Risk factors and predisposing conditions for urinary tract infection.

Understanding individual and population-specific risk factors associated with recurrent urinary tract infections (UTIs) can help physicians tailor prophylactic strategies. Frequent intercourse, vulvovaginal atrophy, change of the local bacterial flora, history of UTIs during premenopause or in childhood, family history, and a nonsecretor blood type are substantiated risk factors for recurrent uncomplicated UTIs. This is a narrative review based on relevant literature according to the experience and expertise of the authors. Asymptomatic bacteriuria is generally benign; however, during pregnancy it is more common and is associated with an increased likelihood of symptomatic infection, which may harm the mother or fetus. Screening of pregnant women and appropriate treatment with antimicrobials must be balanced with the potential for adverse treatment-related outcomes; appropriate prophylaxis should be considered where possible. High-quality data are currently lacking on risks related to asymptomatic bacteriuria in pregnancy and further data in this hard-to-study population should be a primary concern for researchers. Incomplete voiding represents the primary risk factor for UTIs associated with conditions such as urinary incontinence and prolapse. Correcting the presence of residual urine remains the most effective prophylaxis in these populations. Bladder function alters throughout life; however, changes in function may be particularly profound in clinical populations at high risk of UTIs. Patients with neurogenic bladder will also likely have other evolving medical issues which increase the risk of UTIs, such as repeated catheterization and increasing residual urine volume. More aggressive antimicrobial prophylactic strategies may be appropriate in these patients. Again, the paucity of data on prophylaxis in these high-risk patients requires the attention of the research community.

[Buccal mucosa graft augmented anastomotic urethroplasty for the treatment of bulbar urethral strictures]. / GAL EN EL TRATAMIENTO DE LA ESTRECHEZ DE URETRA BULBAR.

OBJECTIVE: To report our outcomes with the use of buccal mucosal graft anastomotic urethroplasty to reconstruct complex anterior urethral strictures. METHODS: Between October 2007 and January 2011 we conducted a retrospective review of a series of 65 patients from 2 different centers. We analyzed demographic data, surgical outcomes and complications. RESULTS: Patient mean age was 50.09 years (range: 25 to 75), mean stricture length was 3.95 cm (range: 3 to 7 cm) and mean follow-up 33.13 months (range: 12.7 to 52.77). Eighty percent of patients had prior treatments, mainly direct visual internal urethrotomy (DVIU) and urethral dilatation. Most frequent etiologies were iatrogenic in 46.15% of patients and idiopathic in 35.38% of patients. Success rate was achieved in 96.92% of patients; only 2 patients presented recurrence and were treated successfully with one DVIU. Clavien Dindo I-II complications were found in 59% of patients. No patient had chronic sequels. CONCLUSION: Augmented anastomotic urethroplasty using dorsal onlay buccal mucosa graft enables correction, in one time, of long segment urethral strictures with severe spongiofibrosis and/or obliterated lumen. Our outcomes are comparable with those of previously reported in international series.

Penile Prosthesis Implantation in Patients with a History of Total Phallic Construction.

INTRODUCTION: Outcomes following penile prosthesis implantation in patients with a history of total phallic construction are not well described. AIM: The aim of this study was to evaluate outcomes following neophallus penile prosthesis placement. METHODS: Retrospective review penile prosthesis placement in patients with prior total phallic construction. GORE-TEX® (Gore Medical, Flagstaff, AZ) sleeve neotunica construction was utilized in all patients. MAIN OUTCOME MEASURE: Success defined as patient sexual activity with a functioning prosthesis. RESULTS: Thirty-one patients underwent neophallic prosthesis implantation at a mean 35.6 years of age. Prosthesis placement occurred at an average 56.3 months following phallic construction and follow-up was a mean of 59.7 months. Malleable prostheses were placed in 21 patients and inflatable in 10; implants were bilateral in 94%. Six percent experienced operative complications including a bladder injury (1) and phallic flap arterial injury (1). Postoperative complications occurred in 23% at a median 5.5 months following placement. Five prostheses were explanted secondary to infection or erosion and two additional required revisions. Of the explanted prosthesis two were later replaced without further complication. Eighty-one percent of patients were sexually active following prosthesis placement. CONCLUSIONS: Penile prosthesis placement is possible in patients with prior penile reconstruction/phallic construction. Although complications rates appear to be elevated in this population compared with historic controls of normal anatomic men, the majority of patients in this series were sexually active following prosthesis placement. This demonstrates the utility of prosthesis implantation in these difficult patients.

