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Frontiers in Surgery 8, 683359 (2021). doi:10.3389/fsurg.2021.683359, Published by Frontiers Media, Lausanne

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. Keywords: Prostate cancer, Decision-making, Multi-disciplinary team (MDT), Patients’ preferences

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. Keywords: Robotic urological surgery, Robotic, Laparoscopic, Robotic-assisted radical prostatectomy

PLOS ONE 15(9), e0239027 (2020). doi:10.1371/journal.pone.0239027, Published by PLOS, San Francisco, California, US

512 Background: Standard management of high risk TCC is either BCG or radical cystectomy, alternative treatment options are limited. It is known that the anti-tumor effect of heated mitomycin is 10 fold higher than at room temperature, which is the standard of intravesical therapy. We herein report the first 2 year follow up (FU) after intravesical therapy with heated mitomycin in a cohort of patients with high risk superficial bladder cancer (TCC). Methods: Treatment was performed for 1 hour with machine bladder irrigation (COMBAT) which maintaines temperature of mitomycin (40 mg) exactly at 43 C. Patients underwent therapy with a 6 week course of weekly treatment and were than followed by cystoscopy every 3 month and if necessary biopsy. Results: We identified 62 patients out of a total group of 108 patients who met the inclusion criteria for high risk TCC according to the EAU Guidelines and who got the complete 6 courses of treatment. 2 were lost of follow up, 1 died due to cardiac problems and 1 from metastatic prostate carcinoma. The remaining 58 patients had a mean FU of 26 month (16-54 m) and included 20 non-responders to BCG. 48/58 patients had CIS or pT1 Tumors or both, 10 patients had pTa+CIS. There were 5 recurrences, all superficial stage pTa, one in the rigth ureter, all could be managed without cystectomy. 8 patients had progressive or recurrent CIS/pT1 or were progressive to pT2 after therapy and underwent cystectomy. Conclusions: In this high risk cohort of 58 patients with a high rate of BCG non-responders only 8 patients had to undergo cystectomy during a 2 year follow up. Intravesical therapy with heated mitomycin is safe and well tolerated and may be an additional alternative treatment before cystectomy is performed in high risk patients with high risk TCC or BCG non responders.

We present a case of a patient with a large, symptomatic abdominal tumour, which finally could be classified as a leiomyoma arising from the right seminal duct/seminal vesicle. In computed tomography (CT) scan, it appeared as a 7.5 × 6.5 cm solid, supravesical mass. A cystoscopy as well as bilateral retrograde studies was normal, a transrectal ultrasound-guided biopsy and an ultrasound-guided transabdominal biopsy of the mass were inconclusive. Subsequently, we performed a tumour extirpation through a lower midline laparotomy. Histological examination showed a leiomyoma arising from the right seminal duct or seminal vesicle. In this article, we discuss clinical presentation, findings on imaging and management of this rare benign tumour and review the relevant literature where only 13 similar cases could be identified.

Arab journal of urology 16(3), 261 (2018). doi:10.1016/j.aju.2018.07.001

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. Keywords: Robotic stone surgery, Urolithiasis, Nephrolithiasis, Stone disease, Endourology

The management of advanced prostate cancer remains challenging. Traditionally, radical prostatectomy was discouraged in patients with locally advanced or node positive disease owing to the increased complication rate and treatment related morbidity. However, technical advances and refinements in surgical techniques have enabled the outcomes for patients with high risk prostate cancer to be improved. More recently, the concept of cytoreductive prostatectomy has been described where surgery (often Combined with an extended lymph node dissection) is performed in the setting of metastatic disease. Indirect evidence suggests an advantage using the cytoreductive approach. Hypothetical explanations for this observed benefit include decreased tumour burden, immune modulation, improved response to secondary treatment and avoidance of secondary complications attributable to local tumour growth. Nevertheless, prospective trials are required to investigate this further.

