Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access

INTRODUCTION

Rectal injury is a rare complication after extraperitoneal laparoscopic radical prostatectomy. The development of rectourethral fistulas (URF) from rectal injuries is one of the most feared and of more complex resolution in urology.

MATERIAL AND METHODS

Between 2013 and 2020 we have operated on a total of 5 patients with URF after extraperitoneal endoscopic radical prostatectomy through a perineal access using the interposition of biological material. All fistulas had a diameter of less than 6 mm at endoscopy and were less than 6 cm apart from the anal margin.

RESULTS

The mean age of the patients was 64 years old. All patients had a previous bowel and urinary diversion for at least 3 months. Under general anesthesia and with the patient in a forced lithotomy position, fistulorraphy and interposition of biological material of porcine origin (lyophilized porcine dermis [Permacol®]) were performed through a perineal access. Mean operative time was 174 min (140-210). Most patients were discharged on the third postoperative day. The bladder catheter was left in place for a mean of 40 days (30-60). Prior to its removal, cystography and a Gastrografin® barium enema were performed, showing resolution of the fistula in all cases.

CONCLUSIONS

The interposition of biological material from porcine dermis through perineal approach is a safe alternative with good results in patients submitted to urethrorectal fistulorraphy after radical prostatectomy.

[Tolerance of prostate biopsy with use of local anesthesia and benzodiazepines: a randomized, prospective study]

INTRODUCTION

Prostate biopsy is an uncomfortable procedure, and attempts are therefore being constantly made to try and decrease biopsy-related pain.

MATERIALS AND METHODS

A randomized, prospective study including 160 procedures was designed. Inclusion criteria were: first biopsy, PSA < 15 ng/mL, and age under 75 years. Patients were randomized into 4 groups. Group A was the control group, while group B received intracapsular anesthesia (8 mL of 2% lidocaine), group C 5 mg of oral clorazepate dipotassium one hour before biopsy, and group D both local anesthesia and clorazepate. Each patient completed a questionnaire including three 10-point visual analog scales for pain immediately after the procedure and 30 minutes later.

RESULTS

Mean pain scores were 5.17 (group A), 1.72 (group B), 2.43 (group C), and 0.88 (group D) in the first questionnaire, and 1.71, 0.25, 0.75 and 0.35 respectively in the second questionnaire. Statistically significant differences were found in the ANOVA test. Group comparisons showed the following: 1. A vs B: statistically significant differences in both questionnaires (p = 0.006 and 0.011). 2. A vs C: a significant difference was found in the first questionnaire (0.051), but not in the second (0.012). 3. A vs D: significant differences in both questionnaires (0.001 and 0.010). No statistically significant differences were seen in both questionnaires (0.825 and 0.685) when benzodiazepines where added to local anesthesia (B vs D).

CONCLUSION

Use of benzodiazepines as a single method to decrease biopsy-related pain is not warranted.

[Greenlight Laser Photoselective vaporization of the prostate (PVP). Surgical advantages in risk patients]

It is more and more common to have patients in our clinics with the diagnosis of BPH and indication for surgery who present limitations due to their medications, age, associated morbidity or psychosocial conditions. Transurethral resection of the prostate, though it is the surgical standard of reference, is not free from complications such as reabsorption syndrome, bleeding, or even blood transfusion in a percentage of cases. Laser PVP may be a valid alternative in this subgroup of patients. We review our experience with this procedure, as well as the published articles on this topic, and describe technical recommendations we consider useful to avoid complications when possible during surgery or the immediate postoperative period.

[Rhabdomyolysis after laparoscopic nephrectomy: case report]

OBJECTIVE

To show the clinical management of rhabdomyolysis secondary to laparoscopic surgery and how clinical treatment may be enough for adequate resolution.

METHODS

Laparoscopic nephrectomy is a routine technique, which may have associated morbidity. We present one case of rhabdomyolysis which presented as gluteal pain and functional impotency, together with skin lesions, acute renal failure and elevated muscle enzymes.

RESULTS

In our case, the patient had a satisfactory outcome with medical treatment. We perform a bibliographic review in which we identify multiple risk factors, such as body mass index, surgical time, position during operation with lateral decubitus and 40-60 degrees flexion. Prevention is the most important factor to avoid acute renal failure secondary to myoglobin.

CONCLUSIONS

Prevention, early detection, and immediate start of therapeutic measures are essential for the good resolution of rhabdomyolysis after surgery.

Uso de la urografía por resonancia magnética en el estudio del aparato urinario frente a la urografía convencional

Conventional urography (IVU) is an essential examination for the assessment of urinary tract but it is not free of complications, such as adverse reactions to contrast agents used (vasovagal and anaphylactic reactions), neurotoxicity, nephrotoxicity, as well as the damage due to the ionizing irradiation applied to the patient. For this reason, alternative imaging techniques such as magnetic resonance (MR) urography or uro-resonance have been developed.

