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Purpose: The perioperative management of patients who are receiving antithrombotic (antiplatelet or anticoagulant) therapy and require urologic surgery is challenging due to the inherent risk for surgical bleeding and the need to minimize thromboembolic risk. The aim of this review is to assess the quality and consistency of clinical practice guidelines (CPGs) and clinical practice recommendations (CPRs) on this topic, and to summarize the evidence and associated strength of recommendations relating to perioperative antithrombotic management. Methods: A pragmatic search of electronic databases and guidelines websites was performed to identify relevant CPGs/CPRs. The AGREE II (Appraisal of Guidelines for REsearch and Evaluation) instrument was used to assess the methodological quality and integrity of the CPGs. Results: The CPGs provided by the European Association of Urology (EAU), the American College of Chest Physicians (ACCP) and the European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA), and the CPRs provided by the International Consultation on Urological Disease (ICUD)/American Urologic Association (AUA) were retrieved and reviewed. The 3 CPGs were critically assessed using the AGREE II instrument. Inconsistent recommendations were provided based on the indication for antithrombotic medication, the antiplatelet/anticoagulant agent and the type of urological procedure. Based on the AGREE II tool for CPG assessment, the EAU CPGs scored higher (83.3 points) compared to the ESC/ESA (75 points) and ACCP CPG (66.7 points). Conclusion: The perioperative management of antithrombotic therapy in urological patients is potentially challenging but inconsistent CPG of varying quality may create uncertainty as to best practices to minimize thromboembolic and bleeding risk. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the role of low intra-abdominal pressure (IAP) in improving postoperative recovery in Robotic-assisted radical cystectomy (RARC) and intracorporeal ileal conduit urinary diversion (ICUD). Methods: A retrospective case–control study of 49 bladder cancer patients offered RARC/ICUD with standard (12 mmHg, n = 24) or low IAP (8 mmHg, n = 25). Outcomes of interest included length of procedure (LoP), estimated blood loss (EBL), blood transfusion, margin positivity rates, time to first flatus (TtFF), time to first bowel movement (TtFBM), ileus and small bowel obstruction (SBO) rates, time to safe discharge (TtSD), postoperative hospital stay (PHS) and pain levels on a postoperative day (POD) 1 and 3. Perioperative complications were recorded using the Clavien-Dindo system. Results: Demographic and baseline clinical characteristics, LoP, EBL and margin positivity rates were similar between groups. No transfusions were recorded. Median (IQR) TtFF, TtFBM and TtSD were significantly longer in Group 1 vs Group 2 (4 (1) vs 2 (1), 7 (3) vs 6 (2) and 8.5 (5.75) vs 5.0 (1), respectively). PHS and rates of postoperative ileus and SBO were lower in Group 2, however not statistically significant. Severe pain was uncommon in both groups but moderate/severe pain was significantly higher in Group 1 (95.8% vs 48% on POD1 and 62.5% vs 16% on POD3). No significant intraoperative complications were recorded and ≥ Grade 3 postoperative complications at 30 and 90 days were similar. Conclusion: With limitations, Low-IAP RARC can be safely offered to RARC/ICUD patients and leads to faster bowel recovery, and shorter time to safe discharge compared to standard pneumoperitoneum. [ABSTRACT FROM AUTHOR]

Background: Making healthcare treatment decisions is a complex process involving a broad stakeholder base including patients, their families, health professionals, clinical practice guideline developers and funders of healthcare. Methods: This paper presents a review of a methodology for the development of urological cancer care pathways (UCAN care pathways), which reflects an appreciation of this broad stakeholder base. The methods section includes an overview of the steps in the development of the UCAN care pathways and engagement with clinical content experts and patient groups. Results: The development process is outlined, the uses of the urological cancer care pathways discussed and the implications for clinical practice highlighted. The full set of UCAN care pathways is published in this paper. These include care pathways on localised prostate cancer, locally advanced prostate cancer, metastatic prostate cancer, hormone-resistant prostate cancer, localised renal cell cancer, advanced renal cell cancer, testicular cancer, penile cancer, muscle invasive and metastatic bladder cancer and non-muscle invasive bladder cancer. Conclusion: The process provides a useful framework for improving urological cancer care through evidence synthesis, research prioritisation, stakeholder involvement and international collaboration. Although the focus of this work is urological cancers, the methodology can be applied to all aspects of urology and is transferable to other clinical specialties. [ABSTRACT FROM AUTHOR]