Genital Mutilation in Males.

PURPOSE OF THE REVIEW: Genital mutilation in males can range from minor injuries (cuts from a blade) to severe urological emergencies (testicular or penile amputation). Due to the rarity of these events, there is a lack of extensive reports, as most of the available literature is regarding single cases. Genital mutilation has been associated with psychotic and non-psychotic causes, psychiatric conditions, drug consumption, sexual practices, or even cultural or religious beliefs. It is crucial to perform a psychiatric evaluation of these patients to obtain the best therapeutic approach. This manuscript serves as a review of the currently available knowledge regarding male genital mutilation. RECENT FINDINGS: A great variety of reasons have been associated with genital mutilation. Previous authors have distinguished between those that present with a clear mental health precursor from cases with no psychotic background. Nevertheless, sometimes, it is difficult to make this distinction. Recently, reconstructive techniques for amputation cases have moved towards a microsurgical approach in order to improve outcomes. A holistic therapeutic approach must be performed to increase the chances of effective treatment. Close collaboration between urologists, psychiatrists, and emergency doctors is essential to ensure the best care for patients performing genital mutilation. Future publications must evaluate differences in treatment options and the impact that these have on the long-term well-being of patients undergoing genital self-mutilation.

Autonomous robots: a new reality in healthcare? A project by European Association of Urology-Young Academic Urologist group.

PURPOSE OF REVIEW: Artificial intelligence appears as a potential revolution in the general process of medical training, disease diagnosis and treatment. A novel disruptive technology of the 21st century will be 'learner' robots from artificial intelligence systems able to use all the combination of the available knowledge in medical repositories to give the best standard of care. RECENT FINDINGS: The autonomy level of robots depends on three factors: the complexity of the task; the environment in which the robot operates, and the required level of human-robot interaction. Autonomous robots in healthcare may be classified in delivery, nurse, and surgical robots. The increasing capability of robots to perform independent actions and complex tasks raises responsibility and accountability issues in a wide variety of application domains. Ethical analyses of these issues are underway and are mostly oriented toward the development of ethical policies requiring a law frame on robotic autonomous behaviors. SUMMARY: Autonomous robots have the potential to improve current medical practice offering a more secure, reliable, and reproducible medicine. Many advancements are required for these new technologies to be fully integrated. Furthermore, the ethical implications of these technologies are yet to be evaluated.

Efficacy and safety of two disposable circumcision suture devices for circumcision in adults: a prospective comparative multicenter study.

The objective of this study was to evaluate and compare efficacy and safety of two different Disposable circumcision suture devices (DCSDs). A prospective comparative non-randomized multicenter study was performed between November 2019 and February 2023. Patients underwent circumcision using a DCSD (CircCurerTM or the ZSR® device) according to the surgeon preference and device availability. A total of 378 patients were circumcised; 184 using CircCurerTM and 194 patients using ZSR®. No differences in baseline characteristics were observed. CircCurer and ZSR Groups showed similar rates of operative time (7.7 ±2.1 vs 7.3 ±2.0 min), surgical site infection (1.1% Vs 1.5%), edema (13% Vs 8.2%), hematomas (2.7% Vs 1.1%), and postoperative pain (2.5 Vs 2.0 points). ZSR Group had a significantly higher rate of clip fallout (62.9% Vs 38%, p < 0.001). At 2 months, patients of both groups reported a median satisfaction of 9 (8-9) points. Main limitation consist in non-randomized study. DCSDs seem to be effective and safe, with short operative times, uncommon and mild complications, and high patient satisfaction. ZSR® device has a higher rate of spontaneous staple dropout.

[Analysis of renal tumor size as a predictive factor of oncological aggressiveness.] / Análisis del tamaño del tumor renal como factor predictivo de agresividad oncológica.