Objective To validate and evaluate the applicability of a new score to describe postsurgical analgesic consumption in urological and surgical patients across different categories of pain medications and the invasiveness of medical interventions. Materials and Methods The cumulative analgesic consumption score (CACS) was determined for two cohorts of patients split into three groups with surgeries involving clinically distinct levels of invasiveness (n = 2 x 60). Nonparametric statistical analyses were performed to determine differences between the CACS among the different groups and to assess the correlation between CACS and numeric rating scale (NRS) values for pain intensity. Results The score was determined for postoperative days 1 and 2 and revealed median scores of 0 (0-11), 3 (0-22) and 10 (6-17) for UA (urological patients from group A), UB (group B) and UC (group C), respectively, and 4 (0-20), 8 (0-38) and 17 (7-68) for SA (surgical patients from group A, SB (group B) and SC (group C), respectively. CACS enabled reliable differentiation between groups involving different levels of invasiveness (p < 0.001). CACS and peak NRS values showed variable degrees of correlation, as expressed by levels of significance ranging from p < 0.001 to p = 0.34 (NS). Conclusions The CACS is a valid and easily applicable tool to describe postsurgical analgesic consumption in urological and surgical patients. It can be used as a surrogate parameter to assess postsurgical pain and the invasiveness of surgical procedures. These aspects may be measured to compare surgical procedures, in both clinical trials and clinical practice settings.

Objective To define the learning curve of robot-assisted laparoscopic surgery for prostatectomy (RALP) and upper tract procedures, and show the differences between the classical approach to training and the new concept of parallel learning. Methods This mini-review is based on the results of a Medline search using the keywords ‘da Vinci’, ‘robot-assisted laparoscopic surgery’, ‘training’, ‘teaching’ and ‘learning curve’. Results For RALP and robot-assisted upper tract surgery, a learning curve of 8–150 procedures is quoted, with most articles proposing that 30–40 cases are needed to carry out the procedure safely. There is no consensus about which endpoints should be measured. In the traditional proctored training model, the surgeon learns the procedure linearly, following the sequential order of the surgical steps. A more recent approach is to specify the relative difficulty of each step and to train the surgeon simultaneously in several steps of equal difficulty. The entire procedure is only performed after all the steps are mastered in a timely manner. Recently, a ‘warm-up’ before robotic surgery has been shown to be beneficial for successful surgery in the operating room. Conclusion There is no clear definition of the duration of the effective learning curve for RALP and robotic upper tract surgery. The concept of stepwise, parallel learning has the potential to accelerate the learning process and to make sure that initial cases are not too long. It can also be assumed that a preoperative ‘warm up’ could help significantly to improve the progress of the trainee.

Objective: To investigate the evidence for the use of hyoscine N-butylbromide (HBB) in the treatment of acute renal colic. Methods: A literature search was performed using the keywords ‘hyoscine N-butylbromide', ‘ureteral colic', ‘spasmolytic', ‘anticholinergic' and ‘analgesia'. The articles were given the appropriate level of evidence according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence guidelines. Results: The analgesic effect of HBB as monotherapy is inferior to that of opioids and/or non-steroidal anti-inflammatory drugs (NSAIDs). It does provide an analgesic and antispasmodic effect, but not as long-lasting as NSAIDs. HBB does not serve as an adjunct to opioids. Furthermore, it does not facilitate passage of ureteral stones and has no effect on expulsion rate. Conclusions: HBB is often used where urinary tract smooth muscle spasm is thought to be part of the pathophysiological process. According to the evidence, administration of HBB follows non-peer-reviewed protocols which are based on empiric recommendations. Its role is still unclear, as it appears to have no advantage when used as monotherapy over established forms of analgesia. There appears to be a time-dependent relation to pain reduction following parenteral administration, but this needs to be confirmed by more prospective randomized cohorts.

Purpose: The Post-Ureteroscopic Lesion Scale (PULS) offers a simple grading system for the description of ureteral lesions after ureteroscopy. In this article, we present the results of a video-based multicenter evaluation of the inter-rater reliability of clinically important PULS grades 0-3. Methods: Video sequences at the end of ureteroscopy (final passage) were recorded for 100 consecutive patients at a single institution and assessed by experienced urologists (n = 20) and senior residents (n = 17) at 19 international centers. The cohort included only patients with lesions grades 0-3 (with grades 2 and 3 subsumed as 2 + since distinction is defined by an extravasation of contrast medium in fluoroscopy). The gradings were evaluated for inter-rater reliability and in terms of simplicity, validity, comprehensibility, reproducibility, and usefulness. Results: Overall, inter-rater reliability was high (Kendall's W = 0.69, p < 0.001) and was comparable between specialists (Kendall's W = 0.69, p < 0.001) and residents (Kendall's W = 0.71, p < 0.001). The matched ratings showed grade 0 in 43.0 % of patients and grades 1 or 2 + in 44.0 and 13.0 % of patients, respectively. Results of the questionnaires indicated a high degree of acceptance, with an overall rating of 1.76 (1.64-1.93 for different items, scale 1-6). Conclusions: Inter-rater reliability of the endoscopically assessable PULS was high among urologists with different levels of experience in different countries worldwide. The validated PULS system may be used for standardized reporting of ureteral lesions/injuries after ureteroscopy. In addition, PULS will enable more selective standardization of indications for postoperative DJ stenting based on the randomized controlled trials.

