Impact of Two Urethral Stent Types on Complications after One-Stage Hypospadias Repair Using the Duckett Procedure

BACKGROUND

The authors evaluated whether the new nickel-titanium alloy stent (NTAS) is superior to the traditional silicone stent used in hypospadias repair surgery in preventing complications such as urinary fistula.

METHODS

This retrospective cohort study included 576 patients with hypospadias who underwent NTAS or traditional silicone stent placement after hypospadias surgery between March of 2002 and August of 2019. The primary outcome was the rate of urinary fistula occurrence at 4 weeks (stent removal time), and the secondary outcomes were the rate of other complications, such as urethral stricture, urethral diverticulum, infection, and so on. The occurrence of complications in both groups was compared, and the important contributing factors of urinary fistula and urethral stricture were determined.

RESULTS

Among 576 patients, 398 were assigned to the NTAS group, and 178 were assigned to the silicone group. Thirty-five patients in the NTAS group and 30 in the silicone group developed urinary fistula, with a rate of 8.8% and 16.9%, respectively ( P = 0.005). Subgroup analysis showed that the differences were mainly in preschool patients (6 years or younger) ( P = 0.004) and those with the penile type of hypospadias ( P = 0.008). In addition, urethral stricture complicated five patients in the NTAS group and two in the silicone group, with a rate of 1.3% and 1.1%, respectively ( P = 1.000). Logistic regression showed that hypospadias type ( P = 0.001) and stent type ( P = 0.001) are the important risk factors for urethral fistula.

CONCLUSION

The NTAS reduced the occurrence of urinary fistula complications after hypospadias repair in preschool patients, and can be presented as a better choice for hypospadias surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Scrotoscopy and traditional open surgery shows a high degree of consistency in the diagnosis of testicular torsion: An initial report

Traditional open surgery (OS) is usually necessary when testicular torsion (TT) cannot be excluded by scrotal ultrasound. Scrotoscopy has been used as a minimally invasive technique to diagnose or treat scrotal diseases, and it may also play a role in diagnosing TT.A retrospective analysis was performed for patients with TT to evaluate the consistency of scrotoscopy and OS in the diagnosis of TT. In the cases where preoperational Color Doppler ultrasonography was performed, scrotoscopy, open surgery, and confirmed TT were included for future analysis.A total of 43 patients were studied. Twisted testes were retained in 11 cases (25.59%), and the remaining 32 patients (74.41%) underwent orchiectomy. There were significant differences in the diagnostic value between the grading of scrotoscopy and ultrasound, as well as between ultrasound grading and blood supply grading (BSG) (both P < .05). However, no significant difference was observed between the grading of scrotoscopy and BSG in traditional OS (P > .05), but a high degree of consistency existed between scrotoscopy grading and BSG in traditional OS (Kappa = 0.733, P ≤ .001).Our limited data indicate that the diagnosis of testicular torsion by scrotoscopy is highly consistent with that of traditional surgical exploration. Therefore, further studies are necessary to confirm its application value in the future. Scrotoscopy may have potential application value for the patients whom testicular torsion are insufficiently diagnosed but cannot be excluded.

Distal hypospadias repair using the needle point bipolar cutting-coagulation forceps

INTRODUCTION

To determine the outcome of distal hypospadias repairs performed using bipolar diathermy (BD) for all the dissection.

METHODS

Retrospective review of 310 patients undergoing distal hypospadias (264 subcoronal/distal penile and 46 coronal/glanular) over a 11-year period. Median age at surgery was 2.0 years (range 9 months-15 years). Caudal anesthesia was performed in all patients. All children underwent an in situ tubularization of the urethral plate, which was combined with midline incision of the plate in 30 (10%). Preputial reconstruction was performed in 303 (98%) patients. BD forceps was used for coagulation and for all the dissection including skin incision, elevation of glans wings, separation of the corpus spongiosum from the corpora cavernosa, and urethral plate incision, when deemed appropriate. The authors assessed surgical complications and cosmetic results. The latter using the hypospadias objective score (HOSE), with a score ≥ 14 considered as acceptable.

RESULTS

The average operative time was 70 min. There was no postoperative bleeding or hematomas that required surgical intervention. There were no wound infections or necrosis. Complications occurred in 37 patients (11.9%). Urethral fistula formation was the commonest (n = 18). Postoperative persistent preputial swelling occurred in 3.5% of cases. Two hundred twelve patients (90.6%) had a HOSE score ≥ 14, and no patient required revision surgery for skin problems after a median follow-up of 8.1 (range 1.2-13.1) years.

DISCUSSION

The study is limited by its retrospective nature and by the fact that a number of other pre-operative, intra-operative, and postoperative variables can affect outcome.

CONCLUSIONS

Bipolar diathermy can be safely used for distal hypospadias repairs. It allowed careful control of intra-operative bleeding and also clear visualization of tissue planes. Complication rate overall compares favorably with the literature, and cosmetic results were satisfactory.

The Rezūm system - a minimally invasive water vapor thermal therapy for obstructive benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) and accompanying lower urinary tract symptoms (LUTS) sits in the top ten prominent and costly disease conditions in men over 50 years of age. In the United States it is the most common diagnosis made by urologists for men 45 to 74 years of age. Twenty percent of the population will reach 65 years of age or older by 2030, and those over 85 years will represent the fastest growing segment of our population. The prevalence of symptomatic BPH increases proportionally with the aging population. It is estimated that BPH now affects 6% of the male population worldwide. Moreover, in Canada, the estimated BPH prevalence is more than 1 million men aged 50 years and older. Among the various surgical treatments, Rezūm water vapor thermal therapy has been developed as a unique, rapid and reproducible minimally invasive surgical treatment exhibiting safe and early effective relief of LUTS/BPH. The targeted prostate tissue ablation is amenable to all zones of the prostate including intravesical median lobes. We present our experiences with this technique, which can be quickly performed under local anesthesia in an office setting.

