Comparative Study of the Efficacy and Complications of Urethral Realignment and Primary Urethral Anastomosis for Traumatic Urethral Injuries in Emergency Surgical Management.

To evaluate the safety and efficacy of a fixed-dose combination (FDC) of tamsulosin prolonged release (PR) and tadalafil in moderate-severe benign prostatic hyperplasia (BPH) and erectile dysfunction (ED). This was a single-arm, phase IV, prospective clinical trial in sexually active men aged 45–75 years with BPH [International Prostate Symptom Score (IPSS) score ≥ 8] and ED [International Index of Erectile Function-Erectile Function (IIEF-EF) score ≤ 25] who were taking tamsulosin 0.4 mg PR and tadalafil 5 mg. Eligible patients received FDC of tamsulosin+tadalafil (0.4 + 5 mg) capsules for 12 weeks. The endpoints included treatment-emergent adverse events (TEAEs), total IPSS, IPSS storage and voiding sub-scores, maximum urinary flow rate (Qmax), post-void residual (PVR) volume, IIEF-EF (questions 1–5 and 15) score, and IPSS quality of life (QoL) index. A total of 172 were enrolled. Overall, 12 TEAEs were reported in 10 (5.81%) patients. None of the TEAEs were severe, serious, life-threatening, or required treatment interruption. A statistically significant improvement (p < 0.0001) in total IPSS after 4, 8, and 12 weeks was observed. Similar improvements from baseline were also observed in IPSS storage and voiding sub-scores, IPSS QoL, Qmax, PVR volume, and IIEF-EF (questions 1–5 and 15) score (p < 0.05 for each parameter). The proportion of men with normal erectile function significantly increased at week 12 (p = 0.0003). The FDC of tamsulosin and tadalafil was associated with significant improvements in lower urinary tract symptoms and EF over 12 weeks and was well tolerated in Indian men with moderate-severe BPH and ED. Prospectively registered at Clinical Trials Registry—India on 10th June 2022 [CTRI/2022/06/043152].

Background Currently, there is no data on the prevalence of urethral stricture illness in India.For short-segment bulbar urethral stricture, end-to-end anastomosis is the gold standard of care. The purpose of this study was to find where the direct vision internal urethrotomy (DVIU)exists in today's era. Also, it compared DVIUs with urethroplasty. Further, the comparison was performed in the urethroplasty group which was converted into two sub-groups; buccal mucosal graft (BMG) and anastomotic urethroplasty. Materials and methods It was a randomized prospective interventional study. The study was conducted at the Department of Urology at Indira Gandhi Institute of Medical Sciences (IGIMS), Patna,India. The total duration of the study was one year and six months. Ethical approval for the conduction of the study has been obtained from the institutional ethics committee (IEC) of IGIMS, Patna, Bihar, India under letter number 840/IEC/IGIMS/2022 dated 10 December 2022. Results The study included two comparisons, one between urethrotomy and urethroplasty, that found significant differences in the International Prostate Symptom Score (IPSS) scores at three months. However, the IPSS scores were found to be insignificant between the groups at six months. Also, no statistically significant difference was observed in the International Prostate Symptom Score-Quality-of-Life (IPSS-QOL) between the two groups at three and six months. The statistically significant difference between them was observed in the maximum urinary flow rate (Qmax) and the International Index of Erectile Function-5 (IIEF-5)scores at three and six months, respectively. Another comparison was done between BMG and the excision and primary anastomosis (EPA) groups, where there was no statistical difference observed between the groups in terms of IPSS, IPSS-QOL, Qmax, and recurrence at three and six months. However, there was a statistical difference observed in IIEF-5 scores between the groups at three and six months, respectively. The mode of anaesthesia in the DVIU group was either total intravenous anaesthesia (TIVA) or spinal anaesthesia. On the other hand, all cases of BMG urethroplasty required general anaesthesia with nasal intubation and all cases of EPA required spinal anaesthesia. Conclusion It has been concluded that in today's era, DVIU can be considered for de-novoshort-segment bulbar urethral stricture in individuals who are concerned about sexual life. And, for short-segment bulbar urethral stricture less than 2 cm, BMG is a better alternative to EPA as it is associated with less erectile dysfunction. A decrease in erectile function is more common in anastomotic urethroplasty as compared to BMG urethroplasty.Further studies comparing muscle sparing, nerve sparing, and vessel sparing are required to address this problem.