Anastomosis ampliada con injerto de mucosa yugal en el tratamiento de la estrechez de uretra bulbar / Buccal mucosa graft augmented anastomotic urethroplasty for the treatment of bulbar urethral strictures

OBJETIVO: Reportar nuestros resultados con la utilización de la anastomosis ampliada con injerto de mucosa yugal para el manejo de la estrechez compleja de la uretra bulbar. MÉTODOS: Análisis retrospectivo de 65 pacientes operados en 2 Centros Hospitalarios independientes de cirugía reconstructiva, entre octubre de 2007 y enero de 2011. Se analizaron datos demográficos, resultados y complicaciones. RESULTADOS: La edad promedio de los pacientes fue de 50,09 años (rango: 25 a 75), siendo la longitud media de la estrechez de 3,95 cm (rango: 3 a 7) y un seguimiento promedio de 33,13 meses (rango: 12,7 a 52,77). El 80% de los pacientes había sido tratado previamente con múltiples uretrotomías internas y dilataciones. Las etiologías más frecuentes fueron instrumental (46,15%) e idiopática (35,38%). La tasa de éxito fue del 96,92%, recidivando en 2 pacientes, que fueron exitosamente tratados con uretrotomía interna. Las complicaciones fueron menores, Clavien Dindo I-II, ocurriendo en el 39,92% de los pacientes, y ninguna de ellas dejó secuelas incapacitantes a largo plazo. CONCLUSIÓN: La anastomosis ampliada permite corregir en un tiempo extensos procesos cicatrizales de la uretra y con gran compromiso de la luz uretral. Los resultados obtenidos en nuestra serie se comparan con aquellos de las series internacionales ya reportados

OBJECTIVE: To report our outcomes with the use of buccal mucosal graft anastomotic urethroplasty to reconstruct complex anterior urethral strictures. METHODS: Between October 2007 and January 2011 we conducted a retrospective review of a series of 65 patients from 2 different centers. We analyzed demographic data, surgical outcomes and complications. RESULTS: Patient mean age was 50.09 years (range: 25 to 75), mean stricture length was 3.95 cm (range: 3 to 7 cm) and mean follow-up 33.13 months (range: 12.7 to 52.77). Eighty percent of patients had prior treatments, mainly direct visual internal urethrotomy (DVIU) and urethral dilatation. Most frequent etiologies were iatrogenic in 46.15% of patients and idiopathic in 35.38% of patients. Success rate was achieved in 96.92% of patients; only 2 patients presented recurrence and were treated successfully with one DVIU. Clavien Dindo I-II complications were found in 59% of patients. No patient had chronic sequels. CONCLUSION: Augmented anastomotic urethroplasty using dorsal onlay buccal mucosa graft enables correction, in one time, of long segment urethral strictures with severe spongiofibrosis and/or obliterated lumen. Our outcomes are comparable with those of previously reported in international series

A Multi-institutional Evaluation of the Management and Outcomes of Long-segment Urethral Strictures.

