Irreversible electroporation is a novel, non-thermal tumor ablation technique that induces cell death through electrical disruption of cellular membranes while preserving surrounding connective tissue structures. Despite its clinical advantages, the high-voltage pulses used during the procedure can provoke hemodynamic and electrophysiological instability, requiring specific anesthetic precautions. Data on anesthesia management during irreversible electroporation, particularly in non-operating room anesthesia, remain limited. This case series describes 12 oncology patients who underwent irreversible electroporation procedures under general anesthesia outside the operating room. Standard monitoring, invasive arterial pressure, and electrocardiographic synchronization were employed to prevent arrhythmias. Hemodynamic stability was preserved in all cases. Transient cardiac events—including bradycardia, ventricular extrasystoles, or mild hypertension—were observed but required no medical intervention. Postoperative pain control was satisfactory, and only one minor complication—corneal epithelial erosion—was reported. Biochemical analyses revealed slight changes, none of which were clinically relevant. Irreversible electroporation appears to be a feasible and potentially safe procedure when appropriate anesthetic precautions are applied. Deep neuromuscular blockade, electrocardiography synchronization, and readiness for arrhythmia management are essential for patient safety. Multidisciplinary coordination and postoperative follow-up further enhance procedural success. Not applicable. This study is a retrospective case series and does not require registration in a clinical trial. • IRE is a non-thermal tumor ablation technique that allows preservation of surrounding structures such as vessels and nerves. • Anesthesia management during IRE must address potential complications, including cardiac arrhythmias and muscle contractions. • This case series of twelve oncology patients highlights perioperative events encountered during IRE procedures outside the operating room. • ECG synchronization and deep neuromuscular blockade are important to prevent arrhythmogenic and neuromuscular complications. • Vigilant monitoring, multidisciplinary planning, and appropriate anesthetic precautions may contribute to the safe performance of IRE.

OBJECTIVE:To assess the efficacy and safety of low-intensity shockwave therapy (LiSWT) for treating erectile dysfunction (ED) compared to sham therapy. METHODS:This summary is based on the Cochrane systematic review published in the Cochrane Database of Systematic Reviews 2025, Issue 7 (CD013166). We included randomised controlled trials (RCTs) comparing LiSWT to sham therapy. We excluded psychogenic or iatrogenic ED, kidney transplants, or radical prostatectomy. Critical outcomes were erectile function, discontinuation, and adverse events; important outcomes included rigidity, satisfaction, and quality of life. Certainty was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. RESULTS:A total of 21 RCTs (1357 men, aged 39-65 years) were analysed. LiSWT may slightly improve short-term erectile function (mean difference [MD] 3.89, 95% confidence interval [CI] 2.89-4.89; I2 = 62%; 15 studies; low-certainty), though clinical importance is uncertain. Long-term function may improve (MD 5.25, 95% CI 2.47-8.04; I2 = 87%; five studies; low-certainty). LiSWT likely has little effect on discontinuation (risk ratio 0.77, 95% CI 0.47-1.27; I2 = 0%) or adverse events (risk difference 0.00, 95% CI -0.01 to 0.02; I2 = 0%). It may improve short-term penile rigidity (MD 1.06, 95% CI 0.83-1.28; I2 = 53%; low-certainty). Data for satisfaction or quality of life were unavailable. CONCLUSIONS:Low-intensity shockwave therapy may improve long-term erectile function and short-term rigidity, with little difference in discontinuation or adverse events. Evidence certainty is low due to methodological limitations and heterogeneity.

