Publications by authors named "Ali Gozen"

82 Publications

Is 'Omega Sign' anatomical endoscopic enucleation of the prostate technique reproducible?

Andrologia 2021 Sep 31;53(8):e14137. Epub 2021 May 31.

Department of Urology, Gazi University Faculty of Medicine, Ankara, Turkey.

We aimed to evaluate the learning curve of the surgically standardised 'Omega Sign' anatomical endoscopic enucleation (AEEP) of the prostate surgery technique for junior surgeons. This study is a retrospective comparison of cases that underwent AEEP by a mentor surgeon and three junior surgeons who have completed their learning curve. A video-based laser enucleation of the prostate assessment tool (LEAT) composed of 8 steps of the technique was used to assess a senior surgeon and junior surgeons' surgical compatibility and consistency. The surgeon who defined Omega Sign technique was determined as group 1, and cases by three junior surgeons were identified as group 2. The end points were to assess the reproducibility and repeatability and operative post-operative outcomes of the technique. 55 patients' videos were rated by five experienced endourologists. There was no significant difference in LEAT scores between the groups among all steps. The most symmetry was found in the 1st and 3rd steps. Inter-rater consistency was also high for each step, with no statistically significant difference between the evaluators. The standardised anatomical 'Omega Sign' technique is reproducible for the junior surgeons. The operative steps can be performed with high consistency, and the functional and perioperative outcomes are comparable with the senior surgeon.
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http://dx.doi.org/10.1111/and.14137DOI Listing
September 2021

Outcomes of EAU-endorsed Live Surgical Events over a 5-year Period (2015-2020) and Updated Guidelines from the EAU Live Surgery Committee.

Eur Urol 2021 Nov 19;80(5):592-600. Epub 2021 May 19.

Department of Urology and Pediatric Urology, SLK Kliniken Heilbronn, Teaching hospital of Heidelberg University, Germany.

Context: Live surgery events (LSEs) have been used in all surgical fields for education and training and to demonstrate new techniques. The European Association of Urology (EAU) live surgery guidelines were established in 2014.

Objective: To review the compliance of outcomes for procedures performed at EAU-affiliated LSEs with the 2014 guidelines and to establish updated guidelines for LSEs and semi-LSEs.

Evidence Acquisition: Patients from EAU-affiliated LSEs were included for all surgical procedures carried out between January 2015 and January 2020. All these events were pre-evaluated by the EAU Live Surgery Committee and met the criteria for an EAU LSE, with outcomes recorded and submitted to the registry. Data were collected for the type of procedure and for intraoperative and short- and long-term complications.

Evidence Synthesis: A total of 246 procedures were performed across 18 LSEs, with an annual volume ranging from 19 to 74 procedures. These included 109 (44.3%) robot-assisted procedures, 21 (8.5%) laparoscopic procedures, 10 (4%) transurethral bladder procedures, 11 (4.4%) prostate enucleation procedures, 72 (29.2%) endourological procedures, and 23 (9.3%) andrology or reconstruction procedures. A total of 77 different surgical techniques and variations for 55 different types of surgery were performed as LSEs over the past 5 yr. There were 44 (17.8%) short-term complications and 11.3% (nine/79) long-term complications observed, with Clavien grade III/IV complications seen in 5.2% and 7.5% of cases over short- and long-term follow-up, respectively.

Conclusions: The 5-yr outcomes for EAU LSEs show that they are safe and follow previous guidelines set by the panel. It seems likely that the fine balance between patient safety and educational value might be best achieved if LSEs are performed by local surgeons in their parent hospital with patients and staff they know, and that technological advances will make live streaming a seamless process. The current EAU Live Surgery Committee has updated the guidelines on LSEs and provided new guidelines for semi-live events.

Patient Summary: We reviewed 5-year outcomes for live surgery events endorsed by the European Association of Urology. We found that the operations carried out at these events were safe and followed the guidelines previously set. We have updated the guidelines and provided new guidelines for semi-live events.
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http://dx.doi.org/10.1016/j.eururo.2021.04.037DOI Listing
November 2021

Development Methodology of the Novel Endoscopic Stone Treatment Step 2/A Training/Assessment Curriculum and a Roadmap on Developing Hands-on Training Curriculums in Future: An International Collaborative Work by European Association of Urology Sections.

J Endourol 2021 Sep;35(9):1419-1426

Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.

Basic simulation training in endourology was established with the endoscopic stone treatment step 1 (EST-s1), which is now recognized worldwide for training and examination. Following on from EST-s1, the endoscopic stone treatment step 2 (EST-s2) was started by the European Association of Urology (EAU) sections. We describe the methodology used in the development of EST-s2 assessment curriculum. The "full-life cycle curriculum development" template was followed for curriculum development, focusing on intermediate training of EST protocol with complex endourologic tasks. A cognitive task analysis (CTA) was run in accordance with EAU Urolithiasis guidelines. The protocol and its details underwent a first consensus by Delphi method with EAU Urolithiasis Section experts in March 2017. Once the outcome and metrics were decided, curriculum development was carried out. Purpose-built stones were developed, and simulator system requirement was defined. Preliminary testing was done in European Urology Residents Education Programme 2019 and in phase five the protocol was finalized with full tutor instruction sheet. The EST-s2/A curriculum development took 38 months and involved EAU Uro-technology and urolithiasis sections with coordination from the European School of Urology training group. Starting from the initial CTA, a 1277-word revision with preliminary task description was produced. Nine intermediate skills were identified and included in the final training protocol. The training content and session evaluations were carried out by 26 experts and 16 final year trainees, respectively. Although the experts agreed that EST-s2/A protocol was well structured (96%), covered the complex endourologic maneuvers (92%), and was useful to optimize and improve hands-on-training (HoT) sessions (92%), the overall evaluation was scored 4.25/5 by trainees. We describe the development methodology for intermediate EST curriculum, which also provides a roadmap on developing other HoT protocols in future. In this report we described the development of the novel intermediate training curriculum for EST, called EST-s2, which took 3 years of collaborative work inside the EAU. This article is aimed to strengthen the standards in curriculum development and clearly describe the background of this new EAU official endourology protocol.
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http://dx.doi.org/10.1089/end.2021.0040DOI Listing
September 2021

A systematic review and meta-analysis of Histoscanning™ in prostate cancer diagnostics.

World J Urol 2021 Oct 7;39(10):3733-3740. Epub 2021 Apr 7.

