to the same negative outcome, highlighting the need for uniformity. Aim: To assess the inter-observer reliability and uniformity among urologists in reporting complications of TURP using the modified Clavien-Dindo classification system. Materials and Methods: A retrospective observational study was conducted at Department of Urology, Shyam Shah Medical College, Rewa, Madhya Pradesh, India, from January 2018 to May 2023. The study included symptomatic patients with BPH and prostate gland sizes greater than 40 cc. Negative outcomes were evaluated and complications were rated by nine different raters. Inter-observer reliability was tested using weighted kappa with Statistical Package for Social Sciences (SPSS) version 21.0 (Fleiss’s kappa test). Results: A total of 523 men with BPH who underwent TURP were evaluated, with a mean age of 66.7±5.2 years and a mean prostate volume of 62 cc. Adverse events occurred in 96 patients (18.36%), and these complications were classified according to the Clavien-Dindo System (CDS) by nine different blinded observers. The rating of these complications was then assessed for concordance. A concordance rate using weighted kappa of 0.847 was observed, indicating high inter-observer reliability for TURP. Conclusion: Clavien-Dindo’s system demonstrated good interobserver concordance and reliability. Some modifications to the grading system are needed, taking into account the impact of pre-existing co-morbidities and auxiliary procedures. Largescale prospective studies are recommended to further validate these findings.

The Short-Term Complications of Augmentation Cystoplasty: A Single Center Experience

Objective: To evaluate the short-term complications of various cystoplasty techniques in pediatric population and determine the predicting factors. Material and Methods: The data of 206 patients (94 males, 112 females) who underwent augmentation cystoplasty between 1991-2016 were analysed retrospectively. Short-term complications within 30 days were evaluated according to the modified Clavien classification system. Grade III, IV, and V were grouped major complications. Chronic renal Disease (CRD) was defined as increasing serum creatinine levels above the normal age-adjusted values. Clinical factors and associated procedures to the surgery (Mitrofanoff procedure, bladder outlet procedures, ureteral anti-reflux surgery) were evaluated to predict overall and major complications. Results: The mean age was 9.8±4.7 years and female/male ratio was 112/94. Overall complication rate was 32% (66 patients) and distributed to Clavien class I, II, IIIb, IVa as 18 (8,7%), 33(16%), 14 (6,81%), 1 (0.48%) patients; respectively. There was no mortality. Age, PUV aetiology and CRD were significant predictor of complication on univariate analysis (p=0.026, p=0.048 and p=0.045, respectively). Age and preoperative CRD were significant on multivariable analysis (p=0.015, OR=0.918 and p=0.046, OR=2.134). Major complications occurred in 15 (7.3%) patients. Bladder exstrophy epispadias complex (BEEC), preoperative CRD, anti-reflux surgery, ileal augmentation were significant parameters on univariate analysis (p=0.007, p=0.003, p=0.043, and p=0.022, respectively). For major complications where BEEC, CRD and ileal AC were significant parameters on multivariate analysis (p=0.009, OR=7.837; p=0.003, OR=9.649, p=0.047, OR=4.241, respectively). Conclusion: Augmentation cystoplasty and associated procedures have acceptable complication rate for pediatric group. Preoperative renal disease and younger age are associated with complications. For major complications, Bladder exstrophy epispadias complex, ileal augmentation and preoperative renal disease are risk factors.

Safety and Intraoperative Results in Live Kidney Donors with Vascular Multiplicity After Hand-Assisted Laparoscopy Living Donor Nephrectomy.

