Resumo em Inglês:

ABSTRACT Purpose: The treatment of kidney stones has undergone continuous evolution. Despite the evolution of retrograde intrarenal surgery, percutaneous nephrolithotomy (PNL) remains the gold standard treatment for large and complex stones. We aimed to evaluate and analyze the temporal evolution of the results of the PNLs conducted at two teaching hospitals. Results: Data from 2660 patients were studied between 2009 and 2022. The rate of complex stones (Guy's 3 and 4) was 55.3%. Supine position was used in 82.1% of the cases. In 74.7% of cases, only 1 puncture was performed. The median surgery time was 120 min (15-240 min). The overall complication rate was 12.2%, the transfusion rate was 4.5%, and the success rate was 59.8%. Regarding temporal evolution, the use of the supine position increased from 73% in 2009 to 100% in 2022 (p < 0.001). The use of nephrostomy dropped from 81.8% to 26.5% (p<0.001), the median duration of surgery dropped from 145 to 130 min, the median time of use of fluoroscopy went from 12 to 8 min, the rate of blood transfusions dropped from 11.5% to 2.8% (p= 0.009), and the complication rate dropped from 18.2% to 12% (p= 0.002), while the average length of stay dropped from 81.8 hours to 50 hours. Conclusions: PNL is an effective surgical option for treating complex kidney stones. The implementation of several technical aspects, along with the standardization of the procedure, led to a significant improvement in most outcomes, reducing complication rates but leaving room for technique improvements in terms of success rates.

Resumo em Inglês:

ABSTRACT This review aims to provide a comprehensive analysis of the anatomy of the bulbospongiosus muscle (BSM) in males, highlighting its morphological features, anatomical variations, and clinical implications in ejaculatory process and urethral surgery. We analyzed papers published in the past 70 years in the databases of Pubmed, Embase and Scielo. We excluded case reports, editorials and opinions of specialists. Studies were excluded if they lacked clear anatomical descriptions of the BSM, if full-text access was unavailable, or if they were published in languages other than Portuguese, English, or Spanish. The BSM is part of the superficial muscular layer of the perineum The perineal arteries provide vascular supply to BSM and, toward the end of their path, give rise to several posterior scrotal branches that supply the skin and dartos muscle of the scrotum. The deep branch of pudendal nerve is primarily muscular and innervates the superficial transverse perineal, bulbospongiosus, ischiocavernosus, deep transverse perineal, and sphincter muscles of the membranous portion of the urethra. This revision concluded that the BSM is a paired skeletal striated muscle that originates from the perineal body enveloping the bulbar portion of the urethra. Stimulation of the dorsal nerve of the penis leads to BSM contraction that provides an indication of anatomic sacral nerve pathway integrity. BSM has some important clinical applications. The bulbar urethral stricture causes minimal alterations in the structure of the BSM during the surgical procedure and the BSM is highly sensitive to androgen and could be used in common androgenic activity evaluation.

Resumo em Inglês:

ABSTRACT Purpose: A preoperative tool is warranted to predict renal function after radical nephroureterectomy, as this would optimize treatment plans and avoid postoperative end-stage renal disease. Therefore, this study aimed to develop an equation to predict postoperative renal function changes. Materials and methods: We reviewed the medical records of 487 patients who were diagnosed with upper tract urothelial carcinoma treated by unilateral radical nephroureterectomy with bladder cuff excision between 2010 and 2020. Renal function was comprehensively evaluated preoperatively using 99mTc-mercaptoacetyltriglycine renal scintigraphy. Serum creatinine was evaluated before, and 3 and 6 months postoperatively. We then developed a predictive equation using Pearson linear correlation analysis. Results: The median preoperative effective renal plasma flow was 241.30 mL/min., of which the lesion side accounted for 35.6% of the total. A predictive equation for changes in postoperative renal function was established. The preoperative lesion-side effective renal plasma flow ratio was significantly associated with an estimated glomerular filtration rate (eGFR) decline ratio at 3 months postoperatively (r = 0.613, P < 0.001). Internal validation of the patients during 2021 confirmed that the equation could predict eGFR decline (r = 0.896) and radical nephroureterectomy-related cisplatin ineligibility (100%) at 3 months postoperatively. Conclusions: We established an equation that assists in predicting changes in postoperative eGFRs based on the preoperative lesion-side effective renal plasma flow ratio. This equation can also predict postoperative residual renal function.