INTRODUCTION: The increased incidenceof diagnosis of kidney tumours has driveninvestigation in the area. It is known that the risk ofmalignancy is correlated with tumour size, but thereare still no specific and objective parameters to characterizethe degree of aggressiveness and to be ableto guide a treatment reliably. OBJECTIVE: To identify the relationship betweenrenal tumour size and the incidence of tumour aggressivecharacteristics. PATIENTS AND METHODS: A retrospective analysisof our series of renal cancers operated between 1998and 2018 was performed. The specific and cumulativeincidence of aggressive characteristics was studied.The following where considered as aggressive characteristics:Presence of sarcomatoid or epidermoiddifferentiation, tumour necrosis, stage pT3-4, histologicalhigh grade (3-4) and the presence of histologicalaggressive variants. RESULTS: A total of 651 patients that had undergonerenal mass surgery were analysed. In tumours below2 cm the appearance of aggressive characteristicsoccurred in less than 5%. For renal masses greaterthan 2 cm, each centimetre increase correlated with arise in cumulative incidence of 2-3% for each characteristicstudied. CONCLUSIONS: In tumours below 2cm and patientswith significant comorbidities active surveillance maybe a reliable alternative to surgery.

INTRODUCCIÓN: El aumento de incidenciade diagnóstico de tumores renales ha conllevadoun mayor estudio y conocimiento de los mismos.Se conoce que el riesgo de malignidad se correlacionacon el tamaño tumoral, pero seguimos sin tener parámetrosespecíficos y objetivos para caracterizar elgrado de agresividad de los mismos y poder orientarun tratamiento de forma fiable. OBJETIVO: Identificar la relación que existe entre eltamaño tumoral y la incidencia de características deagresividad.MATERIAL Y MÉTODOS: Análisis retrospectivo denuestra serie de cáncer renal intervenido quirúrgicamenteen el periodo entre 1998 y 2018. Se estudia laincidencia específica y acumulada de las característicasde agresividad en dichas lesiones y su relación conel tamaño tumoral. Se consideraron característicasde agresividad: la presencia diferenciación sarcomatoiode epidermoide, necrosis tumoral, estadio pT3-4,grado histológico alto (3-4) y la presencia de variantesde histología agresiva. RESULTADOS: Se analizan un total de 651 pacientesintervenidos por cáncer renal. En tumores por debajode 2 cm la aparición de características de agresividadse observó en menos del 5%. A partir de ese tamaño, laincidencia acumulada se incrementa en un 2-3% paracada característica con cada centímetro que aumentael tamaño tumoral. CONCLUSIONES: Este análisis demuestra que conformeaumenta el tamaño de los tumores renales, aumentala incidencia de características de agresividadde los mismos. En tumores por debajo de 2 cm y pacientescon comorbilidades importantes la vigilanciaactiva puede ser una alternativa con cierta seguridad.

Repair of Traumatic Urethral Strictures: La Paz University Hospital Experience.

INTRODUCTION: The management of traumatic urethral strictures remains a challenge for urologists. Alteration of the pelvic anatomy and the significant fibrosis generated by the trauma make surgical repair complex. In most cases, the existing defect between the urethral ends is small, and the ideal treatment is end-to-end perineal urethroplasty. Cases of extensive strictures that are left with long gap defects may require the use of different sequential maneuvers to achieve a tension-free anastomosis. OBJECTIVE: To describe the experience at our center with urethral strictures induced by closed perineal trauma. MATERIALS AND METHODS: A retrospective analysis of 116 patients who underwent urethroplasty for urethral stricture after blunt perineal trauma at our center between 1965 and 2020 was conducted. Demographic data, date, mechanism of action of the trauma, emergency management, previous urethral interventions, surgical technique carried out in our center, complications, presence of erectile dysfunction, and urinary incontinence were collected. RESULTS: 82 patients (70.7%) presented with pelvic fractures. The most frequent etiology of trauma was traffic accidents (68%), followed by crushing injuries (24%). Suprapubic cystostomy was placed in 50.2% of patients, and urethral realignment was performed in 25.3%. The mean stricture length was 2.2 cm, affecting mostly the membranous urethra (67%). During surgery, it was necessary to perform crural separation in 61.5% and partial pubectomy in 18.8% of the cases. Erectile dysfunction developed after trauma in 40.5% of cases, while new erectile dysfunction was noted in 4.3% of patients after surgery. Surgery was successful in 91.3% of cases, with a median follow-up of 16 (6-47) months. CONCLUSION: Delayed anastomotic urethroplasty offers a high success rate in traumatic urethral strictures.

