Urology Research Articles

Role of Tamsulosin and Solifenacin to Reduce Double J Stent Related Symptoms After Uncomplicated Ureteroscopic Lithotripsy

Introduction: Endoscopic urological surgeries are safe procedures with further reduction in morbidity due to double J stents. Stents usually give rise to lower urinary tract symptoms and various drugs have been prescribed singly drug or in combination to ameliorate the symptoms. Since double J stenting of the ureter is one of the most common procedures in our department, we attempted to compare the efficacy of the anti-muscarinic drug Solifenacin over alpha-blocker Tamsulosin. Materials and methods: A prospective study was done where 50 consecutive patients who underwent double J stenting following ureteroscopic lithotripsy were randomized and given 5 mg Solifenacin or 0.4 mg Tamsulosin. Lower urinary tract symptoms were assessed at end of first and second week. The results were analyzed. Results: Fifty consecutive patients who underwent ureteroscopic lithotripsy were enrolled in the study. 25 of them were randomly prescribed Solifenacin and 25 were prescribed Tamsulosin based on computer generated randomization. The IPSS score was higher in the Solifenacin group, compared to the Tamsulosin group in both the first and second weeks, which was significantly higher in the first week. The reduction of symptoms within the first and second week in both groups was clinically significant, Solifenacin group being p <0.0001 and Tamsulosin group being 0.0004. Conclusions: Lower urinary tract symptoms are common and quite bothersome following DJ stent insertion. The symptoms can be ameliorated with the use of alpha blockers and anti-muscarinic drugs.

Operative caseload of general surgeons working in a rural hospital in Central Australia.

There is limited published data on the caseload of general surgeons in Central Australia. The region has a significant Indigenous population, who often face higher rates of chronic diseases and require more frequent surgical interventions compared to non-Indigenous individuals. This study aims to outline the workload of surgeons at Alice Springs Hospital to determine the necessary skill set and surgical education for future surgeons. A retrospective review of all general surgery operative cases performed in Central Australia, Alice Springs Hospital was conducted between January 2012 and December 2021. The RACS Morbidity Audit and Logbook Tool was used to classify surgical procedures along with Medicare Benefits Schedule item numbers. Tables were created to present the annual and specialty-specific data on the types and volumes of procedures. From January 2012 to December 2021, 35 318 cases were performed, with 92.5% being general surgery, 3% plastics and reconstructive surgery and 2.8% vascular procedures. Indigenous patients received a higher proportion of procedures (50-60%) compared to non-Indigenous patients (30-50%). Common procedures included incision and drainage of abscesses and debridement of wounds, while trends across specialties showed a decline in ENT and plastic surgeries, stable thoracic and vascular cases, and increased numbers of urology operations. General surgeons in rural centres must possess a wide range of skills and be capable of performing a variety of procedures. Trainees should be encouraged to consider practicing in rural areas, and those interested should account for the specific needs of the communities they plan to serve.

Preoperative risk factors for venous thromboembolism in major urologic cancer surgeries.

Venous thromboembolism (VTE) is a serious complication of urologic cancer surgeries. Incidence varies by procedure, with cystectomy carrying the highest risk. Our study aims to explore the preoperative risk factors for VTE development in major urologic cancer surgeries. Using the ACS-NSQIP database, cystectomy, prostatectomy or nephrectomy cases between 2011 and 2020 were identified. Patient characteristics and pre-operative variables were compared using χ2 test. Multivariate logistic regression was used to control for confounding variables. 207,861 patients were included. 2484 (1.2%) patients experienced VTE post-operatively, with a rate of 3.16% among cystectomy patients. The incidence of pulmonary embolism (PE) peaked at day 2, while that of deep venous thrombosis (DVT) peaked at days 2 and 8. On multivariate analysis, blood transfusion and cystectomy were associated with the highest risk of VTE (OR = 2.29 [1.64, 3.18], P = < 0.001 and OR = 2.96, 95%CI [2.62, 3.37], P < 0.0001; respectively). Other important risk factors included advanced age ≥ 80 years (OR = 1.98 [1.65, 2.40], P = 0.001), BMI ≥ 40kg/m2 (OR = 1.82 [1.43, 2.24], P = 0.001), congestive heart failure (OR = 1.75 [1.15, 2.66], P = 0.008), steroid use (OR = 1.55 [1.26, 1.94], P = < 0.001), thrombocytosis OR = 1.43 [1.16, 1.76], P = 0.001) and leukocytosis (OR = 1.41 [1.11, 1.54], P = < 0.001). Our study highlights important pre-operative risk factors for the development of VTE after urologic cancer surgeries. This stresses the importance of pre-operative risk assessment to guide counseling and thromboprophylaxis strategies especially among cystectomy patients who are older, obese, and requiring blood transfusion.

