OBJECTIVES: To update the topic of endourethral prosthesis for the treatment of recurrent urethral stenosis comprehensively, focusing on current indications, materials and types of prosthesis in use nowadays.METHODS: We used the PubMed database (1995-2013) with the terms “endourethral”, “prostheses”, ”endourethral prosthesis” and selected the most relevant articles for this publication.RESULTS: Results were variable depending on the series published, with great differences among them. They are not homogeneous groups, so they are not comparable to each other.CONCLUSIONS: Endourethral prostheses have an important role today in the treatment of recurrent urethral stenosis. More studies are required, with longer follow up to be able to establish which one is the one with the lowest complication rates and best results in terms of urethral caliber and symptom questionnaire.

To perform a bibliographic review on female urethra stenosis, following the criteria for evidence based medicine.METHODS: We performed a PubMed Search with the following keywords: “female urethral stricture”, “women urethral stricture”, “female urethral reconstruction” and “ female urethral stricture treatment”, without time limits, both in English and Spanish languages.RESULTS: Female urethra stenosis is a rare pathology, in which the working diagnosis is essential, as much as detailed physical examination, urodynamic study and radiological tests.We found in the literature a total of 73 cases treated with dilation with or without maintenance self catheterization, 120 cases treated with meatotomy, 65 cases treated by flap urethroplasty (46 with vaginal flap, 17 with vestibular flap and 12 with labia minora graft and 28 with oral mucosa grafts).There are not comparative studies between the various techniques, making it difficult to set up a therapeutic algorithm.CONCLUSIONS: The surgical treatment with flaps/grafts has the highest success rate; whereas less invasive procedures such as urethrotomy/meatotomy/dilations/self-catheterization should be reserved for short female urethra stenosis or women with high comorbidity

Reconstructive surgery of large urethral stenosis and the management of congenital anomalies such as hypospadias and epispadias require covering large cutaneous and mucosal defects with different techniques. The objective of this work is to define the main differences between tissues to be transferred and to study the principles that must govern the management of the various flaps and grafts used for these techniques. We analyze the anatomical and physiological features that may be key to understand the success and possible failures of these procedures, and we review technical details that must accompany in every case, not only during the operation, but also during the preoperative and postoperative period. We conclude stating that grafts (mainly oral and preputial mucosa) and flaps are increasingly used for the repair of urethral stenosis. Grafts must be prepared adequately in the back table and thinned to the maximum, and also be fixed properly, to guarantee their immobility until neovascularization is assured.

In this article we present the causes of urethral stenosis in the adult male and review data about incidence. Regarding disease physiopathology we emphasize the inflammatory causes and, more specifically lichen sclerosus, as the clinical scenario that presents the greater difficulty for the management of urethral stenosis since we do not know its natural evolution.Regarding treatment of urethral stenosis we discuss the various options from excision and terminal-terminal anastomosis to oral mucosal graft augmentation urethroplasty, passing by two-step operations in more severe cases.Looking forward to the future a real gate opens with the application of tissue engineering to obtain oral mucosa.

OBJECTIVES: Urethral stenosis is a complex pathology that severely affects the quality of life of patients who suffer it. There are multiple therapeutic options, the main objective of which is to eliminate obstruction and improve symptoms, and consequently maintain or improve the quality of life of the patient. The objective of this article is to perform a systematic review of the literature with the aim to evaluate the results regarding the sexual sphere after urethral surgery.METHODS: We performed a bibliographic search in PubMed, identifying studies that analyzed the results in sexual function after various types of urethroplasties. Preference have been given to those articles evaluating sexual function both preoperative and postoperative, to determine the degree of involvement conditioned by surgery. Fourteen articles have been selected, including those making reference to sexual function (sexual desire, erectile and ejaculatory function).RESULTS: A total of 14 studies were selected to perform the analysis; they were divided into two groups depending of the perspective they have to evaluate results: Use of validated tests for data collection before and after surgery and a second group analyzing more qualitative features of the stenosis making the evaluation of results this way. Site of stenosis is not uniformly distributed in these articles, with predominance of those performing anterior urethra surgery. They have a comprehensive analysis of the various features that may affect directly or indirectly the result of the operation both in the short and long term.CONCLUSIONS: Most articles conclude that specific standardized tools are necessary for this type of pathology, with the aim of obtain results that are more adjusted to urethral surgery. Patient perception of the results of urethroplasty is a parameter that has gained great importance lately. Globally the results of postoperative sexual function are very satisfactory, mainly in young patients. It is important to globally analyze the results and surgical techniques currently in use with the aim to minimize deleterious effects on sexual function; moreover taking into account that the objective of surgery is to try to improve the patient`s quality of life.

