Posterior Urethroplasty Research Articles

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.

Pedicled rectus abdominis muscle and fascia flap sling the bulbar urethra for treatment for male-acquired urinary incontinence: report of ten cases

Male urinary incontinence is relatively common complication of radical prostatectomy and of posterior urethroplasty following traumatic pelvic fracture. Here, we investigate the use of pedicled rectus abdominis muscle and fascia flap sling of the bulbar urethra for treatment for male-acquired urinary incontinence. Ten patients with acquired urinary incontinence were included in the study. Urinary incontinence was secondary to TURP in three patients and was secondary to posterior urethroplasty performed following traumatic pelvic fracture in seven patients. Pedicled rectus abdominalis muscle and fascial flaps, approximately 2.5 cm wide and 15 cm long, were isolated. The flaps were inserted into a perineal incision through a subcutaneous tunnel. The free end of the flap was sectioned to form two muscle strips, each 3 cm in length, and inserted into the space between bulbar urethra and corpus cavernosa. After adequate sling tension had been achieved, the two strips of muscle were anastomosed around the bulbar urethra using a 2-zero polyglactin suture. The patients were followed up for between 12 and 82 months (mean 42.8 months). Complete continence was achieved with good voiding in seven of the 10 patients. In other three patients achieved good voiding following catheter removal, but incontinence was only moderately improved. A pedicled rectus muscle fascial sling of the bulbar urethra is an effective and safe treatment for male patients with mild to moderate acquired urinary incontinence, but it may not be suitable for severe incontinence or for patients with weak rectus abdominalis muscles.

Long-term outcomes following posterior urethroplasty for traumatic pelvic-fracture associated posterior urethral disruption in a contemporary cohort

Figler, Brad David MD; Dy, Geolani MD; Wessells, Hunter B. MD, FACS; Voelzke, Bryan B. MD Author Information

The Relationship Between Erectile Dysfunction and Open Urethroplasty: A Systematic Review and Meta-Analysis

Various urethroplasty techniques have been used to treat urethral stricture. Whether the patient erectile function is affected by this open surgery is still controversial. The aim of this study is to determine the relationship between erectile function and open urethroplasty. A systematic review of the literature was performed using Medline, Embase, the Web of Science, and the Cochrane Library databases through October 2012 to identify articles published in any language that examined the effect of open urethroplasty on the risk of erectile dysfunction (ED). This meta-analysis was conducted according to the guidelines for the meta-analysis of observational studies in epidemiology. The incidence of ED after urethroplasty. This meta-analysis consisted of 23 cohort studies, which included 1,729 cases. No significant difference was noticed in patients with anterior urethral stricture before or after intervention (odds ratio [OR] = 0.86; 95% confidence interval [CI]: 0.52-1.40; P = 0.53). While statistical difference in the incidence of ED was revealed in patients before and after intervention for a posterior urethral (OR = 2.51; 95% CI: 1.82-3.45; P < 0.001), further comparisons demonstrated that most anterior urethroplasties did not have an obvious effect on patient erectile function. However, it seems that the incidence of ED was higher in the bulbar anastomosis group than in the oral graft urethroplasty group (OR = 0.32 95% CI: 0.11-0.93; P = 0.04). For the posterior urethroplasty, previous operative history did not show a strong relationship with ED. No statistically significant difference in the risk of ED was demonstrated comparing the posterior urethral reconstructive techniques included in this analysis. The adverse effect of urethroplasty itself on erectile function is limited, as more patients recover erectile function after urethral reconstruction. For anterior urethroplasty, bulbar anastomosis might cause a slightly higher incidence of ED than other operations. For posterior urethroplasty, trauma might be the main cause of ED.

