Predictores de cirugía uretral compleja en estenosis de la uretra anterior / Predictors of complex urethral surgery in urethral stricture former

Objetivo: Determinar los factores predic-tores asociados a Cirugía Uretral Compleja (CUC) enlos casos de estenosis de la uretra anterior.Material y método: Estudio transversal con registro de datos retrospectivo, incluye a todos los pacientes masculinos a quienes se les practicó una plastía dela uretra anterior entre 2011 y 2018. Como CUC seconsideró a la Uretroplastia con dos o más injertos, laanastomosis término terminal ampliada, la uretroplastíacombinada y la cirugía por estadíos. Los datos se recabaron de la historia clínica electrónica consignándoseaquellos demográficos, antecedente de tratamientosprevios, así como las características de la estenosis(etiología, ubicación anatómica, longitud, número deestenosis entre otras). Se realizó un análisis univariadoy multivariado para identificar variables predictoras deCUC. Resultados: Se analizaron los datos de 665 pacientes con criterios de inclusión válidos. La media de edadfue de 56,1 años, 27,5% eran fumadores crónicos,32,5% habían recibido algún tratamiento previo, siendolas dilataciones el procedimiento más común (17,6%),la etiología más prevalente fue la iatrógena seguida porla idiopática en un 61,1 y un 20,3% respectivamente,la ubicación más común fue la uretra bulbar en 56,2%mientras que la media de longitud de la estenosis fuede 4,8 cm. En el análisis univariado y multivariable elantecedente de dilataciones (HR 2,6), la multifocalidad(HR 2,51), la longitud de la estenosis (>4 cm) (HR 1,49)y la etiología hipospadias (HR 11,9) resultaron ser factores predictores independientes para CUC (p<0,05).Conclusiones: La hipospadia fue dentro de lasetiologías analizadas la única que predice la necesidad de CUC. En lo que respecta a antecedentes yhallazgos radiológicos, las dilataciones y las estenosisextensas y multifocales respectivamente fueron predictores de CUC.(AU)

Objective: To determine the clinical-sur-gical factors associated with Complex Urethral Surgery(CUC) in anterior urethral stenosis.Material and method: This is a cross-sectionalstudy with retrospective data recording, including allmale patients who underwent anterior urethroplasty between 2011 and 2018. CUC included two or moregrafts urethroplasty, excisional augmented anastomoticurethroplasty, combined flaps and grafts urethroplastyand stages surgery. The data were collected electronic medical record, recording the demographicdata, background of previous treatments as well as thecharacteristics of the stenosis (etiology, anatomical location, length, number of strictures, among others). A univariate and multivariate analysis were conducted usingthe chi-squared test and logistic regression to identify thevariables related to CUC.Results: The data of 665 patients met the inclusioncriteria were analyzed. The mean age was 56.1 years,27.5% were smokers, 32.5% had received some previous treatment, and dilatations were the most commonprocedure. The most prevalent etiology was iatrogenic,followed by idiopathic in a 61.1 and 20.3% respectively. Bulbar urethral stricture were the most commonlocation (56.2%) while the mean length of the stenosiswas 4.8 cm. After univariate and multivariate analysis,previous dilations (HR 2.6), multifocality (2.51), lengthof stenosis (>4 cm) (HR 1.49) and the hypospadias etiology (HR 11.9) were independent predictors for CUC(p<0.05).Conclusions: Hypospadias was the only etiologyfactor that predicts the need for CUC. Regarding radiological findings, extensive and multifocal stenosis, werepredictors of complex surgery. History of previous dilations were also predictors of CUC.from the

[Predictors of complex urethral surgery in anterior urethral stricture disease.] / Predictores de cirugía uretral compleja en estenosis de la uretra anterior.

OBJECTIVE: To determine the clinical-surgical factors associated with Complex Urethral Surgery (CUC) in anterior urethral stenosis. MATERIAL AND METHOD: This is a cross-sectional study with retrospective data recording, including all male patients who under went anterior urethroplasty between 2011 and 2018. CUC included two or more grafts urethroplasty, excisional augmented anastomotic urethroplasty, combined flaps and grafts urethroplasty and stages surgery. The data were collected from the electronic medical record, recording the demographic data, background of previous treatments as well as the characteristics of the stenosis (etiology, anatomical location, length, number of strictures, among others). A univariate and multivariate analysis were conducted using the chi-squared test and logistic regression to identify the variables related to CUC. RESULTS: The data of 665 patients met the inclusion criteria were analyzed. The mean age was 56.1 years, 27.5% were smokers, 32.5% had received some previous treatment, and dilatations were the most common procedure. The most prevalent etiology was iatrogenic, followed by idiopathic in a 61.1 and 20.3% respectively. Bulbar urethral stricture were the most common location (56.2%) while the mean length of the stenosis was 4.8 cm. After univariate and multivariate analysis, previous dilations (HR 2.6), multifocality (2.51), lengthof stenosis (>4 cm) (HR 1.49) and the hypospadias etiology (HR 11.9) were independent predictors for CUC (p<0.05)CONCLUSIONS: Hypospadias was the only etiology factor that predicts the need for CUC. Regarding radiological findings, extensive and multifocal stenosis, were predictors of complex surgery. History of previous dilations were also predictors of CUC.