Background:The use of the microsurgical vasovasostomy technique allows for greater precision and the use of extra-fine sutures, resulting in improved outcomes for vasectomy reversal procedures. The challenging nature of these microsurgical procedures has led to the investigation of robotic-assisted microsurgical vasovasostomy for decreased hand tremor and increased dexterity and hand-eye coordination. To date, no research has investigated vasovasostomy using the Symani Surgical System, a robotic device approved by the US Food and Drug Administration (FDA) for microsurgical procedures. This study investigated the feasibility of using the Symani Surgical System to perform vasovasostomy for vasectomy reversal. Methods:In this prospective, controlled study, three surgeons performed vasovasostomy anastomoses on sections of Ovis aries (sheep) vas deferens and sections of synthetic vas deferens segments. Ten sutures were completed for each anastomosis. The interventional surgeries were robot-assisted and performed using the Symani Surgical System, while the control surgeries were performed using the manual microsurgical vasovasostomy technique. All vasovasostomies were performed in a double-layer technique using 9/0 nylon and 10/0 nylon sutures. Outcomes included the net time for each suture placement and knot tie (seconds), the number of suture breaks, and the quality of the anastomosis as measured by a leak test. Results:Three surgeons performed a total of 9 Ovis aries vasal anastomoses, with 5 robot-assisted and 4 manual anastomoses performed. The duration of the mean net suture time for the robotic platform was significantly longer than the mean net suture time for manual surgeries (104 vs. 72 s; P=0.03). However, an evident learning curve with the robotic surgery platform showed a rapid decrease in anastomosis times with each subsequent surgery, for each surgeon. There were no suture breaks during robotic microsurgery and 5 suture breaks during manual microsurgery (P=0.02). Mean leak scores were similar. One surgeon performed 12 anastomoses on synthetic vas segments, and again, the mean net suture time for the robotic platform was significantly longer than the mean net suture time for manual microsurgeries (96 vs. 74 s; P=0.03). For the synthetic vasal anastomoses, the learning curves for the robotic platform and manual microsurgeries were similar and showed an overall decrease in anastomosis times. No significant differences were observed in suture breaks or mean leak scores for the synthetic vas surgeries. Conclusions:This study demonstrates that vasovasostomy can be successfully performed using the Symani surgical platform, with patency outcomes comparable to manual microsurgery as measured by measurement of anastomotic leaks, as well as technical advantages such as improved instrument stability as measured by number of suture breaks. Further research on the use of this surgical platform for vasovasostomy is warranted.

