European Association Of Urology Guidelines Research Articles

Is extracorporeal shockwave lithotripsy (SWL) still suitable for >1.5 cm intrarenal stones? Data analysis of 1902 SWLs

Purpose According to the American Urological Association and European Association of Urology guidelines, shockwave lithotripsy (SWL) is the least-invasive treatment option for kidney stones smaller than 2 cm. However, it is well known that SWL stone-free rates (SFR) decline as stone size increases. We sought to evaluate whether the size limit of 1.5 cm could be a better predictor of success after a single SWL session than current recommendations. Methods Data from an SWL-dedicated center were prospectively scrutinized according to stone locations and sizes. Information on patients’ demography, lithotripsy parameters, and outcomes was evaluated by multivariate analysis among 1902 SWLs. Results The overall SFR was 70.8% (1347/1902). SFRs according to stone size were <1 cm: 73.8% (825/1118), 1–1.5 cm: 70.4% (401/569) and >1.5 cm: 56.2% (121/215); and according to calculi location were lower pole (LP) 64.4% (398/618), mid pole 73.8% (339/459), upper pole 73.8% (273/370) and renal pelvis 74.1% (337/455). Multivariate analysis revealed better SFR independent better SFR in <1.5 cm (p < 0.01), and non-LP stones (p < 0.01). Conclusion SWL is an effective treatment modality for kidney stones. The single session reached up to 74.8% SFRs (range 70.8%–74.8%) when indicated for intrarenal non LP stones smaller than 1.5 cm. Patients with stones >1.5 cm or >1 cm located in the LP should be counseled on the lower SFRs after a single SWL session.

Prognostic value of the systemic immune-inflammation index in non-muscle invasive bladder cancer

PurposeWe assessed the prognostic value of systemic immune-inflammation index (SII) to refine risk stratification of the heterogeneous spectrum of patients with non-muscle-invasive bladder cancer (NMIBC)MethodsIn this multi-institutional cohort, preoperative blood-based SII was retrospectively assessed in 1117 patients with NMIBC who underwent transurethral resection of bladder (TURB) between 1996 and 2007. The optimal cut-off value of SII was determined as 580 using the best Youden index. Cox regression analyses were performed. The concordance index (C-index) and decision curve analysis (DCA) were used to assess the discrimination of the predictive models.ResultsOverall, 309 (28%) patients had high SII. On multivariable analyses, high SII was significantly associated with worse PFS (hazard ratio [HR] 1.84; 95% confidence interval [CI] 1.23–2.77; P = 0.003) and CSS (HR 2.53; 95% CI 1.42–4.48; P = 0.001). Subgroup analyses, according to the European Association of Urology guidelines, demonstrated the main prognostic impact of high SII, with regards to PFS (HR 3.39; 95%CI 1.57–7.31; P = 0.002) and CSS (HR 4.93; 95% CI 1.70–14.3; P = 0.005), in patients with intermediate-risk group; addition of SII to the standard predictive model improved its discrimination ability both on C-index (6% and 12%, respectively) and DCA. In exploratory intergroup analyses of patients with intermediate-risk, the improved discrimination ability was retained the prediction of PFS and CSS.ConclusionPreoperative SII seems to identify NMIBC patients who have a worse disease and prognosis. Such easily available and cheap standard biomarkers may help refine the decision-making process regarding adjuvant treatment in patients with intermediate-risk NMIBC.

Comparison between 1973 and 2004/2016 World Health Organization grading in upper tract urothelial carcinoma treated with radical nephroureterectomy

AimsThe European Association of Urology guideline for upper tract urothelial carcinoma (UTUC) relies on two grading system: 1973 World Health Organization (WHO) and 2004/2016 WHO. No consensus has been made which classification should supersede the other and both are recommended in clinical practice. We hypothesized that one may be superior to the other.MethodsNewly diagnosed non-metastatic UTUC patients treated with radical nephroureterectomy were abstracted from the Surveillance, Epidemiology, and End Results database (2010–2016). Kaplan–Meier plots and multivariable Cox regression models (CRMs) tested cancer-specific mortality (CSM), according to 1973 WHO (G1 vs. G2 vs. G3) or to 2004/2016 WHO (low-grade vs. high-grade) grading systems. Haegerty’s C-index quantified accuracy.ResultsOf 4271 patients, according to 1973 WHO grading system, 134 (3.1%) were G1, 436 (10.2%) were G2 and 3701 (86.7%) were G3; while according to 2004/2016 WHO grading system, 508 (11.9%) were low grade vs 3763 (88.1%) high grade. In multivariable CRMs, high grade predicted higher CSM (Hazard ratio: 1.70, p < 0.001). Conversely, neither G2 (p = 0.8) nor G3 (p = 0.1) were independent predictors of worse survival. The multivariable models without consideration of either grading system were 74% accurate in predicting 5-year CSM. Accuracy increased to 76% after either addition of the 1973 WHO or 2004/2016 WHO grade.ConclusionsFrom a statistical standpoint, either 1973 WHO or 2004/2016 WHO grading system improves the accuracy of CSM prediction to the same extent. In consequence, other considerations such as intra- and interobserver variability may represent additional metrics to consider in deciding which grading system is better.