Background and PurposeVascular multiplicity is the most frequent anatomic variation in kidney donors. Despite concerns about risks, these allografts are increasingly used to overcome the shortage of kidney donors. The safety and clinical outcomes in living kidney donors were evaluated with vascular multiplicity after hand-assisted laparoscopic living donor nephrectomy (HALDN).Patients and MethodsData from all living kidney donors who underwent HALDN from 2008 to 2021 was retrospectively reviewed. Patients were divided into two groups as single (SRV) and multiple renal vessels (MRV), and a comparative analysis was done. The primary outcomes include operating room time (ORT), days of hospital stay, estimated blood loss, complications, conversion, and re-operations.ResultsMRV were present in 166 out of 612 donors (27.1%). Among those, 10 (1.6%) donors had simultaneous multiple arteries and veins. Additionally, the prevalence of artery and vein multiplicity was 21.8% (n = 134) and 3.5% (n = 22), respectively. Warm ischemia time was significantly different among the two groups but not clinically important. The number of conversions to open technique, the mean ORT, the median blood loss, and days of hospital stay were similar between the SRV and MRV groups, without significant differences. According to the modified Clavien-classification system, no differences were found in the complication rates between the two groups (p = 0.29). Complication rates were 3.3% and 3.6% for the SRV and MRV groups, respectively.ConclusionHALDN is a procedure with safe intraoperative results, even with vascular multiplicity. The presence of multiple renal arteries or veins has no negative impact on the outcome of the donor after living donor nephrectomy.

Benchmarking PASADENA Consensus along the Learning Curve of Robotic Radical Cystectomy with Intracorporeal Neobladder: CUSUM Based Assessment.

(1) Aim: Robot assisted radical cystectomy (RARC) with intacorporeal neobladder (iN) is a challenging procedure. There is a paucity of reports on RARC-iN, the extracorporeal approach being the most used. The aim of our study was to assess the learning curve of RARC-iN and to test its performance in benchmarking Pasadena consensus outcomes. (2) Material and methods: The single-institution learning curve of RARC-iN was retrospectively evaluated. Demographic, clinical and pathologic data of all patients were recorded. Indications to radical cystectomy included muscle invasive bladder cancer (pT ≥ 2) or recurrent high grade non muscle invasive bladder cancer. The cumulative sum (CUSUM) technique, one of the methods developed to monitor the performance and quality of the industrial sector, was adopted by the medical field in the 1970s to analyze learning curves for surgical procedures. The learning curve was evaluated using the following criteria: 1. operative time (OT) <5 h; 2. 24-h Hemoglobin (Hb) drop <2 g/dl; 3. severe complications (according to the Clavien classification system) <30%; 4. positive surgical margins <5%; and 5. complete lymph-node dissection defined as more than 16 nodes. Benchmarking of all five items on quintile analysis was tested, and a failure rate <20% for any outcome was set as threshold. (3) Results: the first 100 consecutive RARC-iN patients were included in the analysis. At CUSUM analysis, RARC required 20 cases to achieve a plateau in terms of operative time (defined as more than 3 consecutive procedures below 300 min). Hemoglobin drop, PSM and number of removed lymph-nodes did not change significantly along the learning curve. Overall, 41% of the patients presented at least one complication. Low-grade and high-grade complication rates were 30% and 17%, respectively. When assessing the benchmarks of all five Pasadena consensus outcomes on quintile analysis, a plateau was achieved after the first 60 cases. (4) Conclusions: RARC-iN is a challenging procedure. The potential impact of the learning curve on significant outcomes, such as high grade complications and positive surgical margins, has played a detrimental effect on its widespread adoption. According to this study, in tertiary referral centers, 60 procedures are sufficient to benchmark all outcomes defined in Pasadena RARC consensus.

Supine PCNL-5 year experience in a tertiary care center.

The prone position for percutaneous nephrolithomy (PCNL) has been widely practiced. There has been a shift from prone position to supine position which showed numerous benefits. The aim of our study is to describe the 5 year experience from the perspective of a tertiary care center using a modified Galdakao supine Valdivia position for total tubeless ultra mini supine PCNL, total tubeless supine PCNL, tubeless supine PCNL, and standard supine PCNL. We retrospectively reviewed the data of 90 patients who underwent supine PCNL at the tertiary care center during the period of 5 years from January 2017 to January 2021. The data collection was done from patients' medical records. Pre operatively, complete examination of the patients with laboratory investigations were done. The modified Clavien classification system was used to classify the perioperative complications of PCNL. Operative time was lowest for ultra mini supine PCNL (50 ± 10.4 min) compared to standard supine PCNL (58 ± 11.2 min). Stones were single in 54 patients and multiple in 40 patients with 4 patients with staghorn stones. The size of the stones in the largest dimension ranged from 1.2 to 5.5 cm.Complete clearance was achieved in 84 (89.7%) patients. Seven patients (7.2%) developed mild fever and four patients (4.5%) required blood transfusion. We found supine PCNL to be an immensely convenient, time-saving practice, and with higher stone free rate compared to prone PCNL. The different techniques of supine PCNL were also useful in patients with horseshoe kidney and calyceal diverticulum which resulted in good outcomes in these patients.

