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Este mes en... Arab Journal of Urology:

  • Risk factors for the development of flank hernias and bulges following surgical flank approaches to the kidney in adults

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Tarek Osman, Ahmed Emam, Ahmed Farouk, Karim ElSaeed, Ahmed M. Tawfeek, Abdelawal AbuHalima

    Abstract
    Objectives

    To evaluate the incidence and risk factors for the development of flank incisional hernias or bulges following surgical flank approaches to the kidney.

    Patients and methods

    In all, 100 consecutive adult patients who underwent variable renal surgeries via flank approaches were included in this prospective study. The incidence and risk factors for flank hernias and bulges were studied at 1- and 6-months postoperatively.

    Results

    At 6 months postoperatively, the incidence of flank bulge was 14% and for lumbar hernia was 10%. The univariate analysis showed 13 significant factors to be associated with the occurrence of a flank bulge or hernia following flank incisions. When the significant risk factors in the univariate analysis were studied by multivariate analysis, using a logistic regression analysis, four independent risk factors were identified. These were: body mass index (BMI) ≥26.3 kg/m2 (P = 0.04), the use of a self-retaining retractor during surgery (P = 0.02), not preserving or identifying the neurovascular bundle (NVB) during surgery (P = 0.028), and postoperative abdominal distention (P = 0.001). Moreover, all cases included in our study who underwent en masse wound closure, developed surgical wound infection or who had constipation developed postoperative flank bulge or hernia.

    Conclusion

    High BMI, the use of self-retaining retractor, not identifying or preserving the NVB, postoperative abdominal distention, en masse wound closure, surgical wound infection, and constipation are significant risk factors associated with postoperative flank hernia and bulge.

  • Simulation-based training in urology residency programmes in the USA: Results of a nationwide survey

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Mohamed Kamel, Ehab A. Eltahawy, Renee Warford, Carol R. Thrush, Yasser A. Noureldin

    Abstract
    Objective

    To evaluate the current usage of simulation in urological education in the USA and the barriers to incorporating a simulation-based educational curriculum, as the shift towards competency-based medical education has necessitated the introduction of simulation for training and assessing both non-technical and technical skills.

    Materials and methods

    Residency programme directors at Accreditation Council for Graduate Medical Education (ACGME)-accredited urology training programmes in the USA were invited to respond to an anonymous electronic survey. The study evaluated the programme directors’ experiences and opinions for the current usage of existing urology simulators. The survey also elicited receptiveness and the barriers for incorporating simulation-based training curricula within urology training programmes.

    Results

    In all, 43 completed surveys were received (35% response rate). Amongst responders, 97% (42/43) reported having access to a simulation education centre, and 60% (25/42) have incorporated simulation into their curriculum. A total of 87% (37/43) agreed that there is a role for a standardised simulator training curriculum, and 75% (30/40) agreed that simulators would improve operating room performance. A total of 64% (27/42) agreed that cost was a limiting factor, 12% (5/42) agreed on the cost-effectiveness of simulators, 35% (17/41) agreed there was an increased need for simulator education within work-hour limitations, and 38% (16/42) agreed a simulation programme would reduce patient risks and complications.

    Conclusions

    The majority of urology programme directors consider that there is a role for incorporating a simulation-based curriculum into urology training. Barriers to implementation include cost burden, need for constant technology updates, need for advanced planning, and willingness of faculty to participate in administration.

  • Bilateral same-session flexible ureterorenoscopy for renal and/or ureteric stone disease treatment

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Ersan Arda, Basri Cakiroglu

    Abstract
    Objective

    To evaluate the effectiveness and safety of bilateral same-session flexible ureterorenoscopy (f-URS) in the treatment of bilateral renal and/or ureteric stone disease.

    Patients and methods

    From October 2007 to December 2015, 62 patients who had undergone bilateral, same-session f-URS were included in the study. The procedures were performed under general anaesthesia, in lithotomy, and initiated on the side in which the patient was clinically symptomatic or on the side in which the stone was smaller. Plain abdominal radiography, intravenous urography, renal ultrasonography and/or non-contrast computed tomography scans were conducted in all patients. The success rate was defined as, patients who were stone-free or only had residual fragments of <3 mm.

    Results

    A total of 62 patients (43 male, 19 female), with a mean (SD) age of 39 (15.1) years, were included. The mean (SD) stone size was 23.2 (6.11) mm with a mean (SD) operative time of 58.8 (16.24) min. The stone-free rates were 90.3% and 100% after the first and second procedures, respectively. The mean (SD) hospital stay was 1.58 (0.72) days. There were minor complications (Clavien–Dindo grade I–II) in 10 (16%) patients and major complications (Clavien–Dindo III–IV), e.g. distal ureter laceration and laser injury of the ureter, in two patients.

    Conclusion

    Same session bilateral f-URS is a successful and safe method for bilateral renal and/or ureteric stones.

  • The use of a string with a stent for self-removal following ureteroscopy: A safe practice to remain

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Karen M. Doersch, Amr Elmekresh, G. Luke Machen, Marawan M. El Tayeb

    Abstract
    Abstract objectives

    To examine the safety and effectiveness of the use of a stent with a string attached after ureteroscopy (URS) for self-removal of the stent by the patient.

