Resumo em Inglês:

ABSTRACT The objective of this manuscript is to present intracavernous therapy to readers, serving as a model and guide for physicians on how to introduce and manage it in their patients. Furthermore, we propose a strategy designed to ensure maximum safety with minor complications and provide an effective implementation of intracavernosal injection (ICI) therapy for the management of erectile dysfunction (ED). While phosphodiesterase type 5 inhibitors (PDE5i) are recognized as first-line therapy, approximately one-third of patients do not achieve satisfactory clinical outcomes, highlighting the importance of ICI as a highly effective second-line option. This comprehensive review details patient selection, drug formulation, structured patient education, stepwise dose titration, management of adverse events, and longitudinal follow-up. This approach is intended to minimize treatment-related complications, enhance patient confidence and adherence, and optimize long-term therapeutic outcomes. By suggesting a standardized clinical application of ICI therapy, this review aims to address key barriers that currently restrict its broader adoption in routine clinical practice.

Resumo em Inglês:

ABSTRACT This review aims to provide a comprehensive analysis of the anatomy of the clitoris, focusing on its complex internal structure, topographic relationships, and neurovascular supply highlighting its morphological features and clinical implications in aesthetic, reconstructive and transgender 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 clitoris, if full-text access was unavailable, or if they were published in languages other than Portuguese, English, or Spanish. Long overshadowed by other anatomical studies, the clitoris is now understood as a multi-planar organ with significant depth and extensive innervation with several applications and surgical techniques, such as clitoral hood reduction (hoodectomy) or labiaplasty. The clitoris is a very important structure to female physiology, specially orgasm. Knowledge of clitoris anatomy is a fundamental step in aesthetic surgery and in reconstruction. In aesthetic and reconstructive clitoroplasty, Buck's fascia is a critical anatomical landmark. The neurovascular bundle resides just beneath this fascia on the dorsal aspect of the clitoris. By staying superficial to or carefully dissecting within this layer, surgeons can ensure that the blood supply and sensory fibers remain intact, preventing glans necrosis and desensitization. This narrative review addresses the anatomical integration, surgical techniques, and functional importance of the clitoral complex in the transgender population and transgender surgery.

Resumo em Inglês:

ABSTRACT Objective: To evaluate the efficacy of Veriset™ hemostatic patch as a substitute for conventional renorrhaphy in retroperitoneal robot-assisted partial nephrectomy (RAPN). Materials and Methods: A total of 113 patients underwent retroperitoneal RAPN between January 2024 and January 2025. After propensity score matching on age, BMI, and R.E.N.A.L nephrometry score, 32 and 40 patients underwent Veriset™ placement and renorrhaphy, respectively, were included for final analysis. The clinico-demographic data, R.E.N.A.L. nephrometry score, blood loss, hemoglobin-drop, hospital stay, complications, and renal function on follow-up were prospectively recorded. Results: The mean age, body-mass-index, and R.E.N.A.L. score were 52.6 ± 9.86 years, 27.41 ± 4.06 kg/m2, and 5.24 ± 1.17, respectively. As per the low, intermediate, and high-risk categories of nephrometry, the patients were evenly distributed. The console time and warm ischemia time (WIT) were significantly less in the Veriset group (47.26 ± 17.51 vs. 71.67 ± 22.6 minutes, and 12.86 ± 6.14 vs 17.48 ± 5.40 minutes, respectively, p<0.001). Blood loss was significantly higher in the renorrhaphy group (57.74 ± 22.83 vs. 87.34 ± 33.81 mL, p=0.008). The change in GFR was significantly less in the Veriset group on postoperative day-1 (p=0.008), but became comparable after six months. The postoperative pain score at 6, 12, and 24 hours, blood transfusion, hospital stay, and readmission rates were similar in both groups. Conclusion: As compared to the renorrhaphy group, Veriset group patients had less console time, WIT, blood loss and immediate reduction of GFR. Sutureless retroperitoneal RAPN can produce good perioperative results without increasing complications.

Resumo em Inglês:

ABSTRACT Purpose: To critically evaluate the clinical presentation, imaging performance and surgical findings of malleable penile prosthesis (MPP) fractures in a high-volume tertiary center. Materials and Methods: Medical reports of men who underwent revision surgery with intraoperative confirmation of MPP fracture between January 2008 and January 2025 were reviewed. MPP from a single manufacturer (Promedon®, Cordoba, Argentina) were inserted, and no comparisons were possible. Demographic data, presenting symptoms, imaging findings, and fracture location were analyzed. Diagnostic performance of physical examination and imaging modalities was descriptively compared. Results: Among 741 penile prosthetic procedures, 98 were revisions and 52 (53.1%) were due to MPP fracture. Median time from implantation to fracture was 59 months (IQR 24.8–84.0). Penile instability was the most common symptom (96.1%), while pain was reported in 21.1%. Physical examination correctly identified fractures in 88.5% of cases, outperforming radiography and magnetic resonance imaging. Bilateral fractures occurred in 51.9% of revisions, most commonly in the proximal segment. Recurrent fractures occurred in 28.2% of patients. Conclusions: MPP fractures are more prevalent than expected and a clinically relevant complication in high-volume centers. Diagnosis relies primarily on clinical assessment, with physical examination outperforming imaging modalities. Increased awareness of typical presentation patterns may support earlier recognition and more efficient management. Prospective studies are needed to identify modifiable risk factors, improve device design and quality, and advise patients on use to potentially improve prosthesis lifetime.