IJU this issue

This issue of International Journal of Urology contains one Review Article, 11 Original Articles, two Urological Notes and 13 Editorial Comments. Taguchi et al (Tokyo, Japan) reviewed the evidence on the prognostic significance of tertiary Gleason pattern (TGP), and discussed how to deal with it in the context of the contemporary Gleason score and Gleason grade grouping. According to the 2019 International Society of Urological Pathology, a provisional definition of TGP is “<5% Gleason pattern 4 or 5 in radical prostatectomy specimens.” Although no objective and scientific data supporting this cut-off value have been reported, TGP should be routinely reported in radical prostatectomy specimens and further studies are required to assess the associations of TGP with prognostic significances. In the Original Articles, Kimura et al. (Tottori, Japan) reported the impact of penile rehabilitation on the recovery of erectile function after robot-assisted radical prostatectomy. Erectile dysfunction still remains an important complication after robot-assisted radical prostatectomy despite the preservation of neurovascular bundles with nerve-sparing (NS) surgery. This study presents novel findings regarding postoperative penile rehabilitation with phosphodiesterase-5 inhibitor, not only in cases of bilateral NS and/or unilateral NS, but also in other types of NS, such as partial NS or non-NS. Zhang et al. (Beijing, China) evaluated the outcomes and the learning curves of flexible ureteroscopy (FURS) and mini-percutaneous nephrolithotomy for pediatric kidney stones larger than 2 cm. FURS has already been shown to be a safe and feasible procedure alternative to percutaneous nephrolithotomy for children with upper urinary stones with a systematic review and meta-analysis (Urolithiasis 2019; 47: 189–99); however, this study showed an interesting finding, that a minimum of 20 cases of mini-percutaneous nephrolithotomy and 50 cases of FURS are necessary to achieve a high stone-free rate for pediatric kidney stones larger than 2 cm. Okada et al. (Chiba, Japan) reported the differences in the handling of forceps between the one-surgeon and two-surgeon techniques using an off-site simulator model. Nearly half of endourologists used only the dusting technique in their FURS practice, according to a recent worldwide survey of FURS practice from the European Association of Urology sections of young academic urologists (aged <40 years) and uro-technology groups (Cent. Eur. J. Urol. 2019; 72: 393–7). The European Association of Urology Guidelines on Urolithiasis has mentioned that “dust and go” strategies should be limited to the treatment of large (renal) stones and stones that can be extracted by endoscopic forceps or baskets. Therefore, the establishment of standards, safety requirements and acceptable procedures for basketing is essential. A large-scale study is required to confirm its usefulness as a new standard modality of stone retrieval in FURS. Shobeirian et al. (Rasht, Iran) evaluated the efficacy of intraprostatic injection of prophylactic antibiotics for the prevention of infections after transrectal ultrasonography-guided prostate biopsy. This unique concept of injecting antibiotics directly into the prostate was proposed in both animal and human studies, and its efficacy in the treatment of drug-resistant chronic prostatitis has already been reported. It will be necessary to carry out a randomized controlled trial. In the Urological Notes, Tully et al. (Boston, USA) analyzed bladder cancer incidence trends using the Surveillance, Epidemiology and End Results database, with a focus on distant stage among young individuals. They discussed possible explanations for the rising incidence of distant bladder cancer among young individuals. Unfortunately, the limited space does not allow me to introduce all the articles. However, all the papers are very interesting and informative. Please enjoy this issue of International Journal of Urology. None declared.

P0618 - External validation and head-to-head comparison of all the prognostic models recommended by the European Association of Urology guidelines to predict oncologic outcomes in patients with renal cell carcinoma

P0618 - External validation and head-to-head comparison of all the prognostic models recommended by the European Association of Urology guidelines to predict oncologic outcomes in patients with renal cell carcinoma

Clinical practice in vesicoureteral reflux with respect to EAU guidelines: A multicenter study.