    Patients and methods

    After Institutional Review Board approval, a retrospective chart review was performed concerning patients who underwent URS and received an indwelling stent with or without a string attached to the stent (94 vs 349, respectively). Amongst the string group patients received a single- or a double-arm-stringed stent (31 vs 63, respectively). Statistical analyses included chi-squared and Student’s t-tests.

    Results

    The string group consisted of 94 procedures, in which 59.6% of the patients were male with a mean (SD) age of 50.0 (16.5) years. In the no-string group, 51.3% of the 349 procedures were performed in males and the mean (SD) age was 54.9 (18.1) years. Complication rates were 12.8% in the string group and 14.0% in the no-string group (P = 0.867). In the string group, 17.0% of the patients returned to the Emergency Department, whilst 15.8% of the no-string patients returned (P = 0.753). The complication rate in the single- and double-arm groups were 12.9% and 12.7%, respectively (P > 0.910). Self-removal of stents was successful in 94.7% of patients (89/94).

    Conclusions

    The use of a stent with a string after URS appears safe and effective. Few patients had difficulty removing their stents and complication rates were similar in the groups with and without a string attached to their stents. Single- and double-arm-stringed stents have similar complication rates.

  • Is the 4.5-F ureteroscope (Ultra-Thin) an alternative in the management of ureteric and renal pelvic stones?

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Hakkı Uzun, Nezih Akça

    Abstract
    Objectives

    To compare the 7.5–9.5F ureteroscope (URS) with the 4.5–6.5F URS (Ultra-Thin) in terms of success and complication rates in adult patients with ureteric and renal pelvic stones.

    Patients and methods

    In all, 41 patients treated with 7.5–9.5F semi-rigid URS (Group 1) and 33 patients treated with the Ultra-Thin (Group 2) were prospectively included in the study. All patients underwent holmium laser ureteroscopic lithotripsy. In each group, when the selected ureteroscopic intervention failed to reach or disintegrate the stone, the URS was replaced with the other one. Outcome criteria were: success and complication rates, stone size and stone surface area, operative time, laser time, usage of guidewire, and postoperative JJ-catheter placement.

    Results

    The ureteroscopic lithotripsy in 36 of 41 (87.8%) and 24 of 33 (72.7%) patients was completed without a need to replace the URS with the other one in groups 1 and 2, respectively (P = 0.67). After replacement of the 7.5–9.5F URS with the Ultra-Thin for patients who failed in Group 1, the overall stone-free rate (SFR) improved to 97.5% (P = 0.014). In Group 2, after replacement of the Ultra-Thin with the 7.5–9.5F URS for the failed patients, the overall SFR improved to 96.9% (P = 0.02). There was no significant difference between the groups for complications. Postoperative JJ stenting was significantly less in Group 2 (21.2%) in comparison to Group 1 (46.3%) (P = 0.02).

    Conclusions

    The Ultra-Thin has a similar success rate as the 7.5–9.5F URS in the treatment of ureteric stones and is a feasible option in patients in whom a conventional URS cannot be advanced through any segment of the ureter.

  • Efficacy of silodosin on the outcome of semi-rigid ureteroscopy for the management of large distal ureteric stones: blinded randomised trial

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Ahmed Mohey, Tarek M. Gharib, Hisham Alazaby, Mostafa Khalil, Ahmed Abou-Taleb, Yasser A. Noureldin

    Abstract
    Objective

    To evaluate the efficacy of silodosin therapy, as a new α-adrenergic receptor (α-AR) blocker, on the success rate of semi-rigid ureteroscopy (URS) for the management of large distal ureteric stones.

    Patients and methods

    This prospective study recruited 127 adult patients with single distal ureteric stone of ≥1 cm. The patients were randomly allocated to two groups: the first group included 62 patients who received silodosin (8 mg) for 10 days before URS (Silodosin group), whilst the second group included 65 patients who received placebo, in the form of multivitamins, for 10 days before URS (Placebo group). All patients underwent URS and a pneumatic lithoclast was used for stone fragmentation.

    Results

    The mean (SD) operative time was shorter in the Silodosin group compared with the Placebo group, at 41.61 (4.67) vs 46.85 (4.6) min, respectively. Furthermore, advancing the ureteroscope to access the stone failed in a statistically significant number of patients in the Placebo group compared with the Silodosin group (13 vs two, respectively). The complication rate was significantly higher in the Placebo group compared with the Silodosin group (20% vs 6.4%, P = 0.036). Additionally, the need for postoperative analgesia was significantly lower in the Silodosin group compared with the Placebo group (8.1% vs 26.2%, P = 0.009).

    Conclusion

    Silodosin therapy prior to URS management of large distal ureteric stones seems to be associated with better advancing of the ureteroscope to access the stone, shorter procedure time, higher stone-free rate, lower incidence of complications, and lesser need for postoperative analgesia.

  • Simultaneous antegrade and retrograde endoscopic surgery for benign prostatic hyperplasia with vesical calculi – A single-centre experience

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Tarun Javali, Arvind Nayak K, S.M.L. Prakash Babu

    Abstract
    Objective

    To describe the effectiveness and safety of our novel technique of simultaneous percutaneous cystolithotripsy with transurethral resection of prostate (TURP) for patients with benign prostatic hyperplasia (BPH) complicated with large vesical calculi.

