Posterior Urethral Reconstruction Research Articles

Posterior Urethral Reconstruction at the Time of Rectourethral Fistula Repair: Technique and Outcomes

IntroductionRecto-urethral fistulas (RUF) remain a difficult management problem. To assess the impact of posterior urethral stenosis on outcomes following RUF repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair. MethodsWe identified 130 men who underwent RUF repair at our institution between 2003-2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months pre-operatively), and 20 men suprapubic catheter placement (median, 5.5 months pre-operatively). ResultsRUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intra-operatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%).At a median follow up of 55.7 months (IQR, 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation. ConclusionsPosterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis.

Transperineal anastomotic posterior urethroplasty with bulbocavernosus flap and fibrin sealant in the complicated posterior urethral stricture reconstruction: a retrospective cohort study.

Management of complicated posterior urethral stricture is challenging. Modified transperineal anastomotic urethroplasty (TAU) with bulbocavernosus flap interposition and human fibrin sealant provides another treatment option. The authors aimed to evaluate whether this technique could improve the success rate in the complicated posterior urethral stricture reconstruction in this study. Between 2016 and 2019, 48 patients underwent either conventional or modified TAU. The criteria for success included both the absence of clinical symptoms and no need for further surgical intervention during follow-up. Twelve patients underwent the modified TAU (group A) using bulbocavernosus flap interposition and human fibrin sealant. Thirty-six patients underwent the traditional end-to-end anastomotic urethroplasty (group B). Follow-up was 24.3-57.2 months. The patients in group A had a higher surgery success rate compared to the patients in group B (91.7 vs. 63.9%, P =0.067), with a quasi-significant result. Besides, no postoperative complications were observed in group A, while two individuals in group B had urinary incontinence, but the difference was not significant (0 vs. 5.6%, P =0.404). Based on the preliminary results, modified TAU with bulbocavernosus flap interposition and human fibrin sealant is a safe and feasible technique for complicated posterior urethral stricture reconstruction.

PD35-03 ROBOTIC POSTERIOR URETHROPLASTY: 105 CASES FROM A SINGLE CENTER

You have accessJournal of UrologyCME1 Apr 2023PD35-03 ROBOTIC POSTERIOR URETHROPLASTY: 105 CASES FROM A SINGLE CENTER Alex Wang, Ashley Alford, and Lee Zhao Alex WangAlex Wang More articles by this author , Ashley AlfordAshley Alford More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003333.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic posterior urethroplasty (RPU) has been described in small case series to be a viable option for men requiring posterior urethral reconstruction. Outcomes of RPU in larger scale cohorts are lacking. Herein we present our experience with RPU to date. METHODS: We performed a retrospective review of men who underwent RPU from October 2014 to August 2022. Our cohort included men who required RPU secondary to conditions including prostate cancer treatment, pelvic trauma, and rectourethral fistulas. All RPUs were performed by a single reconstructive urologist at a single institution. We collected pre-operative, intra-operative, and post-operative characteristics. Post-operative complications were graded using the Clavien-Dindo classification system. RESULTS: Cohort characteristics and outcomes are represented in Table 1. A total of 105 patients were included, with median age of 69 and median BMI of 27. 72 (68.6%) patients had a history of prostate cancer treated with surgery and/or radiation. 60 (57%) patients had a history of abdominal or pelvic radiation. Mean follow-up time was 18 months. 63 (60%) patients underwent a previous urethral procedure, 84.1% (53/63) of which was an endoscopic dilation. Intra-operatively, a combined abdominal/perineal approach was used in 41 (27%) patients. Various methods of reconstruction were implemented, the most common of which were excision and primary anastomosis (EPA), Y-V plasty of bladder neck, and re-siting of bladder neck. 7 patients had Clavien-Dindo grade 3a or higher complications within 30 days. 28% (30/105) subsequently required an artificial urinary sphincter (AUS) with average time from surgery to AUS placement of 9 months. One-quarter of patients required at least one subsequent urethral surgery for recurrent stricture, with 4 patients ultimately undergoing cystectomy and urinary diversion. All cystectomy patients had a history of radiation. CONCLUSIONS: We present one of the largest cohorts to date of patients who underwent RPU, demonstrating success of a variety of techniques for urethral reconstruction even in patients with history of failed urethral procedures. Immediate post-operative complications were rare, however 28% of patients did ultimately require AUS placement and 25% patients underwent a subsequent urethral procedure, most commonly via endoscopic approach. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e975 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alex Wang More articles by this author Ashley Alford More articles by this author Lee Zhao More articles by this author Expand All Advertisement PDF downloadLoading ...

