ASTRA - An alternative approach for the posterior urethra

ABSTRACT Introduction: Access represents one of the main challenges in performing posterior urethroplasty (1, 2). Several approaches and tactics have been previously described (3). This video demonstrates the Anterior Sagittal Transrectal Approach (ASTRA), which allows better visualization of the deep perineum (4). Materials and Methods: Our patient was a 65-year-old man with post radical prostatectomy vesicourethral anastomotic stenosis. He failed repeated endoscopic interventions, eventually developing urinary retention and requiring a cystostomy. We offered a vesicourethral anastomotic repair through ASTRA. The patient was placed in the jackknife position and methylene blue instilled through the cystostomy. To optimize access to the bladder neck, an incision of the anterior border of the rectum is performed. Anastomosis is carried out with six 4-0 PDS sutures. These are tied using a parachute technique, after insertion of a 16F Foley. Results: The patient was discharged after 72 hours, and the Foley catheter was removed after 4 weeks. There were no access-related complications. Retrograde urethrogram 3 months after surgery confirmed patency of the anastomosis. Upon review 5 months after surgery the patient had urinary incontinence requiring 5 pads/day and was considered for an artificial urinary sphincter. Discussion: In our series of 92 patients who have undergone reconstructive procedure through ASTRA there have been no cases of fecal incontinence. Two patients with prior history of radiotherapy developed rectourethral fistulas. Urinary incontinence was observed in those patients with stenosis after radical prostatectomy. Conclusion: This video presents a step-by-step description of ASTRA, an approach that provides excellent visualization to the posterior urethra, representing an alternative access for repair of complex posterior urethral stenosis.

Low-fidelity simulation models in urology resident's microsurgery training

Purpose: To evaluate the gain of microsurgical skills and competencies by urology residents, using low-fidelity experimental models. Methods: The study involved the use of training boards, together with a low-fidelity microsurgery simulator, developed using a 3D printer. The model consists in two silicone tubes, coated with a resin, measuring 10 cm in length and with internal and external diameters of 0.5 and 1.5 mm. The support for the ducts is composed by a small box, developed with polylactic acid. The evaluation of the gain of skills and competencies in microsurgery occurred throughout a training course consisting of five training sessions. The first sessions (S1-S4) took place at weekly intervals and the last session (S5) was performed three months after S4. During sessions, were analyzed: the speed of performing microsurgical sutures in the pre and post-training and the performance of each resident through the Objective Structure Assessment of Technical Skill (OSATS) and Student Satisfaction Self-Confidence tools in Learning (SSSCL). Results: There was a decrease in the time needed to perform the anastomosis (p=0.0019), as well as a progressive increase in the score in the OSATS over during sessions S1 to S4. At S5, there was a slightly decrease in performance (p<0.0001), however, remaining within the expected plateau for the gain of skills and competences. The SSSCL satisfaction scale showed an overall approval rating of 96.9%, with a Cronback alpha coefficient of 83%. Conclusions: The low-fidelity simulation was able to guarantee urology residents a solid gain in skills and competencies in microsurgery.

Portable model for vasectomy reversal training

ABSTRACT Objectives To validate an experimental non-animal model for training of vasectomy reversal. Materials and Methods The model consisted of two artificial vas deferens, made with silicon tubes, covered by a white resin, measuring 10 cm (length) and internal and external diameters of 0.5 and 1.5 mm, respectively. The holder of the ducts is made by a small box developed with polylactic acid, using a 3D print. The objective of the invention is to simulate the surgical field of vasovasostomy, when the vas deferens are isolated from other cord structures. For validation, it was verified the acquisition of microsurgical skills during its use, in a capacitation course with 5 urology residents from a Hospital of the region. Along the training sessions, it was analyzed the time (speed) of microsurgical sutures, and quantification of the performance using a checklist. Collected data were analyzed using de BioEstat®5.4 software. Results Medium time for the completion of microsurgical sutures improved considerably during the course, and reached a plateau after the third day of training (p=0.0365). In relation to the checklist, it was verified that during capacitation, there was significant improvement of the scores of each participant, that reached a plateau after the fourth day of training with the model (p=0.0035). Conclusion The developed model was able to allow the students that attended the course to gain skills in microsurgery, being considered appropriate for training vasectomy reversal.

Human Papilloma Virus: Prevalence, distribution and predictive value to lymphatic metastasis in penile carcinoma

Objectives To evaluate the prevalence, distribution and association of HPV with histological pattern of worse prognosis of penile cancer, in order to evaluate its predictive value of inguinal metastasis, as well as evaluation of other previous reported prognostic factors. Material and Methods Tumor samples of 82 patients with penile carcinoma were tested in order to establish the prevalence and distribution of genotypic HPV using PCR. HPV status was correlated to histopathological factors and the presence of inguinal mestastasis. The influence of several histological characteristics was also correlated to inguinal disease-free survival. Results Follow-up varied from 1 to 71 months (median 22 months). HPV DNA was identified in 60.9% of sample, with higher prevalence of types 11 and 6 (64% and 32%, respectively). There was no significant correlation of the histological characteristics of worse prognosis of penile cancer with HPV status. Inguinal disease-free survival in 5 years did also not show HPV status influence (p = 0.45). The only independent pathologic factors of inguinal metastasis were: stage T ≥ T1b-T4 (p = 0.02), lymphovascular invasion (p = 0.04) and infiltrative invasion (p = 0.03). conclusions HPV status and distribution had shown no correlation with worse prognosis of histological aspects, or predictive value for lymphatic metastasis in penile carcinoma. .