    Patients and methods

    This was a retrospective analysis of 25 patients who underwent simultaneous percutaneous cystolithotripsy with TURP between January 2012 and January 2016. Technique: A 28-F Amplatz sheath was inserted percutaneously into the bladder after sequential dilatation under cystoscopic guidance. Percutaneous cystolithotripsy using a nephroscope and pneumatic lithoclast was then performed simultaneously along with monopolar TURP. Preoperative parameters reviewed included: patient’s symptoms, International Prostate Symptom Score, uroflowmetry pattern, prostate volume, and stone burden on ultrasonography of the abdomen and pelvis. Postoperative parameters analysed included: duration of irrigation, time until catheter removal, length of hospital stay, and complications.

    Results

    The mean age of the patients was 67.8 years. The mean prostate size was 62.28 mL and the mean stone burden was 3.18 cm. The mean operating time was 54.2 min. The mean time until catheter removal was 3.2 days.

    Conclusion

    Simultaneous percutaneous cystolithotripsy with TURP in patients with BPH with large bladder calculi is safe and feasible.

  • Thulium laser enucleation of the prostate (ThuLEP): Results, complications, and risk factors in 139 consecutive cases

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Marco Raber, Noor N.P. Buchholz, Augusto Vercesi, Nashaat A. Hendawi, Vincenzo Inneo, Giuseppe Di Paola, Lorenzo Tessa, Ismail M. Hassan

    Abstract
    Objectives

    To report our experience with the emerging technique of thulium laser enucleation of the prostate (ThuLEP) for the treatment for prostate hyperplasia.

    Patients and methods

    Our inclusion criteria were an International Prostate Symptom Score (IPSS) of >15 and a quality-of-life (QoL) score of >3 in patients with confirmed bladder outflow obstruction, no longer responsive to medical therapy, with a significant post-void residual urine volume (PVR; >100 mL), with or without recurrent urinary tract infection and/or acute urinary retention. Patients with neurogenic bladder, urethral strictures, bladder stones, and previously failed transurethral prostate surgery were excluded.

    Results

    In all, 139 men were included in the study. The mean age was 67.8 years. The IPSS and QoL score improved by 17.6 and 2.6, respectively. The flow rate increased from a mean of 9.6 mL to 31.2 mL and the PVR decreased from a mean of 131 mL to 30 mL. On univariate and multivariate analyses, operating time was a predictive factor for haemoglobin drop during the operation. Heparin prophylaxis was the only risk factor identified for postoperative bleeding. Two patients (0.01%) required blood transfusion. One patient (0.007%) required re-intervention for bleeding control, and two patients developed urethral and bladder neck strictures (0.01%).

    Conclusion

    ThuLEP is safe and reproducible. Whilst it significantly reduces intraoperative bleeding as compared to transurethral resection of the prostate, operating time and perioperative heparin prophylaxis may still lead to a Hb drop and constitute a risk factor for postoperative bleeding. Therefore, a potential risk of deep vein thrombosis requiring heparin prophylaxis should be carefully considered and balanced with the expected clinical benefit of the operation.

  • Oral desmopressin in nocturia with benign prostatic hyperplasia: A systematic review of the literature

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Diaa-Eldin Taha, Omar M. Aboumarzouk, Ahmed A. Shokeir

    Abstract
    Objective

    To evaluate the effect of oral desmopressin in patients with nocturia associated with benign prostatic hyperplasia (BPH).

    Patients and methods

    With a rise of the use of oral desmopressin in the treatment of nocturia in patients with BPH, a systematic review was performed according to the Cochrane systematic reviews guidelines and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

    Results

    The literature search yielded 18 studies. The studies were published between 1980 and 2017, and included 3072 patients. Eligible patients were men aged ≥50 years with lower urinary tract symptoms (LUTS) and persistent nocturia. There was a significant 43% reduction in nocturia after using desmopressin alone. Combined α-blockers and desmopressin lead to a decrease in the frequency of night voids by 64.3% compared to 44.6% when using α-blockers only. The first sleep period, significantly increased from 82.1 to 160.0 min and from 83.2 to 123.8 min when using desmopressin + α-blocker and α-blocker only, respectively. The desmopressin dose ranged from the lowest dose (0.05 mg) to the optimum dose (0.4 mg) at bed time. The incidence of hyponatraemia associated with desmopressin use was 4.4–5.7%.

    Conclusion

    Low-dose oral desmopressin therapy alone is an effective treatment for nocturia associated with LUTS in patients with BPH. Oral desmopressin combined with α-blockers is well tolerated and beneficial for improving the International Prostate Symptom Score and nocturnal symptoms. All patients should be educated about the mechanism of desmopressin action to avoid treatment discontinuation due to adverse events.

  • Autologous versus synthetic slings in female stress urinary incontinence: A retrospective study

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Sherif Mourad, Hisham Elshawaf, Mahmoud Ahmed, Diaa Eldin Mostafa, Mohamed Gamal, Ahmed A. Shorbagy

    Abstract
    Objective

    To evaluate and compare the clinical (patient’s morbidity, quality of life [QoL]) and economic impact of autologous vs synthetic slings in female stress urinary incontinence (SUI), as over the last decade, the introduction of synthetic vaginal tapes for managing SUI has gained wide acceptance being quicker with low morbidity. Synthetic vaginal tapes have been progressively replacing the use of autologous rectus fascia. However, the high cost of these synthetic tapes is almost always an obstacle for most patients of limited socio-economic resources in the Egyptian community.