Staged surgery (SS) and primary anastomosis (PA) are alternatives to emergency surgery in Crohn's disease (CD). This study aimed to compare postoperative patient outcomes and medical cost of SS and PA for CD emergencies. Consecutive patients with CD undergoing emergency surgery between December 1997 and January 2017 in three centers were included. The PA and SS groups were compared regarding patient outcomes including postoperative complications and surgical recurrence, as well as hospitalization costs. Altogether 96 (39.5%) patients underwent an emergency PA, and 147 (60.5%) underwent an emergency SS. The incidence of intra-abdominal septic complications (IASC) in the PA group was 15.6% compared with 7.5% in the SS group (P = 0.04). The length of hospitalization was longer (32.36 ± 1.76 d vs 19.33 ± 2.36 d, P <0.01) and the hospitalization cost was higher in the SS group (USD 15 811.1 ± 1697.1 vs USD 8345.3 ± 919.5, P <0.01) than the PA group. SS correlated with a lower surgical recurrence rate than PA (log-rank test, P = 0.04). Presence of diffuse peritonitis, perforating or colonic disease, decision of operation choice made by a senior consultant and more than two concurrent surgical indications were related to the need for SS in emergencies. Localized peritonitis, body mass index (>18.5 kg/m2 ) and iatrogenic perforation were significantly associated with a low risk of IASC in the PA group. SS can be performed with limited IASC and low surgical recurrence rates for surgical emergencies in CD, although it increases hospitalization costs and delays discharge.

Colorectal perforation is often treated with colostomy without primary anastomosis due to the risk of anastomotic leakage. However, colostomy affects the patients’ quality of life and may cause complications during closure. This study aimed to examine the suitability of primary anastomosis for colorectal perforation and determine the risk factors for postoperative anastomotic leakage. We retrospectively examined patients who underwent emergency surgery for colorectal perforation associated with generalized peritonitis between April 2007 and March 2017. Cases with iatrogenic or traumatic causes were excluded. Patients were divided into primary anastomosis and colostomy groups. Their age, time after onset, preoperative sequential organ failure assessment (SOFA) score, perforation site, cause of perforation, shock, intraperitoneal infection, steroid use, chronic renal failure, and mortality were compared. Subgroup analysis of the primary anastomosis group was performed to identify risk factors for anastomotic leakage. The cohort comprised 232 patients (112 men, 120 women; mean age, 73 years). Primary anastomosis and colostomy were performed in 27 and 205 patients, respectively. The primary anastomosis group consisted mainly of men with right colonic perforation. Of the 27 patients who underwent primary anastomosis, anastomotic leakage occurred in 5 (18.5%). Patients with anastomotic leakage demonstrated high SOFA scores (4.2 vs. 1.9, p < 0.05) and Hinchey stage IV disease (80% vs. 27.3%, p < 0.05). Of the 5 patients with anastomotic leakage, 2 died. Anastomotic leakage after primary anastomosis for colorectal perforation occurs in patients with septic complications or severe intraperitoneal infection. Therefore, primary anastomosis should be avoided in this patient population.

We aimed to compare the outcomes of primary anastomosis (PA) and enterostomy as treatments for intestinal atresia in neonates to identify the factors influencing the choice of modality. We conducted a retrospective single-centre analysis of all neonates with intestinal atresia between 2000 and 2020 and measured the clinical outcomes. We performed logistic regression to identify factors that influenced the choice of surgical approach. Of 62 intestinal atresia neonates, 71% received PA. There were no significant differences in gestation, gender, age at operation, birth weight, or body weight at operation between the PA and enterostomy groups. PA reoperation was not required for 78% of patients, and the PA group had shorter hospital stays. Complications, operative time, duration on parenteral nutrition, time to full enteral feeding were comparable in both groups. Upon multivariate regression analysis, surgeons favoured PA in proximal atresia [Odds ratio (OR) 38.5, 95% Confidence Interval (CI) 2.558-579] while enterostomy in smaller body size [OR 2.75, CI 0.538-14.02] and lower Apgar score [OR 1.1, CI 0.07-17.8]. Subgroup analysis in these patient groups demonstrated comparable outcomes with both surgical approaches. Both surgical approaches achieved comparable outcomes, but PA was associated with short hospital stays and the avoidance of stoma-related complications, and reoperation was generally not required. This surgical approach was suitable for patients with proximal atresia, but enterostomy remained a sensible choice for patients with smaller body sizes and lower Apgar scores.

