Safety and efficacy of tixagevimab/cilgavimab for pre-exposure prophylaxis in kidney transplant recipients: a multicenter retrospective cohort study.

BACKGROUND: Immunocompromised patients show an impaired vaccine response and remain at high risk of severe COVID-19, despite vaccination. Neutralizing monoclonal antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been developed for prophylaxis and treatment. The combination tixagevimab/cilgavimab (AZD7442) has been authorized for emergency use as pre-exposure prophylaxis for COVID-19, but data on safety and efficacy in kidney transplant recipients during the Omicron period are limited. METHODS: We conducted a multicenter retrospective cohort study including 253 kidney transplant recipients, of whom 98 were treated with tixagevimab/cilgavimab 150 mg/150 mg and 155 who received only four doses of the BNT162b2 mRNA vaccine. RESULTS: Only 13.3% of patients developed SARS-CoV-2 infection after the administration of tixagevimab/cilgavimab; in comparison, 34.2% of patients had been infected after the fourth dose of vaccine (p = 0.00013). Most infected patients in the AZD7442 group remained asymptomatic (92.3% vs 54.7%), 7.7% had mild symptoms and none had severe disease, need for hospitalization or died, while in the control group, 9.4% of patients had moderate or severe disease (p = 0.04). Using Kaplan-Meier curves we demonstrated that the controls presented early infection compared to the AZD7442 group (p = 0.000014). No changes in eGFR or proteinuria, assessed before and after the administration, were observed. CONCLUSIONS: In conclusion, our study showed that tixagevimab/cilgavimab 150/150 mg is effective and safe in preventing infection and severe disease when administered to patients with weak or no response to COVID-19 vaccine.

Ischemia-Reperfusion Injury in Kidney Transplantation: Mechanisms and Potential Therapeutic Targets.

Kidney transplantation offers a longer life expectancy and a better quality of life than dialysis to patients with end-stage kidney disease. Ischemia-reperfusion injury (IRI) is thought to be a cornerstone in delayed or reduced graft function and increases the risk of rejection by triggering the immunogenicity of the organ. IRI is an unavoidable event that happens when the blood supply is temporarily reduced and then restored to an organ. IRI is the result of several biological pathways, such as transcriptional reprogramming, apoptosis and necrosis, innate and adaptive immune responses, and endothelial dysfunction. Tubular cells mostly depend on fatty acid (FA) ß-oxidation for energy production since more ATP molecules are yielded per substrate molecule than glucose oxidation. Upon ischemia-reperfusion damage, the innate and adaptive immune system activates to achieve tissue clearance and repair. Several cells, cytokines, enzymes, receptors, and ligands are known to take part in these events. The complement cascade might start even before organ procurement in deceased donors. However, additional experimental and clinical data are required to better understand the pathogenic events that take place during this complex process.

Robot-assisted buccal mucosal graft ureteroplasty for the treatment of proximal ureteral strictures.

The authors describe their initial experience with robot-assisted buccal mucosal graft (BMG) ureteroplasty for the management of proximal ureteral strictures.

Sacral Neuromodulation: Device Improvement and Current Applications in Urology.

Sacral neuromodulation (SNM) offers a therapeutic approach to urological patients suffering from idiopathic overactive bladder (OAB) syndrome, with or without incontinence and non-obstructive urinary retention (NOR), who are not responding to or are not compliant with conservative or medical therapies. The exact mechanism of action of SNM is not fully understood but modulation of the spinal cord reflexes and brain networks by peripheral afferents is regarded as the main pathway. Over the years, surgical techniques improved, leading to the development of the modern two-stage implantation technique. The quadripolar lead is positioned percutaneously under fluoroscopy guidance through the third sacral foramen following the trajectory of S3. The procedure can be performed under local or general anesthesia with the patient in prone position. Current applications of sacral neuromodulation in urology are increasing thanks to the recent improvements of the devices that make this a valuable option not only in conditions such as overactive bladder and non-obstructing urinary retention but also neurogenic lower urinary tract dysfunction.

The Role of MUC1 in Renal Cell Carcinoma.