OBJECTIVE: To evaluate the treatment options and surgical outcomes of long-segment urethral strictures-a review of the largest, international, multi-institutional series. METHODS: A retrospective review was performed of patients treated with strictures ≥8 cm at 8 international centers. Endpoints analyzed included surgical complications and recurrence. RESULTS: Four hundred sixty-six patients were identified. Treatment intervals ranged from December 27, 1984 to November 9, 2013. Dorsal onlay buccal mucosal graft (BMG) was the most common procedure (223, 47.9%); others included first- and second-stage Johanson urethroplasty (162 [34.8%] and 56 [12%], respectively), fasciocutaneous (FC) flaps (8, 1.7%), and a combination flap and graft (17, 3.6%). Overall success was achieved in 361 patients (77.5%) with a mean follow-up of 20 months. Second-stage Johanson urethroplasty was found to have a higher recurrence rate compared with that of 1-stage BMG urethroplasty (35.7% vs 17.5%, respectively; P <.01). This was also true in cases of lichen sclerosus (14.0% vs 47.8%, respectively; P <.01). Otherwise, success rates were similar. Urethroplasties performed with FC flaps had a higher complication rate compared with those without (32% vs 14%, respectively; P = .02). Prior dilation or urethrotomy, higher number of prior dilations or urethrotomies, abnormal voiding cystourethrogram, and skin grafts all portend a higher recurrence rate. On logistic regression analysis, only second-stage Johanson had an increased odds ratio of recurrence compared with that of BMG (2.82 [1.41-5.86]). CONCLUSION: Long-segment strictures can be treated with high success rates in experienced hands. BMG was more successful than second-stage Johanson urethroplasty. FC flaps, although successful, had high complication rates.

Traumatic testicular dislocation.

INTRODUCTION: Traumatic testicular dislocation is a rare entity. It occurs after a direct blunt scrotal trauma causing the testicle to migrate outside the scrotum, most frequently to the superficial inguinal region. MATERIALS AND METHODS: A review of the diagnostic database of our two institutions was performed searching for complex genital trauma between 1990 and 2012. RESULTS: Seven cases of traumatic testicular dislocation were identified (four on the left side; one on the right side and two bilateral) for a total of nine testicles. Six were motorcycle accidents, and the other case suffered a pelvic crush injury. All victims had significant associated injuries, one case had an open dislocation and two were killed by the accident. The testicle was located at the inguinal region in four cases at the suprapubic area in four, and the other was an open dislocation. Diagnosis was suspected with the physical examination and confirmed by Doppler ultrasound; however, in one case, the diagnosis was missed during several weeks. In one case, the testicle was reduced into the scrotum immediately at the emergency department. Two cases were operated shortly after admission, performing testicular reduction into the scrotum and standard orchidopexy. Two other cases underwent delayed intervention, and both needed release of peri-testicular adhesions. Two cases (both bilateral) died at the accident site and were diagnosed by autopsy. In all surviving cases, it was possible to obtain a satisfactory orchidopexy with gonadal preservation. CONCLUSIONS: Traumatic testicular dislocation is rare and diagnosis can be elusive. It should be suspected in motorcycle and high-energy accidents around the groin area and depends on a careful physical examination. With proper management, prognosis is excellent.

Initial human feasibility study of DC ablation as a treatment for benign prostatic hyperplasia: 6 month follow-up data.

Direct current (DC) ablation is a novel non-thermal technology that causes focused coagulative necrosis in the lateral lobes of the prostate to treat benign prostatic hyperplasia (BPH). The necrosis is caused by a zone of non-physiologic pH which is created in a predictable pattern around each electrode in which a direct current is applied during treatment. The objective of this study was to optimize treatment parameters and assess treatment tolerability using transurethral DC ablation as an office-based treatment for BPH.

[Renal and perinephric abscesses: a series of 44 cases]. / Abscesos renales y peri-renales: análisis de 44 casos.