A forgotten double J stent with encrustation leading to pelvi-ureteric obstruction: A case report

Double J (DJ) ureteric stents are widely applied in urological operations, they maintain patient’s urinary system postoperatively, thereby accelerating recovery. Prolonged stent insertion is associated with complications. A 38-year-old woman presented with hematuria, right flank pain, and urinary tract infection. She underwent renal calculi removal 8 years ago. KUB radiograph revealed and indwelling DJ stent with vesical calculus and pyelonephritis. Ultrasound revealed a large bladder stone with mild right hydronephrosis. Computed tomographic (CT) urography revealed a DJ stent encrustation and further formation into core of the bladder stone. Cystolithotomy was performed, vesicle calculi retrieved. At 4 weeks, the patient presented with a right-side flank pain for which patient was evaluated with a contrast-enhanced CT urography which revealed a pelvi-ureteric junction obstruction with hydronephrosis. A pyeloplasty was performed and DJ stent was placed in situ, to be retrieved at 6 weeks. With improved biomaterials, design and technological improvements of DJ stents, patient’s discomfort is greatly reduced. As a result, DJ stents got left in place for a longer duration of time, and therefore high incidences of forgetfulness, retained DJ stents. Encrustation, however, is frequently encountered. Patient factors such as low education and socioeconomic status and patients living in far off rural places also contribute to forgotten indwelling stents. Authors recommend placement of DJ stents after pyeloplasty for treating pelvi-ureteric junction obstructions following long-term retained stents. Patient counseling, education, and strict follow-up should ensure a timely stent removal and improved patient safety. Effective patient counseling and awareness reduces incidences of forgotten indwelling stents and patient-related complications.

Teaching residents in emergency surgery for acute bowel obstruction-is supervised surgery safe and feasible? A retrospective single-center analysis from a MIS-specialized hospital.

Emergency surgery for acute bowel obstruction (ABO) is a common and occasionally technically demanding procedure, requiring both surgical skill and strategic planning. The risk entailed in teaching residents during ABO surgery has not been defined or investigated in detail to date. It is the aim of this study to reveal whether surgery for ABO, performed by resident surgeons under supervision, is safe and feasible. A retrospective analysis was conducted of all emergency surgeries for ABO performed between 2009 and 2023 at a community-based hospital. Patients' general characteristics, procedural data and outcome parameters were compared. Differences between teaching procedures and non-teaching procedures were analysed. The study was conducted at the Department of General and Visceral surgery at a community-based hospital (St. John of God Hospital Salzburg, Austria). All emergency surgeries for ABO (n = 300 patients) that were performed during the study period were included. Emergency surgery for ABO was performed in 300 patients during the study period, 15.3% of which operations were performed by residents under supervision and 84.7% by senior surgeons. No differences between these two groups were found in terms of patient characteristics, except for a past medical history of previous gynecologic or urologic surgery that was more frequent in the senior surgeon group (p = 0.02). Neither procedural data nor conversion rates from a minimally invasive (MIS) to an open (OS) approach, nor postoperative complication rates were found to be significantly different between these groups. Emergency surgery for ABO, performed by residents under supervision, is safe and feasible, showing no significant differences in terms of complication rates, morbidity or mortality as compared to procedures performed by senior surgeons.