PD35-05 POSTERIOR URETHRAL RECONSTRUCTION AT THE TIME OF RECTOURETHRAL FISTULA REPAIR: TECHNIQUE AND OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023PD35-05 POSTERIOR URETHRAL RECONSTRUCTION AT THE TIME OF RECTOURETHRAL FISTULA REPAIR: TECHNIQUE AND OUTCOMES Roger Khouri, Joao Pedro Emrich Accioly, Molly Dewitt-Foy, Hadley Wood, and Kenneth Angermeier Roger KhouriRoger Khouri More articles by this author , Joao Pedro Emrich AcciolyJoao Pedro Emrich Accioly More articles by this author , Molly Dewitt-FoyMolly Dewitt-Foy More articles by this author , Hadley WoodHadley Wood More articles by this author , and Kenneth AngermeierKenneth Angermeier More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003333.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recto-urethral fistulas (RUF) remain a difficult management problem in reconstructive urology. The presence of posterior urethral stenosis or obliteration in association with RUF further complicates the situation and may have an impact on deciding whether the patient is a candidate for restorative reconstruction. To assess the impact of posterior urethral stenosis on outcomes following RUF repair, we present a cohort of 23 men who underwent posterior urethroplasty as part of their treatment. METHODS: We identified 130 men who underwent RUF repair at our institution between 2003-2021. Of these, 23 (18%) also underwent simultaneous posterior urethroplasty and were selected for in depth review. RESULTS: 15 men received prior radiation for prostate cancer: 6 EBRT and brachytherapy, 8 brachytherapy alone, and 1 EBRT alone. Of the 8 men who were not radiated, 4 underwent radical prostatectomy, 2 developed RUF following traumatic injuries, and 2 developed RUF in the setting of inflammatory bowel disease. 3 men (13%) underwent attempted RUF repair prior to referral. Initial management included fecal diversion in all 23 cases (mean 10.3 months prior to RUF repair) and suprapubic catheter placement in 20 (87%) at a mean of 6.4 months prior to surgery. RUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). At the time of surgery, 20 men (87%) had significant posterior urethral stenosis, and 3 (13%) had posterior urethral defects due to cavitation and tissue loss associated with RUF. Posterior urethroplasty involved the prostatomembranous urethra in 18 cases (79%), and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (79%) and using buccal mucosal graft in 5 (22%). Gracilis interposition was performed in 21 cases (91%). At a median follow up of 55.7 months (IQR, 23-82 months), 87% had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. 14 men (61%) developed urinary incontinence, with 7 (30%) ultimately undergoing AUS placement. There were no isolated stricture recurrences requiring instrumentation. CONCLUSIONS: Posterior urethral stenosis or obliteration associated with RUF complicates a challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e976 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Roger Khouri More articles by this author Joao Pedro Emrich Accioly More articles by this author Molly Dewitt-Foy More articles by this author Hadley Wood More articles by this author Kenneth Angermeier More articles by this author Expand All Advertisement PDF downloadLoading ...