ObjectiveThis is a prospective randomized study with the aim of comparing (thulium laser enucleation of the prostate (ThuLEP) and transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) treatment.MethodsPatients are assessed preoperatively and up to 6 months postoperatively. International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rates (Qmax), international index of erectile function-5 (IIEF-5) and post-void residual volume (PVR) are collected on each follow-up.ResultsIn comparison to TURP, the ThuLEP group has significantly less need for catheter traction and less need for postoperative irrigation. The operative time is significantly higher in ThuLEP compared to TURP. ThuLEP is significantly superior to TURP in terms of early catheter removal, less drop in haemoglobin, less fall in serum sodium level, and early hospital discharge. ThuLEP and TURP resulted in a significant improvement from baseline in terms of IPSS, PVR, Qmax, and QoL, but there was no significant difference between the 2 groups. The IIEF-5 is the same as the baseline in both groups. Early and late complications are also comparable.ConclusionThe ThuLEP outperforms TURP in terms of blood loss, significantly less need for postoperative catheter traction, bladder irrigations, early catheter removal, and less hospital stay. Transurethral resection of the prostate takes longer operative time in the early stages of experience. The results of both surgeries are comparable in terms of PVR, Qmax, and subjective scoring systems (IPSS, QoL). Transurethral resection of the prostate is a safe and efficient BPH treatment method comparable to the monopolar TURP.

To assess the comparative effects of two surgical regimens on the outcome of acute complicated diverticular disease. Retrospective study. Teaching hospital, The Netherlands. 60 patients who presented with acute complicated diverticular disease. 28 patient were treated by sigmoid resection and a Hartmann operation, and 32 by resection with primary anastomosis and defunctioning stoma. Morbidity and mortality. The severity of peritonitis and the amount of faecal contamination were similar in the 2 groups. 12 patients died (7 in the Hartmann group and 5 in the primary anastomosis group). There were 3 radiological leaks with no clinical implications in the primary anastomosis group. 6 patients in the Hartmann group and 5 in the primary anastomosis group required reoperations for intra-abdominal abscess or infection. 7 and 3 patients, respectively, developed dysfunction of their stomas, and 9/21 and 3/27, respectively, required a permanent stoma (p = 0.02, 95% confidence interval of difference 0.07 to 0.56). 3 patients in the Hartmann group developed anastomotic leaks after closure of their stomas, 1 of whom required reoperation but died. No patient developed an anastomotic leak after closure of the stoma in the primary anastomosis group. Both regimens are accepted treatments for patients with acute complicated diverticular disease, but because of the higher morbidity after the Hartmann procedure we prefer primary anastomosis with covering stoma.