OBJETIVO: Determinar los factores predictores asociados a Cirugía Uretral Compleja (CUC) en los casos de estenosis de la uretra anterior.MATERIAL Y MÉTODO: Estudio transversal con registro de datos retrospectivo, incluye a todos los pacientes masculinos a quienes se les practicó una plastía de la uretra anterior entre 2011 y 2018. Como CUC se consideró a la Uretroplastia con dos o más injertos, la anastomosis término terminal ampliada, la uretroplastia combinada y la cirugía por estadíos. Los datos se recabaron de la historia clínica electrónica consignándose aquellos demográficos, antecedente de tratamientos previos, así como las características de la estenosis (etiología, ubicación anatómica, longitud, número de estenosis entre otras). Se realizó un análisis univariado y multivariado para identificar variables predictoras de CUC. RESULTADOS: Se analizaron los datos de 665 pacientes con criterios de inclusión válidos. La media de edad fue de 56,1 años, 27,5% eran fumadores crónicos, 32,5% habían recibido algún tratamiento previo, siendo las dilataciones el procedimiento más común (17,6%), la etiología más prevalente fue la iatrógena seguida por la idiopática en un 61,1 y un 20,3% respectivamente, la ubicación más común fue la uretra bulbar en 56,2% mientras que la media de longitud de la estenosis fue de 4,8 cm. En el análisis univariado y multivariable el antecedente de dilataciones (HR 2,6), la multifocalidad (HR 2,51), la longitud de la estenosis (>4 cm) (HR 1,49) y la etiología hipospadias (HR 11,9) resultaron ser factores predictores independientes para CUC (p<0,05). CONCLUSIONES: La hipospadia fue dentro de las etiologías analizadas la única que predice la necesidad de CUC. En lo que respecta a antecedentes y hallazgos radiológicos, las dilataciones y las estenosis extensas y multifocales respectivamente fueron predictores de CUC.

Comparing open and robotic salvage radical prostatectomy after radiotherapy: predictors and outcomes.

INTRODUCTION: In the present study, we aim to provide more evidence about benefits of salvage radical prostatectomy (SRP). Our main objective is to assess prostatic-specific antigen control and postoperative urinary incontinence in open and robotic approaches as primary outcomes. MATERIALS AND METHODS: After the Institutional Review Board approval (IRB00010193), we retrospectively analyzed 76 consecutive patients who underwent open or robot-assisted SRP for locally relapsed prostate cancer between 2004 and 2019 at the Urology Department of Hospital Italiano de Buenos Aires, Argentina. Data were collected from our electronic medical record and prospective database.Postoperative variables, such as urinary incontinence, erectile function preservation, and vesicourethral anastomosis stricture development, were analyzed. RESULTS: Before SRP, 59 patients (76.6%) were treated with 3D external beam radiotherapy, 11 (14.3%) with brachytherapy, and 6 (7.8%) with intensity-modulated radiotherapy. Fifty patients underwent open SRP, and 26, robot-assisted SRP. Comparing surgical approaches, the global incontinence rate was 34.2% versus 9.1% in open versus robot-assisted approach, respectively (p: 0.01).Vesicourethral anastomosis stricture occurred in six patients (8.7%), all in the open approach group (p: 0.07). Five patients of 69 (7.2%) preserved erectile function with/without use of phosphodiesterase 5 inhibitors. Two patients in the open approach group needed blood transfusion. Estimated 2-year biochemical recurrence-free survival rate in the open approach group and robot-assisted group was 67% (95% confidence interval: 53.7-80.3) and 60.9% (95% confidence interval: 40.5-81.3), respectively, with no statistical difference (log-rank test p: 0.873). CONCLUSIONS: Robot-assisted SRP is a reliable procedure to treat local recurrences after external beam radiotherapy or brachytherapy, reducing the risk of anastomotic strictures and blood loss and improving continence outcomes.

Glans Preservation in Surgical Treatment of Distal Urethral Strictures With Dorsal Buccal Mucosa Graft Onlay by Subcoronal Approach.

OBJECTIVE: To describe dorsal onlay buccal mucosa graft urethroplasty technique by subcoronal approach and glans preservation in distal penile urethral strictures with fossa navicularis involvement and to report safety, effectiveness, and cosmetic outcomes. METHODS: Retrospective review of a prospective database of patients treated at Hospital Italiano de Buenos Aires between January 2011 and December 2019. Main surgical steps: ventral subcoronal incision, dorsal dissection of glandelar urethra until piercing the tip of the glans, dorsal urethrotomy, and graft transposition. Low urinary tract symptoms, uroflowmetry, and urinalysis were assessed at follow-up. Simplified International Index Erectile Function and Hypospadias Objective Scoring Evaluation were applied 1 year after surgery. RESULTS: Sixteen patients with a median age of 56.5 years (IQR 35.7-66.7) were included. Median stricture length was 5.5 cm (IQR 4-8.7). In 3 patients, Clavien-Dindo grade I-II complications were reported. At 1 year, median peak flow was 18 mL/seg (IQR 12.7-27.4) and median mean flow 7.8 mL/seg (IQR 6.1-9.9). At 41.5 months follow-up (IQR 13.2-74), all patients were stricture free and had no changes in erectile function. Hypospadias Objective Scoring Evaluation score ≥14 points was achieved by 14 patients (87.5%). CONCLUSION: For treatment of distal penile urethral strictures with fossa navicularis involvement, dorsal onlay buccal mucosa graft by subcoronal approach and glans preservation is a feasible technique with excellent functional outcomes, minimal complications, and substantial cosmetic results.

Bulbomembranous Urethral Strictures Repair After Surgical Treatment of Benign Prostatic Hyperplasia. Experience From a Latin American Referral Centre.

OBJECTIVE: To evaluate stricture recurrence and urinary incontinence (UI) rates in patients who underwent bulbomembranous anastomosis for management of short (≤ 2cm) bulbomembranous urethral stricture (BMS) after benign prostatic hyperplasia (BPH) surgical treatment. In addition, we studied if there was any relation between post urethroplasty UI and the method employed for BPH surgical treatment. MATERIALS AND METHODS: A retrospective study was conducted between January 2011 and October 2019. We included all patients who developed BMS after undergoing Transurethral Resection of the Prostate, Holmium Laser Enucleation of the Prostate or Open Simple Prostatectomy (OSP). We excluded patients with UI after BPH surgical treatment as well as patients who underwent a dorsal or ventral onlay oral graft urethroplasty for longer proximal bulbar strictures, and also patients with associated bladder neck contracture or other strictures locations. We defined failure as the need for any intervention to restore the urethral caliber. RESULTS: Overall, 77 patients were included in the study with mean age 70 years (sd 8). Median BMS length was 1.5 cm (IQR 1-2). Median follow-up was 53 months (IQR 24 to 82). Of the patients, 74/77 (96.1%) were classified as success and 3/77 (3.9%), as failure. Out of the 6/77 (7.8%) patients who had postoperative UI, 5 of them had been treated for their BPH with OSP (p 0.001). CONCLUSIONS: Bulbomembranous anastomosis is a suitable reconstructive option for short proximal bulbar urethral strictures after BPH surgical treatment. OSP was associated with postoperative UI more frequently than endoscopic treatments modalities.