Mucins are a family of high-molecular-weight glycoproteins. MUC1 is widely studied for its role in distinct types of cancers. In many human epithelial malignancies, MUC1 is frequently overexpressed, and its intracellular activities are crucial for cell biology. MUC1 overexpression can enhance cancer cell proliferation by modulating cell metabolism. When epithelial cells lose their tight connections, due to the loss of polarity, the mucins become dispersed on both sides of the epithelial membrane, leading to an abnormal mucin interactome with the membrane. Tumor-related MUC1 exhibits certain features, such as loss of apical localization and aberrant glycosylation that might cause the formation of tumor-related antigen epitopes. Renal cell carcinoma (RCC) accounts for approximately 3% of adult malignancies and it is the most common kidney cancer. The exact role of MUC1 in this tumor is unknown. Evidence suggests that it may play a role in several oncogenic pathways, including proliferation, metabolic reprogramming, chemoresistance, and angiogenesis. The purpose of this review is to explore the role of MUC1 and the meaning of its overexpression in epithelial tumors and in particular in RCC.

Kinetics of humoral immune response and severity of infection after three doses of SARS-CoV-2 mRNA vaccine in a large cohort of kidney transplant recipients.

BACKGROUND: COVID-19 in kidney transplant recipients is associated with high morbidity and mortality. In this study we aimed to evaluate: (i) the seroconversion rate after BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 vaccine, (ii) factors associated with humoral response, (iii) clinical outcome of COVID-19 in kidney transplanted patients. METHODS: We enrolled a cohort of 743 kidney transplant recipients followed up from March 2020 until April 2022. A subset of 336 patients, who received three-doses of SARS-CoV-2 vaccine, was analyzed in terms of kinetics of humoral immune response and compared to a control group of 94 healthcare workers. Antibody response was tested before vaccination (T0), 15 and 90 days after the second dose (T1 and T2), on the day of the third dose (T3) and one month after the third dose (T4). RESULTS: We observed that 66 out of 743 subjects had COVID-19 infection pre-vaccination: 65.2% had severe symptoms, 27.3% were hospitalized (9 deaths), none were asymptomatic. After three doses, 51 patients had COVID-19 infection, 60.8% were asymptomatic, 27.5% reported mild symptoms, 3.9% showed severe symptoms, 7.8% were hospitalized (2 deaths). In the subset of 336 vaccinated patients, an antibody level > 0.8 U/ml was detected at T1, that increased at T2 and T3, peaking at T4. Independent factors associated with a negative antibody titer at T4 were decreasing estimated glomerular filtration rate, time from transplantation, and antimetabolites (all p < 0.001) and age (p = 0.007). CONCLUSIONS: The kinetics of humoral response after three doses of vaccine in kidney transplant patients is characterized by a late but effective immune response against SARS-CoV-2, reducing morbidity and mortality.

Renal Cell Carcinoma as a Metabolic Disease: An Update on Main Pathways, Potential Biomarkers, and Therapeutic Targets.

Clear cell renal cell carcinoma (ccRCC) is the most frequent histological kidney cancer subtype. Over the last decade, significant progress has been made in identifying the genetic and metabolic alterations driving ccRCC development. In particular, an integrated approach using transcriptomics, metabolomics, and lipidomics has led to a better understanding of ccRCC as a metabolic disease. The metabolic profiling of this cancer could help define and predict its behavior in terms of aggressiveness, prognosis, and therapeutic responsiveness, and would be an innovative strategy for choosing the optimal therapy for a specific patient. This review article describes the current state-of-the-art in research on ccRCC metabolic pathways and potential therapeutic applications. In addition, the clinical implication of pharmacometabolomic intervention is analyzed, which represents a new field for novel stage-related and patient-tailored strategies according to the specific susceptibility to new classes of drugs.

Novel Insights into Autophagy and Prostate Cancer: A Comprehensive Review.