Surgical treatment for primary premature ejaculation with an inner condom technique

To explore a novel surgical treatment for primary premature ejaculation using an inner condom technique.A total of 20 males with premature ejaculation, who admitted our andrology clinic from June 2016 to July 2017, were enrolled. By surgery, an inner condom made of acellular dermal matrix (ADM) was transferred to the subcutaneous pocket of the penis. The prolongation of intravaginal ejaculatory latency time (IELT) after the surgery was examined. The perioperative complications were also studied.The surgical intervention significantly increased the average IELT in patients, from 0.67 to 2.37 min (P = .009). No serious perioperative complications and adverse psychosexual effects were seen. Patients could resume sexual activity 6 weeks after the surgery.The novel inner condom using ADM is an effective and safe surgical treatment for males with premature ejaculation. The efficacy of this new treatment modality warrants further investigation in independent cohorts.

Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence

CONTEXT

Surgical nonautologous meshes have been used for several decades to repair abdominal wall herniae. Implantable materials have been adopted for the treatment of female and male stress urinary incontinence (SUI) and female pelvic organ prolapse (POP).

OBJECTIVE

A consensus review of existing data based on published meta-analyses and reviews.

EVIDENCE ACQUISITION

This document summarises the deliberations of a consensus group meeting convened by the European Association of Urology (EAU) and the European Urogynecological Association, to explore the current evidence relating to the use of polypropylene (PP) materials used for the treatment of SUI and POP, with reference to the 2016 EAU guidelines (European Association of Urology 2016), the European Commission's SCENIHR report on the use of surgical meshes (SCENIHR 2015), other available high-quality evidence, guidelines, and national recommendations.

EVIDENCE SYNTHESIS

Current data suggest that the use of nonautologous durable materials in surgery has well-established benefits but significant risks, which are specific to the condition and location they are used for. Various graft-related complications have been described-such as infection, chronic pain including dyspareunia, exposure in the vagina, shrinkage, erosion into other organs of xenografts, synthetic PP tapes (used in SUI), and meshes (used in POP)-which differ from the complications seen with abdominal herniae.

CONCLUSIONS

When considering surgery for SUI, it is essential to evaluate the available options, which may include synthetic midurethral slings (MUSs) using PP tapes, bulking agents, colposuspension, and autologous sling surgery. The use of synthetic MUSs for surgical treatment of SUI in both male and female patients has good efficacy and acceptable morbidity. Synthetic mesh for POP should be used only in complex cases with recurrent prolapse in the same compartment and restricted to those surgeons with appropriate training who are working in multidisciplinary referral centres.

PATIENT SUMMARY

Synthetic slings can be safely used in the surgical treatment of stress incontinence in both male and female patients. Patients need to be aware of the alternative therapy and potential risks and complications of this therapy. Synthetic mesh for treating prolapse should be used only in complex cases with recurrent prolapse in specialist referral centres.

Analysis of preoperative antibiotic prophylaxis in stented, distal hypospadias repair

INTRODUCTION

Surgical site infection [SSI] is a risk for any surgical procedure, including hypospadias repair. Prophylactic antibiotic therapy for patients having surgery is often effective in preventing SSIs, but with increasing rates of antibiotic resistance, this practice has been questioned. The objectives of this study are 1) to assess the incidence of SSIs in patients following stented, distal hypospadias repair and 2) to observe for any potential difference in the incidence of SSIs for patients with and without preoperative antibiotic utilization in this setting.

MATERIALS AND METHODS

We retrospectively reviewed consecutive patients treated with stented, distal hypospadias repair from 2011 to 2014 by three surgeons and compared two groups: patients who received preoperative antibiotics and patients who did not. Patients with a history of previous hypospadias repair were excluded from the study.

RESULTS

Two hundred twenty-four subjects were identified. Group 1 (135) received preoperative antibiotic and Group 2 (89) did not receive preoperative antibiotics. There was no statistically significant difference in SSI prevalence with 0 patients in Group 1 and 1 patient in Group 2 having a SSI.

CONCLUSION

Although prophylactic antibiotics prior to hypospadias repair are most often used by pediatric urologists, this study demonstrates further evidence that antibiotics prior to this procedure do not appear to lower the rate of SSI. This study is limited by its retrospective nature and disparate mean follow up in the two cohorts. Surgical site infection does not appear to be decreased by prophylactic antibiotic therapy before distal hypospadias repair.

Comparison of Polypropylene Mesh and Primary Repair in the Treatment of Blunt Testicular Rupture

PURPOSE

This study aimed to show the applicability of Polypropylene mesh (PM) grafting in blunt testicular ruptures.

MATERIALS AND METHODS

Data of 16 patients treated for testicular rupture following blunt scrotal trauma between March 2007 and April 2015 were analyzed retrospectively. Eight primary repairs and eight PM graftings were performed to repair the tunica albuginea (TA). Postoperatively, patients underwent Doppler ultrasonography at 3 weeks and then at 3, 6, and 12 months, followed by annual scans. The measurement of plasma testosterone levels was performed 12 months after the surgery.

RESULTS

The average follow-up time was 24.8 (range 12-48) and 42.8 (range 14-75) months for patients treated with PM grafting and primary repair, respectively. Differences in testicular size between treatment groups were only significant at 12 months postoperatively with the value of 26.5 mL (range 24-28) and 22.8 mL (range 13-27) in patients treated with a PM graft and primary repair, respectively (P = .045). There were no complications for those patients treated with the PM graft. Two patients who underwent primary repair developed testicular atrophy within 1 year postoperatively.

CONCLUSION

PM grafting is a safe alternative to primary closure of a TA defect following blunt testicular trauma.&nbsp.

