Posterior Urethroplasty Research Articles

The effect of combined pudendal nerve and spermatic cord block or caudal epidural block on postoperative analgesia after posterior urethroplasty: a randomized trial

BackgroundPostoperative pain management remains a significant challenge for patients undergoing posterior urethroplasty (PU). In a previous study, we proposed a novel technique of combined pudendal nerve (PN) and spermatic cord (SC) block to manage pain after PU. The present trial was conducted to test the hypothesis that this technique is effective for pain control after PU and provides longer-lasting analgesia than caudal epidural block (CB).MethodsSixty patients undergoing PU were randomized into two groups: Group NB received combined PN and SC block, and Group CB received CB. General anesthesia with a laryngeal mask was performed. The primary outcome was the postoperative analgesic duration, and the secondary outcomes included the Numeric Rating Scale (NRS) scores for pain and the number of patients with different motor scores of the lower limb at 3, 6, 12, and 24 h postoperatively.ResultsTwo patients in Group CB were withdrawn due to block failure. The postoperative analgesic duration was statistically longer in Group NB compared with Group CB (mean difference [95% confidence interval], 115.78 min [17.80, 213.75]; P = 0.021). The NRS scores for pain at 12 and 24 h after surgery were statistically lower in Group NB compared with Group CB. Group NB had statistically more patients with motor score 0 at 3 h postoperatively than Group CB.ConclusionsPN combined with SC block is an effective technique for postoperative analgesia in PU. This technique can achieve a longer duration of analgesia and lower pain scores, especially 12 h after surgery, than a CB.Trial registrationThis study was registered in the Chinese Clinical Trial Register (registration no. ChiCTR2100042971, registration date on 2/2/2021).

Substitution Urethroplasty With Buccal Mucosal Graft in the Management of Stricture of Vesicourethral Anastomosis or Membranous Urethra: Single-institution Long-term Experience With Perineal Approach and Endourethroplasty

ObjectiveTo present long-term experience with buccal mucosa posterior urethroplasty (BMPU) for refractory posterior urethral stenosis (PUS) or vesicourethral anastomosis stenosis (VUAS) either by perineal approach (PA) or by endourethroplasty (EUP). Materials and MethodsA single-center retrospective study of 38 consecutive patients operated on between 1999 and 2022. BMPU consisted of the transfer of onlay or tubular buccal mucosa grafts into dilated and/or incised strictures through an open or endourological approach. If VUAS or PUS recurred with short stenosis within the first 12 months after surgery, it was transected by a cold-knife direct vision internal urethrotomy (DVIU), referred to as an ‘auxiliary’ DVIU. The primary outcome was three-year stricture recurrence-free survival (SRFS). ResultsBMPU by perineal approach and EUP were performed in 27 (71%) and 11 (29%) patients, respectively. The three-year SRFS was 65% for the whole cohort, with rates of 63% for the perineal approach and 73% for endourological approach. With permitted auxiliary DVIU, three-year SRFS for the whole cohort was 81%. De novo incontinence occurred in 2 out of 18 preoperatively continent patients. Limitations include the retrospective nature of the single-center study and a small, heterogenous cohort of patients. ConclusionsWe present two techniques of substitution urethroplasty with BMG in the management of PUS and VUAS with a low rate of recurrence or de novo incontinence. A novel endourological approach (EUP) is a promising minimally invasive alternative to the perineal approach.

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.

