Comparison of the iliac, vaginal and umbilical graft extraction in robot-assisted laparoscopic living donor nephrectomy.

PURPOSE: To compare different extractions routes for robot-assisted living donor nephrectomy in terms of post-operative pain and renal function recovery. METHODS: Live donor kidney transplantation data from our institution were reviewed from November 2011 to March 2017. Postoperative pain was estimated using cumulative painkillers consumption. Variables were compared between the 3 groups with ANOVA for continuous data, χ2 test for categorial data. A survival analysis with Kaplan-Meier curve assessing time to transplant recipient nadir was performed to compare the renal function recovery. RESULTS: Sixty-three RLDN were performed (23 iliac, 23 vaginal and 17 umbilical extractions). There was no significant difference between the three groups in terms of operative time, blood lost, warm ischemia time, cumulative painkiller consumption and renal function recovery time. Postoperative complications for Umbilical, Vaginal and Iliac were, respectively, of 0, 3 and 1. No major difference was found between the 3 groups beside a slightly longer hospital stay in the iliac group. CONCLUSION: Iliac incision might impact post-operative pain with a moderate but significant longer hospital stay. Vaginal extraction is an option when cosmetic outcomes present a real demand. The three options appeared to be safe and should be discussed with the patient in regard of the surgeon experience.

Retrieved but not transplanted kidneys: how to limit the losses? A retrospective national study.

Despite the organ shortage, a significant number of deceased donor kidneys are retrieved but not transplanted (RNTK). This study aims to describe and analyze the main causes of potential grafts discard and to propose adequate solutions. We collected data from the Cristal database of the French Biomedicine Agency about RNTK over one year. Expert opinion was taken from urologists with extensive expertise in renal transplantation. They retrospectively analyzed each record to assess the appropriateness of each graft refusal and subsequent kidney discard. Of 252 kidneys were retrieved but not transplanted in France over one year. The main reasons for discard were vascular abnormalities in 43.7% (n = 110), suspicion of malignant tumor in 18.7% (n = 47), and severe histological lesions on preimplantation biopsy in 12.3% (n = 31). The reason for kidney refusal was undetermined in 4.8% (n = 12). Iatrogenic lesions were responsible for 26.2% (n = 66). Overall, 46.0% (n = 16) and 25.0% (n = 63) of the grafts were, respectively, properly and improperly denied, and the analysis was not possible in 29.0% (n = 73). In total, 36.9% of RNTK could have been transplanted. Reduction of iatrogenic lesions, improvement of microsurgical repair skills, and proper histological examination are necessary to reduce the number of RNTK. A prospective study applying the proposed principles is undoubtedly essential to complete this work.

Prostate Cancer awareness in the Lebanese population: a cross sectional national survey.

BACKGROUND: Prostate cancer (Pca) is the second most common cause of cancer among Lebanese men. Screening is an effective method to reduce prostate cancer mortality. This study assessed the knowledge, awareness, and screening practices among Lebanese population regarding Pca. METHODS: A cross-sectional national study over all the Lebanese governorates on 1558 persons was undergone. Information on Pca knowledge and attitudes towards screening was obtained using a semi structured questionnaire. Bivariate and binary logistic regression were used to assess relations between Pca knowledge and socio-demographic characteristics. RESULTS: The sample consisted of 1088 (69.8%) males and 470 (30.2%) females, with a mean age of 40 Y.O. Concerning early detection methods of Pca, its frequency, the ideal screening age, symptoms and curability of Pca, a significant difference (p < 0.05) was found when studying the following variables: the educational level (university level group having the highest percentage of correct answers), the individual monthly income (more correct answers were found with higher monthly income) and the age groups (most correct answers in the younger age groups). CONCLUSION: Our study points to the need of developing Pca prevention and education programs that should especially target older men, and people of low socioeconomic status and education in Lebanon. Such programs would increase awareness to Pca and screening, ultimately reducing the burden of advanced cancer through its early diagnosis.

Anatomical risk factors for spermatic cord torsion and their involvement in the choice of orchidopexy technique.

