Société Internationale d’Urologie Journal

Introduction: Surgical innovation in urology has significantly transformed clinical practice, balancing the need for dissemination of novel techniques with rigorous safety and efficacy standards. Surgical innovation is influenced by regulatory standards, cost-effectiveness, and evolving publication requirements. This study examines publication trends in pioneering urological procedures and their implications on surgical innovation. Methods: This study analyzed 68 pioneering urological publications, examining the relationship between case numbers and publication trends over time. Data were collected through comprehensive database searches and analyzed using linear regression to identify correlations between publication case numbers and innovation dissemination. Results: A significant increase in the number of cases per publication was observed over time (R² = 0.798, OR = 6.29, 95% CI: 2.57–10.02, p = 0.007). Early transformative techniques were frequently published as single-case reports or small series, whereas incremental innovations required larger case volumes, potentially delaying publication from resource-limited settings. Conclusions: This study highlights the need for a merit-based approach to evaluating surgical innovations, balancing rigorous safety standards with timely dissemination. Frameworks like IDEAL offer structured pathways for evaluating surgical innovations, ensuring robust evidence generation while maintaining flexibility for diverse practice settings. This study advocates for a reassessment of publication criteria to foster a balance between innovation, safety, and inclusivity, ultimately promoting the efficient and equitable advancement of surgical techniques. Full article

Introduction: This narrative review aims to investigate the intricacy of human sexuality, the prevalence and effect of pelvic organ prolapse (POP) repair on overall sexual function and dyspareunia, and the subsequent repercussions on body image self-perception and quality of life. Methods: A MEDLINE and PUBMED search was conducted for studies evaluating the effect of POP surgery on sexual function and dyspareunia in sexually active women as well as its impact on body image self-perception and QoL. We included both observational and randomized controlled studies evaluating this subject. We evaluated patients who underwent anterior and/or posterior compartment repair eventually including vaginal hysterectomy. We excluded studies including women with concomitant anti-incontinence surgical correction and/or any vaginal reconstruction with synthetic materials. Results: Women with POP are more likely to diminish sexual activity due to a perceived impact on body image and attractiveness as well as worry of incontinence. Conservative management (such as pelvic floor muscle physiotherapy or pessary use) or surgical intervention via transabdominal or transvaginal routes have been used to treat POP, but concerns remain regarding sexual consequences. Despite a post-surgical positive sexual outcome, there is an inherent risk of de novo dyspareunia regardless of the surgical technique employed with slightly higher risk for the transvaginal approach. Patient counselling prior to surgery has proved to be an important element of POP treatment. Only studies on complications of POP surgery, specifically its impact on female sexuality, dyspareunia, global quality of life, and self-perceived body image, were included and analyzed for this review. We limited our search to the international English language literature published over the last three decades and excluded all studies involving the use of synthetic material in transvaginal POP repair. Discussion and Conclusions: Although no consistent evidence was found that disorders of the pelvic floor in women have a clear adverse effect on sexuality, their anatomical correction using the patient’s native tissues is recommended. Dyspareunia reduced significantly after repair, but the rate remains higher after the transvaginal approach versus the minimally invasive (robot-assisted and laparoscopic) approach used for sacrocolpopexy. Full article