Dorsal oral mucosa graft in combination with ventral penile flap as an alternative to repair obliterative stenosis of the anterior urethra in a single surgical time

ABSTRACT Purpose: Obliterative urethral stenosis is a type of urethral lesion that compromises the whole corpus spongiosum's circumference. We present our experience in resolving complex long segment urethral obliteration in a single procedure using a combination of dorsal onlay oral mucosa graft (OMG) and ventral fasciocutaneous penile skin flap. Materials and methods: A prospectively maintained database was reviewed, which included data of men presenting long, obliterative strictures. Patients were excluded if they were lost to follow-up before one year. Failure was defined as need for further urethral instrumentation. The surgical technique used consisted on the fixation of OMG to the tunica albuginea of the corpus cavernosum, thus creating a new urethral plate. Penile or foreskin flaps were employed to complete the ventral aspect. Postoperative follow-up was done with a voiding cystourethrography at week 3. Results: A total of 21 patients were included with a median age of 49 years. Mean follow-up was 25 months. Failure was found for 3 patients (2 of them needing dilations and only one required a new urethral reconstruction). Conclusion: Single stage combination of dorsal OMG with ventral fasciocutaneous penile flap showed good results for selected patients affected with obliterative urethral stenosis.

Dorsal oral mucosa graft in combination with ventral penile flap as an alternative to repair obliterative stenosis of the anterior urethra in a single surgical time.

PURPOSE: Obliterative urethral stenosis is a type of urethral lesion that compromises the whole corpus spongiosum's circumference. We present our experience in resolving complex long segment urethral obliteration in a single procedure using a combination of dorsal onlay oral mucosa graft (OMG) and ventral fasciocutaneous penile skin flap. MATERIALS AND METHODS: A prospectively maintained database was reviewed, which included data of men presenting long, obliterative strictures. Patients were excluded if they were lost to follow-up before one year. Failure was defined as need for further urethral instrumentation. The surgical technique used consisted on the fixation of OMG to the tunica albuginea of the corpus cavernosum, thus creating a new urethral plate. Penile or foreskin flaps were employed to complete the ventral aspect. Postoperative follow-up was done with a voiding cystourethrography at week 3. RESULTS: A total of 21 patients were included with a median age of 49 years. Mean follow-up was 25 months. Failure was found for 3 patients (2 of them needing dilations and only one required a new urethral reconstruction). CONCLUSION: Single stage combination of dorsal OMG with ventral fasciocutaneous penile flap showed good results for selected patients affected with obliterative urethral stenosis.

Safety and effectiveness evaluation of open reanastomosis for obliterative or recalcitrant anastomotic stricture after radical retropubic prostatectomy

ABSTRACT Purpose: To evaluate safety, efficacy and functional outcomes after open vesicourethral re - anastomosis using different approaches based on previous urinary continence. Materials and Methods: Retrospective study of patients treated from 2002 to 2017 due to vesicourethral anastomosis stricture (VUAS) post radical prostatectomy (RP) who failed endoscopic treatment with at least 3 months of follow-up. Continent and incontinent patients post RP were assigned to abdominal (AA) or perineal approach (PA), respectively. Demographic and perioperative variables were registered. Follow-up was completed with clinical interview, uroflowmetry and cystoscopy every 4 months. Success was defined as asymptomatic patients with urethral lumen that allows a 14 French flexible cystoscope. Results: Twenty patients underwent open re-anastomosis for VUAS after RP between 2002 and 2017. Mean age was 63.7 years (standard deviation 1.4) and median follow-up was 10 months (range 3 - 112). The approach distribution was PA 10 patients (50%) and AA 10 patients (50%). The mean surgery time and median hospital time were 246.2 ± 35.8 minutes and 4 days (range 2 - 10), respectively with no differences between approaches. No significant complication rate was found. Three patients in the AA group had gait disorder with favorable evolution and no sequels. Estimated 2 years primary success rate was 80%. After primary procedures 89.9% remained stenosis - free. All PA patients remained incontinent, and 90% AA remained continent during follow-up. Conclusion: Open vesicourethral re - anastomosis treatment is a reasonable treatment option for recurrent VUAS after RP. All patients with perineal approach remained incontinent while incontinence rate in abdominal approach was rather low.

Safety and effectiveness evaluation of open reanastomosis for obliterative or recalcitrant anastomotic stricture after radical retropubic prostatectomy.

PURPOSE: To evaluate safety, efficacy and functional outcomes after open vesicourethral re - anastomosis using different approaches based on previous urinary continence. MATERIALS AND METHODS: Retrospective study of patients treated from 2002 to 2017 due to vesicourethral anastomosis stricture (VUAS) post radical prostatectomy (RP) who failed endoscopic treatment with at least 3 months of follow-up. Continent and incontinent patients post RP were assigned to abdominal (AA) or perineal approach (PA), respectively. Demographic and perioperative variables were registered. Follow-up was completed with clinical interview, uroflowmetry and cystoscopy every 4 months. Success was defined as asymptomatic patients with urethral lumen that allows a 14 French flexible cystoscope. RESULTS: Twenty patients underwent open re-anastomosis for VUAS after RP between 2002 and 2017. Mean age was 63.7 years (standard deviation 1.4) and median follow-up was 10 months (range 3 - 112). The approach distribution was PA 10 patients (50%) and AA 10 patients (50%). The mean surgery time and median hospital time were 246.2 ± 35.8 minutes and 4 days (range 2 - 10), respectively with no differences between approaches. No significant complication rate was found. Three patients in the AA group had gait disorder with favorable evolution and no sequels. Estimated 2 years primary success rate was 80%. After primary procedures 89.9% remained stenosis - free. All PA patients remained incontinent, and 90% AA remained continent during follow-up. CONCLUSION: Open vesicourethral re - anastomosis treatment is a reasonable treatment option for recurrent VUAS after RP. All patients with perineal approach remained incontinent while incontinence rate in abdominal approach was rather low.