Objectives Thirty years after its introduction, extracorporeal shockwave lithotripsy (ESWL) is still first-line treatment for more than half of all urinary tract stones, but machines and treatment strategies have significantly developed over time. In this review, we summarise the latest knowledge about the clinically important aspects of ESWL. Methods We searched PubMed to identify relevant reports and the latest European Association of Urology guidelines, and standard urological textbooks were consulted. Results New technical developments include: Twin-head and tandem-pulse shock-wave generators; wide-focus, low-pressure systems; optimised coupling; and automated location and acoustic tracking systems. Indications have been refined, making possible the identification of patients in whom ESWL treatment is likely to fail. By lowering the shock-wave rate, improving coupling, applying abdominal compression, power ‘ramping’ and postoperative medical expulsion therapy, treatment protocols have been optimised. Conclusions Promising new technical developments are under development, with the potential to increase the stone-free rate after ESWL. For optimal results, the refined indications need to be respected and optimised treatment protocols should be applied.

Objectives To present the chronological development of the different positions described for percutaneous nephrolithotomy (PCNL), in an attempt to identify the reasons for their development and to highlight their specific advantages and disadvantages. Methods Previous reports were identified by a non-systematic search of Medline and Scopus. Results The classic prone position for PCNL was first described in 1976. The technique was gradually standardised and PCNL with the patient prone became the generally accepted standard approach. In the next 35 years many other positions were described, with the patient placed prone, lateral or supine in various modifications. Modifications of the classic prone position in the early 1990s aimed to provide the option of a simultaneous retrograde approach during the procedure. As PCNL became more popular the lateral position was first described in 1994, to allow the application of PCNL to patients who were unable to tolerate being prone because of their body habitus. The supine position for percutaneous access was originally described even before 1990, but become more popular after 2007 when the Galdakao modification was reported. Several other modifications of the supine position have been described, with the latest being the flank-free modified supine position, which allows the best exposure of the flank among the supine positions. Each position has its specific advantages and disadvantages. Conclusion Urologists who perform PCNL should be familiar with the differences in the positions and be able to use the method appropriate to each case.

Introduction: Benign prostatic hyperplasia (BPH) and cataract formation are common in older people. Medical management of symptomatic BPH is often preferred to surgical treatment as surgery increases the risk of morbidities, whereas, surgery is the main form of treatment to restore sight in patient with cataract. The clinical treatment of BPH is either alpha-1 adrenergic antagonist alone or combination of alpha reductase inhibitor and alpha adrenergic receptor (AR) antagonist. There are four alpha-AR antagonists currently available to treat BPH. The uroselective alpha-blocker tamsulosin is the most commonly used drug among all. Studies showed that the majority of the patients who develop intraoperative floppy iris syndrome (IFIS) were on tamsulosin. Women are more likely to develop cataract than men and some recent studies showed that tamsulosin is effective in treating female lower urinary tract symptoms and thereby can cause IFIS during cataract surgery. Evidence Acquisition: We performed a critical review of the published articles and abstracts on association of IFIS with alpha-blockers and other medications as well as other medical conditions. Evidence Synthesis: Tamsulosin is the most common cause of formation of IFIS. However, not all patients given tamsulosin develop IFIS and cases have been reported without any tamsulosin treatment. Conclusion: Tamsulosin is a recognized cause to impede mydriasis and lead to IFIS during cataract surgery. Urologist should collaborate with their ophthalmology colleagues and general practitioner during prescribing tamsulosin in patients with history of cataract or waiting for planned cataract surgery. The increasing life expectancy and growth of older people will increase the number of men and women who suffer from lower urinary tract symptoms as well as cataract. Therefore, further research and studies are required to properly understand the relation of alpha blockers and IFIS.

The use of percutaneous renal surgery has been recently revolutionised with novel endourological instruments and techniques. However, the incidence, prevention and management of severe complications such as colon perforation still lack consensus. By presenting our 10-year experience, we would like to highlight the diagnosis and management of the rare complication of colon perforation.

