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.

Mind the model for end-stage liver disease: model for end-stage liver disease score as an indicator of hemoderivate transfusion and survival in liver transplantation

The scarcity of liver donors has increased the necessity to closely select recipients to improve liver transplantation outcomes. If we were able to recognize those recipients with the best outcomes, then this could result in a better and more accurate selection of our donors. Hemoderivate transfusion is one of the main important factors to analyse. We reviewed the data of all of our liver transplant recipients from May 1998 to December 2013 and selected 888 patients with complete records. We divided these patients into 5 groups to get a better selection. We found differences between these groups with respect to the following: recipient age at the time of transplantation, percentage of patients with hepatocarcinoma, and those with hepatitis C virus (HCV)-related etiology. Also, intensive care unit (ICU) time and the need for retransplantation were distinctive factors with observable differences between our groups. With respect to model for end-stage liver disease (MELD) score, the groups were clearly defined by their mean MELD score, finding significant statistical differences between these groups with respect to this score. We also found a significant relationship between MELD scores and survival in the different groups. This is also the first review in which the MELD score and intraoperative transfusion requirements are well associated with patient and graft survival.

An approach to the rational use of steatotic donor livers in liver transplantation

Steatosis or fatty change is a common finding in donor liver biopsies during liver transplantation, and seems to be more frequent than in the general population. Fat can be stored in hepatocytes within macrovacuoles (macrosteatosis) or microvacuoles (microsteatosis), with different degrees of severity. Higher degrees of both macro and microsteatosis may increase the severity of the ischemia-reperfusion lesion producing an initial poor function in the recipient. Different pathogenic mechanisms have been investigated. However, only severe macrosteatotic (> 60%) grafts have been associated with primary non-function, and are universally rejected for transplantation. While donor livers with any severity of microsteatosis do not influence recipient survival and can be safely implanted, donor livers with moderate to severe macrosteatosis (30-60%) have a relative risk of primary non-function and should be considered for transplantation in the absence of other known risk factors. A protocol with a rational use of these steatotic livers is suggested.