Retrospective Analysis of the Factors Affecting Intraoperative and Immediate Postoperative Complications of Retrograde Intrarenal Surgery Classified by the Clavien and Satava Grading Systems.

Background: To classify intraoperative and postoperative complications using the modified Clavien classification system (MCCS) and modified Satava classification system (SCS) and to evaluate the parameters associated with complications in patients undergoing retrograde intrarenal surgery (RIRS) for renal and proximal ureteral stones. Materials and Methods: We performed a retrospective analysis of 949 patients who underwent RIRS for renal stones and proximal ureteral stones at two institutions between March 2015 and June 2020. Intraoperative complications were assessed using the SCS, and postoperative complications were graded according to the MCCS. Univariate and multivariate analyses were undertaken to determine predictive factors affecting complication rates. Results: The median stone size was determined as 13 mm (range 10-20 mm). The stone-free rate was 83.6% after the first intervention. Reprocedure was applied to 89 of the patients with residual stones and the final stone-free rate was 94.4% after reprocedure. According to SCS, the number of intraoperative events and complication incidences was 153 (16.1%). MCCS revealed postoperative complications in 121 (12.8%) patients. Major complications were observed in 18 (1.9%) patients. The rate of complications was higher in patients with renal anomalies (9.9% vs 3.4%, p = 0.001). Stone location, stone size, stone burden, stone number, stone density, and residual fragments were determined to be associated with the development of complications (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.002, and p < 0.001, respectively). In addition, the multivariate analysis revealed that only the presence of residual fragments was a significant predictor of complication development for the patients with Grade ≥3 complications according to MCCS (p = 0.032). However, significant predictors were stone burden (p < 0.001), stone density (p = 0.002), and fluoroscopy time (p < 0.001) for those with Grade ≥2b complications according to SCS. Conclusion: This study showed that abnormal kidney anatomy, operation time, stone burden, and residual fragments were reliable predictors of complication development during and after RIRS. Appropriate preoperative management should be planned according to these predictors to prevent intraoperative and postoperative complications.

Frequency of grading of complications using modified clavien classification system after transurethral resection of prostate.

Objective: To determine the frequency of post-operative complications of transurethral resection of prostate (TURP), in benign prostatic hyperplasia (BPH) patients, using the Modified Clavien Classification System (MCCS). Study Design: Descriptive study. Setting: Urology Department, Sindh Institute of Urology and Transplantation, Karachi. Period: 26th May, 2019 to 25th Nov, 2019. Material &amp; Methods: A total number of 162 patients with benign prostatic hyperplasia planned for TURP were included in this study and Post-operative complications data was collected, and classified according to the Modified Clavien Classification System (MCCS). Patient’s demographics and other parameters like prostate volume, operative time, mean prostatic tissue resected and hospital stay was collected. Results: Mean age was 63.32±8.36 years. Mean prostate volume was 56.99±13.25 grams. Mean operative time was 26.55±9.46 mins. Mean prostate tissue resected was 16.75±12.09 grams. Mean hospital stay was 1.27±0.60 mins. Grade I complication was occurred in 06 (3.70%) patients, grade II in 03 (1.85%) patients, grade III in 00 patients, grade IV in 01 (0.62%) patients and grade V in no patient. While there were no complications in remaining 152 (93.83%) patients. Conclusion: Clavien–Dindo classification system can be easily applied by urologists to grade the post-operative transurethral resection of prostate (TURP) complications. We observed that TURP is a very safe procedure for surgical management of benign prostatic hyperplasia, and is having low morbidity and mortality.

