Impacto De La Pandemia En La Actividad De Las Unidades De Cirugía Reconstructiva Urológica Y De Andrología En España Durante El Estado De Alarma (Covid-19) En 2020: Resultados De Una Encuesta Nacional

Introducción

El estado de alarma debido a la COVID-19 revolucionó la actividad asistencial y quirúrgica. Dentro de la enfermedad urológica, aquellas consideradas «demorables» como la andrológica y la reconstructiva sufrieron un retraso considerable en su atención.

Material y métodos

En mayo de 2020, tras haber superado casi la primera ola de la pandemia y en pleno estado de alarma, se envió una encuesta con 24 ítems a 120 urólogos integrados en los Grupos de Cirugía Reconstructiva Urológica y Andrología de la Asociación Española de Urología (AEU) para conocer la repercusión asistencial sobre la actividad clínica y quirúrgica en ambas subespecialidades.

Resultados

Se alcanzó una tasa de respuesta del 75,8% con 91 encuestas recibidas. Previo al estado de alarma, el 49,5% disponía de uno a 2 quirófanos semanales, el 71,4% afrontaba una lista de espera quirúrgica de entre 3 y 12 meses, y el 39,6% atendía entre 20 y 40 pacientes semanales en consulta. Durante el estado de alarma, el 95,6% recibió directrices sobre cirugías a realizar, priorizando la cirugía urgente y la oncológica. En el 85,7% de los centros no se realizó ninguna cirugía andrológica ni reconstructiva. Alrededor del 50% de las consultas no fueron presenciales, recurriendo a la telemedicina (teléfono o e-mail) en la mayoría de los casos.

Conclusiones

Las repercusiones de la pandemia sobre las enfermedades andrológicas y las candidatas a cirugía reconstructiva fueron muy importantes. Tras casi 2 años del inicio de la pandemia, aún queda por determinar el verdadero impacto final en nuestro sistema sanitario.

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center

INTRODUCTION

Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes.

MATERIAL AND METHODS

Descriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t-test for independent groups or Mann-Whitney test. Statistical significance if P < .05.

RESULTS

The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Uretericre implantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%).

CONCLUSION

Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center

INTRODUCTION

Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes.

MATERIAL AND METHODS

Descriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t test for independent groups or Mann-Whitney test. Statistical significance if P<.05.

RESULTS

The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Ureteric reimplantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%).

CONCLUSION

Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Management of male anterior urethral strictures in adults. Results from a national survey among urologists in Spain

INTRODUCTION AND OBJECTIVE

Assessment of urethral stricture (US) management seems important to evaluate the quality of attention and plan educational interventions. We aim to investigate the practice patterns on diagnostic and therapeutic approaches to adult male anterior US among urologists in Spain.

MATERIALS AND METHODS

23-question on-line survey conducted among all members of AEU (Spanish Urological Association). Demography data and practices on evaluation and treatment of US were included. 1737 invitation letters sent by email, with 21.7% response rate. Data were prospectively collected during 2016. Descriptive analysis and univariate comparisons conducted using X² test. Statistical significance considered when P≤.05.

RESULTS

Responders were mainly from Tertiary and Teaching University Hospitals. 63.2% treated≥10 patients/year with US. Retrograde urethrogram (RUG) was the commonest diagnostic tool followed by uroflowmetry (UF), and internal urethrotomy under direct vision (DVIU) the most frequent treatment. 84.4% limited DVIU for US≤1.5cm. 62.3% performed≤5 urethroplasties/year. Anastomotic urethroplasties were performed by 75.7% and graft repairs by 68.9%. Dorsal grafting was preferred rather than ventral. Non-transecting techniques were used by 23.9%. UF was the most common follow-up tool. 88.4% felt that referral units were required. Tertiary hospitals used Patient Reported Outcome Measure (PROM) questionnaires more frequently than secondary centres. High-volume urologists were more likely to use non-transecting techniques and to choose urethroplasty as first choice procedure.

CONCLUSIONS

Male anterior US in Spain are treated by many urologists, mainly using endoscopic procedures. RUG is preferred for diagnosis, and UF for follow-up. A high percentage of urologists perform urethroplasties, mainly anastomotic repairs, but in low volume.

Nontraumatic posterior urethral stenosis

INTRODUCTION

Posterior urethral stenoses and contractures are complications after treatment of benign prostatic hyperplasia (BPH), localised prostate cancer (PCa), and orthotopic neobladder formation, compromising prognosis and functional outcomes.

OBJECTIVES

To identify factors related to aetiology, prevention and treatment of non-traumatic posterior urethral stenosis and contractures.

ACQUISITION OF EVIDENCE

Review of the published evidence related to posterior urethral stenosis and contractures after PCa treatment, BPH therapies and orthotopic neobladder formation. PubMed database search with English and Spanish papers considered. Cohort studies, case series, prospective and retrospective studies and review papers were included.