Robotic Urethral Reconstruction Outcomes in Men With Posterior Urethral Stenosis

To evaluate surgical outcomes stratified by posterior urethral obstruction (PUO) etiology in men undergoing definitive robotic posterior urethral reconstruction. A retrospective, single surgeon, review of men undergoing robotic posterior urethral reconstruction between 2018 and 2020 was performed. Differences in complications, reconstructive success (no further intervention), and urinary continence by PUO etiology were assessed. Robotic posterior urethral reconstruction was performed in 21 men. PUO etiology included benign prostatic hypertrophy treatment in 5 (24%), prostatectomy in 10 (48%), radiation in 5 (24%), and trauma in 1 (5%). Median number of prior endoscopic treatments was 3 (benign prostatic hypertrophy), 3 (prostatectomy), and 2 (radiation) with an average time between obstruction and reconstruction of 9, 12, and 15 months (P = .52). Median length of stay after reconstruction was 2, 1, and 2 days (P = .45). Thirty-day complications occurred in 0%, 20%, 40% (P = .19). Post-reconstruction re-intervention was necessary in 0%, 10%, 80% (P = .004). Ultimately, anatomic success was achieved in 100%, 90%, 80% (P = .63), with functional success rates of 100%, 100%, 60% (P = .035). Median postoperative pad/day usage was 0,0, 10.5 (P <.001), and ultimately 0%, 30%, 80% (P = .013) underwent artificial urinary sphincter placement. Endoscopic treatment of posterior urethral obstruction (PUO) secondary to benign and malignant prostate conditions is associated with a high incidence of treatment failure. Robotic posterior urethral reconstruction is a safe and effective surgical solution for men with PUO in the absence of pelvic radiation. Men with pelvic radiation appear to be at increased risk of complications, PUO recurrence, and clinically significant stress urinary incontinence.

MP03-15 ROBOTIC URETHRAL RECONSTRUCTION IS AN EFFECTIVE TREATMENT SOLUTION IN NON-IRRADIATED MEN WITH POSTERIOR URETHRAL OBSTRUCTION

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) I (MP03)1 Sep 2021MP03-15 ROBOTIC URETHRAL RECONSTRUCTION IS AN EFFECTIVE TREATMENT SOLUTION IN NON-IRRADIATED MEN WITH POSTERIOR URETHRAL OBSTRUCTION Elizabeth Bearrick, Kevin Hebert, Laura Maciejko, Bridget Findlay, Katherine Theisen, and Boyd Viers Elizabeth BearrickElizabeth Bearrick More articles by this author , Kevin HebertKevin Hebert More articles by this author , Laura MaciejkoLaura Maciejko More articles by this author , Bridget FindlayBridget Findlay More articles by this author , Katherine TheisenKatherine Theisen More articles by this author , and Boyd ViersBoyd Viers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001964.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Endoscopic treatment of posterior urethral obstruction (PUO) secondary to benign and malignant prostate conditions is associated with a high incidence of treatment failure. Herein, we evaluate surgical outcomes stratified by PUO etiology in men undergoing definitive robotic posterior urethral reconstruction. METHODS: A retrospective, single surgeon, review of 21 men undergoing robotic posterior urethral reconstruction between 2018 and 2020 was performed. Differences in complications, reconstructive success (no further intervention), and urinary continence by PUO etiology were assessed. RESULTS: Robotic posterior urethral reconstruction was performed in 21 men with a median follow up of 5 months (IQR 4–18.4). PUO etiology included BPH treatment in 5 (24%), prostatectomy in 10 (48%), radiation in 5 (24%), and trauma in 1 (5%). Median number of prior endoscopic treatments was 3 (BPH), 3 (prostatectomy), and 2 (radiation) with an average time between obstruction and reconstruction of 9, 12, and 15 months (p=0.52). Median length of stay after reconstruction was 2, 1, and 2 days (p=0.45). 30-day complications occurred in 0%, 20%, 40% (p=0.19). PUO re-intervention was necessary in 0%, 10%, 20% (p=0.63). Median postoperative pad/day usage was 0.0, 10.5 (p<0.001), and ultimately 0%, 30%, 80% (p=0.013) underwent artificial urinary sphincter placement. CONCLUSIONS: Robotic posterior urethral reconstruction is a safe and highly effective surgical solution for men with PUO in the absence of pelvic radiation. Men with pelvic radiation appear to be at increased risk of complications, PUO recurrence, and clinically significant stress urinary incontinence. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e27-e27 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elizabeth Bearrick More articles by this author Kevin Hebert More articles by this author Laura Maciejko More articles by this author Bridget Findlay More articles by this author Katherine Theisen More articles by this author Boyd Viers More articles by this author Expand All Advertisement Loading ...