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Robotic-assisted Posterior Urethroplasty: Outcomes From 105 Men in a Single-center Experience

To determine surgical outcomes in a large of cohort men undergoing robotic-assisted posterior urethroplasty (RPU), which has been described in small series as a viable option. We performed a retrospective review of all 105 men who underwent RPU from October 2014 to August 2022 at a single institution. We evaluated postoperative outcomes, including complications; surgical success defined as no need for reintervention; and incontinence requiring artificial urinary sphincter placement. We performed descriptive statistics and chi-square testing to determine if outcomes were associated with certain posterior urethral disease etiologies. Mean follow-up time was 18.7months. Over half of patients (57.1%) received prior pelvic radiation. The most common reconstructive techniques were excision and primary anastomosis (n = 45, 30.0%), resitting of the bladder neck (n = 26, 24.8%), Y-V plasty (n = 21, 20.0%), and buccal mucosal graft urethroplasty (n = 14, 13.3%). Forty-one patients (39.0%) required a combined abdominoperineal approach. Seven patients (6.7%) had ≥CD grade 3 complications within 30days. Thirty patients (28.6%) developed incontinence with subsequent artificial urinary sphincter placement. One-quarter (24.8%) of patients required at least one subsequent surgical reintervention. In the largest RPU cohort to date, surgical success rates were similar and continence rates were improved compared to open surgery and align with existing robotic series, adding to the growing body of evidence demonstrating advantages of RPU.

Effects of continuous use of Tadalafil on male sexual function after posterior urethroplasty: A clinical trial.

Posterior urethral injuries in men commonly occur following pelvic and perineal trauma. Erectile dysfunction (ED), whether brought on by the severity of the initial trauma or the surgery itself, is one of the complications in these patients. In this study, we divided candidates of posterior urethroplasty due to traumatic urethral injury into intervention and placebo groups; the former received continuous treatment with tadalafil (10 mg daily), and the latter received a placebo. Other services were provided equally to both groups. Before and after the intervention, both groups completed the International Index of Erectile Function version 5 (IIEF-5) questionnaire, and the findings were analyzed. Forty patients were studied in groups of 20 with a mean age of 43.87 ± 15.70 years. The patient's most common cause of urethral injury was a pelvic fracture. Before the intervention, the mean scores of IIEF for patients in the intervention group and placebo group were 14.85 ± 7.39 and 14.77 ± 6.48, respectively with no statistical significance (p = 0.962) and patients of the groups were similar in terms of the severity of ED. The mean IIEF score in the intervention group was 20.12 ± 4.94 and in the placebo group, it was 18.05 ± 4.88 at the three-month follow-up, with no statistically significant difference (p = 0.063). In both the intervention and placebo groups, the IIEF score was significantly increased by 5.27 ± 4.04 (p < 0.001) and 3.27 ± 2.97 (p < 0.001), respectively. The rate of IIEF increase in the intervention group was higher than in the placebo group during the follow-up at 3-month follow-up with statistical significance. (p = 0.022). The findings of this study suggest that tadalafil, in a 3-month treatment course, may improve erectile function in individuals with mild-to-moderate ED, significantly more than placebo. However, more studies, specifically with longer duration of follow-up and larger populations, are necessary for generalizing the current findings.

Idiopathic urethral stricture in adolescents: A case series presentation and review of the literature

Objective: To present our case series of idiopathic urethral stricture in adolescents, analyzing the treatments applied and the results obtained. Methods: A retrospective study of 7 patients with idiopathic urethral stricture treated at our center between 2000 and 2021 was performed. Results: The average age at the moment of surgery was 14.7 years. In 85% of cases the main symptom was voiding difficulty. The diagnosis was by voiding cystourethrography (VCUG) in five patients and by cystoscopy in two, locating the stricture in the anterior urethra in all cases. Six patients were treated with endoscopic urethrotomy and one with balloon dilation. Two patients recurred. The subsequent treatment in both cases was a second endoscopic urethrotomy and one of them required a posterior urethroplasty. Currently 6 out of 7 patients are asymptomatic and the patient who underwent urethroplasty is undergoing regular dilations. Limitations: The number of patients is limited due to the shortage of this pathology in childhood. Value: The available literature is quite limited. It is usually secondary to trauma or surgical interventions such as hypospadias repair. Idiopathic etiology represents less than a third of urethral strictures in adolescents and it causes the greatest controversy regarding its management. Conclusions: We should suspect idiopathic urethral stricture in childhood when symptoms appear, such as voiding difficulty in patients without previous pathologies. VCUG can help diagnosis, but a cystoscopy allows diagnosis and treatment at the same time. Endoscopic urethrotomy should be the treatment of choice for idiopathic strictures smaller than 1 cm, since the success rate is greater than 85%.