[Application of scrotoscope in the diagnosis and treatment of testicular and epididymal diseases]

OBJECTIVE

To evaluate the safety and efficacy of scrotoscope in diagnosis and treatment of testicular and epididymal diseases.

METHODS

From September 2010 to March 2012, a total of 75 patients, aged 15-64 years (mean age is 42.4 years) were included in this study. Based on ultrasonagraphy before surgery, 12 cases were diagnosed as testicular torsion and 63 cases were diagnosed as epididymal mass. All the patients underwent scrotoscope examination or scrotoscope epididymectomy. A small scrotal incision of 1.0 cm was performed. Bluntly dissection was then performed through the scrotal layer until the tunica sac was disclosed. We used cystoscope or resectoscope as scrotoscope. Keeping the drip fusion of isotonic solution inflowing, the scrotum was maintained appropriate distended. The tunica sac wall including parietal and visceral tunica was checked. The testis, epididymis was then examined from the anterior, posterior and both lateral aspects to find out any potential pathology. The operation time of scrotoscope, postoperative complications, surgery record, ultrasound and pathology results were collected from medical record. Visual analog pain scale (range from 0 points to 10 points, 0 represent no pain, 10 represent the most severe pain) was used to assess scrotal pain. The postoperative complications, recurrence and pain relief were evaluated, the accuracy rates of the diagnosis was compared between scrotoscope and ultrasound based on pathology results.

RESULTS

All the patients were successfully performed scrotoscope except one because of inflammatory adhesion. The average time of the operation was 34.3±5.8 minutes, and no serious complications, such as severe edema, hematoma, testicular hydrocele and wound infection occurred. The accuracy rate of scrotoscope and ultrasound for the diagnosis of testicular torsion was 100% vs. 66.7%, and the accuracy rate of scrotoscope and ultrasound for the diagnosis of epididymal mass was 76.2% vs. 58.7%. In the study, 63 patients received scrotoscope epididymectomy, the visual analogue pain score before surgery was 7.1±0.8, 6 months after operation, and the pain score was 2.4±0.6.

CONCLUSION

Scrotoscope is safe. There are no serious complications such as severe edema, hematoma, testicular hydrocele and wound infection occurred. Scrotoscope is superior to ultrasound for diagnosis of testicular torsion and epididymal mass. Scrotoscope epididymectomy is effective for pain relief, especially for patients with epididymal cyst.

Efficacy and complications of the adjustable sling system ArgusT for male incontinence: results of a prospective 2-center study

OBJECTIVE

To evaluate prospectively the efficacy and the safety of the ArgusT in male patients with persistent stress urinary incontinence.

METHODS

A prospective 2-center evaluation was conducted on consecutive patients treated for persistent stress incontinence. Forty-two patients were implanted with the ArgusT male sling system with no associated surgery. Measurements included daily pad usage, 24-hour pad weight test, International Quality of Life questionnaire, International Consultation on Incontinence Questionnaire short form, and the Patient Global Impression of Improvement. Postoperative complications were assessed using the Clavien-Dindo classification. The definitions used were cured, 0-5 g in 24-hour pad weight test; improved, reduction of urine loss in 24-hour pad weight test >50%; and failed, all others.

RESULTS

After a mean follow-up of 28.8 months (20-38 months), 26 patients were dry (61.9%) with a pad test of 0-5 g/24 hours. Eleven patients (26.2%) improved. Five patients are considered failures. Overall daily pad use, urine loss in the 24-hour pad test, and quality of life scores improved significantly after sling implantation. Median adjustment rate was 1.7. There were no perioperative complications. Postoperative complications were mainly grade I and II complications according to the Clavien-Dindo classification.

CONCLUSION

The ArgusT sling system offers an effective and safe treatment option for male patients with moderate to severe stress urinary incontinence in a follow-up >2 years, even after radiotherapy.

Robotic assisted andrological surgery

The introduction of the operative microscope for andrological surgery in the 1970s provided enhanced magnification and accuracy, unparalleled to any previous visual loop or magnification techniques. This technology revolutionized techniques for microsurgery in andrology. Today, we may be on the verge of a second such revolution by the incorporation of robotic assisted platforms for microsurgery in andrology. Robotic assisted microsurgery is being utilized to a greater degree in andrology and a number of other microsurgical fields, such as ophthalmology, hand surgery, plastics and reconstructive surgery. The potential advantages of robotic assisted platforms include elimination of tremor, improved stability, surgeon ergonomics, scalability of motion, multi-input visual interphases with up to three simultaneous visual views, enhanced magnification, and the ability to manipulate three surgical instruments and cameras simultaneously. This review paper begins with the historical development of robotic microsurgery. It then provides an in-depth presentation of the technique and outcomes of common robotic microsurgical andrological procedures, such as vasectomy reversal, subinguinal varicocelectomy, targeted spermatic cord denervation (for chronic orchialgia) and robotic assisted microsurgical testicular sperm extraction (microTESE).

Discontinuous intrabdominal splenogonadal fusion with germ cell tumor. Excision with robotic assistence. Adult case report

OBJECTIVE

Present the case of a patient with a discontinuous intrabdominal splenogonadal fusion with an associated germ cell tumor.

METHODS

A case of a man of 29 years with bilateral cryptorchidism and left intra-abdominal discontinuous splenogonadal fusion associated with seminoma as an accidental finding in the context of a robotic pyeloplasty due to ipsilateral ureteropelvic junction stenosis.

RESULTS

The total operative time was 80 minutes (atrophic gonad removal and pyeloplasty by the Anderson-Hynes technique) with an estimated blood loss less than 100 cc. The hospitalization time was less than 36 hrs. The pathology and immunohistochemical report was compatible with intratubular germ cell neoplasia (seminoma).

CONCLUSION

The splenogonadal fusion is an uncommon pathology. While a high clinical suspicion may avoid unnecessary orchiectomy in young patients, its association with disorders such as cryptorchidism should make us suspect the possible presence of a concomitant germ cell neoplasia.