Partial Inferior Pubectomy in the Delayed Repair of Pelvic Fracture Urethral Injury: Adopting a Bone-nibbling Technique

Background: The use of wedge inferior pubectomy can be challenging to many urethral surgeons. Our objective was to introduce a bone-nibbling technique to accomplish a partial inferior pubectomy (PIP) in a resource-poor setting, and to report the medium- to longterm outcome of using the technique.&#x0D; Methods: Five patients were recruited (mean age: 38.8 years) who presented, over a 30-month period, with posterior urethral fibrosis from a pelvic fracture urethral injury (PFUI). One had failed a previous attempt at posterior urethral reconstruction elsewhere. The length of urethral defect was from 2 to 4 cm. We describe a bone-nibbling technique used to carry out PIP for the delayed repair of PFUI in these patients. The outcomes in the medium to long term of surgical procedures done with this technique are presented.&#x0D; Results: Immediate postoperative complications in all were essentially a Clavien–Dindo grade I. Peak flow rate assessed 12 weeks’ post operation was between 20 mL/s and 23 mL/s (mean: 21 mL/s). The longest duration of follow-up was 34 months, and all patients were voiding satisfactorily.&#x0D; Conclusions: A satisfactory and durable outcome can be obtained from nibbling at the bone from the inferior margin of the pubic bone to achieve PIP. This is of interest to lower urinary tract reconstructive surgeons who have concerns with chiseling-out wedge of the inferior pubis.&#x0D; Keywords: Bone nibbling, Partial inferior pubectomy, PFUI, Posterior urethra, Urethral anastomosis

V06-07 ROBOTIC ASSISTED BUCCAL MUCOSA GRAFT POSTERIOR URETHROPLASTY

You have accessJournal of UrologyLower-Tract Reconstruction I: Sling/ Sphincter/ Penile & Urethral Reconstruction (V06)1 Apr 2020V06-07 ROBOTIC ASSISTED BUCCAL MUCOSA GRAFT POSTERIOR URETHROPLASTY Min Suk Jun*, Michael Siev, and Lee Zhao Min Suk Jun*Min Suk Jun* More articles by this author , Michael SievMichael Siev More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000885.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic-assisted posterior urethral reconstruction has shown great promise in early series with excellent patency rates. While Y-V or T plasty remains useful for short supra-sphincteric stenoses, longer stenoses, especially those that are trans-sphincteric, pose a great surgical challenge. The standard approach usually involves urethral transection, often including the bulbar arteries. This increases the risk for incontinence, bulbar urethral necrosis, and future AUS erosion. A buccal mucosa graft posterior urethroplasty may obviate the need for urethral transection, potentially avoiding the aforementioned complications. We present our technique of robotic assisted buccal mucosa graft posterior urethroplasty (RBMGPU). METHODS: This is a retrospective chart review of men who underwent RBMGPU by a single surgeon with the Da Vinci SP robot during 2019. Indications included vesicourethral anastomotic stenosis, radiation induced stenosis, and fistula. Nonobliterative stenoses were approached retropubically or transvesically, while obliterative stenoses were approached posteriorly. A simple prostatectomy was performed if the prostate was in situ. If the stenosis spanned both sides of the sphincter, a perineal dissection was performed. When a well-vascularized flap was required for graft backing or interposition, a rectus or omental flap was used. The primary endpoint was surgical success defined by the absence of obstructive voiding symptoms or urethral patency >16 French. The secondary endpoint was de novo incontinence. RESULTS: 7 men with mean age of 65 years (range 49-72) underwent RBMGPU. Mean operative time was 512 minutes with mean estimated blood loss of 185 mL. Average length of stay was 1.4 days. At a mean of 2.2 months follow up (range 0.8-4.5), 6 of 7 patients reached the primary endpoint while 1 patient experienced de novo incontinence. There was 1 major complication (Clavien > 2), which was a Richter hernia related to the rectus flap. CONCLUSIONS: RBMGPU is a feasible approach to posterior urethroplasty, while minimizing known risk factors for future incontinence surgery. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e557-e558 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Min Suk Jun* More articles by this author Michael Siev More articles by this author Lee Zhao More articles by this author Expand All Advertisement PDF downloadLoading ...