Institute for Urology and Reproductive Health, Sechenov University, Bolshaya Pirogovskaya str. 2 bld. 1, Moscow, 119991, Russia.

Context: The value of Histoscanning™ (HS) in prostate cancer (PCa) imaging is much debated, although it has been used in clinical practice for more than 10 years now.

Objective: To summarize the data on HS from various PCa diagnostic perspectives to determine its potential.

Materials And Methods: We performed a systematic search using 2 databases (Medline and Scopus) on the query "Histoscan*". The primary endpoint was HS accuracy. The secondary endpoints were: correlation of lesion volume by HS and histology, ability of HS to predict extracapsular extension or seminal vesicle invasion.

Results: HS improved cancer detection rate "per core", OR = 16.37 (95% CI 13.2; 20.3), p < 0.0001, I = 98% and "per patient", OR = 1.83 (95% CI 1.51; 2.21), p < 0.0001, I = 95%. The pooled accuracy was markedly low: sensitivity - 0.2 (95% CI 0.19-0.21), specificity - 0.12 (0.11-0.13), AUC 0.12. 8 of 10 studiers showed no additional value for HS. The pooled accuracy with histology after RP was relatively better, yet still very low: sensitivity - 0.56 (95% CI 0.5-0.63), specificity - 0.23 (0.18-0.28), AUC 0.4. 9 of 12 studies did not show any benefit of HS.

Conclusion: This meta-analysis does not see the incremental value in comparing prostate Histoscanning with conventional TRUS in prostate cancer screening and targeted biopsy. HS proved to be slightly more accurate in predicting extracapsular extension on RP, but the available data does not allow us to draw any conclusions on its effectiveness in practice. Histoscanning is a modification of ultrasound for prostate cancer visualization. The available data suggest its low accuracy in screening and detecting of prostate cancer.
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http://dx.doi.org/10.1007/s00345-021-03684-8DOI Listing
October 2021

"VirtualBasket" ureteroscopic holmium laser lithotripsy: intraoperative and early postoperative outcomes.

Minerva Urol Nephrol 2021 Mar 26. Epub 2021 Mar 26.

Department of Urology, ASST Valle Olona, Busto Arsizio, Varese, Italy.

Background: The "VirtualBasket" technology is the result of pulse modulation during holmium laser emission: the laser emits part of the energy to create an initial bubble, and a second pulse is emitted when the vapor bubble is at its maximum expansion, so that it can pass through the previously created vapor channel. The aim of this study is to outline the outcomes of the "VirtualBasket" technology in ureteral and renal stones.

Methods: 160 Patients were randomly assigned to holmium laser lithotripsy with or without the "VirtualBasket" technology in ureteric or renal cases (40 per 4 groups). All procedures were performed by four experienced urologists. The Quanta System Cyber Ho 100W laser generator with 365 μm fibers was used for all of the ureteral cases, whereas, 272 μm fibers were used for all of the cases in the renal pelvis. Demographic data, stone parameters, perioperative complications and success rates were compared. A statistical analysis was carried out to assess patients data and outcomes. All of the reported p-values were obtained with the two-sided exact method at the conventional 5% significance level. The degree of stone retropulsion was graded on a Likert scale from zero (no retropulsion) to 3 (maximum retropulsion).

Results: All groups were comparable in terms of age, and pre-operative stone size (ureter stone size: 1.2 vs. 1.1 cm; renal pelvis stone size: 1.55 vs. 1.62 cm). Compared to the regular mode, the "VirtualBasket" technology was associated with significantly lower fragmentation time (mean time for ureteral stones: 20.4 vs. 16.1 minutes, p<0.05; mean time for renal stones: 28.7 vs. 19.8 minutes, p<0.05) and total procedural time (mean time for ureteral stones 49 vs. 35.7 minutes; mean time for renal stones 67.1 vs. 52.4 minutes). There were no significant differences in terms of energy delivered to the stones, intraoperative complications and success rate at 1 month. The "VirtualBasket" technology was associated with significantly lower retropulsion.

Conclusions: The "VirtualBasket" technology is associated with significantly lower fragmentation and procedural times. The reduced fragmentation time is a result of the significantly lower retropulsion of the stones during laser lithotripsy, which improves stone fragmentation efficiency.
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http://dx.doi.org/10.23736/S2724-6051.21.04025-XDOI Listing
March 2021

Predictors and Strategies to Avoid Mortality Following Ureteroscopy for Stone Disease: A Systematic Review from European Association of Urologists Sections of Urolithiasis (EULIS) and Uro-technology (ESUT).

Eur Urol Focus 2021 Mar 3. Epub 2021 Mar 3.

University Hospital Southampton NHS Trust, Southampton, UK; Manipal Academy of Higher Education, Manipal, India. Electronic address:

Context: While kidney stone disease is common and ureteroscopy (URS) is perceived as minimally invasive, there is mortality associated with treatment.

Objective: The aim of this review was to ascertain the number of mortalities from URS for stone disease over the past three decades, identify relevant patient risk factors and predictors of mortality, and summarise the key recommendations so that similar instances can be avoided, and lessons can be learnt.

Evidence Acquisition: A systematic literature search was conducted following Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) methodology for English-language article reporting on data from 1990 to December 2020. Data collated from each study included patient and stone characteristics, number of mortalities, and cause of death.

Evidence Synthesis: Fifteen studies met our inclusion criteria and revealed a total of 72 mortalities from ten countries. The age range of reported patients varied from 21 to 89 yr, with over 60% being above 65 yr of age and 97% with some comorbidity. Based on available data, death reports in females were three times more than those in males. The stone size ranged from 10 to 38 mm. Treatment of larger stones corresponded to a longer operative time, with procedural duration varying from 30 to 120 min. Of the reported causes of mortality in 42 patients, the aetiology was sepsis in over half of the patients, with other causes being cardiac-related, respiratory-related, multiorgan failure, and haemorrhagic complications.

Conclusions: Although the reported URS mortality rate seems to be low, there has been a rise in deaths over the past decade. Efforts must be made to have preoperative urine culture, and reduce operative time and stage procedures in patients with a large stone burden. Care must be taken in patients with robust preoperative assessment, intraoperative techniques, and postoperative monitoring for early detection of complications with interdisciplinary management of complex cases.

Patient Summary: We reviewed the risk factors associated with postureteroscopy mortality and ways to minimise this. Evidence shows that although reported mortality remains low, there seems to be an increase in mortality in the past decade and urologists must remain vigilant of this.
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http://dx.doi.org/10.1016/j.euf.2021.02.014DOI Listing
March 2021

Holmium laser enucleation of the prostate with Virtual Basket mode: faster and better control on bleeding.