Implementation of a Urologic Surgery Skills Fair for Medical Students

To increase the proportion of applicants to urology residencies, we created a surgical skills fair to introduced urology early in undergraduate medical education. Funded by the Department of Urology, the fair was designed to have student rotations through 12 hands-on practice stations supervised by faculty and an advanced care practitioner or resident physicians. At conclusion, medical students completed a voluntary survey about their experience. Surgical skills fairs were organized at Yale School of Medicine (New Haven, CT) in 2022 and 2023. The fair was designed to encourage interaction between medical students, urology residents, and urology faculty by highlighting common urologic procedures and skills. The fair was well received by medical students at all levels of training. Over 2 years, 155 medical students attended, including 67 (43%) first-year and 60 (39%) second-year medical students. Eighty-two medical students completed the survey. An average of 19 attendings, advanced care practitioners and residents attended each event. Of the survey respondents, 42.7% reported prior interest in a surgical specialty but had not considered urology. Students reported increased interest in urology and greater confidence in urologic skills after the event (p < 0.001). We demonstrate that creating a surgical fair in urology is feasible and enhances early exposure and interest in urology. For students who do not pursue urology, the fair provides knowledge of urological pathologies and valuable skills for all physicians.

Editorial Comment to “Integrating a virtual reality mask in functional urological surgeries under local anaesthesia: A prospective cohort study on utility and satisfaction”

Editorial Comment to “Integrating a virtual reality mask in functional urological surgeries under local anaesthesia: A prospective cohort study on utility and satisfaction”

Impact of antibiotic treatment duration for preoperative asymptomatic bacteriuria, during urological surgery, on postoperative infectious complications: results from the multicentric TOCUS cohort.

According to the European guidelines, any urological surgery breaching the mucosa requires preoperative screening and antibiotic treatment of any asymptomatic bacteriuria (ABU). The aim of this study was to determine whether the preoperative antibiotic treatment duration of ABU in urological surgery impact postoperative infectious complications. National multicenter, retrospective study including all consecutive patients screened for ABU before urologic surgery in 10 centers from 1st April 2019 to April 2023. The primary endpoint was all postoperative infectious complications occurring within 30 days after surgery. Short antibiotic treatment (SAT) of ABU was defined by 5- day regimen or less. Long antibiotic treatment (LAT) was defined by duration longer than 5 days. Among the 2389 patients included, 839 (35.1%) patients had positive urine culture (UC), of whom 546 (65%) had positive mono or bimicrobial UC and 292 (34.8%) polymicrobial UC. There were 106 (4.4%) postoperative infectious complications occurring within 30 days including 62 (58.5%) in the positive UC group. In the positive UC group, 336 (40%) had received SAT, 261 (31.1%) LAT and 231 (27.5%) had not received any treatment. The 30-day surgery-related infection rates were 8.3%, 6.1% and 7.36% respectively. There was no statistical difference between SAT versus LAT in the univariate analysis (P=0.6) or in the multivariate analysis OR 1.97 [0.37, 1.86] (P=0.06). Our results found no association between antibiotic treatment duration and urinary infectious complication among patients with preoperative ABU who undergo urological surgery. These results need a RCT to be confirmed.

Ambulatory urologic surgery A paradigm shift towards optimizing resource use in outpatient settings.

Ambulatory urologic surgery A paradigm shift towards optimizing resource use in outpatient settings.

Establishing maximal wait times for urologic surgery in Canada in 2024

Establishing maximal wait times for urologic surgery in Canada in 2024

Advances in Robotic Surgery: A Review of New Surgical Platforms

In recent decades, the development of surgical systems which minimize patient impact has been a major focus for surgeons and researchers, leading to the advent of robotic systems for minimally invasive surgery. These technologies offer significant patient benefits, including enhanced outcome quality and accuracy, reduced invasiveness, lower blood loss, decreased postoperative pain, diminished infection risk, and shorter hospitalization and recovery times. Surgeons benefit from the elimination of human tremor, ergonomic advantages, improved vision systems, better access to challenging anatomical areas, and magnified 3DHD visualization of the operating field. Since 2000, Intuitive Surgical has developed multiple generations of master-slave multi-arm robots, securing over 7000 patents, which created significant barriers for competitors. This monopoly resulted in the widespread adoption of their technology, now used in over 11 million surgeries globally. With the expiration of key patents, new robotic platforms featuring innovative designs, such as modular systems, are emerging. This review examines advancements in robotic surgery within the fields of general, urological, and gynecological surgery. The objective is to analyze the current robotic surgical platforms, their technological progress, and their impact on surgical practices. By examining these platforms, this review provides insights into their development, potential benefits, and future directions in robotic-assisted surgery.