Robotic urethral reconstruction: redefining the paradigm of posterior urethroplasty.

Outlet procedures for benign prostatic hypertrophy, prostate cancer therapy, and trauma can result in stenosis of the posterior urethra, a complex reconstructive problem that often fails conservative endoscopic management, necessitating more aggressive and definitive reconstructive solutions. This is typically done with an open technique which may require a combined abdominoperineal approach, pubectomy, and/or flap interposition. Implementation of a robot-assisted platform affords several potential advantages including smaller incisions, magnified field of vision, near-infrared fluorescence (NIRF) imaging to characterize tissue integrity, enhanced dexterity within the deep and narrow confines of the male pelvis, sparing of the perineal planes, and shorter convalescence. Herein, we describe important surgical considerations for robotic posterior urethral reconstruction.

Tissue expander capsule as an induced vascular bed to prefabricate an axial vascularized buccal mucosa-lined flap for tubularized posterior urethral reconstruction: preliminary results in an animal model

Surgical repair of complex posterior urethral disruptions remains one of the most challenging problems in urology. The efficacy of using a tissue expander capsule as an induced vascular bed to prefabricate axial vascularized buccal mucosa-lined flaps for tubularized posterior urethral reconstruction in a rabbit model was tested. The experiments were performed in three stages. First, silicone tissue expanders were inserted into the groin to induce vascularized capsule pouch formation. Next, buccal mucosa grafts were transplanted into the newly formed capsular tissue supplied by axial vessels for buccal mucosa-lined flap prefabrication. Then, circumferential posterior urethral defects were created and repaired with the buccal mucosa graft (Group 1), the capsule flap (Group 2), and the prefabricated capsule buccal mucosa composite flap (Group 3). After surgery, notable contracture of the tubularized buccal mucosa graft was observed in the neourethra, and none of the rabbits in Group 1 maintained a wide urethral caliber. In Group 2, the retrieved neourethra showed little evidence of epithelial lining during the study period, and the lumen caliber was narrowed at the 3-month evaluation. In Group 3, the buccal mucosa formed the lining in the neourethra and maintained a wide urethral caliber for 3 months. The capsule may serve as an induced vascular bed for buccal mucosa-lined flap prefabrication. The prefabricated buccal mucosa-lined flap may serve as a neourethra flap for posterior urethral replacement.

Robotic-assisted Proximal Perineal Urethroplasty: Improving Visualization and Ergonomics

ObjectiveTo describe the use of the robotic platform for proximal suture placement during perineal urethroplasty in the posterior and proximal anterior urethra. Repair of posterior urethral and proximal bulbar strictures requires deep perineal dissection, making visualization and accurate placement of sutures challenging. The robotic platform has demonstrated benefits in these characteristics in deep pelvic surgery. MethodsWe report a retrospective review of 10 patients who underwent robotic-assisted urethroplasty at a single institution by a single surgeon in a 1 year period. All patients underwent a standard perineal dissection with robotic-assisted placement of proximal sutures. Postoperative outcomes include urethroplasty leak rate as determined by voiding cystourethrograms, urethroplasty success rate, and perioperative complications. ResultsThe mean age of this cohort was 43 years old (14-68). Average stricture length was 2.2 cm (1.5-3.0 cm) and most frequently in the bulbar urethra (5/10). Seven patients underwent nontransecting urethroplasties while 3 underwent transecting anastomotic repair. At postoperative voiding cystourethrograms, no patient had urinary extravasation. Average set-up time for the robotic portion of the surgery was 15 minutes with 30-45 minutes needed for suture placement. ConclusionRobotic-assisted urethroplasty provides excellent visualization and ergonomics for posterior and proximal bulbar urethral reconstruction. This is particularly helpful in patients with narrow pelvic anatomy and long distances from the perineal skin to the proximal urethral edge. Operative and postoperative outcomes are comparable to the standard approach with improved surgeon comfort and visualization. Additional follow-up is required to assess long-term outcomes in comparison to a standard approach.