BMC Urol 2021 Feb 23;21(1):28. Epub 2021 Feb 23.

ESUT, European Section for UroTechnology, Arnhem, Italy.

Background: To compare clinical intra and early postoperative outcomes between conventional Holmium laser enucleation of the prostate (HoLEP) and Holmium laser enucleation of the prostate using the Virtual Basket tool (VB-HoLEP) to treat benign prostatic hyperplasia (BPH).

Methods: This prospective randomized study enrolled consecutive patients with BPH, who were assigned to undergo either HoLEP (n = 100), or VB-HoLEP (n = 100). All patients were evaluated preoperatively and postoperatively, with particular attention to catheterization time, operative time, blood loss, irrigation volume and hospital stay. We also evaluated the patients at 3 and 6 months after surgery and assessed maximum flow rate (Qmax), postvoid residual urine volume (PVR), the International Prostate Symptom Score (IPSS) and the Quality of Life score (QOLS).

Results: No significant differences in preoperative parameters between patients in each study arm were found. Compared to HoLEP, VB-HoLEP resulted in less hemoglobin decrease (2.54 vs. 1.12 g/dl, P = 0.03) and reduced operative time (57.33 ± 29.71 vs. 42.99 ± 18.51 min, P = 0.04). HoLEP and VB-HoLEP detrmined similar catheterization time (2.2 vs. 1.9 days, P = 0.45), irrigation volume (33.3 vs. 31.7 l, P = 0.69), and hospital stay (2.8 vs. 2.7 days, P = 0.21). During the 6-month follow-up no significant differences in IPSS, Qmax, PVR, and QOLS were demonstrated.

Conclusions: HoLEP and VB-HoLEP are both efficient and safe procedures for relieving lower urinary tract symptoms. VB-HoLEP was statistically superior to HoLEP in blood loss and operative time. However, procedures did not differ significantly in catheterization time, hospital stay, and irrigation volume. No significant differences were demonstrated in QOLS, IPSS, Qmax and PVR throughout the 6-month follow-up.

Trial Registration: Current Controlled Trials ISRCTN72879639; date of registration: June 25th, 2015. Retrospectively registred.
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http://dx.doi.org/10.1186/s12894-021-00797-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903737PMC
February 2021

Impact of three-dimensional vision in laparoscopic partial nephrectomy for renal tumors.

Turk J Urol 2021 Mar 16;47(2):144-150. Epub 2020 Dec 16.

Department of Urology, SLK-Kliniken, University of Heidelberg, Heilbronn, Germany.

Objective: To compare three-dimensional (3D) with standard two-dimensional (2D) laparoscopic partial nephrectomy (LPN) with respect to intra- and postoperative outcomes.

Material And Methods: Data from 112 patients who underwent transperitoneal LPN from 2012 to 2014 by a single experienced surgeon were collected. Sixty patients (group 1) underwent conventional 2D LPN and 52 patients (group 2) 3D LPN. Perioperative patient, procedure, and tumor data were recorded. The follow-up period was 1-5 years.

Results: The two groups had similar patient age (p=0.834) and body mass index (p=0.141). The total laparoscopy time (LT) was shorter in group 2 (119.0 vs. 106.0 min; p=0.009). Warm ischemia times (WITs) were also shorter in group 2 (11.5 vs. 10.0 min; p=0.032). The estimated blood loss (EBL) (350.0 vs. 250.0 mL; p<0.001) and hemoglobin (Hb) decrease (1.55 vs. 1.35 g/dL; p=0.536) were lower in the 3D LPN group. Creatinine (0 vs. 0 g/dL; p=0.610) increase and estimated glomerular filtration rate (eGFR) decrease (0 vs. 0 mL/min/1.73 m; p=0.553) did not demonstrate statistically significant differences. Duration of hospitalization (7 vs. 7 days; p=0.099) and complication rates (p=0.559) were similar between the two groups.

Conclusion: The new-generation 3D laparoscope has a great impact on significant LPN intraoperative parameters, mainly LT, WIT, and EBL. Hb decrease is also in favor of 3D vision, although not dramatically altered. Therefore, 3D LPN appears to be superior to conventional 2D LPNs.
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http://dx.doi.org/10.5152/tud.2020.20439DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8018808PMC
March 2021

Role of sparing of puboprostatic ligaments on continence recovery after radical prostatectomy: a randomized controlled trial.

Scand J Urol 2021 Feb 26;55(1):22-26. Epub 2020 Nov 26.

SLK-Kliniken Urology Department, Heidelberg University, Heilbronn, Germany.

Objective: Sparing of puboprostatic ligaments (PPLs) during radical prostatectomy was introduced as a technique to improve urinary continence. This study aims to study the effect of sparing of PPLs during laparoscopic radical prostatectomy in terms of continence during the first 3 months.

Methods: A total of 74 patients, diagnosed with clinically localized prostate cancer, were randomly assigned to two equal groups; PPLs division and sparing during LRP. Based on the number of daily used pads, both groups completed 3 months follow-up to assess continence recovery. The effects of age, preoperative total prostate-specific antigen (PSA) and clinical tumor stage on continence recovery were also studied. The study was registered and approved by the Ethics Committee of Alexandria University-Faculty of Medicine (Protocol No. 0201074).

Results: Seventy-four patients were enrolled, with a mean age of 63.8 years. Baseline characteristics were comparable, except significantly higher mean PSA in the division group. Sixty patients were continent (0-1 pad/day) at 3 months follow-up. Continence was significantly better in the sparing than division group at 1 week after catheter removal (67.6% vs 40.5%,  = 0.01), at 1 month (73% vs 45.9%,  = 0.009) and 2 months (89.2% vs 51.4%,  = 0.0001). At 3 months follow-up, there was no significant difference between both groups (83.3% vs 78.4% for sparing and division groups, respectively;  0.28). Moreover, continence was significantly improved at 3 months compared to 1 week in both groups.

Conclusion: Sparing of puboprostatic ligaments during radical prostatectomy significantly improves postoperative early recovery of urinary continence.
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http://dx.doi.org/10.1080/21681805.2020.1849389DOI Listing
February 2021

Impact of COVID-19 on Clinical and Academic Urological Practice: A Survey from European Association of Urology Section of Uro-technology.