Urethroplasty After Urethral Urolume Stent: An International Multicenter Experience.

OBJECTIVE: To evaluate the outcomes and factors affecting success of urethroplasty in patients with stricture recurrence after Urolume urethral stent. MATERIAL AND METHODS: This is a retrospective international multicenter study on patients treated with urethral reconstruction after Urolume stent. Stricture and stent length, time between urethral stent insertion and urethroplasty, age, mode of stent retrieval, type of urethroplasty, complications and baseline, and posturethroplasty voiding parameters were analyzed. Successful outcome was defined as standard voiding, without need of any postoperative adjunctive procedure. RESULTS: Sixty-three patients were included. Stent was removed at urethroplasty in 61 patients. Reconstruction technique was excision and primary anastomosis in 14 (22.2%), dorsal onlay buccal mucosa graft (BMG) in 9 (14.3%), ventral onlay BMG in 6 (9.5%), dorsolateral onlay BMG in 9 (14.3%), ventral onlay plus dorsal inlay BMG in 3 (4.8%), augmented anastomosis in 5 (7.9%), pedicled flap urethroplasty in 6 (9.5%), 2-stage procedure in 4 (6.4%), and perineal urethrostomy in 7(11.1%). Success rate was 81% at a mean 59.7 ± 63.4 months. Dilatation or internal urethrotomy was performed in 10 (15.9%) and redo-urethroplasty in 5 (7.9%). Total International Prostate Symptom Score, quality of life, urine maximum flow, and postvoid residual significantly improved (P <.0001). Complications occurred in 8 (12.7%), all Clavien-Dindo ≤2. Disease-free survival rate after reconstruction was 88.1%, 79.5%, and 76.7% at 1, 3, and 5 years, respectively. Explant of individual strands followed by onlay BMG is the most common approach and was significantly advantageous over the other techniques (P = .018). CONCLUSION: Urethroplasty in patients with Urolume urethral stents is a viable option of reconstruction with a high success rate and very acceptable complication rate. Numerous techniques are viable; however, urethral preservation, tine-by-tine stent extraction, and use of BMG augmentation produced significantly better outcomes.

Tratamiento Quirúrgico de la estenosis bulbomembranosa secundaria a fractura pelviana: resultados funcionales / Bulbomenbranous Urethral Stricture After Pelvic Fracture: Surgical Managment and Functional Outcomes

Objetivos: La incidencia de lesión uretral bulboprostática secundaria a fractura pelviana es del 5-10%. Una uretroplastia exitosa garantiza el comienzo de la rehabilitación de los pacientes. Presentamos nuestra experiencia en el manejo quirúrgico de la estenosis uretral secundaria a fractura pelviana y resultados funcionales: tasa de éxito, reestenosis, disfunción eréctil e incontinencia urinaria. Evaluamos si existe asociación entre la falta de erecciones postrauma y la reestenosis. Materiales y métodos: Cincuenta y tres pacientes fueron operados durante el período comprendido entre 2001 y 2015. Todos fueron estudiados con cistoscopia flexible, cistouretrografía retrógrada y miccional. La técnica quirúrgica empleada fue la resección y anastomosis primaria. Se utilizó siempre la sistemática del abordaje perineal progresivo para lograr una anastomosis sin tensión. Interrogamos sobre la calidad de las erecciones posterior al trauma y después de la cirugía, y su estado de continencia urinaria. Se realizó un análisis estadístico donde se evaluó si la falta de erecciones era un factor de riesgo para recaída. Resultados: La edad promedio de los pacientes fue de 34,5 (r=17-67) años. La longitud promedio de la estenosis fue de 2,28 cm, siendo la uretra bulbomembranosa la más afectada (89%). La tasa de éxito fue del 86% (46/53), que asciende al 94% (50/53) al asociar un procedimiento endoscópico. Un solo paciente refirió disfunción eréctil postcirugía (1/19; 5,3%). Dos (3,7%) pacientes evolucionaron con incontinencia de orina de esfuerzo. No se hallaron diferencias estadísticamente significativas entre el grupo de pacientes con erecciones y aquellos sin erecciones en cuanto a la posibilidad de reestenosis. Conclusiones: La anastomosis bulbomembranosa por vía perineal es el tratamiento de elección de la estenosis uretral postfractura pelviana. Los índices de incontinencia de orina y disfunción eréctil no aumentan significativamente luego de la uretroplastia. En nuestra experiencia, la falta de erecciones preoperatoria no predice mayor índice de recaídas(AU)