Urethral Stricture Disease: Challenges and Ongoing Controversies.

Urethral Stricture Disease: Challenges and Ongoing Controversies.

Total Bladder and Posterior Urethral Reconstruction: Salvage Technique for Defunctionalized Bladder with Recalcitrant Posterior Urethral Stenosis

Recalcitrant posterior urethral stenosis is a challenging disease. When combined with a defunctionalized bladder, cutaneous urinary diversion is the most common surgical option. We present a novel technique of total lower urinary tract reconstruction, combining salvage cystectomy, ileal neobladder formation and urethral pull-through, as an orthotopic alternative in patients with a defunctionalized bladder and recalcitrant posterior urethral stenosis. We completed a retrospective review of 8 patients who underwent salvage cystectomy, orthotopic ileal neobladder formation and urethral pull-through. Artificial urinary sphincter placement was performed in a staged fashion. Six patients received prostate cancer treatment including radiation therapy, 1 had urethral disruption after robotic radical prostatectomy, and 1 experienced bladder rupture and urethral distraction injury during a motorcycle accident. Patient demographics, operative variables and postoperative outcomes were examined. No high grade complications were observed after salvage cystectomy, orthotopic neobladder formation and urethral pull-through. After staged artificial urinary sphincter placement, a median of 2 revision surgeries (range 0 to 4) was required to establish social continence. All patients maintained functional urinary storage, urethral patency and social continence at a median followup of 58 months. No patient had complications related to orthotopic neobladder formation, including ureteroileal anastomotic stricture or pyelonephritis, and no patient required cutaneous diversion. Total lower urinary tract reconstruction with cystectomy, ileal neobladder formation and urethral pull-through offers an orthotopic alternative for patients with recalcitrant posterior urethral stenosis and defunctionalized bladders. Although it requires staged placement of an artificial urinary sphincter, this approach can offer functional urinary storage, durable urethral patency and avoidance of cutaneous urinary diversion.

Early return of continence in patients undergoing robot-assisted laparoscopic prostatectomy using modified maximal urethral length preservation technique.

To evaluate the impact of maximal urethral length preservation (MULP) technique in comparison with posterior urethral reconstruction and anterior bladder suspension (PRAS) technique on the continence rates (CR), time to achieve continence among patients with prostate cancer (PCa) undergoing robot-assisted laparoscopic prostatectomy (RALP). We prospectively analyzed the CR, time to achieve continence, pre- and postoperative prostate-specific antigen (PSA) levels, rates of positive margins among three groups of continent men with PCa undergoing RALP from whom consent was obtained. Each group consisted of 30 patients: PRAS was performed in group A, combined MULP and PRAS in group B, and MULP in group C. Continence was measured by patient self-reporting of the number of pads/24 h. No differences were detected in the age, preoperative PSA levels, biochemical recurrence, prostate volume, and positive margins for the three groups. Men in groups B and C had marked improvement in CR 1, 3, and 6 months after catheter removal vs group A (50% and 70% vs 10%, 90% and 96.66% vs 23.3% and 100%, 100% vs 53.3%, respectively, P<0.0001). The average and median times to continence were significantly shorter in group B (5.4 and 4 weeks) and C (3.8 and 3 weeks) vs group A (27.4 and 22.5 weeks), P<0.00001. Using Cox regression analysis, only MULP and MULP+PRAS techniques were significantly correlated with continence outcomes 1, 3, and 6 months after catheter removal. MULP rather than PRAS confers higher postoperative CR and shorter time to achieve continence among patients with PCa who underwent RALP without increasing risk of positive margin.