Our experience of laser lithotripsy under local anesthesia in the treatment of bladder stones in obese male patients

Introduction: Our century has witnessed a significant increase in obesity, which in its turn, bears several major risks in management of systemic anesthesia. In this context, use of this treatment without general or regional anesthesia is of critical importance for patients under this group. &#x0D; Aim: In present study, it was aimed to analyze the efficacy and safety of holmium laser lithotripsy (HLL) under local anesthesia in obese male patients with bladder stones.&#x0D; Material and Method: In our study, we evaluated a total of 64 obese male patients with body mass index (BMI) ≥ 30 kg/m2, diagnosed with bladder stones and treated HLL under local anesthesia. Demographic data, stone size, operative time, urethral catheterization time and length of hospital stay of the patients were analyzed. Visual Analogue Scale (VAS) scores was calculated for each patient during the procedure. Complications were graded according to modified Clavien classification system.&#x0D; Results: The mean age of patients was 50.58 ± 13.04 years and BMI was 33.46 ± 2.59 kg/m2. Mean stone size was 2.51 ± 1.04 cm and operative time was 43.91 ± 15.92 minutes. None of the patients had severe pain and the mean VAS score was calculated as 2.31 ± 1.02. Mean length of hospital stay was 1.25 ± 1.04 days. Grade 3 or higher complications were not observed according to modified Clavien classification system. Mean urethral catheterization time was 1.56 ± 1.45 days, although varying due to underlying etiological factor. All patients were stone-free and there was a marked improvement in clinical findings.&#x0D; Conclusion: Use of HLL under local anesthesia is a safe and efficacious approach in obese male patients with bladder stone.

Laparoscopic simple prostatectomy: a large single-center prospective cohort study.

BACKROUND The aim of our study was to analyze outcomes and safety of laparoscopic simple prostatectomy (LSP) in a high-volume center. METHODS A consecutive series of men with lower urinary tract symptoms and large prostates (>80 cc) prospectively enrolled between November 2015 and December 2017 in one center. All patients underwent laparoscopic simple prostatectomy. Outcomes were evaluated considering the trifecta favorable outcome which was defined as a combination of the following items: 1) no perioperative complications; 2) postoperative IPSS max >15 mL/s. Complications were evaluated according to the modified Clavien classification system. Univariate and multivariate binary logistic regression was performed to identify predictors of a positive trifecta outcome. RESULTS Overall 272 patients were enrolled. At three months after surgery median IPSS total score was 4 (IQR: 3-7), median IPSS QoL was 1 (IQR:1-2), median prostate-specific antigen was 0.53 (IQR: 0.33-1.00) ng/ml and median Q max was 23 (IQR: 17-30) mL/s. All these parameters improved statistically when compared to baseline (P<0.001). The overall complication rate was 21% however most of the complications were low grade complications according to modified Clavien-Dindo classification (grade ≤2). Overall, 68% of the patients presented a positive trifecta outcome. On multivariate analysis only preoperative hemoglobin and hospital stay were confirmed predictors of positive trifecta outcome. CONCLUSIONS LSP represents a safe and effective procedure in the treatment of large adenomas. Although RCTs are needed before reaching definitive conclusions, LSP is a promising technique for patients with LUTS and large prostates.

Outcomes of Ultrasound-Guided Percutaneous Nephrostomy in Carcinoma Cervix with Upper Tract Obstruction

Cancer cervix is the fourth most common cancer and a fourth common cause of cancer mortality in women worldwide. In India, cervical cancer is the second most common cancer among women and approximately 70% of patients present at an advanced stage with one-third of them in obstructive uropathy. The present study aims to analyze the outcomes of percutaneous nephrostomy (PCN), as a urinary diversion technique, in advanced cancer cervix. All patients with advanced cancer cervix with bilateral hydronephrosis or unilateral hydronephrosis with elevated serum creatinine (> 1.4 mg/dl) who underwent PCN in the Department of Urology, JIPMER, between November 2014 and December 2016 were included in the study in a prospective manner. The change in blood urea and serum creatinine levels was estimated by paired t test. The complications were graded according to the modified Clavien classification system. A total of 368 patients underwent PCN in the study period out of which 133 were due to cancer cervix. There were no failure or intraoperative complications during the procedure. There were no deaths noted until the follow-up period of 30 days. Only two patients developed sepsis. Out of 20 (15%) patients who developed haematuria, four (20%) required blood transfusion and was self-limiting in 16 (80%) patients. Reinsertion of PCN was required in 11 patients within a month. Percutaneous nephrostomy is a safe and effective procedure in advanced cancer cervix with obstructive uropathy.