Autophagy is a complex process involved in several cell activities, including tissue growth, differentiation, metabolic modulation, and cancer development. In prostate cancer, autophagy has a pivotal role in the regulation of apoptosis and disease progression. Several molecular pathways are involved, including PI3K/AKT/mTOR. However, depending on the cellular context, autophagy may play either a detrimental or a protective role in prostate cancer. For this purpose, current evidence has investigated how autophagy interacts within these complex interactions. In this article, we discuss novel findings about autophagic machinery in order to better understand the therapeutic response and the chemotherapy resistance of prostate cancer. Autophagic-modulation drugs have been employed in clinical trials to regulate autophagy, aiming to improve the response to chemotherapy or to anti-cancer treatments. Furthermore, the genetic signature of autophagy has been found to have a potential means to stratify prostate cancer aggressiveness. Unfortunately, stronger evidence is needed to better understand this field, and the application of these findings in clinical practice still remains poorly feasible.

Management of severe complications following penile surgery for erectile dysfunction and Peyronie disease: Three case reports.

RATIONALE: Erectile dysfunction (ED) and Peyronie's disease (PD) are conditions commonly observed in andrology. Despite the surgical refinement and the technical improvement in this field, even in expert hands, detrimental consequences have been reported and it can be related to patient's comorbidities or misconduct in the postoperative period. In this article we report anecdotal cases of severe complications following penile surgery for ED and PD in high volume centers, describe the strategies adopted to treat it and discuss the options that would have helped preventing these events. PATIENTS' CONCERNS: The first case describes a patient with history of ED and PD causing penile shortening and a slight dorsal deviation of penile shaft. In the second case it is described a corporeal necrosis and urethral fistula following inflatable penile prosthesis implant. In the last case it is described the migration of reservoir into the abdomen after inflatable penile prosthesis implantation post-radical prostatectomy. DIAGNOSIS: All 3 patients were investigated with a penile doppler ultrasound with PGE1 intracorporeal injection for ED and PD diagnosis. An abdominal computed tomography scan and magnetic resonance imaging were ordered for patient of case three. INTERVENTIONS: The patients underwent different combined procedures depending on the case and including: glansectomy, penile prosthesis implantation associated with a penile elongation with double dorsal-ventral patch graft ("sliding technique"), penile urethroplasty with buccal mucosa graft, and laparotomy for reservoir removal. OUTCOMES: No further serious complications were reported after the procedures described. LESSONS: Penile surgery in patients with concomitant PD and systemic comorbidities can be at high risk of complications. As shown in this series there are possible dramatic evolution of these complications that may cause irreversible consequences to the patient. For this reason, a dedicated surgical and nursing team is necessary to reduce the chances that it happens. When this event occurs, a team trained in their management can improve the patient outcome.

Penile prosthesis implant for primary erectile dysfunction in patient with Klippel-Trenaunay syndrome complicated by consumptive coagulopathy: A case report.

RATIONALE: Klippel-Trenaunay syndrome (KTS) is a congenital disorder characterized by cutaneous port wine capillary malformations, varicose veins with hemihypertrophy of soft tissue and bone.Pelvic and retroperitoneal vascular malformations have been described up to the 30% of patients with KTS while hemangiomas of the urinary tract have been reported in 6% PATIENT CONCERNS:: A 30-year-old man with KTS was referred to our center for primary erectile dysfunction (ED) associated with varicosities of unusual distribution and asymmetry of the lower limbs. Furthermore, he suffered from hypertension and autosomal dominant polycystic kidney disease.During penile prosthesis implantation, a significant intraoperative bleeding (1 liter) due to large scrotal venous malformations and profuse bleeding from both corpora was recorded. One month later, the day after the first prosthesis training session, the patient returned with swelling in the penoscrotal region. A large inguino-scrotal hematoma was drained. There was a complete bilateral dehiscence of corpora cavernosa with a spread venous bleeding in the scrotum. DIAGNOSES: CT scan showed hypertrophy of the right hypogastric artery with severe vascular malformations: the right pudendal artery was massively dilated with early visualization of venous drainage without evidence of arteriovenous fistulae; regular bulbocavernous capillary blush; right upper gluteus artery hypertrophic and dilated. Multiple twisting and aneurysms of the right internal pudenda artery were bleeding from multiple points. Cystoscopy showed a fistula between the proximal urethra and the penoscrotal dartos. Coagulation tests revealed the presence of factor XIII deficiency INTERVENTIONS:: The patient underwent several procedures including percutaneous scleroembolization of the internal pudendal arteries, removal of the penile implant, recombinant factor XIII (FXIII) administration, and cord blood platelet gel application. OUTCOMES: The patient was discharged after almost 3 months in hospital, hemodynamically stable. LESSONS: Experience regarding management of ED in KTS patient is limited and in case of concomitant factor XIII deficiency, the clinical scenario can be life-threatening. A multidisciplinary approach including a urologist, an interventional radiologist and a hematologist in our experience represented the key approach in case of severe bleeding following surgery for ED.

