Clavien-Dindo Classification System Research Articles

Predictive Value of the Mayo Adhesive Probability (MAP) Score in Laparoscopic Partial Nephrectomies: A Systematic Review from the EAU Section of Uro-Technology (ESUT).

The Mayo Adhesive Probability (MAP) score is a radiographic scoring system that predicts the presence of adherent perinephric fat (APF) during partial nephrectomies (PNs). The purpose of this systematic review is to summarize the current literature on the application of the MAP score for predicting intraoperative difficulties related to APF and complications in laparoscopic PNs. Three databases, PubMed, Scopus and Cochrane, were screened, from inception to 29 October 2023, taking into consideration the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. All the inclusion criteria were met by eight studies. The total operative time was around two hours in most studies, while the warm ischemia time was <30 min in all studies and <20 min in four studies. Positive surgical margins, conversion and transfusion rates ranged from 0% to 6.3%, from 0% to 5.0% and from 0.7% to 7.5%, respectively. Finally, the majority of the complications were classified as Grade I-II, according to the Clavien-Dindo Classification System. The MAP score is a useful tool for predicting not only the presence of APF during laparoscopic PNs but also various intraoperative and postoperative characteristics. It was found to be significantly associated with an increased operative time, estimated blood loss and intraoperative and postoperative complication rates.

The effect of advanced age on peri- and post-operative complications following pelvic floor repair surgeries.

To assess whether advanced age is a risk factor for complications following pelvic organ prolapse (POP) repair surgeries using the Clavien-Dindo classification system. In this retrospective cohort study, 260 women who had undergone POP repair surgery at the Soroka University Medical Center (SUMC) between the years 2014-2019 were included. A univariate analysis was conducted to compare the demographical, clinical, obstetrical and operative characteristics of patients by age group (younger or older than 70years). We performed a similar analysis to assess for the possible association between several variables and post-operative complications. Variables that were found to be associated with post-operative complications (P < 0.2) were included in a multivariate analysis along with advanced age. During the 12months follow-up period, more than half of the women had experienced at least one post-operative complication. Minor complications (grades 1-2 according to the Clavian-Dindo classification system) were the most common. One woman had died during the follow-up period, and none had experienced organ failure (grade 4). Hysterectomy, as part of POP surgery, was found to be significantly associated with post-operative complications. Additionally, grandmultiparity (> 5 births) showed a tendency towards an increased risk for post-operative complications, however this reached only borderline significance. We found no association between advanced age and post-operative complications. POP repair surgeries are safe for women of all ages. Major complications (grades 3-5) are rare in all age groups. Although advanced age was associated with a higher prevalence of comorbidity and a higher grade of prolapse, no significant difference in the post-operative complications was found between age groups. Concomitant hysterectomy at the time of POP repair surgery is a risk factor for post-operative complications.

Percutaneous Image-Guided Cryoablation of Endophytic Renal Cell Carcinoma

PurposeEndophytic renal cancer treatment is a challenge. Due to difficulties in endophytic tumor visualization during surgical extirpation, image-guided percutaneous cryoablation (PCA) is an attractive alternative. The minimally invasive nature of PCA makes it favorable for comorbid patients as well as patients in which surgery is contraindicated. Oncological outcomes and complications after PCA of endophytic biopsy-proven renal cell carcinoma (RCC) were reviewed in this study.Materials and MethodsPatients were included after a multidisciplinary team conference from January 2015 to November 2021. Inclusion criteria were endophytic biopsy-proven T1 RCC treated with PCA with one year of follow-up. Complications were reported according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system and the Clavien-Dindo classification (CDC) system. Major complications were defined as a grade ≥ 3 according to the CDC.ResultsFifty-six patients were included with a total of 56 endophytic tumors treated during 61 PCA sessions. The median RENAL nephrometry score was 9 (IQR 2), and the mean tumor size was 25.7 mm (SD ± 8.9 mm). Mean hospitalization time was 0.39 (SD ± 1.1) days. At a mean follow-up of 996 days (SD ± 559), 86% of tumors were recurrence free after one PCA. No patients progressed to metastatic disease. According to the CIRSE classification, 10.7% (n = 6) had grade 3 complications, and 5.4% (n = 3) had CDC major complications.ConclusionThis study demonstrates that PCA of endophytic biopsy-proven T1 RCC is safe with few major complications and excellent local tumor control rates at almost three-year mean follow-up.Level of Evidence 3Retrospective cohort study.Graphic