Advancements in Urethral Reconstruction Using Biodegradable Tissue: A Comprehensive Review

Urethral reconstruction, a pivotal domain within the realm of urology, has undergone a transformative evolution with the advent of innovative strategies utilizing biodegradable tissue. This article presents a comprehensive exploration of the burgeoning field of Urethral Reconstruction with Biodegradable Tissue (URBT), shedding light on its intricate nuances and clinical implications. The utilization of biodegradable materials in urethral reconstruction represents a paradigm shift aimed at circumventing the limitations inherent in traditional non-biodegradable approaches. The inherent ability of these materials to provide temporary structural support during the critical phases of tissue healing, coupled with subsequent degradation, obviates the need for secondary interventions for material removal, thus mitigating the risk of complications associated with prolonged foreign body presence. This review scrutinizes the biomechanical properties of various biodegradable scaffolds, examining their capacity to withstand physiological stresses while fostering optimal tissue regeneration. Immunological responses to these materials are also elucidated, providing insights into the biocompatibility and host reactions critical for long-term success. Furthermore, the nuanced kinetics of biodegradation are explored, emphasizing their impact on the temporal dynamics of tissue healing and functional restoration. Delineating the clinical applicability of diverse biodegradable constructs, ranging from synthetic polymers to naturally-derived matrices, constitutes a focal point of this analysis. The article critically evaluates the outcomes and complications associated with URBT, providing a comprehensive understanding of the efficacy and challenges inherent in this emerging field. As the landscape of urological surgery continues to evolve, this article serves as a beacon for clinicians, researchers, and medical practitioners navigating the complexities of urethral reconstruction. By delving into the molecular intricacies and clinical implications of URBT, it aims to contribute substantively to the ongoing discourse that shapes the future trajectory of urological surgery, offering a roadmap towards optimized patient outcomes and improved quality of life.

Patient reported health related quality of life outcomes after viable cryopreserved umbilical tissue placement directly over spared neurovascular bundles after robotic assisted radical prostatectomy.

Incontinence and sexual dysfunction remain common side effects from robotic-assisted radical prostatectomy (RARP) despite nerve sparing (NS) and bladder neck reconstruction techniques. Placing growth factors and anti-inflammatory substances over neurovascular bundles is an emerging technique to enhance recovery of continence and potency. Viable cryopreserved umbilical tissue (vCUT) is FDA-approved for surgery. The objective is to determine if vCUT use in NS-RARP accelerates return of continence and sexual function. A retrospective cohort of 176 patients undergoing NS-RARPs with and without vCUT from 2015 to 2020 was identified through the Michigan Urological Surgery Improvement Collaborative (MUSIC). Return to social urinary continence at 3, 6, and 12months, postoperatively was evaluated using MUSIC patient-reported outcomes (PRO), a validated questionnaire assessing urinary and sexual quality of life at baseline and post-treatment. A distinct cohort of 65 patients undergoing NS-RARP with and without vCUT was assessed for erections firm enough for intercourse at 12 and 24months post-operatively using MUSIC-PRO. The association between vCUT use and social continence at 3months was assessed via multivariable logistic regression. A descriptive analysis among patients with quality erections prior to surgery assessed the association between vCUT use and erection quality. Continence was achieved by 3months post-op in 86% (99/115) of vCUT patients versus 74% (45/61) in non-vCUT patients (p = 0.044). In a multivariable analysis, although not reaching conventional statistical significance, vCUT patients were more likely to achieve continence than non-vCUT patients (OR = 2.21, p = 0.073). At 24months post-op, 32% of vCUT patients reported good sexual function versus 33% in non-vCUT patients (p = 0.9). vCUT use during NS-RARP is associated with quicker return to social urinary continence. However, no differences were seen in return of potency. Further studies with longer follow-up and larger sample sizes may further evaluate effectiveness of vCUT in accelerating return of postoperative continence and potency.