RATIONALE:Low-intensity shockwave therapy (LiSWT) is a new way of treating erectile dysfunction using sound waves to help improve blood flow to the penis. No existing systematic reviews comparing LiSWT to placebo or other therapies for treating erectile dysfunction have used rigorous Cochrane methodology. Many existing studies appear to be of poor methodological quality, and several trials are ongoing, reflecting an evolving evidence base. Therefore, it is unclear whether LiSWT truly helps men who have erectile dysfunction. Furthermore, there is very limited focus on patient-important outcomes in the existing systematic reviews. In this comprehensive Cochrane review, we compared LiSWT to sham therapy to evaluate its efficacy and safety. OBJECTIVES:To evaluate the benefits and harms of low-intensity shockwave therapy for erectile dysfunction in men compared to sham treatment. SEARCH METHODS:We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, Scopus, and two trial registries up to 7 July 2024. We applied no restrictions on publication status or language. ELIGIBILITY CRITERIA:We included randomized controlled trials (RCTs) that compared LiSWT to either sham or no treatment. We excluded trials involving people with prior kidney transplants or who had surgical procedures to remove the prostate gland (i.e. radical prostatectomy). OUTCOMES:Critical outcomes were erectile function, discontinuation from treatment, and treatment-related adverse events; important outcomes were patient/partner satisfaction, penile rigidity, and quality of sexual life. We assessed all outcomes in the short term (≤ 3 months) and long term (> 3 months). RISK OF BIAS:We assessed the risk of bias using Cochrane's risk of bias assessment tool (RoB1). SYNTHESIS METHODS:We performed statistical analyses following Cochrane Handbook of Systematic Reviews of Interventions guidance. We synthesized results for each outcome using meta-analysis using a random-effects model. We used GRADE to assess the certainty of evidence. INCLUDED STUDIES:We focused on RCTs that applied LiSWT treatment utilizing electrohydraulic, electromagnetic, or piezoelectric energy. We included 21 RCTs, including 1357 randomized participants (men aged 39 to 65 years old with erectile dysfunction between 3 and 68 months); 16 were published in full text, and the rest as abstract proceedings. The baseline International Index of Erectile Function-Erectile Function domain (IIEF-EF) scores of participants in these studies ranged from seven to 20. Based on this scale, most men had mild-to-moderate (12 to 16) and mild (17 to 21) erectile dysfunction. SYNTHESIS OF RESULTS:We included 21 RCTs that randomized 1357 participants. The certainty of the evidence for reported outcomes was low, mostly due to inconsistency, imprecision, and study limitations. Erectile function Based on the IIEF-EF scale (6 to 30; higher score indicates higher erectile function; minimal clinically important difference (MCID): 4 point change), LiSWT, compared to sham treatment, may have a small effect on erectile function in the short term (mean difference (MD) 3.89 points higher, 95% confidence interval (CI) 2.89 higher to 4.89 higher; I2 = 62%; 15 studies, 937 participants; low-certainty evidence). However, based on the selected MCID, this small effect may not be clinically important. In the long term, it may improve erectile function (MD 5.25 points higher, 95% CI 2.47 higher to 8.04 higher; I2 = 87%; 5 studies, 276 participants; low-certainty evidence). Discontinuation from treatment LiSWT, compared to sham treatment, may have little to no effect on discontinuation from treatment in the short term (RR 0.77, 95% CI 0.47 to 1.27 higher; I2 = 0%; 17 studies, 1132 participants; low-certainty evidence). This corresponds to 15 fewer (34 fewer to 17 more) discontinuations from treatment with the use of LiSWT per 1000 patients. There were no studies with an active treatment period longer than three months; therefore, we found no eligible data on this outcome in the long term. Treatment-related adverse events LiSWT, compared to sham treatment, may have little to no effect on treatment-related adverse events in the short term (risk difference (RD) 0.00, 95% CI -0.01 to 0.02; I2 = 0%; 20 studies, 1400 participants; low-certainty evidence). Long term, it may also have little to no effect on treatment-related adverse events (RD 0.00, 95% CI -0.02 to 0.02; I2 = 0%; 6 studies, 411 participants; low-certainty evidence). Patient/partner satisfaction We found no evidence on patient or partner satisfaction in either the short or long term. Penile rigidity Based on the Erectile Hardness Scale (EHS) (1 to 4; higher score indicates higher penile rigidity; MCID: 1 point change), LiSWT compared to sham treatment may improve penile rigidity in the short term (MD 1.06 points higher, 95% CI 0.83 higher to 1.28 higher; I2 = 53%; 4 studies, 252 participants; low-certainty evidence). In the long term, it may have a small improving effect on penile rigidity (MD 0.91 points higher, 95% CI 0.36 higher to 1.46 higher; I2 = 89%; 3 studies, 169 participants; low-certainty evidence). However, based on the selected MCID, this small effect may not be clinically important. Sexual quality of life We found no evidence on sexual quality of life in either the short or long term. AUTHORS' CONCLUSIONS:LiSWT may have a small effect on erectile function in the short term, although it may not be perceived to be clinically important by men with erectile dysfunction. It may improve erectile function in the long term. There may be little to no difference in treatment discontinuations in the short term. Since all eligible trials applied a treatment duration of three months or less, we found no data to compare treatment discontinuations in the long term. LiSWT may have little to no effect on treatment-related adverse events in the short or long term, and may improve penile rigidity in the short term. In the long term, LiSWT may have a small improving effect on penile rigidity that may not be clinically important. We found no evidence on patient/partner satisfaction or sexual quality of life, either short or long term. The certainty of evidence was low for all outcomes due to shortcomings in the methodology of the included studies. Several studies were industry-funded, mainly by device makers. FUNDING:This Cochrane review had no dedicated funding. REGISTRATION:Protocol (2023): doi.org/10.1002/14651858.CD013166.pub2.

