Minilaparoendoscopic Single-site Pyeloplasty: The Best Compromise Between Surgeon's Ergonomy and Patient's Cosmesis (IDEAL Phase 2a)

Comparison of the safety and efficacy of laparoscopic single-incision triangulated umbilical surgery pyeloplasty with traditional three-hole surgery in a pediatric tertiary center

OBJECTIVE

To report the application of laparoscopic single-incision triangulated umbilical surgery (SITUS) pyeloplasty in children with ureteropelvic junction obstruction (UPJO) and compare its feasibility and efficacy with traditional three-hole laparoscopic pyeloplasty.

METHODS

Data from children with UPJO who underwent SITUS between July 2018 and August 2021 were included in this retrospective study and patients who were treated with traditional laparoscopic pyeloplasty were chosen for comparison. Thirty-two patients from SITUS group and 72 patients from traditional group were reviewed. The clinical characteristics, complications, and follow-up results were collected and compared.

RESULTS

The preoperative demographic data and imaging parameters, including sex, surgical side, age, BMI, and preoperative anterior-posterior pelvic diameter (APD), showed no significant differences between the two groups. The median surgical time was 135 min (IQR: 119.75-160.5) in SITUS group, while 163.5 min (IQR: 141.25-187.5) in the traditional group (p = 0.0008). Two Clavien-Dindo III complications (6.25%) in SITUS group and 11 (15.3%) in the traditional group were recorded (p = 0.335). The success rate was 100% (32/32) in SITUS group and 94% (68/72) in the traditional group (p = 0.309).

CONCLUSION

SITUS pyeloplasty is a feasible and effective laparo-endoscopic single-site (LESS) technique for pediatric patients with excellent cosmetic results comparable to the conventional laparoscopic pyeloplasty. More cases and longer follow-up periods are needed to determine the exact outcomes of the modified LESS technique.

Examining the application of the IDEAL framework in the reporting and evaluation of innovative invasive procedures: secondary qualitative analysis of a systematic review

OBJECTIVES

The development of new surgical procedures is fundamental to advancing patient care. The Idea, Developments, Exploration, Assessment and Long-term (IDEAL) framework describes study designs for stages of innovation. It can be difficult to apply due to challenges in defining and identifying innovative procedures. This study examined how the IDEAL framework is operationalised in real-world settings; specifically, the types of innovations evaluated using the framework and how authors justify their choice of IDEAL study design.

DESIGN

Secondary qualitative analysis of a systematic review.

DATA SOURCES

Citation searches (Web of Science and Scopus) identified studies following the IDEAL framework and citing any of the ten key IDEAL/IDEAL_D papers.

ELIGIBILITY CRITERIA

Studies of invasive procedures/devices of any design citing any of the ten key IDEAL/IDEAL_D papers.

DATA EXTRACTION AND SYNTHESIS

All relevant text was extracted. Three frameworks were developed, namely: (1) type of innovation under evaluation; (2) terminology used to describe stage of innovation and (3) reported rationale for IDEAL stage.

RESULTS

48 articles were included. 19/48 described entirely new procedures, including those used for the first time in a different clinical context (n=15/48), reported as IDEAL stage 2a (n=8, 53%). Terminology describing stage of innovation was varied, inconsistent and ambiguous and was not defined. Authors justified their choice of IDEAL study design based on limitations in published evidence (n=36) and unknown feasibility and safety (n=32) outcomes.

CONCLUSION

Identifying stage of innovation is crucial to inform appropriate study design and governance decisions. Authors' rationale for choice of IDEAL stage related to the existing evidence base or lack of sufficient outcome data for procedures. Stage of innovation was poorly defined with inconsistent descriptions. Further work is needed to develop methods to identify innovation to inform practical application of the IDEAL framework. Defining the concept of innovation in terms of uncertainty, risk and degree of evidence may help to inform decision-making.

Outcome selection, measurement and reporting for new surgical procedures and devices: a systematic review of IDEAL/IDEAL-D studies to inform development of a core outcome set

BACKGROUND

Outcome selection, measurement and reporting for the evaluation of new surgical procedures and devices is inconsistent and lacks standardization. A core outcome set may promote the safe and transparent evaluation of surgical innovations. This systematic review examined outcome selection, measurement and reporting in studies conducted within the IDEAL (Idea, Development, Exploration, Assessment and Long-term monitoring) framework to examine current practice and inform the development of a core outcome set for early-phase studies of surgical procedures/devices.

METHODS

Web of Science and Scopus citation searches were performed to identify author-reported IDEAL/IDEAL-D studies for any surgical procedure/device. Outcomes were extracted verbatim, including contextual information regarding outcome selection and measurement. Outcomes were categorized to inform a conceptual framework of outcome domains relevant to evaluating innovation.

RESULTS

Some 48 studies were identified. Outcome selection, measurement and reporting varied widely across studies in different IDEAL stages. From 1737 outcomes extracted, 22 domains specific to evaluating innovation were conceptualized under seven broad categories: procedure completion success/failure; modifications; unanticipated events; surgeons' experiences; patients' experiences; resource use specific to the innovative procedure/device; and other innovation-specific outcomes. Most innovation-specific outcomes were measured and reported in only a small number of studies.