7 ANASTOMOTIC RECONSTRUCTION OF RADIOTHERAPY INDUCED POSTERIOR URETHRAL STENOSIS

You have accessJournal of UrologyTrauma/Reconstruction: Traum & Reconstructive Surgery (1)1 Apr 20137 ANASTOMOTIC RECONSTRUCTION OF RADIOTHERAPY INDUCED POSTERIOR URETHRAL STENOSIS Lee C. Zhao, Allen F. Morey, Matthias D. Hofer, J. Francis Scott, Christopher M. Gonzalez, and Steven B. Brandes Lee C. ZhaoLee C. Zhao Dallas, TX More articles by this author , Allen F. MoreyAllen F. Morey Dallas, TX More articles by this author , Matthias D. HoferMatthias D. Hofer Chicago, IL More articles by this author , J. Francis ScottJ. Francis Scott Dallas, TX More articles by this author , Christopher M. GonzalezChristopher M. Gonzalez Chicago, IL More articles by this author , and Steven B. BrandesSteven B. Brandes St. Louis, MO More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1381AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The efficacy of anastomotic urethroplasty for radiotherapy induced proximal urethral stenosis has been questioned (BJU Int 2012; 110, 304-325). We describe the results of a multi-institutional experience of anastomotic urethroplasty in this setting. METHODS We reviewed of urethroplasty for radiotherapy induced bulbomembranous stenosis at 3 institutions was performed. All patients with greater than 6 months follow up were included. Surgery involved complete scar excision, urethral mobilization, and bulbomembranous primary anastomosis. Patient characteristics and surgical parameters were reviewed. Recurrence was defined as cystoscopic identification of urethral narrowing to less than 16Fr in diameter. RESULTS Among 78 men treated, 72 (92%, mean age 69.5 years) underwent anastomotic reconstruction at 3 institutions. Successful bulbomembranous urethral reconstruction was achieved in 52 men (72%) at a mean follow up of 2.7 years. Mean stricture length was 2.4 cm (range 1 to 6). Hospitalization was one day or less for 75% of the patients. Many patients had incontinence preoperatively (25/72, 34%). After surgery, incontinence was present in 23 (32%), and new onset incontinence in 14 (19%), with 12 (17%) requiring an artificial urinary sphincter. The rate of erectile dysfunction was unchanged following urethroplasty (48% preoperative, 52% postoperative). Prostate cancer treatment was the most common reason for radiotherapy (70/72, 97%); within this group, external beam radiotherapy was performed in 30 men (42%), brachytherapy in 31 (43%), and a combination of the 2 modalities in 10 (14%). Two patients who underwent radiotherapy for colorectal cancer were also included. The type of radiotherapy, external beam or brachytherapy, did not affect stricture length (2.4 cm vs 2.2 cm, p=0.42) or risk for recurrence (27% vs 29%, p=0.93). Of the 20 men with recurrence, mean time to stricture recurrence was 10 months (range 1 to 64). CONCLUSIONS While the results are not as reliable as posterior urethroplasty for pelvic fracture related urethral injuries, radiotherapy induced strictures can often be successfully treated by urethroplasty without tissue transfer techniques. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e3 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lee C. Zhao Dallas, TX More articles by this author Allen F. Morey Dallas, TX More articles by this author Matthias D. Hofer Chicago, IL More articles by this author J. Francis Scott Dallas, TX More articles by this author Christopher M. Gonzalez Chicago, IL More articles by this author Steven B. Brandes St. Louis, MO More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