Objectives: Bulboprostatic urethral stricture after pelvic fracture occurs in about 5-10%. A successful urethroplasty guarantees the beginning of patient recovery. We present our experience in the surgical management of posterior urethral stricture after pelvic fracture and functional outcomes (success and failure rates, erectile dysfunction and urinary incontinence). The association between the lack of erections post-trauma and the incidence of restenosis was also evaluated. Materials and methods: 53 patients were operated between 2001- 2015. Preop workout included a flexible cystoscopy and a combination of retrograde and voiding cystourethrogram to define the site and length of urethral stricture. Resection and primary anastomosis was the technique always employed. In all cases the progressive perineal approach was followed in order to achieve a tension free anastomosis. Erectile function and urinary continence were evaluated before and after surgery. Statistical analysis was performed to evaluate if lack of erections was a failure predictor. Results: Median age was 34.5 (r=17-67) years. Median urethral stricture length was 2.28 cm. Bulbomembranous junction was the most affected portion (89%). Success rate was 86% (46/53) ascending to 94% (50/53) when an endoscopic procedure was associated. One patient referred erectile dysfunction after surgery (1/19; 5.3%). Two patients (3.7%) developed stress urinary incontinence. The restenosis rate did not show statiscally differences between the erectile dysfunction and non-erectile dysfunction group. Conclusions: Perineal bulbomembranous anastomosis is the elected procedure for urethral stricture after pelvic fracture. Incidence of urinary incontinence and erectile dysfunction are not significantly elevated after urethroplasty. In our experience, lack of erections before surgery does not predict a higher rate of restenosis(AU)

[Comparison of the Biochemical Recurrence risk between Radical Prostatectomy and Brachytherapy in the treatment of low- and intermediate-risk prostate cancer]. / COMPARACIÓN DEL RIESGO DE RECAÍDA BIOQÍMICA ENTRE PROSTATECTOMÍA RADICAL Y BRAQUITERAPIA EN EL TRATAMIENTO DEL CÁNCER DE PRÓSTATA DE RIESGO BAJO E INTERMEDIO.

OBJECTIVES: To evaluate the results of patients treated with Radical Prostatectomy (RP) and Brachytherapy for low- and intermediate-risk localized prostate cancer and to determine the Biochemical Recurrence (BCR) risk according to the treatment performed. METHODS: The study included 129 patients treated with iodine-125 seeds Brachytherapy, 98 patients treated with Laparoscopic RP (LRP), and 61 patients treated with Robotic RP (RRP) at our institution between December 1999 and January 2010, who had a low-risk disease according to D'Amico criteria (PSA <10 ng/mL, Gleason < or = 6, cT1c-T2a), or an intermediate-risk disease (PSA = or >10 and < 20 ng/mL, Gleason = 7, cT2b), but with a tumor burden of up to 30%. Follow-up was conducted with PSA at 1, 3, and 6 months, and then every six months. As for Brachytherapy, annual digital rectal examinations were also performed. A PSA level increase of 2 ng/mL above the nadir in Brachytherapy (confirmed in 2 cases) and a PSA value greater than 0.2 ng/mL after RP were considered BCR. RESULTS: Overall mean follow-up was 60.5 months (R:1-152), with a mean time for BCR of 51.7 months (R:1-138). Estimated 5-year Biochemical Recurrence-free Survival (BCRFS) in patients with D'Amico low-risk was 85.7%, 77.2% and 90.7% (p 0.336), while for intermediate-risk it was 75.8%, 68.1% and 65.1% (p 0.114), for Brachytherapy, LRP and RRP respectively. In the univariate analysis, the Gleason score 7, a clinical stage T2b, and a D'Amico intermediate-risk were associated with an increased BCR risk, and treatment with Brachytherapy was associated with a decreased BCR risk, all these being statistically significant. In the multivariate analysis, only the Gleason score 7 was significant; treatment with LRP, RRP or Brachytherapy was not associated with a greater BCR risk. CONCLUSION: Brachytherapy and Laparoscopic or Robotic Radical Prostatectomy showed no difference in terms of Biochemical Recurrence risk in patients treated for low-risk or intermediate-risk tumors, with low tumor volume.

Comparación del riesgo de recaída bioquímica entre Prostatectomía Radical y Braquiterapia en el tratamiento del cáncer de próstata de riesgo bajo e intermedio / Comparison of the biochemical recurrence risk between radical prostatectomy and brachytherapy in the treatment of low- and intermediate-risk prostate cancer

OBJETIVO: Analizar los resultados de pacientes tratados con prostatectomía radical (PR) y braquiterapia para cáncer localizado de próstata de riesgo bajo e intermedio y establecer el riesgo de recaída bioquímica (RB) según el tratamiento realizado. MÉTODOS: Se incluyeron 129 pacientes tratados con Braquiterapia con semillas de Iodo 125, 98 tratados con PR Laparoscópica (PRL) y 61 con PR Robótica (PRR), en nuestra institución desde diciembre de 1999 hasta enero de 2010, que presentaban una enfermedad de bajo riesgo según criterios de D'amico (PSA <10 ng/ml, Gleason < o = 6, cT1c-T2a), o un riesgo intermedio (PSA = o >10 y < 20 ng/ml, Gleason = 7, cT2b), pero con una carga tumoral de hasta un 30%. El seguimiento se realizó mediante PSA al mes, a los 3 meses, a los 6 meses, y luego semestralmente. También con tacto rectal anual en el caso de braquiterapia. Se consideró RB a la elevación del PSA en 2 ng/ml sobre el valor del nadir en la braquiterapia (confirmado en 2 oportunidades) y un valor de PSA mayor a 0,2 ng/ml luego de la PR. RESULTADOS: El seguimiento global medio fue de 60,5 meses (R:1-152), con un tiempo medio a la RB de 51,7 meses (R:1-138). La supervivencia estimada libre de recaída bioquímica a los 5 años en pacientes con riesgo bajo de D'amico fue 85,7%, 77,2% y 90,7% (p 0,336), mientras que para riesgo intermedio fue 75,8%, 68,1% y 65,1% (p 0,114), para braquiterapia, PRL y PRR respectivamente. En el análisis univariado el score de Gleason 7, un estadio clínico T2b, y un riesgo de D'amico intermedio se asociaron a un incremento del riesgo de RB y el tratamiento con Braquiterapia se asocio a una disminución del riesgo de RB, siendo todas estas estadísticamente significativas. En el análisis multivariado solo el score de Gleason 7 fue significativo; el tratamiento con PRL, PRR o Braquiterapia no se asoció con mayor riesgo de RB. CONCLUSIÓN: La braquiterapia y la prostatectomía radical laparoscópica o robótica, no mostraron diferencias en términos de riesgo de recaída bioquímica en pacientes tratados por tumores de bajo riesgo, o riesgo intermedio con bajo volumen tumoral

