Impact of COVID-19 on endourology surgical practice in Saudi Arabia:A national multicenter study

Objective:To identify the impact of COVID-19 on endourology surgical practice in Saudi Arabia.Methods:A retrospective study of seven tertiary hospitals from January 2019 to April 2019,and from January 2020 to April 2020 was performed.Records of urology outpatient department(OPD)visits and endourology procedures in the first third of 2020 were analyzed and compared with those in the first third of 2019,as well as,during the full curfew time,i.e.April 2020 versus April 2019.Results:Number of OPD visits in the first third of 2020 and 2019 were 19499 and 26594,respectively(p<0.001).Number of OPD visits in April 2020 was 1512,with a 78.6%decrease compared to that in April 2019,and among them 1373(90.8%)were teleclinics.Number of elective procedures in the first third of 2020 has decreased by 34.3%(from 3025 to 1988)compared to that in the first third of 2019(p<0.001).There were 120 elective procedures in April 2020,84.1%lower than that in April 2019.Percutaneous nephrolithotomy,shockwave lithotripsy,and transurethral resection of prostate procedures declined by 94.2%,98.5%,and 93.8%,respectively.Most procedures were performed as day surgery(85.0%).Number of emergency procedures in 2020 have fallen by 9.3%compared to 2019(pZ0.286).Urolithiasis was the commonest pathology(52.6%)presented to the emergency room(52.6%).Conclusion:During COVID-19 pandemic,urology services slashed by>75%,including OPD visits and elective endourology procedures.Most hospitals have changed their strategic preventive measures by increasing the rate of teleclinics and day surgeries.

Prevention of complications in endourological management of stones:What are the basic measures needed before,during,and after interventions?

Objective:This narrative review aims to describe measures to minimise the risk of complications during percutaneous nephrolithotomy(PCNL),ureteroscopy,and retrograde intrarenal surgery.Methods:A literature search was conducted from the PubMed/PMC database for papers published within the last 10 years(January 2012 to December 2022).Search terms included“ureteroscopy”,“retrograde intrarenal surgery”,“PCNL”,“percutaneous nephrolithotomy”,“complications”,“sepsis”,“infection”,“bleed”,“haemorrhage”,and“hemorrhage”.Key papers were identified and included meta-analyses,systematic reviews,guidelines,and primary research.The references of these papers were searched to identify any further relevant papers not included above.Results:The evidence is assimilated with the opinions of the authors to provide recommendations.Best practice pathways for patient care in the pre-operative,intra-operative,and post-operative periods are described,including the identification and management of residual stones.Key complications(sepsis and stent issues)that are relevant for any endourological procedure are then be discussed.Operation-specific considerations are then explored.Key measures for PCNL include optimising access to minimise the chance of bleeding or visceral injury.The role of endoscopic combined intrarenal surgery in this regard is discussed.Key measures for ureteroscopy and retrograde intrarenal surgery include planning and technique to minimise the risk of ureteric injury.The role of anaesthetic assessment is discussed.The importance of specific comorbidities on each step of the pathway is highlighted as examples.Conclusion:This review demonstrates that the principles of meticulous planning,interdisciplinary teamworking,and good operative technique can minimise the risk of complications in endourology.

Transforming urinary stone disease management by artificial intelligence-based methods:A comprehensive review

Objective:To provide a comprehensive review on the existing research and evidence regarding artificial intelligence(AI)applications in the assessment and management of urinary stone disease.Methods:A comprehensive literature review was performed using PubMed,Scopus,and Google Scholar databases to identify publications about innovative concepts or supporting applications of AI in the improvement of every medical procedure relating to stone disease.The terms“endourology”,“artificial intelligence”,“machine learning”,and“urolithiasis”were used for searching eligible reports,while review articles,articles referring to automated procedures without AI application,and editorial comments were excluded from the final set of publications.The search was conducted from January 2000 to September 2023 and included manuscripts in the English language.Results: A total of 69 studies were identified.The main subjects were related to the detection of urinary stones,the prediction of the outcome of conservative or operative management,the optimization of operative procedures,and the elucidation of the relation of urinary stone chemistry with various factors.Conclusion: AI represents a useful tool that provides urologists with numerous amenities,which explains the fact that it has gained ground in the pursuit of stone disease management perfection.The effectiveness of diagnosis and therapy can be increased by using it as an alternative or adjunct to the already existing data.However,little is known concerning the potential of this vast field.Electronic patient records,containing big data,offer AI the opportunity to develop and analyze more precise and efficient diagnostic and treatment algorithms.Nevertheless,the existing applications are not generalizable in real-life practice,and high-quality studies are needed to establish the integration of AI in the management of urinary stone disease.

