Laparoscopic pyeloplasty proficiency during a residency program after adoption of a standardized simulation training program is maintained during the COVID pandemic despite reduced surgery volume

ABSTRACT Purpose: To evaluate the effect of the standardized laparoscopic simulation training program in pyeloplasty, following its implementation and during the COVID-19 pandemic. Material and Methods: A retrospective chart review was performed at Hospital de Clínicas de Porto Alegre, a tertiary referral center in south Brazil, in which 151 patients underwent laparoscopic pyeloplasty performed by residents between 2006-2021. They were divided into three groups: before and after adoption of a standardized laparoscopic simulation training program and during the COVID-19 pandemic. The main outcome was a combined negative outcome of conversion to open surgery, major postoperative complications (Clavien-Dindo III or higher) or unsuccessful procedure, defined as need for redo pyeloplasty. Results: There was a significant reduction in the combined negative outcome (21.1% vs 6.3%), surgical time (mean 200.0 min vs 177.4 min) and length of stay (median 5 days vs 3 days) after the adoption of simulation training program. These results were maintained during the COVID-19 pandemic (combined negative outcome of 6.3%, mean surgical time of 160.1 min and median length of stay of 3 days) despite a reduction in 55.4% of the surgical volume. Conclusion: A structured laparoscopic simulation program can improve outcomes of laparoscopic pyeloplasty during the learning curve.

Multicenter comparative study of open, laparoscopic, and robotic pyeloplasty in the pediatric population for the treatment of ureteropelvic junction obstruction (UPJO)

ABSTRACT Introduction: Dismembered open pyeloplasty described by Anderson and Hynes is the "gold standard" for the treatment of ureteropelvic junction obstruction. The aim of our study was to compare the results of open (OP) vs laparoscopic (LP) vs robotic (RALP) pyeloplasty. Material and Methods: A multicenter prospective review was conducted of pyeloplasty surgeries performed at five high-volume centers between 2014 and 2018. Demographic data, history of prenatal hydronephrosis, access type, MAG3 renogram and differential renal function, surgery time, length of hospital stay, and complication rate (Clavien-Dindo) were recorded. Access type was compared using the Kruskal-Wallis, Chi-square, or Fisher's exact tests. Results: A total of 322 patients were included: 62 OP, 86 LP, and 174 RALP. The mean age was 8.13 (r: 1-16) years, with a statistically significant lower age (mean 5 years) in OP (p < 0.001). There were no significant differences in the distribution of the side affected. Operative time was 110.5 min for OP, 140 min for LP, and 179 min for RALP (p < 0.0001). Hospital stay was significantly shorter in the RALP group than in the other groups (p < 0.0001). There were no differences in postoperative complications and reoperations between the three groups. Conclusions: Minimally invasive surgery for the management of UPJO in children is gaining more acceptance, even in patients younger than 1-year-old. Operative time continues to be significantly shorter in OP than in LP and RALP. Hospital stay was shorter in RALP compared to the other techniques. No differences were found in complication rates, type of complications, and reoperation rate.

Corporoplasty: A simplified technique for clitoroplasty

ABSTRACT Introduction Clitoroplasty constitutes an important step in feminizing surgery for congenital adrenal hyperplasia (CAH) ( 1 ). In this video we present a technique that aims to preserve clitoral sensitivity and engorgement while minimizing the risk of neurovascular lesion. Materials and methods We present a video of a three-year-old girl with history of CAH classical form, PRADER-III, who underwent clitoroplasty. After an initial endoscopic evaluation of the urogenital sinus, the clitoris was degloved and a rectangular incision was made on the ventral corpora cavernosa 15mm above the corpora bifurcation and 0.5 mm below the coronal sulcus. The cavernous tissue was partially resected. The upper and lower borders of the rectangular gap were closed by a 5-0 PDS running suture similar to the Mikulicz technique. Next, the edge of the glans was deepithelialized to reduce its size. For improved clitoral positioning, the clitoris was sutured to the pubic fat. From that point onward the procedure followed that of a standard vaginoplasty using the en-bloc technique ( 2 - 4 ). Thus far we have performed this technique in 33 patients, with 31 of them being girls with CAH and 2 being women with clitoral hypertrophy. Conclusion Corporoplasty is a simplified technique for clitoroplasty, with the advantage being that is faster and safer than the technique that involves the dissection of the neurovascular bundle. In addition, corporoplasty has the possible benefit of preserving the cavernosal blood flow that permits the engorgement of the clitoris during sexual arousal.

