What's known on the subject? and What does the study add?: Ureteroscopic lithotripsy sometimes causes severe complications, e.g. septic shock, and the relationship between long operative duration and complication rate has been empirically recognised. But due to the rarity, evidence is limited. We analysed 12372 cases and showed that the complication rate increased according to operative duration, especially for operations taking >90 min. Also, we found that high‐volume centres had lower complication rates. Objective: To develop a nomogram to predict severe adverse events ( AEs ) after ureteroscopic lithotripsy ( URSL ) including the effects of operative duration and hospital volume. Patients and Methods: We identified patients undergoing URSL from the J apanese D iagnosis P rocedure C ombination database between 2007 and 2010, and defined severe adverse events as (i) in‐hospital mortality; (ii) postoperative medication including catecholamine, γ globulin, protease inhibitors, medications for disseminated intravascular coagulation and transfusion; and (iii) postoperative interventions including percutaneous nephrostomy, central vein catheterisation, intensive care unit, dialysis, mechanical cardiopulmonary support. Univariate and multivariate logistic regression models addressed the occurrence of severe AEs . Results: Of 12 372 patients, 296 patients (2.39%) had severe AEs . M ultivariate analysis showed a positive linear trend of operative duration and severe AEs (odds ratio [ OR ] 1.58 in 90–119 min to OR 4.28 in ≥210 min compared with ≤ 59 min; each P < 0.05) and an inverse relationship between hospital volume and severe AEs ( OR 0.64 in ≥39 URSLs /year compared with ≤ 15 URSLs /year; P = 0.004) with adjustment for other significant factors including sex, age, Charlson comorbidity index, type of anaesthesia and type of admission. A nomogram and a calibration plot based on these results were well‐fitted to predict a probability between 0.01 and 0.10 (concordance index 0.677). Conclusion: Severe AEs after URSL were associated with longer operative duration and lower hospital volume, and were accurately predicted using the present nomogram.

Study Type – Prognosis (outcome) Level of Evidence 2b What's known on the subject? and What does the study add? Reportedly, Fournier's gangrene has a high mortality rate, ∼7.5–40%, and experts recommend early surgical debridement. This study examines 379 patients and shows that an early intervention, i.e. within 2 hospital days could halve the mortality rate compared with later intervention. OBJECTIVE: To examine how early surgical intervention influenced cases of Fournier's gangrene (FG) fatality. PATIENTS AND METHODS: Patients with FG (defined as an International Classification of Diseases‐10 code of M72.6 [necrotizing fasciitis] at the perineum or external genitalia), who received surgical intervention ≤5 days after admission, were identified from the Diagnosis Procedure Combination database for the 6‐month period July to December, in the years 2007–2010. Data included age, sex, comorbidities, ambulance use, operations and debridement ranges. Multivariate logistic regression analysis of mortality was performed to show whether early (≤2 hospital days) or delayed (3–5 hospital days) surgical treatment affected FG outcomes. RESULTS: A total of 302 male and 77 female patients with FG were identified for which the overall case fatality rate was 17.1% (65 cases). There were no significant differences in patient characteristics between the early operation group ( n = 327) and the delayed operation group ( n = 52), with the exception of ambulance use (33.3% vs 17.3%, P = 0.020). Cystostomy, colostomy, orchiectomy/penectomy (male patients only), or debridement ≥3000 cm ² were performed on 42 (8.8%), 56 (11.5%), 46 (10.8%) and 17 (4.4%) patients, respectively. Multivariate analysis showed that there was a significantly lower case fatality rate among the early operation group (odds ratio [OR]= 0.38; P = 0.031). Older age (OR 1.80, for 10‐year increments), Charlson comorbidity index score (OR = 1.33, for 1‐point increments), sepsis or disseminated intravascular coagulation at admission (OR 4.01), and debridement range ≥3000 cm ² (OR 5.22, compared with other operations) were significantly associated with a higher case fatality rate. CONCLUSION: Early (≤2 hospital days) surgical intervention for FG is significantly associated with lower mortality than delayed (3–5 hospital days) action.

In this study we used nationwide population based data to compare perioperative outcomes, including severe bladder injury, between monopolar and bipolar transurethral resection of bladder tumors. Data of patients with clinical T2 or less bladder cancer who underwent monopolar or bipolar transurethral bladder tumor resection were collected from 788 hospitals in the Japanese Diagnosis Procedure Combination database 2007-2012. One-to-one propensity score matching was performed. End points assessed were severe bladder injury requiring placement of a drainage tube or repair surgery within 3 postoperative days, hemostasis procedures consisting of clot removal or transurethral coagulation within 3 postoperative days, transfusion, other complications, anesthesia duration, postoperative length of stay and total costs. Multivariate analyses compared outcomes of bipolar and monopolar transurethral bladder tumor resection with gender, age, Charlson comorbidity index, clinical stage, hospital volume and hospital academic status as covariates. A total of 8,188 pairs were generated. Compared with monopolar transurethral bladder tumor resection, bipolar resection was associated with a significantly lower incidence of severe bladder injury (0.3% vs 0.6%, OR 0.57), other complications (4.6% vs 5.8%, OR 0.78), slightly shorter postoperative stay (mean 6.4 vs 6.7 days, difference -3.3%) and slightly lower total costs (mean $4,628 vs $4,727; difference -1.1%, all p <0.05). There were no differences in postoperative hemostasis procedures, transfusion and anesthesia duration. Bipolar transurethral bladder tumor resection was associated with a substantially lower incidence of several perioperative complications including severe bladder injury. The findings support the benefit of bipolar transurethral bladder tumor resection over monopolar resection in real-world clinical practice.