Resumo em Inglês:

ABSTRACT Objective: To evaluate the impact of dynamic Magnetic Resonance of the Urethra (d-MRU) on postoperative results and their agreement with intraoperative findings in patients with urethral stricture after radical prostatectomy. Methods: Forty-eight male patients (mean age 65.2 ± 8.1 years) with vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy confirmed by cystoscopy were evaluated using dynamic MRU and cystourethrography (CUG). They were divided into two groups: d-MRU and CUG. Patients in the d-MRU group were evaluated using a new MRI protocol: urethral filling with lidocaine gel and distal urethral obstruction with sterile gas tourniquet; MR urethrography including axial T1-weighted images, coronal space, sagittal T2-weighted, axial T2-weighted, sagittal maximum intensity projection (MIP) with urographic effect, voiding sagittal MIP, and T1-weighted with fat saturation (T1 fat-sat) before and after gadolinium enhancement. Dynamic imaging acquisition with motion images was performed during voiding. Results: No significant difference in restenosis rates was observed between the D-MRI and UCG groups (5.6% vs. 16.7%, respectively; p = 0.261), but a significant difference in vascular preservation (94.4% vs. 63.3%, p=0.016). We found consistent dynamic MRU and intraoperative measurements of VUAS. Intraclass correlation coefficients showed satisfactory to excellent levels of agreement between the two imaging modalities and a strong correlation of dynamic MRU and intraoperative findings. Additionally, the Bland-Altman analysis revealed an agreement bias close to zero. Conclusions: Dynamic MRU is a safe and appropriate evaluation method that can provide guidance for surgical treatment planning in patients with VUAS after radical prostatectomy.

Resumo em Inglês:

ABSTRACT Purpose: Tissue availability for revision vaginoplasty in trans feminine individuals is often limited, creating challenges in cases with prior surgery or inadequate local tissue. While not yet extensively studied in genital reconstruction, Kerecis SurgiClose®, a decellularized fish skin xenograft, has shown promise as a skin substitute in other surgical contexts, including burn care and chronic wound management. This study aims to describe the surgical technique and evaluate the short-term clinical outcomes of revision vaginoplasty using decellularized fish skin xenograft (FSXRV) in trans feminine individuals. Materials and Methods: A retrospective review of 27 trans feminine patients who underwent FSXRV between February 2023 and December 2024 was conducted. Data on preoperative characteristics, intraoperative details, and postoperative outcomes were collected from electronic medical records and analyzed. Results: The median age was 36 years, and the median BMI was 27 kg/m2. Median postoperative follow-up was 261 days. Indications for FSXRV included loss of neovaginal depth (81.5%), proximal introital narrowing (14.8%), and devitalized neovaginal grafts (3.7%). The xenograft was applied in various configurations and anatomical locations using either a perineal-only or combined perineal-robotic approach. No intraoperative or major (Clavien-Dindo ≥II) complications occurred within 30 days postoperatively. Five patients (18.5%) underwent subsequent canal revision after FSXRV. Positive outcomes were reported in 74% of patients using the Patient Global Impression of Improvement scale. Conclusion: Fish skin xenograft revision vaginoplasty demonstrated early safety and feasibility for revision neovaginal lining and appeared to reduce reliance on autologous grafts or flaps in complex revision settings.

Resumo em Inglês:

ABSTRACT Purpose: Artificial urinary sphincter (AUS) is the gold standard treatment for severe male stress urinary incontinence (SUI). While survival outcomes after primary implantation are now well established, the prognosis following reintervention remains poorly understood. We aimed to assess long-term reintervention-free survival after a second AUS implantation and to compare outcomes between device replacement and reimplantation after removal. Materials and Methods: We performed a nationwide, population-based, retrospective cohort study including all men aged ≥18 years in France who underwent a second AUS implantation between 2006 and 2018 for SUI following prostate cancer or benign prostatic hyperplasia treatment. AUS procedures were identified through a unique device identifier. Of 5,132,311 eligible men, 8,475 received a first AUS and 1,619 a second AUS: 1,165 after device replacement and 454 after reimplantation following removal. The primary outcome was reintervention-free survival, estimated by Kaplan–Meier analysis. Secondary outcomes included replacement and removal rates. Predictors of reintervention were identified using multivariable Cox regression. Results: Median follow-up was 53 months (IQR 26–81). Reintervention-free survival after second AUS was 81% (95% CI 79–83) at 2 years, 68% (95% CI 65–71) at 5 years, and 61% (95% CI 57–64) at 10 years. Device replacement achieved significantly better survival than reimplantation after removal (p < 0.001). Notably, only 21% of patients whose first AUS was removed underwent reimplantation. Conclusions: Second AUS implantation provides durable long-term outcomes, approaching those of primary implants. The indication for reintervention critically influences prognosis, with replacement outperforming reimplantation after removal. The low reimplantation rate after AUS removal provides a clinically relevant piece of information to counsel patients requiring device removal.

Resumo em Inglês:

ABSTRACT Objective: To investigate the efficacy and safety of robotic-assisted bladder neck reconstruction in patients with refractory vesicourethral anastomotic stenosis (VUAS) following radical prostatectomy (RP) or radical cystectomy (RC) with orthotopic neobladder (ONB) reconstruction. Methods: The clinical data from patients with VUAS who underwent robot-assisted bladder neck reconstruction at our center from August 2022 to February 2025 were retrospectively analyzed. The minimum postoperative follow-up period was 3 months, and bladder neck patency was defined as either the passage of a F16 flexible cystoscope or a maximum urinary flow rate (Qmax)>15 mL/s. Results: A total of 27 patients were analyzed, including 25 with a history of RP and 2 with a history of RC with ONB reconstruction. The median operative time was 210 min (interquartile range [IQR]:168-259), with a median estimated blood loss of 152 mL (IQR: 80–255) and a median postoperative hospital stay of 3.5 d (IQR: 3-6 d). At the median follow-up of 11 months (IQR: 3–34), 20 patients (74.1%) achieved patent reconstruction and 9 patients (75%) remained continent in 12 patients without preexisting stress urinary incontinence (SUI) at last follow-up. Postoperative complications occurred in five patients (18.5%), including two cases of Clavien-Dindo grade I and three cases of grade II. Conclusions: Robotic-assisted bladder neck reconstruction represents a safe and effective surgical option with high patency and low de novo SUI rates for refractory VUAS following RP or RC with ONB reconstruction.

Resumo em Inglês:

ABSTRACT Purpose: To assess the distribution of neuroendocrine cells in the male penile urethra and the influence of age and estrogen therapy. Materials and methods: A retrospective immunohistochemical cohort study was conducted on 26 penile urethras obtained during feminizing genitoplasty. Three anatomical regions were analyzed: bulbar, distal, and glans urethra. Neuroendocrine cells were identified by double immunohistochemistry and quantified as chromogranin A-positive cells per mm2 of epithelium. Results: Patients were divided according to estrogen exposure: Group 1 (n=12, median age 23.5 years, estrogen 5.5 years) and Group 2 (n=14, median age 43.0 years, estrogen 18.0 years). A clear gradient of neuroendocrine cell density was observed, with the bulbar urethra showing the highest values compared to distal urethra and glans. Group 2 had significantly higher bulbar urethral cell density than Group 1 (p<0.005). A negative correlation between age and bulbar density was observed. Conclusions: This study provides evidence of a neuroendocrine cell gradient in the human male urethra, concentrated in the bulbar region. Cell density declines with age but is preserved by long-term estrogen therapy. These findings underscore the bulbar urethra as a key sensory structure that should be preserved during surgery and suggest that hormone therapy may mitigate age-related sensory decline.