A biomechanical, histological and biochemical study in an experimental rabbit hypospadias repair model using scanning acoustic microscopy

OBJECTIVE

To investigate the biomechanical, histological and biochemical properties of rabbit urethra at long-term follow up after hypospadias simulation and acute repair.

MATERIALS AND METHODS

Thirty-eight white New Zealand male rabbits underwent experimental creation of a hypospadias-like defect and acute repair (mobilization and advancement, tubularized incised posterior urethral plate (TIP), modified TIP) and sham operation. After 23 weeks all groups + controls underwent biomechanical, histological and biochemical assessments.

RESULTS

The mobilization and advancement group showed a higher stiffness compared to the TIP groups (P < 0.05) in the posterior urethra, whereas the TIP group was stiffer compared to the other two operative groups (P < 0.001) in the ventral urethra. In the dorsal urethra, the mobilization and advancement group and the modified TIP group had a higher collagen content compared to shams (P < 0.05). No differences in collagen content were found between groups in the ventral urethra. A correlation between acoustic and histological layers was found, partially related to collagen content.

CONCLUSION

The urethras had different microelastic properties in different layers of the dorsal and ventral urethra, with higher stiffness in the connective tissue layers surrounding and within the urethra. The repaired urethras had partially recovered their elasticity at micrometer resolution at long-term follow up. Scanning acoustic microscopy elucidated structure-function relationships at microscopic level in normal and operated urethra.

[Surgical trends in secondary hypospadias]

The severity of secondary hypospadias can range from a mild cosmetic problem to severe functional impairment. Accordingly, surgical management of the defect can be either simple or extremely demanding. During the operation the penis should always be regarded as a functional unit so that the treatment goal of a good cosmetic and functional result can be achieved. In addition, the surgeon should have an extensive repertoire of operative techniques at his disposal and should be well versed in skin grafting methods so that he is able to adapt the procedure optimally to the intraoperative findings as necessary. If certain do's and don'ts of hypospadias correction are additionally observed good results can usually be obtained even in complicated hypospadias patients with multiple previous operations. Unreflected treatment, on the other hand, usually leads to further worsening of the problem resulting in the so-called hypospadias cripple.

Contemporary management of postprostatectomy incontinence

CONTEXT

In recent years, despite improvement in the surgical technique, the prevalence of postprostatectomy incontinence has increased due to a rise in the number of radical prostatectomies performed annually.

OBJECTIVE

The aim of this review is to evaluate contemporary noninvasive and invasive treatment options for postprostatectomy incontinence.

EVIDENCE ACQUISITION

In August 2010, a review of the literature was performed using the Medline database.

EVIDENCE SYNTHESIS

All articles concerning noninvasive and invasive treatment for postprostatectomy incontinence were included.

CONCLUSIONS

No randomised controlled trials exist to compare currently used noninvasive and invasive treatments for postprostatectomy incontinence. Pelvic floor muscle training is recommended for the initial treatment of stress urinary incontinence (SUI). Additionally, antimuscarinic therapy should be applied for urgency or urge incontinence. For decades, the artificial urinary sphincter was the reference standard for persistent SUI. Nowadays, male slings are an alternative for men with mild to moderate postprostatectomy SUI.

[Corpus cavernosum-corpus spongiosum shunt plus intracavernous tunneling for the treatment of prolonged ischemic priapism]

OBJECTIVE

To investigate the efficacy and safety of corpus cavernosum-corpus spongiosum shunt (CC-CSS) plus intracavernous tunneling(CC-CSS+ICT) for the treatment of prolonged ischemic priapism (PIP) were investigated.

METHODS

Of 21 patients with PIP, 11 (Group A) underwent CC-CSS and 10 (Group B) CC-CSS+ICT surgery. The penile hardness score (PHS) and pain visual analogue score (PVAS) were used to assess the efficacy of the surgery.

RESULTS

The erectile functions of the two groups were normal (IIEF5 23.6+/-1.1) before the onset of PIP, and the duration of PIP was (3.4+/-1.3) d. PHS 3.9+/-0.4, and PVAS 8.4+/-0.7. There was no statistical difference between the two groups (P>0.05). On 1, 3 and 5 days after the operation, the PHS and PVAS of Group B decreased significantly than those of Group A (P<0.05).

CONCLUSION

CC-CSS+ICT could quickly restore penile detumescence and relieve pain as compared with CC-CSS, which might be a safe and effective method for the treatment of PIP.

Evolution of robotic radical prostatectomy: assessment after 2766 procedures

BACKGROUND

Robotic-assisted radical prostatectomy (RAP) is the dominant minimally invasive surgical treatment for patients with localized prostate cancer. Only a few large series have been published to date, with few long-term data available. The current study presents what to the authors' knowledge is the largest series of patients undergoing RAP with the longest follow-up to data available to date. Using a continuous quality improvement initiative, several technical refinements were adopted, evaluating the impact of this on patient outcome.

METHODS

Over a 6-year period, 2766 consecutive men underwent RAP at the study institution. Data were collected prospectively including demographic, surgical, oncologic, and functional outcomes with up to 5-year follow-up. The first 200 and most recent 200 patients were compared to determine the impact of experience and quality improvement for patients.

RESULTS

The mean age of the patients was 60.2 years and the mean prostate-specific antigen (PSA) level at time of diagnosis was 6.43 ng/mL; 42.4% and 64.2% of patients, respectively, had a biopsy and pathologic Gleason sum of >/=7. The mean surgical and console time was 154 minutes and 116 minutes, respectively. Estimated blood loss was 100 mL; 96.7% of patients were discharged within 24 hours of surgery. At a median follow-up of 22 months, 7.3% of men had a PSA recurrence. The 5-year actuarial biochemical free survival rate was 84%.