We designed a multicenter, retrospective study to investigate the current trends in initial management of reflux with respect to European Association of Urology (EAU) Guidelines in Urology clinics of our country. The study group consisted of 1988 renal units (RU) of 1345 patients treated surgically due to vesicoureteral reflux (VUR) (between years 2003 and 2017) in nine different institutions. Patients were divided into two groups according to time of initial treatment and also grouped according to risk factors by "EAU guidelines on VUR." In this series, 1426 RUs were treated initially conservatively and 562 RUs were initially treated with surgery. In initially surgically treated group, success rates of surgery decreased significantly in low and moderate risk groups after 2013 (P = .046, P = .0001, respectively), while success rates were not significantly different in high risk group (P = .46). While 26.6% of patients in low risk group were initially surgically treated before 2013, this rate has increased to 34.6% after 2013, but the difference was not statistically significant (P = .096). However, performing surgery as the initial treatment approach increased significantly in both moderate and high risk groups (P = .000 and P = .0001, respectively) after 2013. Overall success rates of endoscopic treatments and ureteroneocystostomy (UNC) operations were 65% and 92.9% before 2013 and 60% and 78.5% after 2013, respectively. Thus, the overall success rate for surgery was 72.6%. There was significant difference between success rates of UNC operations before and after 2013 (P = .000), while the difference was not significant in the injection group (P = .076). Current trends in management of reflux in our country do not yet follow the EAU guidelines on VUR in low and moderate risk groups despite these reliable and accepted guidelines were expected to influence our daily approach.

Impact of the Implementation of the EAU Guidelines Recommendation on Reporting and Grading of Complications in Patients Undergoing Robot-assisted Radical Cystectomy: A Systematic Review

In 2012, the European Association of Urology (EAU) Ad Hoc Panel proposed a standardised methodology on reporting and grading complications after urological surgical procedures. The aim of the current study was to assess the impact of this implementation on complications reporting for patients undergoing robot-assisted radical cystectomy (RARC). A systematic review of all English-language original articles published on RARC until March 2020 was performed using PubMed, Scopus, and Web of Science databases. The study selection process followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) criteria. The quality of reporting and grading complication was evaluated according to the EAU recommendations. Our analysis failed to observe a statistically significant improvement in reporting outcomes after the EAU guidelines recommendations except for three of the 14 criteria proposed (ie, follow-up duration, utilisation of a severity grade system, and risk factors included in the analyses). A lower statistically significant adherence to outcome reporting in terms of inclusion of readmissions and causes (p = 0.02), was observed. Patient summaryIn this study, we evaluated the impact of the proposed European Association of Urology (EAU) standardised reporting tool for urological complications, in patients treated with robot-assisted radical cystectomy. A low adherence to EAU guidelines recommendations for complications reporting was observed.

678 An Audit of TRUS Biopsy Sepsis Within A District General Hospital Setting

Abstract Introduction Transrectal ultrasound (TRUS) biopsy is the standard investigation of suspected prostate cancer within the United Kingdom. TRUS biopsy has significant risks of associated complications, the most serious being sepsis. An audit was designed to evaluate the rate of sepsis following TRUS biopsy within a district general hospital setting. Method All men who underwent TRUS biopsy over a four-month period between October 2019 and January 2020 were retrospectively reviewed. Standard rate of sepsis for benchmarking was identified as 0.8% as quoted in the European Association of Urology (EAU) prostate cancer guidelines. Results 88 men underwent TRUS biopsy between October and January. Three cases of TRUS biopsy sepsis requiring hospital admission were identified. The rate of sepsis determined was 3.4%. The average length of stay for the cases was 4.7 days. Oral co-trimoxazole was used as the empirical antibiotic prophylaxis pre-procedure in all. Conclusions The rate of sepsis was higher than the figure quoted in EAU guidelines. Routine local audit for TRUS sepsis is necessary to maintain standards and efficacy of prophylaxis, as well as the accurate counselling of patients on the expected risks of the procedure. Consideration should be given to targeted antibiotic prophylaxis based on pre-biopsy rectal swabs.

Erectile dysfunction management: a critical appraisal of clinical practice guidelines with the AGREE II instrument.