Predictive factors of stone-free rate and complications in patients undergoing minimally invasive percutaneous nephrolithotomy under local infiltration anesthesia.

To evaluate predictive factors affecting the stone-free rates (SFR) and complications of minimally invasive percutaneous nephrolithotomy (MPCNL) under local infiltration anesthesia (LIA) METHODS: A retrospective analysis was conducted on 976 consecutive patients who underwent MPCNL under LIA from January 2015 to June 2018. Postoperative complications were classified according to modified Clavien classification system. Univariate and multivariate logistic regression analyses were used to determine factors affecting SFR and complications. The pain was acceptable with postoperative visual analog scale (VAS) scores being 3.58, 2.99, 2.25, and 2.07 after 0, 6, 24, and 48h, respectively. The SFR after primary MPCNL reached 85.7%. Postoperative complications were recorded in 77 patients (7.9%). In the univariate logistic analysis, larger stone size, staghorn stone, and multiple calyxes were significantly associated with lower SFR. The higher American Society of Anesthesiologists (ASA) score, staghorn stone, positive urine culture, multiple tracts, and longer operation time were associated with occurrence of complications. However, hydronephrosis was associated with lower complication rate. Multivariate analysis indicated that larger stone size (P < 0.001) and staghorn stone (P < 0.001) were associated with lower SFR, while development of complications was independently influenced by higher ASA score (P = 0.002), multiple tract (P = 0.004), and staghorn stone (P = 0.028). MPCNL can be safely and effectively performed under LIA. Stone size and staghorn stone are factors associated with SFR while ASA score, multiple tracts, and staghorn stone are associated with the development of complications. For the first time, we developed a model to predict the SFR and complications in MPCNL under LIA.

Is spinal anesthesia an alternative and feasible method for proximal ureteral stone treatment?

IntroductionWe investigated the clinical, operational, and pain parameters of patients who underwent semirigid ureterorenoscopy (sURS) under spinal anesthesia (SA) and general anesthesia (GA) for proximal ureter stones.Material and methodsPatients treated with sURS after diagnosis of proximal ureter stones between January 2014 and May 2017 were reviewed retrospectively. The patients were divided into two groups (the SA group and the GA group) based on the type of anesthesia used. Perioperative variables and operation results were evaluated and compared. Success was defined as the patient being stone-free as observed on low-dose non-contrast computed tomography performed in the first month postoperatively.ResultsThe SA and GA groups had 40 and 32 patients, respectively. There were no statistically significant differences between the groups in terms of age (p = 0.593), gender (p = 0.910), average stone size (p = 0.056), side (p = 0.958), or density (p = 0.337). Based on the Clavien classification system, complication rates between the two groups were similar. The postoperative visual pain scale in the SA group was statistically significantly lower (p <0.05) than in the GA group. Success rates in the SA and GA groups were found to be 90% (36/40) and 93.7% (30/32), respectively, with no significant difference between the groups (p = 0.819).ConclusionsUreterorenoscopy, which is performed for proximal ureter stone treatment in adult patients, is a reliable surgical method that can be performed under both SA and GA. SA offers the advantage of reduced postoperative pain as compared to GA.

Laparoscopic simple prostatectomy: a large single-center prospective cohort study.