Organ-sparing cystectomy techniques: Functional and oncological outcomes, review and current recommendations.

INTRODUCTION: With increasing survival from bladder cancer, quality of life, should be one of the main goals following radical cystectomy and bilateral pelvic lymph node dissection (PLND). This techniqueis associated with significant morbidity, which may have a critical effect on quality of life. Concerns about functional outcomes, such as continence, potency, and sexual function in women, play a role in decision making for urologists and younger patients with muscle-invasive bladder cancer. Several modifications to the classic radical cystectomy technique, include preservation of genital or pelvic organs, developing in the improvement of postoperative continence, potency rates and sexual functionin female patients. OBJECTIVE: This review summarizes the organ-sparing cystectomy techniques and its functional and oncological outcomes. EVIDENCE ACQUISITION: A PubMed-based literature search was conducted up to April 2020. We selected the most recent and relevant original articles, metanalysis and reviews that have provided relevant information to guide organ-sparing cystectomy techniques and its functional and oncological outcomes. EVIDENCE SYNTHESIS: In this review, we discuss selection criteria for male and female patients, organ-sparing cystectomy surgical techniques and its functional and oncological outcomes. CONCLUSIONS: Radical cystectomy is associated with significant morbidity, which may have a critical effect on quality of life. Preservation of genital or pelvic organsin men and women, yield better sexual outcomes compared to radical cystectomy without compromising oncological outcomes in well selected patients. But no one of these techniques can be recommended over the classical standard radical cystectomy. Large-scale of prospective and multi-institutional studies are needed to conclude which patients are suitable for these techniques.

INTRODUCCIÓN: Con el aumento de la supervivencia del cáncer de vejiga, la calidad de vida debe ser uno de los objetivos principales después de la cistectomía radical y linfadenectomía pélvica (LNP). Esta técnica está asociada con una morbilidad significativa, que puede tener un efecto crítico en la calidad de vida. El interés sobre los resultados funcionales, como la continencia, la potencia y la función sexual en las mujeres, juegan un papel en la toma de decisiones para los urólogos y pacientes jóvenes con cáncer vesical musculo infiltrante. Varias modificaciones a la técnica clásica de cistectomía radical incluyen la preservación de los órganos genitales o pélvicos, desarrollando mejoría de la continencia postoperatoria, la potencia y función sexual femenina.OBJETIVO: Esta revisión resume las técnicas de cistectomía con preservación de órganos y sus resultados funcionales y oncológicos.ADQUISICIÓN DE EVIDENCIA: Se realizó una búsqueda bibliográfica en PubMed hasta Abril 2020. Seleccionamos los artículos originales retrospectivos y prospectivos, revisiones sistemáticas, revisiones bibliográficas más recientes y relevantes que han proporcionado información de técnicas de cistectomía con conservación de órganos y sus resultados funcionales y oncológicos.SÍNTESIS DE EVIDENCIA: En esta revisión, discutimos los criterios de selección de pacientes masculinos y femeninos, las técnicas quirúrgicas de cistectomía con preservación de órganos y sus resultados funcionales y oncológicos.CONCLUSIONES: La cistectomía radical se asocia con una morbilidad significativa, que puede tener un efecto crítico en la calidad de vida. La preservación de los órganos genitales o pélvicos en hombres y mujeres produce mejores resultados sexuales en comparación con la cistectomía radical sin comprometer los resultados oncológicos en pacientes bien seleccionados. Pero ninguna de estas técnicas se puede recomendar sobre la cistectomía radical estándar clásica. Se necesitan estudios prospectivos y multiinstitucionales a gran escala para concluir qué pacientes son adecuados para estas técnicas.