OBJECTIVE: We aim by this article to present a literature review on the anatomical risk factors for spermatic cord torsion and their involvement the different techniques of orchidopexy. MATERIALS AND METHODS: The literature review was conducted following PRISMA check-list, using PubMed database and the Mesh terms: testis, torsion, anomaly, orchidopexy. Techniques of surgical management provided by the EMC (French medico-surgical encyclopedia) were also used. RESULTS: Database research identified 500 articles, and 16 mores articles were added from the review of the references lists of relevant articles. At the end, 42 articles were useful for our review including 6 reviews, 5 cross-sectional studies, 14 cohorts, 10 case reports, 1 meta-analysis, 1 letter, and 5 experimental studies. High insertion of the tunica vaginalis, a long mesorchium, deficient attachment of the epididymis to the testis, and anomalies of the gubernaculum testis are the anatomical predispositions for spermatic cord torsion. After reduction of torsion, many surgical techniques for the fixation of the testis have been suggested including: conventional technique by triangulation with or without fasciotomy, window orchidopexy, scrotal pouch, and vaginal eversion with or without dartos fixation. CONCLUSION: The most common anatomical factor associated with spermatic cord torsion is the high insertion of the tunica vaginalis. Vaginal eversion with fixation to the dartos might be superior to other known techniques and seems promising to become standard.

EVALUATION OF MULTIDISCIPLINARY TEAM MEETINGS IN URO-ONCOLOGY.

OBJECTIVES: The objective of this study was to examine the impact of multidisciplinary team meetings on the management decisions for urological cancers. A pro- spective study was conducted. METHODS: The study popu- lation is cases presented to multidisciplinary teams at Notre- Dame de Secours University Medical Center between July 2012 and July 2014. Data was collected by a standard pro forma. RESULTS: 189 cases were presented in multidisci- plinary meetings during the study period. Results of this study showed that multidisciplinary team meetings change management decisions in 40.7% of cases. Change in man- agement decisions was mainly significant in testicular can- cer (57.1%), prostate cancer (42.7%) and bladder cancer (38.2%), with less important changes in renal cancer (33.3%). Prostate cancer cases with Gleason score 7 (51.7%) and bladder tumors with TNM ;t T2 (85.7%) were the most mod- ified in their respective groups. CONCLUSION: Multidiscipli- nary team meetings have a major impact in therapeutic de- cisions taken by urologists for newly diagnosed urological cancers.

Diagnosis and Management of Polyorchidism: A Case Report and Literature Review.

Polyorchidism, or supernumerary testis, is a rare congenital abnormality of the genitourinary system. In this paper, we present the case of triorchidism in a seven-year-old asymptomatic child with a suspect left scrotal mass detected on routine physical examination. Imaging studies revealed a third testicle in the left hemiscrotum, with comparable dimensions, signal intensity on MRI, and Doppler flow on ultrasound with the ipsilateral testis. We also discuss the clinical presentations, classifications, and current diagnostic and therapeutic strategies of this condition.

A Potential Protective Effect of Alcohol Consumption in Male Genital Lichen Sclerosus: A Case-Control Study.

Materials and Methods: A nested case-control study design was chosen. Subjects enrolled were adult male patients who had a circumcision between January 2010 and December 2020 at our university hospital, with a confirmed LSc diagnosis on pathology. Cases were matched with controls by age with a ratio of 1 : 1, all of whom were circumcised and had a negative pathology report. Data collection consisted of sociodemographic, behavioral, and past medical and familial history characteristics. Results: A total of 94 patients were enrolled. The mean age was 49.81 (±22.92) in the group of men with LSc. No significant differences in sociodemographic characteristics (age and BMI) were found between the two compared groups. Smoking cannot predict LSc as opposed to alcohol consumption, which we found to be a protective factor against the appearance of LSc (p=0.027). Men with LSc had significantly higher rates of diabetes (p=0.021) and hypertension (p=0.004). No associations were found between LSc and the presenting chief complaints, family history of LSc, and past penile trauma. Conclusion: In this study, we were able to compare multiple variables between 47 circumcised patients diagnosed with LSc and a control group. We found that LSc patients showed higher rates of diabetes and hypertension. A potential protective effect of alcohol consumption is to be explored in future projects with bigger sample sizes and higher statistical powers.