The surgical and non-surgical treatment of localised prostate cancer may be complicated by bladder neck contractures, prostatic urethral stenoses and bulbomembranous urethral strictures. In general, such complications following radical prostatectomy are less extensive, easier to treat and associated with a better outcome and more rapid recovery than the same complications following radiotherapy, high-intensity focussed ultrasound and cryotherapy. Treatment options range from minimally invasive endoscopic procedures to moreArch. Esp. Urol. 2014; 67 (1): 77-91complex and specialised open surgical reconstruction.In this chapter the surgical management of bladder neck contractures following the treatment of prostate cancer is described together with the management of prostatic urethral stenoses and bulbomembranous urethral strictures, given the difficulty in distinguishing them from one another clinically.

OBJECTIVES: While efforts have been made to study erectile function in patients with urethral stricture, very few prior investigations have specifically assessed erectile function in men with failed hypospadias surgery. We set forth to assess the baseline erectile function of men with hypospadias failure presenting for urethroplasty as adults.METHODS: Retrospective data was analyzed on 163 adult patients with prior failed hypospadias repair who presented for urethroplasty from 2002-2007 at two sites in the United States and Italy. All patients had completed the International Index of Erectile Function (IIEF) preoperatively. Standard IIEF-6 categories were used to assess baseline level of erectile dysfunction (ED) defined as none (≥26), minimal (18-25), moderate (11-17), and severe (≤10). A subset of 13 hypospadias patients prospectively completed the IIEF questionnaire pre and post-operatively.RESULTS: The mean age at presentation for urethroplasty was 39.7 years. Based on IIEF-6 scores, 54% of patients presented with some degree of ED with 22.1%, 3.7%, and 28.2% reporting severe, moderate and mild ED respectively. While the oldest patient population (>50) had the highest incidence of severe ED (38.9%), the youngest age group (≤30) had a 60% rate of ED with 18% classified as severe (Table I). Subset analysis of 13 failed hypospadias patients following urethroplasty revealed that 11 (85%) patients had the same or improved erectile function following surgery. CONCLUSIONS: Patients presenting for repair after hypospadias failure often require complex penile reconstruction impacting both urinary as well as sexual quality of life. Among these patients there appears to be a high baseline prevalence of ED. Older patients had a higher incidence of more severe ED; however, the majority of younger patients still presented with some form of ED and a significant number with severe ED. Urethroplasty does not appear to negatively impact erectile function in men with previous hypospadias failure; however a disease specific questionnaire is needed to fully address this issue.