Introduction and Objectives: Multimorbidity, defined as the coexistence of two or more chronic conditions, poses significant challenges in healthcare by affecting patient outcomes and increasing costs. This study aimed to evaluate multimorbidity’s impact on patients with genitourinary cancer (GUC) in Chile, focusing on prevalent comorbidities, their combinations, and their association with hospitalization severity. Materials and Methods: A retrospective, population-based study was conducted using data from the Fondo Nacional de Salud (FONASA) in Chile, including patients with bladder, prostate, kidney, and testicular cancer between 2019 and 2021. Diagnosis-related group (DRG) data were used to analyze comorbidity prevalence, hospitalization type (elective vs. emergency), severity (moderate/major vs. minor/none), length of stay, and associated costs. Results: Among 4,028,597 hospital events, 11.6% were related to GUC, involving 18,792 patients. Multimorbidity was present in 67.3% of patients, with hypertension and diabetes being the most common comorbidities. These patients accounted for 69.1% of total GUC care costs. Hospital mortality was higher in multimorbid patients (7.5% vs. 3.7%; p < 0.001), who also had longer stays (mean 8 vs. 5 days). Most patients were admitted electively (60.3%), while 39.7% were admitted through the emergency room. Patients with multimorbidity had higher rates of moderate/major severity hospitalizations compared to those without (56.1% vs. 32.5%; p < 0.001). Conclusions: In Chile, multimorbidity among GUC patients is linked to increased costs, longer hospital stays, higher mortality, and greater hospitalization severity. Comprehensive care strategies are needed to improve outcomes and reduce healthcare system burdens. Full article

Background/Objectives: Using chatbots to seek healthcare information is becoming more popular. Misinformation and gaps in knowledge exist regarding the risk and benefits of testosterone replacement therapy (TRT). We aimed to assess and compare the quality and readability of responses generated by four AI chatbots. Methods: ChatGPT, Google Bard, Bing Chat, and Perplexity AI were asked the same eleven questions regarding TRT. The responses were evaluated by four reviewers using DISCERN and Patient Education Materials Assessment Tool (PEMAT) questionnaires. Readability was assessed using the Readability Scoring system v2.0. to calculate the Flesch–Kincaid Reading Ease Score (FRES) and the Flesch–Kincaid Grade Level (FKGL). Kruskal–Wallis statistics were completed using GraphPad Prism V10.1.0. Results: Google Bard received the highest DISCERN (56.5) and PEMAT (96% understandability and 74% actionability), demonstrating the highest quality. The readability scores ranged from eleventh-grade level to college level, with Perplexity outperforming the other chatbots. Significant differences were found in understandability between Bing and Google Bard, DISCERN scores between Bing and Google Bard, FRES between ChatGPT and Perplexity, and FKGL scoring between ChatGPT and Perplexity AI. Conclusions: ChatGPT and Google Bard were the top performers based on their quality, understandability, and actionability. Despite Perplexity scoring higher in readability, the generated text still maintained an eleventh-grade complexity. Perplexity stood out for its extensive use of citations; however, it offered repetitive answers despite the diversity of questions posed to it. Google Bard demonstrated a high level of detail in its answers, offering additional value through visual aids. With improvements in technology, these AI chatbots may improve. Until then, patients and providers should be aware of the strengths and shortcomings of each. Full article

Objectives: We aimed to evaluate management strategies for female urinary incontinence, specifically stress urinary incontinence (SUI), and anterior vaginal prolapse (pelvic organ prolapse, POP), emphasizing diagnostic methods, treatment options, and factors influencing surgical outcomes. Methods: We conducted a thorough literature review examining diagnostic tools, including physical examinations, urodynamic testing, and pessary evaluations, alongside treatment options for SUI and POP. Both surgical interventions, such as mid-urethral sling placement and anterior colporrhaphy, and non-surgical methods, including pelvic floor exercises, were analyzed. This review assesses these approaches’ efficacy, complications, and outcomes, incorporating current clinical guidelines and evidence-based practices. Results: Evidence indicates that SUI frequently coexists with POP, with a notable proportion of cases being occult until a prolapse is reduced. Diagnostic methods such as pessary testing and urodynamic evaluations are essential in identifying masked SUI, though their predictive accuracy varies. Surgical techniques such as using mid-urethral slings are highly effective but pose risks, including voiding dysfunction and lower urinary tract injury. Long-term data emphasize the need for personalized treatment strategies, with combined procedures showing superior outcomes for the concurrent management of POP and SUI in select cases. Conclusions: Effective management of SUI and POP requires a personalized approach, factoring in the severity of a prolapse and the likelihood of postoperative incontinence. While conservative treatments are practical initial options, surgical solutions, such as mid-urethral slings and apical suspension procedures, offer robust, lasting results for advanced cases. Preoperative diagnostics, collaborative decision-making, and tailored treatment plans are essential to optimize success and minimize complications. Future research should prioritize enhancing diagnostic precision and refining surgical methods to further advance patient care. Full article