Sexuality of Female Spina Bifida Patients: Predictors of a Satisfactory Sexual Function / Sexualidade feminina em pacientes com espinha bífida: preditores de uma função sexual satisfatória

Abstract Objective To assess the sexual function of women with spina bifida (SB), and to verify the factors that influence their sexual function. Methods A cross-sectional study in which a validated female-specific questionnaire was applied to 140 SB female patients from four different cities (Porto Alegre, Brazil; and Barcelona, Madrid, and Málaga, Spain) between 2019 and 2020. The questionnaires collected data on the clinical characteristics of SB, and female sexual function was assessed using the 6-item version of the Female Sexual Function Index (FSFI-6) validated to Portuguese and Spanish. Results Half of the patients had had sexual activity at least once in the life, but most (57.1%) did not use any contraception method. Sexual dysfunction was present in most (84.3%) patients, and all sexual function domains were impaired compared those of non-neurogenic women. The presence of urinary and fecal incontinence significantly affected the quality of their sexual activity based on the FSFI-6. Conclusion The specific clinical aspects of the SB patients, such as urinary and fecal incontinence, should be properly addressed by their doctors, since they are associated with reduced sexual activity and lower FSFI-6 scores in the overall or specific domains. There is also a need to improve gynecological care among sexually-active SB patients, since most do not use any contraceptive methods and are at risk of inadvertent pregnancy.

Resumo Objetivo Analisar a função sexual de pacientes do sexo feminino com espinha bífida (EB), e avaliar quais fatores influenciam na função sexual. Métodos Uma pesquisa transversal em que um questionário validado para mulheres foi aplicado em 140 pacientes com EB de quatro cidades diferentes (Porto Alegre, Brasil; e Barcelona, Madri e Málaga, Espanha) entre 2019 e 2020. Os questionários coletaram dados sobre características clínicas da espinha bífida, e a função sexual feminina foi avaliada com a versão de seis itens do Índice de Funcionamento Sexual Feminino (IFSF-6) nas versões validadas para português e espanhol. Resultados Metade das pacientes havia praticado atividade sexual pelo menos uma vez na vida, mas a maioria (57.1%) não utilizava nenhum método contraceptivo. A disfunção sexual estava presente na maioria das pacientes (84.3%), sendo todos os domínios de função sexual prejudicados em comparação com os de mulheres não neurogênicas. A presença de incontinência urinária e fecal afetou significativamente a qualidade da atividade sexual das pacientes. Conclusão Aspectos clínicos específicos da EB, como incontinência urinária e fecal, devem ser adequadamente abordados pelos médicos assistentes, visto que estão associados à redução na atividade sexual e piores resultados no IFSF-6. Também é necessário melhorar o atendimento ginecológico das pacientes sexualmente ativas, uma vez que a maioria não utiliza métodos contraceptivos e corre o risco de gravidez inadvertida.

Step by step male to female transsexual surgery

ABSTRACT Introduction After the diagnosis of transsexualism is confirmed therapy commences with psychotherapeutic preparation for the conversion, and after conversion, long-term patient rehabilitation is maintained for at least two years. The indication for surgery is chronic discomfort caused by discord with the patient's natural gender, intense dislike of developing secondary sex characteristics and the onset of puberty. The surgical conversion of transsexuals is the main step in the complex care of these problematic patients (1). This surgery was first described by Benjamin H, using a flap of inverted penile skin (2) and is considered the gold standard since then. Male-to-female transsexual surgical techniques are well defined and give good cosmetic and functional results. Sex reassignment surgery promotes the improvement of psychological aspects and social relationships as shown in the World Health Organization Quality of Life Assessment applied in the patients submitted to this procedure (3). Techniques include the creation of a normal appearing female introitus, a vaginoplasty allowing sexual intercourse and the capability of clitoral orgasm (4). Various methods for neovaginoplasty have been described and can be classified into five categories, i.e. pedicled intestinal transplants, penile skin grafts, penile skin flaps, non-genital skin flaps and non-genital skin grafts (5). In our Hospital, we use penile and scrotal skin flaps. Until now, 174 procedures have been performed by our team using this technique with high rates of satisfaction (3). Patients and methods We present a step-by-step male to female transsexual surgery. Conclusion Surgical gender reassignment of male transsexuals resulted in replicas of female genitalia which enabled coitus with orgasm (1). With this video we show step by step that a surgery using penile skin flaps is able to be performed with good cosmetic results.

Assessment of satisfaction and Quality of Life using self - reported questionnaires after urethroplasty: a prospective analysis

ABSTRACT Objectives To assess patient satisfaction and quality of life after urethroplasty using two different self-reported outcome measures and to compare it with objective clinical data. Materials and Methods We prospectively collected data from 35 consecutive patients who underwent urethroplasty from January 2013 to September 2014. Patient demographics, International Prostate Symptom Score (IPSS), quality of life score, urethral stricture surgery patient-reported outcome measure (USS-PROM), maximum flow rate (Qmax) and post-void residual urine were collected before, two and eight months after surgery. Failure occurred when any postoperative instrumentation was performed. General estimation equation was used to compare the results and linear regression analysis to correlate both questionnaires with objective data. Results Mean age was 61 years. Urethroplasties were equally divided between anastomotic and buccal mucosa grafts and 19 patients (59.3%) had a previous urethral procedure. Overall success rate was 87.5%. IPSS improved from a mean 19 at baseline to 5.32 at 8 months (p <0.001). The mean USS-PROM score also improved from 13.21 preoperatively to 3.36 after surgery (p <0.001) and 84.3% of patients were satisfied or very satisfied with surgical results. Mean Qmax increased from 4.64mL/s to 11mL/s (p <0.001). Strong negative correlation was found respectively between flow rate and USS-PROM (r=-0.531, p <0.001) and with IPSS (r=-0.512, p <0.001). Conclusions Significant improvements in urinary symptoms and in quality of life are expected after urethroplasty and they are correlated with objective measures.