OBJECTIVES: To evaluate the results of patients treated with Radical Prostatectomy (RP) and Brachytherapy for low- and intermediate-risk localized prostate cancer and to determine the Biochemical Recurrence (BCR) risk according to the treatment performed. METHODS: The study included 129 patients treated with iodine-125 seeds Brachytherapy, 98 patients treated with Laparoscopic RP (LRP), and 61 patients treated with Robotic RP (RRP) at our institution between December 1999 and January 2010, who had a low-risk disease according to D'Amico criteria (PSA < or = 6, cT1c-T2a), or an intermediate-risk disease (PSA = or >10 and < 20 ng/mL, Gleason = 7, cT2b), but with a tumor burden of up to 30%. Follow-up was conducted with PSA at 1, 3, and 6 months, and then every six months. As for Brachytherapy, annual digital rectal examinations were also performed. A PSA level increase of 2 ng/mL above the nadir in Brachytherapy (confirmed in 2 cases) and a PSA value greater than 0.2 ng/mL after RP were considered BCR. RESULTS: Overall mean follow-up was 60.5 months (R:1-152), with a mean time for BCR of 51.7 months (R:1-138). Estimated 5-year Biochemical Recurrence-free Survival (BCRFS) in patients with D'Amico low-risk was 85.7%, 77.2% and 90.7% (p 0.336), while for intermediate-risk it was 75.8%, 68.1% and 65.1% (p 0.114), for Brachytherapy, LRP and RRP respectively. In the univariate analysis, the Gleason score 7, a clinical stage T2b, and a D'Amico intermediate-risk were associated with an increased BCR risk, and treatment with Brachytherapy was associated with a decreased BCR risk, all these being statistically significant. In the multivariate analysis, only the Gleason score 7 was significant; treatment with LRP, RRP or Brachytherapy was not associated with a greater BCR risk. CONCLUSION: Brachytherapy and Laparoscopic or Robotic Radical Prostatectomy showed no difference in terms of Biochemical Recurrence risk in patients treated for low-risk or intermediate-risk tumors, with low tumor volume

International multi-institutional experience with the vessel-sparing technique to reconstruct the proximal bulbar urethra: mid-term results.

OBJECTIVE: To present mid-term outcomes from an international, multi-institutional cohort of patients undergoing vessel-sparing excision and primary anastomosis urethroplasty for the reconstruction of the anterior urethra. MATERIALS AND METHODS: From June 2003 to December 2011, 68 patients underwent vessel-sparing anterior urethral reconstruction at five different international institutions using the vessel-sparing technique described by Jordan et al. (J Urol 177(5):1799-1802, 2007). RESULTS: Patients' age range was from 3 to 82 years (mean 51.2). Stricture length ranged from 1 to 3 cm (mean 1.78). After a mean follow-up of 17.6 months, 95.6 % of patients had a widely patent urethral lumen. Three patients failed the procedure, requiring either direct vision internal urethrotomy or urethral dilation, after which all were free of symptoms and did not require further instrumentation. Complications were minimal and as expected following open urethroplasty. CONCLUSION: Preservation of blood supply is a noble pursuit in surgery; however, it can be technically difficult and often requires more time and effort. This vessel-sparing technique for anterior urethral reconstruction is reproducible and appears to be reliable in this international cohort. Larger studies and longer follow-up are needed to support these encouraging results.

Salvage radical prostatectomy after radiotherapy.

OBJECTIVES: To determine the oncological and functional results obtained after salvage radical prostatectomy (SRP) in patients with recurrence following radiotherapy (3 consecutive PSA rises after a nadir until the year 2006, then 2 ng/mL above nadir ) for prostate cancer (PC), and to analyze the impact of different pre-and postoperative variables on biochemical recurrence-free survival (BCR-free survival). METHODS: Retrospective analysis of 29 cases treated with SRP, 23 cases of conventional technique and 6 cases assisted by the Da Vinci surgical system between August 2004 and March 2012 at the Hospital Italiano de Buenos Aires. There was an attempt to preserve neurovascular bundles in cT1c patients with low tumor volume, Gleason score 7 or less, and favorable surgical anatomy. The degrees of postoperative incontinence and erectile function were recorded. The overall survival, the disease-specific survival, and the BCR-free survival were assessed. The BCR-free survival was compared among groups in accordance with the pre-and post-operative variables. RESULTS. No complications,injury to nearby organs or blood transfusions were recorded. Of all the patients, 85.7% showed normal continence (no pads used). Eight patients (27.5%) preserved their potency with sildenafil. There were 6 positive margins for tumor extension, 44.8% of pT3a, and 10.3% pT3b. All patients are alive at present, and 58.6% with at least 1 year of follow-up have a PSA with recovery criteria (less than 0.02 ng/mL). The biochemical recurrence (BCR) was 41.3%, and the estimated 4-year BCR-free survival was 51.7%. Of the groups analyzed, the presence of a preoperative Gleason score ≥8 and the presence of positive surgical margins (PSMs) significantly influenced the BCR-free survival, both in the univariate as well as the multivariate analysis (p=0.02 and 0.017, respectively). CONCLUSIONS. SRP is a challenging and achievable surgery with an acceptable complication rate, and constitutes a chance to cure patients with biochemical recurrence following prostate radiotherapy. The presence of a preoperative Gleason score ≥8, and the presence of PSMs in the specimen increase the chances of a BCR after four years post-SRP.