Female bladder outlet obstruction: Common symptoms masking an uncommon cause.

OBJECTIVE: Bladder outlet obstruction (BOO) in women remains an underdiagnosed condition. Although diagnosed rarely in general urologic practice, its incidence in specialist centers has been reported to be up to 29%. In the present study we evaluated the incidence of female BOO in adult women referred for evaluation of lower urinary tract symptoms or urinary incontinence, assessing its etiology and correlating this with its clinical presentation. METHODS: The present study consisted of a retrospective review of a prospectively acquired videourodynamic database of 1142 consecutive women referred for evaluation of lower urinary tract symptoms (LUTS) or urinary incontinence from March 2007 to December 2012 and diagnosed with BOO. After exclusions, data from 1014 patients were analyzed. BOO was defined using a combination of radiographic evidence of obstruction during the voiding phase of the urodynamic study and pressure-flow criteria (Solomon-Greenwell nomogram). Diagnosis was confirmed by cystoscopy, maximal urethral closure pressure, and magnetic resonance imaging as clinically indicated. RESULTS: In all, 192 women (19%) were diagnosed with BOO. Functional sphincteric obstruction was diagnosed in 70 women (36%). The most common anatomical cause of BOO was previous anti-incontinence surgery, followed by urethral stricture, diagnosed in 21% and 20% of patients, respectively. The most common presenting symptoms were storage phase symptoms of daytime and night-time urinary frequency. CONCLUSIONS: BOO was present in 19% of women with LUTS. Functional sphincteric obstruction was the most common cause (36%), followed by obstruction after anti-incontinence surgery (21%). The most common presenting symptom was daytime urinary frequency. BOO should be suspected in women with refractory LUTS, especially those presenting with urinary frequency.

Buccal mucosal graft urethroplasty in men-risk factors for recurrence and complications: a third referral centre experience in anterior urethroplasty using buccal mucosal graft.

BACKGROUND: Urethral stricture disease is a challenging condition to treat and several approaches including direct visual internal urethrotomy (DVIU) and anastomotic or augmentation urethroplasties based on the use of flaps and graft have been reported. The aim of this study is to determine risk factors for stricture recurrence and complications in patients having buccal mucosal graft (BMG) urethroplasty for anterior urethral stricture under a single surgeon in a third referral centre in UK. METHODS: We conducted a retrospective review of a prospectively gathered database of 128 patients having various forms of BMG urethroplasty between 2001 and 2015. Success and failure in terms of stricture recurrence, patient demographics, stricture aetiology and anatomy, and the adverse outcomes of: post-micturition dribbling (PMD), erectile dysfunction (ED) >12 months and complications were recorded in order to determine risk factors for recurrent stricture and complications. RESULTS: The mean age of all patients was 42.8 years (range, 16-74 years). Average follow-up was 45 months (range, 3-159 months). The total re-stricture rate was 19% (24 men). PMD was reported in 16% (n=20) and ED in 12.5% (n=16). All ED was none organic and responded to oral PDE5 inhibitor treatment. Post-operative complications were reported in 16 patients (12.5%). The most frequent complications recorded were urinary fistula (n=4; 3.1%), graft contracture (n=4; 3.1%) and graft failure (n=4; 3.1%), all reported after penile urethroplasty. Univariate analysis indicated that age at surgery, stricture length, site and aetiology were all significant risk factors for stricture recurrence. On multivariate analysis penile site was the only significant independent variable for restricture. CONCLUSIONS: BMG urethroplasty represents a reliable therapeutic option for patient with urethral strictures with a success rate of 81% at 45 months of follow-up. Complications are more common in complex stricture of the penile urethra. On multivariate analysis penile site was the only significant independent variable for re-stricture.

Ventral-onlay buccal mucosa graft substitution urethroplasty for urethral stricture in women.

