Fissure-in-ano, to divide or not to divide?

Anal fissure is one of the most common and painful proctological pathologies affecting mainly young individuals. The physiopathology in the development of a chronic anal fissure seems to be a combination of internal anal sphincter hypertonia and poor vascularization at the posterior midline. Treatment of acute fissures is conservative with supportive therapy, leading to healing in the majority of the patients. Open or closed lateral internal sphincterotomy is the treatment of choice for chronic anal fissures. In low pressure chronic fissures, sphincterotomy should be avoided and a V-Y island advancement flap may be an alternative procedure. Sphincterotomy can induce anal incontinence, a feared complication of this technique. Recent interest has developed in chemical sphincterotomy with local botulin toxin injections or glyceryl trinitrate application. Long-term follow-up is needed to evaluate these new therapeutic options.     

Should Antibiotics Be Given Prior to Outpatient Cystoscopy? A Plea to Urologists to Practice Antibiotic Stewardship

BackgroundAntimicrobial resistance is a major health problem, caused primarily by overuse of antibiotics in clinical situations in which they are not necessary. Practice guidelines recommend that antibiotics be given before outpatient cystoscopy to prevent symptomatic urinary tract infection (UTI).ObjectiveTo determine the frequency of febrile UTI after outpatient flexible cystoscopy in antibiotic-naive bladder tumor patients.Design, setting, and participantsA total of 2010 consecutive outpatients with bladder tumors were entered into a prospective registry study. All patients underwent cystoscopy after they submitted a voided urine sample for culture. Significant bacteriuria was defined as >10⁴ colony-forming units per milliliter with a single organism. Patients were stratified for known risk factors for UTI.InterventionPatients underwent flexible cystoscopy and received no antibiotics immediately before or after cystoscopy. They were followed for 30 d for onset of febrile UTI.Outcome measurements and statistical analysisThe end point was incidence of febrile UTI within 30 d of cystoscopy. Febrile UTI was defined as temperature >38 °C and dysuria, or having received antibiotics from an outside physician for urinary symptoms.Results and limitationsOf the 2010 patient cystoscopies, 489 (24%) had asymptomatic bacteriuria, and 1521 (76%) had sterile urine. Thirty-nine patients (1.9%) developed febrile UTI ≤30 d after cystoscopy—4.5% in colonized patients and 1.1% in uninfected patients (p = 0.02). All UTIs resolved in ≤12–24 h with oral antibiotics. None of the patients was admitted for bacterial sepsis. Limitations of the study are that it is a single-surgeon experience in one institution, and results may not apply to other patient populations.ConclusionsAntibacterial therapy before outpatient flexible cystoscopy does not appear necessary in bladder tumor patients who have no clinical signs or symptoms of acute UTI, including asymptomatic bacteriuria. Antibiotic stewardship is the responsibility of all urologists.     

Incarcerated hernia: to reduce or not to reduce?

Purpose  Before the advent of general anesthesia, taxis (hernia reduction) was the treatment of choice of incarcerated hernia but, over the years, its use subsided in favor of urgent herniorrhaphy. The role of taxis for incarcerated hernias in a growing geriatric population must be reexamined. Methods  We attempted taxis in 101 adult patients diagnosed with anterior abdominal wall incarcerated hernia. Following successful taxis, patients were hospitalized for a 24-h period of observation to obviate any complications of taxis. Upon their discharge, the patients were advised to follow with an elective hernia repair. Unsuccessful attempts at taxis were followed by emergency surgery. The gender of the patient, type of hernia, time lapse since incarceration, and signs of intestinal occlusion were recorded and mortality and morbidity rates were calculated. Results  Taxis was successful in 60.3% of cases. No taxis-related complication was observed, even though the mean delay in presentation since incarceration was 12 h. Mortality and morbidity within the taxis group were null. Conclusion  Taxis is a feasible and safe maneuver pending an eventual surgical treatment. By offering better conditions at a later repair, the mortality and morbidity may be considerably lowered. Further studies are needed in order to elucidate various aspects of this two-stage treatment of incarcerated hernia.     

Is sensitization to pig antigens detrimental to subsequent allotransplantation?

An important question in xenotransplantation is whether an allotransplant can safely be carried out in a patient who has become sensitized to a pig xenograft. To answer this question, we have searched the literature. We primarily limited our review to the clinically relevant pig‐to‐non‐human primate (NHP) model and found five studies that explored this topic. No NHP that had received a pig graft developed antibodies to alloantigens, and in vitro studies indicated no increased humoral and/or cellular alloreactivity. We carried out a small in vitro study ourselves that confirmed this conclusion. There have been three experiments in which patients undergoing dialysis were exposed to wild‐type pig kidneys and three clinical studies related to bridging a patient in hepatic failure to liver allotransplantation. Despite the development of anti‐pig antibodies, all subsequent organ (kidney or liver) allografts were successful (except possibly in one case). In addition, pig fetal islets were transplanted into patients with kidney allografts; there was no increase in panel‐reactive alloantibodies and the kidney grafts continued to function satisfactorily. In conclusion, the limited data suggest that, after sensitization to pig antigens, there is no evidence of antibody‐mediated or accelerated cellular rejection of a subsequent allograft.     

Asymptomatic Renal Stones—to Treat or Not to Treat

Purpose of Review

There are no current guidelines on the optimal management of asymptomatic renal stones. This review summarizes the current literature, focusing on more recent studies that have been done to grow the body of evidence on this topic.

Recent Findings

Recent studies have found that stone size is a significant predictor of need for future surgical intervention, with >?7 mm for pediatric population and >?4 mm for residual fragments after both PNL and ureteroscopy (URS). The role of URS has been better defined with a recent RCT concluding that URS and SWL had comparable outcomes for an asymptomatic lower pole stone <?1 cm.

Summary

The treatment decision for asymptomatic renal stones should take into consideration a variety of relevant patient and stone factors; however, ultimately, a shared decision-making approach should be used. In the properly counseled patient, active surveillance or prophylactic surgical intervention may be appropriate.

     

Erectile dysfunction: to prescribe or not to prescribe?

Even with the help of modern pharmacology, treatment of erectile dysfunction often remains complex, and requires taking into account the social, psychological, and behavioral dimensions of the disorder. This brief report presents a case study highlighting this complexity.