Initial experiences and troubleshooting of Senhance robotic system: A community hospital perspective

Purpose: The purpose of this study is to demonstrate the feasibility and safety of the Senhance robotic system in urologic surgeries. Materials and methods: Patients were included prospectively from July 2018 to December 2020. The exclusion criteria included severe cardiopulmonary diseases and previous extensive abdominal surgeries. Institutional approval and informed consent were obtained. We used the Clavien-Dindo classification system to evaluate the complications that occurred within 30 days after surgery. Common technical and mechanical events encountered were also recorded. Results: A total of 173 patients were recruited. The median age was 65 (58–74) years, and the median body mass index was 24.7 (16.5–35.6) kg/m2. Seventeen (9.8%) patients had previously undergone abdominal surgeries. Eighty-three (48%) cases had total extraperitoneal hernioplasty and 32 (18.5%) cases radical prostatectomy, which were the largest 2 surgeries in our study. Sixty-one (35.3%) patients received surgeries due to malignancy. The median docking time was 5 (1–35) minutes. There were 28 (16.2%) cases with grade I complications and 9 (5.2%) cases with grade II complications. Only one case of a grade IIIb complication occurred during radical prostatectomy. No grade IV complications or mortalities were noted. Robotic arm collisions and forces exceeding the limit were the most commonly encountered problems intraoperatively. Conclusion: In our initial experiences, the Senhance robotic system was feasible in oncologic and nononcologic urologic surgeries and had acceptable outcomes. The haptic feedback system is unique and requires a learning period. This system may serve as an alternative tool for robotic urologic surgeries.

Association between frailty and clinical outcomes in patients undergoing craniotomy—systematic review and meta-analysis of observational studies

BackgroundFrailty in patients undergoing craniotomy may affect perioperative outcomes. There have been a number of studies published in this field; however, evidence is yet to be summarized in a quantitative review format. We conducted a systematic review and meta-analysis to examine the effects of frailty on perioperative outcomes in patients undergoing craniotomy surgery.MethodsOur eligibility criteria included adult patients undergoing open cranial surgery. We searched MEDLINE via Ovid SP, EMBASE via Ovid SP, Cochrane Library, and grey literature. We included retrospective and prospective observational studies. Our primary outcome was a composite of complications as per the Clavien–Dindo classification system. We utilized a random-effects model of meta-analysis. We conducted three preplanned subgroup analyses: patients undergoing cranial surgery for tumor surgery only, patients undergoing non-tumor surgery, and patients older than 65 undergoing cranial surgery. We explored sources of heterogeneity through a sensitivity analysis and post hoc analysis.ResultsIn this review of 63,159 patients, the pooled prevalence of frailty was 46%. The odds ratio of any Clavien–Dindo grade 1–4 complication developing in frail patients compared to non-frail patients was 2.01 [1.90–2.14], with no identifiable heterogeneity and a moderate level of evidence. As per GradePro evidence grading methods, there was low-quality evidence for patients being discharged to a location other than home, length of stay, and increased mortality in frail patients.ConclusionIncreased frailty was associated with increased odds of any Clavien–Dindo 1-4 complication. Frailty measurements may be used as an integral component of risk-assessment strategies to improve the quality and value of neurosurgical care for patients undergoing craniotomy surgery.Ethics and disseminationFormal ethical approval is not needed, as primary data were not collected.Systematic review registrationPROSPERO identification number: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=405240

Kolorektal Kanser Cerrahi Geçiren Hastalarda Clavien-Dindo Sınıflandırma Sistemine Göre Postoperatif Komplikasyonlar