Eur Urol Open Sci 2020 Oct 17;21:22-28. Epub 2020 Aug 17.

SLK Kliniken Urology Department, Teaching Hospital of Heidelberg University, Heilbronn, Germany.

Background: The unexpected coronavirus disease 2019 (COVID-19) pandemic has spread worldwide rapidly, developing into a global health crisis. At the same time, it has seriously impacted the daily activities in all the fields of urology.

Objective: To better understand the impact of the COVID-19 pandemic on clinical, academic, and scientific activities as well as on the quality of life of urologists from the main centers in Europe.

Design Setting And Participants: We conducted a survey using a 37-item questionnaire. The survey included three main sections: clinical practice, academic/scientific activities, and personal/social quality of life.

Outcome Measurements And Statistical Analysis: A descriptive analysis was performed using the collected data.

Results And Limitations: A total of 107 representatives affiliated to different centers from 22 countries completed the survey. Clinical activities were affected in 54.2% of the centers, and 85.0% of the elective surgeries were cancelled. Of the urological departments, 64.5% were still performing minimally invasive surgery for malignant disease. In 33.6% of the hospitals, dedicated and specially equipped operating theaters for COVID-19-positive patients were not available. According to 72.9% of participants, COVID-19 had a substantial negative impact on academic activities, and 82.3% of the respondents agreed that their quality of life has been affected negatively by the pandemic. Finally, 92.5% of the participants believe that the pandemic will have a moderate to severe impact on the health system of their countries.

Conclusions: Data collected in this survey provide insight into changes brought about in clinical and academic settings amid COVID-19. Along with shortages such as bed occupancy and personal protective equipment, it highlights negative impacts on academic and scientific activities, including the personal and social life of urologists.

Patient Summary: It is essential to understand the impact of the coronavirus disease 2019 (COVID-19) pandemic on clinical, academic, and scientific urological activities, as well as on related personal and social issues.
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http://dx.doi.org/10.1016/j.euros.2020.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430276PMC
October 2020

Transperitoneal and retroperitoneal approach in laparoscopic partial nephrectomy for posterior cT1 renal tumors: A retrospective, two-centers, comparative study.

Arch Ital Urol Androl 2020 Oct 2;92(3). Epub 2020 Oct 2.

Department of Urology, Korgialenio-Benakio Hellenic Red Cross Hospital, Athens.

Objectives: To compare perioperative, oncological and functional outcomes of Laparoscopic Transperitoneal Partial Nephrectomy (LTPN) and Retroperitoneal Laparoscopic Partial Nephrectomy (LRPN) for posterior, cT1 renal masses (RMs).

Materials And Methods: Databases of two urologic institutions applying different laparoscopic surgical approaches on posterior cT1 RMs between June 2016 and November 2018 were retrospectively evaluated. Data on patient demographics, perioperative data and tumor histology were collected and further analyzed statistically.

Results: Each group consisted of 15 patients. Baseline characteristics were comparable in each group. When compared to LTPN, LRPN was associated with significantly shorter operative time (OT) (115 min versus 199 min, p < 0.05). No significant differences were detected in the other outcomes.

Conclusions: LRPN is associated with a significantly shorter OT compared to LTPN for posterior cT1 RMs. Both surgical approaches are safe, feasible and credible, demonstrating optimal results.
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http://dx.doi.org/10.4081/aiua.2020.3.230DOI Listing
October 2020

Robot-assisted vasovasostomy and vasoepididymostomy: Current status and review of the literature.

Turk J Urol 2020 Sep 1;46(5):329-334. Epub 2020 Sep 1.

Department of Urology, SLK-Kliniken Heilbronn, University of Heidelberg, Heilbronn, Germany.

Objective: Microscope-assisted vasovasostomy (MAVV) is a standard procedure used to reverse vasectomies. Robotic surgery has been established primarily for technically demanding urological procedures and has also been recently implemented in male reproductive surgery. We aimed to review the current evidence of robot-assisted vasovasostomy (RAVV) and robot-assisted vasoepididymostomy (RAVE).

Material And Methods: We performed a systematic literature review using PubMed to identify relevant original articles. We identified 2017 records through database search, and after removing duplicates, 782 records remained for further analysis.

Results: In total, 12 human and three animal studies were selected. Reported vasal patency rate ranges were 88%-100% for RAVVs and 55%-61% for RAVEs. The sperm count and postoperative pregnancy rates of RAVV ranged between 8.4 × 10-120 × 10 sperm/mL and 65%, respectively. Finally, procedure times in the human studies, recorded for extracorporeal RAVVs and RAVEs ranged from 97 to 238 minutes.

Conclusion: Robot-assisted vasal reversal is feasible with similar patency rates as for the microsurgical approach and showing comparable outcomes. Additional benefits of this technique include improved vision and movement precision.
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http://dx.doi.org/10.5152/tud.2020.20257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483453PMC
September 2020

Evaluation of a remote-controlled laparoscopic camera holder for basic laparoscopic skills acquisition: a randomized controlled trial.

Surg Endosc 2021 08 26;35(8):4183-4191. Epub 2020 Aug 26.

MRC Centre for Transplantation, King's College London, Guy's Hospital, King's Health Partners, London, SE1 9RT, UK.

Background: Unsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH.

Methods: Novices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants.

Results: Forty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n = 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P = 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P = 0.0004). No significance differences were achieved in the circle cutting (P = 0.18) or needle guidance tasks (P = 0.32). The RCH group experienced significantly lower workload (P = 0.014) due to lower levels of distraction (P = 0.047).

Conclusions: Remote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice.

Trial Registration: ISRCTN 83733979.
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http://dx.doi.org/10.1007/s00464-020-07899-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263395PMC
August 2021

Analysis of performance factors in 240 consecutive cases of robot-assisted flexible ureteroscopic stone treatment.

J Robot Surg 2021 Apr 16;15(2):265-274. Epub 2020 Jun 16.

Department of Urology, SLK-Kliniken Heilbronn, University of Heidelberg, 74078, Heilbronn, Germany.