Objectives: This study aims to assess the impact of a virtual reality trainer in improving percutaneous renal access skills of urological trainees. Methods: A total of 36 urology trainees participated in this prospective study. Initially, they were taken through the exercise of gaining access to the lower pole calyceal system and introducing a guidewire down the ureter. Trainees’ performance was then assessed by virtual reality-derived parameters of the simulator at baseline and after 2 h of training. Results: Participants who underwent training with the simulator demonstrated significant improvement in several parameters compared to their baseline performance. There was a statistically significant correlation between total time to perform the procedure and time of radiation exposure, radiation dose and correct calyx puncture (p < 0.01). Trainees needed a mean of 15.8 min from skin puncture to correct guidewire placement into the pelvicalyceal system before and 6.49 min following training. Conclusions: We found percutaneous renal access skills of trainees improve significantly on a number of parameters as a result of training on the PERC Mentor TM VR simulator. Such simulated training has the potential to decrease the risks and complications associated with the early stages of the learning curve when training for percutaneous renal access in patients.

Objectives: To evaluate whether the use of sheaths to access the ureter has increased after the introduction of new digital ureterorenoscopes in patients undergoing flexible ureteroscopy. Methods: 140 patients with kidney stones were randomised to be scoped with either an old-generation fibre-optic flexible ureteroscope (DUR-8, Elite, ACMI; distal tip diameter = 6.75 Fr) or a new-generation digital LCD flexible ureteroscope (Invisio D-URD flexible ureteroscope; distal tip diameter = 8.7 Fr). We recorded the necessity to use a sheath to access the ureter, sheath-related and postoperative complications, and whether or not a JJ stent was left behind. Results: 157 (80 fibre-optic and 77 digital) ureterorenoscopies were performed. Ureteral access sheaths were used significantly more frequently with digital scopes (p = 0.00174). Two patients in the digital scope group had a small distal ureteric perforation from the introducer sheath compared with none in the fibre-optic scope group. Conclusions: A statistically significant increase in sheath use was observed in the new-generation digital flexible ureteroscopy group. Despite the improvement in image quality, better durability and improved stone clearance, there are some potential drawbacks of these scopes. The increased distal tip diameter can result in increased use of ureteric access sheaths and this may increase morbidity and expense.

Tumors metastasizing to the glans penis are uncommon and a rare occurrence. The majority of the primary tumors are located in the pelvis and they arise from the genitourinary tract and rectum (>75%). We report a 61-year-old man with known metastatic (lymph nodes and maxilla) esophageal cancer who was treated with chemotherapy and referred to urology with phimosis for circumcision. He did not have any other urological or penile complaints. During circumcision the glans penis looked nodular and a biopsy was taken. The histological examination of the biopsy showed metastasis from esophageal primary adenocarcinoma. The case was discussed in a multi-disciplinary meeting and palliative radiotherapy was recommended and commenced.

Objective We provide a comprehensive overview of the main aspects of shock wave lithotripsy (SWL) for renal and ureteric stones. Evidence acquisition We reviewed current literature, concentrating on high-quality reviews in international journals. In addition, the latest European Association of Urology guidelines and standard textbooks were consulted. Evidence synthesis SWL can treat >90% of stones in adults and has revolutionized the treatment of urolithiasis. Despite the progress of minimally invasive endourologic procedures, SWL still contributes to >50% of all stone treatments worldwide. With modern machines, stone-free rates of the initial Dornier HM3 have not been reached again. Apart from stone size, multiple predictive outcome factors like stone composition, position, and renal anatomy have been identified, and indications have been refined. Interestingly, a growing number of nonurologic indications for SWL such as stimulating re-epithelization and improving myocardial function, have been reported recently. Furthermore, treatment protocols have been optimized by lowering shock wave rate, improving coupling, applying abdominal compression, power ramping, and postoperative medical expulsion therapy. New promising developments are twin-head and tandem-pulse shock wave generators. Automated localization and acoustic tracking and feedback systems have been developed with the potential to improve stone disintegration, to limit radiation, and to avoid overtreatment and complications. Conclusions SWL is a safe and well-established procedure that still plays an important role in the treatment of upper urinary tract stone disease. To achieve optimal results, the refined indications need to be respected and patients need to be carefully selected. Treatment protocols need to be optimized. Novel promising technical developments are upcoming, and there is growing interest in shock wave therapy from other specialties. SWL is a substantial part of urology that every urologist should learn to master during his or her training.