Amaç: Bu araştırma ile kolorektal kanser cerrahisi geçiren hastalarda görülen postoperatif komplikasyonlar incelenmiştir. Yöntem: Kesitsel bir araştırma olarak yürütülen çalışmaya kolorektal kanser cerrahisi geçiren 127 hasta dahil edilmiştir. Postoperatif 30 gün boyunca komplikasyon açısından takip edilen hastalarda görülen komplikasyonlar Clavien-Dindo sınıflandırma sistemi kullanılarak kaydedilmiştir. Bulgular: Clavien-Dindo sınıflandırma sistemine göre hastaların %44,9’unda I. derece, %42,5 inde II. derece, %8,6’sında III. derece, %2,4’ünde IV. Derece ve %1,6’sında V. derece komplikasyon geliştiği tespit edilmiştir. Çalışmada kolorektal kanser cerrahisi geçiren hastaların 30 günlük majör postoperatif komplikasyon oranı %12,6; mortalite oranı %1,6’dır. Daha önce bağırsak cerrahisi geçirme durumu, cerrahi işlem süresi, postoperatif hastanede kalış süresi ve komplikasyon dereceleri arasında anlamlı bir ilişki olduğu belirlenmiştir. Sonuç: Kolorektal kanser cerrahisi geçiren hastaların postoperatif komplikasyon riskleri açısından değerlendirmesi, mevcut risklere karşı önlemler alınması ve postoperatif komplikasyonların uygun şekilde yönetimi ve takibi sağlanmalıdır.

A Study to Evaluate the Complications of Laparoscopic Renal and Adrenal Surgeries Using Modified Clavien-Dindo Classification

Background: Laparoscopic surgery has become a widely accepted approach for the treatment of renal and adrenal diseases. However, there is a need to assess the post-operative complications associated with these procedures using standardized classification systems. The modified Clavien-Dindo classification system offers a comprehensive framework for evaluating surgical outcomes and determining the severity of complications. Methods: This prospective study involved 106 patients who underwent laparoscopic renal and adrenal resective surgeries. Post-operative complications were recorded and graded according to the modified Clavien-Dindo classification system. The data collected were analysed to assess the incidence and severity of complications in relation to patient demographics, comorbidities, and surgical procedures. Results: Among the 106 patients, 16.03% experienced post-operative complications, with 13.20% classified as minor complications and 2.83% as major complications. The most common minor complications included delayed bowel movements and wound infection, while major complications included conversion to open surgery and the need for ventilator support or haemodialysis. No deaths were reported in the study. The association between complication rates and age, gender, ASA grade, side of pathology, comorbidities, and pathology/diagnosis was not statistically significant. However, higher grade complications tended to occur more frequently in elderly patients, males, and those with comorbidities. Conclusions: This study supports the effectiveness of laparoscopic surgery for renal and adrenal diseases, as evidenced by low complication rates. The modified Clavien-Dindo classification system proved valuable in assessing and categorizing post-operative complications, enabling a comprehensive evaluation of surgical outcomes. Implementation of this standardized classification system can contribute to improving patient safety and the overall quality of surgical care. Further research with larger sample sizes and longer follow-up periods is recommended to obtain more precise and comprehensive data on long-term morbidity and mortality associated with laparoscopic renal and adrenal resective surgeries.

The effect of routine ureteral stent placement on post-ureteroscopy complications: A prospective study from a resource limited setting