A new extra-abdominal channel alternative to the mitrofanoff principle: experimental and preliminary clinical experience

INTRODUCTION: The appendix is the gold-standard channel for the Mitrofanoff principle in pediatric urology, but the search for alternatives is justified considering it may not be available or preferably used for colonic stomas (Malone antegrade continence enema). The aim of this study is to report on technical feasibility of a new approach for creating catheterizable channels in a rabbit model and to present our preliminary clinical experience. MATERIAL AND METHODS: We configured a tube from two rectangular skin flaps 1x4 cm opposite each other in the middle line of the lower inferior abdomen. The channel was anastomosed to the bladder dome with embedding sutures to create a valvular mechanism. The experimental study consisted of 12 rabbits, divided in 4 groups according to the sacrifice schedule at 2, 4, 8 and 12 weeks. At 30th postoperative day, an urodynamic evaluation was performed to record continence of the stoma. A histological analysis of the specimens stained with hematoxylin-eosin, Masson trichrome and Picrosirius red was also done in group 2 (sacrifice at 4 weeks postoperatively). We used this method in 3 patients with congenital non-neurogenic bladder disease presenting with massive residual volumes without compliance deficits. RESULT: The technique proved feasible in all animals, 9 of 12 could be easily catheterized and underwent urodynamic study. No stoma leakage was observed in 7 animals at high bladder pressures (> 50 cm H20) and only 2 animals had some leakage at 40 cm H20. Urodynamics performed through the stoma showed urethral leakage at 20 cm H20, therefore demonstrating the efficacy of the valvular mechanism. Histological analysis confirmed good integration between the tube and the bladder. Mean follow-up of the clinical series (3 patients) was 7.2 months. Two patients remained continent up to 4 hours, whereas 1 patient had some leakage after 2 hours. CONCLUSION: We were able to confirm feasibility of a new extra-abdominal...

Estudo de viabilidade de aloenxerto de traquéia em ratos - o papel da omentoplastia na vigência de imunossupressão / Study of rat's tracheal allograft viability: the role for omentoplasty with imunossupression

A cirurgia de traquéia enfrenta dificuldades em acompanhar os recentes avanços da terapêutica cirúrgica. Os resultados cirúrgicos são baseados em trabalhos clássicos desenvolvidos há mais de dez anos. Características específicas de vascularização e de regeneração estão entre os problemas que os cirurgiões enfrentam no tratamento das lesões adquiridas ou congênitas da traquéia. As próteses e o transplante ainda não fazem parte do arsenal terapêutico. Com o objetivo específico de determinar o valor da gordura na viabilidade de aloenxertos traqueais, os autores utilizaram ratos Fischer 344 para estudar a regeneração e a viabilidade de aloenxertos, associados à imunossupressão. Um doador possibilitou o implante de um fragmento traqueal em gordura do subcutâneo de dez ratos e de um fragmento no omento. Estes fragmentos de traquéia foram estudados histologicamente visando determinar a viabilidade. Os resultados demonstraram que a gordura extraperitonial, no rato, não serve para manter a viabilidade de aloenxerto, mesmo utilizando imunossupressão (p<0,05), quando comparada à gordura intraperitoneal

Fibrose retroperitoneal: relato de dois casos e revisäo da literatura / Retroperitoneal fibrosis: relate of two cases and literature review

A fibrose retroperitoneal é uma doença rara, geralmente vista em pacientes com idade entre os 40 e 70 anose é secundária a um processo inflamatório crônico do retroperitôneo quepode comprimir os ureteres. A etiologia é desconhecida na maioria dos casos, ainda que vários fatores, como medicaçöes, doenças malignas einflamatórias, possamestar envolvidos. O diagnóstico de fibrose retroperitoneal deve ser considerado em pacientes com dor abdominal ou lombar e lesäo no retroperitôneo. Os sinais e sintomas säorelacionados com comprometimento de estruturas retroperitoneais como veia cava, aorta e ureteres. Quando ambos ureteres säo comprometidos, a insuficiência renal do tipo obstrutivo pode se desenvolver. Várias opçöes medicamentosas têm sido utilizadas nessas situaçöes. Apresentam-se neste trabalho dois casos de fibrose retroperitoneal: um deles idiopático e o outro, provavelmente, secundário a processo inflamatório crönico. Ambos foram submetidos a procedimentos cirúrgicos convencionais com a liberaçäo cirúrgica dos ureteres ou nefrostomia"au"