Resumo em Inglês:

ABSTRACT Purpose: To evaluate the prevalence, predictors, and progression of acute kidney injury (AKI) in patients undergoing mPCNL for nephrolithiasis. Materials and methods: We retrospectively analyzed data from 569 patients who underwent mPCNL at a single tertiary academic center (01/2016-10/2024). AKI was defined per KDIGO criteria as sCr increase >0.3 mg/dL or ≥1.5× baseline. Stone-free status was no residual stones on CT at 3-month follow-up. Complications were classified using the modified Clavien system. Kidney function was reassessed 30–90 days post-op. Descriptive statistics, logistic regression, and Cox regression were applied. Results: Median (IQR) age and stone volume were 57 (48–66) years and 2.1 (0.9–4.2) cm³. Median preoperative sCr and operative time were 0.9 (0.7–1.1) mg/dL and 90 (73–120) minutes. Post-mPCNL, 40 patients (7.0%) developed AKI. Complications occurred in 138 (24.2%) patients; 449 (78.9%) were stone-free. AKI patients had higher CCI (1.3 vs. 0.5, p=0.04), pre-op sCr (1.1 vs. 0.8 mg/dL, p<0.01), stone volume (5.7 vs. 2 cm³, p=0.02), and longer operative time (130 vs. 90 min, p=0.01). Complications were more frequent in AKI patients (42.5% vs. 22.8%, p=0.01). At multivariate analysis, operative time (OR 1.1, p=0.03), pre-op sCr (OR 3.8, p=0.001), and early complications (OR 2.5, p=0.02) were independently associated with AKI. AKI persisted in 9 (22.5%) patients, mainly those with complications (88.9% vs. 38.7%, p=0.01). On Cox analysis, lower BMI (HR 0.8, p=0.02) and absence of complications (HR 0.3, p=0.01) predicted faster AKI recovery. Conclusion: Acute kidney injury remains a clinically significant complication following mPCNL.

Resumo em Inglês:

ABSTRACT Introduction: Robotic-assisted radical prostatectomy (RARP) in patients with pre-existing inflatable penile prostheses (IPP) poses technical challenges due to the intrapelvic reservoir. With rising rates of prostate cancer and IPP use, evidence on safely performing RARP in this group is limited. This study assesses the feasibility, safety, and perioperative outcomes of RARP in men with prior IPP. Materials and Methods: We retrospectively analyzed 32 prostate cancer patients with functional three-piece IPPs who underwent RARP (2016-2024), excluding those with prior pelvic radiation, malleable implants, or incomplete data. Key adaptations included tailored port placement, cold dissection near the reservoir, site-specific retraction without reservoir removal, and intraoperative deflation as needed. Perioperative, functional, and oncologic outcomes were systematically assessed. Results: Median age was 67 years (IQR 61–73). Follow up duration was 24 months from RARP. Median operative time and blood loss were 110 minutes (IQR 98–120) and 100 mL (IQR 50–120), respectively. No intraoperative prosthesis injuries occurred. Clavien–Dindo grade I–II complications were observed in 8 patients (25%). Median time to continence (≤1 pad/day) was 56 days (IQR 46–92). All IPPs remained functional postoperatively without revision. 31 patients were continent at 12 months. Pathologic pT2 disease was present in 16 (50%) patients; positive margins occurred in 4 (12.5%) patients. Biochemical recurrence was noted in 9.4% at 12-month median follow-up. Conclusion: RARP in patients with a pre-existing penile prosthesis reservoir is technically feasible and safe, with no increase in procedure-related or reservoir-specific complications.

Resumo em Inglês:

ABSTRACT Purpose: Benign ureteroenteric anastomosis stricture (BUES) is a well-recognized long-term complication following urinary diversion (1). While endourological interventions are often first-line, their success rates are limited (2, 3). Open uretero-ileal reimplantation remains the gold standard but is technically challenging and carries high complication risks (2). Robotic surgery offers a promising alternative with comparable success rates and minimally invasive benefits (4). In addition to the da Vinci® system, several new surgical robotic systems have been developed, demonstrating comparable safety and efficacy (5-7). This study reports our experience with robotic-assisted Boari-flap using the KangDuo-Surgical-Robot-01 (KD-SR-01) System in managing long-segment BUES after radical cystectomy with orthotopic neobladder. Materials and Methods: A 64-year-old man developed left BUES 2.5 years after robot-assisted radical cystectomy with orthotopic neobladder. After nephrostomy drainage for 6 months, a robotic-assisted Boari-flap was performed using the KD-SR-01 system in the Trendelenburg position. Surgical steps included: neobladder mobilization, distal ureter dissection, neobladder flap creation, ureter-flap anastomosis, and flap tubularization. Results: Surgery was successful without conversion. The stricture length was 5 cm. The neobladder flap measured 5 × 3 cm (length × width). Operating time was 145 minutes, with 30 mL of blood loss. The nephrostomy tube and double-J stent were removed two months postoperatively. At three-month follow-up, the patient remained asymptomatic with stable serum creatinine. Cine magnetic resonance urography demonstrated normal ureteral peristalsis and ureteral jets. No postoperative complications occurred. Conclusions: Robotic-assisted Boari-flap after radical cystectomy with orthotopic neobladder is technically feasible. A larger cohort with longer follow-up is necessary to assess its safety and effectiveness.