Background: Rigid ureterorenoscopy (URS) stands as a highly successful treatment for ureteral stones. The current guidelines from the European Association of Urology (EAU) recommends selective double J (DJ) stent placement post-URS to mitigate major complications. However, in resource-limited hospital setups, executing selective stent placement poses substantial risks in preventing complications and reducing readmission rates. This study aims to unveil the ramifications of our routine stent replacement approach after ureteric stone surgery on surgical outcomes in a resource-constrained setting.Materials and Methods: This prospective study was conducted at a urological unit within a tertiary care center in Sri Lanka, over a one-year period, involving 112 diagnosed patients. Patients underwent routine DJ stenting following rigid URS for ureteral stone management, without additional intervention. Data collected from clinical records encompassed demographics, stone characteristics, and complications. Postoperative complications linked to routine DJ stenting were assessed using the Clavien-Dindo classification system. Descriptive statistics were employed for data summary using SPSS version 23.0.Results: The mean age of patients was 47.3±14.9 years (range: 13-76 years), with 67.9% being males. The mean stone size was 15.35±6.58 mm (range: 4.5-35 mm), distributed across right (48.2%), left (44.6%), and bilateral (7.1%) ureters, of which 52.7% were proximal, 30.4% distal, and 17% mid ureteric stones. Postoperative evaluation revealed 26.8% of patients experiencing Clavien-Dindo grade I complications (e.g.,dysuria, haematuria, loin pain, and lower urinary tract symptoms), managed conservatively. Moreover, 4.5% encountered Clavien-Dindo grade II complications, predominantly postoperative fever, necessitating hospital readmission specifically for intravenous antibiotic administration.Conclusion: Despite guidelines advocating selective stent placement, this study underscores the safety and efficacy of routine DJ stent implementation after the URS laser procedure. The findings showcase a notable reduction in postoperative complications alongside decreased hospital readmission rates in resourcelimited environments. Embracing routine DJ stenting post- URS in such settings could serve as a pragmatic approach, potentially enhancing patient outcomes and minimizing healthcare burdens.

Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis.

Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties. The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design. A total of 294 studies comprising 97643 patients, of which 33070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001). Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.

Influence of Tumor Characteristics on Early Surgical Complications in Operable Gastric Cancer

Background: Gastric cancer is the 5th most common cause of cancer related death in Bangladesh. Curative resection remains the main modality of its successful treatment but the rate of postoperative complications is still high. Besides surgical factors, patient’s clinicopathological characteristics influence complications. Aims: To observe the nature of complications and correlate the tumor characteristics with nature of complications. Methods: Following convenience sampling 46 patients of operable gastric cancer who underwent gastrectomy in the Department of General Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), from July 2021 to June 2022 were observed for their postoperative complications rate, type, and grade by Clavien-Dindo classification system. Data were analyzed with Statistical Packages for Social Sciences (SPSS- 22.0) and Chi-square test (2) was done to find out the association of complications with the tumor characteristics. Results: Tumor located in fundus and corpus found in 10 cases, out of which 4(40.0%) and 6(60.0%) had developed major and minor complication respectively (p&lt;0.05). Five 5 cases were adenocarcinoma (signet ring), among them 1(20.0%) developed major complication and 4(80.0%) developed minor complication. Five cases were adenocarcinoma (mucinous), 3(60.0%) developed major complication and 2(40.0%) developed minor complications (p&lt;0.05). Grade III lesion was observed in 20 cases, out of which 5(25.0%) developed major complication and 15(75.0%) developed minor complications (p&lt;0.05). Tumor size more than 6 cm was found in 3 cases, among them 1(33.3%) had major and 2(66.7%) had minor complication. Tumor size belonged to 3 - 6 cm was found in 34 cases, out of which 4(11.8%) had developed major complication, 28(81.4%) minor complication and 2(5.9%) had no complication (p&lt;0.05). Tumor located in fundus and corpus, adenocarcinoma (signet ring), adenocarcinoma (mucinous), grade III lesion, tumor size 3 cm or more, .........

The evolution of liver transplant program in Pakistan and the challenges ahead

Background and aimThe burden of Liver disease has significant implications on the healthcare infrastructure in Pakistan, with viral hepatitis being the leading etiology of end-stage liver disease. Liver transplant remains the only curative treatment option for end-stage liver disease. A decade ago, the liver transplant facility was almost non-existent for the Pakistani population, and the patients with end-stage liver disease had to travel overseas to receive liver transplantation. Gradually, during the last decade the country has progressed steeply and achieved various milestones in living donor liver transplantation. Various public and private sector hospitals are providing liver transplant services nationwide. The study aimed to describe the evolution and success of living donor liver transplant programs in Pakistan. We will also discuss the current practices involved in donor and recipient selection, factors related to non-existent deceased donor organ programs, and the introduction of innovative strategies to overcome the shortage of donor organ pools. MethodsWe retrospectively analyzed the data of the first 416 living donor liver transplants (LDLTs) performed at PKLI&RC from March 2019 to April 2023. The stepwise approach for the donor and recipient selection process is described in detail, along with the survival outcomes of LDLT at our center. ResultsAmong the 416 living donor liver transplants performed between March 2019 and April 2023. The Hepatitis C virus was the most common etiology (50.5 %) for chronic liver disease. Hepatocellular carcinoma (HCC) was present in 27.9 % of cases. Most donors were offspring of the recipients, with sons accounting for 23 % and daughters for 17.5 % of cases. Only a single (0.24 %) patient had a deceased donor transplant. The annual donor rejection rate was up to 68 % at our center. Nine SWAP transplants were performed to overcome the donor shortage. The Clavien Dindo classification system was used to grade the severity of complications after donor hepatectomy. No donor mortality (grade-5 complication) was observed in our cohort, whereas 1- and 3-year recipient survival rates were 89 % and 88 %, respectively. ConclusionHepatitis C virus remains the most common etiology of chronic liver disease requiring liver transplantation. The major pool of living donations was from first-degree relatives. There was no donor mortality with acceptable 1- and 3-year recipient's survival rates. Living donor liver transplantation is a feasible and safe strategy in regions where cadaveric liver transplant program is limited.