The "Cut-to-the-Light" Technique Laser Endoureterotomy for Complete Ureteral Obstruction Resurfaces! A New Application of an Old Technique.

Objective: To describe our new endoscopic approach in treating iatrogenic ureteral stenosis using the "cut-to-The-light" technique. Methods: Case of a 54 year-old female patient who underwent a right percutaneous nephrolithotomy to treat a staghorn calculus with two subsequent complimentary ureteroscopies complicated by a severe proximal ureteral obstruction. An antegrade flexible uretereroscope and a retrograde rigid ureteroscope were used to locate the stenosis. With the aid of a 365-µm Ho: YAG laser fiber (settings 0.4 J, 12 Hz), we managed to successfully create a small incision in the stenotic lesion, the rigid ureterscopy light was clearly seen by the antegrade flexible ureteroscope and a through-and-through guidewire was then placed, securing the ureter. Ureteral dilatation was then performed followed by a full thickness incision of the ureteral stenosis. A single 8Fr, 28 cm double J ureteral stent was finally placed after stone fragmentation. Results: The operating time was 200 mins. No blood loss. No fever or signs of UTI were seen shortly after the operation. The Foley catheter was successfully removed at day one post-op. The hospital stay was short of only 2 days. Conclusion: The "cut-to-the-light" technique is a new application in the arsenal of ureteral stricture treatment that has been scarcely described in the literature before. The use of this method seems to offer excellent outcomes thus demonstrating the importance of this minimally invasive technique as an alternative to conventional invasive methods used. We believe that studies with larger samples and longer follow up are needed in order to fully determine the benefits of this method and to assess and reveal its suitable application and its drawbacks.

[Thymoglobulin as induction treatment in kidney transplantants with low immunological risk: a Moroccan experience]. / La thymoglobuline en traitement d'induction chez les transplantés rénaux à faible risque immunologique: une expérience marocaine.

Introduction: Thymoglobulin® is a polyclonal antibody indicated for induction treatment in kidney transplantation. The purpose of this study is to estimate the effectiveness of Thymoglobulin® as induction treatment in kidney transplant patients with low immune risk. Methods: we conducted a retrospective study between January 2012 and September 2017. Patients with low immunological risk, defined as the absence of previous transplantation and donor-specific antibodies (DSA), were included and received Thymoglobulin® induction therapy. Demographic and clinical characteristics, biological parameters and post-renal transplant complications were studied. Results: we enrolled 55 kidney transplant patients with an average follow-up period of 38 ± 16 months. The average age of patients was 39,1 ± 12,1 years with a male predominance (58.2%). No patient had DSA prior to transplant. Cumulative dose of Thymoglobulin® was 4,26 ± 0,87 mg/kg, with an average duration of 5 ± 0,82 days. Lymphocyte depletion was maximal on the first day of infusion. Three patients had delayed graft function, at least one episode of bacterial infection in 56,4% of patients, 7 cases of CMV infections (12,7%) and 2 cases of CMV disease (3,6%). Graft survival rate was calculated for all patients with an average serum creatinine of 11,7 ± 3,6 mg/l during the last visit. Conclusion: although it is not indicated for first line treatment in patients with low immunological risk, Thymoglobulin® can nevertheless be prescribed at a lower dose, with similar efficacy and without exposure to a higher risk of rejection.

Low-intensity extracorporeal shock wave therapy for Peyronie's disease: a single-center experience.