OBJECTIVE: To present our outcomes of ventral-onlay buccal mucosa graft (BMG) substitution urethroplasty in treating female urethral stricture (FUS). PATIENTS AND METHODS: We conducted a review of a prospectively collected database of 22 consecutive women (median [range] age 50 [34-72] years) with urethral stricture who underwent ventral onlay BMG substitution urethroplasty after June 2012 and who had a minimum follow-up of 6 months (median 21.5, range 6-51 months). Data were analysed for stricture recurrence, change in median maximum urinary flow rate (Qmax ) and median post-void residual urine volume (PVR). Statistical analysis was performed using the Wilcoxon signed rank test, Student's t-test and the Mann-Whitney U-test. RESULTS: Freedom from stricture recurrence was achieved in 21/22 (95.5%) women. The median (range) Qmax significantly improved, increasing from 7 (3.5-11) to 18 (5-37) mL/s (P <0.05). The median (range) PVR was significantly reduced from 100 (0-300) to 15 (0-150) mL (P < 0.05). Short- and longer-term complication rates were low. One woman developed mild de novo stress urinary incontinence, which settled with conservative management by 6 months. CONCLUSIONS: Early and medium-term results indicate that ventral onlay BMG substitution urethroplasty is an excellent treatment for FUS that can avoid the need for the repeat procedures regularly required after traditional endoscopic management.

The uses and outcomes of the Martius fat pad in female urology.

PURPOSE: To assess the indications, morbidity, efficacy and outcomes of Martius fat pad (MFP) interposition in reconstructive female urology. MATERIALS AND METHODS: Data on 159 women with MFP interposition as part of their primary procedure between 2 September 2005 and 2 July 2015 were prospectively collected. Patient demographics and the indications for MFP interposition along with the outcomes of their primary procedures and short- and long-term complications related to the MFP, along with patient reported perception of post-operative appearance, were noted. RESULTS: The main indications for MFP interposition were urethral diverticulum excision (74), vaginal repair of vesicovaginal fistula (VVF) (43), removal and repair of urethral erosion of mid-urethral tape (MUT) (24), female urethroplasty for stricture (12), vaginal closure of bladder neck for complex end-stage stress urinary incontinence (USUI) (4) and as a MUT wrap for protection of urethra and vagina in women with fragile urethras (2). The majority of patients (127 or 79 %) rated the post-operative appearance of their labia as good or excellent. Only 1 patient (0.6 %) felt the post-operative appearance was unsatisfactory. There were 2 post-harvest labial haematoma (1.25 %), 1 labial wound infection in an overweight diabetic patient (0.6 %) and no other significant short- or long-term complications. CONCLUSIONS: MFP interposition is associated with good cosmesis and a very low complication rate (<2 %). It appears to lower new onset post-procedure USUI, prevent erosion in the 'fragile' urethra and improve outcomes following repair of post-surgery VVF/UVF. MFP is a versatile and effective tool in the female urologists' armamentarium.

Urethral diverticulectomy with Martius labial fat pad interposition improves symptom resolution and reduces recurrence.

OBJECTIVE: To assess the presenting features and medium-term symptomatic outcomes in women having excision of urethral diverticulum with Martius labial fat pad (MLFP) interposition. PATIENTS AND METHODS: We reviewed our prospective database of all female patients having excision of a symptomatic urethral diverticulum between 2007 and 2015. Data on demographics, presenting symptoms and clinical features were collected, as well as postoperative outcomes. RESULTS: In all, 70 women with a mean (range) age of 46.5 (24-77) years underwent excision of urethral diverticulum with MLFP interposition. The commonest presenting symptoms were a urethral mass (69%), urethral pain (61%), and dysuria (57%). Pre-existing stress urinary incontinence (SUI) was present in 41% (29) of the women. After surgery, at a mean (SD) of 18.9 (16.4) months follow-up (median 14 months), complete excision of urethral diverticulum was achieved in all the women, with resolution of urethral mass, dysuria and dyspareunia in all, and urethral pain in 81%. Immediately after surgery, 10 (24%) patients reported de novo SUI, which resolved with time and pelvic floor muscle training such that at 12 months only five (12%) reported continued SUI. There was one symptomatic diverticulum recurrence (1.4%). CONCLUSIONS: The commonest presenting symptom of a female urethral diverticulum is urethral pain followed by dysuria and dyspareunia. Surgical excision with MLFP interposition results in complete resolution of symptoms in most women. The incidence of persistent de novo SUI in an expert high-volume centre is 12%.