Radiation protection measures during endourological therapies

Objective The objective of this narrative review was to search the existing literature for studies reporting measures to minimize radiation use during endoscopic management of stone disease and present ways of reducing the exposure of both patients and operating room staff.Methods A literature review in PubMed was performed to identify studies describing protocols or measures to reduce radiation received during endourological procedures from January 1970 to August 2022.Eligible studies were those that reported outcomes for ureteroscopy or percutaneous nephrolithotripsy regarding measures to minimize radiation doses used intraoperatively,performed either in real-life theatres or using phantoms.Both comparative and non-comparative studies were deemed eligible.Results Protection can be achieved initially at the level of diagnosis and follow-up of patients,which should be done following an algorithm and choice of more conservative imaging methods.Certain protocols,which follow principles for minimized fluoroscopy use should be implemented and urologists as well as operating room staff should be continuously trained regarding radiation damage and protection measures.Wearing protective lead equipment remains a cornerstone for personnel protection,while configuration of the operating room and adjusting X-ray machine settings can also significantly reduce radiation energy.Conclusion There are specific measures,which can be implemented to reduce radiation exposure.These include avoiding excessive use of computed tomography scans and X-rays during diagnosis and follow-up of urolithiasis patients.Intraoperative protocols with minimal fluoroscopy use can be employed.Staff training regarding dangers of radiation plays also a major role.Use and maintenance of protective equipment and setting up the operating room properly also serve towards this goal.Machine settings can be customized appropriately and finally continuously monitoring of exposure with dosimeters can be adopted.

Retrograde intrarenal surgery:An expanding role in treatment of urolithiasis

During the past 3 decades,the surgical management of kidney stones has undergone many technological advances and one is the development of the flexible ureteroscopy.The development of this instrument as well as ancillary equipment such as baskets,graspers,and others,and improvements in lithotripsy with Holmium:YAG laser have led to expand its indications with diagnostic and therapeutic management of medical issues of the upper urinary tract such as urolithiasis and urothelial tumors.The objective of this review is to describe its indications and results in the different scenarios for the treatment of urinary stones.

Innovative endoscopic enucleations of the prostate--Xie’s Prostate Enucleations

In the past 2 decades,endoscopic enucleation of the prostate has become a safe and effective surgical treatment for benign prostatic hyperplasia(BPH),with comparable outcomes to traditional surgeries.Transurethral vapor enucleation and resection of the prostate(TVERP),transurethral vapor enucleation of the prostate(TVEP),and ultrasound-navigated TVEP(US-TVEP)are new,innovative endoscopic enucleation procedures.These procedures are named Xie’s Prostate Enucleations(Xie’s Procedures for short).Current clinical data indicate that Xie’s Procedures are safe and effective treatment options for patients with BPH,especially for patients with larger prostates.Further prospective,randomized clinical trials compared with traditional transurethral resection of prostate(TURP)are still needed.

Validation of laparoscopy and flexible ureteroscopy tasks in inanimate simulation training models at a large-scale conference setting

Objective:Simulation based training with training models is being increasingly used as a tool to help trainees mount the learning curve.However,validation studies of surgical simulators are often limited by small numbers.We aim to evaluate the feasibility of validating simulation-training tasks in laparoscopy and flexible ureteroscopy(FURS)rapidly at a large-scale conference setting for residents.Methods:Seventy-six urology residents from various Asian countries were assessed on their laparoscopic and FURS skills during the 14th Urological Association of Asia Congress 2016.Residents performed the peg transfer task from the fundamentals of laparoscopic surgery(FLS)and completed inspection of calyces and stone retrieval using a flexible ureteroscope in an en-dourological model.Each participant’s experience(no experience,1-30 or>30 procedures)in laparoscopy,rigid ureteroscopy(RURS)and FURS was self-reported.Results:Median time taken to complete the laparoscopic task decreased with increasing laparoscopic experience(209 s vs.177 s vs.145 s,p=0.008)whereas median time taken to complete the FURS tasks reduced with increasing FURS experience(405 s vs.250 s vs.163 s,p=0.003)but not with RURS experience(400.5 s vs.397 s vs.331 s,p=0.143),demonstrating construct validity.Positive educational impact of both tasks was high,with mean ratings of 4.16/5 and 4.10/5 respectively,demonstrating face validity.Conclusion:Our study demonstrates construct and face validities of laparoscopy and FURS simulation tasks among residents at a conference setting.Validation studies at a conference setting can be an effective avenue for evaluating simulation models and curriculum in the future.