S166 INTERNAL URETHROTOMY COMBINED WITH ANTEGRADE FLEXIBLE CYSTOSCOPY FOR MANAGEMENT OF OBLITERATIVE URETHRAL STRICTURE

We studied the safety and efficacy of flexible cystoscopy-guided internal urethrotomy in the management of obliterative urethral strictures.Forty-three flexible cystoscopy-guided internal urethrotomies were performed between 1999 and 2005. The indication for the procedure was nearly blinded bulbar or membranous urethral strictures not longer than 1 cm that would not allow passage of guide wire. Candidates were those who refused or were unable to undergo urtheroplasty. By monitoring any impression of the urethrotome on the monitor through the flexible cystoscope, we were able to do under-vision urethrotomy. All of the patients were started clean intermittent catheterization afterwards which was tapered over the following 6 months. Follow-up continued for 24 months after the last internal urethrotomy.Seventeen patients were younger than 65 years with a history of failed posterior urethroplasty, and 26 were older than 65 with poor cardiopulmonary conditions who had bulbar urethral stricture following straddle or iatrogenic injuries. Urethral stricture stabilized in 16 patients (37.2%) with a single session of urethrotomy and in 17 (39.5%) with 2 urethrotomies. Overall, urethral stricture stabilized in 76.7% of patients with 1 or 2 internal urethrotomies within 24 months of follow-up. No severe complication was reported.Flexible cystoscopy-guided internal urethrotomy is a simple, safe, and under-vision procedure in obliterative urethral strictures shorter than 1 cm. It can be an ideal option for patients who do not accept posterior urethroplasty or are in a poor cardiopulmonary condition that precludes general anesthesia.

Outcomes of Endoscopic Realignment of Pelvic Fracture Associated Urethral Injuries at a Level 1 Trauma Center

We examined the success of early endoscopic realignment of pelvic fracture associated urethral injury after blunt pelvic trauma. A retrospective review was performed of patients with pelvic fracture associated urethral injury who underwent early endoscopic realignment using a retrograde or retrograde/antegrade approach from 2004 to 2010 at a Level 1 trauma center. Followup consisted of uroflowmetry, post-void residual and cystoscopic evaluation. Failure of early endoscopic realignment was defined as patients requiring urethral dilation, direct vision internal urethrotomy, posterior urethroplasty or self-catheterization after initial urethral catheter removal. A total of 19 consecutive patients (mean age 38 years) with blunt pelvic fracture associated urethral injury underwent early endoscopic realignment. Twelve cases of complete urethral disruption, 4 of incomplete disruption and 3 of indeterminate status were noted. Mean time to realignment was 2 days and mean duration of urethral catheterization after realignment was 53 days. One patient was lost to followup after early endoscopic realignment. Using an intent to treat analysis early endoscopic realignment failed in 15 of 19 patients (78.9%). Mean time to early endoscopic realignment failure after catheter removal was 79 days. The cases of early endoscopic realignment failure were managed with posterior urethroplasty (8), direct vision internal urethrotomy (3) and direct vision internal urethrotomy followed by posterior urethroplasty (3). Mean followup for the 4 patients considered to have undergone successful early endoscopic realignment was 2.1 years. Early endoscopic realignment after blunt pelvic fracture associated urethral injury results in high rates of symptomatic urethral stricture requiring further operative treatment. Close followup after initial catheter removal is warranted, as the mean time to failure after early endoscopic realignment was 79 days in our cohort.