OBJECTIVES: To evaluate the results of various reconstructive surgical procedures in patients with failed hypospadias repair.METHODS: We performed a retrospective, observational, descriptive chart analysis of patients treated for complications after primary hypospadias repair at two tertiary European centers from 1998 to 2007. Study inclusion criteria were: patients presenting urethral, glans or corpora cavernosa defects and/or penile and genital deformities. Exclusion criteria were: precancerous or malignant penile lesions, incomplete data on medical charts and any condition that would interfere with the patient’s ability to provide an informed consent. Preoperative evaluation included urine culture, urethrography and urethroscopy. The patients were classified into four groups according to the type of surgery. Success was defined as a normal functional urethra with apical meatus, no residual chordee or cosmetic deformity of the genitalia. The need for meatal or urethral dilation, complications or poor cosmesis requiring revision was considered a failure.RESULTS: A total of 1.176 patients (mean age 31 years) were evaluated and treated. Nine hundred fifty-three patients (81%) were treated in Serbia and 223 (19%) in Italy. Mean follow-up was 60.4 months. Group 1 included 301 patients (25.6%) who underwent urethroplasty. Group 2 included 60 patients (5.1%) who underwent corporoplasty. Group 3 included 166 patients (14.1%) who underwent urethroplasty and corporoplasty. Group 4 included 649 patients (55.2%) requiring complex resurfacing of the genitalia. Evaluations were scheduled 3, 6 and 9 months post-operatively and annually thereafter. At follow-up, patients underwent a physical examination and uroflowmetry. Out of the 1.176 cases, 1.036 (88.1%) were classified as successful and 140 (11.9%) as failures. The success rate was 89.7% in Group 1, 96.7% in Group 2, 88.5% in Group 3, and 86.4% in Group 4, respectively.CONCLUSIONS: Failed hypospadias presents a variety of surgical difficulties. Patients requiring complex repair should be referred to a specialized center of expertise.

Hypospadias is one of the most frequent male congenital anomalies. Its surgical correction is under permanent review and it is always controversial. The best surgical technique can only be chosen intrao-peratively, since it is the level of corpus spongiosum di-vision what marks the severity of the case, although it is essential to evaluate position of the meatus, penile curvature, quality of the preputial skin and penile size. It is recommended treatment age between 6-12 months. Nowadays, The most frequently used technique for hy-pospadias repair is the Snodgrass tubularized incised urethral plate (TIP). Moreover, distal and medial hypos-padias may be treated with urethral advance or flap te-chniques and proximal hypospadias with modifications of these in one-step or two-step procedures. Neverthe-less, there are other controversies about hypospadias, such as to preserve or not the prepuce, the use of central or peripheral anesthesia blockade, or the use of wound dressings.

Posterior urethral injuries typically arise in the context of a pelvic fracture. The correct and appropriate initial treatment of associated urethral rupture is critical to the proper healing of the injury.In this paper, we provide a comprehensive review of the literature with special emphasis on the various treatments available: open or endoscopic primary realignment, immediate or delayed urethroplasty after suprapubic cystostomy, and delayed optical urethrotomy.

Penile urethra stenoses generally appear as a sequel after acute (sexually transmitted diseases) or chronic urethritis processes, associated with diseases such as lichen sclerosus or as a consequence of traumatism, iatrogeny and forced distention of the urethral lumen. One third of these lesions may be congenital and they usually present in the youngest patients.When there is indication for surgical urethral reconstruction there are multiple surgical techniques and different tissues. The selection of the best technique depends on the availability of different tissue sources, the knowledge of the various technical options, and being familiar or having personal experience with the surgical techniques.This chapter aims to review the various technical options of more frequent use for urethral lumen reconstruction, to offer the greatest number of resources to solve a medical problem of complex solution.

Endoscopic urethrotomy is a simple, reproducible, highly widespread technique that enables an appropriate management of patients with urethral stenosis, if the indication is well established. Determinants of success of this procedure are stenosis length, site, number, degree of spongiofibrosis and previous treatments. The best results would be obtained in single, short bulbar stenoses with limited spongiofibrosis, in which it may be the first choice. Its main limitation is the fact that the procedure itself is a controlled intentional trauma the result of which depends on multiple variables, including the technique employed.

