Management of penile urethral strictures: Challenges and future directions

The anatomy of the penile urethra presents additional challenges when compared to other urethral segments during open stricture surgery particularly because of its unsuitability for excision and primary anastomosis and its relatively deficient corpus spongiosum. Stricture aetiology, location, length and previous surgical intervention remain the primary factors influencing the choice of penile urethroplasty technique. We have identified what we feel are the most important challenges and controversies in penile urethral stricture reconstruction, namely the use of flaps vs grafts, use of skin or oral mucosal tissue for augmentation/substitution and when a single or a staged approach is indicated to give the best possible outcome. The management of more complex cases such as panurethral lichen-sclerosus strictures and hypospadias "cripples" is outlined and potential developments for the future are presented.

Periprocedural management of hemostatic alterations in patients with cirrhosis and vascular liver disorders: a step forward of the American Association for the Study of Liver Diseases

“Time flies over us,but leaves its shadow behind”(Nathaniel Hawthorne,1860,The Marble Faun).The shadow that separates the latest guidance on vascular liver disorders of the American Association for the Study of Liver Diseases(AASLD)from its former counterpart is 12 years long(1,2).Along the course,several guidelines from different societies have been published on this topic(3-7).As acknowledged in the preamble,the lack of high-quality evidence in the field led the AASLD to commission a guidance from an expert panel based on formal review and analysis of the literature.It thus differs from other guidelines that perform systematic reviews with explicit methods of searching,selection,and rating the quality of evidence and,if appropriate,meta-analysis on certain clinical questions(2).

Single-stage tubular urethral reconstruction using oral grafts is an alternative to classical staged approach for selected penile urethral strictures

Penile urethral strictures have been managed by a staged surgical approach.In selected cases,spongiofibrosis can be excised,a neo-urethral plate created using buccal mucosa graft(BMG)and tubularized during the same procedure,performing a“twoin-one”stage approach.We aim to identify stricture factors which indicate suitability for this two-in-one stage approach.We assess surgical outcome and compare with staged reconstruction.We conducted an observational descriptive study.The data were prospectively collected from two-in-one stage and staged penile urethroplasties using BMG in a single center between 2007 and 2017.The minimum follow-up was 6 months.Outcomes were assessed clinically,radiologically,and by flow-rate analysis.Failure was defined as recurrent stricture or any subsequent surgical or endoscopic intervention.Descriptive analysis of stricture characteristics and statistical comparison was made between groups.Of 425 penile urethroplasties,139 met the inclusion criteria:59 two-in-one stage and 80 staged.The mean stricture length was 2.8 cm(single stage)and 4.5 cm(staged).Etiology was lichen sclerosus(LS)52.5%(single stage)and 73.8%hypospadias related(staged).40.7%of patients had previous failed urethroplasties in the single-stage group and 81.2%in the staged.The most common stricture locations were navicular fossa(39.0%)and distal penile urethra(59.3%)in the single-stage group and mid or proximal penile urethra(58.7%)in the staged group.Success rates were 89.8%(single stage)and 81.3%(staged).A trend toward a single-stage approach for select penile urethral strictures was noted.We conclude that a single-stage substitution penile urethroplasty using BMG as a“two-in-one”approach is associated with excellent functional outcomes.The most suitable strictures for this approach are distal,primary,and LS-related strictures.

Effects of obstructive sleep apnea and its treatment over the erectile function： a systematic review

Erectile dysfunction （ED） is considered a condition with a broad range of etiologies. Obstructive sleep apnea （OSA） syndrome is one of the lesser studied risk factors for ED. We intend to summarize the current evidence on the relationship between OSA and sexual impairment, focusing on the results in terms of erectile function of the different therapies offered to OSA patients. A systematic review was conducted, selecting articles related to the physiology of OSA and ED, and to the treatments of OSA syndrome and their reported outcomes in erectile and sexual function. Higher prevalences of ED in the OSA groups have been published. However, whether this effect on the erectile function occurs in the entire range of OSA severities remains unclear. Several hypotheses were proposed to explain the physiology of this association. Continuous Positive Airway Pressure as a treatment for OSA patients with ED has achieved a significative improvement in the sexual parameters in most of the studies. Phosphodiesterase type 5 inhibitors （iPDE5） on demand are useful as a treatment for ED in this subgroup of patients, with high satisfaction rates. The surgical treatment for the OSA evidenced benefits over the erectile function, and the effect on the sexual satisfaction of the therapy using Mandibular Advancement Devices is still undefined.

Perioperative management and early complications after intestinal resection with ileocolonic anastomosis in Crohn’s disease:analysis from the PRACTICROHN study

Background:This study is aimed at describing the prevalence of and risk factors associated with early post-operative complications after Crohn’s disease-related intestinal resection.Methods:This was a retrospective analysis of data from the PRACTICROHN cohort.Adult Crohn’s disease patients who underwent ileocolonic resection with ileocolonic anastomosis between January 2007 and December 2010 were included.The complications evaluated included death,ileus,anastomotic leak,abscess,wound infection,catheter-related infection,digestive bleeding and other extra-abdominal infections that occurred in the 30 days after surgery.Results:A total of 364 patients(median age at surgery 38 years and 50%men)were included.Indication for surgery was:stricturing disease(46.4%),penetrating disease(31.3%),penetrating and stricturing disease(14.0%)or resistance to medical treatment(5.8%).Early complications were recorded in 100(27.5%)patients,with wound infection,intra-abdominal abscess and anastomotic leakage being the most frequent complications.Median hospitalization duration was 16 days for patients with complications vs.9 days without complications(P<0.001).Complications were more common among patients with penetrating disease(36/114,31.6%)and those refractory to treatment(9/21,42.9%)compared with stricturing disease(45/169,26.6%)or stricturingtpenetrating disease(6/51,11.8%)(P=0.040).The rate of complications was higher among patients with diagnosis made at the time of surgery(15/31,48.4%)compared with the rest(85/331,25.7%)(P=0.013).Medication received at the time of surgery did not affect the rate of complications.Conclusions:Almost a quarter of patients developed early complications after intestinal resection.Penetrating disease and urgent surgery were associated with an increased risk of complications.