Background: Advanced pelvic organ prolapse (POP) can have a significant impact on women’s health and quality of life (QoL). Several treatments, both conservative and surgical, can be offered to patients. These include vaginal pessaries, abdominal reconstructive surgeries, vaginal reconstruction, as well as obliterative procedures. Methods: This is a narrative review of the management of advanced POP using the PubMed, Google Scholar, and Cochrane databases. Results: Gellhorn pessaries are the most used space-occupying pessaries, with good long-term success rates. The only space-occupying pessaries that allow for self-management by the patient and that could be associated with prolapse reduction are cube pessaries. Laparoscopic sacrocolpopexy (L-SCP) is the gold standard for POP surgery. Other abdominal reconstructive procedures include sacrocervicopexy (SCerP) and laparoscopic lateral suspension (LLS). The two most common vaginal reconstructive techniques are sacrospinous ligament fixation (SSLF) and uterosacral ligament suspension (USLS). Both procedures have comparable success rates. Obliterative procedures include the total, Lefort, and Labhart colpocleisis. These procedures are ideal for women who do not wish to have intercourse or who cannot tolerate extensive surgical procedures. There is a general tendency towards uterine preservation when performing these surgeries. Conclusions: Several therapeutic options exist for advanced POP, and most of them are associated with good long-term success rates. Treatment should be chosen based on patient comorbidities and in the context of shared decision-making. Full article

Background/Objectives: Prostate cancer (PCa) is one of the most prevalent cancers in men. While PSA testing aids in early detection, it often identifies clinically insignificant PCa (ciPCa), which may not necessitate treatment. Prostate-specific membrane antigen (PSMA) PET scans have emerged as a promising tool to evaluate of localised PCa. This review aims to assess the current evidence of using PSMA PET scans for localised PCa. Methods: Peer-reviewed publications on PSMA PET scans in localised PCa, from inception to May 2024, were retrieved from PubMed. The outcomes evaluated included diagnostic performance in identifying intraprostatic lesions, detecting csPCa (ISUP GG ≥ 2), and role peri-treatment. Results: The addition of PSMA PET/CT to MRI improved the sensitivity (from 83% to 97%) and NPV (72% to 91%) of detecting csPCa. PSMA PET helped improve risk stratification in active surveillance by identifying MRI-occult lesions in up to 29% of patients, of which up to 10% may harbour underlying unfavourable pathology. In local staging, PSMA PET/MRI outperforms MRI in identifying extra-prostatic extension (77% vs. 73%) and seminal vesicle invasion (90% vs. 87%). PSMA PET scans are also superior to MRI in nodal staging and bone scans in identifying bony metastasis. PSMA PET scans appear useful in guiding treatment of localised PCa and aiding follow-up. Conclusions: PSMA PET scans are valuable for evaluating localised PCa by improving the detection of csPCa and enhancing local staging. However, most available studies are retrospective, and long-term oncological outcomes remain underreported due to the relative novelty of PSMA PET scans. Full article