    Patients and methods

    This retrospective study included 126 women with SUI. Data for patients that matched the study inclusion criteria were collected from the Urology Department of Ain-Shams University Hospitals from March 2011 to May 2013. Patients were categorised into two groups: Group I included 62 patients who underwent an autologous sling procedure using rectus sheath; and Group II included 64 patients that had a synthetic sling, using transobturator tape (TOT). The following variables were compared: operative time, postoperative pain scores, duration of indwelling urethral catheter, hospital stay, cost including the price of the synthetic tape when used, return to normal activity, and QoL assessment (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form [ICIQ-UI-SF]) before and after discharge from hospital.

    Results

    Patients amongst the two groups were normally distributed with no statistically significant differences in patient’s demographic data and comorbidities. The mean hospital stay was longer and the return to normal activity was delayed in Group I compared to Group II. The highest mean postoperative pain score was recorded in Group I. The overall morbidity was 12.9% and 4.68% in groups I and II, respectively. The mean (SD) overall cost was 2571.65 (254.8) and 3502.34 (196.9) Egyptian pounds (local currency) in groups I and II, respectively, being insignificantly lower in Group I when compared to Group II (P > 0.05). There were statistically significant differences between groups I and II for operative time, hospital stay, and postoperative pain scores. However, the differences in hospital cost amongst Group I and Group II were in favour of Group I. Post-surgical outcome was categorised into either complete cure (dry) or improved or failed with no significant differences in success rate and QoL amongst the study groups. The mean (SD) change in the QoL score was 10.95 (4.19) and 12.32 (4.1) in groups I and II, respectively. The higher success rate (complete cure) was in Group II, at 93.75%. Also, a statistically significant improvement of >70% of mean ICIQ-UI-SF score was shown in all groups when compared to baseline on both the 1- and 6-month follow-up visits.

    Conclusion

    Autologous grafts should be considered as a repair option in females with SUI in countries were health insurance policies do not cover the cost of synthetic materials in many instances. The cost-effectiveness of synthetic TOT slings, as a minimally invasive procedure with lower overall morbidity, has yet to be confirmed in larger scale studies with longer periods of follow-up, to confirm the durability of its successful outcomes and be considered as the primary treatment of choice in female SUI.

  • The first Iraqi experience in sacral neuromodulation for patients with lower urinary tract dysfunction

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Issam S. Al-Azzawi, Mohamed A.J. Al-Tamimi

    Abstract
    Objectives

    To present our experience, in Iraq, with sacral neuromodulation (SNM) in patients with refractory lower urinary tract dysfunction, with discussion of the factors that affect the response rate.

    Patients and methods

    In this prospective, clinical, interventional study, 24 patients were evaluated and treated by a team comprised of a Urologist and a Neurosurgeon with SNM over a 1.5-year period. The gender, age, pathology, and clinical presentation, were all studied and evaluated. Successful clinical response was defined as achieving a ≥50% improvement in voiding diary variables.

    Results

    The mean age of those that responded to SNM was 28 years, with females responding better than males (10 of 14 vs four of 10). The SNM response rate according to presentation was six of 10 in those with overactive bladder/urge urinary incontinence, six of nine of those with urinary retention, and two of five in those with a mixed presentation. The response rate in idiopathic voiding dysfunctions was 11 of 13, whilst for neurogenic dysfunctions it was three of 11. Other benefits such as in bowel motion, erectile function, menstruation, power of lower limbs, and quality of life (QoL), were also recorded. The complications were reasonable for this minimally invasive procedure.

    Conclusion

    SNM offers a good and durable solution for some functional bladder problems, if patients are well selected. There may also be additional extra-urinary benefits that contribute to improvements in QoL. SNM was well tolerated by our patients with an encouraging response rate, especially in psychologically stable patients with idiopathic dysfunctions.

  • Positive ureteric margins at radical cystectomy: Can it be predicted at initial transurethral resection of bladder tumour?

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Onkar Singh, Thampi John Nirmal, Rajiv Paul Mukha, Gowri Mahasampath, J. Chandrasingh, Antony Devasia, Santosh Kumar, Nitin Sudhakar Kekre

    Abstract
    Objective

    To identify primary tumour-related factors at transurethral resection of bladder tumour (TURBT) that may predict positive distal ureteric margins (PUM) at the time of radical cystectomy (RC).

    Patients and methods

    A retrospective, cohort study was conducted using our institution’s data from June 2007 to June 2016. Patients who underwent TURBT followed by RC for non-metastatic urothelial carcinoma (UC) of the bladder were identified. In all, 211 patients underwent RC for UC during the study period. The patients were divided into two groups: Group-I (n = 17) with PUM and Group-II (n = 194) with negative ureteric margins. Univariate and multivariate analyses were performed to determine the predictors of PUM.

    Results

    On univariate analysis, multifocality, tumours involving the ureteric orifice, trigonal tumours, presence of carcinoma in situ (CIS), and lymphovascular invasion at TURBT, were significantly more common in Group-I. On multivariate analysis, tumour involvement in the ureteric orifice(s) and presence of associated CIS significantly predicted PUM.