The aim of this article is to assess the outcomes of a low-intensity extracorporeal shock wave therapy (LiESWT) protocol for the treatment of Peyronie's disease (PD). Patients treated for PD were prospectively recorded, and data were retrospectively reviewed. Age, characteristics of fibrous plaques, concomitant treatments, International Index of Erectile Function (IIEF-5), Lue score, and pain score on Likert scale were collected. Patients in acute phase of PD and an angulation of <40° were included. The protocol consisted of 6 weekly sessions of 4000 pulses each, applied from different directions, with a maximal power of 20 W and 8 Hz frequency. We included 39 patients (median age: 56.8 years, interquartile range [IQR]: 35.8-62.2 years). The median number of sessions received per patient was 7.2. After treatment, the median Lue score decreased from 6.8 initially to 3.3 (P = 0.003), the median Likert pain score dropped from 1.8 to 0.7 (P = 0.004), the median plaque size was reduced from 2 cm to 1.2 cm (P = 0.08), and the median penile curvature diminished from 31° to 17° (P = 0.07). On univariate and multivariate analysis, the only predictors of success were younger age (odds ratio [OR] = 0.95, P = 0.03 and OR = 0.91, P = 0.04, respectively) and concomitant use of phosphodiesterase-5 inhibitors (PDE5i; OR = 0.92, P = 0.02 and OR = 0.93, P = 0.01, respectively). LiESWT had a favorable impact on Lue score and notably penile pain, curvature, plaque size, and erectile function in patients treated for PD during the early inflammatory phase, with no side effects. Younger age and concomitant use of PDE5i were the only success predictors.

Long-term outcomes after penile prosthesis placement for the Management of Erectile Dysfunction: a single-Centre experience.

BACKGROUND: Penile prothesis (PP) is the gold-standard treatment of drug-refractory erectile dysfunction (ED). While postoperative outcomes have been widely described in the literature, there are few data about patient satisfaction and intraoperative events. We aimed to assess long-term patient satisfaction and perioperative outcomes after PP implantation in a single-centre cohort of unselected patients using validated scales. RESULTS: A total of 130 patients received a PP (median age: 62.5 years [IQR: 58-69]; median International Index of Erectile Function (IEEF-5) score: 6 [IQR: 5-7]). Median follow-up was 6.3 years [IQR: 4-9.4]. Thirty-two (24.6%) patients underwent surgical revision, of which 20 were PP removals (15.4%). Global PP survival rate was 84.6% and previous PP placement was a risk factor for PP removal (p = 0.02). There were six (4.6%) non-life-threatening intraoperative events including two which resulted in non-placement of a PP (1.5%). EAUiaic grade was 0 for 124 procedures (95.4%), 1 for four procedures (3.1%) and 2 for two procedures (1.5%). Of patients who still had their PP at the end of the study, 91 (80.5%) expressed satisfaction. CONCLUSIONS: PP implantation is a last-resort treatment for ED with a satisfactory outcome. PPs are well accepted by patients.

RéSUMé: CONTEXTE: La prothèse pénienne (PP) est. le traitement de référence de la dysfonction érectile (DE) réfractaire aux médicaments. Le but de ce travail est. d'évaluer les résultats à long terme chez les patients traités par prothèses péniennes (PP) dans notre hôpital. RéSULTATS: Un total de 130 patients a eu une pose de PP (âge médian: 62,5 ans [IQR: 58­69]; score médian de l'indice international de la fonction érectile (IEEF-5): 6 [IQR: 5­7]). Le suivi médian était de 6.3 ans [IQR: 4­9.4]. Trente-deux (24,6%) patients ont eu une reprise chirurgicale, dont 20 étaient des retraits de PP (15,4%). La durée de vie global des PP était de 84,6% et la pose antérieure de PP était un facteur de risque pour l'ablation (p = 0,02). Il y a eu six (4,6%) événements peropératoires ne mettant pas la vie en danger, dont deux qui ont empêché la pose de PP (1,5%). Le score EAUiaic était de 0 pour 124 procédures (95,4%), 1 pour quatre procédures (3,1%) et 2 pour deux procédures (1,5%). Parmi les patients qui avaient encore leur PP à la fin de l'étude, 91 (80,5%) ont exprimé leur satisfaction. CONCLUSIONS: L'implantation de PP est. un traitement de dernier recours pour la dysfonction érectile avec un résultat satisfaisant. Les PP sont bien acceptés par les patients.