90 IS TRANSPUBIC URETHROPLASTY PERFORMED FREQUENTLY IN CHILDREN?

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 201290 IS TRANSPUBIC URETHROPLASTY PERFORMED FREQUENTLY IN CHILDREN? Mamdouh koraitim Mamdouh koraitimMamdouh koraitim Alexandria, Egypt More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.137AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Transpubic urethroplasty has been repeatedly reported to be used more frequently in children than in adults. Also, it has been claimed that this is attributed to the confined perineum and delicate structures in children. In this study we attempted to learn how much frequently the transpubic urethroplasty is performed in children compared to adults. Also, we attempted to determine the reasons for the use of the transpubic approach in this group of patients. METHODS A total of 45 boys, 3 to 18 years old, underwent anastomotic repair of a post-pelvic fracture urethral injury (PFUI) between 1995 and 2009. During the same period 87 adults, 19 to 50 years old, underwent the same urethral repair of a PFUI. All preoperative, operative and postoperative data were recorded prospectively in our data base. The preoperative urethrograms were reinterpreted to measure the length of bulboprotatic urethral gap, length of bulbar urethra and transverse diameter of the pubic arch (as a representative of the operative space available in the perineum). In addition, we calculated the index of gapo/urethrometry (G/U) by dividing the length of urethral gap by that of bulbar urethra. RESULTS Of 45 children 26 (58%) were corrected by a simple perineal bulbo-prostatic urethral anastomosis and 19 (42%) by a perineo-abdominal transpubic procedure. Of 87 adults 61 (70%) were corrected via the perineum and 26 (30%) via a transpubic approach. In children group the mean (range) of width of the pubic arch of cases who underwent perineal and transpubic repair was 3.6 (3.0-4.5) cm vs. 3.4 (3.0-4.5) cm, respectively (p >0.05). The mean (range) of urethral gap length and G/U index of same cases were 1.3 (0.5-2.7) cm vs. 3.5 (2.5-6.0) cm, and 0.20 (0.11-0.34) vs. 0.64 (0.40-0.90), respectively (p <0.001). CONCLUSIONS The transpubic approach for posterior urethroplasty is more frequently used in children than in adults (42% vs. 30%, p <0.05). It seems that the “confined perineum” in children is not a significant determinant of the frequently used transpubic approach in this group of patients. Rather, this may be explained by the normally inherited short bulbar urethra and, consequently, the high value of Gapo/Urethrometry index in children. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e37-e38 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mamdouh koraitim Alexandria, Egypt More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Unsuccessful Outcomes After Posterior Urethroplasty: Definition, Diagnosis, and Treatment

To establish some guidelines for the definition, diagnosis, and treatment of failed posterior urethroplasty. We identified 20 successive patients who required a secondary endoscopic or surgical procedure after anastomotic repair of a postpelvic fracture urethral injury from 1979 to 2010. Of the 20 patients, 18 had undergone perineal repair and 2 a perineo-abdominal procedure. Their medical records were reviewed with a focus on 6 postoperative items: symptoms, onset of unsuccessful result, urethral calibration, urethrocystography, urethroscopy, and treatment. Follow-up ranged from 1 to 25 years (mean 14). Of the 20 patients, 11 (55%) presented shortly after removal of the urethral stent with failure to void (n = 9) or incontinence (n = 2), and 9 (45%) presented 1 month to 12 years after surgery with a weak stream. Early failures resulted from obstruction at the site of repair in 5 patients, retraction of the bulbar urethra in 3, wrong anastomosis to a false tract in 1, and an open bladder neck in 2. Correction was accomplished by salvage urethroplasty in 8 patients and bladder neck repair in 2. Late failures resulted from narrowing of the anastomosis and were corrected by direct visual internal urethrotomy in 7 patients and surgery in 2. Unsuccessful outcomes can be encountered shortly after removal of the urethral stent or delayed for several months or years after surgery. Early cases present by an inability to void or incontinence and usually require salvage urethroplasty or bladder neck repair. Late cases present by a weak urinary stream, are due to narrowing of the anastomosis, and are usually corrected by direct visual internal urethrotomy.

Inlay buccal mucosal graft for reoperative posterior urethroplasty

Posterior urethral distraction injury following major pelvic trauma is a surgical challenge. Although rarely seen, cases of failure after formal urethral reconstruction are even more problematic. We adapted the concept of augmented free buccal mucosal grafts, which have been successful in anterior urethroplasty, for repairing the posterior urethra in these rare cases with the aim of reducing the likelihood of penile chordee postoperatively. During 2007–2009, four patients were candidates for the proposed procedure because they had received formal transperineal urethral reconstruction but were unable to urinate through the urethra. The urethra was approached transperineally and opened in the midline, rather than divided. Buccal mucosal grafts of an appropriate size were placed in the created urethral groove from 4- to 8 o’clock in the lithotomy view. After the procedure, the urethral catheter was kept for 3 weeks. All patients voided through the urethra after the procedure. The maximal postoperative urinary flow rates were between 12–15 ml/seconds in all cases for a follow-up period of 18–30 months. The recurrence rate was 50% (2/4). Recurrent strictures were minor, and they showed a web-like stricture ring near the suture line. Restricture within 6 months of surgery responded well to endoscopic internal urethrotomy plus dilatations. In conclusion, without further compromising urethral length, reoperative posterior urethroplasty with the inlay grafting technique can be considered in selective cases.