    Conclusions

    Primary tumour-related factors on initial TURBT that predicted PUM (at RC) were involvement of the ureteric orifice(s) and presence of associated CIS. These results may help to select patients who can be selectively offered intraoperative frozen section analysis.

  • Radical nephrectomy and intracaval thrombectomy for advanced renal cancer with extensive inferior vena cava involvement utilising cardiopulmonary bypass and hypothermic circulatory arrest: Is it worthwhile?

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Hosam Serag, Jonathan M. Featherstone, David F. Griffiths, Dheeraj Mehta, John Dunne, Owen Hughes, Philip N. Matthews

    Abstract
    Objective

    To report our long-term outcomes of surgical treatment of renal tumours with inferior vena cava (IVC) tumour thrombus above the hepatic veins, utilising cardiopulmonary bypass (CBP) and hypothermic circulatory arrest (HCA), as surgical resection remains the only effective treatment for renal cancers with extensive IVC tumour thrombus.

    Patients and methods

    We retrospectively reviewed 48 consecutive patients (median age 58 years) who underwent surgical treatment for non-metastatic renal cancer with IVC tumour thrombus extending above the hepatic veins. Perioperative, histological, disease-free (DFS) and overall survival (OS) data were recorded.

    Results

    Tumour thrombus was level III in 23 patients and level IV in 25 patients. The median (range) CBP and HCA times were 162 (120–300) min and 35 (9–64) min, respectively. Three patients underwent synchronous cardiac surgical procedures. There were three (6.3%) perioperative deaths. American Society of Anesthesiologists grade and perioperative blood transfusion requirement were significant factors associated with perioperative death (P < 0.05). Despite extensive preoperative screening for metastases the median (range) DFS was only 10.2 (1.2–224.4) months. The median (range) OS was 23 (0–224.4) months. Cox regression analysis revealed that perinephric fat invasion conferred a significantly poorer DFS (P = 0.005).

    Conclusions

    Radical surgery for patients with extensive IVC tumour thrombus has acceptable operative morbidity and mortality. It provides symptom palliation and the possibility of long-term survival. Improvements in preoperative detection of occult metastasis may improve case selection and newer adjuvant therapies may improve survival in this high-risk group.

  • Multi-disciplinary and shared decision-making approach in the management of organ-confined prostate cancer

    Publication date: December 2018

    Source: Arab Journal of Urology, Volume 16, Issue 4

    Author(s): Syed M. Nazim, Mohamed Fawzy, Christian Bach, M. Hammad Ather

    Abstract

    Decision-making in the management of organ-confined prostate cancer is complex as it is based on multi-factorial considerations. It is complicated by a multitude of issues, which are related to the patient, treatment, disease, availability of equipment(s), expertise, and physicians. Combination of all these factors play a major role in the decision-making process and provide for an interactive decision-making preferably in the multi-disciplinary team (MDT) meeting. MDT decisions are comprehensive and are often based on all factors including patients’ biological status, disease and its aggressiveness, and physician and centres’ expertise. However, one important and often under rated factor is patient-related factors. There is considerable evidence that patients and physicians have different goals for treatment and physicians’ understanding of their own patients’ preferences is not accurate. Several patient-related key factors have been identified such as age, religious beliefs, sexual health, educational background, and cognitive impairment. We have focused on these areas and highlight some key factors that need to be taken considered whilst counselling a patient and understanding his choice of treatment, which might not always be match with the clinicians’ recommendation.

  • Corrigendum to “Twin penile skin flap, is it the answer for repair of long anterior urethral strictures?” [Arab J. Urol. 16(2) (2018) 224–231]

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Diaaeldin Mostafa, Hisham Elshawaf, Mohamed Abuelnaga, Mohamed Kotb, Abdelwahab Elkassaby

  • Robotic stone surgery – Current state and future prospects: A systematic review

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Philippe F. Müller, Daniel Schlager, Simon Hein, Christian Bach, Arkadiusz Miernik, Dominik S. Schoeb

    Abstract
    Objective

    To provide a comprehensive review of robot-assisted surgery in urolithiasis and to consider the future prospects of robotic approaches in stone surgery.

    Materials and methods

    We performed a systematic PubMed© literature search using predefined Medical Subject Headings search terms to identify PubMed-listed clinical research studies on robotic stone surgery. All authors screened the results for eligibility and two independent reviewers performed the data extraction.

    Results

    The most common approach in robotic stone surgery is a robot-assisted pyelolithotomy using the da Vinci™ system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Several studies show this technique to be comparable to classic laparoscopic and open surgical interventions. One study that focused on ureteric stones showed a similar result. In recent years, promising data on robotic intrarenal surgery have been reported (Roboflex Avicenna™; Elmed Medical Systems, Ankara, Turkey). Initial studies have shown its feasibility and high stone-free rates and prove that this novel endoscopic approach is safe for the patient and comfortable for the surgeon.

    Conclusions

    The benefits of robotic devices in stone surgery in existing endourological, laparoscopic, and open treatment strategies still need elucidation. Although recent data are promising, more prospective randomised controlled studies are necessary to clarify the impact of this technique on patient safety and stone-free rates.