Objective To report our initial experience with extraperitoneal approach Robotic-Assisted Urethra-sparing simple prostatectomy(US-RASP)on large-gland (>100 ml) benign prostatic hyperplasia(BPH). Methods From August 2015 to April 2018, 32 patients with large volume prostate underwent US-RASP performed by single surgical team were retrospectively reviewed. The patient's median age was 73 (range 59-80) years, and median BMI was 24.9 (19.3-34.8 ) kg/m2, The estimated prostate volume(V), postvoid residual volume(PV) by transrectal ultrasonography and PSA were 152.0(119.0-223.1)ml, 145(0-280)ml and 13.7(5.2-27.3)ng/ml, respectively. Four of 32 patients underwent preoperative urinary catheterization. The perioperative functional parameters including international prostate symptom score (IPSS) questionnaire, maximum flow rate (Qmax), maximum voided volume(Vmax), quality of life questionnaires (QOL) and International Index of erectile function-erectile function (IIEF-EF) were 27(23-33), 5.9 (2.5-7.8) ml/s, 110 (80-210)ml, 5(3-6), and 27(26-29), respectively. Functional parameters including IPSS, QOL, Qmax, Vmax, PV and IIEF-EF were compared and analyzed at 3 and 12 months postoperatively during the following-up. Results The US-RASP was completed in all 32 patients and no open conversion. Median operation time was 180 (115-240) min, the estimated blood loss was 300(range 100 to 400)ml, Hemoglobin loss was 17(5-38)g/L. The median Foley catheterization time was 7 (5-12) days and drainage was removed after a median of 5 (4-7) days with median hospital stay of 8(6-14)days. Median specimen weight on pathological examination was 107.7 (79.8-147.4)g with median of 64.2% (49.4%-86.2%) resection ratio. At 3-mo follow-up, median IPSS score, Qmax, Vmax, PV and QOL were 6(4-18), 17.3 (13.8-21.1)ml/s, 167(140-310)ml, 50(0-61)ml, 1(0-3) , respectively. At 12-mo follow-up, median IPSS score, Qmax, Vmax, PV and QOL were 4(1-9), 20.1 (17.9-24.1)ml/s, 205(176-305)ml, 24(0-35)ml and 1(0-2) , respectively. All patients showed great improvement of IPSS, Qmax, Vmax, PV and QOL after median 17 (12-44) months follow-up compared with preoperative parameters (P<0.05). Erectile function was not impaired in 17 patients who have normal erectile function pre-operatively and 14 cases (82.4%) preserved satisfactory anterograde ejaculation. No significant complication occurred during the procedure. No patient developed permanent urinary incontinence. Conclusions US-RASP is a safe and effective treatment option for selected patients with large-gland obstructive BPH(>100 ml). Our data showed significant improvement in voiding function and maintaining satisfactory anterograde ejaculation following urethral-sparing technique. It may be a new alternative method in the future for large-volume symptomatic BPH. Key words: Prostatic hyperplasia; Prostatectomy; Robotic-assisted surgery; Extraperitoneal approach; Urethra-sparing

Evaluating outcomes of primary anastomosis versus Hartmann's procedure in sigmoid volvulus: A retrospective-cohort study

Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES): a multicentre, parallel-group, randomised, open-label, superiority trial

We present a single-center experience with very low birth weight (VLBW) infants with focal intestinal perforation (FIP), comparing the results of primary anastomosis (PA) and stoma opening (SO). Clinical records of VLBW infants with FIP who underwent surgery between 2006 and 2015 were reviewed. Patients were divided into two groups according to the procedure performed: limited bowel resection and PA or SO. Patients with gastric perforation or patients who underwent clip and drop were excluded. Information regarding birth weight (BW), gestational age (GA), weight at surgery (WS), number of abdominal reoperations, duration of parenteral nutrition (PN), and demise was recorded. In this study, 40 patients were included: 22 in PA group and 18 in SO group. BW was 865 g in PA and 778 in SO (p-value: 0.2). GA was 26.1 weeks in PA and 25.6 in SO (p-value: 0.3). WS was 1,014 g in PA and 842 in SO (p-value: 0.09). Duration of surgery was 115 minutes in PA and 122 in SO (p-value: 0.67). Five patients (23%) belonging to PA group developed complications and required SO. Five patients (23%) demised in PA group and six (33%) in SO (p-value: 0.2). Seventeen abdominal reoperations were performed in PA group and 22 in SO group (p-value: 0.08). Both procedures appear to be safe. When possible, PA should be performed as it reduces the number of abdominal reinterventions.