The incidence of ureteric obstruction after kidney transplantation is 3-12.4%, and the most common cause is ureteric stenosis. The standard treatment remains open surgical revision, but this is associated with significant morbidity and potential complications. By contrast, endourological approaches such as balloon dilatation of the ureter, ureterotomy or long-term ureteric stenting are minimally invasive treatment alternatives. Here we discuss the available minimally invasive treatment options to treat transplant ureteric strictures, with an emphasis on long-term stenting. Using an example patient, we describe the use of a long-term new-generation ureteric metal stent to treat a transplant ureter where a mesh wire stent had been placed 5 years previously. The mesh wire stent was heavily encrusted throughout, overgrown by urothelium and impossible to remove. Because the patient had several previous surgeries, we first considered endourological solutions. After re-canalising the ureter and mesh wire stent by a minimally invasive procedure, we inserted a Memokath® (PNN Medical, Kvistgaard, Denmark) through the embedded mesh wire stent. This illustrates a novel method for resolving the currently rare but existing problem of ureteric mesh wire stents becoming dysfunctional over time, and for treating complex transplant ureteric strictures.

Introduction: The Memokath 051™ is a semipermanent inert metal alloy ureteric stent which can bridge strictures and, compared to double J stents, causes less bladder irritation and pain, is more resistant to external compression forces and may be more effective in patients with malignant ureteric obstruction. We present our experience with this novel stent in such cases. Methods: All suitable patients referred to us with malignancy-associated ureteric strictures over a 4-year period had ureteric Memokath 051™ stents inserted. Data on aetiology and position of the strictures as well as length of the Memokath stents used and their efficacy and complications were recorded prospectively. Results: 42 ureteric Memokath 051™ stents were inserted in 37 patients (mean age 64 years). 40.5% of strictures were related to gynaecological cancer, 21% to bowel cancer, 14% were post radiation, 14% occurred in prostate cancer patients and 9.5% were found in other cancers. The mean follow-up was 22 months (range 5–60 months). The main complications were stent migrations in 5, urinary tract infections in 3 and blockage of stent due to progressive transitional cell carcinoma of the ureter in 2 cases. Conclusion: Memokath 051™ ureteric stents are safe, effective and durable in the long-term treatment of malignant strictures.

Uretero-ileal anastomotic stricture is a potentially serious late complication after ileal conduit formation, with a reported incidence of 3-9%. The standard management technique is open surgical revision of the anastomosis with reimplantation of the affected ureter. This is technically challenging and has potential significant morbidity for the patient. Advances in endourological techniques now offer a variety of less-invasive treatment options, like balloon dilatation or laser ureterotomy followed by stent insertion. What happens when such open and minimally invasive techniques fail? Recently, using a combined antegrade and retrograde approach, we inserted a novel, semi-permanent, dual-expansion thermo-expandable metallic alloy stent across a recurrent ileal-ureteric stricture. We describe the technique and potential advantages of this minimally invasive method. This minimally invasive treatment option is of interest, as in contrast to other stents, it does not require routine change, and is resistant to corrosion and urothelial ingrowth, hence ensuring ease of exchange or removal if required.

The surgical management of urolithiasis, in particular cystolithiasis, has been known for more than two millennia. The term lithotomy was first used by the Greek surgeon Ammonius (276 BCE), but the practice of cutting the stone would have existed long before that. However, Hippocrates (460 BCE) discouraged the procedure. His oath reads: ‘I will not cut persons labouring under the stone, but will leave this to be done by practitioners of this work’. Most probably he wished to disassociate himself from this frequently unsuccessful procedure, in an attempt to prevent it from tarnishing the physicians’ reputation. The Roman physician Celsius (25 BCE–25 CE) provided the earliest proper description of a lithotomy procedure for bladder stones. Notably, his description remained broadly accurate for the techniques used over the next 1500 years. The procedure remained associated with a relatively poor success rate, with frequent and often unpleasant complications, such as damage to the rectum or bladder, and death. Only over the last 150 years, with the techniques of asepsis and anaesthesia, has more complex surgery become possible. For almost all stones in the urinary tract, open surgical procedures have been developed and applied. The invention of cystoscopy allowed the endoscopic removal of bladder stones [1]. Then, over the last three decades the development of endourological and nonsurgical less-invasive techniques, such as ESWL, percutaneous nephrolithotomy (PCNL), ureterorenoscopy (URS) including flexible retrograde intrarenal surgery, and (more recently but to a lesser extent) laparoscopy, have revolutionized stone treatment and led to a marked decrease in the need for open stone surgery [2,3].