Enhanced Recovery Protocol after Radical Cystectomy for Bladder Cancer

Enhanced recovery after surgery protocols aim to improve patient care and decrease complications and hospital stay. We evaluated our enhanced recovery after surgery protocol, focusing on length of stay, early complication and readmission rates after radical cystectomy for bladder cancer. From May 2012 to July 2013 a perioperative protocol was applied in 126 consecutive patients who underwent open radical cystectomy and urinary diversion. Nonconsenting patients (2), those with previous diversion (2) and prolonged postoperative intubation (3), and those who underwent additional surgery (9) were excluded from study. The protocol focuses on avoiding bowel preparation and nasogastric tube, early feeding, nonnarcotic pain management and the use of cholinergic and μ-opioid antagonists. Outcomes were compared to those in matched controls from our bladder cancer database. A total of 110 patients with a median age of 69 years were included in analysis, of whom 68% underwent continent urinary diversion. Of the patients 82% had a bowel movement by postoperative day 2. Median length of stay was 4 days. The 30-day minor and major complication rates were 64% and 14%, respectively. The most common minor complication was anemia requiring transfusion in 19% of patients, urinary tract infection in 13% and dehydration in 10%. The latter 2 complications were the most common etiologies for readmission. The 30-day readmission rate was 21% (23 patients). Patients 75 years old or older had a longer length of stay (5 vs 4 days, p = 0.03) and a higher minor complication rate (72% vs 51%, p = 0.04) than younger patients. Our enhanced recovery after surgery protocol expedites bowel function recovery and shortens hospital stay after RC and urinary diversion without an increase in the hospital readmission rates.

Outcomes after Urethroplasty for Radiotherapy Induced Bulbomembranous Urethral Stricture Disease

We recently demonstrated that radiotherapy induced urethral strictures can be successfully managed with urethroplasty. We increased size and followup in our multi-institutional cohort, and evaluated excision and primary anastomosis as treatment for radiotherapy induced urethral strictures. A retrospective review was performed of 72 patients from 3 academic institutions treated for radiotherapy induced bulbomembranous strictures. Outcome parameters of successful repair included recurrence, incontinence and erectile dysfunction. Among the 72 men treated for radiotherapy induced strictures 66 (91.7%) underwent excision and primary anastomosis. Mean followup was 3.5 years (median 3.1, range 0.8 to 11.2). Prostate cancer was the most common reason for radiotherapy (in 64 of 66, 96.9%). External beam radiotherapy and brachytherapy were performed in 28 of 66 men (42.4%) each, and a combination of both was performed in 9 (13.6%). Mean time from radiation to excision and primary anastomosis was 6.4 years (range 1 to 20) and mean stricture length was 2.3 cm (range 1 to 6). Successful reconstruction was achieved in 46 men (69.7%). Mean time to recurrence was 10.2 months (range 1 to 64) with new onset of incontinence observed in 12 men (18.5%). This was associated with stricture length greater than 2 cm (p = 0.013) and treatment center (p <0.001). The rate of erectile dysfunction remained stable (preoperative 45.6%, postoperative 50.9%, p = 0.71). Radiotherapy type did not affect stricture length (p = 0.41), recurrence risk (p = 0.91), postoperative incontinence (p = 0.88) or erectile dysfunction (p = 0.53). Radiotherapy induced bulbomembranous urethral strictures can be successfully managed with excision and primary anastomosis. Substitution urethroplasty with graft or flap is needed infrequently. Patients should be counseled on the potential risks of urinary incontinence and erectile dysfunction.

Effect of Bladder Neck Preservation and Posterior Urethral Reconstruction during Robot-Assisted Laparoscopic Radical Prostatectomy for Urinary Continence

PurposeTo report our results on urinary continence after bladder neck preservation (BNP) and posterior urethral reconstruction (PUR) during robot-assisted laparoscopic radical prostatectomy (RALP).Materials and MethodsData from 107 patients who underwent RALP were compared on the basis of whether the patients underwent BNP and PUR, BNP only, or the standard technique (ST). In group A (n=31 patients), ST was performed by using Ven velthoven continuous suturing for urethrovesical anastomosis. In group B (n=28 patients), ST with only PUR was performed. In group C (n=48 patients), both the BNP and PUR techniques were used. "Recovery of continence" was defined as the use of 1 pad (50 ml) or less within 24 hours.ResultsThe three groups were comparable in terms of patient demographics. The mean operative time and the mean blood loss decreased significantly from group A to group C (p=0.021 for mean operative time and p=0.004 for the mean blood loss). Mean catheterization time was 8.9, 7.8, and 7.1 days in each group (p=0.047). Early return of urinary continence at 3 months was observed in group B (89.2%) and group C (90.6%) compared with group A (71%). However, continence at 6 months was comparable in the 3 groups (87.5% in group A, 92.8% in group B, and 92.3% in group C). Rates of positive surgical margins decreased from 30.2% in group A to 20% in group B and 12% in group C.ConclusionsBNP and PUR during RALP showed a favorable impact on the early postoperative recovery of continence while not affecting positive surgical margins.