Flexible ureteroscopy is the keystone of modern kidney stone treatment. Although a simple surgical technique achieves good clinical results and a low complication rate, there are high demands on the surgeon's dexterity and ergonomic restrictions. Robotic-assisted flexible ureteroscopy (rfURS) could overcome these limitations. After 4 years of use of rfURS at a tertiary stone center, performance factors were analyzed to define the role of rfURS in kidney stone management. A rfURS system was installed in August 2014 at the SLK Kliniken (Heilbronn, Germany). Treatment data of N = 240 consecutive patients undergoing rfURS were prospectively collected and analyzed. The patient cohort represents typical stone formers. N = 240 renal units containing 443 stones with an average stone load of 1798 mm were treated. Surgical parameters as well as the peri- and postoperative complications were recorded, analyzed and compared to the current data in the literature. OR time 91 min, stone treatment time 55 min, stone treatment efficacy 33 mm/min; perioperative complications 5.4%; robot times: preparation 5 min, docking 5 min, console time to stone contact 6 min, console time 75 min; postoperative complications 6.7%; postoperative length of stay 1.5 days; stone-free rate (residuals < 2 mm) 90% and re-treatment rate 8.75%. This consecutive series represents real-life data about the utilization of rfURS. The detailed analysis of performance factors revealed the successful utilization of the first generation of robotic systems in endourologic stone surgery, and indicates that the robot performs comparably to conventional flexible URS. Optimal ergonomics maintain the surgeon's endurance in long-lasting surgeries.
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http://dx.doi.org/10.1007/s11701-020-01103-5DOI Listing
April 2021

Laparoscopic totally intracorporeal ileal ureter replacement: a multi-institutional study.

Minim Invasive Ther Allied Technol 2020 May 19:1-8. Epub 2020 May 19.

Department of Urology SLK-Kliniken Heilbronn, University of Heidelberg, Heilbronn, Germany.

To prove the feasibility, as well as the reproducibility of laparoscopic totally intracorporeal ileal ureter replacement (LIUR), by presenting a multicenter patient cohort with a long follow-up. Records of patients undergoing different types of ureteral replacements have been collected. Follow-up included a chemical profile and urine cultures. Imaging consisted of renal ultrasonography and excretory urography, as well as a cystography or an isotopic renography when indicated. Forty patients were included in the study. Twelve underwent a right, 20 a left, and eight a bilateral laparoscopic ureteral replacement. The mean procedure time was 335 (150-680) minutes and the mean estimated blood loss was 221 (50-400) mL. Only three patients presented intraoperative complications, which were managed immediately, and three patients presented a Clavien III postoperative complication. Abdominal drains and nephrostomy tubes were removed after 24-36 h and 7-10 days, respectively. The mean hospital stay was 13.5 (10-35) days. Follow-up was at least six months. LIUR constitutes a feasible and reproducible method for the restoration of long ureteral defects.
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http://dx.doi.org/10.1080/13645706.2020.1762094DOI Listing
May 2020

European Association of Urology Guidelines Office Rapid Reaction Group: An Organisation-wide Collaborative Effort to Adapt the European Association of Urology Guidelines Recommendations to the Coronavirus Disease 2019 Era.

Eur Urol 2020 Jul 27;78(1):21-28. Epub 2020 Apr 27.

Department of Urology, Medical University of Innsbruck, Innsbruck, Austria.

The coronavirus disease 2019 (COVID-19) pandemic is unlike anything seen before by modern science-based medicine. Health systems across the world are struggling to manage it. Added to this struggle are the effects of social confinement and isolation. This brings into question whether the latest guidelines are relevant in this crisis. We aim to support urologists in this difficult situation by providing tools that can facilitate decision making, and to minimise the impact and risks for both patients and health professionals delivering urological care, whenever possible. We hope that the revised recommendations will assist urologist surgeons across the globe to guide the management of urological conditions during the current COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.eururo.2020.04.056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183974PMC
July 2020

Comparison of synchronous bilateral transperitoneal and posterior retroperitoneal laparoscopic adrenalectomy: results of a multicenter study.

Surg Endosc 2021 03 9;35(3):1101-1107. Epub 2020 Mar 9.

Department of Urology, SLK Kliniken, University of Heidelberg, Heilbronn, Germany.

Background: Different techniques for laparoscopic adrenalectomy have been proposed with the lateral transperitoneal approach and posterior retroperitoneal approach being the two more frequently minimally invasive surgeries in most of the clinics. There are no sufficient studies in which the results of lateral transperitoneal and posterior retroperitoneal approaches in synchronous bilateral laparoscopic adrenalectomy have been compared. In the current study, we aimed to report our multicenter results of the lateral transperitoneal and posterior retroperitoneal synchronous bilateral laparoscopic adrenalectomy experience in patients who had different bilateral adrenal pathologies and to compare the outcomes of these two different operative procedures.

Methods: Between 2012 and 2018, a total of 52 patients with a mean age of 43.5 years underwent simultaneous bilateral laparoscopic adrenalectomy at 6 different centers. Twenty-seven and 25 patients underwent bilateral lateral transperitoneal and posterior retroperitoneal laparoscopic adrenalectomy, respectively. Patients' age, gender, body max index, operative indications, mass size, operation time, blood loss, length of hospitalization, intraoperative and postoperative complications and pathology reports were analyzed.

Results: Synchronous bilateral transperitoneal group was younger than synchronous posterior retroperitoneal group (37 years vs. 50.4 years.) (p: 0.001). Posterior retroperitoneal group had significantly decreased operating time and less blood loss than transperitoneal group. No significant difference was found with regard to postoperative hospital stay, perioperative and postoperative complications between two groups. Majority of the histopathological results were adrenal hyperplasia associated with Cushing's disease (61.5%). Less frequent pathological results were adrenal adenoma and pheochromocytoma (15.4% and 13.5%, respectively). During the follow-up period, no recurrence or disease-related mortality was observed in the patients.

Conclusion: Our results shows that shorter operative time and less bleeding can be achieved with posterior retroperitoneal approach in synchronous bilateral laparoscopic adrenalectomy. In our series, intraoperative and postoperative complication rates were similar between both surgical approaches.
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http://dx.doi.org/10.1007/s00464-020-07474-yDOI Listing
March 2021

Thulium-laser retrograde intra renal ablation of upper urinary tract transitional cell carcinoma: an ESUT Study.

Minerva Urol Nephrol 2021 Feb 30;73(1):114-121. Epub 2020 Jan 30.

ESUT (European section for UroTechnology), Arnehm, the Netherlands.

Background: Radical nephroureterectomy (RNU) is the gold standard treatment for upper urinary tract urothelial carcinoma (UTUC); however, patients presenting with small low-grade UTUC have been treated by flexible ureteroscopic laser ablation with good outcomes. Different types of laser have been discussed in the literature including Holmium and Neodymium lasers. We aimed to assess the safety and efficacy of Thulium laser (Tm:YAG) in the ureteroscopic ablation of UTUC.