The aim of our study was to analyze outcomes and safety of laparoscopic simple prostatectomy (LSP) in a high-volume center. A consecutive series of men with lower urinary tract symptoms and large prostates (>80 cc) prospectively enrolled between November 2015 and December 2017 in one center. All patients underwent laparoscopic simple prostatectomy. Outcomes were evaluated considering the trifecta favorable outcome which was defined as a combination of the following items: 1) no perioperative complications; 2) postoperative IPSS <8; 3) postoperative Q<inf>max</inf> >15 mL/s. Complications were evaluated according to the modified Clavien classification system. Univariate and multivariate binary logistic regression was performed to identify predictors of a positive trifecta outcome. Overall 272 patients were enrolled. At three months after surgery median IPSS total score was 4 (IQR: 3-7), median IPSS QoL was 1 (IQR:1-2), median prostate-specific antigen was 0.53 (IQR: 0.33-1.00) ng/ml and median Q<inf>max</inf> was 23 (IQR: 17-30) mL/s. All these parameters improved statistically when compared to baseline (P<0.001). The overall complication rate was 21% however most of the complications were low grade complications according to modified Clavien-Dindo classification (grade ≤2). Overall, 68% of the patients presented a positive trifecta outcome. On multivariate analysis only preoperative hemoglobin and hospital stay were confirmed predictors of positive trifecta outcome. LSP represents a safe and effective procedure in the treatment of large adenomas. Although RCTs are needed before reaching definitive conclusions, LSP is a promising technique for patients with LUTS and large prostates.

The Development of the Preoperative Nomogram Predicting Major Perioperative Complications after Radical Cystectomy with Ileal Conduit or Orthotopic Neobladder

Radical cystectomy (RC) is the gold standard for managing muscle-invasive and high-risknon-muscleinvasive bladder cancer, but is accompanied by non-negligible operative risk. The aim of this study is to identify preoperative variables to predict major perioperative complications after RC and to develop a nomogram using the cohort from multiple institutions in Japan. We retrospectively reviewed 668 patients who underwent open RC with ileal conduit or neobladder at Hokkaido University hospital and 20 affiliated institutions between 1997 and 2010. Complications occurring within 90 days of surgery were graded using modified Clavien classification system. We defined modified Clavien grade 3 or more as major complications and performed univariate and multivariate logistic regression analyses. Predictive accuracy of the nomogram was evaluated with the area under the receiver operating characteristics curve (AUC). A total of 528 men and 140 women were included in this study. There were a total of 160/668 patients (24%) with major perioperative complications. A multivariate model identified gender (OR : 1. 63, p=0. 04), cardiovascular comorbidity (OR : 1.48, p=0.03) and simultaneous nephroureterectomy (OR : 2.81, p=0. 01) as independent predictors. Using these 3 variables, a nomogram was developed with the AUC of 0.58. Predictive performance of our nomogram showed only fair performance ; but at least, we identified male, cardiovascular comorbidity and simultaneous nephroureterectomy as independent predictors of perioperative major complications.

Prospective audit of complications after ultrasonography-guided percutaneous nephrostomy for upper urinary tract obstruction using modified Clavien classification system.

Introduction:Percutaneous nephrostomy (PCN) is a commonly performed intervention in urology for various benign and malignant conditions causing upper urinary tract obstruction. We present a prospective audit of complications of ultrasonography (USG) guided PCN using modified Clavien classification system (mCCS).Methods:The data were prospectively collected for 368 PCN performed in 344 patients from June 2015 to January 2017, for various benign and malignant diseases causing upper urinary tract obstruction. Patients were followed for 1 month, and complications arisen of PCN were noted.Results:PCN was successful in 356 renal units. The 12 patients in which PCN failed was due to minimal pelvicalyceal dilatation and PCN was successfully performed after 48 h by a senior urologist. 207 patients had malignant disease and 161 patients had benign condition. Most common malignant disease was carcinoma cervix. 238 were noninfected while 130 had infected renal units. 62 (16.84%) patients had Grade I (self-limiting hematuria/cot/debris/fever). 37 (10.0%) patients had Grade II (7 - transfusion and 30 - urinary tract infection). 34 (9.2%) had Grade III a (repositioning/change/reinsertion of PCN tube under local anesthesia) and 4 (1.1%) had Grade III b (repositioning under anesthesia). 8 (2.2%) Grade IV a (Sepsis), 0 Grade IV b, and 0 Grade V complications were observed.Conclusion:USG-guided PCN is a safe, minimally invasive, and effective procedure for upper urinary tract diversion with a low rate of morbidity. Individual complications are within the threshold limits set by the American College of Radiology, the Society of Interventional Radiology. mCCS is well applicable and easily reproducible tool for reporting the complications of PCN.