(439) Penile Revascularization Utilizing The Lateral Femoral Circumflex Artery After Pelvic Fracture Urethral Injury

Abstract Introduction Pelvic fracture urethral injury (PFUI) is associated with erectile dysfunction (ED) in up to 62% of patients, often due to decreased arterial inflow. For select healthy patients with isolated arterial insufficiency, penile revascularization utilizing the inferior epigastric artery to either the cavernosal or dorsal penile artery has been shown to be an effective treatment ED. The patient originally presented with a PFUI after a motor vehicle collision. He underwent suprapubic tube placement and selective embolization of a right internal pudendal artery pseudoaneurysm. Four months later, he underwent a posterior urethroplasty with corporal splitting and inferior pubectomy. During follow-up, he reported no erectile function following his initial trauma with no prior history of erectile dysfunction. He was trialed on PDE5is which were ineffective and ICI which was discontinued due to pain and minimal efficacy. Penile Doppler ultrasound with ICI showed bilateral arterial insufficiency with peak systolic velocities of 11.3 and 18.8 cm/second and no evidence of veno-occlusive dysfunction with end-diastolic flows of 2.85 and 4.66 cm/second of the cavernosal arteries (Figure 1). Bilateral inferior epigastric arteriography demonstrated 20-30% ostial stenosis with left traumatic occlusion of the internal pudendal and complete occlusion of the right internal pudendal artery post-embolization. The dorsal penile arteries filled in a delayed fashion via small-caliber collaterals. Objective We present this case to demonstrate use of an alternative arterial donor vessel for penile revascularization. Methods An infrapubic incision was made to expose the right dorsal penile artery. Another incision was made from the right anterior superior iliac spine to just above the patella tendon. The rectus femoris and vastus lateralis were atraumatically split and the descending branch of the lateral femoral circumflex artery was exposed. Small branches were clipped (Figure 2). The most distal branch to the rectus femoris was divided to become the donor vessel, leaving the proximal branch to maintain muscular perfusion. The donor branch was mobilized and passed via a subcutaneous tunnel into the infrapubic incision (Figure 3). Using an operating microscope the dorsal penile artery was ligated and the distal end was anastomosed to the donor artery and an end-to-end fashion using 8-0 nylon interrupted sutures. A drain was placed in the thigh wound, and both wounds were closed in two layers. Results The patient was started on 325mg of daily aspirin and remained on bed rest for two days. He was discharged on postoperative day two and his thigh drain remained in place for two weeks. He was restricted to less than 30-degree abduction of the right thigh for four weeks. Four months postoperatively the patient was achieving erections with 7/10 rigidity using only 5mg of tadalafil as needed. His SHIM was 17. At six months postoperatively he had increased his tadalafil dose to 20mg and was achieving erections with 8/10 rigidity from his pre-injury baseline. Conclusions This case demonstrates an excellent result from penile revascularization utilizing the lateral femoral circumflex artery. This artery can be considered an alternate donor for penile revascularization procedures following pelvic fracture urethral injury when there is a contraindication to the use of the inferior epigastric artery. Disclosure No

Posterior urethroplasty and recto-urethral fistula repair by bulbospongiosus muscle flap: A new surgical technique

Introduction: Recto-Urethral Fistula (RUF) is a relatively uncommon surgical condition requiring complex and precise surgery that is often challenging for surgeons.

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 ...

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 ...