OBJECTIVES: Limited articles are publis-hed on re-operative urethroplasty outcomes. We soughtto perform a systematic review of re-operative urethro-plasty articles over the past fifteen years.METHODS: A systematic review was performed on Pub-Med using the search terms “Urethra” AND “SurgicalProcedures, Operative” OR “Urethroplasty”.RESULTS: Five articles out of 3,541 articles identifiedbetween 1998 and 2012 specifically addressed re-operative urethroplasty patients. A total of 212 patientswere included in these five studies. Re-operative urethro-plasty success rates ranged from 35% to 84%. Successrates were higher in the two studies with over 40 pa-tients and ranged from 78-84%.CONCLUSION: Limited studies address re-operativeurethroplasty outcomes. Success rates for re-operationare lower than those for initial urethroplasty procedures.Overall, studies with a higher number of patients had anincreased success rate

In this review we present an update on the anatomy and vascularization of the male urethra. The real objective of this review is to make the following chapters more understandable, both to know the physio-pathological mechanisms of urethral pathology and also to help us in their surgical management.

OBJECTIVE: To describe the anatomicalcharacteristics and vascularization of the biaxial hairfree scrotal flap (BAES-flap) and to detail its surgicalapplication to reconstruction of the more complexurethral strictures.METHODS: We performed macro and micro anatomicaldissections of the scrotum in 15 cryopreserved cadaversfor the study of the arterial microvascularization of theBAES flap, and this anatomical knowledge has beenimplemented with the aim to improve the anterior andposterior urethra reconstructive surgical technique. Forscrotal skin conditioning we performed definitive hairremoval with the alexandrite laser.RESULTS: The BAES flap, thanks to its rich biaxialvascularization, its anatomical disposition over theurethral axis, and the suitable characteristics of hair freescrotal skin, has allowed us to perform successful one-step urethral reconstruction in complex cases such aspanurethral disease, multioperated hypospadias, failedurethroplasties and obliterative stenosis.CONCLUSIONS: Detailed study of scrotal skin arterialvascularization is essential to design reliable andversatile genital skin flaps that result appropriate for themost complex reconstructive urethral surgery. The BAESscrotal flap complies with these requirements offeringthe patient a one step reconstructive option with a verysatisfactory surgical experience over more than 20years

Urethral strictures are one of the mostcommon urological problems, yet the natural limitationsof wound healing and the physiologic demands on theanatomic structures combine to also make urethral stric-tures one of the most challenging urological problems tomanage. Proper wound healing demands well approxi-mated edges because prolonged inflammation andgranulation, required to close large, deep wounds, willresult in excess collagen production, fibrosis, and theformation of a scar or, in the urethra, a stricture. Bioma-terials have successfully been used to approximate theECM of several different tissue types and can define athree dimensional space suitable for the formation of newtissues with both appropriate structure and appropriate function. Biomaterials can be broadly categorized as ei-ther synthetic polymers or tissue matrices, each with theiradvantages and limitations. Recent studies utilizing cellseeded natural biomaterials in urethral repair has yiel-ded some promising results. However, advancements inthe use of alternative sources of cells for matrix seedingand cell-seeded synthetic materials hold the possibility ofeven better results in the future

OBJECTIVES: There are various treatments forprostate cancer nowadays, including techniques that have been used for manyyears such as surgery and radiotherapy, and newer procedures that are gaining prominence in the Urological field like cryotherapy or HIFU (high intensity focused ultrasound). Rectourethral fistula is a rare complication that demands the urologist a great capacity; it may happen after either existent treatment.EVIDENCE ACQUISITION: PubMed literature review with articles published during the last 10 years using the terms “rectourethral fistula” and “prostate cancer”.EVIDENCE SINTHESIS: We present the current situation of rectourethral fistula secondary to prostate cancer in terms of epidemiology, diagnosis and treatment, with special focus on the various types of fistulae and their management. We comment on general features in relation to surgical management of this pathology; type of approach, type of repair, use of flaps, concomitant fistula and urethralstenosis, delay of surgery and bowel diversion. We describe the surgical techniques more frequently used today and their limitations. We present theresults published by different groups with each of these techniques, as well as the corresponding recommendations based on each group`s experience.CONCLUSIONS: Rectourethral fistula is a surgical challenge for the urologist. We must choose the appropriate management in accordance to the characteristics of the fistula.