MP20-20 RISK FACTORS FOR PERI-OPERATIVE HIGH-GRADE COMPLICATIONS IN PATIENTS WITH PROSTATE CANCER TREATED WITH ROBOTIC RADICAL PROSTATECTOMY

INTRODUCTION AND OBJECTIVE: Aim of our study was to evaluate the risk factors for high-grade complications (Clavien Classification System ≥3a) in patients treated with with robotic assisted radical prostatectomy (RARP) METHODS: Between 2012 and 2017, a consecutive series of patients with prostate cancer were treated with robotic radical prostatectomy (RRP). Demographic, clinical and histological characteristics of the patients were recorded. Histological specimens were graded according to the new PGG classification. Complications were classified according to the modified Clavien classification system (CCS). Logistic regression analysis was performed to evaluate the risk of high grade complications (CCS³3a) RESULTS: Overall 9273 patients were enrolled. Median age was 65 (60/70) years, median BMI was 27 (25/29) kg/m^2, median prostate volume was 38 (29/50) ml and median PSA was 7.4 (5.5/11) ng/ml. Overall 323/9273 (3,5%) presented high grade complications;Patients with high grade complications presented a higher BMI, larger prostates, higher ASA score and performed a non-nerve sparing procedure (p<0.05). On age-adjusted multivariate analysis BMI (OR: 1,05, 95%CI:1.01-1.07, p=0.002), prostate volume OR: 1,05, 95%CI:1,00-1,01, p=0.045, Nerve Sparing (OR: 0,50, 95%CI:0,35-0,72, p=0.001) and ASA score³3 (OR: 1,50, 95%CI:1,09-2,06, p=0.001) were independent predictors of high grade complications CONCLUSIONS: High grade complications are uncommon event in patients treated with RARP. However obese patients, with large prostate and high ASA score still present a significant risk when a non-nerve sparing procedure is performed. Our results if confirmed could be used to counsel patients before surgery Source of Funding: None

Semi-rigid Ureteroscopy for the Management of Ureteric Calculi: Our Experience and Complication Encountered.

Semi-rigid ureteroscopy lithotripsy have become standard of treatment for ureteral calculi. The aim of this study isto review outcome of Semi-rigidureteroscopy lithotripsy and to report the complications encountered. After approval from institutional committee of Public Health Concern Trust Nepal,we retrospectively reviewed the chart of all patients of ureteral stone who underwent ureteroscopy and pneumatic lithotripsy at Kathmandu Model Hospital between January 2013 and September 2017. Patient characteristics, stone size, success rate and complications were assessed. Intraoperative complications were graded using modified Satava classification system and the postoperative complications graded according to modified Clavien classification system. The success rate was based on stone free status after primary semi-rigid ureteroscopy lithotripsy, without the need of any other secondary procedures. Total 232 patients underwent semi-rigidureteroscopy lithotripsy. Mean age was 46 (16-76) years, with 128 males and 104 females. Size of the stone ranges from 5-18mm. The success rate of primary semi-rigidureteroscopy lithotripsy was in218 (93.9%) cases.Most intraoperative complications were modified Satava grade I (41.7%) andII(3.87%).Four(1.7%) patient had grade III complication, requiring conversion to open surgery. Ureteral avulsion was seen in 1(0.43%) patient, requiring ureteral reimplantation.The postoperative complication were modified Clavien grade I(10.7%), grade II(5.17%), grade III (4.6%) and grade IV(0.43%). Double J stents were inserted in all the patients postoperatively.The mean hospital stay was 2.2(1-14)days. Semi-rigid ureteroscopy lithotripsy for the management of ureteral stones is efficacious and have a lesser major complications.