An Assessment of the Efficacy and Safety of Sildenafil Administered to Patients with Erectile Dysfunction Referred for Posterior Urethroplasty: A Single‐Center Experience

Urethral trauma is often associated with erectile dysfunction (ED). Reconstructive surgery is complex and may impact negatively on sexual function. The aim of this article is to investigate ED in patients with pelvic fracture urethral distraction defects (PFUDD) who underwent urethroplasty, and efficacy of treatment with sildenafil citrate. A total of 41 patients with urethral stricture who suffered from PFUDD were assessed to exclude systemic diseases that may cause ED, such as hypertension, diabetes mellitus, heart disease, and chronic liver disease. The International Index of Erectile Function-5 was used as an evaluation tool. Assessments were made at three time points: the time of admission, two weeks after urethroplasty, and 3 months post-treatment with sildenafil. Pharmacopenile duplex ultrasonography was used to examine blood flow of the cavernosum in order to distinguish arterial ED, venous ED, and nonvascular ED. All patients were treated with oral sildenafil, 100 mg once daily, three times a week, for 3 months. The incidence of ED following injury was 95.12%. There were no significant changes in scores following surgery. However, sildenafil had a success rate of approximately 81%, which appeared to be independent of age. Drug treatment seemed most effective for those with less severe ED at the outset. There was no significant difference in scores post-treatment between those who had vascular and nonvascular ED. Overall, the incidence of side effects due to sildenafil was 19.5%. Urethral trauma is frequently associated with ED. Sildenafil citrate is useful in the drug treatment of ED in these patients and appears to be well-tolerated.

Surgical treatment of post-traumatic complex posterior urethral stricture in male patients

Objective To investigate the therapeutic effect of post-traumatic complex posterior urethral stricture in the male patients.Methods Clinical data of 479 male patients with post-traumatic complex posterior urethral stricture were reviewed.One-stage resection of the stenosis and end-to-end anastomosis was performed in 422 patients and scrotal flap with blood pedicle posterior urethroplasty in 57.Results The mean operation time was 115 minutes(range,90-140 minutes).The mean blood loss was 225 ml(range,100-300 ml).No intraoperative blood transfusion was needed.The mean follow-up time was 15 months(range,12-24 months).Among the 422 patients performed end-to-end anastomosis,386 patients had good voiding and 36 had dysuria because of the formation of anastomotic stoma valve(21 patients)or stricture ring(15 patients).The problem was resolved by transurethral valve/stricture ring resection.Among 57 patients undergone posterior urethroplasty,45 patients had good voiding nine patients were found with anterior urethra-skin tube anastomotic stoma stricture,of which four patients were treated by urethral dilatation and five by endourethrotomy; three patients were found with posterior urethra-skin tube anastomotic stoma stricture,of which one patient was treated by urethral dilation and two by endourethrotomy.Conclusions One-stage resection of the stenosis and end-to-end anastomosis is the main treatment for post-traumatic complex posterior urethral stricture.If the condition of the patients does not allow the end-to-end anastomosis,posterior urethroplasty can be an alternative. Key words: Male; Trauma; Posterior urethral stricture; Surgery

Transpubic posterior urethroplasty via perineal approach in children: A new technique