Erectile function evaluation in patients after urethroplasty: systematic review and meta-analysis

Background. The success of surgical treatment of urethral strictures is often assessed in terms of the quality of urination and the patency of the urethral lumen. Despite the fact that this assessment is carried out according to the above parameters, it seems important to take into account such a possible complication as erectile dysfunction, which can significantly impair the patient’s quality of life. This is the difference in the perception of the success of the surgical intervention by the clinician and the patient.Aim. To determine the relationship between urethroplasty and the likelihood of erectile dysfunction in the postoperative period according to world literature.Materials and methods. The PubMed database was analyzed using the keywords: anterior urethroplasty, posterior urethroplasty, urethroplasty, sexual dysfunction, erectile dysfunction. All articles were reviewed by two independent authors for inclusion based on predetermined criteria. Among the included scientific papers are randomized controlled trials, systematic reviews.Results. Sixteen scientific papers with a total of 1476 patients were included in the final study. The decrease in erectile function after surgery in this meta-analysis is 3 %. The main factors influencing postoperative parameters were age and erectile function at the time of surgery.Conclusion. Most studies state that urethroplasty does not imply a significant impact on erectile function, however, they acknowledge that the occurrence of this complication affects the assessment of treatment outcomes among patients and the further impact on their quality of life, regardless of postoperative urinary function.

A TriNetX Registry Analysis of the Need for Second Procedures following Index Anterior and Posterior Urethroplasty.

We queried a global database to understand re-intervention rates following urethroplasty with the goal of evaluating whether they align with previously published data. Using the TriNetX database and Common Procedural Terminology (CPT) and International Classification of Diseases-10 (ICD) codes, we identified adult male patients with urethral stricture disease (ICD N35) who underwent one-stage anterior (CPT 53410) or posterior urethroplasty (CPT 53415), with or without (substitution urethroplasty) a tissue flap (CPT 15740) or buccal graft (CPT 15240 or 15241). We set urethroplasty as the index event and used descriptive statistics to report the incidence of secondary procedures (using CPT codes) within 10 years after the index event. There were 6606 patients who underwent urethroplasty within the last 20 years, with 14.3% of patients undergoing a second procedure after index event. Upon subgroup analysis, reintervention rates were 14.5% for anterior urethroplasty vs. 12.4% of patients with an anterior substitution urethroplasty (RR 1.7, p = 0.09) and 13.3% for posterior urethroplasty vs. 8.2% for patients with a posterior substitution urethroplasty (RR 1.6, p < 0.01). Most patients will not need any form of re-intervention following urethroplasty. These data align with previously described recurrence rates, which may help urologists counsel patients considering urethroplasty.

MRI in Preoperative Planning for the Repair of Pelvic Fracture Urethral Distraction Defects: A New Tool for Determining Reconstructive Options

Pelvic fracture urethral distraction defects are typically imaged with retrograde urethrogram and voiding cystourethrogram during the work up for delayed posterior urethroplasty following trauma. The imaging results often dictate the decision-making regarding treatment options. Magnetic resonance imaging can offer a more detailed picture of the defect and can aid in preoperative planning. We present the case of an individual who was deemed unrepairable by routine imaging, however, the MRI indicated that surgery was possible.

Could the bulbar urethral end location on the cystourethrogram predict the outcome after posterior urethroplasty for pelvic fracture urethral injury?

ABSTRACT Objectives To identify cystourethrogram (CUG) findings that independently predict the outcome of posterior urethroplasty (PU) following pelvic fracture urethral injury (PFUI). Methods Findings of CUG included the location of the proximal end of the bulbar urethra in zones A (superficial) or B (deep) according to its relationship with the pubic arch. Others included the presence of pelvic arch fracture, bladder neck, and posterior urethral appearance. The primary outcome was the need for reintervention either endoscopically or by redo urethroplasty. Independent predictors were modeled using a logistic regression model and a nomogram was constructed and internally validated using 100-bootstrap resampling. Time-to-event analysis was performed to validate the results. Results A total of 196 procedures in 158 patients were analyzed. The success rate was 83.7% with 32 (16.3%) procedures requiring direct vision internal urethrotomy, urethroplasty, or both in 13 (6.6%), 12 (6.1%), and 7 (3.6%) patients, respectively. On multivariate analysis, bulbar urethral end located at zone B (odds ratio [OR]: 3.1; 95% confidence interval [CI]: 1.1–8.5; p = 0.02), pubic arch fracture (OR: 3.9; 95%CI: 1.5–9.7; p = 0.003), and previous urethroplasty (OR: 4.2; 95% CI: 1.8–10.1; p = 0.001) were independent predictors. The same predictors were significant in the time-to-event analysis. The nomogram discrimination was 77.3% and 75% in the current data and after validation. Conclusions The location of the proximal end of the bulbar urethra and redo urethroplasty could predict the need for reintervention after PU for PFUI. The nomogram could be used preoperatively for patient counseling and procedure planning.