Methods: A retrospective observational multicentre study of patients diagnosed with papillary UTUC between January 2015 and December 2016 was carried out. All patients underwent ureteroscopic biopsy of the UTUC followed by Tm:YAG ablation. Based on the histopathological grade of the tumor, patients were counseled to undergo either RNU (high- grade tumors) or conservative management and follow-up (low-grade tumor).

Results: RNU was performed in 31 patients, while the remaining 47 patients (undergone Tm:YAG ablation only) were followed up for a mean of 11.7 months with only 19.2% of patients showing upper tract recurrence and no patients showed postoperative ureteral strictures. Limitations include the short follow-up and retrospective nature of the study.

Conclusions: On the short term, thulium Laser ablation of UTUC is safe and feasible especially in low-grade UTUC.
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http://dx.doi.org/10.23736/S0393-2249.20.03689-9DOI Listing
February 2021

Embarking with laparoscopic radical prostatectomy and dealing with the complications and collateral problems: A single-center experience.

Turk J Urol 2020 01 21;46(1):37-43. Epub 2019 Oct 21.

SLK-Kliniken Urology Department, Heidelberg University, Heilbronn, Germany.

Objective: The aim of the present study was to report our single-center initial experience in laparoscopic radical prostatectomy (LRP) with special emphasis on the complications and collateral problems and their management.

Material And Methods: A total of 48 patients (mean age 64 years) underwent LRP in our institution between August 2014 and July 2018. Two surgeons completed a fellowship training program for LRP before. Mentored operations started after the first 10 cases. The patients were divided in two groups of 30 (group I) and 18 (group II) patients. Demographic, preoperative, peroperative, and postoperative data were collected prospectively. Anesthesiology and nurses' team performances, as well as problems and their management, were reviewed.

Results: The demographic data for both groups (group I vs. group II) were similar. Estimated blood loss (695.5±139.23 vs. 398±339.39 mL) and intraoperative complication rates (36.66% vs. 5.55%) were significantly (p<0.05) higher in group I. Conversion to open surgery occurred in 7 (20%) patients in group I and in 1 (5.55%) patient in group II. Continence rates at 12 (83%) months were similar in both groups. Positive surgical margins were 8.33% for pT2 and 27.1% for pT3 stages.

Conclusion: A validated fellowship program before starting LRP and performing the first cases under mentorship are helpful. The complication and conversion rates decrease after 30 cases in addition to the improved experience also with improved cooperation with the anesthesiologist and scrub nurse.
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http://dx.doi.org/10.5152/tud.2019.19008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6944418PMC
January 2020

Current status of urology surgical training in Europe: an ESRU-ESU-ESUT collaborative study.

World J Urol 2020 Jan 13;38(1):239-246. Epub 2019 Apr 13.

Department of Urology, La Paz University Hospital, Madrid, Spain.

Purpose: To determine the current status of surgical training amongst European Urology Residents, including their satisfaction with training and their confidence in performing procedures.

Methods: A 23-item survey was distributed to the 15th European Urology Residents Education Programme (EUREP) 2017 participants. An analysis of demographics, workload, training resources, surgical exposure, surgical caseload, satisfaction and confidence in performing each procedure was performed.

Results: A total of 152/350 participants completed the survey (response rate 43%), of which 14% think they perform enough surgeries during their training, and 83% would like to continue training with a fellowship. Confidence in performing procedures without supervision and satisfaction with training was associated with higher surgical caseloads. Confidence in all laparoscopic/robotic procedures (except for laparoscopic/robotic partial nephrectomy) was associated with laparoscopic and robotics training, participation in practical courses and having training resources in hospitals. Satisfaction with surgical training was statistically associated with working ≤  50 h per week, laparoscopic training and having laparoscopic training boxes.

Conclusions: Surgical exposure of European Urology residents for major/minimally invasive procedures, confidence in performing these procedures, and overall satisfaction with training is low. A higher volume of cases, as well as resources for training are associated with higher individual confidence and satisfaction with training.
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http://dx.doi.org/10.1007/s00345-019-02763-1DOI Listing
January 2020

Validation of the endoscopic stone treatment step 1 (EST-s1): a novel EAU training and assessment tool for basic endoscopic stone treatment skills-a collaborative work by ESU, ESUT and EULIS.

World J Urol 2020 Jan 27;38(1):193-205. Epub 2019 Mar 27.

Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK.

Introduction: The endoscopic stone treatment step 1 (EST s1) protocol has been developed after 2 years of collaborative work between different European Association of Urology (EAU) sections.

Objectives: In this study, we added construct validity evidence to the EST s1 curriculum.

Materials And Methods: The EST-s1 curriculum includes four standardized tasks: flexible cystoscopy, rigid cystoscopy, semi-rigid URS and flexible URS. Validation was performed during the annual 2016 EUREP meeting in Prague. 124 participants provided information on their endoscopic logbook and carried out these 4 tasks during a DVD recorded session. Recordings were anonymized and blindly assessed independently by five proctors. Inter-rater reliability was checked on a sample of five videos by the calculation of intra-class correlation coefficient. Task-specific clinical background of participants was correlated with their personal performance on the simulator. Breakpoint analysis was used to define the minimum number of performed cases, to be considered "proficient". "Proficient" and "Non-proficient" groups were compared for construct validity assessment. Likert scale-based questionnaires were used to test content and to comment on when the EST-s1 exams should be undertaken within the residency program.

Results: 124 participants (105 final-year residents and 19 faculty members) took part in this study. The breakpoint analysis showed a significant change in performance curve at 36, 41, 67 and 206 s, respectively, corresponding to 30, 60, 25 and 120 clinical cases for each of the 4 tasks. EST-s1 was scored as a valid training tool, correctly representing the procedures performed in each task. Experts felt that this curriculum is best used during the third year of residency training.

Conclusion: Our validation study successfully demonstrated correlation between clinical expertise and EST-s1 tasks, adding construct validity evidence to it. Our work also demonstrates the successful collaboration established within various EAU sections.
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http://dx.doi.org/10.1007/s00345-019-02736-4DOI Listing
January 2020

Tract sizes in percutaneous nephrolithotomy: does miniaturization improve outcome?

Curr Opin Urol 2019 03;29(2):118-123

Department of Urology, SLK Kliniken, Heilbronn, Germany.