  • Robot-assisted partial nephrectomy: How to minimise renal ischaemia

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Chandran Tanabalan, Avi Raman, Faiz Mumtaz

    Abstract

    Renal ischaemia research has shown an increase in renal damage proportional to ischaemic time. Therefore, we assessed the importance of renal ischaemic times for warm and cold ischaemia approaches, and explored the different surgical techniques that can help to minimise renal ischaemia in robot-assisted partial nephrectomy (RAPN). Minimising renal ischaemia during nephron-sparing surgery (NSS) is a key factor in preserving postoperative renal function. Current data support a safe warm ischaemia time (WIT) of ≤25 min and cold ischaemic time of ≤35 min, resulting in no significant deterioration in renal function. In general, patients undergoing NSS have increased comorbidities, including chronic kidney disease, and in these patients it is difficult to predict their postoperative renal function recovery. With RAPN, efforts should be made to keep the WIT to <25 min, as minimising the ischaemic time is vital for preservation of overall renal function and remains a modifiable risk factor. Parenchymal or segmental artery clamping, early unclamping or off-clamp techniques can be adopted when ischaemic times are likely to be >25 min, but may not lead to superior functional outcome. Careful preoperative planning, tumour factors, and meticulous surgical technique are critical for optimum patient outcome.

  • Successful management of ureteric endometriosis by laparoscopic ureterolysis – A review and report of three further cases

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Deepa Talreja, Vivek Salunke, Shinjini Pande, Chirag Gupta

    Abstract
    Objective

    To review articles highlighting the effectiveness of conservative laparoscopic ureterolysis as a primary treatment option in patients with ureteric endometriosis and to report on a further three cases.

    Patients and methods

    PubMed, EMBASE, Cochrane database were searched to identify articles reporting cases of laparoscopic management of ureteric endometriosis and, in particular management by ureterolysis. We further described three new cases of ureteric endometriosis managed at our institute.

    Results

    The present study illustrates the significance of laparoscopic ureterolysis in the management of patients with ureteric endometriosis. In our cases, a systematic surgical approach was followed in order to perform complete but careful excision of the all visible endometriotic implants. During follow-up successful treatment was established by relief of hydroureteronephrosis by ultrasonographic evaluation.

    Conclusion

    Considering the risk of loss of renal function and due to the nonspecific symptoms, a prompt clinical suspicion and thorough preoperative assessment can potentially help in the diagnosis. We conclude that laparoscopic ureterolysis is a minimally invasive technique with low complication and recurrence rates. It is a suitable option as a primary approach for selected patients with ureteric endometriosis, if done in a systematic step-by-step approach.

  • Contemporary use of ultrasonic versus standard electrosurgical dissection in laparoscopic nephrectomy: Safety, efficacy and cost

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Nand Kishore Arvind, Qutubuddin Ali, Onkar Singh, Shilpi Gupta, Surbhi Sahay

    Abstract
    Objective

    To assess the safety, efficacy and cost-effectiveness of ultrasonic dissection (USD) compared with standard monopolar electrosurgery (ES) in laparoscopic nephrectomy (LN).

    Patients and methods

    Retrospective analysis of patients’ records who underwent elective LN was performed. Patients were divided in to two groups: USD and ES groups depending on the energy source used during LN. The preoperative (demographics, indication for surgery), intraoperative (conversion to open surgery, operative time, estimated blood loss [EBL], complications), and postoperative (morbidity/mortality, volume of drainage, hospital stay, cost) data were collected and analysed.

    Results

    Between February 2004 and February 2008, 136 patients were included. The indications for nephrectomy were: inflammatory (51 patients), non-inflammatory (64), and tumours (21). The two groups were similar for preoperative data. The conversion rate to open surgery (12.5%) and mean operative time did not differ significantly between the groups. However, intraoperative mean EBL was significantly less with USD, at 140.8 mL vs 182.6 mL for ES. There were no differences in postoperative parameters and morbidity. USD was significantly more expensive than ES (59 000 vs 26 000 Indian Rupees).

    Conclusions

    ES is a safe and feasible tool like USD in LN when used with caution. USD facilitates completion of difficult cases and reduces intraoperative blood loss. However, the majority of LNs can be completed safely with ES. ES is sturdy and cheap; therefore, selective use of USD appears to be the most cost-effective policy in the developing world.

  • Laparoscopic and hand-assisted laparoscopic donor nephrectomy: A systematic review and meta-analysis

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Mark P. Broe, Rose Galvin, Lorna G. Keenan, Richard E. Power

    Abstract
    Objective

    To compare the perioperative outcomes of hand-assisted laparoscopic donor nephrectomy (HALDN) and pure LDN, as HALDN and LDN are the two most widely used techniques of DN to treat end-stage renal disease.

    Methods

    In this systematic review and meta-analysis, we performed a literature search of PubMed, Embase, Web of Science, and Cochrane from 01/01/1995 to 31/12/2014. The primary outcome was conversion to an open procedure. Secondary outcomes were warm ischaemia time (WIT), operation time (OT), estimated blood loss (EBL), complications, and length of stay (LOS). Data analysed were presented as odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs), I2, and P values. Subgroup analysis was performed.

    Results

    There were 24 studies included in the meta-analysis; three randomised controlled trials (RCTs), one randomised pilot study, two prospective, and 18 retrospective cohort studies. There were no differences in conversion to an open procedure between the two techniques for both RCTs (OR 0.42, 95% CI 0.06, 2.90; I2 = 0%, P < 0.001) and cohort studies (OR 1.06, 95% CI 0.63, 1.78; I2 = 0%, P = 0.84). WIT was shorter for the HALDN (−41.79 s, 95% CI −71.85, −11.74; I2 = 96%, P = 0.006), as was the OT (−26.32 min, 95% CI −40.67, −11.97; I2 = 95%, P < 0.001). There was no statistically significant difference in EBL, complications or LOS.