Our study aimedto assess the methodological strengths and weaknesses of erectile dysfunction clinical practice guidelines (CPGs) for individuals using the AGREE II tool. Erectile dysfunction related CPGs were identified from three databases: the National Guideline Clearinghouse, the Guidelines International Network, and PubMed between 2000 and 2020. We designed an independent assessment for each of the erectile dysfunction related CPGs using the AGREE II tool. Four appraisers performed these assessments. The literature search identified 8 CPGs that met our inclusion criteria. The evaluation of the AGREE II domains of each individual revealed that the median scores of domains related to applicability were quite low (39%). Also, the median scores of domains related to the rigour of development and the stakeholder involvement were relatively low (53% and 63%). We determined the highest median scores in three AGREE II domains: clarity of presentation (80.5%), editorial independence (77%), and scope and purpose (89.5%). We found that the European Association of Urology (EAU), the American Urological Association (AUA), and the British Society for Sexual Medicine (BSSM) guidelines had >60% in >4 domains and that their average AGREE II scores were over 70%. In the Canadian Diabetic Association (CDA) and the Japanese Society for Sexual Medicine (JSSM) guidelines, we found that >4 domains were >60%, but their average AGREE II scores were below 70%. The British Medical Journal (BMJ), the Canadian Urologic Association (CUA), and the Malaysian Urologic Association (MUA) guidelines had >60% in <3 domains. We highly recommended EAU, AUA and BSSM guidelines, while we moderately recommended CDA and JSSM guidelines. BMJ, CUA and MUA guidelines were weakly recommended. The quality of the guidelines for erectile dysfunction was variable according to AGREE II. We noted significant deficiencies in the methodological quality of the CPGs developed by different organisations in the areas of applicability and rigour of development.

Population-Based Comparison of Different Risk Stratification Systems Among Prostate Cancer Patients.

BackgroundIt is not known which risk stratification system has the best discrimination ability for predicting prostate cancer death.MethodsWe identified patients with non-metastatic primary prostate adenocarcinoma diagnosis between 2004 and 2015 using the Surveillance, Epidemiology, and End Results database. Patients were categorized in different risk groups using the three frequently used risk stratification systems of the National Comprehensive Cancer Network guideline (NCCN-g), American Urological Association guideline (AUA-g), and European Association of Urology guideline (EAU-g), respectively. Associations between risk classification and prostate cancer-specific mortality (PCSM) were determined using Kaplan–Meier analyses and multivariable regression with Cox proportional hazards model. Area under the receiver operating characteristics curve (AUC) analyses were used to test the discrimination ability of the three risk grouping systems.ResultsWe analyzed 310,062 patients with a median follow-up of 61 months. A total of 36,368 deaths occurred, including 6,033 prostate cancer deaths. For all the three risk stratification systems, the risk groups were significantly associated with PCSM. The AUC of the model relying on NCCN-g, AUA-g, and EAU-g risk stratification systems for PCSM at specifically 8 years were 0.818, 0.793, and 0.689 in the entire population; 0.819, 0.795, and 0.691 in Whites; 0.802, 0.777, and 0.681 in Blacks; 0.862, 0.818, and 0.714 in Asians; 0.845, 0.806, and 0.728 in Chinese patients. Regardless of the age, marital status, socioeconomic status, and treatment modality, AUC of the model relying on NCCN-g and AUA-g for PCSM was greater than that relying on EAU-g; AUC of the model relying on NCCN-g system was greater than that of the AUA-g system.ConclusionsThe NCCN-g and AUA-g risk stratification systems perform better in discriminating PCSM compared to the EAU-g system. The discrimination ability of the NCCN-g system was better than that of the AUA-g system. It is recommended to use NCCN-g to evaluate risk groups for prostate cancer patients and then provide more appropriate corresponding treatment recommendations.

Gender Representation in American Urological Association Guidelines

To study patterns and factors associated with female representation in the American Urological Association (AUA) guidelines. We gathered publicly available information about the panelists, including the AUA section, practice setting, academic rank, fellowship training, years in practice, and H-index. The factors associated with the proportion of female panelists and trends were investigated. We also examined the proportion of female panelists in the European Association of Urology (EAU) and National Comprehensive Cancer Network (NCCN) urology guidelines. There were 483 non-unique panelists in AUA guidelines, and 17% are female. Non-urologist female panelists in AUA guidelines represented a higher proportion than female urologists (30% vs 13%, P<0.0001). Compared with male panelists, females had lower H-indices (median 23 vs 35, P<0.001), and fewer were fellowship-trained (77.2% vs 86.8%; P=0.042). On multivariate analysis, non-urologists and panelists with lower H-indices were more likely to be female but there was no association between guideline specialties, academic ranking, geographic section, years in practice, and fellowship training with increased female authorship. Overtime, the proportion of female participation in guidelines remained stable. In the EAU and NCCN guideline panels, 12.2% and 10.7% were female, respectively. Female representation among major urologic guidelines members is low and unchanged overtime. Female urologist participation was proportional to their representation in the urology workforce. Being a non-urologist and lower H-indices were associated with female membership in guideline panels.