Hard flaccid syndrome: state of current knowledge.

INTRODUCTION: Hard-flaccid syndrome is gaining increased interest among male sexual dysfunctions in the last years. It is poorly understood and defined. Most of the information comes from online forums. This paper is a review of current knowledge on the clinical presentation, diagnosis, pathophysiological mechanisms and treatments of this newly recognized condition. MATERIAL AND METHODS: A literature review was conducted on MEDLINE, CENTRAL, PASCAL databases and google scholar, using the terms: hard, flaccid, syndrome. The research identified 16 articles published between 2018 and February 2019. After reference lists review and duplicates removal, 7 full text references were eligible and useful for our review that follows PRISMA guidelines. RESULTS: The condition is acquired, chronic and painful. It is characterized by a constantly semi-rigid penis at the flaccid state and a loss in erectile rigidity. Patients have penile sensory changes, urinary symptoms, erectile dysfunction, pelvic floor muscles contraction and psychological distress. Symptoms are worse in standing position. The majority of the cases aged between their second and third decades. A traumatic injury at the base of an erect penis is the initial event. Neurovascular structures damage and subsequent sensory, muscular and vascular changes follow. Initial symptoms trigger emotional distress and reactional sympathetic stimulation that worsen symptoms. Diagnosis is based on patient's history. Imaging and blood tests are normal. Differential diagnosis includes high-flow priapism and non-erecting erections. A multimodal treatment has been so far the most beneficial strategy, consisting of behavioral modifications to reduce stress and decrease pelvic floor muscles contraction, evaluation and treatment of the associated psychological conditions, and medical therapy for pain control and the treatment of the associated erectile dysfunction. CONCLUSION: Hard-flaccid syndrome is poorly recognized in the daily clinical experience and not well defined. A multimodal approach seems so far the most efficient strategy for treatment. Additional evidence based studies with better quality are needed to define the exact pathophysiological mechanisms and subsequently more efficient therapeutic strategies.

CONTEXTE: Le syndrome de la détumescence rigide (STR) fait le sujet de plusieurs discussions en ligne concernant les dysfonctions sexuelles. Cette entité est. mal définie et peu reconnue. Nous présentons dans cet article une revue de la littérature sur la présentation clinique, le diagnostic, les mécanismes physiopathologiques et les stratégies de thérapeutique du STR. MATÉRIEL ET MÉTHODES: La revue de la littérature a été réalisée selon les recommandations PRISMA. En cherchant sur MEDLINE, CENTRAL, PASCAL et google scholar les termes « hard, flaccid et syndrome ¼, on a identifié 16 articles publiés entre 2018 et février 2019. Après la revue des références des articles et le triage des doublons, 7 articles ont été retenus. RÉSULTATS: Il s'agit d'une pathologie acquise, chronique et douloureuse, caractérisée par une verge semi rigide à l'état flaccide avec une perte de rigidité lors des érections. Les patients souffrent de troubles sensitifs péniens et érectiles avec une contracture permanente des muscles pelviens ainsi que des troubles urinaires et psychologiques. Les symptômes sont aggravés par la position debout. La notion de traumatisme de la base de la verge est. rapportée par la majorité des patients. Ce traumatisme semble entrainer une altération des structures nerveuses et vasculaires péniennes à l'origine des troubles sensitifs et érectiles. Ces derniers créent des troubles émotionnels avec une stimulation sympathique réactionnelle qui engendre une contraction surajoutée des muscles pelviens et qui empire les symptômes. Le diagnostic est. clinique et les examens paracliniques sont normaux. Le traitement est. multimodal, il englobe les thérapies comportementales, la prise en charge des altérations psychologiques et de la douleur, afin d'agir sur la contraction des muscles pelviens et sur le stress associé à la dysfonction érectile. CONCLUSION: Le syndrome de la détumescence rigide reste peu connu et mal défini dans la pratique clinique. Une approche thérapeutique multimodale parait la plus adéquate actuellement. Des études supplémentaires sont nécessaires afin de mieux cerner cette entité dans le but d'améliorer sa prise en charge.