Resumo em Inglês:

ABSTRACT Objectives: To evaluate outcomes of FT (HIFU or cryotherapy) in prostate cancer (PCa) patients who do not meet the ideal focal therapy candidate profile, assessing whether expanding selection criteria beyond traditional parameters is safe. Materials and Methods: A retrospective analysis was performed on 282 patients treated with FT for ISUP 1 and 2 PCa at a single European center (2009–2020). Patients were categorized into three groups: G1 (ideal candidates: single lesion ≤12mm, favorable biopsy features), G2 (ISUP 1 with minor deviations), and G3 (ISUP 2 with multiple lesions, larger tumor size, or positive cores outside the target zone). A secondary exploratory analysis compared ISUP 2 patients fully meeting criteria versus those with one deviating feature. Multivariable regression with propensity score matching was applied. Results: Overall recurrence occurred in 187 patients (66%): 77% in G1, 60% in G2, and 77% in G3. No significant differences were observed between G1 and G3 regarding infield recurrence-free survival, clinically significant infield recurrence-free survival, or outfield recurrence-free survival (all p>0.05). In the secondary analysis, lesion size ≥12mm was the only feature associated with worse infield recurrence-free survival (p=0.04) and clinically significant infield recurrence-free survival (p=0.001). Multivariate Cox regression confirmed lesion size as an independent predictor (HR: 1.21; 95% CI: 1.05–1.40; p=0.01). Conclusions: Expanding FT selection criteria to include selected ISUP 2 patients with features outside traditional parameters appears safe. These preliminary findings highlight the need for multicenter studies to validate these results.

Resumo em Inglês:

ABSTRACT Purpose: To compare SwimCount Harvester™, a non-centrifugal sperm selection system, with Density Gradient Centrifugation (DGC) in terms of sperm DNA fragmentation (SDF), agreement between analytical methods, and total motile sperm recovery. Materials and Methods: This pilot study evaluated semen samples processed using DGC and SwimCount Harvester™. SDF was assessed in raw and processed samples using the Sperm Chromatin Dispersion (SCD; Halosperm®) assay, analyzed both manually and via computer-assisted sperm analysis (SCA® CASA). Agreement between manual and CASA classification (>20% threshold) was evaluated using Cohen's kappa with bootstrap confidence intervals (10,000 resamples). Total motile sperm count (TMSC) was compared between DGC and Harvester (n=36), and effect size was calculated using Cohen's d. Results: Both DGC and Harvester significantly reduced SDF compared with raw semen (p<0.001 for all comparisons), with no significant difference between techniques (CASA p=0.219; manual p=0.341). Agreement between manual and CASA assessment improved following processing, reaching perfect concordance after Harvester (κ=1.00; bootstrap 95% CI 0.54–1.00). Harvester yielded significantly higher TMSC compared with DGC (p=0.001), with a large effect size (Cohen's d=0.81). Conclusion: SwimCount Harvester™ achieves SDF reduction comparable to DGC while significantly increasing motile sperm recovery. These findings support the potential of non-centrifugal sperm selection as an alternative to conventional methods. Larger studies are required to confirm these results and determine their clinical implications.

Resumo em Inglês:

ABSTRACT Purpose: Long-segment urethral strictures following hypospadias repair (LUSPH) represent a formidable reconstructive challenge. Few techniques simultaneously achieve durable stricture resolution while preserving the distal urethral meatus. This study evaluates the efficacy, safety, and patient-reported outcomes of staged buried oral mucosal strip urethroplasty for LUSPH. Patients and Methods: A retrospective analysis was conducted on patients undergoing this procedure between June 2016 and June 2024. Stage one involved inlay of an oral mucosal graft. In the second stage, the healed composite mucosal strip was tubularized using penile fascial flap. Outcomes assessed included maximum flow rate (Qmax), patient-reported outcome measures (USS-PROM, QoL-PROM, IIEF-5), surgical success (defined as unobstructed voiding without intervention, Qmax >15 mL/s, and absence of major complications), and complications. Results: Sixty-one patients were enrolled, with a mean age of 29.8 ± 9.1 years and mean stricture length of 4.7 ± 0.7 cm. Ultimately, 51 patients (83.6%) achieved unobstructed voiding meeting the definition of surgical success. The mean Qmax at 1-year postoperatively was 18.5 ± 4.3 mL/s. From preoperatively to 1-year postoperatively, USS-PROM scores significantly decreased from 21.0 ± 2.0 to 6.6 ± 2.2 (P < 0.001), while QoL-PROM scores significantly improved from 46.6 ± 6.7 to 87.2 ± 8.2 (P < 0.001). IIEF-5 scores showed no significant change. Finally, 54 patients (88.5%) maintained a meatus positioned above the coronal sulcus. Conclusions: In this single-center retrospective cohort, staged buried oral mucosal strip urethroplasty demonstrated favorable mid-term efficacy and safety for LUSPH.