Upper Urinary Tract Calculi in Senegal: A Comparative Study between Open Surgery and Endoscopy, a Review of 89 Cases

Objective: The aim was to assess the place of endourologic intervention in our practice and compare it to open surgery in the management of upper urinary tract calculi in Senegal. Patients and Methods: This was a retrospective study conducted at both the Principal and Grand Yoff Hospitals of Dakar from January 2009 to December 2013 in which 89 patients with upper urinary tract calculi were mobilized. All patients with symptomatic upper urinary tract colic symptoms were included. Results: Eighty-nine were followed up during the study period, 63 men and 36 women (sex of ratio 1.2). The average age was 44 years with extremes 22 - 75 years. Forty two patients, including 28 men and 14 women (sex ratio 1: 2) were treated with open surgery. The mean age was 42.75 years (4 - 75 years). The average duration of hospitalization after open surgery was 8 days (4 - 60 days). The mean stone size in open surgery was 23 mm (5 mm - 45 mm). Complications noted were: 2 cases of urinomas (4.76%), 1 case of lower back fistula (2.38%), 1 case of renal pelvis fistula (2.38%) and 1 case (2.38%) of infection. Forty seven patients including 35 men (55.6%) and 12 women (46.2%) were treated by endourology. The average length of hospital stay was 2 days (2 d - 3 d). The average stone size treated by endourology was 13 mm (5 mm - 40 mm). No complications were observed in this group. The cost of open surgery was a third of that of endourology. Conclusion: Endoscopic surgery, as is observed from industrialized countries occupies a prominent place in the treatment of upper urinary tract calculi in Senegal;however, the only limiting factor encountered is the cost which remains out of reach for patients and burdening the budgets of our hospitals with limited means.

Forgotten Ureteral Stents in a Tertiary Hospital in Accra and a Review of Endourological Management of Upper Urinary Tract Pathologies in the West Africa Sub-Region

Background: Forgotten ureteral stent is defined as prolong indwelling ureteral stent whose function is no longer desired. Ureteral stents are used in the management of upper urinary tract pathologies. Prolonged indwelling ureteral stents may be complicated by urosepsis or renal failure, encrustation, stone formation, spontaneous fracture which may either be retained or voided in the urine (stenturia). Hitherto, these complications were managed by open procedures alone in our center. We report our recent experience in endourology with the management of three cases of forgotten ureteral stents with durations of ten years and two years (two cases) and review endourological practice in West Africa. Conclusion: Although encrusted stents can be managed successfully by minimally invasive approaches in the majority of cases, the best treatment is prevention. Urology units should have preferably an electronic stent register such that when the time for removal is due, the patient's name and details are flagged red. If electronic register is not available, then a hard paper/book register should be made to prevent situations of forgotten stents. Also, efforts must be made to improve endourological services in the West Africa subregion to allow patients to have the benefit of endourology in the management of upper urinary tract pathologies including that of stones originating from an encrusted or fractured forgotten ureteral stent.

Role of virtual reality in improving the spatial perception of the kidney during flexible ureteroscopy:A feasibility study using virtual reality simulators and 3D models

Background:The aims were to describe a software-based reconstruction of the patient-specific kidney cavity intraluminal appearance via a head-mounted device and to estimate its feasibility for training novices.Materials and methods:In total,15 novices were recruited.Each novice was shown a three-dimensional reconstruction of a patient's computed tomography scan,whose kidney was printed.They then joined the surgeon in the operating room and assisted them in detecting the stone during flexible ureteroscopy on the printed model.Then,each participant did a 7-day virtual reality(VR)study followed by virtual navigation of the printed kidney model and came to the operating room to help the surgeon with ureteroscope navigation.The length of the procedure and the number of attempts to find the targeted calyx were compared.Results:With VR training,the length of the procedure(p=0.0001)and the number of small calyces that were incorrectly identified as containing stones were significantly reduced(p=0.0001).All the novices become highly motivated to improve their endourological skills further.Participants noticed minimal values for nausea and for disorientation.However,oculomotor-related side effects were defined as significant.Five specialists noticed a good similarity between the VR kidney cavity representation and the real picture,strengthening the potential for the novice's education via VR training.Conclusions:Virtual reality simulation allowed for improved spatial orientation within the kidney cavity by the novices and could be a valuable option for future endourological training and curricula.