SYNTHESIS OF EVIDENCE

Posterior urethral stenoses and contractures are common, leading to significant morbidity. A worsening on voiding quality should rise some concerns. Careful surgical and/or radiotherapic techniques prevent their development. Endoscopic therapies are the initial approach, with complex urethroplasties often required. Subsequent urinary incontinence, the most important sequelae, may need artificial sphincters.

CONCLUSIONS

Non-traumatic posterior urethral stenoses could be important complications, potentially compromising the outcomes of initial therapy. They could require complex surgeries leading to urinary incontinence.

Traumatic lesions of the posterior urethra

INTRODUCTION

The posterior urethral lesions are associated with pelvis fractures in 5-10% of cases. The posterior urethra is attached to the pelvis bone by puboprostatic ligaments and the perineal membrane, which explains why disruption of the pelvic ring can injure the urethra at this level.

OBJECTIVES

To identify suspected cases of posterior urethral trauma and to perform the diagnosis and its immediate or deferred management.

ACQUISITION OF EVIDENCE

Search in PubMed of articles related to traumatic posterior urethral lesions, written in English or Spanish. We reviewed the relevant publications including literature reviews and chapters from books related to the topic.

SYNTHESIS OF THE EVIDENCE

With patients with pelvis fractures, we must always rule out posterior urethral lesions. The diagnostic examination of choice is retrograde urethrography, which, along with the severity of the condition, will determine the management in the acute phase and whether the treatment will be performed immediately or deferred. Early diagnosis and proper acute management decrease the associated complications, such as strictures, urinary incontinence and erectile dysfunction.

CONCLUSIONS

Despite the classical association between posterior urethral lesions and pelvic fractures, the management of those lesions (whether immediate or deferred) remains controversial. Thanks to the growing interest in urethral disease, there are an increasing number of studies that help us achieve better management of these lesions.

The nested variant of bladder transitional cell carcinoma: Review of 12 cases and review of the literature

OBJECTIVES

The nested variant of bladder transitional cell carcinoma is extremely rare and has a different biological behavior to other bladder tumors. The aim of this study is to analize if their behavior is as aggressive as has been described in the literature.

MATERIAL AND METHOD

Review of 12 diagnosed cases with nested variant of bladder transitional cell carcinoma and analysis of demographic characteristics, clinical presentation, tumor characteristics, treatment options, analysis of recurrence and cancer-specific survival between January 1997 and December 2010 in our hospital.

RESULTS

50% of the cases had a pathologic stage ≥T2, with grade of differentiation G2 (50%) or G3 (50%). After the pathological result of the TUR (transurethral resection) Bladder, 5 cases underwent radical cystoprostatectomy, 3 a second TUR bladder and 4 cases with treatment chemotherapy and/or radiotherapy (RT). Five out of 12 cases (41.7%) died due to bladder cancer and 3 died (25%) of other causes (urinary sepsis, respiratory failure, renal failure). With a median follow up of 40 months, the overall survival was 50% and cancer-specific survival of 65.6%.

CONCLUSIONS

The nested variant of bladder transitional cell carcinoma is a disease with an advanced-stage presentation, with high recurrence and mortality rates despite the use of different treatments. So far there is not a clinical practice guideline for this variety of urothelial tumor.

Predictive factors of evolution of patients after pT0 radical cystectomy due to bladder cancer

OBJECTIVES

To analyze the influence of the different pre - cystectomy factors, both clinical and pathological, in the follow up of patients with no residual tumor ( pT0) in the pathological examination of the radical cystectomy specimen as predictors of tumor recurrence. Secondly we intend to compare overall survival, disease free survival and cancer-specific survival with the rest of cystectomy patients in our series.

METHODS

Between 1985 and 2010, radical cystectomy was performed in 280 patients with bladder cancer, being 41 pT0 (14.6%). We analyzed potential predictors for overall survival and disease-free survival: age, sex , number of transurethral resections of bladder tumor before cystectomy , tumor type , tumor grade, tumor stage, tumor size, number of tumors, associated Cis and previous instillations. We used univariate analysis of Cox regression. Survival analysis was performed using Kaplan - Meier curves and log-rank test.

RESULTS

Mean age was 61.7 years and 37 patients were males (90.2%). Stages before cystectomy were pT1 in eight (19.5%) , pT2 in 31 (75.6%) and Cis in two (4.9 %) with tumor grade III in 37 (90.2%). Cystectomy specimens revealed the presence of papillary transitional cell carcinoma in 38 (92.7%) cases. The median number of pre-cistectomy-TURBT was one. Eleven patients (26.8%) received intravesical instillations. Six patients (14.63 %) had tumor recurrence and 10 (24.4 %) died from causes unrelated to the disease. None of the variables analyzed was statistically significant in the univariate analysis as a predictor of tumor recurrence. With a median follow up of 70 months (3-272) disease-free survival and overall survival at five years were 85.9% and 72.8% respectively. Compared to the non pT0 cystectomies in our series, pT0 had a statistically significant difference for better recurrence-free survival (63.4 % and 36.8%, respectively in pT0 and no-pT0 patients) (p〈0,05).