Review of Microsurgical Posterior Urethral Reconstruction

Posterior urethra reconstruction can be a challenging proposition for both patient and surgeon. The vast majority of urethras can be successfully reconstructed with either anastomosis or grafting. However, there are some patients who have recurrent urethral strictures that require more complex reconstruction. There is some speculation that microsurgical penile revascularization may allow subsequent graft reconstruction with lower stricture rates, but this is not yet proven. For the most tenacious urethral strictures, free tissue transfer may be required. The free radial forearm flap is well suited for urethral reconstruction, and the free anterolateral thigh flap may also have a role for these patients. This article will review urethral trauma and strictures and microsurgery's role in reconstruction of the posterior urethra.

Hyperbaric oxygen therapy for recovery of erectile function after posterior urethral reconstruction

To prospectively study the effects of hyperbaric oxygen therapy (HBOT) on the recovery of erectile function (EF) after posterior urethral reconstruction. Between August 2006 and March 2010, a total of 24 male patients with posterior urethral reconstruction and without erectile dysfunction (ED) before urethral stricture were involved in the study. Twelve of them were assigned to HBOT group that received HBOT, and the others comprised the control group. All 24 participants were asked to assess their EF pre-operatively and 3 months postoperatively by using the International Index of Erectile Function (IIEF). All 24 participants completed the study. The total IIEF scores and scores in two domains of IIEF (erectile function (EF) and overall satisfaction (OS) domain) were significantly lower than the preoperative baseline scores in HBOT group (P < 0.05). Meanwhile, a significant decrease in the total IIEF scores and scores in three domains of IIEF (EF, OS and intercourse satisfaction (IS) domain) was observed in control group (P < 0.05). However, at 3 months postoperatively, the total IIEF scores and scores in three domains of IIEF (EF, OS and IS domain) after HBOT were significantly higher in HBOT group than in control group (P < 0.05). These preliminary results suggest that HBOT may be effective for improving EF recovery after posterior urethral reconstruction.

Effect of Posterior Urethral Reconstruction (PUR) in Early Recovery of Urinary Continence after Robotic-Assisted Radical Prostatectomy

Purpose: Prolonged urinary incontinence is one of the greatest concerns for patients undergoing radical prostatectomy. One of the possible causes for this urinary incontinence is a postoperative deficiency of the external striated urethral sphincter (EUS) complex and continence nerves. We evaluated the effect of posterior urethral reconstruction (PUR) in the early recovery of urinary continence after robotic-assisted radical prostatectomy. Materials and Methods: Between January 2008 and March 2009 we performed robotic-assisted radical prostatectomy with PUR in 30 patients (PUR group) and without PUR in 30 patients (non-PUR group). We compared perioperative parameters and postoperative continence rates between the two groups. Continence was defined as no pads or one diaper per 24 hours and was assessed 1 month, 3 months, and 6 months after the procedure. Results: Patients in the PUR group achieved better continence rates at 1 month (43% vs. 35%) and 3 months of follow-up (89% vs. 64%). At 6 months of follow-up, the continence rate was similar between the two groups (96% vs. 90%). No major complications were observed in the PUR group. However, 2 cases of anastomotic site leakage and 1 case of delayed bleeding were observed in the non-PUR group. Conclusions: Posterior urethral reconstruction appears to be an easy and reproducible technique in robotic-assisted radical prostatectomy. Our early experience demonstrates that PUR in robotic-assisted radical prostatectomy appears to confer early continence recovery and reduce intraoperative complications. (Korean J Urol 2009;50:1203-1207) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