The da Vinci Surgical System (Intuitive Surgical Inc.) continues to develop as a platform in urological surgery. Synchronous upper and lower urinary tract tumours requiring extirpative surgery are not uncommon. We report the first case robotic series of combined complex upper and lower urinary tract surgery. Six high-risk anaesthetic patients with a median age of 71 years and apparent synchronous upper and lower urinary tract pathologies underwent concurrent robotic surgery. Five underwent robotic nephroureterectomyand robotic-assisted radical cystectomy (RARC); 1 had combined robotic nephroureterectomy and robotic-assisted radical prostatectomy (RALP). The mean length of stay was 10 days, with an average blood loss of 416.7 mL. The median console time for nephroureterectomy, RALP and RARC was 90, 90 and 210 minutes, respectively. Four patients had intra-corporeal ileal conduit urinary diversion. There were no Clavien grade 3, 4, or 5 complications. In all patients, 30- and 90-day mortality was nil. Margins were clear in the entire cohort. We concluded that combined upper and lower urinary tract robotic surgery is safe and technically feasible with acceptable complications and oncological outcomes.

Although the optimal treatment for patients with high-risk prostate cancer remains unclear, combined radiotherapy and androgen-deprivation therapy (ADT) has become the standard of care; however, more recently, this paradigm has been challenged. In contemporary surgical series, using a multimodal approach with primary radical prostatectomy and adjuvant radiotherapy, when appropriate, had comparable efficacy in patients with high-risk disease to radiotherapy in combination with ADT. Furthermore, perioperative and postoperative morbidity associated with radical prostatectomy seem to be similar in patients with low-risk, intermediate-risk, or high-risk prostate cancer. Importantly, downstaging and downgrading of a substantial proportion of tumours after surgery suggests that many patients might be overtreated using radiotherapy and ADT. Indeed, the potential benefits of surgery include the ability to obtain tissues that can provide accurate histopathological information and, therefore, guide further disease management, in addition to local control of disease, a potentially reduced risk of developing metastases, and avoidance of long-term ADT. Thus, patients with high-risk disease should be offered a choice of first-line treatments, including surgery. However, effective management of high-risk prostate cancer is likely to require a multimodal approach, including surgery, radiotherapy, and neoadjuvant and adjuvant ADT, although the optimal protocols remain to be determined.

The treatment of urolithiasis has changed dramatically over the past several decades. Novel technologies have led to new management protocols. Percutaneous chemolysis as a primary or adjuvant treatment for urinary tract stones has widely been neglected. We present our own experience with it and discuss it in the light of an extensive literature review. From a MEDLINE search on percutaneous chemolysis we evaluated the most important studies, a total of 58 articles, 43 case series and 15 review articles. In our unit between 2001 and 2011, 29 patients (mean age 62 years) with infectious staghorn calculi were treated with adjuvant percutaneous chemolysis post-percutaneous nephrolithotripsy. There were 17 women, with 10 complete and 14 partial staghorn stones (mean size 32 mm). Patients were generally deemed at high risk to undergo another procedure in the future. Suby G solution was used following an established protocol. Sixteen patients (55.1 %) were stone free after chemolysis, eight stones showed partial dissolution, half of them with so-called "insignificant" residual fragments

Objective To present the damage to digital flexible ureteroscopes after 1 year of use in a tertiary stone center and our strategy to reduce the damage. Materials and Methods Data regarding all procedures performed with 3 new digital flexible ureteroscopes (Olympus URF-V) were collected. We examined the conditions under which the damage occurred and retrieved the manufacturer's repair reports. Two study groups were created. Group 1 included all the procedures performed before the introduction of a set of guidelines for safe use of the digital flexible ureteroscopes and a stepwise credentialing process for new surgeons. Group 2 included all the procedures performed thereafter. Results A total of 141 procedures were performed in 122 patients. Five events of damage occurred in the first study group and were related to working in maximum deflection. In the second group only 3 events occurred. The damage affected the angulation system, working channel, or body shaft. No damage occurred to the imaging system of any ureteroscope. The changes that were made after the first 5 months of use resulted in a significant prolongation of the number of uses before damage occurred for every ureteroscope (10.6 vs 21.6 uses before damage, P = .035). Conclusion The optical system of the new digital ureteroscopes is very durable; however, the overall longevity depends on the correct handling of their use. By following the proposed guidelines for safe use and with monitored training of new users, these instruments can have a significantly longer lifespan.