Which is More Accurate? Urologist or STONE Nomogram: An Original Study

Background: Comparing and determining the accuracy of -urolo gists and STONE nomogram prediction about the Percutaneous Nephrolithotomy (PCNL) outcomes in urolithiasis patients. Methods: This retrospective cohort study was performed on 70 patients who underwent PCNL in Firoozgar Hospital (Tehran, Iran) from March 2019 to April 2020. Two expert urologists, who were not informed about the actual result of the procedure and did not have access to the post-operative data, were asked to predict the success rate of PCNL based on pre-operative imaging. The remaining stone size of less than 4 mm was considered as stone-free in PCNL. On the other hand, the STONE nomogram calculated the stone-free rate, and if the predicted success rate was over 60%, PCNL was considered successful based on the STONE nomogram. Results: The accuracy of the urologist’s prediction was 76.42%. The STONE nomogram correctly predicted the PCNL result in 59 cases (84.28%). There was a significant correlation between the actual success rate of the PCNL and the nomogram’s prediction (p-value= 1.013×10-5). There was no significant difference between the surgeons and the nomogram’s prediction (p-value=0.336). The number of stones did not significantly affect the correct prediction of surgical results (p-value&lt;0.05). Upper calyx stones caused a significant difference between correct prediction of surgical results by surgeons and nomograms (p-value&lt;0.05). Conclusion: No significant difference was found between surgeons’ prediction and STONE nomogram, but only in patients with kidney stones in the upper calyx; the nomogram’s prediction accuracy was higher.

Implementation of Electronic Medical Record Interventions to Maximize Opioid Disposal after Surgery in Routine Clinical Practice.

Despite guideline directed opioid prescribing after surgery, many patients retain excess opioids. Leftover pills increase the risk for misuse, diversion, and dependency. It is unclear whether interventions applied in routine clinical practice can increase excess opioid disposal rates. All adult patients at our institution with postoperative opioid prescriptions were identified in general surgery, otolaryngology, plastic surgery, neurosurgery, urology and transplant surgery. Disposal rates for 453 pre-intervention patients (surgery between 3/1/23-6/30/23) were compared with 545 intervention patients (surgery between 10/1/23-1/31/24). Pre- and post-intervention patients were called 1-3 months after surgery and asked about excess opioids.Interventions:1. Opioid disposal information sheets provided after surgery.2. Opioid disposal reminder delivered via patient portal in electronic medical record (EMR).3. Best practice alert (BPA) triggered in EMR at post operative visit reminded providers to discuss opioid disposal. Opioid disposal outcomes were obtained from 70% (699/998) of patients. 54% (375/699) had excess opioids. The percentage of patients disposing of their excess opioids increased from 30% (39/130) pre-intervention to 83% (204/245) post-intervention, p<0.00001. Forty-seven percent (247/545) of post-intervention patients had discussions with their providers after a BPA fired at their post-operative visits. Patients who had a provider discussion were more likely to dispose of excess opioids than those who only received an information sheet and patient portal reminder (92% vs 70%, p < 0.00001). Interventions easily incorporated into the EMR as part of routine clinical practice can markedly increase excess opioid disposal rates after surgery. When information on opioid disposal and patient portal reminders are combined with disposal discussions with providers at the postoperative visit, opioid disposal rates of >90% can be achieved.

An initial exploratory clinical study and outcome assessment of gastrointestinal surgeries using advanced robotic-assisted techniques.

In addition to the Da Vinci surgical robot, domestic surgical robots are being developed rapidly. Chinese Toumai® laparoscopic surgical robot was approved for urological surgery in 2022.This study aims to systematically evaluate the safety and efficacy of the Toumai® robotic surgical system in performing complex gastrointestinal surgeries. This prospective, single-center, single-arm exploratory study was conducted at Gansu Provincial Hospital between June 2022 and October 2023, enrolling 12 patients undergoing gastrectomyand 9 patients undergoing colorectal resection. The primary endpoints are oncological outcomes and surgical success rates, while secondary endpoints encompassed intraoperative blood loss, operative duration, complication rates, system performance metrics, length of hospital stay, and postoperative pain levels. All patients successfully underwent robotic-assisted surgery with adequate oncological resection and favorable postoperative outcomes. There were no conversions to open or laparoscopic surgery, resulting in a 100% procedural success rate. The median docking time for radical gastrectomy was 17.50 (14.25, 21.50) minutes, with a median master-slave control time of 121.50 (105.50, 172.00) minutes, median intraoperative blood loss of 100.00 (50.00, 275.00) mL, and a median postoperative hospital stay of 9.00 (7.25, 10.75) days. For radical colorectal surgery, the median docking time was 22 (17.50, 30.50) minutes, the median master-slave control time was 68 (56.50, 119.00) minutes, with a median blood loss of 50 (50.00, 150.00) mL, and a median postoperative hospital stay of 7 (7.00, 10.00) days. No intraoperative organ injury, mortality, system failure, or severe postoperative complications were reported. These preliminary findings provide compelling evidence supporting the safety and efficacy of the Toumai® laparoscopic surgical robotic system in performing gastric and colorectal surgeries.