CONCLUSIONS

According to the results, we have found a better outcome for pT0 patients after cystectomy compared to those with residual tumor. We have not found any pre - cystectomy predictive factor related to disease-free survival and overall survival.

Review of a series of cystectomies in women for bladder cancer:Complications and quality of life

OBJECTIVES

To analyze the complications and quality of life after cystectomies performed in women with bladder cancer at our hospital.

METHODS

Descriptive analysis of demographic data and early/late complications of cystectomies and urinary diversions performed in women at our hospital between 1990-2010. We also assessed quality of life using the Functional Assessment of Cancer Therapy-Bladder Cancer (ACT-BL) questionnaire and a comparison was drawn between groups of clinical variables.

RESULTS

Out of 265 cystectomies, 25 (10%) were performed in women. The predominant urinary diversion was ureterosigmoidostomy (60%), followed by cutaneous ureterostomy (16%), orthotopic ileal neo-bladder Studer pouch (12%), ileal conduit (10%) and permanent nephrostomy (4%). Mean age was 55.75 years. The most commonly occurring early complications were prolonged ileus (20%) and urinary fistula (20%). Late complications included hydronephrosis (32%) and pyelonephritis (32%). The results of quality of life questionnaires were very similar for the different types of urinary diversions, with a mean score of 104.5 out of 156 points.

CONCLUSIONS

Radical cystectomy is a high-risk procedure associated with many complications. In women, ureterosigmoidostomy may be a good choice for urinary diversion in selected patients, with a quality of life very similar to those with different urinary diversions.

Comparative study of morbidity and mortality between ileal conduit and ureterosigmoidostomy after radical cystectomy for bladder neoplasm

OBJECTIVES

Despite the growing trend in the development of orthotopic neobladders, the procedure cannot be performed in many cases, thereby retaining the validity of other techniques. We propose a comparative analysis between patients with radical cystectomy for bladder neoplasm and reconstruction using the ileal conduit (IC) or ureterosigmoidostomy (USG).

PATIENTS AND METHOD

Observational retrospective study on 255 patients with radical cystectomy between 1985 and 2009, selecting group assignments by the use of IC and USG. Analysis of the demographic and preoperative characteristics, perioperative complications, pathology and medium to long-term complications. Comparison of groups using T-Student, U-Mann-Whitney and chi square tests, with P<.05 indicating statistical significance. Preparation of survival tables according to Kaplan-Meier, establishing comparisons using the log-rank test.

RESULTS

There were 41 cases of IC and 55 cases of USG, with a mean patient age of approximately 61 years. USGs were performed on a greater number of females than ICs. There were no differences in the need for transfusion, with similar results as other series. There was a greater trend towards the appearance of intestinal fistulae and greater morbidity and mortality in the postoperative period in USG, although it was not significant. There was a greater long-term presence of eventrations in IC, and of pyelonephritis and the need for taking alkalinizing agents in USG. The appearance of peristomal hernias in IC was less than in previous series. With a mean follow-up greater than 50 months, the overall survival was 40% at 5 years, with no differences according to urinary diversion.

CONCLUSIONS

IC and USG are two applicable urinary diversions in the event that orthotopic neobladder surgery cannot be performed. They have a similar long-term complication and survival profile in our series, although with a higher morbidity in postoperative complications for USG.

Urinary fistula repair in a renal graft through a partial nephrectomy and omentoplasty

OBJECTIVES

We present the management with partial nephrectomy and interposition of the greater omentum in case of urinary fistulas in renal allograft.

MATERIAL AND METHOD

We present a patient with necrosis at the inferior pole of the renal graft that affected calyceal system but with pyeloureteral vascularization preserved. The patient's condition was satisfactorily managed with a partial nephrectomy of the necrotic renal segment and primary suturing of the collecting system with interposition of the greater omentum. We reviewed the cases published to date of partial nephrectomy in renal allograft, and examined their outcomes by analyzing the patient presentation, diagnostic tools, and surgical techniques used.

RESULTS

There are few cases in the current literature that describe conservative surgical management of urinary fistulas caused by segmental necrosis after renal transplantation. Surgical approach using partial nephrectomy in these cases produces favorable outcomes in our experience and reported cases.

CONCLUSIONS

Despite its obvious surgical complexity, this nephron-sparing management is feasible and should be implemented in cases where the prior renal function and the quantity of healthy parenchyma indicate a favorable subsequent evolution for the renal graft.