Purpose Of Review: To provide a summary of surgical outcomes in percutaneous nephrolithotomy (PCNL) according to various techniques and tract sizes.

Recent Findings: Recent literature in this field concluded that standard PCNL (sPCNL) remains the optimal treatment for stones between 1 and 2.5 cm and can be managed with tracts 14-20 F, whereas small stones less than 1.5 cm can be treated with tracts under 14 F. According to new datasets, smaller tracts can be equally effective in the treatment and might offer the possibility to reduce bleeding, length of hospital stay, postoperative pain as well as overall complication rates when compared with sPCNL. On the other hand, longer operative time as well as lower stone-free rates, which have been the main drawbacks of the miniaturized approach, have recently shown to be comparable with sPCNL.

Summary: At present, tract size is a highly debatable topic in percutaneous stone therapy. New systems for miniaturized PCNL have been developed to achieve comparable stone-free rates while reducing the incidence of common complications. The adoption of these techniques demands skilled surgeons and institutional investment for the acquisition of new equipment.
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http://dx.doi.org/10.1097/MOU.0000000000000574DOI Listing
March 2019

A match-pair analysis of continence in intermediate and high-risk prostate cancer patients after robot-assisted radical prostatectomy: the role of urine loss ratio and predictive analysis.

Prostate Int 2018 Sep 24;6(3):94-98. Epub 2017 Sep 24.

Department of Urology, SLK Klinikum Heilbronn, Am Gesundbrunnen 20, Heilbronn, Germany.

Background: We aimed to study the continence between intermediate and high-risk cancer patients and the influential factors to recover continence.

Materials And Methods: In total, 655 patients underwent surgery by robot-assisted radical prostatectomy between 2010 and 2015. Of 655 patients, 294 were classified according to D'Amico risk groups as intermediate risk or high risk and completed the micturition protocol. Patients with intermediate risk were matched in a 1:1 ratio to patients with high risk for age and body mass index. Urine loss ratio (ULR) was defined as urine loss divided by micturition volumes. Immediate continence was defined with the best cut-off value of ULR.

Results: In total, 117 patients with intermediate risk were matched to those with high risk. The comparison did not show any statistically significant difference in the ULR value ( = 0.359) or continence rate ( = 0.449). Predictive analysis was performed for the 294 patients (intermediate and high risk), of which 9.5% were classified as incontinent (>1 pad/d). Immediate continence was defined as ULR < 0.049 in 232 (78.9%) patients. Age, preoperative hemoglobin, and duration of catheterization were found influent by univariate analysis. Only age [odds ratio (OR) = 1.072; 95% confidence interval (CI) = 1.020-1.127;  = 0.006] and duration of catheterization (OR = 1.060; 95% CI = 1.003-1.120;  = 0.040) were independent influential factors to predict immediate continence.

Conclusion: D'Amico intermediate- and high-risk groups do not differ in continence terms. The ULR value of < 0.049 identifies those patients who recover continence earlier. Age and duration of catheterization were influential factors in predicting immediate continence.
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http://dx.doi.org/10.1016/j.prnil.2017.09.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6104473PMC
September 2018

Laparoscopic Radical Prostatectomy in Patients with High-Risk Prostate Cancer: Feasibility and Safety. Results of a Multicentric Study.

J Endourol 2018 09 21;32(9):843-851. Epub 2018 Aug 21.

6 Division of Experimental Oncology, Department of Urology, Vita-Salute San Raffaele University of Milan , Milan, Italy .

Introduction: In Western countries about 25% of prostate cancer (PCa) are high-risk tumors at presentation and its treatment is still a matter of debate among urologists. When a surgical approach is preferred the use of a mininvasive tecnique is still difficult due to the lack of data supporting it in literature. The aim of this study is to evaluate feasibility and safety of laparoscopic radical prostatectomy (LRP) for high-risk PCa.

Materials And Methods: The study included 1114 patients with high-risk PCa submitted to LRP between 1998 and 2014. High-risk patients were defined according to D'Amico classification. We collected functional and oncological long-term outcomes and evaluated with univariate and multivariate analyses the role of predictive factors for survival and biochemical recurrence (BR).

Results: Mean age at treatment was 62 ± 8 years; mean follow-up was 74 ± 50 months. We obtained an overall survival (OS) of 96.6% at a mean follow-up of 74 months (1076 patients) and a disease-free survival of 66.2% (737 patients). Age (p = 0.0006), pT (p < 0.0001), pN (p = 0.0018), and surgical margins (p = 0.0076) resulted as independent predictors for BR in multivariate analysis. pN (p = 0.0025) and Gs (p = 0.0003) are independent predictors for OS and cancer-specific survival in a univariate analysis; just the Gs results significant in the multivariate model.

Conclusions: According to our encouraging data about oncological and functional outcomes we believe that radical prostatectomy represents an effective treatment for patients with high-risk PCa and that laparoscopy is a safe approach offering a mini-invasive alternative to open surgery.
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http://dx.doi.org/10.1089/end.2018.0086DOI Listing
September 2018

The Novel and Minimally Invasive Treatment Modalities for Female Pelvic Floor Muscle Dysfunction; Beyond the Traditional

Balkan Med J 2018 09 28;35(5):358-366. Epub 2018 Jun 28.

Department of Urology, SLK-Kliniken Heilbronn, University of Heidelberg, Heilbronn, Germany

Pelvic floor dysfunction is a clinical entity that is prevalent among female patients. Determining the exact underlying cause of pelvic floor dysfunction is difficult, and surgical intervention for this clinical entity may be challenging. Pelvic floor dysfunction can affect the quality of life of the patient by causing stress urinary incontinence, pelvic organ prolapse, or both. Well-defined surgical treatment options, minimally invasive approaches, and novel techniques for the treatment of pelvic floor dysfunction have been recently introduced. Here, we evaluated the management options available for patients with stress urinary incontinence and pelvic organ prolapse. We searched Medline and EMBASE databases for relevant articles by using the keywords “pelvic floor dysfunction,” “minimally invasive procedures,” “stress urinary incontinence,” “pelvic organ prolapse,” and “novel techniques”. Traditional treatment options for stress urinary incontinence and pelvic organ prolapse are beyond the scope of our review. Laparoscopic and robotic surgical treatments for pelvic floor dysfunction continue to evolve and develop. These minimally invasive techniques will soon replace open procedures. Alternative novel treatment modalities have also been developed from novel human-compatible materials and are emerging as successful treatments for stress urinary incontinence. The development of these various treatment options has implications for future surgical practice in the field of uro-gynecology.
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http://dx.doi.org/10.4274/balkanmedj.2018.0869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6158473PMC
September 2018

The European Urology Residents Education Programme Hands-on Training Format: 4 Years of Hands-on Training Improvements from the European School of Urology.