Safety and Effectiveness Comparison of Epidural Block and Quadratus Lumborum Block in Patients Undergoing Renal and Urological Surgery: A Systematic Review and Meta-Analysis.

Safety and Effectiveness Comparison of Epidural Block and Quadratus Lumborum Block in Patients Undergoing Renal and Urological Surgery: A Systematic Review and Meta-Analysis.

Guidelines for robotic credentialling in reconstructive and functional urology. Consensus study

AbstractObjectivesThis study aims to define criteria for robotic reconstructive and functional urology credentialing using expert consensus. A recent narrative review identified a lack of standardised minimal requirements for performing robotic‐assisted surgery procedures. The substantial variability or absence of a standardised curriculum and credentialing process within a highly specialised surgical field is often insufficient to guarantee surgeon proficiency and could potentially jeopardise patient safety.Subjects and MethodsThirty‐five international robotic surgery experts in urology and urogynaecology, selected based on surgical and research expertise, were invited to participate as expert panellists. Using a modified Delphi process the experts were asked to indicate their agreement with the proposed list of recommendations that was identified from the literature and review of relevant international credentialing policies in three electronic survey rounds.ResultsFourteen experts participated in round 1 of online surveys, 9 in round 2 and 13 in round 3. From 50 statements presented to the Delphi panel in round 1, a total of 39 recommendations (32 from round 1, 4 from round 2 and 3 from round 3) with median importance (MI) ≥ 7 and disagreement index (DI) &lt; 1 were proposed for inclusion into the final draft set and were reviewed by the project team. Panellists agreed reconstructive and functional urology required its own specific modular training curriculum as the foundation for robotic training and a surgeon must have appropriate training i.e., fellowship or evidence of speciality training in functional urology.ConclusionsThis was the first study to develop preliminary guidelines on credentialing for robotic surgery in reconstructive and functional urology. A Delphi approach was employed to establish comprehensive credentialing criteria for robotic‐assisted surgery. The consistent adoption of these criteria across institutions will foster the proficiency of robotic surgeons and has the potential to bring improvements in patient outcomes.

Comparison of the Radiation Protection Effectiveness between Lead and Antimony-Tungsten Bed Skirt in Fluoroscopic-guided Simulated Urological Surgery

Objective: This study aimed to develop a new shielding device, a bed skirt, and compare the radiation protection effectiveness between lead and antimony-tungsten (Sb-W) bed skirts in fluoroscopic-guided urological surgery. Material and Methods: The simulated surgery of ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL), using the phantoms, was set. The lead and Sb-W skirts were mounted around the operating table. The fluoroscopy time was 120 seconds, and the experiment was repeated 10 times. The radiation dose to the body parts of the patient, surgeon, and anesthesiologist was measured with optically stimulated luminescent dosimeters and compared in the following conditions: conventional operating table, Sb-W bed skirt, and lead bed skirt.Results: By installing a bed skirt, the radiation dose was decreased, with lead being dominant in all areas. The lead bed skirt reduced the radiation dose by 20% to the patient, 66% to the surgeon, and 91% to the anesthesiologist. The absorbed radiation dose of the lead bed skirt was lower than the Sb-W bed skirt in URS settings (23.3±1.8 µGy vs 32.0±1.9 µGy, p-value&lt;0.001) as well as PCNL settings (257.2±15.6 µGy vs 296.5±24.6 µGy, p-value&lt;0.001). There was no statistically significant difference between the conventional operating table and the Sb-W bed skirt in both URS settings (p-value=0.066) and PCNL settings (p-value=0.153).Conclusion: The lead bed skirt significantly reduced the radiation exposure and provided superior radiation protection compared with the Sb-W bed skirt. This shielding technique is practical to minimize the harmful effects of radiation from fluoroscopy.

Comparison of two methods of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed and complication in urologic surgery

Comparison of two methods of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed and complication in urologic surgery