Resumo em Inglês:

ABSTRACT Purpose: Xanthogranulomatous pyelonephritis (XGP) represents an uncommon and challenging clinical scenario (1). XGP in a horseshoe kidney poses additional surgical complexity due to the anatomical anomaly (2). Robot-assisted radical nephrectomy (RARN) for XGP has been rarely reported (3), and single-port (SP) RARN via a retroperitoneal lower anterior approach (LAA) represents a recent innovation in the field (4). The aim of this video is to describe a case of SP RARN via LAA in a horseshoe kidney with XGP. Materials and Methods: We report the case of a 51-year-old female (BMI 23 kg/m2) with XGP in a horseshoe kidney. A CT scan revealed severe left renal enlargement and hydroureteronephrosis, and a renal scan demonstrated <5% function of the left kidney, with a normal right kidney. The decision was made to proceed with SP RARN (5). Briefly, the patient was positioned in a modified supine position, and LAA was obtained via a 6-cm incision placed two fingerbreadths medial to the anterior superior iliac spine. The retroperitoneal space was bluntly developed, the large access port kit was introduced, and a 15-mm assistant port was placed through the same skin incision but via a separate fascial incision. The left renal hilum was identified, and the renal artery, vein, and ureter were ligated and transected. The isthmus was controlled using bipolar electrocautery and sharply divided. The kidney was freed and extracted. Results: Total operative time was 4.5 hours, estimated blood loss was 150 mL, and no perioperative complications occurred. The patient tolerated the procedure well and was discharged on postoperative day 1. The specimen weighed 500 g and showed a multinodular kidney with pathology consistent with XGP. The patient remained asymptomatic and complaint-free at the 3-month follow-up. Conclusions: SP RARN for XGP is feasible and can be safely performed. The LAA provides a versatile surgical approach and facilitates rapid postoperative recovery.

Resumo em Inglês:

ABSTRACT Introduction and Objective: Urachal adenocarcinoma is a rare malignancy that typically arises from the bladder dome and is often diagnosed incidentally or during evaluation for hematuria (1, 2). Surgical excision remains the cornerstone of treatment (3, 4). This video demonstrates the robotic technique for partial cystectomy with en bloc urachal resection, combined with synchronized intraoperative cystoscopic imaging—an approach that has proven feasible and oncologically safe in selected cases (5-7). Materials and Methods: A 74-year-old hypertensive male presented with self-limited gross hematuria. Cystoscopy revealed a lesion at the bladder dome, and transurethral resection confirmed urachal adenocarcinoma. Staging chest and abdominal CT scans showed no evidence of metastasis. Robotic partial cystectomy with urachal excision was performed using a da Vinci platform and an auxiliary 5-mm port, in line with contemporary minimally invasive techniques, including single-port surgery (8). The urachus was dissected to the umbilicus, the bladder dome excised, and the bladder closed in two layers with barbed sutures. The specimen was retrieved through the umbilical incision following concomitant umbilectomy. Intraoperative cystoscopy provided simultaneous tumor visualization via picture-in-picture overlay. Results: Operative time was 45 minutes, with an estimated blood loss of 20 mL and no complications. The patient was discharged on postoperative day one with a Foley catheter, which was removed after seven days. Pathological analysis revealed moderately differentiated urachal adenocarcinoma with a mucinous component, detrusor and perineural invasion, and negative margins. At 6-month follow-up, the patient remained asymptomatic, continent, and recurrence-free on surveillance CT. Conclusion: Robotic partial cystectomy with urachal excision is a safe and effective treatment for localized urachal adenocarcinoma. Intraoperative cystoscopy enhances anatomical correlation and may contribute to oncologic safety.