Patients with panurethral and complex urethral strictures after failed urethral reconstruction due to strictures and hypospadias repair is a rare but challenging condition. Contemporary surgical techniques include one and two staged urethroplasties using different graft substitutes (i.e., buccal mucosa) or full thickness skin grafts (i.e., from the inner thigh), thereby providing satisfactory results with reducing the re-stricture rate in these patients. However, all current techniques do so at the expense of higher revision rates and thus requiring multiple procedures. Studies investigating the outcomes of reconstruction in panurethral and complex urethral strictures often have heterogeneous patient cohorts including children and adults, different underlying causes, and different techniques, thus allowing only limited interpretation of the published data. In the field of urethral reconstruction, where personal experience and expertise presents an accepted necessity, however, leading to rather small single center studies,only well-designed randomized clinical trials can truly answer the question of which technique will be advantageous in these patients.

Traditionally, anastomotic procedures with transection and urethral excision are suggested for short bulbar strictures, while longer strictures are treated by patch graft urethroplasty preferably using the buccal mucosa as gold-standard material due to its histological characteristics.However, anastomotic urethroplasties may cause sexual complications related to vascular damage of the spongiosum following the urethral section or to excessive urethral shortening.On the other hand, one-sided graft procedures, using either dorsal or ventral graft location, could be insufficient in providing a lumen of adequate width in strictures with a particularly narrow area.The double buccal graft urethroplasty is a new technique that aims to obtain a sufficient “two-sided” augmentation of the urethra avoiding its transection and preserving the urethral plate.In this chapter we discuss the rationale for utilizing our procedure. In addition, the surgical technique is described in detail.

Although radical prostatectomy is a curative therapy that has proven effective in many of our patients with prostate cancer, it is still associated with significant morbidity, which includes postoperative erectile dysfunction among its leading exponents. Potency after the intervention may be influenced by many factors, among which, presence of adequate erectile function before surgery, patient’s age, stage of disease at the time of treatment, surgeon’s experience and, of course, interpersonal anatomical variations may be pointed out.In recent decades, the exact knowledge of the neuroanatomy of the male pelvis has become very important, for both the student of human anatomy and the pelvic surgeon. Therefore, the anatomical nerve sparing techniques have led to fewer complications related to the injury of these structures. This article presents a brief description of the neuroanatomical substrate of the neurovascular bundles along with a detailed compilation of the different surgical techniques for their preservation during radical retropubic prostatectomy.

The most important current concept in therapeutic management of female genital prolapse is the use of non absorbable prosthesis through a vaginal approach. The application of these surgical techniques to repair prolapse aims to restore the anatomic position of the pelvis, while preserving urinary, bowel and sexual functions. Since 2005, we use the Apogee® prosthesis for the treatment of both the vault prolapse and associated posterior colpocele.The purpose of this paper is the detailed description of the technique of placement of Apogee® prosthetic sys-tem, so that it can be useful to clarify the key points of this surgical reconstructive surgical technique and different gestures associated with the placement of this type of prosthesis.

Historically, the surgical treatment of benign prostatic hyperplasia (BPH) in glands with volumes over 75-80 grams was performed using the conventional surgical approaches described by Terence Millin and Peter Freyer.Due to technological advancement over the past three decades, at present, minimally invasive techniques are being used with good results in the treatment of BPH. The incorporation of the laparoscopic approach to urologic surgery has allowed the technical development of adenomectomy using the same guidelines followed by conventional approaches.The aim of this paper is to describe in detail, step by step, the surgical technique of laparoscopic prostatectomy to treat BPH in glands larger than 60 cc., and to perform a re-trospective analysis of preliminary results obtained in the immediate postoperative period of our initial series.