Prostatectomía radical de rescate post radioterapia / Salvage radical prostatectomy after radiotherapy

OBJETIVO: Determinar los resultados oncológicos y funcionales obtenidos tras prostatectomía radical de rescate (PR-R) en pacientes recidivados post radioterapia (elevación del PSA en 3 oportunidades consecutivas hasta 2006, luego 2ng/ml sobre el nadir) por cáncer de próstata (CP), y analizar el impacto en la supervivencia libre de recaída bioquímica de diferentes variables pre y postoperatorias. MÉTODOS: Análisis retrospectivo de 29 casos tratados con PR-R, 23 técnica convencional y 6 asistidos por el sistema robótico da Vinci, entre agosto de 2004 y marzo de 2012 en el Hospital Italiano de Buenos Aires. Se intento realizar conservación neurovascular en pacientes cT1c con bajo volumen tumoral, gleason 7 o menor y anatomía quirúrgica favorable. Se objetivó el grado de incontinencia y erección postoperatoria. Se evaluó la supervivencia global y especifica por enfermedad así como también la supervivencia libre de recaída bioquímica (SLRB). Se comparó la SLRB entre grupos de acuerdo a variables pre y postoperatorias. RESULTADOS: No se registraron complicaciones ni lesiones a órganos vecinos, ni transfusiones de sangre. El 85,7 % presenta continencia normal (no utiliza paño). Ocho pacientes (27,5%) conservan su potencia con sildenafil. Hubieron 6 márgenes positivos para extensión tumoral, 44,8% de pT3a y 10,3% pT3b. Todos los pacientes se encuentran vivos al momento y 58.6% con por lo menos 1 año de seguimiento presentan un PSA con criterio de curación (menor de 0,02ng/ml). La recaída bioquímica fue del 41,3% y la SLRB estimada a 4 años fue del 51,7%. De los grupos analizados, tanto la presencia de un score de gleason preoperatorio ≥ 8 y la presencia de márgenes quirúrgicos positivos (MQP) influyeron de manera significativa en la SLRB tanto en el análisis univariado como en el multivariado (p=0,02 y 0,017, respectivamente). CONCLUSIONES: La PR-R es una cirugía desafiante y realizable con un índice de complicaciones aceptable, siendo una oportunidad de curación en pacientes con recidiva bioquímica tras radioterapia de próstata. La presencia de un score de gleason preoperatorio ≥ 8 y la presencia de MQP en la pieza aumentan las posibilidades de tener una recaída bioquímica a los cuatro años post PR-R

OBJECTIVES: To determine the oncological and functional results obtained after salvage radical prostatectomy (SRP) in patients with recurrence following radiotherapy (3 consecutive PSA rises after a nadir until the year 2006, then 2 ng/mL above nadir) for prostate cancer (PC), and to analyze the impact of different pre- and postoperative variables on biochemical recurrence-free survival (BCR-free survival). METHODS: Retrospective analysis of 29 cases treated with SRP, 23 cases of conventional technique and 6 cases assisted by the Da Vinci surgical system between August 2004 and March 2012 at the Hospital Italiano de Buenos Aires. There was an attempt to preserve neurovascular bundles in cT1c patients with low tumor volume, Gleason score 7 or less, and favorable surgical anatomy. The degrees of postoperative incontinence and erectile function were recorded. The overall survival, the disease-specific survival, and the BCR-free survival were assessed. The BCR-free survival was compared among groups in accordance with the pre- and post-operative variables. RESULTS. No complications, injury to nearby organs or blood transfusions were recorded. Of all the patients, 85.7% showed normal continence (no pads used). Eight patients (27.5%) preserved their potency with sildenafil. There were 6 positive margins for tumor extension, 44.8% of pT3a, and 10.3% pT3b. All patients are alive at present, and 58.6% with at least 1 year of follow-up have a PSA with recovery criteria (less than 0.02 ng/mL). The biochemical recurrence (BCR) was 41.3%, and the estimated 4-year BCR-free survival was 51.7%. Of the groups analyzed, the presence of a preoperative Gleason score ≥8 and the presence of positive surgical margins (PSMs) significantly influenced the BCR-free survival, both in the univariate as well as the multivariate analysis (p=0.02 and 0.017, respectively). CONCLUSIONS: SRP is a challenging and achievable surgery with an acceptable complication rate, and constitutes a chance to cure patients with biochemical recurrence following prostate radiotherapy. The presence of a preoperative Gleason score ≥8, and the presence of PSMs in the specimen increase the chances of a BCR after four years post-SRP

SIU/ICUD Consultation on Urethral Strictures: Anterior urethra--primary anastomosis.

The management of primary and recurrent bulbar urethral stricture disease has been a source of controversy with the choice being between endoscopic urethrotomy and open urethroplasty. Further debate exists with regard to the choice of urethroplasty--either excision and primary anastomosis (EPA) or augmentation with a graft or flap. Using PubMed, a 35-year literature search was conducted (1975-2010) for peer-reviewed articles on bulbar strictures treated using EPA. Exclusions included articles with <10 patients, duplications, reviews, or in which the cohort was mixed and the data could not be separately analyzed. Seventeen articles fulfilled the criteria with a total of 1234 patients. Overall success was 93.8%. Reported complications were <5%, and there was no evidence of persistent loss of sexual function. The authors conclude that EPA is associated with a high success rate with low complication rate. Our recommendation is that it should be performed in patients with short isolated bulbar strictures, when expected success rates of other procedures are <90%.

Histologic changes after urethroplasty using small intestinal submucosa unseeded with cells in rabbits with injured urethra.

OBJECTIVE: To determine whether small intestine submucosa has the same regenerative capacity when urethroplasty is performed in injured urethras. METHODS: Our experiment was conducted in 30 New Zealand male rabbits, all of which had urethral injury. One month after the injury, the animals were randomized into a control group or a group with onlay urethroplasty with small intestine submucosa. The animals were euthanized at 2, 4, 12, 24, and 36 weeks after urethroplasty, and their urethras were removed for histologic and immunohistochemical examination. Before the scheduled euthanasia, urethrography and cystoscopy were performed. RESULTS: After 2 weeks, there was evidence of a continuous monolayer of stratified epithelial cells and absence of smooth muscle fibers. One month later, the epithelium showed no changes from the previously observed features, but some smooth muscle fibers (representing newly formed vessels) became apparent. After 3 months, the graft showed increased concentration of smooth muscle fibers. After 6 and 9 months, the density of smooth muscle cells remained unchanged. Fiber arrangement was irregular, particularly at the anastomosis site. Epithelial and smooth muscle phenotypes were confirmed by immunohistochemistry using anti-pan-citokeratin (AE1/AE3) antibodies and anti-α-smooth muscle actin, respectively. CONCLUSION: Small intestine submucosa promotes regeneration in traumatized urethras, with slightly delayed epithelialization and abnormal distribution of smooth muscle. Urethral damage caused by trauma interferes with the normal healing process.