Association of Malnutrition Diagnosed Using Global Leadership Initiative on Malnutrition Criteria with Severe Postoperative Complications After Gastrectomy in Patients with Gastric Cancer.

Background: The purpose of this study was to investigate the relationship between malnutrition assessed by the Global Leadership Initiative on Malnutrition (GLIM) criteria and the occurrence of severe postoperative complications (SPCs) after gastrectomy in patients with gastric cancer. Methods: A total of 220 patients with gastric cancer were included in this retrospective study. According to the GLIM criteria, the first step was to use the Nutrition Risk Screening Score 2002 to conduct nutritional risk screening for patients and the second step was to diagnose and grade the severity of malnutrition in patients at risk of malnutrition. According to the Clavien-Dindo classification system, SPCs were defined as C-D Grade IIIa or higher. Results: Overall, 66 (30.0%) patients were diagnosed with malnutrition, including 32 (14.5%) with moderate malnutrition and 34 (15.5%) with severe malnutrition. The incidence of SPCs was 14.5%, and the most frequent postoperative event was anastomotic leakage. In the multivariate regression analysis, malnutrition was considered an independent risk factor for SPCs (P < .001). After adjusting for various factors, the grading association remained statistically significant. Compared with patients with normal nutrition, patients with moderate and severe malnutrition have a nearly 15-fold (OR = 15.682, 95% CI: 4.481-54.877, P < .001) and 20-fold (OR = 20.554, 95% CI: 5.771-73.202, P < .001) increased risk of developing SPCs, respectively. Conclusions: Malnutrition assessed by GLIM was an independent risk factor for SPCs in gastric cancer patients. Therefore, early identification of malnourished patients is crucial for timely implementation of nutritional treatment and reducing the occurrence of postoperative complications.

Radiotherapy vs. Cystectomy for Treatment of Muscle Invasive Bladder Cancer in Very Elderly Patients

