David Martinho

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.

Bilateral synchronous testicular seminoma: A rare presentation of a rare disease

OBJECTIVE To present a case of a bilateral synchronous testicular seminoma in a young male clinical stage IIB. MATERIAL AND METHOD A 37 years old man presented a bilateral testicular mass with elevated tumoral markers. Histology of frozen section revealed bilateral seminoma and bilateral radical orchiectomy was performed. RESULT Enhanced chest and abdominopelvic staging CT scan revealed a lymphadenopathy of 30 mm within the inter-aortocava nodal chain (stage IIB). Patient received three cycles of BEP. Three months later 18F-FDG PET showed no evidence of hypermetabolic activity and serum tumoral markers were normal. CONCLUSION Bilateral testicular germ cell tumors are a rare disease. Management of this tumors is controversial. Bilateral radical orchiectomy is the standard of care, nevertheless, in order to preserve fertility and androgen production, an organsparing surgery can be attempted in selected cases. Although prognosis is good, with overall survival rates similar to patients with unilateral disease, life-long close follow-up may be advocated due to relapse risk.

“Horrendoplasty” – A case of total perineal destruction by agricultural implement

Although posterior urethral injury occurs almost always in association with pelvic fracture, it may result from severe trauma to the perineum with its associated potential lethality and severe morbidity. Early primary endoscopic realignment over a urethral catheter can be attempted, although an immediate suprapubic tube placement remains the standard of care. Definitive treatment consists of elective open posterior anastomotic urethroplasty through a perineal approach. The authors present a 53-year-old man who sustained total, massive perineal destruction resulting from work accident with an agricultural implement. Immediate suprapubic tube placement was performed followed by delayed elective transperineal anastomotic posterior urethroplasty. A major multidisciplinary approach was necessary in the management strategy, including orthopedic, general, plastic, vascular surgeries, and reconstructive urology teams. At a later stage, with the patient stabilized and recovered from major, life-threatening lesions dealt with by a multidisciplinary team, urethral reconstruction can be undertaken with ultimate good functional outcomes.

A Prospective Randomized Trial Comparing the Vienna Nomogram and a Ten-Core Prostate Biopsy Protocol: Effect on Cancer Detection Rate

&NA; We performed a prospective randomized study of men undergoing prostate biopsy randomized to a Vienna nomogram protocol (group A) or a 10‐core protocol (group B). The results suggest that the use of the Vienna nomogram does not significantly increase the overall cancer detection rate compared with a 10‐core biopsy scheme. Further prospective randomized studies, with adequate sample sizes, are needed to definitively determine the best prostate biopsy protocol. Background: We evaluated whether the Vienna nomogram increases the detection rate of transrectal ultrasound‐guided prostate biopsy compared with a 10‐core biopsy protocol. Patients and Methods: In the present prospective randomized study, men eligible for prostate biopsy were randomized to a Vienna nomogram protocol (group A) or a 10‐core protocol (group B). They were further stratified according to age (≤ 65, > 65 but ≤ 70, and > 70 years) and prostate volume (≤ 30, > 30 but ≤ 50, > 50 but ≤ 70, and > 70 cm3). The cancer detection rate (CDR) was compared between the groups by logistic regression analysis, with adjustment for age as necessary, overall and with age and prostate volume stratification. Additional statistical analysis was performed with Fishers exact test for contingency tables and the Mann‐Whitney U test for 2 independent samples. P < .05 was considered statistically significant. A subgroup analysis was performed for patients with serum prostate‐specific antigen levels of 2 to 10 ng/mL. Results: From January 2009 to July 2010, 456 patients were enrolled, 237 to the Vienna nomogram group and 219 to the 10‐core group. No significant differences were found in serum prostate‐specific antigen or prostate volume between the 2 groups. Multivariate analysis with adjustment for age revealed no significant differences in CDR, with 42.6% in group A and 38.4% in group B (P = .705). When stratified by age and prostate volume, no statistically significant differences were found in the CDR between the groups in all subclasses. Also, in the subgroup analysis, CDR was not significantly different, 37.9% versus 34.7% for groups A and B, respectively (P = .891). Conclusion: These results study suggest that the use of the Vienna nomogram does not significantly increase the overall CDR compared with a 10‐core biopsy scheme. Further prospective randomized studies, with adequate sample sizes, are needed to definitively determine the best prostate biopsy protocol.

Hutch bladder diverticulum - unusual cause of adult obstructive uropathy

OBJECTIVE To present a case of a Hutch bladder diverticulum containing the ureteral opening. MATERIAL AND METHODS An 83-year-old man presented a giant bladder diverticulum causing obstructive azotemia due to bilateral ureteral compression. Endoscopy revealed an unusual and potentially harmful anatomical alteration: the left ureteral orifice was inside in the diverticulum. Despite bladder emptying, the diverticulum remained full, causing bilateral ureteral compression. The patient underwent diverticulectomy with ureteroneocystostomy. RESULT Post-operative follow-up showed renal and voiding functions restoration. CONCLUSION Although clinical watching is a valid option in patients with Hutch diverticulum, reconstructive surgical approach, especially when complications are present, should be the standard of care.