The aim was to assess the results of primary anastomosis (PA) compared to enterostomy (ES) in infants with spontaneous intestinal perforation (SIP) and a weight below 1000 g. Between 2014 and 2016, enterostomy was routinely carried out on extremely low birth weight (ELBW) patients with SIP. From 2016 until 2019, all patients underwent anastomosis without stoma formation. We compared outcome and complications in both groups. Forty-two patients with a median gestational age of 24.3 weeks and a birth weight of 640 g with SIP were included. Thirty patients underwent PA; ES was performed in 12 patients. Overall in-hospital mortality was 11.9% (PA: 13.3%, ES: 8.3%). Reoperations due to complications became necessary in 10/30 patients with PA and 4/12 patients with ES. Length of stay was 110.5 days in the PA group and 124 days in the ES group. Median weight at discharge was higher in the PA group (PA: 2258 g, ES: 1880 g, p = .036).Conclusion: Primary anastomosis is a feasible treatment option for SIP in infants < 1000 g and may have a positive impact on weight gain and length of hospitalization. However, further studies on selection criteria for PA are necessary.What is Known:• Enterostomy (ES) and primary anastomosis (PA) are feasible treatment options in preterm infants with spontaneous intestinal perforation (SIP).• Stomal complications or failure to thrive due to poor food utilization can pose significant problems.What is New:• Primary anastomosis in case of SIP is equal to enterostomy in terms of mortality and revision rate; however, length of stay and weight gain can be presumably positively influenced.• Primary anastomosis is a valid treatment option even for patients weighing less than 1000 g.

Primary anastomosis and stoma are the main options in the restoration of intestinal continuity following urgent sigmoidectomy in sigmoid volvulus (SV). Our purpose was to evaluate the outcomes of both techniques in a 1,083-patient SV series. Total 1,083 cases with SV treated in Ataturk University Research Hospital in 58-year period between June 1966 and July 2024 were included in this study. We reviewed the records of 612 patients (56.5%) retrospectively, while the remaining 471 cases (43.5%) were evaluated prospectively. We investigated some preoperative, operative, and postoperative characteristics in non-matched analyses. Among total 379 patients treated with urgent colectomy, primary anastomosis was used in 173 cases (45.6%), while stoma was required in 206 patients (54.4%). The mean age was significantly lower in primary anastomosis group (P<0.005), while male/female ratios were statistically similar (P>0.05). Mean ASA score (P<0.001) and rates of shock (P<0.001), bowel gangrene (P<0.001), bowel perforation (P<0.01), and risky bowel (P<0.005) were also significantly lower in the primary anastomosis group. When stoma closure was considered, operation time was significantly shorter (P<0.001), additionally, morbidity and mortality rates were significantly lower in the primary anastomosis group (P<0.001, in each). The distributions of reoperation rates were statistically similar in both groups (P>0.05). Conversely, hospitalization time was significantly shorter and cost was significantly lower in the primary anastomosis group (P<0.001, in each). Primary anastomosis has some advantages in comparison to stoma in the restoration of intestinal continuity following urgent sigmoidectomy in SV. However, stoma is generally preferred in patients with bad health status, old age, and risky bowel. New prospective randomized clinical studies or matched analyses may help to clarify the optimal choice.

ObjectiveTo assess the safety and efficacy of Rezūm therapy in small versus large prostates through a four-year follow-up.Patients and methodsOne-hundred seventy patients who underwent Rezūm therapy were retrospectively included and divided into 2 equal groups, small (˂ 80gm) and large prostate groups (80-120 gm). Both groups were assessed preoperatively and at 3, 12, 24, 36, and 48 months post-procedure for operative time, number of vapor injection, catheterization time, hospital stay and post-procedure: prostatic size, prostate-specific antigen (PSA), post-void residual (PVR), maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), quality of life (QoL), International Index of Erectile Function (IIEF) and complications.ResultsThe number of vapor injections was significantly higher in the large prostate group compared to the small prostate group (p < 0.001). Operative time and catheter duration were significantly longer in the large prostate group (p < 0.001), while hospital stay was similar between groups (p = 0.407). At 48 months post-Rezūm, both groups demonstrated statistically significant improvement in all measured outcomes (Qmax, IPSS, PVR, QoL, PSA, IIEF, and prostate size) (p < 0.05). Regarding postoperative complications, there were no significant differences between the groups except that the need for retreatment was significantly higher in the large prostate group.ConclusionRezūm therapy offers a safe and effective treatment option for both small and large prostates with sustained improvement over four years. However, patients with large prostates exhibited a higher retreatment rate (15.2%).

BiVap Saline Vaporization of the Prostate in Men With Benign Prostatic Hyperplasia: Our Clinical Experience