Radical cystectomy (RC) has long remained the principal treatment of muscle invasive bladder cancer (MIBC). It is, however, associated with significant morbidity, long recovery, and reported worse overall and cancer specific survival, particularly for the very elderly (age > = 80). Bladder preservation with transurethral resection of bladder tumor (TURBT) followed by radiotherapy (RT) +/- concurrent chemotherapy (ChT) is regarded as a curative-intent alternative to RC in well-selected patients. The optimal treatment strategy remains unclear in very elderly patients. We hypothesize that outcomes following RT vs RC are clinically equivalent for treatment of MIBC in very elderly patients. Patients > = 80 years old with T2-T4 N0-N1 bladder cancer treated definitively with RT versus RC were included. Exclusion criteria included history of pelvic RT, prior cystectomy, or palliative treatment intent. Clinicopathologic and treatment-related details, as well as clinical outcomes and toxicities were retrospectively abstracted. Kaplan-Meier analyses were performed. At a median follow-up of 17 months (range 0.25-190), 47 patients received RT vs 83 patients who underwent RC with median age of 86 years (80-97) vs 83 years (range 80-91) (p<0.01), respectively. Median Charlson Comorbidity Index was similar between groups (p = 0.35) with median 7 for both cohorts, predicting 0% estimated 10y survival. Most patients had cT2 tumors (91% vs 99%, p = 0.06), cN0 nodal status (96% vs 100%, p = 0.06), and urothelial carcinoma histology (79% vs 90%, p = 0.22). Most RT patients received concurrent ChT (90%) and a minority of RC patients received neoadjuvant ChT (16%). 70% of RT pts had complete TURBTs prior to RT. Common RT regimens were 50-55 Gy in 20-25 fractions or 60-64.8 Gy in 30-36 fractions, using IMRT (89%) or 3D conformal (11%) technique. Overall survival for RT vs RC at 1- and 2- years was 79% vs 85% and 57% and 69%, respectively (p = 0.20). Locoregional control at 1- and 2-years was 73% vs 70% and 63% vs 66% (p = 0.59), respectively. Progression free survival at 1- and 2-years was 69% vs 66% and 52% vs 54% (p = 0.75), respectively. No RT patients went on to receive salvage cystectomy. Treatment complications are listed in Table 1; the Clavien Dindo classification system was used to describe acute surgical complications of RC and the Common Terminology Criteria for Adverse Events (CTCAE) Dictionary v5.0 was used for acute and late toxicity of RT. In the very elderly, RT (with or without concurrent ChT) offers survival and locoregional control rates comparable to RC, with a favorable side effect profile. RT should be offered for definitive management of non-metastatic MIBC as an alternative to RC in selected, well- informed, and compliant very elderly patients.

Long-term results of clam enterocystoplasty in non-neurogenic refractory urge incontinence.

This study aims to assess the efficacy of Clam enterocystoplasty (CECP) surgery for the treatment of non-neurogenic refractory urgency urinary incontinence (UUI). We conducted a retrospective evaluation of 17 female patients who underwent CECP for non-neurogenic refractory UUI between May 2010 and November 2022. The median of ICIQ-SF was 19 (15-21) before treatment, which decreased to a median of 0 (0-5) after treatment (p = 0.01). The average preoperative pad use among the participants was 4 (3-6), while it became 0 postoperatively (p < 0.01). The median preoperative cystometric bladder capacity was 251 ml (100-350 ml), increasing to 456 ml (400-650 ml) postoperatively (p < 0.01). According to the Clavien-Dindo classification system, the majority of patients experienced either no complications (66%) or minor complications (CD I/CD II) (33%) within the initial 90 days following surgery. "Clam" iliocystoplasty emerges as a secure and successful treatment option in the patient group whose symptoms persist after first, second, and third-line treatments with the diagnosis of urge incontinence.

Outpatient hysteroscopic removal of retained products of conception: evaluation of effectiveness, safety and patient satisfaction

ObjectiveTo assess effectiveness, safety and patient satisfaction of hysteroscopic removal of retained products of conception using a tissue removal system in the outpatient setting. Study designA prospective observational study was carried out in a tertiary care hospital over a 10-month period. Fifty-two women who underwent an outpatient hysteroscopy for removal of retained products of conception were included. Effectiveness was evaluated as complete removal of retained products of conception in a one-time procedure. Safety was determined based on the rate of complications using the Clavien–Dindo classification system. Patient satisfaction and pain were assessed using a visual analogue scale survey completed by patients after the procedure. ResultsComplete removal of retained products of conception in a one-time procedure was achieved in 98.1% of cases. The mean morcellation time was 6.0 min. The complication rate recorded in this study was 9.6%; most complications were mild, but there was one case of uterine perforation. A global satisfaction ratio of 8.9 out of 10 was reported by patients. The study did not find any significant differences in complete removal of retained products of conception based on type of hysteroscope, presence of symptoms or Gutenberg classification. Although not significant, a linear relationship was observed between a higher volume of retained products of conception and a higher Gutenberg classification (p=0.229). ConclusionOutpatient management of retained products of conception using a tissue removal system is effective and safe, and has a high level of patient satisfaction. The results of this study have the potential to alter the standard approach to the management of retained products of conception.