Objective parameters for the classification of ureteral injuries and resulting indications for ureteral stent placement after ureteroscopy are lacking. We hereby present a new classification system including proof of interrater reliability and validation of recommendations for postoperative ureteral stent placement.The Postureteroscopic Lesion Scale (PULS) was applied in 435 patients undergoing ureteroscopy. Interrater reliability between three surgeons (junior resident, senior resident, and specialist) was evaluated in 112 patients. Postoperative ureteral stent placement was performed according to PULS. For follow-up with ultrasonography, we assumed hydronephrosis to be an indirect sign for significant postoperative ureteral obstruction.No ureteral lesion was seen in 46.2% of patients (grade 0). A grade 1, 2, or 3 lesion was seen in 30.8%, 19.1%, and 3.9% of patients, respectively. No grade 4 or 5 lesions were observed in our series. Interrater reliability was high (Kendall W=0.91; mean Spearman Rho=0.86). This was particularly true between senior resident and specialist (Rho=0.95), compared with junior resident and senior resident or specialist (Rho=0.83, Rho=0.79, respectively). All patients with documented lesions had a Double-J stent placed. Indwelling time varied according to PULS. Results of a postoperative ultrasonographic follow-up could be obtained in 95.6% of cases. No patient showed clinical or sonographic signs of upper urinary tract obstruction.According to these preliminary data for the clinical application of PULS, interrater reliability is high. Standardized empiric recommendations for the use and duration of postoperative stent placement after ureteroscopy might be useful in guiding urologists in this conversely discussed issue, ultimately preventing ureteral strictures as a late complication of ureteroscopy. These will have to be confirmed, however, by controlled trials in the future.

INTRODUCTION AND OBJECTIVES: The incidence of postrenal transplant ureteric stenosis ranges from 2%‐12%. Currently the gold standard treatment is open revision, but minimally invasive endourological procedures may provide an attractive alternative. We present our data on the successful use of a thermo-expandable, metallic alloy ureteric stent, (Memokath® 051) as a long-term treatment for posttransplant ureteric strictures. METHODS: We retrospectively analysed the medical records of patients undergoing Memokath 051® insertion for ureteric strictures following renal transplantation. The records were reviewed for age, site of stricture, duration of stenting and complications. RESULTS: Seven male patients, mean age 48 (23-74) with strictured or otherwise obstructed ureters following kidney transplantation have been treated with ureteric Memokath (MMK) 051® insertion. At a mean follow up of 3 years, 4 stents were patent and patient’s kidney function has been normal. Average indwelling time of these stents was 31 month. In two patients the stricture extended the whole ureter so that full length MMKs (60mm and 150mm) were inserted; one patient had a 4 cm proximal ureteric stricture which was bridged by a 10 cm MMK, one presented with a blocked, previously inserted Wallstent bridging the stricture through which the Memokath (10cm) was placed. Spontaneous resolution of the stricture without the need for further stenting was seen in two patients: an anastomotic stricture between transplant ureter and a Boari flap resolved spontaneously and the MMK was expelled after 5 month indwelling time. The other patient underwent removal of his MMK due to blockage after 13 month indwelling time - intraoperatively, the stricture showed to be resolved so no further treatment was necessary. In one patient MMK treatment had failed: After extra-anatomical implanted kidney he developed a massively torted, obstructive ureter, which was bridged by a full length Memokath. Due to migration, this was removed after 1 month and replaced with a JJ stent. The overall success rate of Memokath placement was 85% (4 stents patent in situ and 2 spontaneous resolutions of stricture, 1 failure). No other morbidities were recorded and all other patients tolerated the stents well. CONCLUSIONS: Permanent ureteric stenting with the Memokath® 051 is a safe and effective minimally invasive treatment alternative for ureteral strictures after kidney transplantation. It provides an attractive alternative to open surgery and is well tolerated by patients.