Since the initial report in 1992, lapa-roscopic adrenalectomy has proved substantial advan-tages over the conventional procedure in terms of de-creased postoperative pain and hospital stay, allowing earlier return to normal activity. The technical details are in permanent evolution and the most widely accepted laparoscopic surgery for the adrenal gland is the transabdominal lateral approach. We hereby describe step by step the way we perform the lateral approach after 41 consecutive cases.

Radical cystectomy with extended pelvic lymphadenectomy remains the treatment of choice for muscle invasive bladder cancer and non-metastatic cho-rion-invasive high grade tumors resistant to treatment with intravesical chemotherapy. During the last decade the procedure has been refined and we have acquired the skills necessary to perform it using the laparoscopic approach. In this way, the oncologic and functional outcomes obtained can be compared to those of its open counterpart. This article descri-bes in detail the technique of radical cystoprostatectomy and urinary diversion in the male patient conducted by our group in an attempt to improve the knowledge and spread of this always difficult procedure.

Currently, we have different technical options for treating clinically complex scenarios such as neurogenic bladder, difficult to manage lower urinary tract obstruction and many disasters sometimes seen after prostate cancer treatment.During the seventies, clean intermittent bladder catheterization was established as the best treatment option for these patients. As a method, suprapubic urinary diversion has undergone a major evolution over the past fifty years trying to solve the most refractory and poor prognosis cases. Continent ileovesicostomy is an easy emptying and low-pressure non-catheterizable urinary conduit that enables safe and durable urine elimination. In this article a detailed and updated knowledge of this technique is provided.

Renal artery aneurysm is an infrequently seen disease. The most feared symptom is ruptu-re, which is often rapidly fatal. Indications for interven-tion include size, intractable symptoms and pregnancy. Many cases are managed by endovascular techniques; however, very complex cases often are referred to the urologist. We report our experience with the rarely used technique of renal artery aneurysms repair comprised of nephrectomy, extracorporeal vascular reconstruction with aneurysmectomy, and autotransplant.

During the past 15 years, orthotopic uri-nary diversion surgery has evolved from “experimental” to become the standard treatment in higher volume and experience world centers as the preferred method of uri-nary diversion in both sexes.The overall complication rate of the intussuscepted affe-rent segment required for the construction of a continent Koch reservoir, led to the late 90’s development and des-cription by Skinner et al. of the continence and anti-reflux “T- mechanism”. Based on the sub-serosal appendix-tun-neling described by Mitrofanoff and the extra-serosal ureteric-tunnelling by Ghoneim, this new mechanism has been used successfully incorporated into an orthotopic diversion system (“T-neobladder or T-pouch”). Apparent-ly, this “T-mechanism” has eliminated the problems asso-ciated with the intussuscepted intestinal segment, while maintaining an effective anti-reflux and continence sys-tem. This article describes in detail the surgical steps for the construction of an ileal T-neobladder.

Holmium laser enucleation of the prostatic adenoma (HoLEP) represents an innovative surgical option for the treatment of bladder outlet obstruction caused by benign prostatic hypertrophy. The results of numerous randomized prospective studies and clinical case series have confirmed that HoLEP is a procedure that attains immediate bladder outlet obstruction release, that improvement of symptomatic and uroflowmetry parameters is maintained in the midterm and, it is associated with less morbidity than conventional surgery. On the other hand, the shortage of urologists with experience in this procedure, and its technical difficulty have limited its spread in our environment. In this article we describe in detail the technique we use in our center for the performance of HoLEP, emphasizing the modifications we have introduced with time to make the operation easier and to avoid complications.

The excision of large retroperitoneal mas-ses poses a challenge for every surgeon. Sometimes the urologist must face situations that do not fit to any con-ventional approach or technique previously described. Obtaining adequate exposure for safe and oncologi-cally correct management of these masses is based, on many cases, in the mobilization of anatomical adjacent structures to generate a sufficient field in abdominal areas of difficult access.Complex visceral mobilization maneuvers derived from multivisceral transplantation organ procurement surgery provides ancillary techniques that used properly facilita-te their successful resolution.The main purpose of this paper is the description of the-se surgical maneuvers essential to increase both exposu-re and vascular control in addressing the ever-dreaded high-volume retroperitoneal masses.