CONCLUSIONS

To the authors' knowledge, the current study is the first report of 5-year outcomes in men undergoing RAP. These data demonstrate that RAP can be performed with favorable outcomes while minimizing complications. As experience increases, further improvements in clinicopathologic and functional parameters are achieved.

[A variant of transvesical extraurethral adenomectomy]

To facilitate extraurethral adenomectomy, we used a semicylindric scalpel and metallic tube (tubus) to make a semioval cut parallel to proximal prostatic portion of the urethra along the posterior semicircle of the bladder neck in 260 patients with prostatic adenoma (PA). The urethra was isolated from the adenomatous tissues. The vesicular cut was prolonged left and right to the level of ureteral ostia. This manipulation was followed with bimanual index finger enucleation of adenomatous tissue. The defect of the vesicourethral segment was sutured with catgut or monocril. Extra-urethral adenomectomy with semicylindric scalpel injured prostatic urethra in lesser extent than endourethral adenomectomy, it reduced the risk of hemorrhage, entailed neither stricture of the posterior urethra nor incontinence of urine in the postoperative period.

Outcome after treatment of detrusor–sphincter dyssynergia by temporary stent

OBJECTIVES

To evaluate follow-up treatments used after treatment of detrusor-sphincter dyssynergia (DSD) by a temporary urethral sphincter stent.

MATERIALS AND METHODS

Between February 1994 and June 2003, 147 men with a mean age of 41.3+/-14.4 years were treated by temporary urethral stent inserted across the external sphincter for DSD. The underlying neurologic disease was quadriplegia in 85 cases, multiple sclerosis in 24 cases and paraplegia in 21 cases. A Nissenkorn (Bard) stent was used in 130 cases and a Diabolo (Porgès) stent was used in 17 cases. All patients were either unable to or they refused to perform intermittent self-catheterization. DSD was demonstrated by urodynamic studies in every case.

RESULTS

The mean duration of temporary stenting was 10.15+/-16.07 months. After temporary stenting, 92 patients were treated by permanent stent (Ultraflex, Boston Scientifics), 7 started intermittent self-catheterization, 12 had repeated changes of the temporary stent, 4 had an indwelling catheter, 3 underwent cystectomy with non-continent diversion, 2 were treated by endoscopic sphincterotomy, 1 was treated by bladder neck incision, 1 was treated by neuromodulation and 1 was treated by cystostomy. Fifteen patients were lost to follow-up. Two patients died during follow-up (not related to DSD).

CONCLUSION

After treatment of DSD by a temporary urethral sphincter stent, 70.7% of patients subsequently require a permanent urethral sphincter stent. This period allows selection of patients unlikely to benefit from permanent urethral sphincter stent.

[Transurethral electrosurgery of a new generation (TURis) in the treatment of the lower urinary tract and prostate diseases]

Surgical interventions were made in 175 patients aged 23-87 years (mean age 64.8 years) with different diseases of the lower urinary tract (adenoma, prostatic cancer, cancer of the urinary bladder, etc.) with application of a new generation of endoscopic technique--transurethral resection in saline (TURis system) with a generator UES-40 SurgMaster (Olympus). Three patients had a cardiac pacemaker. The size of the prostate in prostatic adenoma ranged from 4.8 to 121 cm3 (mean 62.5 cm3), residual urine--92.3 ml (42.6 to 310.2 ml). Duration of surgery averaged 63 min (14 to 127 min). Mean amount of the resected tissue in sclerosis of urinary bladder cervix was 7 g (5-11 g), in prostatic adenoma--41 g (10-85 g), prostatic cancer--27 g (17-49 g). In postoperative period tamponade of the urinary bladder developed in 2 (1.5%) patients. Red cell transfusions were not necessary. Incontinence was observed in 7 (5.3%) patients after removal of urethral catheter, in 5 (3.8%) patients it stopped spontaneously to the time of discharge from the hospital, 2 (1.5%) patients with prostatic cancer retained partial orthostatic incontinence. TURis raised Qmax from 8.1 to 19.8 ml/s, on the average. The scores by IPSS fell from 20.8 to 7.5, QoL--from 5.1 to 3.7, on the average. Residual urine after operation reached 35 ml maximum. Informative value of histological material rose significantly in view of a minimal zone of coagulatory changes in the samples. Standard time limitation for transurethral resection (60-90 min) becomes insignificant in using isotonic irrigation allowing urologists to resect safely larger adenomas than it was possible earlier.

Role of laparoscopy for reconstructive urology

PURPOSE OF REVIEW

Laparoscopic reconstructive urology is a challenging and technically demanding field of urology. As urologists' experience strengthened and technical modifications developed, urologic laparoscopy was applied in the treatment of malignancies and evolved from simple to technically demanding reconstructive techniques. This article reviews the latest published literature in the field of laparoscopic reconstructive urology and introduces our own persuasion for the role of this approach in urology.

RECENT FINDINGS

Some laparoscopic procedures like orchidopexy, ureterolithotomy, pyelolithotomy and pyeloplasty require "a middle class level of laparoscopic skills" whereas other reconstructive techniques such as radical prostatectomy and cystectomy and partial nephrectomy are technically demanding and are still being developed with promising results. The reconstructive part of partial nephrectomy is small and refers to good hemostasis whereas in radical prostatectomy and cystectomy, the reconstructive part--urethrovesical anastomosis and urinary diversion, respectively--is an important factor, affecting the patient's postoperative quality of life.

SUMMARY

The development of new instrumentation as well as the amelioration of urologists' laparoscopic skills will pave the way for the establishment of laparoscopic reconstructive urology in everyday practice. So far, laparoscopic reconstructive urology seems to be a well tolerated and effective treatment modality but still with not a completely clear role.

Two-trocar laparoscopic varicocelectomy: cost-reduction surgical technique

OBJECTIVES

To describe the technique of two-trocar laparoscopic varicocelectomy and compare it with the standard three-trocar laparoscopic technique in terms of effectiveness, morbidity, and cosmesis.