Renal abscesses are infrequent event and may occasionally be fatal. In order to characterize its main clinical features, its diagnosis and evolution, a retrospective-descriptive study was done with cases identified between 1996 and 2006 in a teaching hospital. Forty-four cases were collected (mean age 49.9 years). Diabetes mellitus was present in 38.6%, urinary calculi in 36.4%, and previous urinary tract infection in 11.4% of the studied population. Enterobacteriaceae were the most frequent isolated microorganisms (44.4%), and 33.3% had a poli-microbial culture in abscess samples. S. aureus was rarely identified. Main therapeutic approaches were minimally invasive procedures (pigtails, percutaneous drainage or nephrostomy) in 50% followed by surgical interventions (nephrectomy or surgical debridement) in approximately 30%. Only 20.5% of patients were treated exclusively by antibiotics. Minimally invasive procedures were applied progressively after 2001 (p < 0.005). In this series case-fatality rate was 4.5%; 13.6% (n = 6) developed septic shock. Nephrectomy was performed in 9 cases (20.5%). Patients selected for nephrostomy had a lower risk for ICU admission (Odds Ratio 0.083 IC95 0.008-0.911). Renal abscesses are cause of morbidity but had a low case-fatality ratio; the therapeutic approach has changed in recent years favoring at present minimally invasive procedures.

[Prospective trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi]. / Estudio prospectivo que compara la litotricia extracorpórea y la ureteroscopia en el tratamiento de la litiasis de uréter distal.

PURPOSE: To compare the efficacy of ureteroscopy and extracorporeal shock wave lithotripsy (ESWL) in treating distal ureteral calculi and evaluate the best treatment alternative for this disease. MATERIAL AND METHODS: A total of 104 patients with distal ureteral calculi requiring surgical intervention were enrolled and observed in a prospective follow-up. For ESWL, a Modulix SLX Storz lithotriptor was used and for ureteroscopy, a Storz 33 cm semi-rigid ureteroscope with a diameter of 7,5 to 9,5 french and a 6-degree optic. Out of the patient total, 54 patients underwent ESWL and 50 underwent ureteroscopy. 62 patients were men and 42 women; mean age in the ESWL group was 49.72, and in the ureteroscopy group, 52,16. Mean calculus size for ESWL was 8.29 mm and 8,96 mm for ureteroscopy. A P< .05 was considered statistically significant. RESULTS: Mean procedure time for ESWL was 55 minutes in men and 45 minutes in women. For ureteroscopy, procedure time was 80 minutes for men and 55 minutes for women. For ESWL, the mean hospital stay was 4.8 hours (same-day discharge for all patients). Mean hospital stay for ureteroscopy patients was 22 hours. 7% of ESWL patients experienced complications compared with 7.9% of those undergoing ureteroscopy. At the 30-day follow up, 74.3% of ESWL patients were stone free, while 92,3% of the ureteroscopy patients were stone free (P< .05). CONCLUSIONS: Based on the results of this study, ureteroscopy is a better method for treating distal ureteral calculi because of its stone free rates and because the difference in complication rates was not significant.

Estudio prospectivo que compara la litotricia extracorpórea y la ureteroscopia en el tratamiento de la litiasis de uréter distal / Prospective trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi

Objetivos: Comparar los resultados en el manejo de la litiasis de uréter distal entre la litotricia extracorpórea (LEC) y ureteroscopia (URS) y así evaluar la mejor alternativa de tratamiento en esta afección. Material y métodos: Un total de 104 pacientes con diagnóstico de litiasis de uréter distal, que requerían tratamiento quirúrgico. Se realizó un enrolamiento y seguimiento prospectivo. Se utilizó en LEC un litotriptor Modulix SLX Storz, en la URS se utilizó un ureteroscopio semirrígido Storz 33 cm, diámetro de 7,5 a 9,5 Fr, óptica 6º. Del total de pacientes, 54 fueron a LEC y 50 a URS, y 62 eran varones y 42, mujeres, con una edad promedio de 49,72 años para LEC y de 52,16 años para URS. En la LEC el promedio de tamaño fue 8,29 mm y en la URS, de 8,96 mm. Se estableció una significación estadística p <0,05. Resultados: El tiempo del procedimiento para la LEC, separado por sexo, fue de 55 min en el caso de los varones y de 45 min en las mujeres. Para la URS fue de 80 min para los varones y de 55 min para las mujeres. El tiempo de hospitalización promedio para la LEC fue de 4,8h (todos los procedimientos ambulatorios). En el caso de la URS, fue de 22 h. Las complicaciones en el caso de la LEC fueron del 7% y para la URS, del 7,9%. De los pacientes tratados por LEC, el 74,3% presentó stone free a los 30 días, a diferencia de la URS, que presentó un porcentaje de stone free del 92,3% (p < 0,05).Conclusiones: Basados en los resultados de este estudio, la URS es el método más adecuado para el manejo de la litiasis de uréter distal, tanto en resultados de stone free como en la falta de significación en la comparación de complicaciones (AU)