Eur Urol Focus 2019 11 14;5(6):1152-1156. Epub 2018 Mar 14.

Department of Urology and Kidney Transplant, Grande Ospedale Metropolitano, Reggio Calabria, Italy; School of Medicine, Hofstra University, New York, NY, USA; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.

Background: The European School of Urology (ESU) started the European Urology Residents Education Programme (EUREP) in 2003 for final year urology residents, with hands-on training (HOT) added later in 2007.

Objective: To assess the geographical reach of EUREP, trainee demographics, and individual quality feedback in relation to annual methodology improvements in HOT.

Design, Setting, And Participants: From September 2014 to October 2017 (four EUREP courses) several new features have been applied to the HOT format of the EUREP course: 1:1 training sessions (2015), fixed 60-min time slots (2016), and standardised teaching methodology (2017). The resulting EUREP HOT format was verified by collecting and prospectively analysing the following data: total number of participants attending different HOT courses; participants' age; country of origin; and feedback obtained annually.

Results And Limitations: A total of 796 participants from 54 countries participated in 1450 HOT sessions over the last 4 yr. This included 294 (20%) ureteroscopy (URS) sessions, 237 (16.5%) transurethral resection (TUR) sessions, 840 (58%) basic laparoscopic sessions, and 79 (5.5%) intermediate laparoscopic sessions. While 712 residents (89%) were from Europe, 84 (11%) were from non-European nations. Of the European residents, most came from Italy (16%), Germany (15%), Spain (15%), and Romania (8%). Feedback for the basic laparoscopic session showed a constant improvement in scores over the last 4 yr, with the highest scores achieved last year. This included feedback on improvements in tutor rating (p=0.017), organisation (p<0.001), and personal experience with EUREP (p<0.001). Limitations lie in the difficulties associated with the use of an advanced training curriculum with wet laboratory or cadaveric courses in this format, although these could be performed in other training centres in conjunction with EUREP.

Conclusions: The EUREP trainee demographics show that the purpose of the course is being achieved, with excellent feedback reported. While European trainees dominate the demographics, participation from a number of non-European countries suggests continued ESU collaboration with other national societies and wider dissemination of simulation training worldwide.

Patient Summary: In this paper we look at methodological improvements and feedback for the European Urology Residents Education Programme hands-on-training over the last 4 yr.
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http://dx.doi.org/10.1016/j.euf.2018.03.002DOI Listing
November 2019

In Vivo Comparison of "V-Loc 90 Wound Closure Device" With "Vicryl" and "Monocryl" in Regard to Tissue Reaction in a Rabbit Bladder Model.

Urology 2018 Jun 2;116:231.e1-231.e5. Epub 2018 Mar 2.

University of Heidelberg, SLK-Kliniken, Department of Urology, Heilbronn, Germany. Electronic address:

Objective: To compare the barbed polyglyconate suture (BPS) with 2 commonly used conventional sutures, this prospective randomized trial was designed. The sutures applied in the urinary collecting system, in terms of long-term histopathologic and macroscopic suture material features.

Materials And Methods: Eight female and 6 male New Zealand rabbits were included in the study. Each animal served as its own control and was subjected to cystotomy. Watertight running cystorrhaphies were performed using 3 different sutures in a randomized fashion, namely Monocryl, Vicryl, and V-Loc 90. Seven animals were sacrificed after the third and 7 after the sixth week. Macroscopic and histopathologic examinations were performed. Tissue reaction, like inflammation and fibrosis, around the sutures were evaluated. Friedman and Wilcoxon signed ranks test was used for the statistical analysis.

Results: The BPS demonstrated no adhesion. However, in the six-week group, stone formation was recorded on 4 BPS and 1 Vicryl thread, a difference being statistically significant (P = .039). Additionally, in the third- and in the sixth-week group, 1 (P = .368) and 3 (P = .050) BPS threads migrated, respectively. The histopathologic analysis revealed less inflammation and fibrosis associated with the BPS thread in both the third and the sixth-week groups (P = .010 and P = .002, respectively).

Conclusion: The BPS appears to be superior to conventional sutures in terms of local inflammation and fibrosis. However, suture migration and stone formation following collecting system closure could be potential predicaments.
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http://dx.doi.org/10.1016/j.urology.2018.02.027DOI Listing
June 2018

Evaluation of the complications in laparoscopic retroperitoneal radical nephrectomy; An experience of high volume centre.

Arch Ital Urol Androl 2017 Dec 31;89(4):266-271. Epub 2017 Dec 31.

Department of Urology, SLK-Kliniken, University of Heidelberg, Heilbronn, Germany.

Objectives: To provide a standardised report of complications after retroperitoneal laparoscopic radical nephrectomy (rLRN) in a high-volume centre using Clavien-Dindo classification.

Materials And Methods: We analysed records maintained in a prospective database of 330 consecutive patients that underwent rLRN between March 1995 and September 2016. All complications were graded according to the modified Clavien-Dindo classification. Three generations of surgeons were defined and the learning curve in rLRN was evaluated by comparing the first 100 cases (Group A) performed by firstgeneration surgeons with the last 100 cases (Group B) by thirdgeneration surgeons.

Results: The mean age of our cohort was 66 ± 11.9 years. The overall complication rate was 19.7%. The majority of complications (12.7%) were Clavien 1 (5.1%) and Clavien 2 (7.6%) and did not require any interventions; blood transfusion was the most frequently encountered intervention (4.8%). Half of which were because of major intraoperative bleeding. Mortality rate was 0.9%. We found a trend towards lower complication rate in group B (19%) compared to group A (23%); this was mainly because of the reduction in the incidence of Clavien 1 and 2 complications. The pathological stage varied significantly in the two groups while the rate of negative surgical margins was comparable.

Conclusions: rLRN is a safe procedure with an acceptable rate of complications. The learning curve was shorter for the thirdgeneration surgeons (group B); although these surgeons operated on a significantly higher number of patients with more advanced diseases. The Clavien-Dindo classification is suitable for assessing rLRN complications. Adopting this standardised system can help in the evaluation and comparison of surgical quality of LRN series.
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http://dx.doi.org/10.4081/aiua.2017.4.266DOI Listing
December 2017
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