Immunotherapy toxicity. Diagnosis and treatment.

Anti CTLA-4, anti PD-L1 and anti PD-1immune check point inhibitors (ICI) down regulate natural inhibitory pathways of the immune system, in turn increasing tumour surveillance and elimination. Cancer treatment through immune regulation has revolutionised many cancer therapies. However, these new treatments have also brought unique immune related adverse events (irAEs). OBJECTIVE: This paper presents a review of the available knowledge regarding irAE grading, incidence, diagnosis and management, serving as a clinical aid forall clinicians involved with ICI therapy. EVIDENCE ACQUISITION: A comprehensive English-language literature research of original and review articles in the Medline database until June 2020 has been carried out, using the MeSH terms: "immune checkpoint inhibitor toxicities" and "immune related adverseevent". CONCLUSIONS: Further research should aim to investigate if the greater effect of combining ICI treatments issufficient to justify the increased risk of complications, as well as to identify specific subgroups that will benefit the most from these.

Los fármacos anti CTLA-4, anti PD-L1 y antiPD-1 inhiben vías inhibidoras del sistema inmunitario, consiguiendo una vigilancia y eliminación de células tumorales aumentada. El uso de terapias de regulación inmune ha revolucionado el manejo de muchos cánceres. Sin embargo, estos tratamientos también han traído una nueva serie de eventos adversos relacionados conel sistema inmune.OBJETIVO: Este artículo presenta una revisión de los conocimientos disponibles sobre la clasificación, incidencia, diagnóstico y mantenimiento de los efectos adversos relacionados con el sistema inmune, de manera que pueda servir como una ayuda clínica para todos los médicos involucrados en las terapias inmunes.ADQUISICIÓN DE EVIDENCIA: Realizamos una búsqueda bibliográfica exhaustiva de la literatura en inglés sobre artículos originales y de revisión utilizando la base de datos Medline hasta junio de 2020, utilizando los términos MeSH: "toxicidades del inhibidor del punto de control inmunitario" y "evento adverso relacionado con el sistema inmunitario". CONCLUSIONES: En el futuro se debe investigar si el mayor riesgo de complicaciones ocasionado por las terapias inmunomoduladores de combinación está justificado por su mayor efecto terapéutico, debiéndose igualmente identificar subgrupos de pacientes que más pueden beneficiar.

Análisis del tamaño del tumor renal como factor predictivo de agresividad Oncológica / Analysis of renal tumor size as a predictive factor of oncological aggressiveness

INTRODUCCIÓN: El aumento de incidencia de diagnóstico de tumores renales ha conllevado un mayor estudio y conocimiento de los mismos.Se conoce que el riesgo de malignidad se correlacionacon el tamaño tumoral, pero seguimos sin tener parámetros específicos y objetivos para caracterizar elgrado de agresividad de los mismos y poder orientarun tratamiento de forma fiable.OBJETIVO: Identificar la relación que existe entre eltamaño tumoral y la incidencia de características deagresividad.MATERIAL Y MÉTODOS: Análisis retrospectivo denuestra serie de cáncer renal intervenido quirúrgicamente en el periodo entre 1998 y 2018. Se estudia laincidencia específica y acumulada de las características de agresividad en dichas lesiones y su relación conel tamaño tumoral. Se consideraron característicasde agresividad: la presencia diferenciación sarcomatoiode, epidermoide, necrosis tumoral, estadio pT3-4,grado histológico alto (3-4) y la presencia de variantesde histología agresiva.RESULTADOS: Se analizan un total de 651 pacientesintervenidos por cáncer renal. En tumores por debajode 2 cm la aparición de características de agresividadse observó en menos del 5%. A partir de ese tamaño, laincidencia acumulada se incrementa en un 2-3% paracada característica con cada centímetro que aumentael tamaño tumoral.CONCLUSIONES: Este análisis demuestra que conforme aumenta el tamaño de los tumores renales, aumenta la incidencia de características de agresividadde los mismos. En tumores por debajo de 2 cm y pacientes con comorbilidades importantes la vigilanciaactiva puede ser una alternativa con cierta seguridad. (AU)