Describing the learning curve for bulbar urethroplasty.

BACKGROUND: Learning curves have been described for a number of urological procedures including radical prostatectomy and laparoscopic nephrectomy but rarely for urethroplasty. We describe the learning curve for bulbar urethroplasty in a single surgeon series. METHODS: A retrospective case note review was performed of 91 consecutive men median age 32 years (range, 15-66 years) having bulbar urethroplasty performed by a single surgeon. Data was collected on type of urethroplasty, restricture rate (as defined by urethrogram and/or flow rate) and duration of follow up. The restricture rates were compared by quartiles and statistical analysis was by ¦Ö2 between the first and fourth quartiles. RESULTS: The 91 men had 42 dorsal onlay buccal mucosal graft (Dorsal BMG), 20 BMG augmented bulbobulbar anastomotic (Augmented Rooftop) and 29 bulbobulbar anastomotic (BBA) urethroplasties performed. Median follow up was 39 months for the first quartile, 42 months for the second, 36 months for the third, and 35 months for the fourth. The restricture rate was 17% in the first quartile, 8.7% in the second and third quartiles and 4.5% in the fourth quartile. There were no restrictures noted after 24 months. There were 4 restrictures in the first quartile and 1 restricture in the fourth quartile (¦Ö2 P<0.01). CONCLUSIONS: There is a statistically and clinically significant difference in restricture rates between first and fourth quartiles with rates falling from 17% to 4.5%. There is a learning curve for bulbar urethroplasty with a reduced restricture rate each quartile and it may take as many as 90 cases to reach optimum restricture rates.

A Challenging Surgical Approach to Locally Advanced Primary Urethral Carcinoma: A Case Report and Literature Review.

Primary urethral carcinoma (PUC) is a rare and aggressive cancer, often underdetected and consequently unsatisfactorily treated. We report a case of advanced PUC, surgically treated with combined approaches.A 47-year-old man underwent transurethral resection of a urethral lesion with histological evidence of a poorly differentiated squamous cancer of the bulbomembranous urethra. Computed tomography (CT) and bone scans excluded metastatic spread of the disease but showed involvement of both corpora cavernosa (cT3N0M0). A radical surgical approach was advised, but the patient refused this and opted for chemotherapy. After 17 months the patient was referred to our department due to the evidence of a fistula in the scrotal area. CT scan showed bilateral metastatic disease in the inguinal, external iliac, and obturator lymph nodes as well as the involvement of both corpora cavernosa. Additionally, a fistula originating from the right corpus cavernosum extended to the scrotal skin. At this stage, the patient accepted the surgical treatment, consisting of different phases. Phase I: Radical extraperitoneal cystoprostatectomy with iliac-obturator lymph nodes dissection. Phase II: Creation of a urinary diversion through a Bricker ileal conduit. Phase III: Repositioning of the patient in lithotomic position for an overturned Y skin incision, total penectomy, fistula excision, and "en bloc" removal of surgical specimens including the bladder, through the perineal breach. Phase IV: Right inguinal lymphadenectomy.The procedure lasted 9-and-a-half hours, was complication-free, and intraoperative blood loss was 600 mL. The patient was discharged 8 days after surgery. Pathological examination documented a T4N2M0 tumor. The clinical situation was stable during the first 3 months postoperatively but then metastatic spread occurred, not responsive to adjuvant chemotherapy, which led to the patient's death 6 months after surgery.Patients with advanced stage tumors of the bulbomembranous urethra should be managed with radical surgery including the corporas up to the ischiatic tuberosity attachment, and membranous urethra in continuity with the prostate and bladder. Neo-adjuvant treatment may be advisable with the aim of improving the poor prognosis, even if the efficacy is not certain while it can delay the radical treatment of the disease.

Noninvasive treatments for iatrogenic priapism: Do they really work? A prospective multicenter study.