METHODS

Two matched groups of patients with left varicocele were recruited. Each group included 30 patients. One group underwent three-trocar and the other two-trocar laparoscopic varicocelectomy. The results of the two approaches were compared.

RESULTS

No significant differences were found in terms of mean hospital stay or morbidity between the two-trocar and three-trocar techniques. A significant difference was found in the operative time and proportion of patients needing postoperative parenteral narcotic analgesia in favor of the two-trocar technique. In both approaches, the previously infertile patients had a significant improvement in sperm count and motility (P <0.05). Cosmetically, the trocar wound scars were aesthetically superior using the two-trocar technique.

CONCLUSIONS

No significant difference was found between two-trocar and three-trocar laparoscopic varicocelectomy in terms of effectiveness and morbidity. The cost of an extra 5-mm disposable trocar in the three-trocar technique and the improved cosmesis after the two-trocar technique have made us prefer the latter technique.

Induratio penis plastica

Peyronie's disease is characterized by the formation of a plaque of the tunica albuginea that leads to a mainly dorsally directed penile curvature and penile shortening due to scarification. The exact ethiopathology remains unclear. The natural history of the disease is variable, ranging from spontaneous remissions to chronic, and including severe penile curvature. Therapy should be conservative in the early, painful, progressive phase. No conservative medical or semi-invasive treatment modality, such as extracorporeal shock wave therapy or radiation therapy, is currently available for curing all of the symptoms of this disorder in all patients. All studies with a controlled design showed poor therapeutic outcomes that are frequently identical to the natural course. Surgical therapy should only be performed in the stable stage of the disease. This means that Peyronie's disease should have been present for at least 12 months, and the patient should not have suffered from pain or the progression of symptoms for at least 6 months. The surgical treatment modalities comprise plication procedures (Essed-Schroeder, Nesbit), plaque-incisions with grafting, and the insertion of penile implants with simultaneous correction of the curvature by "penile cracking" or incisions of the plaque.

Novel use of da Vinci Robotic Surgical System: Removal of seminal vesicle cyst in previously dissected pelvis

We report a novel use of the da Vinci Robotic Surgical System to remove a seminal vesicle cyst in a previously dissected pelvis.

Early catheter removal after anterior anastomotic (3 days) and ventral buccal mucosal onlay (7 days) urethroplasty

INTRODUCTION

Physicians who perform urethroplasty have varying opinions about when the urinary catheter should be removed post-operatively, but research on this subject has not yet appeared in the literature. We performed voiding cystourethrogram (VCUG) on our anterior urethroplasty patients on days 3 (anastomotic) and 7 (buccal) in an effort to determine the earliest day for removal of the urethral catheter.

MATERIALS AND METHODS

Retrospective chart review of 29 urethroplasty patients from October 2002-August 2004 was performed at two reconstructive urology centers. 17 patients had early catheter removal (12 anastomotic and 5 ventral buccal onlay urethroplasty) and were compared to 12 who had late removal (7 anastomotic and 5 buccal).

RESULTS

Of those with early catheter removal, 2/12 (17%) of anastomotic urethroplasty patients had extravasation, which resolved by the following week and 0/5 (0%) of the buccal mucosal urethroplasty patients had extravasation. Patients with late catheter removal underwent VCUG 6-14 days (mean 8 days) after anastomotic urethroplasty and 9-14 days (mean 12 days) after buccal mucosal urethroplasty. 0% of the anastomotic urethroplasty had leakage after the late VCUG and 1/5 (20%) of the buccal patients had extravasation after the VCUG. Recurrences were low in all patient groups.

CONCLUSION

Catheter removal after anastomotic and buccal mucosal urethroplasty can be safely attempted on the 3rd and 7th post-operative days respectively, with a low rate of extravasation on VCUG. Eliminating the catheter as soon as possible should improve patient comfort without harming results and decrease the overall negative impact of surgery on the patient.

Komplizierte Harnröhrenrekonstruktionen bei Erwachsenen und Kindern

The urethral reconstruction is a challenge in the adult, but even more in infant and young male patients. Good knowledge of the anatomy of the penis (blood supply and the course of the nerve fibers) with the availability of microsurgery suturing and instruments improved the outcome significantly. The growing knowledge opened the possibility to reconstruct complicate strictures with grafts. The buccal mucosa flap is one of those improvements, which made a tremendous impact to have a successful outcome. Recently we looked into the outcome of urethral reconstruction of long urethral strictures by using a buccal mucosa only flap. We used a modified technique for hypospadias repair to reconstruct coronar or subcoronar defects by meatal mobilization (MEMO). In cases with a long urethral stricture the success rate was over 90% with a mean follow up of 16 months. In all children the outcome with the MEMO-technique was successful without any major complication with a mean follow-up of 12.5 months.

[The management of azoospermic patient]

OBJECTIVES

Since first pregnancy after ICSI was achieved in 1992, the treatment and prognosis of severe male factor, i.e azoospermia, has radically changed. The objective of this article is to review the issue from the urologist-andrologist point of view.

METHODS

We perform a short revision of the two types of azoospermia and diagnostic tests, and show the algorithm used in our centre for the management of patients with azoospermia. We review the techniques for spermatozoid recovery and surgical treatment of obstructive azoospermia because the role of the urologist is maximum in these aspects. Genetic anomalies in azoospermic patients is one of the issues analyzed in more detail for being one of the most important and of maximum interest currently.

RESULTS

Nearly 1% of pregnancies in developed countries are achieved by assisted reproduction techniques, and genetic anomalies among newborns from ICSI cycles have increased to 1.6%, three times normal population. Genetic anomalies are tenfold in azoospermic patients in comparison to general population. We analyze the importance of these studies in patients with secretory azoospermia. We review the most frequent genetic anomalies associated with azoospermia and diagnostic tests employed. Its importance is based on this diagnosis allowing genetic counselling and pre-implant or prenatal diagnosis with the aim of trying to minimize genetic anomalies and disease transmission to next generations.