INTRODUCTION: The increased incidence of diagnosis of kidney tumours has driveninvestigation in the area. It is known that the risk ofmalignancy is correlated with tumour size, but thereare still no specific and objective parameters to characterize the degree of aggressiveness and to be ableto guide a treatment reliably. OBJECTIVE: To identify the relationship betweenrenal tumour size and the incidence of tumour aggressive characteristics.PATIENTS AND METHODS: A retrospective analysisof our series of renal cancers operated between 1998and 2018 was performed. The specific and cumulativeincidence of aggressive characteristics was studied.The following where considered as aggressive characteristics: Presence of sarcomatoid or epidermoiddifferentiation, tumour necrosis, stage pT3-4, histological high grade (3-4) and the presence of histologicalaggressive variants.RESULTS: A total of 651 patients that had undergone renal mass surgery were analysed. In tumours below 2 cm the appearance of aggressive characteristicsoccurred in less than 5%. For renal masses greaterthan 2 cm, each centimetre increase correlated with arise in cumulative incidence of 2-3% for each characteristic studied.CONCLUSIONS: In tumours below 2cm and patientswith significant comorbidities active surveillance maybe a reliable alternative to surgery. (AU)

Organ-sparing cystectomy techniques: Functional and oncological outcomes, review and current recommendations / Técnicas de cistectomía con preservación de órganos: Resultados funcionales y oncológicos. Revisión y recomendaciones actuales

INTRODUCTION: With increasing survival from bladder cancer, quality of life, should be one of the main goals following radical cystectomy and bilateral pelvic lymph node dissection (PLND). This technique is associated with significant morbidity, which may have a critical effect on quality of life. Concerns about functional outcomes, such as continence, potency, and sexual function in women, play a role in decision making for urologists and younger patients with muscle-invasive bladder cancer. Several modifications to the classic radical cystectomy technique, include preservation of genital or pelvic organs, developing in the improvement of postoperative continence, potency rates and sexual function in female patients. OBJECTIVE: This review summarizes the organ-sparing cystectomy techniques and its functional and oncological outcomes. EVIDENCE ACQUISITION: A PubMed-based literature search was conducted up to April 2020. We selected the most recent and relevant original articles, metanalysis and reviews that have provided relevant information to guide organ-sparing cystectomy techniques and its functional and oncological outcomes. EVIDENCE SYNTHESIS: In this review, we discuss selection criteria for male and female patients, organ-sparing cystectomy surgical techniques and its functional and oncological outcomes. CONCLUSIONS: Radical cystectomy is associated with significant morbidity, which may have a critical effect on quality of life. Preservation of genital or pelvic organs in men and women, yield better sexual outcomes compared to radical cystectomy without compromising oncological outcomes in well selected patients. But no one of these techniques can be recommended over the classical standard radical cystectomy. Large-scale of prospective and multi-institutional studies are needed to conclude which patients are suitable for these techniques

