Alexandre Pompeo

Early effectiveness of endoscopic posterior urethra primary alignment.

BACKGROUND Posterior urethra primary realignment (PUPR) after complete transection may decrease the gap between the ends of the transected urethra, tamponade the retropubic bleeding, and optimize urinary drainage without the need of suprapubic catheter facilitating concurrent pelvic orthopedic and trauma procedures. Historically, the distorted anatomy after pelvic trauma has been a major surgical challenge. The purpose of the study was to assess the relationship of the severity of the pelvic fracture to the success of endoscopic and immediate PUPR following complete posterior urethral disruption using the Young-Burgess classification system. METHODS A review of our Level I trauma center database for patients diagnosed with pelvic fracture and complete posterior urethral disruption from January 2005 to April 2012 was performed. Pelvic fracture severity was categorized according to the Young-Burgees classification system. Management consisted of suprapubic catheter insertion at diagnosis followed by early urethral realignment when the patient was clinically stable. Failure of realignment was defined as inability to achieve urethral continuity with Foley catheterization. Clinical follow-up consisted of radiologic, pressure studies and cystoscopic evaluation. RESULTS A total of 481 patients with pelvic trauma from our trauma registry were screened initially, and 18 (3.7%) were diagnosed with a complete posterior urethral disruption. A total of 15 primary realignments (83.3%) were performed all within 5 days of trauma. The success rate of early realignment was 100%. There was no correlation between the type of pelvic ring fracture and the success of PUPR. Postoperatively, 8 patients (53.3%) developed urethral strictures, 3 patients (20.0%) developed incontinence, and 7 patients (46.7%) reported erectile dysfunction after the trauma. The mean follow-up of these patients was 31.8 months. CONCLUSION Endoscopic PUPR may be an effective option for the treatment of complete posterior urethral disruption and enables urinary drainage to best suit the multispecialty surgical team. The success rate of achieving primary realignment did not appear to be related to the complexity and type of pelvic ring fracture. LEVEL OF EVIDENCE Epidemiologic study, level III; therapeutic study, level V.

Penile cancer: organ-sparing surgery.

Purpose of review Penile cancer is a devastating disease, usually diagnosed late, that requires wide excisions, which causes alterations in self-esteem and body image, affecting sexual and urinary functions, which compromise quality of life. Recently, an increasing interest in penile-sparing surgeries (PSSs) has emerged, aiming to spare patients from these complications. Recent findings Several options of PSS have been popularized for selected cases (Ta-1, Tis and some T2), such as wide local excision, circumcision, partial penectomy, total or partial glansectomies with or without glans-resurfacing procedures, as well as new glans reconstructions using spatulated urethral advances or free skin grafts. These options, in general, achieve good local control, with adequate functional results and satisfactory cosmetic appearance. The local recurrences, however, are slightly higher than amputations. Contemporary techniques such as laser or cryotherapy can be performed in selected cases. Summary PSS must be indicated only for superficial penile cancer cases, such as Tis and Ta-1, and for selected invasive lesions (small distal pT2 tumors). Candidates for PSS should be adherent to follow-up requirements, allowing early detection of local recurrences. Prompt and effective salvage procedures are mandatory in these situations.

Comparison beetwen open and laparoscopic radical cistectomy in a Latin American reference center: perioperative and oncological results.

ABSTRACT Objectives: To evaluate the differences of peri-operatory and oncological outcomes between Laparoscopic Radical Cystectomy and Open Radical Cystectomy in our center. Materials and Methods: Overall, 50 patients were included in this non randomized match-pair analysis: 25 patients who had undergone Laparoscopic Radical Cystectomy for invasive bladder cancer (Group-1) and 25 patients with similar characteristics who had undergone Open Radical Cystectomy (Group-2). The patients were operated from January 2005 to December 2012 in a single Institution. Results: Mean operative time for groups 1 and 2 were 350 and 280 minutes (p=0.03) respectively. Mean blood loss was 330 mL for group 1 and 580 mL for group 2 (p=0.04). Intraoperative transfusion rate was 0% and 36% for groups 1 and 2 respectively (p=0.005). Perioperative complication rate was similar between groups. Mean time to oral intake was 2 days for group 1 and 3 days for group 2 (p=0.08). Median hospital stay was 7 days for group 1 and 13 for group 2 (p=0.04). There were no differences in positive surgical margins and overall survival, between groups. Conclusions: In a reference center with pelvic laparoscopic expertise, Laparoscopic Radical Cystectomy may be considered a safe procedure with similar complication rate of Open Radical Cystectomy. Laparoscopic Radical Cystectomy is more time consuming, with reduced bleeding and transfusion rate. Hospital stay seems to be shorter. Oncologically no difference was observed in our mid-term follow-up.

1539 THE S.T.O.N.E. SCORE: A NOVEL INSTRUMENT TO PREDICT STONE FREE RATES IN URETEROSCOPY FROM PRE-OPERATIVE FEATURES

INTRODUCTION AND OBJECTIVES: Success of treatment for renal and ureteral stones depends on qualitative data such as stone size and location. Surgical decision making and data set comparisons would be significantly enhanced by a consistent, reproducible system that quantitates the pertinent characteristics of renal and ureteral stones. We have developed and propose a standardized lithometric scoring system (S.T.O.N.E Score) to quantify the anatomical characteristics of stones on computerized tomography. METHODS: The STONE score consists of 5 features known to effect the stone free rates of nephrolithiasis with ureteroscopy. The features examined include (S)ize, (T)opography (location), (O)bstruction, (N)umber of stones, and (E)valuation of Hounsfield Units. Each component is scored on a 1-3 point scale as shown in Table 1. We applied the STONE score to 186 consecutive ureteroscopy at Denver Health Medical Center. A logistic model was formed to our data for stone free rates. Stone free was considered the absence of stones or residual stone fragments less than 2 mm on visual inspection or by KUB. RESULTS: Stone free rates were found to be related to STONE Sum. As STONE Sum increased, the stone free rates decreased with a logical regression trend. The logistic model found was Stone Free 1 1/[1 Exp(5.5246 0.3669 * Score)] with an ROC 0.7. The comparison between our data and the model is shown in Table 2. In the STONE model, a score less than 9 has a stone free rate of more than 90% while a stone score greater than 14 has a rate less than 60%. Sum scores of 5, 6 and 14 did not fit with the model, likely because of too few cases. None of the patients in our series had a sum of 15. CONCLUSIONS: Our model correlated with our stone free rate data; however, Our model was limited by our small sample size. A model with individual weights to each feature from a multi-institutional study would more accurately predict stone free rates. This is a pragmatic model to implement in a clinical setting and is the first model to predict stone free rates from ureteroscopy.