Bilateral Laparoscopic Transperitoneal Pyelolithomy: Dare You Do This?

Introduction: The aim of this article is to describe our technique of bilateral laparoscopic pyelolithotomy (LP) in a 54-year-old patient with bilateral large stones of which one is a staghorn stone (SS). Case Presentation: The patient's legs were extended and spaced from each other; the table was tilted to the right and to the left in a way to use only five trocars for both sides. The calculi were delivered intact at the end of the procedure. Operating time was 208 minutes. Blood loss was 250 mL. Hospital stay was 3 days. Double-J stents were removed 4 weeks later. The patient was stone free with a stable serum creatinine. Conclusion: This case report is the first to describe a bilateral LP for large and SS. This procedure can minimize the postoperative morbidity and is associated with high stone-free rates. It is safe when done by expert surgeons, but further investigations are required to assess its reproducibility.

Large Cell Neuroendocrine Carcinoma of the Bladder with Adenocarcinomatous Component.

Large cell neuroendocrine carcinoma (LCNC) is one of the rarest types of bladder cancer occurring in <1%. Either pure or mixed with another component, it remains one of the most aggressive types of bladder cancer. We report a case of LCNC of the bladder with an adenocarcinomatous component. The patient was a 64-year-old smoker male, who presented for the first time with dysuria and hematuria. A bladder tumor invading the anterior and right lateral bladder walls was discovered, without any secondary localizations. Tumor biopsy showed an LCNC with adenocarcinomatous components. The patient was treated by recurrent tumor resections, chemotherapy, and radiotherapy. No improvement was noted despite close follow-up and adequate treatment. Neuroendocrine bladder tumor is known to have an aggressive, rapid, and disadvantageous evolution. Multiple case reports were published so far, and a recent review was conducted in March 2020 by Sanguedolce et al. (2020). More cases are needed to establish the best management plan for this type of tumor.

Renal Oncocytoma: An Algorithm for Diagnosis and Management.

Renal oncocytoma is an uncommon tumor that exhibits numerous features which are characteristic but not necessarily unique. Percutaneous biopsy is a safe method of diagnosis. However, differentiation from other tumor subtypes often requires sophisticated analysis and is not universally feasible. This is why, surgical management can be considered as a first-line treatment or after surveillance. Potential triggers for change in management are: tumor size >3 cm, stage progression, kinetics of size progression (>5 mm/y), and clinical change in patient or tumor factors. Long-term follow-up data are lacking and greater centralization should be considered to reach adequate management.

Management of proximal penile prosthetic cylindrical complications: a novel direct crural approach.

INTRODUCTION: Patients with proximal penile prosthetic cylindrical complications (PPPCC) can be treated with a direct crural technique without using the original traditional approach. In this article we present our novel direct crural approach for management of patients with PPPCC. MATERIALS AND METHODS: Between 2014 and 2019, data were retrospectively collected from 13 patients who underwent surgical revision using our novel direct crural approach for PPPCC. The procedure commences with identification of the affected zone. The patient is in a low lithotomy position. A 2-centimeter longitudinal incision is made directly over the affected site. Dissection is carried down through Colles' fascia, followed by a longitudinal incision through the tunica albuginea at the proximal part of the affected cylinder. Via the incision we can deliver out the cylinder and manage its problem. RESULTS: Mean operative time was 40 min. No intra or post-operative complications were reported. All patients (Mean age = 57) were discharged on the same day. Postoperative follow-up found correction of all existing deformities at month 1, 3 and 6. All patients were satisfied and reported less pain and faster recovery than the first procedure. CONCLUSION: Our technique, which can be used for all types of penile prosthesis, is both feasible and safe. It may simplify PPPCC revision by avoiding adhesions below the original incision, without jeopardizing the already implanted materials or the urethra. It may also improve patients' safety and satisfaction, by reducing iatrogenic injury and post-operative recovery time.