PURPOSE:Non-obstructive azoospermia (NOA) is a common, but complex problem, with multiple therapeutic options and a lack of clear guidelines. Hence, there is considerable controversy and marked variation in the management of NOA. This survey evaluates contemporary global practices related to medical and surgical management for patients with NOA. MATERIALS AND METHODS:A 56-question online survey covering various aspects of the evaluation and management of NOA was sent to specialists around the globe. This paper analyzes the results of the second half of the survey dealing with the management of NOA. Results have been compared to current guidelines, and expert recommendations have been provided using a Delphi process. RESULTS:Participants from 49 countries submitted 336 valid responses. Hormonal therapy for 3 to 6 months was suggested before surgical sperm retrieval (SSR) by 29.6% and 23.6% of participants for normogonadotropic hypogonadism and hypergonadotropic hypogonadism respectively. The SSR rate was reported as 50.0% by 26.0% to 50.0% of participants. Interestingly, 46.0% reported successful SSR in <10% of men with Klinefelter syndrome and 41.3% routinely recommended preimplantation genetic testing. Varicocele repair prior to SSR is recommended by 57.7%. Half of the respondents (57.4%) reported using ultrasound to identify the most vascularized areas in the testis for SSR. One-third proceed directly to microdissection testicular sperm extraction (mTESE) in every case of NOA while others use a staged approach. After a failed conventional TESE, 23.8% wait for 3 months, while 33.1% wait for 6 months before proceeding to mTESE. The cut-off of follicle-stimulating hormone for positive SSR was reported to be 12-19 IU/mL by 22.5% of participants and 20-40 IU/mL by 27.8%, while 31.8% reported no upper limit. CONCLUSIONS:This is the largest survey to date on the real-world medical and surgical management of NOA by reproductive experts. It demonstrates a diverse practice pattern and highlights the need for evidence-based international consensus guidelines.

Purpose: Non-obstructive azoospermia (NOA) represents the persistent absence of sperm in ejaculate without obstruction, stemming from diverse disease processes. This survey explores global practices in NOA diagnosis, comparing them with guidelines and offering expert recommendations. Materials and Methods: A 56-item questionnaire survey on NOA diagnosis and management was conducted globally from July to September 2022. This paper focuses on part 1, evaluating NOA diagnosis. Data from 367 participants across 49 countries were analyzed descriptively, with a Delphi process used for expert recommendations. Results: Of 336 eligible responses, most participants were experienced attending physicians (70.93%). To diagnose azoospermia definitively, 81.7% requested two semen samples. Commonly ordered hormone tests included serum follicle-stimulating hormone (FSH) (97.0%), total testosterone (92.9%), and luteinizing hormone (86.9%). Genetic testing was requested by 66.6%, with karyotype analysis (86.2%) and Y chromosome microdeletions (88.3%) prevalent. Diagnostic testicular biopsy, distinguishing obstructive azoospermia (OA) from NOA, was not performed by 45.1%, while 34.6% did it selectively. Differentiation relied on physical examination (76.1%), serum hormone profiles (69.6%), and semen tests (68.1%). Expectations of finding sperm surgically were higher in men with normal FSH, larger testes, and a history of sperm in ejaculate. Conclusions: This expert survey, encompassing 367 participants from 49 countries, unveils congruence with recommended guidelines in NOA diagnosis. However, noteworthy disparities in practices suggest a need for evidence-based, international consensus guidelines to standardize NOA evaluation, addressing existing gaps in professional recommendations.