Background: The last decade has seen the emergence of a variety of supine positions for carrying out percutaneous nephrolithotomy (PCNL). These positions all differ with regard to ease of puncture under image guidance, operative field availability, ability to make and dilate multiple tracts and ease of combining retrograde intrarenal surgery (RIRS). As all of these positions have their limitations regarding the important parameters mentioned above, there is a need for a supine position which addresses some of the difficulties. Methods: We describe and illustrate our flank-free modified supine position, which we believe addresses a number of the issues. Results: Our position allows easy percutaneous access under fluoroscopy (torso only tilted to around 15°), space for placing (flank free of support) and dilating multiple tracts (kidney lies in a fairly neutral position and hence less mobile), a fairly horizontal tract allowing low intrarenal pressures and easy washout of fragments as well as allowing RIRS in a position of relative familiarity. The lesser torso rotation compared with the Valdivia, Galdakao modified and the Barts modified Valdivia positions also means it is more comfortable for patients. Conclusions: Our results are encouraging and easily comparable with published series on prone position, Valdivia, complete supine and the Barts modified Valdivia positions. We would like to highlight the Barts ‘flank-free’ modified supine position as one of the standard positions for carrying out supine PCNL.

The aim of the study was to evaluate the impact of age on the efficacy of extracorporeal shock wave lithotripsy (SWL), in a comparative study based on the principles of matched-pair analysis. Over a period of 4 years, 2,311 patients were treated with SWL in a tertiary referral center. Patient and stone data were recorded in a prospective electronic database. Among these patients, 115 (4.97%) were older than 70 years of age and fulfilled the criteria for inclusion in the study (Group A). For the purposes of the comparative analysis, Group A patients were matched for gender and stone parameters (side, location of stone, and diameter ±2 mm) with a control group of patients under the age of 70 (Group B). Following matching, the patients’ electronic medical records were reviewed, to identify SWL success rates at 3 months and McNemar’s test was used to compare the efficacy of SWL between the two groups. Matching was possible in all cases. The results indicate that there were no statistically significant differences in the mean number of SWL sessions or in the mean number of impulses per session between the two groups. The overall stone clearance rate achieved by SWL alone was 71.3% for Group A and 73.9% for group B. Discordant pairs were found in 37 cases (in 17 pairs only patients in Group A became stone-free, while in 20 pairs only patients in Group B became stone-free). By using McNemar’s test, the difference in stone clearance rates between the two groups was not found to be statistically significant (p = 0.742). A total of 22 patients (19.1%) in Group A and 17 patients (14.7%) in Group B underwent an adjuvant procedure to achieve stone clearance. McNemar’s test also revealed the absence of any statistically significant difference in SWL success rates between older and younger patients in the subgroups of patients presenting with either ureteric or renal stones (p = 0.727 and p = 0.571, respectively). In conclusion, SWL is still considered one of the first-line tools for geriatric patients suffering from urolithiasis, as increased age alone does not seem to adversely affect the efficacy of SWL.

The robotic surgery programme at the Bristol Urological Institute started in 2009. The bedside assistants for the initial patients changed frequently as the role was given to the uro-oncology train...

Surgery is no longer what we knew it to be. Rapid technological and medical developments, and especially a changing infrastructural, political and ethical environment, have changed the face of modern surgery. This puts more and novel demands on the surgeons and the surgeons-to-be. When we were asked by Professor Shokeir to put together another special issue for the AJU, being endourologists what first came to our minds were all sorts of sub-speciality issues. Then we asked what could connect all urologists worldwide. Not only that, but what connects them with the rest of the surgical community, and with associated co-operating specialties? The answer is simple: training. The training to do the right thing for the right patient at the right time, in the context of urology, surgery, and medicine in general. All of us are in training. Training does not stop with graduation, or even a professorship. Training and learning is a life-long process. Some still learn when they look immediate death in the eye. Trainees need to learn how to master the skills required, and then how to become teachers themselves. Teachers have to learn how to become better teachers, not least by listening to the trainees. In surgery, over centuries the training and teaching followed the apprenticeship model. However, the increasing accountability of surgeons, increasing patient awareness, and reductions in working times for surgeons and trainees in an attempt to achieve a safer work environment and a better work-life balance, have made this model unsuitable for modern training and teaching in many parts of the world. In addition, new learning concepts are continuously evolving and often cross traditional borders between trainer and trainee, surgery and other medical specialties, and even extra-medical professions. What has been good for centuries does not necessarily mean that it cannot be improved. Trainers and trainees can learn from each other, as can surgeons from anaesthesiologists, or even from other high-risk professions such as airline pilots. In this issue we tried to bring together all these aspects of training and teaching, from concepts to practice, from the trainees view to the trainers view, from the educationalist to the practical urologist. We believe that this special issue might not only be of interest to trainers, but for all of us, as we all keep learning and we all should be keen to understand how we do it, how others do it and how we can improve our current beliefs and standards.