Prostate cancer follow-up costs in Germany from 2000 to 2015

PurposeThe main objective of this study is to estimate and evaluate 10-year follow-up costs after prostate cancer treatment with curative (surgery, radiotherapy) and non-curative intent (hormone, androgen deprivation) per patient in Germany in 2000, 2008, and 2015.MethodsProstate cancer follow-up recommendations were extracted from the European Association of Urology guidelines from 2000 to 2015. Per patient costs were calculated with a detailed micro-costing approach considering direct and indirect medical expenses. Input parameters were derived from expert interviews, literature research, and official scales of tariffs. Costs for insurers, providers, and payers were included to estimate societal costs.ResultsMean 10-year follow-up costs per patient after treatment with curative intent amounted to EUR 4415 in 2000, EUR 4224 in 2008 (p < 0.001), and EUR 5159 in 2015 (p < 0.001). Costs after hormone therapy with metastasis cumulated to EUR 10,846 in 2000, EUR 9818 in 2008 (p < 0.001), and EUR 11,978 in 2015 (p < 0.001). While insurers covered 37% of costs in 2000 (EUR 1664), only 23% of costs were reimbursed in 2015 (EUR 1195; p < 0.001). Cost sources mainly included consultations (55%), transportation (18%), and imaging (27%).ConclusionEarly detection and advances in prostate cancer treatment increased 10-year survival rates beyond 80% in Germany, ultimately expanding the number of survivors requiring follow-up. Statutory insurers reacted by decreasing the reimbursement rates to reduce per patient cost by up to 46%. Consequently, the economic burden was mainly shifted to payers and providers.Implications for Cancer SurvivorsEquitable and effective follow-up schedules covered by insurance funds are necessary to care for prostate cancer patients.

IJU this issue

This issue deals with a wide range of clinical topics of urology, and contains 14 Original Articles. Percutaneous nephrolithotomy (PCNL) is a minimally invasive endourological procedure recommended as first-line therapy for kidney stones >2 cm in diameter. In general, however, nephrectomy is carried out in patients with large stones within non-functioning atrophic kidneys. Su et al. (Beijing, China) evaluated outcomes in patients who underwent total ultrasound-guided PCNL for the management of large stones (>2 cm) within non-functioning atrophic kidneys. Their results showed that ultrasound-guided PCNL is safe and feasible, even for stones >2 cm in diameter within non-functioning atrophic kidneys. However, PCNL is not recommended for patients with diabetes. Several energy sources have been used for stone fragmentation during ureteroscopy. Nowadays, the holmium:YAG laser is a standard method that provides effective and safe disintegration of all stone types. However, it has some disadvantages, such as relatively high retropulsion (which might lead to relocation of the stone into the renal pelvis). Enikeev et al. (Moscow, Russia) estimated the efficacy and safety of SuperPulsed thulium-fiber laser ureteral lithotripsy, and identified optimal laser settings. Their results showed that the SuperPulsed thulium-fiber laser provides effective and safe lithotripsy during ureteroscopy regardless of stone density. Fiber diameter and laser frequency do not influence visibility or safety. Optimal laser settings are 0.5 J × 30 Hz for fragmentation and 0.15 J × 100 Hz for dusting. Subclinical Cushing syndrome is defined as a condition of hypercorticolism in patients with adrenal tumors in the absence of clinical features of Cushing syndrome. Although surgical removal of adrenal tumors for subclinical Cushing syndrome patients has been reported to be beneficial with the improvement of comorbidities, such as hypertension, diabetes mellitus and obesity, the surgical benefit is still controversial. Sato et al. (Chiba, Japan) retrospectively investigated whether the result of the 1-mg dexamethasone suppression test could predict the improvement of comorbidities after adrenalectomy in patients with subclinical Cushing syndrome. Their results showed that the greatest reduction of prescribed drugs is observed in patients whose serum cortisol levels are between 1.8 and 3.0 μg/dL after the 1-mg dexamethasone suppression test, implicating that the 1-mg dexamethasone suppression test can be a useful factor predicting the improvement of comorbidities after adrenalectomy. Today, it is well known that approximately half of cases of infertility are attributable to male factors. Recently, the European Association of Urology guideline for male infertility emphasized that oral anti-oxidants were associated with a significant increase in markers of sperm quality. Among the anti-oxidants, one of the elements perhaps most familiar and well known to the general public is zinc. Tsujimura et al. (Chiba, Japan) tried to clarify the factors associated with semen quality, and confirm whether there was an association between semen quality and serum zinc concentration. Although there was no significant correlation between serum zinc concentration and semen quality, the independent predictors for having values below the World Health Organization criteria for assessing sperm quality in binomial logistic regression analysis were follicle-stimulating hormone and serum zinc concentration. They suggested that semen analysis might be considered in men with a low level of serum zinc and high level of follicle-stimulating hormone when developing a reproductive life plan for fertilization. Yasuda et al. (Tokyo, Japan) developed the gasless approach as another type of minimally invasive endoscopic surgery, and applied it to many kinds of urological surgeries, including partial nephrectomy. In gasless partial nephrectomy, they prioritized clampless and sutureless surgery, if feasible, as an attempt to obtain maximal functional preservation. They investigated the outcomes and feasibilities of gasless laparoendoscopic single-port clampless sutureless partial nephrectomy. Their results showed that clampless and sutureless partial nephrectomy can be safely accomplished in most patients undergoing gasless laparoendoscopic single-port surgery, yielding favorable oncological and functional outcomes. Transurethral resection of the prostate represents the standard surgical technique for the management of benign prostatic hyperplasia with a prostate size <80 mL. However, considerable morbidities are associated with larger sizes. Higazy et al. (Cairo, Egypt) evaluated the safety, efficacy and cost-effectiveness of holmium enucleation of the prostate and bipolar transurethral enucleation of the prostate. Their results showed that both holmium enucleation of the prostate and bipolar enucleation of the prostate are safe and effective in the surgical management of large prostatic adenomas. However, holmium enucleation of the prostate has a shorter operative time and hospital stay, with an earlier catheter removal time, and is more cost-effective than bipolar enucleation of the prostate. None declared.