CONCLUSIONS

The diagnosis and treatment of azoospermia continues to be one of the most thrilling challenges in the field of infertility, with promising research lines such as in vitro spermatogenesis from stem cells and autotransplantation of criopreserved cells in patients undergoing radiotherapy and chemotherapy.

Longitudinal urethral sling with prepubic and retropubic fixation for male urinary incontinence

OBJECTIVE

Description and early results of a new urethral sling technique for treatment of postprostatectomy urinary incontinence, which combines efficacy, low cost and technical simplicity.

MATERIALS AND METHODS

From May 2003 to April 2004, 30 patients with moderate or total urinary incontinence, following radical prostatectomy or endoscopic resection of the prostate, underwent the new technique. The technique is based on the placement of a longitudinal-shaped sling in the bulbar urethra, measuring 4 cm in length by 1.8 cm in width, made of Dacron or polypropylene mesh, fixed by 4 sutures on each side, with 2 sutures passed with Stamey-Pereira needle by retropubic approach and 2 by prepubic approach, which are then tied over the pubis. Pressure control was determined by interrupting the loss of infused water through a suprapubic cystostomy 60 cm from the pubis level.

RESULTS

Pre-operative assessment excluded vesical instability, urethral stenosis and urinary infection. Suprapubic cystostomy was removed when the patient was able to satisfactorily void with urinary residue lower than 100 mL, which occurred in 29 of the 30 cases. In 2 cases, there was infection of the prosthesis, requiring its removal. In 3 cases, there was the need to adjust the sling (increasing the tension), due to failure of the urinary continence. Overall, 20 of 30 (66.7%) operated patients became totally continent, and did not require any kind of pads. Four of 30 (13.3%) patients achieved partial improvement, requiring 1 to 2 pads daily and 6 of 30 (20%) patients had minimal or no improvement. There was no case of urethral erosion.

CONCLUSION

This new sling technique has shown highly encouraging preliminary results. Its major advantage over other surgical techniques for treatment of moderate or severe stress urinary incontinence is the simplicity for its execution and low cost. A long-term assessment, addressing maintenance of continence, detrusor function and preservation of the upper urinary tract, is still needed.

Temporary urethral stenting for membranous urethral stricture helps complete healing without compromising continence

We report the case of a patient with a recurrent membranous urethral stricture who was treated with temporary implantation of a UroLume endoprosthesis and recovered completely, without any sphincteric insufficiency or stricture recurrence, during a 1-year follow-up period.

Use of a computer-controlled bipolar diathermy system in radical prostatectomies and other open urological surgery

BACKGROUND

Ligasure is a computer-controlled bipolar diathermy system, designed to optimally seal vessels < or = 7 mm in diameter. The aim of the present study was to evaluate its application to open urological surgery.

METHODS

The Ligasure device was used in 32 consecutive open surgical cases, including 25 radical prostatectomies, five radical nephrectomies, one partial nephrectomy and one nephro-ureterectomy. All procedures were performed using standard surgical techniques, with the exception that the Ligasure device was used for haemostasis. This included pelvic lymphatics and prostatic, adrenal, gonadal and aberrant obturator vessels, as well as vessels associated with the ureter, vasa, seminal vesicles, peri-renal fat, peritoneum and peri-adrenal tissues. Vessels > 7 mm in diameter, such as the renal artery, were ligated. In no patients were haemostatic clips used.

RESULTS

In all procedures, vessels and other structures < 7 mm were successfully sealed using the Ligasure device. For some structures, such as the prostatic pedicles and the seminal vesicles, the Ligasure device was much easier to apply than haemostatic clips. Use of the Ligasure device reduced the operating time (mean: 113 min vs 135.5 min; P < 0.001) and blood loss (mean: 529 mL vs 642 mL; P < 0.02) for radical prostatectomies. No intraoperative or postoperative blood transfusions were required. There were no postoperative haemorrhages, lymph leakage or lymphocoeles. Median inpatient hospital stay was 7 days (range: 6-9 days) and no patients required readmission.

CONCLUSION

The Ligasure, device was safe and easy to use in major urological procedures.

Artificial urinary sphincter AMS 800 for urinary incontinence after radical prostatectomy: the French experience

Post-radical prostatectomy urinary incontinence (PRP-UI) has a major negative impact on the patient's quality of life with the incidence accounting for over 30% on a patient questionnaire basis. In 1995 the French Urological Association started a prospective survey to investigate the efficacy and safety of the AMS 800 artificial urinary sphincter (AUS) in PRP-UI, and preliminary results are presented for the 103 men enrolled in the study in whom bulbar urethral cuff placement was used exclusively. Surgical revision was necessary in 22 patients (21%). Infection and erosion accounted for 12 non-mechanical revisions leading to complete removal of 6 AUS and to eventual replacement of 6 devices with new ones. Mechanical malfunction accounted for revision in l0 patients (9.7%). Fifty-nine patients (61.45%) reported no leakage for the 96 working devices. Twenty-seven patients (28%) wore no pads, 3 patients used 1 pad and 4 patients used 2 pads/day, and all these patients reported improvement, with only 3 patients (3%) having had more than 2 pads/day. Currently, no non-prosthetic procedure reliably affords such good objective results. Insertion of the AMS 800 AUS no doubt represents an attractive treatment modality available for male urinary incontinence following radical prostatectomy.

Clinical review of the 'Snodgrass' hypospadias repair

BACKGROUND

Snodgrass first described the tubularized, incised plate (TIP) urethroplasty for distal hypospadias repair in 1994 based on the concept of hingeing the incised urethral plate. The use of this technique allows a vertically orientated glanular meatus to be produced. A retrospective review of patients who had this procedure for the primary repair of distal hypospadias at New Children's Hospital was performed to objectively assess the cosmetic and functional outcomes of this technique.