Emerging Roles of Penile Traction Therapy and Vacuum Erectile Devices.

Penile traction therapy (PTT) and vacuum erection devices (VED) are nonsurgical conservative treatment options that have been used in the treatment of various urologic and sexual disorders such as Peyronie's Disease (PD) and Erectile Dysfunction (ED). Recently expanded uses for these therapies now include penile lengthening and with surgical interventions such as penile prosthesis surgery (PPS) and radical prostatectomy (RP). These devices can be used as both monotherapy or combination therapy. To review the indications and clinical studies for PTT and VED. A literature search was conducted using PubMed to identify relevant studies addressing PTT, VED, and their indications. Searched terms included penile traction therapy, penile traction device, vacuum erection device, Peyronie's disease, penile prosthesis, radical prostatectomy, subjectively small penis, penile lengthening, erectile dysfunction. PTT with dynamic traction devices has shown favorable benefits for PD in many studies. The benefits of VED for PD cannot be confirmed due to limited studies with poor quality. In posterior urethroplasty, VED shows promise postoperatively, with additional trials also needed. In PPS, both PTT and VED have had positive findings in pre- and postoperative treatment. In RP patients, VED use has had positive outcomes while new literature shows beneficial effects of dynamic PTT and provides a basis for future studies. VED use does not show great benefit in patients with small penis, however PTT does have some positive findings. In ED, VED has a history of successful use and PTT has promising new data available. PTT and VED have been utilized in urologic and sexual conditions with various success. Several promising areas utilizing both PTT and VED are being studied, however, more research needs to be done in these areas prior to becoming a standard treatment. Mehr J, Santarelli S, Green TP, et al. Emerging Roles of Penile Traction Therapy and Vacuum Erectile Devices. Sex Med Rev 2022;10:414-426.

Defining Success after Anterior Urethroplasty: An Argument for a Universal Definition and Surveillance Protocol.

A successful urethroplasty has been defined in different ways across studies. This variety in the literature makes it difficult to compare success rates and techniques across studies. We aim to evaluate the success of anterior urethroplasty based on different definitions of success in a single cohort. Data were collected from a multi-institutional, prospectively maintained database. We included men undergoing first-time, single-stage, anterior urethroplasty between 2006 and 2020. Exclusion criteria included lack of followup, hypospadias, extended meatotomy, perineal urethrostomy, posterior urethroplasty and staged repairs. We compared 5 different ways to define a "failed" urethroplasty: 1) stricture retreatment, 2) anatomical recurrence on cystoscopy, 3) peak flow rate <15 ml/second, 4) weak stream on questionnaire and 5) failure by any of these measures. Kaplan-Meier survival curves were generated for each of the definitions. We also compared outcomes by stricture length, location and etiology. A total of 712 men met inclusion criteria, including completion of all types of followup. The 1- and 5-year estimated probabilities of success were "retreatment," 94% and 75%; "cystoscopy," 88% and 71%; "uroflow," 84% and 58%; "questionnaire," 67% and 37%; and "any failure," 57% and 23%. This pattern was inconsistent across stricture length, location and etiology. The estimated probability of success after first-time, anterior urethroplasty is highly dependent on the way success is defined. The variability in definitions in the literature has limited our ability to compare urethroplasty outcomes across studies.