The Impact of Previous Prostate Surgery on Surgical Outcomes for Patients Treated with Robot-assisted Radical Cystectomy for Bladder Cancer

BackgroundThe feasibility and safety of robot-assisted radical cystectomy (RARC) may be undermined by unfavorable preoperative surgical characteristics such as previous prostate surgery (PPS). ObjectiveTo compare perioperative outcomes for patients undergoing RARC with versus without a history of PPS. Design, setting, and participantsThe study included 220 consecutive patients treated with RARC and pelvic lymph node dissection for bladder cancer at a single European tertiary centre. Of these, 43 had previously undergone PPS, defined as transurethral resection of the prostate/holmium laser enucleation of the prostate (n=21) or robot-assisted radical prostatectomy (n=22). Surgical procedureRARC in patients with a history of PPS. MeasurementsData on postoperative complications were collected according to the quality criteria for accurate and comprehensive reporting of surgical outcomes recommended by the European Association of Urology guidelines. Multivariable logistic, linear, and Poisson regression analyses were performed to test the effect of PPS on surgical outcomes. Results and limitationsOverall, 43 patients (20%) were treated with RARC after PPS. Operative time (OT) was longer in the PPS group (360 vs 330min; p<0.001). Patients with PPS experienced higher rates of intraoperative complications (19% vs 6.8%) and higher rates of 30-d (67% vs 39%), and Clavien-Dindo >3 (33% vs 16%) postoperative complications (all p<0.05). Moreover, the positive surgical margin (PSM) rate after RARC was higher in the PPS group (14% vs 4%; p=0.03). On multivariable analyses, PPS at RARC independently predicted higher risk of intraoperative (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.04–6.21; p=0.01) and 30-d complications (OR 2.26, 95% CI 1.05–5.22; p=0.02), as well as longer OT (relative risk [RR] 1.03, 95% CI 1.00–1.05; p=0.02) and length of stay (RR 1.13, 95% CI 1.02–1.26; p=0.02). Lack of randomization represents the main limitation. ConclusionsRARC in patients with a history of PPS is feasible, but it is associated with a higher risk of complications and longer OT and length of stay. Moreover, higher PSM rates have been reported for these patients. Thus, measures aimed at improving surgical outcomes appear to be warranted. Patient summaryWe investigated the effect of previous prostate surgery (PPS) on surgical outcomes after robot-assisted removal of the bladder. We found that patients with PPS have a higher risk of complications and longer hospitalization after bladder removal. These patients deserve closer evaluation before this type of bladder operation.