Abstract: Objectives: This study aimed to map the distribution of nephrolithiasis’ environmental risk factors (occupational heat and heavy metal exposure and ambient seasonal temperature) and to assess the correlations of these exposures with the best estimates of the reported nephrolithiasis incidence in Canada. Methods: The regional average heat burden was defined as the mean temperature in the hottest three months of the year for 2020, 2021, and 2022. The employment rates in the top five industries with occupational heavy metal (cadmium, lead, and arsenic) and heat exposure were obtained from the Statistics Canada 2021 database. Statistical significance was calculated based on the 95% confidence interval difference from the null hypothesis. Correlation analysis was performed between our rates of nephrolithiasis risk factors and previously published estimates of the stone incidence: kidney stone interventions and acute kidney stone event rates. Results: Lower-latitude provinces had higher overall mean temperatures in 2020 to 2022, with Ontario, Manitoba, and Prince Edward Island having the highest seasonal heat burdens, in this order. Nunavut had the lowest rate of occupational heat exposure, while the remaining regions had similar rates. Yukon, the Northwest Territories, and Nunavut had significantly higher rates of occupational heavy metal exposure compared to the remaining regions. The ambient temperature and occupation heavy metal and heat exposure showed no significant correlation with the estimates of the stone incidence. Conclusions: The occupational heat exposure was relatively similar between regions. Northern Canada had higher occupational heavy metal exposure compared to other regions. Occupational exposures and temperature variations were not associated with the nephrolithiasis incidence in Canada. Full article

Background: In salvage cystoprostatectomies (SCPs), rectal injuries can occur at a rate of 1% to 10%. Factors including T3 disease and prior pelvic radiation can lead to complications such as bleeding, recurrent wound infections and the need for colonic diversion. Methods: We present a male patient in his late 70s with a new diagnosis of pT2 muscle-invasive bladder cancer (MIBC). This is on a background of Stage IIB prostate cancer 10 years ago, managed with external beam radiotherapy. He patient had hyaluronic acid (HA) rectal spacer infiltration into the Denonvilliers’ space two weeks prior, for rectal protection. HA rectal spacers are easily identifiable due to their anechoic appearance on ultrasound imaging, making them easily distinguishable when injected into the Denonvilliers’ space intraoperatively. Results: The patient did not experience any symptoms related to rectal injury and had full bowel continence postoperatively. Conclusion: Although approved for use in radiation treatment for prostate cancer, their role in aiding dissection during SCP remains unexplored. We exhibit the use of HA rectal spacers for rectal protection during SCP. Full article

To conduct a multi-institutional international survey to determine the clinical utility and applicability of nephrometry scoring systems in contemporary clinical practice. Methods: A cross-sectional anonymous 15-item online survey was conducted on REDCap between January 2023 and May 2023. Survey invitations were sent via email within Australia and internationally to urologists who are either members of the Urological Society of Australia and New Zealand (USANZ) or the Urological Association of Asia (UAA) or who have direct professional relationships with their members. The survey underwent a trial run on REDCap with several urologists at our institution to test the technical functionality and comprehension prior to dissemination. Results: First, 158 responses were collected and analysed. Just over half (51%) responded that they use a nephrometry system in clinical practice, and the RENAL nephrometry scoring system is the most commonly used. Amongst respondents who use a nephrometry scoring system, 63% stated that it helps with counselling patients and 54% stated it serves as a decision-making tool on whether to perform a partial or radical nephrectomy. Furthermore, 54% use a nephrometry scoring system in surgical planning meetings, and 67% believe that it is helpful for research purposes. Common concerns included that they are too time-consuming to complete, they are unhelpful for treatment decision-making and they are only useful for research purposes. Conclusions: Nephrometry scoring systems are utilised by roughly one in two urologists in contemporary clinical practice. Further qualitative studies are required to better ascertain perspectives towards them and enhance their clinical applicability. Full article