Donor Safety First: Postoperative Hepatectomy Outcomes in Living Liver Donors

Living donor liver transplantation (LDLT) has become a popular treatment option because some countries lack a deceased organ program and the growing demand for liver transplants. Although postoperative outcomes are similar to deceased donor liver transplants, there is still an element of risk to the donor. The Clavien-Dindo classification system has been used to standardize reporting across different institutions and surgeons to categorize surgical outcomes. Between January 1, 2022, and December 31, 2022, 207 living donors underwent hepatectomies at our center. All donors underwent a 3-step process of mandatory screening. Postsurgical complications were classified using the Clavien-Dindo classification. A total of 207 donor hepatectomies for LDLT were performed during our study period. Most donors (92.8%) were aged between 18 and 39 years. The most common type of graft used was a right lobe without the middle hepatic vein (82.6%). Most donors (91.7%) experienced an intraoperative blood loss of ≤500 mL. A total of 140 patients had an ordinary postoperative course. Grade 1 complications were observed in 16.9%, grade 2 in 12.1%, and grade 3 in 3.4% of the remaining patients. No grade 4 or grade 5 (patient death) complications were observed in this cohort. Living donor liver transplantation remains the most practiced liver transplant surgery in Pakistan. Our findings highlight the safety of the LDLT program with minimal risk of significant complications. The study also underscores the importance of careful screening and monitoring of living donors and the need for standardized reporting of surgical outcomes using the Clavien-Dindo classification system.

Comparison of robotic-assisted laparoscopic radical prostatectomy: SP versus XI, a single surgeon experience.

Currently, there is a paucity of data regarding Single Port (SP) robotic-assisted laparoscopic prostatectomy (RALP). Our objective was to compare our single-institution single-surgeon SP RALP experience to our XI RALP experience with regard to patient selection, perioperative data, and outcomes. Patients who underwent prostatectomy at our institution between August 2019 and April 2021 were selected for analysis. All patients had biopsy confirmed prostate cancer. All surgeries were performed by one urologist at our institution to limit inter-surgeon variability. Demographic and clinical information were extracted from the medical record in standardized fashion. All documented classifications were graded using the Clavien-Dindo classification system. Patients with previous prostate cancer therapies were excluded. Categorical variables were compared using Chi-square or Fisher's exact test where appropriate. Continuous variables were compared using t tests or Wilcoxon rank sum tests where appropriate. Complete records were available for 208 patients. Of the total patient population 127 (61.1%) underwent SP prostatectomy compared to 81 (38.9%) underwent XI prostatectomy. There was no significant difference between the two cohorts in terms of mean age (65 vs. 66 years; p = 0.60), BMI (29.2 vs. 30.1; p = 0.22), preop ASA score ≥ 3 (68.5% vs. 64.2%; p = 0.52), or preop PSA (7.1 vs. 7.4, p = 0.94). There no difference in procedure time for SP prostatectomy (170 vs. 168 min, p = 0.035), estimated blood loss (100 vs. 100 mL; p = 0.14), or average length of stay (1 vs. 1 days; p = 0.22). There was a significant difference in Gleason grade group between the two cohorts with patients undergoing XI RALRP more likely to have higher stage disease (p = 0.025) and a trend towards higher D'Amico risk scores in the XI group (p = 0.053). There was no difference in rate of positive surgical margins (29.9% vs. 29.6%; p = 0.96). There was no difference in the distribution of complications between the two groups (p = 0.99) with 89% of patients having no complication. There was no difference in the number of lymph nodes removed by modality (p = 0.94). To date, this study represents one of the largest cohorts of patients who underwent SP RALP. Importantly, it is among the first studies comparing perioperative variables between the SP and XI platforms. As surgeons become more facile with the SP system there appear to minimal differences in patient factors, perioperative results, or outcomes between the platforms. These findings provide evidence that surgeons who are competent on the XI platform can confidently perform SP RALPs through a single incision without compromising outcomes.

The impact of a previous cesarean section on the risk of perioperative and postoperative complications during vaginal hysterectomy.