Purpose: To compare the efficacy of ureteroscopy and extracorporeal shock wave lithotripsy (ESWL) in treating distal ureteral calculi and evaluate the best treatment alternative for this disease. Material and methods: A total of 104 patients with distal ureteral calculi requiring surgical intervention were enrolled and observed in a prospective follow-up. For ESWL, a Modulix SLX Storz lithotriptor was used and for ureteroscopy, a Storz 33 cm semi-rigid ureteroscope with a diameter of 7,5 to 9,5 french and a 6-degree optic. Out of the patient total, 54 patients underwent ESWL and 50 underwent ureteroscopy. 62 patients were men and 42 women; mean age in the ESWL group was 49.72, and in the ureteroscopy group,52,16. Mean calculus size for ESWL was 8.29mm and 8,96 mm for ureteroscopy. A P<0.05 was considered statistically significant. Results: Mean procedure time for ESWL was 55 minutes in men and 45 minutes in women. For ureteroscopy, procedure time was 80 minutes for men and 55 minutes for women. For ESWL, the mean hospital stay was 4.8 hours (same-day discharge for all patients). Mean hospital stay for ureteroscopy patients was 22 hours. 7% of ESWL patients experienced complications compared with 7.9% of those undergoing ureteroscopy. At the 30-day follow up, 74.3% of ESWL patients were stone free, while 92,3% of the ureteroscopy patients were stone free (P<0.05). Conclusions: Based on the results of this study, ureteroscopy is a better method for treating distal ureteral calculi because of its stone free rates and because the difference in complication rates was not significant (AU)

[Use of paroxetine on-demand in premature ejaculation]. / Uso de paroxetina a demanda en eyaculación precoz.

INTRODUCTION: It has been described varied definitions of premature ejaculation (PE), which has determined different prevalences and rates of success for the different therapies with selective serotonin re-uptake inhibitors. Our goal was evaluate the effectiveness of paroxetine like treatment of premature ejaculation administered on-demand (4-6 hours previous to intercourse) compared to the scheme of daily dose. PATIENTS AND METHOD: A prospective study type crossover was designed with 14 patients. Grupo A: 7 patient received paroxetine 20 mg/d by three weeks followed by paroxetine 20 mg 4-6 hours before the intercourse by three weeks. Group B: the other 7 patients received the same scheme but replacing by placebo. Later to three weeks of therapy suspension, crossover was made. RESULTS: The intravaginal ejaculatory latency time (IELT) pre-treatment was 0.4 minutes. In the group A the IELT average was of 4.3 minutes in the treatment with daily paroxetine; 5.8 minutes when they received paroxetine on-demanad; 0.9 with daily placebo and 0.6 with placebo on-demand (p < 0.001). For group B the IELT during the daily placebo was 0.8 minutes and with placebo on-demand it was of 1.1. When they received daily paroxetine the IELT was 3.3 minutes and during the phase of paroxetine on-demand it was increased to 6.1 (p<0.001). CONCLUSIONS: The treatment of premature ejaculation with paroxetine in daily dose and scheme on-demand appears similar like effective options.