Carlos Giudice

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.

Estudio randomizado sobre continencia urinaria postprostatectomía radical con rehabilitación perineal kiesica previa

La incontinencia urinaria es una de las principales complicaciones luego de la realizacion de prostatectomia radical (PR). La rehabilitacion kinesica preoperatoria, podria ser de utilidad como tratamiento preventivo de esta complicacion. Demostrar la utilidad de la kinesiologia perineal preoperatoria en la recuperacion precoz de la continencia urinaria post prostatectomia radical. METODOS Ensayo Clinico Controlado Randomizado Aleatorizado. 38 pacientes fueron divididos en dos grupos de 19 previo a la realizacion de la PR. El primer grupo (K) recibio tratamiento kinesico preoperatorio, mientras que el segundo grupo (NK) no (grupo control). Se evaluo la continencia de orina a los 14, 30 y 60 dias post extraccion de sonda. RESULTADOS No hubo diferencias epidemiologicas y de biologia tumoral entre grupos. El porcentaje de pacientes continentes en el grupo K al los 14, 30 y 60 dias, respectivamente fue de 47,36%, 47,36% y 78,9%, respectivamente, mientras que en el grupo NK fueron de 47,36%, 47,36% y 89,4%, respectivamente (p>0,05). CONCLUSIONES Los ejercicios kinesicos perineales previos a la prostatectomia radical, no disminuyeron los tiempos de recuperacion de la continencia urinaria ni la ocurrencia de la misma.

Fractura de pene con lesión asociada de uretra: presentación de un caso y revisión de la literatura

Resumen es: Objetivo: La fractura de pene es una lesion que responde habitualmente a un traumatismo cerrado que ocurre con el pene en ereccion. Cerca del 20-30% de l...

Initial experience with clinical islet transplantation in Argentina.

WHOLE pancreas transplantation may be the best therapeutic option for type I diabetic patients in advanced stages of their disease. However, those patients who are not eligible for whole pancreas transplantation may still benefit from pancreatic cell transplantation, which in spite of its lower rate of insulin independence, involves a minor surgical procedure and a lower posttransplant risk. We herein report our initial experience on pancreatic islet transplantation at a kidney and pancreas transplantation program based in Argentina since 1995.

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.