Diagnósticos e intervenções de enfermagem em fasceíte necrotizante secundária a cisto pilonidal / Nursing diagnosis and interventions in necrotizing faciitis secondary to pilonidal cyst

Introdução: A doença pilonidal é uma afecção supurativa, de localização subcutânea, encontrada, quase sempre, na região sacrococcígea. Apresenta sintomatologia complexa e apresentações clínicas variáveis. O retardo no seu diagnóstico pode desencadear fasceíte necrotizante, infecção rara, polibacteriana, destrutiva e rapidamente progressiva. Objetivo: O propósito deste estudo foi revisar criticamente o tema através da descrição de um caso de fasceíte necrotizante secundária a cisto pilonidal com elaboração de diagnósticos e intervenções de Enfermagem. Método: Descreve-se o caso de um paciente de 14 anos apresentando fasceíte necrotizante extensa em região dorsal do tronco secundária a cisto pilonidal. Resultado e Discussão: Inicialmente, o tratamento foi realizado com reposição e controle hidroeletrolítico, antibioticoterapia de amplo espectro e desbridamento cirúrgico imediato e radical do tecido necrótico com cicatrização por segunda intenção. Os curativos foram diários, sendo realizados com Colagenase-Cloranfenicol. No 2º PO iniciaram-se as sessões de oxigenoterapia hiperbárica. No 16º PO, foi realizado enxerto dermo-epidérmico. Utilizou-se Granugenol (pasta) nas áreas doadoras diariamente. O tratamento hiperbárico estendeu-se até após a alta hospitalar, a qual ocorreu nove dias após o enxerto. As características das doenças são discutidas. Foram identificados 18 Diagnósticos de Enfermagem da taxonomia II da North American Nursing Diagnosis Association, com as respectivas Intervenções /Atividades principais da Nursing Intervention Classification.

Introduction: Pilonidal disease is a subcutaneous suppurative infection usually found in the sacrococcygeal area, of complex symptomatology and varied clinical characteristics. Its late diagnosis may develop into necrotizing fasciitis, a destructive and rapidly spreading rare polybacterial infection. Objective: the objective of this research was to discuss and review this subject through the descrition of a case of necrotizing fasciitis secondary to pilonidal cyst, with the elaboration of Nursing diagnoses and interventions. Method: The case involves a previously healthy 14 year-old patient who presented extensive necrotizing fasciitis in the dorsal part of the torso, secondary to pilonidal cyst. Results/Discussion: The initial treatment was done with hydroelectrolytic control and reposition, large spectrum antibiotic therapy and immediate and radical surgical debridement of the necrotized tissue with healing by second intention. Daily bandaging was done using Collagenase/Cloranphenicol. In the 2nd PO the hyperbaric oxygen therapy sessions were started. In the 16th PO, an dermoepidermic graft was done. Granugenol (balm) was daily applied to donating areas. The hyperbaric treatment was maintained until after the patient's discharge from hospital, which occurred nine days after graft. The characteristics of the disease are also discussed. It was possible to identify 18 Nursing Diagnoses of taxonomy II of the North American Nursing Diagnosis Association, with the respective Interventions / Main activities of the Nursing Intervention Classification.

Prevalência da síndrome metebólica em indivíduos atendidos em uma unidade básica de saúde / Prevalence of the methabolic syndrome in individuals assisted in a basic unit of health

Introdução. A síndrome metabólica, característica das transiçõese pidemiológica, demográfica e comportamental, associa-se à doença cardiovascular e aumenta a morbimortalidade populacional. Alguma sações programáticas realizadas em Unidades Básicas de Saúde objetivam controlar fatores de risco cardiovascular, preocupando-se individual e coletivamente. Objetivo O propósito desta pesquisa foi estabelecer a prevalência da síndrome metabólica nos indivíduos integrantes dos Programas Municipais de Saúde do Adulto de Controle da Hipertensão Arterial Sistêmica e do Diabetes, atendidos em uma Unidade Básica de Saúde de Bauru (SP), e correlacionar fatores determinantes entre si. Métodos. A amostra incluiu 169 indivíduos, submetidos a medidas antropométricas, de pressão arterial e perfil bioquímico. Foram utilizados pontos de corte propostos pelas Diretrizes Brasileiras de Diagnóstico e Tratamento da Síndrome Metabólica, de Hipertensão, de Dislipidemias, e Atualização Brasileira sobre Diabetes...

Introduction: The metabolic syndrome, a characteristic of the epidemiological, demographic and comportmental transition, can be associated to cardiovascular disease and promote increase morbimortality. Some programmed actions conducted by HealthBasic Units aim at controlling cardiovascular risk factors at theindividual and the community level of concern. Objective: the objective of this study was to establish the prevalence of metabolic syndrome in individuals participating Municipal Health Programsfor Adults to Control Systemic Arterial Hypertension and Diabetes, and who attend a Health Basic Unit in Bauru (SP), as well as to correlate determining factors. Methods: Sample included 169 individuals submitted to anthropometric measures of blood pressure and biochemical profi le. The study employed cut points proposed bythe Brazilian Guidelines for Diagnosis and Treatment of Metabolic Syndrome, of Arterial Hypertension, of Dislipidemies, and Brazilian Upgrade on Diabetes...