OBJECTIVES: Intracorporeal injections (ICIs) of vasoactive substances during penile Doppler ultrasound (PDU) are a common investigation for erectile dysfunction (ED) diagnosis. ICI can be responsible of priapism, a pathological condition of prolonged penile erection not related to sexual stimulation. The aim of our study is to investigate the effectiveness of physical exercise and medical treatment as noninvasive therapy to restore detumescence in prolonged erections after ICI. MATERIALS AND METHODS: Data were prospectively collected on men undergoing PDU in three urological centers. Three hundred and sixty-nine patients underwent PDU for the investigation of ED. All the participants received an ICI of quadrimix; prostaglandine E1, papaverine, phentolamine, and atropine. The data of the patients have been analyzed to record their comorbidities, results of PDU, and the complications encountered. RESULTS: Fifty-three patients (14.4%) developed prolonged erections. Physical exercise alone was successful in reversing prolonged erection within 30 min in 21 (39.6%) patients. Out of the remaining 32 patients, oral salbutamol induced detumescence in 18 (34%) within the observation period of 60 min. Nonresponders were managed successfully with aspiration and irrigation of corpora with saline (11 patients, 20.75%) or with Phenylephrine (three patients, 5.66%). CONCLUSIONS: Physical exercise and oral salbutamol are safe and effective in restoring detumescence of pharmacologically-induced priapism. Noninvasive therapy may save a significant number of these patients an invasive treatment.

A tertiary experience of ileal-ureter substitution: Contemporary indications and outcomes.

OBJECTIVE: Complex ureteric stricture disease in contemporary practice is typically related to prior pelvic surgery, radiotherapy, or complicated, repeated retrograde stone surgery, although outcomes in this group have not been well studied. The aim of this study was to report medium-term outcomes with ileal-ureter substitution for complex ureteric stricture disease. MATERIALS AND METHODS: All patients who had undergone ureteric reconstructive surgery using small bowel over a 5 year period between 2010 and 2015 were identified from the theatre database and their case notes reviewed. Data were collected on aetiology of ureteric stricture, prior surgery or radiotherapy, baseline renal function and comorbidity. Postoperative complications were recorded using the Clavien-Dindo classification, and overall outcome and need for further intervention were documented. RESULTS: Nine patients underwent ileal-ureter substitution for complex ureteric stricture disease over this period, with four having bilateral ileal interpositions. Median age was 48 years (38-62 years) with a median follow-up of 17 months (1-40 months). Simple untailored ileal segments and refluxing anastomoses were used in all cases. One case of anastomotic leak and restricture required reintervention, but all others had favourable outcomes with no stricture and no requirement for further intervention. Two patients reported recurrent cystitis following surgery but there was no deterioration in renal function in any patient, with no metabolic complications reported. CONCLUSION: Ileal-ureter substitution surgery is a valuable option for selected patients with complex, difficult-to-treat ureteric defects that cannot be bridged by other methods. Simple onlay techniques do not seem to affect renal or metabolic function. Avoiding the extra complexity of tailored and tunnelled anastomoses may reduce the potential morbidity and reintervention rate in patients with challenging surgical fields.

Urethral diverticula in women.

Female urethral diverticula are rare, benign epithelium-lined outpouchings of the female urethra. Patients can present with a multitude of symptoms, most commonly urinary incontinence, recurrent UTIs and dyspareunia. These presenting symptoms are often confused with other diagnoses leading to delayed diagnosis or misdiagnosis. Diagnosis and preoperative assessment of bladder function is most accurate using a combination of clinical examination, T2-weighted postvoid MRI and videocystometrography. Best treatment is by vaginal excision, a procedure with a very low recurrence rate and high patient acceptability. Excision also results in high cure rates for associated dyspareunia, UTI and voiding dysfunction. Pre-existing urodynamically proven stress urinary incontinence (USUI) resolves in 50% of patients after excision of the diverticulum with Martius labial fat pad interposition without the need for further treatment. Potential adverse effects after surgery are new-onset USUI, urethrovaginal fistula and urethral stricture. The rate of onset of these potential adverse effects is low and related to the preoperative appearance of the diverticulum on an MRI scan and the complexity of the diverticulum.