Factors predicting the success of intradetrusor onabotulinum toxin-A treatment in children with neurogenic bladders due to myelomeningocele: The outcomes of a large cohort

This study aimed to determine the effectiveness of intradetrusor injections of onabotulinum toxin-A (BoNT-A) in pediatric patients with neurogenic bladders (NB) due to myelomeningocele (MMC). The factors predicting success were also evaluated. We retrospectively identified 62 patients with NB due to MMC who underwent intravesical BoNT-A injection (100-300 U) between May 2013 and December 2018. Indications for BoNT-A injection were according to the European Association of Urology guidelines and included children for whom clean intermittent catheterization (CIC) and anticholinergic therapy had failed. Children who had previous bladder surgery or anti-reflux operations, coagulation disorders, myasthenia gravis, and non-neurogenic bladders were excluded. Twenty-one patients had accompanying vesicoureteral reflux (VUR). Preoperative and postoperative urodynamic parameters, clinical success, and VUR grades for all patients were recorded. Clinical success was defined as 4h of dryness or bladder control between CICs. Logistic regression analysis was performed to evaluate the factors affecting treatment success. The mean age of the children was 9±3.36 years. The mean follow-up was 28.5±12.2 months. Clinical success was achieved in 64.5% (n: 40) of the patients. The mean maximal cystometric capacity increased from 172.4±45.6mL to 236.3±67.2mL. The mean bladder compliance increased from 14.8±8.1mL/cm H2O to 19.3±7.4mL/cm H2O, and the mean maximal detrusor pressure decreased from 56.7±18.8cmH2O to 36.6±10.1cmH2O. Urodynamic parameters did not improve in patients with hypocompliant (fibrotic) bladders. In patients with accompanying VUR, reflux was completely resolved in 53.8% (n: 14) of the ureters, improved in 26.9% (n: 7) of the ureters, and remained unchanged in 19.2% (n: 5) of the ureters after subureteral injection. Intradetrusor BoNT-A injections provide excellent outcomes in children with NB refractory to conservative treatments. Poor responses were observed in patients who had low-compliant bladders without detrusor overactivity.

Priapism, a symptom of claudication of the cauda equina in spinal stenosis

Priapism is defined as a persistent penile erection in the absence of sexual arousal. This symptom has been documented in patients with spinal stenosis although it is considered a rare finding. The European Association of Urology guidelines on priapism [Salonia et al., 2014] list cauda equina syndrome and spinal stenosis as causative factors for ischemic priapism although the literature describing this phenomenon appears sparse. Priapism can be a rare symptom of lumbar spine stenosis/transient cauda equina compression. This presentation is complex and believed to be a parasympathetic mediated autonomic disorder. This article discusses the relationship between spinal stenosis, cauda equina syndrome and priapism using available literature. Greater awareness of this clinical finding may help clinicians in their clinical decision making. In patients with suspected cauda equina syndrome, subjective enquiry regarding the symptom priapism may add to the patients overall clinical picture.

Applicability of COVID-19 Pandemic Recommendations for Urology Practice: Data from Three Major Italian Hot Spots (BreBeMi)

BackgroundLombardy has been the first and one of the most affected European regions during the first and second waves of the novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]). ObjectiveTo evaluate the impact of coronavirus disease 2019 (COVID-19) on all urologic activities over a 17-wk period in the three largest public hospitals in Lombardy located in the worst hit area in Italy, and to assess the applicability of the authorities’ recommendations provided for reorganising urology practice. Design, setting, and participantsA retrospective analysis of all urologic activities performed at three major public hospitals in Lombardy (Brescia, Bergamo, and Milan), from January 1 to April 28, 2020, was performed. Outcome measurements and statistical analysisJoin-point regression was used to identify significant changes in trends for all urologic activities. Average weekly percentage changes (AWPCs) were estimated to summarise linear trends. Uro-oncologic surgeries performed during the pandemic were tabulated and stratified according to the first preliminary recommendations by Stensland et al (Stensland KD, Morgan TM, Moinzadeh A, et al. Considerations in the triage of urologic surgeries during the COVID-19 pandemic. Eur Urol 2020;77:663–6) and according to the level of priority recommended by European Association of Urology guidelines. Results and limitationsThe trend for 2020 urologic activities decreased constantly from weeks 8–9 up to weeks 11–13 (AWPC range –41%, –29.9%; p < 0.001). One-third of uro-oncologic surgeries performed were treatments that could have been postponed, according to the preliminary urologic recommendations. High applicability to recommendations was observed for non–muscle-invasive bladder cancer (NMIBC) patients with intermediate/emergency level of priority, penile and testicular cancer patients, and upper tract urothelial cell carcinoma (UTUC) and renal cell carcinoma (RCC) patients with intermediate level of priority. Low applicability was observed for NMIBC patients with low/high level of priority, UTUC patients with high level of priority, prostate cancer patients with intermediate/high level of priority, and RCC patients with low level of priority. ConclusionsDuring COVID-19, we found a reduction in all urologic activities. High-priority surgeries and timing of treatment recommended by the authorities require adaptation according to hospital resources and local incidence. Patient summaryWe assessed the urologic surgeries that were privileged during the first wave of coronavirus disease 2019 (COVID-19) in the three largest public hospitals in Lombardy, worst hit by the pandemic, to evaluate whether high-priority surgeries and timing of treatment recommended by the authorities are applicable. Pandemic recommendations provided by experts should be tailored according to hospital capacity and different levels of the pandemic.