You have accessJournal of UrologyStone Disease: Medical & Dietary Therapy (MP26)1 May 2024MP26-04 HOW MIRABEGRON AFFECTS THE HUMAN URETER: AN IN VITRO STUDY Meylis Artykov, Esin Ozcelebi, Mehmet Yildirim Sara, Ahmet Gudeloglu, Alper Bektas Iskit, and Fazil Tuncay Aki Meylis ArtykovMeylis Artykov , Esin OzcelebiEsin Ozcelebi , Mehmet Yildirim SaraMehmet Yildirim Sara , Ahmet GudelogluAhmet Gudeloglu , Alper Bektas IskitAlper Bektas Iskit , and Fazil Tuncay AkiFazil Tuncay Aki View All Author Informationhttps://doi.org/10.1097/01.JU.0001009408.66023.77.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Aim of this study was to investigate the effects of mirabegron (MRB), a β3-adrenergic receptor agonist, on isolated human ureter. METHODS: The approval of the ethical committee was obtained before the study. This study was designed as series of in vitro experiments. Living donor graft kidney's ureters were preferred. Operations were between December 2020 and June 2021. Informed consent was obtained from all patients. Distal ureters were harvested at the back-table. Tissue was transferred in the flask with pre-gassed Krebs solution. Ureters were detubularized into stripes for organ baths. The tissue activity was recorded after stripes were left to rest until spontaneous contractions were observed. Consequently, responses were recorded by adding increasing concentrations of mirabegron. The activity was recorded via electro-mechanical transducer set-up using AcqKnowledge® 4.2 software (BIOPAC Systems, Inc.). Data analysis was performed with software SPSS 24.0 (IBM Corp., USA) and GraphPad Prism 6 (GraphPad, USA). RESULTS: 24 tissue strips from 16 ureters were prepared and studied. Only 15 strips showed spontaneous or inducible activity. The effect of MRB was investigated in tissues with spontaneous activity. The data of strips without activity was excluded. MRB lowered the frequency of spontaneous ureteric contraction in the concentration-dependent manner (Figure 1; A sample trace showing the effect of MRB in cumulative concentration on ureteral strips. Molar concentrations showed in means of logarithmic value). The decrease in frequency was statistically significant in presence of MRB at 10−6.5-10−4.5 M (Figure 2; Response values were compared with baseline contraction. All data in graphs is presented as arithmetic mean±standard error of the mean. a p<0.05, b p<0.005). Also, MRB reduced the spontaneous ureteric contractile force in a dose-dependent manner compared to the baseline contractile force. The decrease in amplitudes was statistically significant at 10−7-10−4.5 M MRB concentrations. CONCLUSIONS: MRB shows suppressive properties on the human ureter. This effect is achievable dose-dependently in isolated tissues. Download PPTDownload PPT Source of Funding: This study was financially supported by the Scientific Research Unit of Hacettepe University in Ankara Turkiye. © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e414 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Meylis Artykov More articles by this author Esin Ozcelebi More articles by this author Mehmet Yildirim Sara More articles by this author Ahmet Gudeloglu More articles by this author Alper Bektas Iskit More articles by this author Fazil Tuncay Aki More articles by this author Expand All Advertisement PDF downloadLoading ...

INTRODUCTION:This study aimed to investigate the effect of mirabegron, a β3-adrenoceptor agonist with widespread clinical use for treating overactive bladder disease, on isolated healthy human ureter strips. MATERIALS AND METHODS:This was a prospective study employing a series of in vitro organ bath experiments using ureteral tissues of kidney grafts from 10 healthy donors. The ureteral strips were subjected to cumulative mirabegron concentrations (10-9-10-4.5 M). Effects on frequency or amplitude of spontaneous, 10 mM KCl- or EFS-induced contractions were evaluated. RESULTS:Mirabegron decreased the frequency of spontaneous ureteric contraction in a concentration-dependent manner. Statistically significant decrease in the frequency of spontaneous contraction was observed at 10-8-10-4.5 M. In 10 mM KCl medium, statistically significant change in frequency was observed at 10-9-10-4.5 M. Statistically significant decrease in the amplitudes of spontaneous contraction was observed at 10-7-10-4.5 M. In a 10 mM KCl medium, statistically significant change in amplitudes was observed at 10-8-10-4.5 M. CONCLUSIONS:Mirabegron reduced the amplitude and frequency of human ureter activity in in vitro organ bath studies. This effect was achieved in a dose-dependent manner on isolated tissue strips. Although monotherapy with mirabegron remains uncertain, this study has the potential to elucidate the mechanism underlying the effectiveness of mirabegron, particularly in combination therapy for ureteral stones.

The conventional approach to harvest of the gracilis muscle flap necessitates a medial thigh incision that is often related to several donor site complications. In this report we describe the robotic harvest of the free gracilis muscle flap in order to reduce the morbidity associated with the open incision. Through three ports, the robotic system (Da Vinci Xi, Intuitive Surgical) enables precise dissection of the gracilis muscle, the vascular pedicle, and the obturator nerve; thus, enhancing surgical control, optimizing visualization through magnification, aiding in detailed vascular pedicle dissection and minimizing human error. We believe that the technique of totally robotic harvest of the free gracilis muscle flap, herein introduced, is a feasible and effective approach, and confers specific advantages over traditional harvest technique.