EDITORIAL COMMENT

The authors present a large retrospective cohort of patients with pelvic fracture urethral injury (UR), who underwent posterior urethroplasty with an expert surgeon (and a wonderful guy by all reports). The authors report outstanding results, with >95% of patients being free from postoperative stricture. These results are similar to other recent retrospective outcome studies.1 Some important injury characteristics included a 13% rate of concomitant bladder injury and a 6% utilization of pelvic angioembolization.

Intraoperative cell salvage transfusion in patients undergoing posterior urethroplasty: Its efficacy of reducing allogeneic blood transfusion, safety, and cost.

A significant blood loss may be encountered with complex urethroplasty surgery. Blood management aims at reducing allogeneic blood transfusion (ABT) because of limited supply, associated risks, and cost. Intraoperative cell salvage (ICS) has been used in different urological and nonurological surgeries to achieve this goal. However, no study evaluated its role in perineal urethroplasty. We set out to determine the efficacy of reducing ABT, safety, and cost of ICS in posterior urethroplasty. We reviewed the charts of all patients who underwent posterior urethroplasty between 2012 and 2017. We collected data for patients' demographics, pre- and postoperative hemoglobin level, ICS volume, complications, equivalent ABT units saved, and cost. Seventy patients with a median age of 27.5 ± 10.2 years underwent posterior urethroplasty. Of the 70 patients, 20 (28.57%) required ICS intraoperatively with a median of 441 ml/patient, equivalent to 1.47 units per patient of allogenic blood. No patient needed intraoperative ABT, whereas two patients required transfusions postoperatively. The median pre- and postoperative hemoglobin levels were 124.2 ± 9.2 and 110.3 ± 12.6 g/dl, respectively. There were no significant complications noted while using ICS. There was a 41% cost reduction of equivalent ABT units. ICS is safe and effective in reducing ABT during posterior urethroplasty. In our hospital, it is associated with a significant cost reduction of blood transfusion.

Single-Port Robotic Posterior Urethroplasty Using Buccal Mucosa Grafts: Technique and Outcomes

ObjectiveTo describe the technique, feasibility and short-term outcomes of buccal mucosa grafts in robotic lower urinary tract reconstruction. MethodsWe reviewed 9 patients who underwent single-port robotic posterior urethroplasty with buccal mucosa graft from May-December 2019. Variables included patient demographics, diagnosis/etiology, and intraoperative parameters. Intraabdominal or extraperitoneal transvesical approaches are used for the stricture via supraumbilical access, and if necessary, perineal dissection is performed. Cystoscopy identifies the extent of stenosis. Anastomosis is completed with buccal mucosal graft and rectus abdominis, omental or gracilis flaps as needed. ResultsThe mean age was 65.4 years. Robotic urethroplasty with buccal mucosa graft was performed for vesicourethral anastomotic strictures (n = 7), urethral strictures (n = 4), pubic fistula after robotic posterior urethroplasty (n = 1), and anastomotic distraction (n = 1). Strictures occurred after prostate cancer treatments (n = 8) and trauma (n = 1). All patients had prior failed endoscopic interventions: balloon dilatation, resection/incision of bladder neck, internal urethrotomy under direct vision, urethral stents, and posterior urethroplasty. Mean defect length was 3.9 cm. Five of 9 patients had ancillary procedures including rectus abdominis (n = 3), omental or gracilis (both n = 1) flap harvests. No intraoperative complications occurred. Median operative time was 377 minutes, blood loss was 200 mL, and length of stay was 2 days. Postoperative 30-day complications included urinary tract infection, epididymitis, anemia, recurrent stricture, and small bowel obstruction requiring surgery (all n = 1). Median follow-up was 11.7 months. ConclusionBuccal mucosa grafts with ancillary maneuvers such as flap interposition or adjacent tissue transfer in robotic lower tract reconstruction is durable, safe, and comparable to open approaches.