CONCLUSION

This review highlighted the need for guidance and standardization in outcome selection and reporting in the evaluation of new surgical procedures/devices. Novel outcome domains specific to innovation have been identified to establish a core outcome set for future evaluations of surgical innovations.

Imaging guided percutaneous renal biopsy: do it or not?

Since its first reported application, renal biopsy became an important part of the diagnostic algorithm, considered advantages and risks, to better manage therapeutic options. The biopsy can be performed with different techniques (open, laparoscopic, transjugular, transurethral and percutaneous). Currently, the percutaneous approach is the modality of choice. Percutaneous biopsy can be performed under CT or US guidance, but critical benefits and disadvantages have to be considered. Core needle biopsy is usually preferred to fine-needle aspiration because of the sample quality, usually obtaining multiple cores, especially in heterogeneous tumors. Principal complications are hematuria (1-10%), perinephric hematoma (10-90%), pneumothorax (0,6%), clinically significant pain (1,2%).

Use of the IDEAL framework in the urological literature: where are we in 2018?

OBJECTIVES

To assess uptake and application of the IDEAL principles in original surgical procedure- or device-related clinical research studies, as well as its reported relevance as characterized by secondary publications, editorials and reviews.

MATERIALS AND METHODS

IDEAL (Idea, Development, Exploration, Assessment, Long-term study) is a framework that provides stage-specific guidance for surgical innovation and represented a major advance towards raising evidential standards. We performed a comprehensive literature search of all urology-related publications citing one or more of seven key publications on IDEAL in The Lancet and BMJ using multiple databases up to 31 December 2017.

RESULTS

We identified a total of 150 urology-related manuscripts citing IDEAL, of which 83 (55.3%) were original research and 67 (44.7%) were secondary publications. Among the original research articles, 40 (48.2%) did not explicitly apply IDEAL principles or were not surgical innovation studies. The IDEAL phases of the 43 (51.8%) remaining original research studies were IDEAL, in nine (20.9%), 27 (62.8%), four (9.3%), 0 (0%), and three publications (7.0%), respectively. Across IDEAL stages, 30 (75.0%) studies were prospective, 29 (85.3%) reported ethical oversight, and 39 (90.7%) captured treatment-related harms. None of the studies collected information on physician experience.

CONCLUSIONS

The IDEAL framework has found widespread adoption in the urology literature as witnessed by a large number of original manuscripts and secondary publications citing IDEAL; however, its application is largely limited to the early stages of surgical innovation, frequently with inappropriate and incomplete implementation. Further efforts are needed to guide investigators in the optimal use of the IDEAL framework as it relates to surgical innovation in urology.

New Hybrid Mini-laparoendoscopic Single-site Partial Nephrectomy With Early Unclamped Technique for Renal Tumors With Intermediate PADUA Score (IDEAL Phase 2a)

OBJECTIVE

To evaluate a new hybrid technique, which we defined as mini-laparoendoscopic single-site partial nephrectomy (MILESS-PN), for renal masses presenting an intermediate PADUA score.

MATERIALS AND METHODS

Forty consecutive cases of MILESS-PN performed between April 2013 and November 2015 were included in this study. Mini-laparoendoscopic single-site surgery consisted of the simultaneous use of two 3-mm pararectal trocars and an umbilical SILS trocar; the sequence of steps of MILESS-PN was comparable with standard laparoscopic partial nephrectomy. Demographic data and the main perioperative and oncological outcome parameters were gathered and analyzed.

RESULTS

The median operative time was 134.6 (interquartile range [IQR] 110-180) minutes with a median warm ischemia time of 12.1 (IQR 9.5-15.5) minutes. Postoperatively, 4 early complications were recorded and the median hospital stay was 4.2 (IQR 3.5-6.0) days. The median renal tumor size was 3.6 (IQR 2.4-5.3) cm with a median PADUA score of 8.3 (IQR 8-9). The definitive pathologic results revealed a renal cell carcinoma in 32 cases (80%), an angiomyolipoma in 3 cases (7.5%), and an oncocytoma in 5 cases (12.5%). All tumors were removed with negative surgical margins, and at the median follow-up of 34.5 (IQR 24-48) months, all patients were alive without evidence of tumor recurrence or port-site metastasis. A statistically significant decrease in the estimated glomerular filtration rate (eGFR) was observed postoperatively (postoperative vs preoperative median eGFR: 87.6 [IQR 70.4-101.8] and 104.7 [IQR 82.7-123.3], P <.0001) and at 6 months (6 months vs preoperative eGFR 93.6 [IQR 79.1-110.2] and 104.7 [IQR 82.7-123.3], P <.0001).

CONCLUSION

MILESS-PN for renal tumors with an intermediate PADUA score in well-selected patients is not associated with increased risks for the patients, presenting excellent oncological and functional results at the midterm follow-up. Mini-laparoendoscopic single-site surgery could represent a valid alternative to laparoendoscopic single-site surgery or minilaparoscopy because of its higher surgical reproducibility.