METHODS

All patients having a TIP urethroplasty for the primary repair of distal hypospadias between 1996 and 1998 were requested to attend for review in an independent clinic. The parents were interviewed and the patient was examined to determine meatal location, meatal size, glanular configuration, urinary stream, straightness of erections, cosmesis, and the presence or absence of cutaneous sinus tracts or a urethral fistula.

RESULTS

Sixty patients were identified. Forty-nine were reviewed in person, 10 were reviewed by telephone and one could not be traced. The median age at surgery was 13 months (range: 6-144 months), with a median follow up of 27 months (range: 2-33 months). A glanular meatus was achieved in 57 patients (97%) and a conical glanular configuration was achieved in 58 patients (98%). The urinary stream and erections were straight in 54 (89%) and 58 patients (98%), respectively. Suture sinus tracts were present in 14 (24%) patients. Six patients (10%) developed a urethral fistula and three (5%) developed meatal stenosis. A good or satisfactory final cosmetic and functional result was achieved in 58 patients (98%).

CONCLUSIONS

The results of TIP urethroplasty are satisfactory at New Children's Hospital with the benefit of a cosmetic final outcome similar to a circumcised penis.

Hydraulic urethral dilatation after optical internal urethrotomy: preliminary report

OBJECTIVES

To determine the rate of early recurrence of urethral stricture in the first six months in patients who perform hydraulic urethral dilatation(HUD) after optical internal urethrotomy (OIU) and compare the early recurrence rate in patients who perform HUD after OIU with the recurrence rates in patients reported in the literature who undergo OIU without performing HUD.

DESIGN

Prospective descriptive case series.

SETTINGS

Urology clinic, Muhimbili Medical Centre, Dar es Salaam, Tanzania.

SUBJECTS

Patients with symptoms of urethral stricture subsequently radiologically demonstrated to have urethral stricture that was deemed treatable by OIU.

INTERVENTIONS

Evaluation included urethrography, renal biochemical profile and urethroscopy at the time of OIU. Patients with strictures no longer than 50 mm, no complete block or marked tortuousness, and no paraurethral sepsis were selected for OIU, urethral catheter for seven days followed by HUD) for one month.

RESULTS

During a follow up period of five to seventeen months (mean 10.1 months), only two out of twenty three patients (8.7%) showed clinical evidence of stricture recurrence. The remaining patients reported normal voiding.

CONCLUSION

This report suggests that HUD, a cost-free technique, is an effective method for preventing stricture recurrence after OIU. As follow up of these and subsequent patients continue, it is hoped that this not-so-well-known technique will undergo evaluation at other centres in our region.

Stenturia: An unusual manifestation of spontaneous ureteral stent fragmentation

Two patients presented with passage of worm-like stent fragments in the urine. The first had undergone attempted percutaneous removal of left renal calculus and ureteral stenting 4 months prior to presentation. The second had left-sided stent placement for obstructive anuria on account of bilateral renal calculi 3 months earlier. The stents had fragmented into multiple pieces over a mean indwelling time of only 3.5 months. Apart from calculus disease, both patients had documented urinary tract infection. Stent fragmentation is a relatively rare (0.3%) but major complication. However, spontaneous excretion of these fragments has not been hitherto reported. These cases of rapid stent disintegration highlight the need for closer monitoring of the indwelling stents, especially in patients with calculus disease and associated persistent infection. In such patients the stent should probably be changed within 3 months.

Transurethral resection of benign prostatic hyperplasia using a vaporizing resecting loop, UROloop

New electrosurgical instruments for the treatment of benign prostatic hyperplasia (BPH) have been developed during the past few years. We determined the efficacy and safety of transurethral prostatectomy (TUR-P) using a new electrosurgical device (UROloop) for the treatment of BPH. Twenty-four patients, with a mean age of 67.7 years, with BPH underwent TUR-P using the UROloop between April 1996 and March 1997. We evaluated the pre- and postoperative symptom scores and urodynamic parameters of the patients. The International Prostate Symptom Score (IPSS) was used for symptom scoring. The urodynamic parameters included peakflow rates (PFR) and postvoid residual urine (PVR). The average preoperative IPSS score for all patients was 15.4 +/- 1.4. The IPSS score was significantly improved to 4.3 +/- 0.24 at 12 weeks after the TUR-P (p = 0.0002). The average PFR was increased by 117% at 12 weeks postoperatively. The average preoperative PVR of 65.4 ml was reduced to 15.2 ml postoperatively. The changes in the urodynamic parameters were statistically significant. No severe complications were observed in the present study. The changes in the serum sodium and hemoglobin levels were small. This study revealed significantly sustained clinical improvement with minimal morbidity. The results of the present study also confirmed the usefulness of the new endoscopic treatment for BPH.

Use of contact laser crystal tip firing Nd:YAG to relieve urinary outflow obstruction in male neurogenic bladder patients

BACKGROUND AND OBJECTIVE

Endoscopic urologic procedures for transurethral prostatectomy (TURP), external sphincterotomy (TURS), bladder neck incision, and incising strictures using diathermy have resulted in excessive bleeding and risk of hyponatremia. This presentation is a review of a methodology developed to evaluate the use of contact laser crystal firing Nd:YAG laser. Details of the technique are presented.

RESULTS

A review of 129 patients following laser TURS with 34% of these patients also needing TURP and 29% of patients also requiring TUIP has been done. Following contact laser endoscopic surgery, the catheter was removed in 24 hours. There was minimal to nil haemorrhage perioperatively and secondary haemorrhage was absent.

CONCLUSIONS

The technique employing contact laser crystal provides an easy TURP, TURS, and stricture ablation. Follow up indicates durable results.