Two-sided urethra-sparing reconstruction combining dorsal preputial skin plus ventral buccal mucosa grafts for tight bulbar strictures.

OBJECTIVES: To report our initial experience with urethra-sparing reconstruction combining dorsal preputial skin and ventral buccal mucosa grafts for tight bulbar urethral strictures. METHODS: Between November 2006 and September 2012, 26 patients with tight bulbar strictures underwent urethroplasty. Using a ventral urethrotomy approach, the two-sided urethral reconstruction was carried out avoiding the transection of urethra and augmenting the preserved urethral plate by dorsal preputial skin plus ventral buccal mucosa grafts. The primary outcome was the objective urinary result, defined as the absence of stricture recurrence. The outcome was considered a failure when any postoperative instrumentation was required. Postoperative sexual dysfunctions were investigated using a validated questionnaire. RESULTS: Mean follow up was 30.1 months (range 12-79 months). Mean stricture length was 3.3 cm (range 1.5-6 cm). Mean length for dorsal preputial skin and ventral buccal mucosa grafts was 3.2 cm (range 2-7 cm) and 4.9 cm (range 4-6 cm), respectively. Of 26 cases, 23 (88.5%) were successful and three (11.5%) were failures with stricture recurrence. Failures were treated with perineal urethrostomy in one case, ventral buccal graft urethroplasty in one case and internal urethrotomy in one case. Among 12 sexually active men preoperatively, none reported postoperative penile curvature/shortening, impaired erection or dissatisfaction regarding erection; sexual activity was unaltered pre- and post-surgery. CONCLUSIONS: In tight bulbar urethra strictures, the two-sided urethroplasty combining dorsal preputial skin and ventral buccal mucosa grafts provides a safe and effective semi-circumferential reconstruction by augmenting the preserved urethral plate, with no impact on sexual function.

Urethral pseudodiverticulum secondary to penile fracture and complete urethra dissection.

A 22-year-old man reported cracking sound and acute pain during sexual intercourse followed by rapid penile detumescence and ecchymosis. He experienced more pain because he could not urinate and had a palpably full bladder. Moreover, his urethra was bleeding. Physical examination revealed swollen, ecchymotic and deviated penis and penis ultrasonography showed an injury of the tunica albuginea and Buck's fascia with an expanding hematoma. Suprapubic catheter was positioned. Surgical exploration revealed a tear of tunica albuginea of both corpora cavernosa and complete urethral dissection. End-to-end urethral anastomosis and suture of corpora cavernosa lesion were performed. Vescical catheter was mantained for 6 days and suprapubic catheter for 3 months to allow a complete urethral healing. A pseudodiverticulum was found at anastomosis level on the urethrocistography 1 month after surgery. It disappeared by allowing micturition via the suprapubic catheter. The patient presented regular urinary flow and physiological erections 30 days later. In our experience, prompt surgical repair preserved erectile function and keeping the suprapubic catheter protected the urethra; this was the correct management for repairing the urethral lesion.

A prospective trial comparing consecutive series of open retropubic and robot-assisted laparoscopic radical prostatectomy in a centre with a limited caseload.

BACKGROUND: Robot-assisted radical prostatectomy (RALP) is performed worldwide, even in institutions with limited caseloads. However, although the results of large RALP series are available, oncologic and functional outcomes as well as complications from low-caseload centres are lacking. OBJECTIVE: To compare perioperative, oncologic, and functional outcomes from two consecutive series of patients with localised prostate cancer treated by retropubic radical prostatectomy (RRP) or recently established RALP in our hospital, which has a limited caseload. DESIGN, SETTING, AND PARTICIPANTS: One hundred fifty consecutive patients were enrolled. Their data and outcomes were collected and extensively evaluated. INTERVENTION: Seventy-five consecutive patients underwent RRP, and 75 consecutive patients underwent RALP, including all patients of the learning curve. MEASUREMENTS: Patient baseline characteristics, perioperative and postoperative outcomes, and complications were evaluated. End points were oncologic data (positive margins, prostate-specific antigen [PSA]), perioperative complications, urinary continence, and erectile function at 3- and 12-mo follow-up. RESULTS AND LIMITATIONS: The preoperative parameters from the two groups were comparable. The positive surgical margin (PSM) rates were 32% for RRP and 16% for RALP (p=0.002). For RRP and RALP, the PSA value was <0.2 ng/ml in 91% and 88% of patients 3 mo postoperatively (p=0.708) and in 87% and 89% of patients 12 mo postoperatively (p=0.36), respectively. Continence rates for RRP and RALP were 83% and 95% at 3-mo follow-up (p=0.003) and 80% and 89% after 12-mo follow-up (p=0.092), respectively. Among patients who were potent without phosphodiesterase type 5 inhibitors (PDE5-I) before RRP and RALP, recovery of erectile function with and without PDE5-Is was achieved in 25% (12 of 49 patients) and 68% (25 of 37 patients) 3 mo postoperatively (p=0.009) and in 26% (12 of 47 patients) and 55% (12 of 22 patients) 12 mo postoperatively (p=0.009), respectively. Minimal follow-up for RRP was 12 mo; median follow-up for the RALP group was 12 mo (range: 3-12). According to the modified Clavien system, major complication rates for RRP and RALP were 28% and 7% (p=0.025), respectively; minor complication rates were 24% and 35% (p=0.744), respectively. CONCLUSIONS: Despite a limited caseload and including the learning curve, RALP offers slightly better results than RRP in terms of PSM, major complications, urinary continence, and erectile function.

Intra-abdominal fire due to insufflating oxygen instead of carbon dioxide during robot-assisted radical prostatectomy: case report and literature review.

We report the first case of intra-abdominal combustion involving the plastic covering of monopolar scissors secondary to use of incorrect gas (oxygen [O(2)] instead of carbon dioxide [CO(2)]) during robot-assisted laparoscopic radical prostatectomy (RALP). The insufflating system was connected to a provisional O(2) gate into the operating theater. A patient underwent RALP and extended pelvic lymph node dissection for localized prostate cancer, according to standard technique. Approximately 1.5 h after the start of surgery, flames arose from the scissor tips during monopolar coagulation. After extinguishing the fire, we promptly withdrew and changed instruments before recognizing and resolving the cause of the incident. The procedure was carried out without patient injury, and the postoperative period was uneventful.