Resumo em Inglês:

ABSTRACT Introduction: Retroperitoneal lymph node dissection (RPLND) is an established treatment option for clinical stage I–II non-seminomatous germ cell tumors (NSGCT), among which bilateral template dissection represents the most oncologically rigorous approach (1, 2). Robot-assisted RPLND has demonstrated reduced surgical morbidity while maintaining oncologic equivalence to open surgery (3). However, the prevailing multiport transperitoneal approach requires extensive bowel mobilization for bilateral exposure, adding operative complexity and bowel-related complication risk (4-6). A completely extraperitoneal single-port approach may circumvent these limitations by avoiding peritoneal entry and visceral manipulation (7). Materials and Methods: We present a 21-year-old male with clinical stage IIA NSGCT who underwent right radical orchiectomy and was found to have multiple enlarged retroperitoneal lymph nodes on CT. The procedure was performed using the da Vinci Xi system with the patient in the supine position. A 4.0-cm right pararectal incision was made to access the retroperitoneal space, and a single-port multichannel device was deployed. Robotic instruments were introduced in a chopstick configuration, including a 30° endoscope, monopolar scissors, and bipolar forceps. The bilateral ureters and great vessels were first exposed to delineate the standard boundaries of the bilateral template while establishing an adequate retroperitoneal working space. A split-and-roll technique was then applied from the right ureter medially, progressively skeletonizing and preserving the vascular structures through sharp dissection to achieve complete lymphadenectomy within the bilateral template, with meticulous clipping of lymphatic channels. Results: Operative time was 175 minutes with an estimated blood loss of 35 mL. The patient resumed oral intake on postoperative day 1 and was discharged on day 2 (VAS: 2) without complications. Thirty-two lymph nodes were retrieved; three harbored teratoma (pN1). At 36-month follow-up, the patient remains disease-free with normal tumor markers and no retroperitoneal recurrence. Conclusions: To our knowledge, this represents the first reported extraperitoneal single-port bilateral robot-assisted RPLND. This approach achieves oncologically thorough dissection while minimizing morbidity and facilitating rapid recovery.

Resumo em Inglês:

ABSTRACT Objective: Penile urethral stricture is a potential complication after any form of urethral instrumentation. Treatment options may be limited when considering direct urethrotomies or urethroplasties without grafting, due to the increased risk of penile shortening and functional compromise. In this context, among the various graft materials described in the literature (including buccal mucosa, lingual mucosa, bladder mucosa, colonic mucosa, augmentation urethroplasty with skin flaps, and injectable antifibrotic agents) (1, 2) the use of bovine pericardium appears promising (3). In this video, we present a clinical case in which the L-Hydro® tissue treatment technology 100% aldehyde free, VIVENDI™ graft was used as a graft for the surgical repair of penile urethral stricture following radical prostatectomy. Materials and Methods: The present study was approved by the hospital's Institutional Ethics Committee in accordance with ethical standards for research involving human subjects. A 65-year-old male patient developed a penile urethral stricture following urethral instrumentation and prolonged urinary catheter use after radical prostatectomy. Preoperative evaluation included cystourethrography, which demonstrated a 1.2 cm stricture in the penile urethra. Urethroplasty was indicated for definitive surgical management. Under regional anesthesia, a longitudinal penile incision was made, followed by a ventral sagittal urethrotomy directly over the stricture segment. A free aldehyde-free bovine pericardium graft (VIVENDI™) was tailored to the defect and placed as a dorsal onlay within the urethrotomy. The graft was secured with interrupted 4-0 poliglecaprone 25 sutures. The ventral urethrotomy was closed over a 16 Fr silicone Foley catheter, and the penile incision was closed in layers. Follow-up assessments included uroflowmetry and post-void residual urine measurement at 4 weeks, with urethroscopy performed at 7 weeks postoperatively to evaluate urethral patency and graft integration. Results: No intraoperative or postoperative complications occurred. Seven weeks after surgery, the patient underwent urethroscopy, which demonstrated a well-appearing urethral lumen without evidence of stricture or signs of infection. The graft was observed to be well incorporated into the urethral wall with no adverse tissue reaction. At follow-up, the patient also demonstrated adequate bladder emptying, with satisfactory voiding parameters and low post-void residual urine. Conclusions: In this reported case, the use of a bovine pericardium graft demonstrated satisfactory results in penile urethroplasty for the treatment of a urethral stricture. Based on current evidence, bovine pericardium appears to be a feasible graft option for complex urethral reconstruction. However, further studies involving larger patient cohorts and multicenter collaboration are necessary to confirm these findings and better define the long-term efficacy and safety of this approach.