Chronic orchialgia (CO) or chronic scrotal pain (CSP) has been defined as greater than 3 months of unilateral or bilateral scrotal pain that leads to the pursuit of treatment. Classic symptoms include dull pain that originates anywhere from the lower abdomen to the scrotum/glans penis and is a frustrating disease that decreases the quality of life (QoL) tremendously. It is challenging to treat the disease since the pathophysiology and the etiology are not fully understood and there is lack of structured, evidence -based treatment schemes to guide the physician. This article reviews the current literature, shares the surgical techniques and our own experience with thousands of CO patients to provide the latest advancements in the management of this debilitating disease in addition to an algorithm to help the urologist plan the patient's treatment. The algorithm consists of a structured approach starting from conservative therapies and spermatic cord block the outcomes of which act as a surrogate to predict the success of further invasive treatments. There are various reported success rates for the modalities discussed in this algorithm and include microsurgical denervation of the spermatic cord (77-100%), ultrasound guided peri spermatic cord cryoablation (59-75%), radical orchiectomy (20-75%), targeted robotic intra-abdominal denervation (71%) and alternate therapies.

Objective:To determine which preoperative patient characteristics are predictive of intraoperative complications (IOC) and postoperative complications (POC) in patients undergoing nephrectomy for non-oncological diseases.Materials and Methods:Demographics, pre-operative characteristics, the surgical technique and perioperative outcomes of 295 adult patients who had underwent simple nephrectomy between 2002 and 2019 in a single reference institution were analyzed retrospectively. Univariate and multivariable statistical analyses were performed to determine the factors affecting POC (Clavien-Dindo score ≥1) and IOC. All statistical analyses were performed using the Statistical Package for the Social Sciences v. 24.0 (SPSS Inc., Chicago, IL, USA) software for Windows.Results:The mean age of the patients was 44.84±15.51 years, with a female-to-male ratio of 154/141. The statistically significant factors associated with IOC in the multivariable analysis were male gender, higher American Society of Anesthesiologists (ASA) score and urgent surgical intervention (p=0.002, p=0.001, p=0.021, respectively). In multivariable analysis, preoperative anemia, emergency surgery and open surgery were found to be statistically significant and associated with POC (p<0.001, p=0.004, and p=0.049, respectively).Conclusion:Improved surgical outcomes can be achieved through treatment adapted to individual preoperative characteristics such as ASA score, pre-operative hemoglobin level and male gender. An elective laparoscopic approach should be used whenever possible.

Abstract Oleogranuloma of the penis is a complex set of pathological processes caused by the injection of a foreign substance (gel, balls, rods, etc.) into the penis with the purpose of penile augmentation. We investigated the relevance of this problem to Kazakhstan and described our experience in managing the complications. We analyzed data on 18 patients with penile self-injections admitted to the hospitals of Astana city, Kazakhstan during an 11-year period. The mean age of patients at admittance was 37.4 years. The most common substance of injection was vaseline (n=16, 88%). The mean interval between the time of injection and the first presentation to the hospital was 10.8 years. Complications included necrosis (n=13, 72.2%), pain or swelling (n=6, 33.3%), cosmetic dissatisfaction (n=5, 27.8%). All patients received surgical treatment (n=18, 100%): primary incision was performed for one half of patients (9, n=50%), while another half of patients underwent the Reich’s surgery (9, n=50%). Our data suggest that the prevalence of oleogranuloma in Kazakhstan is higher than it was previously admitted. The findings of this study should raise the awareness about the complications of penile self-injections among high-risk groups (e. g. prisoners) and physicians for prevention and early diagnosis, respectively.

Life expectancy is increasing globally, leading to a larger population base older than age 60. Aging has several detrimental effects on the urinary and reproductive tracts. This leads to elder males presenting with symptoms and signs of androgen deficiency, impotence, and benign prostate hyperplasia, while patients of both sexes present with lower urinary tract symptoms, incontinence, and tumors more frequently with older age. This chapter discusses the evaluation and care of elderly patients from a urologic perspective and emphasizes the importance of awareness of the effects of aging on the urinary and reproductive tracts by the healthcare team.