To investigate whether a previous cesarean section increases the risk of perioperative and postoperative complications during vaginal hysterectomy. A retrospective cohort study of women who had undergone a vaginal hysterectomy for benign indications between 2014 and 2019 was conducted, comparing patients with or without a previous cesarean section. Perioperative and postoperative complications during vaginal hysterectomy were assessed according to the Clavien-Dindo classification system within 30 days of surgery. Duration of surgery, estimated blood loss, and postoperative hospitalization days were also recorded. A two-sided P value of less than 0.05 was considered significant. A total of 185 women were included, 25 (13.5%) patients had undergone a previous cesarean section (study group) and 160 (86.5%) had no history of cesarean section (comparison group). We found no significant differences in demographic and clinical characteristics as well as postoperative complications and interventions, duration of surgery, estimated blood loss, and postoperative hospitalization days (P > 0.05). However, patients who underwent two or more cesarean sections had a significantly (P = 0.01) higher rate and grade of complications during vaginal hysterectomy, compared with women with only one previous cesarean section. All women who underwent two or more cesarean sections had mild complications during vaginal hysterectomy (40% grade I and 60% grade II, P = 0.01). Vaginal hysterectomy is a safe procedure with few severe complications, regardless of a previous cesarean section. More than one previous cesarean section may increase the risk of minor complications during a vaginal hysterectomy. Patients who underwent a previous cesarean section could be reassured that they do not face an increased risk of complications during a vaginal hysterectomy.

Obesity is not an independent risk factor for peri- and post-operative complications following mid-urethral sling (MUS) surgeries for the treatment of stress urinary incontinence (SUI).

To inquire whether obesity is a risk factor of peri- and post-operative complications following Mid-urethral sling (MUS) surgeries for SUI repair using the Clavien-Dindo classification system (CDcs). This retrospective cohort included 304 women who undergone a MUS in a 1000 beds tertiary University medical center between the years 2012-2018. Univariate analysis was conducted to compare clinical and operative traits by BMI group and to examine associations of obesity and complications rates and severity according to the CDcs. Multivariate analysis was conducted to assess the risk for post-operative complications and adjust to potential confounders. The study group included 106 (34.9%) women with BMI 30 or higher and the comparison group included 198 (65.1%) women with BMI lower than 30. In the study group we found a significantly higher prevalence of hypertension (P = 0.019), previous abdominal surgeries (P = 0.012) including cesarean section (P = 0.025), previous pelvic floor surgeries (P = 0.005) and pelvic organ prolapse (P = 0.02). In the control group we found a significantly higher rates of concomitant hysterectomy which performed during the MUS (P = 0.005). Obesity was not associated with increased rates of peri and post-operative complications (P = 0.973). In our study, obesity was not associated with peri- and post-operative complications following MUS.

Mechanical Ablation of the Posterior Urethral Valve Omitting Thermal Energy: A Brief Report.

Management of the posterior urethral valve (PUV) is a clinical challenge in pediatric urology. We report the results of a modified valve ablation method without using a pediatric resectoscope and thermal energy. Patients were selected from children with PUV who were referred to the pediatric urology clinic of Shahid Labbafinejad Hospital, Tehran, Iran, and have undergone endoscopic valve ablation surgery between May 2019 to May 2021. Ten male patients with PUV underwent mechanical valve ablation without the use of the conventional pediatric resectoscope, and thermal energy was replaced by a 6F semi-rigid urethroscope and 3Fr ureteral catheter. Patients were assessed both pre-and postoperatively using serum creatinine, urinary tract ultrasound imaging, and voiding cystourethrography. The mean age was 23.88±30.13 months (range= 25 days to 8 years). Four out of 10 patients (40%) had elevated serum creatinine, and seven had unilateral or bilateral hydroureteronephrosis (70%). No major complications were reported according to Clavien-Dindo Classification System. The level of serum creatinine, the grade of hydroureteronephrosis, and the ratio of the prostatic urethra to anterior urethra diameter in postoperative voiding cystourethrography were decreased. A decrease in serum creatinine level occurred in patients after valve ablation, but this decrease was not statistically significant (P=0.059). The decrease in hydroureteronephrosis grade on the right (P=0.006) and left (P=0.022) was statistically significant. There was no evidence of urethral stenosis or need for repeating resection. It can be concluded that our mechanical valve ablation method might be a safe and effective technique for PUV ablation.