ObjectiveTo evaluate a new technique of transpubic urethroplasty via perineal approach for management of pelvic fracture urethral distraction defects (PFUDD) in children. MethodsOf 78 children undergoing posterior urethroplasty for PFUDD, 12 (15.4%) had a short urethra that could not bridge the gap (>5 cm) for a tension-free anastomosis. Age ranged from 5.2 to 12 years (median = 8.5 years). The median distraction defect length was 4.8 cm (range 3.7–6.4 cm). For the latter group, the new technique of transpubic posterior urethroplasty via perineal approach was performed. The first follow-up visit was scheduled 1 month after suprapubic catheter removal. Radiological studies and uroflowmetry were repeated at 6-month intervals for 1 year and once yearly thereafter. ResultsPatients were followed up for a period of 6 months to 5 years with a mean of 2.7 years. Mean operative time was 2.5 h (range 1.9–3.2 h) with a mean blood loss of 200 ml (range 50–640 cc) and the mean hospital stay was 4 days. All 12 children had a good urinary stream over the follow-up period; 3/12 (25%) developed stress urinary incontinence that resolved within 6 months postoperatively; 9/12 (75%) complained of (retracted) short penis. ConclusionsTranspubic urethroplasty via perineal approach is a feasible technique for management of complex PFUDD in children, and presents many advantages over other routes.

Low Yield of Early Postoperative Imaging After Anastomotic Urethroplasty

To evaluate the necessity and clinical effect of posturethroplasty imaging. We reviewed our database of all urethroplasties performed by a single surgeon at our referral center during a 2-year period. The patients underwent voiding cystourethrography at a mean of 24 days postoperatively. The data analyzed included patient history and demographics, operative details, imaging results, and clinical outcomes. From 2007 to 2009, 210 patients underwent urethral reconstruction at our center. The patients undergoing meatoplasty or staged repairs were excluded, leaving 156 patients with postoperative imaging studies for analysis. Of 110 anterior urethroplasties, 59 (54%) consisted of excision and primary anastomosis, 28 (25%) an augmented anastomotic procedure, and 23 (21%) a pure ventral onlay with a flap or graft. All 46 posterior urethroplasties were performed with scar excision and primary anastomosis. Of the 156 patients, only 4 (3%) had extravasation on postoperative voiding cystourethrography (2 after posterior urethroplasty, 1 after augmented anastomosis, and 1 after ventral onlay)--all were successfully managed with catheter replacement and removal at a mean of 8 days afterward. None of the 59 men undergoing excision and primary anastomosis demonstrated extravasation. Extravasation on posturethroplasty voiding cystourethrography is rare after approximately 3 weeks of catheter drainage. Imaging can be omitted after uncomplicated excision and primary anastomosis urethroplasty.

Urethral Rest: Role and Rationale in Preparation for Anterior Urethroplasty

To report the outcomes of men treated initially with a period of urethral rest to allow tissue recovery before anterior urethroplasty. Many men referred to referral centers for anterior urethral reconstruction often present soon after the endoscopic manipulation of severe strictures. We reviewed our database of all anterior urethroplasties performed by a single surgeon from 2007 to 2009. Urethral rest was accomplished by removal of the indwelling catheter, cessation of self-catheterization, and/or suprapubic urinary diversion before urethral reconstruction. During the study period, 210 patients underwent urethral reconstruction at our center. Men who had undergone meatoplasty or posterior urethroplasty were excluded, leaving 128 anterior urethroplasty patients available for analysis. Of these men, 28 (21%) were preoperatively given an initial period of urethral rest (median duration 3 months) because of recent urologic manipulation occurring immediately before referral. Of the 28 patients, 15 (54%) received suprapubic catheters. Urethral rest promoted identification of severely fibrotic stricture segments, enabling focal or complete excision in 75% (excision and primary anastomosis in 12 [43%] and augmented anastomosis in 9 [32%]), a percentage similar to that for those undergoing reconstruction without preliminary manipulation mandating urethral rest (82%). Stricture recurrence developed in 4 (14%) of the 28 rest patients, a rate again similar to that for the remainder of the urethroplasty population (10%). The results of our study have shown that recently manipulated anterior urethral strictures often declare themselves to be obliterative within several months of urethral rest, thus enabling successful urethroplasty by focal or complete excision.