Comparison of outcomes of Holmium enucleation of the prostate for small- and moderate-sized prostates.

There is an ongoing discussion in the literature on the surgical treatment option for small prostate size benign prostate hyperplasia (BPH) patients. This study aimed to evaluate the efficacy of Holmium laser enucleation of the prostate (HoLEP) surgery in small (<30ml) and moderate (30-80ml) prostate size as accepted in European Association of Urology guideline. We retrospectively analysed our database between May 2016 and May 2019 and patients who underwent HoLEP surgery. Patients who have prostate size <80ml were included the study. These patients were divided into two group: group 1 with prostate size <30ml (n: 64) and group 2 with prostate size 30-80ml (n: 101). Enucleation time (ET), morcellation time (MT), total operation time (OT), enucleation efficiency (EE), morcellation efficiency (ME), intra- and post-operative complications were analysed. While EE and Hb drop were better in favour of group 2; PSA drop, ET, MT, OT and ME were superior in favour of group 1. In group 1, intra-operative complications were higher (6 vs. 2; p<.05) and post-operative complications did not differ statistically between groups (p=.14). No statistically significant finding was found between groups regarding incontinence. In conclusion, HoLEP is a reliable method in terms of its results in patients with small prostates.

Long-term oncological outcomes of the Agarwal loop-ligation technique for management of the distal ureter during laparoscopic radical nephroureterectomy.

To describe the Agarwal loop-ligation technique for the management of the distal ureter during laparoscopic radical nephroureterectomy (LRNU) for upper tract urothelial carcinoma (UTUC) and report on long-term oncological outcomes. In the Agarwal loop-ligation technique, the distal ureteric stump is controlled using endoscopic Endoloop® or PolyLoop® ligation to ensure en bloc excision of the bladder cuff and prevent spillage of upper tract urine into the perivesical space. A retrospective review of the medical records of 76 patients who underwent the Agarwal loop-ligation technique for UTUC at participating centres from July 2004 to December 2017 was performed. Data collected included demographics, perioperative, and long-term oncological outcomes. Survival was calculated using Kaplan-Meier survival analyses. A total of 76 patients were included. The median age was 71.5years and median operative time was 4.3h. The intramural ureter and bladder cuff were completely excised in all patients. Distal surgical margins were clear in all, with only two patients found to have tumour extending to the circumferential surgical margin. There were no cases of perivesical recurrence or port-site metastasis. The 5-year bladder, local, and contralateral recurrence-free survival was 59.6%, 89.0% and 93.5%, respectively. Metastasis-free survival at 5-years was 73.5%. The 5-year overall survival and cancer-specific survival rates were 70.3% and 84.7%, respectively. We have described the Agarwal loop-ligation technique for the management of the distal ureter in LRNU. This technique complies with oncological principles outlined in the European Association of Urology guidelines, which minimises tumour spillage. Long-term oncological outcomes are satisfactory, with no cases of perivesical recurrence detected in this series.

Guideline of the guidelines: urolithiasis.

We reviewed the latest guidelines on urolithiasis to highlight the commonalities and differences in the most important recommendations. Most guidelines utilize systematic review of literature and grade evidence to generate the appropriate recommendations and statements. Only the latest versions of guidelines were included in this review. Four national and international guidelines were included in this review, including those of the EAU (European Association of Urology), the AUA (American Urological Association)/ES (Endourological Society), the UAA (Urological Association of Asia) and the NICE (National Institute for Health and Care Excellence) guidelines. There are general similarities in the most important recommendations. The EAU guidelines provide the latest evidence updates.