OBJECTIVE

We present a case study assessing the diagnostic accuracy, specificity and sensitivity of uro-resonance and IVU as a morphological and functional examination of the urinary tract: and a quality study of the urographic images obtained with MR versus IVU.

MATERIALS AND METHODS

150 patients have submited to a MR study, 63 of them with an IVU study already performed, acquiring high-intensity signals at T2 corresponding to abdominal and retroperitoneal fluid, initially using furosemide at low doses and, in a final study, administering gadolinium at a rate of 0.1 mg/Kg. The test was indicated in patients with antecedents of adverse reactions to iodine contrast, acute or chronic kidney failure, functional cancellation of the kidneys, pregnant patients and those in paediatric age. The capacity of diagnosis of urinary obstruction and the aetiology of this obstruction of both tests was studied, as well as the quality of the images obtained by the urographic study using MR.

RESULTS

High resolution images were obtained of all the upper urinary tracts using MR, especially in the renal pelvis, without artefacts caused by peristalsis or intestinal fluid interposition. In 83.3% of cases, examinations revealed urological pathology. The diagnostic accuracy of the involvement cause of the urinary tract was 83.3%, with a sensitivity of 89.6%, a specificity of 69.2%. a positive predictive value of 86.6% and a negative predictive value of 75%.

CONCLUSION

MR urography is a high sensitive technique for the study of urinary tract, used as an alternative to conventional urography particularly in cases of the contraindication of ionizing radiation or allergy to the contrast agent, as well as in patients with renal failure, and offers a wider morphological and functional study, with a high image quality, able to displace conventional examinations in the short or medium term.

[Diagnosis and management of cystic dysplasia of the seminal vesicle]

INTRODUCTION AND OBJECTIVES

Cystic dysplasia of the seminal vesicle represents a rare congenital urologic anomaly of which elective treatment is controversial. We present our experience in the diagnosis and management of this uncommon pathology.

PATIENTS AND METHOD

During the last twelve years we have managed eight patients affected by this pathology. The diagnosis was incidental in the three asymptomatic patients, while the other five consulted because of low urinary tract sympthoms. Ectopic drainage of the ureter in the pathological seminal vesicle was found in three of the patients. Two of these patients presented large pelvic and ureteral ectasy. Other five patients presented renal agenesis.

RESULTS

In asymptomatic patients we adopted an expectant attitude, while the other five patients underwent surgical treatment. We performed open surgery in the two cases presenting ureterohydronephrosis, whereas in the other three we performed transurethral incision of the seminal vesicle. We obtained excellent results in all of them, with no evidence of symptomatic pseudodiverticulum.

CONCLUSIONS

Transurethral incision of the seminal vesicle cyst is a minimal invasive procedure with low morbidity. We have proved in all of our cases that the retraction of the cyst was practically complete, this has led us into believing that transurethral incision is the elective treatment. Therefore, open surgery would only be indicated in cases of failure of the procedure due to existence of symptomatic pseudodiverticulum, or in patients presenting renoureteral ectasy associated.

Complicaciones de la prostatectomía radical: evolución y manejo conservador de la incontinencia urinaria

OBJECTIVES

Radical retropubic prostatectomy is the major procedure for curing early stage prostate cancer. In this retrospective study we valued the complications of this surgery and its evolution in time, as well as the efectiveness of the urinary incontinence preservative treatment in the recovery of urinary continence.

MATERIALS AND METHODS

During the period between december of 1998 to january of the 2005 we have treated 168 patients suffering prostatic adenocarcinoma clinically confined to the gland by means of retropubic radical prostatectomy. We removed the vesical catheter the fourteenth day of the postoperative and made a clinical monitoring the first, third and sixth month after the surgery, and thereafter every six months.

RESULTS

Of the 168 patients who underwent clinical surgery, 15% required postoperative blood transfusion in the immediate postoperative. Other complications, with a lower incidence, were the intestinal perforation, surgical wound infection and the haematoma. The most frequent delayed complications we registered were erectile dysfunction, observed in 164 patients (98%), micturition alterations in 32 patients (19%) and intestinal alterations in approximately 11%. Among the micturitional alterations found, the most frequent (64%) was the Urinary Incontinence (UI). However, most of them were of minor importance (34%) and all improved during the first six months after the surgery. We advised patients with minor and moderate UI to perform pelvic floor muscle training, being very useful since they allowed to anticipate the recovery of continence.

CONCLUSIONS

Radical prostatectomy continues to be the most effective treatment for the non spared prostate cancer, in spite of the associated morbidity. The IU is the main factor for the high standard of living these patients. Despite the number of patients with UI being so high, most cases are moderate and minor and may improve with pelvic floor muscle training. Hence, this is a significant tool to tackle this illness, whether in connection with the use of absorbent, the pharmacologic therapy or the use of penile collectors.