Pelvic organ prolapse (POP) is a prevalent condition characterized by the descent of one or more pelvic organs, such as the bladder, uterus, or rectum, into the vaginal canal due to weakened pelvic floor support. This comprehensive review elucidates the multifactorial etiology of POP, which includes genetic predisposition, hormonal changes, obstetric factors, lifestyle influences, and age-related pelvic floor decline. Epidemiological data underscore its rising prevalence, particularly among older women, highlighting disparities across populations and risk factors such as parity and socioeconomic status. POP frequently coexists with significant comorbidities like urinary incontinence, sexual dysfunction, and pelvic pain, which exacerbate its impact on quality of life. Accurate evaluation through patient history, physical examinations, and imaging modalities like ultrasound and MRI is critical for diagnosis and management. The review emphasizes advancements in POP evaluation methods, including the POP-Q system, and explores the interplay of anatomical, functional, and psychosocial factors affecting patient outcomes. Key findings reveal that a tailored and holistic approach to treatment, addressing both anatomical correction and associated symptoms, significantly improves patient outcomes. Surgical interventions can alleviate related comorbidities, including urinary and bowel dysfunctions, as well as enhance body image and sexual function. However, the long-term success of such treatments necessitates continued research into preventive strategies and innovative therapeutic approaches. In conclusion, understanding the complexities of POP’s etiology, epidemiology, and management is vital for mitigating its burden and improving the health and well-being of affected individuals. This review highlights the need for integrated care strategies and further studies to advance diagnostic and therapeutic paradigms. Full article

Introduction: Future evolutions of artificial intelligence (AI) will support autonomous surgery, conducted without the need for human decision making and implementation, but we have not yet achieved this level of technology. Presently, the predominant applications of AI in urological surgery are achieved using the tool of computer vision. This review aims to summarise potential intra-operative AI tools for urologists. Method: A systematic search was conducted through Scopus, PubMed, Embase, and Medline by two independent reviewers, with a third to resolve any conflicts. As a rule, only original articles describing the use or potential use of artificial intelligence intra-operatively in urologic surgery were included. A total of 60 articles were reviewed. Key content and findings: There is significant research investigating the ability to diagnose bladder tumours using AI assistance at the time of cystoscopy, with studies showing the ability to also grade tumour based on appearance and differentiate between carcinoma in situ and indeterminate lesions. With the aid of AI, kidney stones can accurately be identified and diagnosed morphologically intra-operatively. Various studies show the ability to overlay 2D and 3D anatomical models on a surgeon’s screen, as well as correctly identify important anatomical landmarks and surgical instruments, with AI support. All types of intra-operative data can be analysed with AI to assess surgeon performance, predict post-operative outcomes such as continence post prostatectomy, and recognise complications such as bleeding and ischemia. Conclusions: AI holds great potential for urologists during surgery to improve safety, diagnostic accuracy, identification of anatomical structures and surgical instruments, assessment of the surgeon for self-evaluation, and prediction of post-operative outcomes. Before the use of AI as an aid during surgery becomes standard practice, more prospective studies are needed to evaluate its real-world application, feasibility, and costs. Full article

Background: Prostate cancer is a significant global health concern, with rising incidence and disease burden in the Middle East (ME). This review aims to explore the current state of prostate cancer epidemiology in the ME, particularly in low- to middle-income settings, investigating trends in incidence and mortality, assessing challenges related to de novo metastatic prostate cancer, and evaluating the need for region-specific screening guidelines. Methods: We conducted a comprehensive narrative review of epidemiological data on prostate cancer in the ME, examining trends in incidence and mortality, de novo metastatic cases, and current screening practices. Additionally, we assessed the applicability of international guidelines for prostate cancer screening to the ME context. Results: The ME exhibits a rising trend in prostate cancer incidence, with a mortality-to-incidence ratio of 0.3–0.4, compared to 0.1 in the United States, reflecting significant differences in healthcare access and quality that contribute to poorer outcomes. The incidence rates are particularly high in Lebanon, reaching 37.2 per 100,000 in 2012. De novo metastatic prostate cancer is also more prevalent in the ME, often exceeding 20–30%, with a value of 23% reported in Lebanon and reaching 54% in a study including six Middle Eastern countries, compared to 4–14% in the United States. Our review identified a critical need for enhanced screening and early detection efforts tailored to the ME’s unique epidemiological and socio-cultural factors. Conclusions: The substantial burden of de novo metastatic prostate cancer in the ME underscores the need for region-specific screening guidelines. Tailored approaches, including increased awareness, early detection, and resource-stratified strategies, are essential to address the unique epidemiological and socio-cultural factors of the ME and improve patient outcomes. Full article