Robot-assisted radical prostatectomy (RARP) has now become a gold standard approach in radical prostatectomy. The aim of this study was to investigate incidence and risk factors of inguinal hernia (IH) after RARP. This study included 307 consecutive men who underwent RARP for the treatment of prostate cancer from January 2011 to August 2015. The incidence of IH after RARP was investigated. Clinical and pathological factors were also investigated to assess relationship with development of postoperative IH. Median follow-ups were 380 days, and median age of patients was 67 years. Incidence of IH was 11.3, 14.0, and 15.4% at 1, 2, and 3 years after RARP, respectively. Postoperative IH occurrence was significantly associated with low surgeon experience and postoperative incontinence at 3 or 6 months after surgery (P = 0.019, P = 0.002, and P = 0.016, respectively). Most of the IH occurred within the first 2 years with a rate of 14%. Incidence of IH after RARP was significantly associated with surgical experience and incontinence outcomes.

In 2012, Japanese national insurance started covering robot‐assisted surgery. We carried out a population‐based comparison between robot‐assisted and three other types of radical prostatectomy to evaluate the safety of robot‐assisted prostatectomy during its initial year. We abstracted data for 7202 open, 2483 laparoscopic, 1181 minimal incision endoscopic, and 2126 robot‐assisted radical prostatectomies for oncological stage T3 or less from the Diagnosis Procedure Combination database (April 2012–March 2013). Complication rate, transfusion rate, anesthesia time, postoperative length of stay, and cost were evaluated by pairwise one‐to‐one propensity‐score matching and multivariable analyses with covariants of age, comorbidity, oncological stage, hospital volume, and hospital academic status. The proportion of robot‐assisted radical prostatectomies dramatically increased from 8.6% to 24.1% during the first year. Compared with open, laparoscopic, and minimal incision endoscopic surgery, robot‐assisted surgery was generally associated with a significantly lower complication rate (odds ratios, 0.25, 0.20, 0.33, respectively), autologous transfusion rate (0.04, 0.31, 0.10), homologous transfusion rate (0.16, 0.48, 0.14), lower cost excluding operation (differences, −5.1%, −1.8% [not significant], −10.8%) and shorter postoperative length of stay (–9.1%, +0.9% [not significant], –18.5%, respectively). However, robot‐assisted surgery also resulted in a + 42.6% increase in anesthesia time and +52.4% increase in total cost compared with open surgery (all P < 0.05). Introduction of robotic surgery led to a dynamic change in prostate cancer surgery. Even in its initial year, robot‐assisted radical prostatectomy was carried out with several favorable safety aspects compared to the conventional surgeries despite its having the longest anesthesia time and the highest cost.

Objectives:  To show the characteristics and therapeutic trends of renal trauma in Japan using a nationwide database.Methods:  All renal trauma cases from the Diagnosis Procedure Combination database during 6 months of each year from 2006 to 2008 were included in the analysis. The following variables were considered: demographics, ambulance use, comorbid trauma, interventions, mechanism of injury and the Abbreviated Injury Scale. Patients were divided into two groups by trauma range: limited to rib, abdomen and pelvis (group A) or more extended (including supradiaphragmatic regions or lower extremities; group B). Rib fracture impact was assessed as a predictor of comorbid organ trauma. The incidences of angioembolization failure and nephrectomy were also evaluated.Results:  A total of 1505 renal trauma cases (1014 and 491 in groups A and B, respectively) were identified. Comorbid trauma in the liver, spleen and lumbar/pelvic fractures were 7.4%, 5.6% and 5.1% in group A and 24.0%, 11.2% and 17.5% in group B, respectively. The rates of angioembolization (and its failure proportion), nephrectomy, transfusion and mortality were 7.9% (12.5%), 3.3%, 15.6% and 1.1% in group A, and 17.1% (11.9%), 2.6%, 28.3% and 8.1% in group B, respectively. Risks of coincident traumas in the liver, spleen and pelvic fracture were 2.23, 2.35 and 2.72 times higher if a rib fracture was observed. The incidences of renal trauma and nephrectomy (per 100 000 person‐years) were estimated as 2.06 and 0.063, respectively.Conclusions:  Angioembolization failure is not rare, and nephrectomy is an important last resort. Patients with comorbid rib fracture should be explored for coincident traumas.