Ureteroscopy during pregnancy under local anesthesia and light sedation:Technique and video

Ureteroscopy during pregnancy has become increasingly recognized as a safe intervention.Performing it under local anesthesia and light sedation reduces the risks associated with general or regional anesthesia,such as difficult airway scenarios,hypothermia,and hypotension.In addition,this approach reduces the total amount of fetal exposure to medications and anesthetic agents.Performing ureteroscopy in this manner requires a number of adjustments and modifications to the standard technique.This article provides a summary in a step-by-step format,as well as an accompanying video demonstration.

Ureteroscopy during pregnancy:Outcomes and lessons learned over 4 decades at a tertiary center in Norway

Background:The management of suspected kidney stone disease in pregnancy is challenging.In cases of persistent flank pain and where investigations may have rendered equivocal results,ureteroscopy(URS)is a recognized diagnostic and therapeutic intervention.This study aimed to investigate the safety and outcomes associated with performing URS during pregnancy,as the technique has evolved over the past 4 decades at our center.Materials and Methods:We performed a retrospective analysis of pregnant patients who underwent URS at our tertiary center between 1984 and 2022.Outcomes of interest included anesthetic approach,operative time,hospital stay,and complications.Results:Eighty-seven pregnant patients underwent 96 URS procedures,and 60%(n=57)of these procedures were performed during the third trimester.Overall,58%(n=56)of the procedures were achieved with local anesthesia and light sedation.During the most recent decade,the latter was successfully carried out in 97%of the procedures,with the remainder occurring under spinal anesthesia as per patient choice.Overall,57%(n=50)of the whole study group had ureteral calculi found at the time of surgery and in 88%(n=44)of these cases,fragmentation/extraction was performed.The remainder had insertion of ureteral stent with definitive clearance deferred until postpartum.Mean operative time and postprocedure hospital stay was 33 minutes(range,7-100 minutes)and 2.2 days(range,0-16 days),respectively.The overall intraoperative and postoperative complication rates were 2%and 11%,respectively.During the final decade,the latter improved to 6%and all adverse events were minor(ClavienⅠ/Ⅱ),with the exception of a single case.Regarding exit strategy,ureteral stent was placed in 42%(n=40)of the procedures,23%(n=22)had ureteral catheter inserted,and the remainder(35%,n=34)had none.Conclusions:Ureteroscopy can be safely performed during pregnancy using anesthetic approach with local anesthesia and light sedation.Development of a local protocol and multidisciplinary management algorithm are instrumental in enabling the delivery of such a service.

Miniaturizing the approach to upper tract renal calculi:Is smaller always better?A narrative review

Newer modalities for treating upper tract urinary stones focus on maintaining and improving outcomes,reducing complications,and op-timizing patient care.This narrative review aims to outline novel miniaturized endourological innovations for managing upper tract calculi.

Impact of liver disease severity on outcomes of patients undergoing endourological procedures for urolithiasis

Objectives:This study is aimed to determine the impact of liver disease severity on the outcome of patients undergoing endourological procedures for urolithiasis,and to understand the factors that are helpful in improving the outcome.Materials and methods:We retrospectively analyzed the records of patients with chronic liver disease who underwent endourological procedures between January 2014 and February 2020.Inpatient records and charts were assessed for age,sex,height,weight,body mass index,model for end-stage liver disease(MELD)score,Child-Turcotte-Pugh score,type of procedure and anesthesia,intensive care unit(ICU)stay,duration of hospitalization,number,size,and position of stones,and postoperative complications such as hematuria,sepsis,and secondary procedures.Data are presented as mean±standard deviation or frequency.The chi-square test was applied to determine the exact association between categorical data and Student t-test or Mann-Whitney U test as appropriate for continuous data.Statistical significance was set at p<0.05.Results:Hospital and ICU stay as well as administration of different blood products were significantly longer in the Child C than in the Child A and B categories(p<0.001).Two patients in the Child C category died,while 3 left the hospital against medical advice.The duration of ICU stay and blood products administered increased with augmenting MELD scores.The durations of hospitalization and blood product administration were significantly higher in patients with an MELD score≥20 than in the group with MELD score<20.Conclusions:Hospital and ICU stay and blood product administration were significantly higher in Child C than in Child A and B class patients.Hospitalization duration and blood product administration were significantly higher in patients with an MELD score≥20.