    Conclusion

    There is little statistical evidence to recommend one technique. HALDN is associated with a shorter WIT and OT. LDN has equal safety to HALDN. Further studies are required.

  • Re: Laparoscopic renal surgery is here to stay. By Angus Chin On Luk, Rajadoss MuthuKrishna Pandian and Rakesh Heer. Department of Urology, Freeman Hospital, High Heaton, Newcastle upon Tyne, UK

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Elenko Popov, Noor N.P. Buchholz

  • Laparoscopic renal surgery is here to stay

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Angus Chin On Luk, Rajadoss Muthu Krishna Pandian, Rakesh Heer

    Abstract
    Objectives

    To review the current literature comparing the outcomes of renal surgery via open, laparoscopic and robotic approaches.

    Materials and methods

    A comprehensive literature search was performed on PubMed, MEDLINE and Ovid, to look for studies comparing outcomes of renal surgery via open, laparoscopic, and robotic approaches.

    Results

    Limited good-quality evidence suggests that all three approaches result in largely comparable functional and oncological outcomes. Both laparoscopic and robotic approaches result in less blood loss, analgesia requirement, with a shorter hospital stay and recovery time, with similar complication rates when compared with the open approach. Robotic renal surgeries have not shown any significant clinical benefit over a laparoscopic approach, whilst the associated cost is significantly higher.

    Conclusion

    With the high cost and lack of overt clinical benefit of the robotic approach, laparoscopic renal surgery will likely continue to remain relevant in treating various urological pathologies.

  • Robot-assisted radical cystectomy with intracorporeal urinary diversion – The new ‘gold standard’? Evidence from a systematic review

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Niyati Lobo, Ramesh Thurairaja, Rajesh Nair, Prokar Dasgupta, Muhammad Shamim Khan

    Abstract
    Objective

    To investigate whether a totally intracorporeally radical cystectomy (RC) can be considered the new ‘gold standard’ in bladder cancer, as open RC (ORC) is the current ‘gold standard’ for surgical treatment of muscle-invasive and high-grade non-muscle-invasive bladder cancer. However, robot-assisted radical cystectomy (RARC) is becoming the preferred surgical approach in many centres as it seems to maintain the oncological control of open surgery whilst offering improved perioperative benefits.

    Materials and methods

    A review of the literature was conducted using the Pubmed/MEDLINE, ISI Web of Knowledge and Cochrane Databases to identify studies that included both ORC and RARC with intracorporeal and extracorporeal urinary diversion (UD) published up to July 2017.

    Results

    Evidence from four single-centre randomised controlled trials and now the multicentre Randomized Trial of Open versus Robotic Cystectomy (RAZOR) trial demonstrate the oncological equivalence of RARC to ORC. The only convincing evidence for the superiority of RARC is in the area of blood loss and transfusion rates. However, the UD procedure in these trials was performed extracorporeally and, to realise the full benefits of RARC, a totally intracorporeal approach is needed. Intracorporeal UDs (ICUDs) have been shown to be technically feasible by a few expert centres and have demonstrated some improved short-term perioperative outcomes compared to extracorporeal UDs.

    Conclusions

    Although initial outcomes appear promising, RARC with ICUD is far from gaining ‘gold standard’ status. Further studies are needed to confirm that outcomes are reproducible widely. Furthermore, the benefits of a totally intracorporeal approach must be confirmed in randomised controlled trials.

  • Different approaches to the prostate: The upcoming role of a purpose-built single-port robotic system

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Jihad Kaouk, Juan Garisto, Riccardo Bertolo

    Abstract

    With the aim of minimising the patient’s postoperative pain, expediting recovery and improving cosmesis, the idea of performing a laparoscopic procedure through a single abdominal incision was introduced. In the present report, we describe five different access routes to the prostate that may be at the surgeon’s disposal with the potential of decreasing patient’s perioperative morbidity. Robotic radical prostatectomy has been refined and became a standard of care in surgery for localised prostate cancer. The advent of single-port robotic surgery has prompted the re-discovery of different access routes to the prostate and ideally all of them are feasible. The potential for avoiding the abdominal cavity will decrease the surgical morbidity and minimise the surgical dissection. In the near future, each of the described approaches could be chosen on the basis of the patient’s preoperative comorbidities, body habitus, anatomy, and disease characteristics and location.

  • How robotic surgery is changing our understanding of anatomy

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Fabrizio Dal Moro

    Abstract

    The most recent revolution in our understanding and knowledge of the human body is the introduction of new technologies allowing direct magnified vision of internal organs, as in laparoscopy and robotics. The possibility of viewing an anatomical detail, until now not directly visible during open surgical operations and only partially during dissections of cadavers, has created a ‘new surgical anatomy’. Consequent refinements of operative techniques, combined with better views of the surgical field, have given rise to continual and significant decreases in complication rates and improved functional and oncological outcomes. The possibility of exploring new ways of approaching organs to be treated now allows us to reinforce our anatomical knowledge and plan novel surgical approaches. The present review aims to clarify some of these issues.