IIdiopathic retroperitoneal fibrosis is an un-common disorder of unclear etiology characterized by a chronic and non-specific inflammatory process of the retroperitoneal fibro-fatty tissue. During the last decade, major advances have been made in the understanding and management of this entity and it is nowadays pro-posed to be the result of an autoimmune reaction that involves other surrounding structures, notably the ureters, leading the development of obstructive uropathy and secondary renal failure as the disease advances.To date, it has not been reported a widely accepted therapeutic schedule, although surgical approach has become the best treatment option in case of conservati-ve strategies failure. Surgical treatment main goals are obtaining biopsies of the fibrous plaque during the release of both ureters and their transposition inside the peritoneal cavity. This procedure is completed with a ureteral comwrapping with omentum to prevent a new entrapment. The purpose of this paper is the de-tailed description of the ureterolysis and omentoplasty technique, since, although recently some authors have reported small series of similar laparoscopic procedu-res, it is time consuming, complex and there is a possibility of potential serious complications, which still keep alive the con-ventional technique.

The propensity of upper tract transitional cell carcinoma towards recurrence and the limitations of upper tract endoscopy have led to nephroureterec-tomy being the gold standard treatment, even though major open surgery risks outweigh the risks of cancer. Thus, removal of the entire unit may not be warranted when the tumor can be safely controlled endoscopica-lly. Recent advances in technology and techniques have permitted the effective endourologic management of up-per transitional cell carcinoma.

Since the introduction of extracorporeal shock wave lithotripsy and the various modalities of endoscopic surgery, the number of open procedures for the treatment of urolithiasis has decreased dramatically. The use of these techniques in the management of easier cases leaves no doubt, but there is still some controversy about what should be the best treatment option for the largest and most complex staghorn calculi. Anatrophic nephrolithotomy is still considered the gold standard for the treatment of such lithiasis. This paper presents in detail the key technical points to consider during its performance.

Renal cell cancer with tumor thrombus is present in 4-15% of cases. The prognostic significance of this entity has been object of intense debate. Nowadays, it is considered, that the presence of thrombus itself does not have a negative prognostic impact on survival rates if the thrombus could be excised satisfactorily. Complete removal of renal malignant tissue is the only curative strategy for the treatment of this kind of tumors.During the last three decades, there has been steady im-provements in surgical technique and preoperative care fields that have favorably modified the surgeons’ ability to safely excise these tumors. In this sense, the experien-ce provided by multiorgan, kidney-pancreas and liver procurement and transplantation techniques led the uro-logists re-examine their approaches to the inferior vena cava and retroperitoneum, thus they could result useful in the always challenging resection of these complex tumors with neoplasic extension into the vena cava.

Moderate-severe urinary incontinence and refractory-to-treatment erectile dysfunction after radical prostatectomy are two entities causing an important loss of quality of life to patients.The double implant of penile prosthesis and artificial urinary sphincter is a safe and effective option in these cases. This article describes preoperative considerations and the most important technical steps to do it satisfactorily.

Approximately 4-14% pelvic fractures cause a posterior urethral injury. Pelvic fractures associa-ted with straddle injuries or large trauma accidents are more frequently involved with this kind of lesions. Primary open repair of the urethral injury is discouraged in the acute setting. 3-6 months after urinary diversion a formal open reconstruction can be safely attempted. This gives time for scar maturation, reabsorption of pelvic hematomas, and relative restoration of anatomical fascial layers. The complexity of such interventions can be mini-mized following proper diagnostic and surgical protocols. Anastomotic urethroplasty under the precepts of the progressive perineal approach provides an excellent treatment option for these patients.The aim of this paper is the detailed description of the procedure for the treatment of such injuries.