INTRODUCCIÓN: Con el aumento de la supervivencia del cáncer de vejiga, la calidad de vida debe ser uno de los objetivos principales después de la cistectomía radical y linfadenectomía pélvica (LNP). Esta técnica está asociada con una morbilidad significativa, que puede tener un efecto crítico en la calidad de vida. El interés sobre los resultados funcionales, como la continencia, la potencia y la función sexual en las mujeres, juegan un papel en la toma de decisiones para los urólogos y pacientes jóvenes con cáncer vesical musculo infiltrante. Varias modificaciones a la técnica clásica de cistectomía radical incluyen la preservación de los órganos genitales o pélvicos, desarrollando mejoría de la continencia postoperatoria, la potencia y función sexual femenina. OBJETIVO: Esta revisión resume las técnicas de cistectomía con preservación de órganos y sus resultados funcionales y oncológicos. ADQUISICIÓN DE EVIDENCIA: Se realizó una búsqueda bibliográfica en PubMed hasta Abril 2020. Seleccionamos los artículos originales retrospectivos y prospectivos, revisiones sistemáticas, revisiones bibliográficas más recientes y relevantes que han proporcionado información de técnicas de cistectomía con conservación de órganos y sus resultados funcionales y oncológicos. SÍNTESIS DE EVIDENCIA: En esta revisión, discutimos los criterios de selección de pacientes masculinos y femeninos, las técnicas quirúrgicas de cistectomía con preservación de órganos y sus resultados funcionales y oncológicos. CONCLUSIONES: La cistectomía radical se asocia con una morbilidad significativa, que puede tener un efecto crítico en la calidad de vida. La preservación de los órganos genitales o pélvicos en hombres y mujeres produce mejores resultados sexuales en comparación con la cistectomía radical sin comprometer los resultados oncológicos en pacientes bien seleccionados. Pero ninguna de estas técnicas se puede recomendar sobre la cistectomía radical estándar clásica. Se necesitan estudios prospectivos y multiinstitucionales a gran escala para concluir qué pacientes son adecuados para estas técnicas

Immunotherapy toxicity. Diagnosis and treatment / Toxicidad de la immunoterapia. Diagnóstico y tratamiento

Anti CTLA-4, anti PD-L1 and anti PD-1 immune check point inhibitors (ICI) downregulate natural inhibitory pathways of the immune system, in turn increasing tumour surveillance and elimination. Cancer treatment through immune regulation has revolutionized many cancer therapies. However, these new treatments have also brought unique immune related adverse events (irAEs). OBJECTIVE: This paper presents a review of the available knowledge regarding irAE grading, incidence, diagnosis and management, serving as a clinical aid for all clinicians involved with ICI therapy. EVIDENCE ACQUISITION: A comprehensive English-language literature research of original and review articles in the Medline database until June 2020 has been carried out, using the MeSH terms: "immune check point inhibitor toxicities" and "immune related adverse event". CONCLUSIONS: Further research should aim to investigate if the greater effect of combining ICI treatments is sufficient to justify the increased risk of complications, as well as to identify specific subgroups that will benefit the most from these

Los fármacos anti CTLA-4, anti PD-L1 y anti PD-1 inhiben vías inhibidoras del sistema inmunitario, consiguiendo una vigilancia y eliminación de células tumorales aumentada. El uso de terapias de regulación inmune ha revolucionado el manejo de muchos cánceres. Sin embargo, estos tratamientos también han traído una nueva serie de eventos adversos relacionados con el sistema inmune. OBJETIVO: Este artículo presenta una revisión de los conocimientos disponibles sobre la clasificación, incidencia, diagnóstico y mantenimiento de los efectos adversos relacionados con el sistema inmune, de manera que pueda servir como una ayuda clínica para todos los médicos involucrados en las terapias inmunes. ADQUISICIÓN DE EVIDENCIA: Realizamos una búsqueda bibliográfica exhaustiva de la literatura en inglés sobre artículos originales y de revisión utilizando la base de datos Medline hasta junio de 2020, utilizando los términos MeSH: "toxicidades del inhibidor del punto de control inmunitario" y "evento adverso relacionado con el sistema inmunitario". CONCLUSIONES: En el futuro se debe investigar si el mayor riesgo de complicaciones ocasionado por las terapias inmunomoduladores de combinación está justificado por su mayor efecto terapéutico, debiéndose igualmente identificar subgrupos de pacientes que más pueden beneficiar