  • A brief overview of the development of robot-assisted radical prostatectomy

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Oliver W. Hakenberg

    Abstract

    Robot-assisted radical prostatectomy (RP) has gained remarkable worldwide distribution and has become a standard procedure for localised prostate cancer, indeed a new ‘gold standard’. There are proven advantages in reduced blood loss and shorter recovery time. Whilst case series publications often report improved functional outcomes, systematic hospital and healthcare data analyses mostly do not support these findings. Robotic surgery remains more costly. Its use has also increased knowledge about the anatomy of RP.

  • Complications in robotic urological surgeries and how to avoid them: A systematic review

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Rafael Rocha Tourinho-Barbosa, Marcos Tobias-Machado, Adalberto Castro-Alfaro, Gabriel Ogaya-Pinies, Xavier Cathelineau, Rafael Sanchez-Salas

    Abstract
    Objectives

    To review the main complications related to the robot-assisted laparoscopic (RAL) approach in urology and to suggest measures to avoid such issues.

    Methods

    A systematic search for articles of the contemporary literature was performed in PubMed database for complications in RAL urological procedures focused on positioning, access, and operative technique considerations. Each complication topic is followed by recommendations about how to avoid it.

    Results

    In all, 40 of 253 articles were included in this analysis. Several complications in RAL procedures can be avoided if the surgical team follows some key steps. Adequate patient positioning must avoid skin, peripheral nerve, and muscles injuries, and ocular and cognitive complications mainly related to steep Trendelenburg positioning in pelvic procedures. Port-site access and closure should not be neglected during minimally invasive procedures as these complications although rare can be troublesome. Technique-related complications depend on surgeon experience and the early learning curve should be monitored.

    Conclusions

    Adequate patient selection, surgical positioning, mentorship training, and avoiding long-lasting procedures are essential to prevent RAL-related complications. The robotic surgical team must be careful and work together to avoid possible complications. This review offers several steps in surgical planning to reach this goal.

  • Expanding the indications of robotic surgery in urology: A systematic review of the literature

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Raj P. Pal, Anthony J. Koupparis

    Abstract
    Objectives

    To evaluate the recent developments in robotic urological surgery, as the introduction of robotic technology has overcome many of the difficulties of pure laparoscopic surgery enabling surgeons to perform complex minimally invasive procedures with a shorter learning curve. Robot-assisted surgery (RAS) is now offered as the standard for various surgical procedures across multiple specialities.

    Methods

    A systematic search of MEDLINE, PubMed and EMBASE databases was performed to identify studies evaluating robot-assisted simple prostatectomy, salvage radical prostatectomy, surgery for urolithiasis, distal ureteric reconstruction, retroperitoneal lymph node dissection, augmentation ileocystoplasty, and artificial urinary sphincter insertion. Article titles, abstracts, and full text manuscripts were screened to identify relevant studies, which then underwent data extraction and analysis.

    Results

    In all, 72 studies evaluating the above techniques were identified. Almost all studies were retrospective single-arm case series. RAS appears to be associated with reduced morbidity, less blood loss, reduced length of stay, and comparable clinical outcomes in comparison to the corresponding open procedures, whilst having a shorter operative duration and learning curve compared to the equivalent laparoscopic techniques.

    Conclusion

    Emerging data demonstrate that the breadth and complexity of urological procedures performed using the da Vinci® platform (Intuitive Surgical Inc., Sunnyvale, CA, USA) is continually expanding. There is a gaining consensus that RAS is producing promising surgical results in a wide range of procedures. A major limitation of the current literature is the sparsity of comparative trials evaluating these procedures.

  • The age of robotic surgery – Is laparoscopy dead?

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Hartwig Schwaibold, Felix Wiesend, Christian Bach

    Abstract
    Introduction

    Robot-assisted laparoscopic surgery (RALS) has become a widely used technology in urology. Urological procedures that are now being routinely performed robotically are: radical prostatectomy (RP), radical cystectomy (RC), renal procedures – mainly partial nephrectomy (PN), and pyeloplasty, as well as ureteric re-implantation and adrenalectomy.

    Methods

    This non-systematic review of the literature examines the effectiveness of RALS compared with conventional laparoscopic surgery for the most relevant urological procedures.

    Results

    For robot-assisted RP there seems to be an advantage in terms of continence and potency over laparoscopy. Robot-assisted RC seems equal in terms of oncological outcome but with lower complication rates; however, the effect of intracorporeal urinary diversion has hardly been examined. Robotic PN has proven safe and is most likely superior to conventional laparoscopy, whereas there does not seem to be a real advantage for the robot in radical nephrectomy. For reconstructive procedures, e.g. pyeloplasty and ureteric re-implantation, there seems to be advantages in terms of operating time.

    Conclusions

    We found substantial, albeit mostly low-quality evidence, that robotic operations can have better outcomes than procedures performed laparoscopically. However, in light of the significant costs and because high-quality data from prospective randomised trials are still missing, conventional urological laparoscopy is certainly not ‘dead’ yet.

  • The age of robotic surgery – Is laparoscopy dead?

    Publication date: September 2018

    Source: Arab Journal of Urology, Volume 16, Issue 3

    Author(s): Noor N.P. Buchholz, Christian Bach

 

 

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