10 OUTCOMES OF ENDOSCOPIC REALIGNMENT OF POSTERIOR URETHRAL INJURIES AT A LEVEL 1 TRAUMA CENTER

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery1 Apr 201110 OUTCOMES OF ENDOSCOPIC REALIGNMENT OF POSTERIOR URETHRAL INJURIES AT A LEVEL 1 TRAUMA CENTER Laura Leddy, Hunter Wessells, and Bryan Voelzke Laura LeddyLaura Leddy Seattle, WA More articles by this author , Hunter WessellsHunter Wessells Seattle, WA More articles by this author , and Bryan VoelzkeBryan Voelzke Seattle, WA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.071AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We sought to examine the success of initial endoscopic realignment following blunt pelvic trauma. METHODS A retrospective review was performed of all patients with pelvic fracture urethral disruption defect (PFUDD) who underwent endoscopic realignment from 2004–2010 at a Level 1 trauma center. Retrograde urethrogram, flexible cystoscopy, and clinical suspicion aided diagnosis of PFUDD. Endoscopic realignment of the posterior urethra was performed when the patient was clinically stable. Subsequent need for urethral dilation, internal urethrotomy, posterior urethroplasty, or intermittent self-catheterization following urethral catheter removal was considered failure. Uroflowmetry, postvoid residual and cystoscopic evaluation were utilized to diagnose failure of endoscopic realignment. RESULTS Nineteen patients with PFUDD who underwent endoscopic realignment were identified. Mean age was 38 (median 36). Injury etiology included the following: 10 motor vehicle crashes, 4 crush injuries, 3 vehicle vs. pedestrian accidents, 1 snowboarding accident, and 1 motorcycle crash. The following posterior urethral injuries were identified during endoscopic realignment: 12 complete urethral disruptions, 4 incomplete disruptions, 3 unable to determine. Mean time from injury to endoscopic realignment was 2 days (range 0–7 days). Mean duration of urethral catheterization following endoscopic realignment was 53 days (range 12–87 days). Fourteen of 19 patients failed initial endoscopic realignment. One patient was lost to follow up. Mean time to identification of failure following initial urethral catheter removal was 79 days (range 0–288 days). The following interventions were performed among the endoscopic realignment failures: posterior urethroplasty (11) and DVIU (3). Mean follow up for the remaining 4 patients considered to have undergone successful endoscopic realignment is 565 days (range 109–939 days). Findings identified at the time of endoscopic realignment in patients treated successfully with this technique included: complete disruption (2), 2cm dorsal bulbar laceration (1), vertical laceration at bladder neck (1). CONCLUSIONS Primary endoscopic urethral realignment following PFUDD results in high rates of symptomatic urethral stricture requiring further operative treatment. Close follow up after initial catheter removal is warranted. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e4 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Laura Leddy Seattle, WA More articles by this author Hunter Wessells Seattle, WA More articles by this author Bryan Voelzke Seattle, WA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Dorsal Versus Ventral Anterior Urethral Spatulation in Posterior Urethroplasty

To compare dorsal versus ventral anterior urethral spatulation in posterior urethroplasty. In a retrospective study, we evaluated the records of 320 posterior urethroplasties which have been done in our center over a 7-year period from January 2000 to December 2006. The results of dorsal and ventral anterior urethral spatulations were compared. The studied subjects consisted of 264 men and 54 prepubescent boys (≤ 15 years) with the mean age of 23 years (range, 5 to 84 years). The mean follow-up was 52 months (range, 27 to 107 months). Six o'clock (group A) and 12 o'clock (group B) anterior urethral spatulations were performed in 101 (32%) and 219 (68%) of the patients, respectively. The success rates were 96% and 87.6% in groups A and B, respectively (P = .025). There were no urethro-rectal fistula and perineal wound infection during the follow-up period. Our data suggest that the dorsal anterior urethral spatulation in urethroplasty is more efficient than ventral anterior urethral spatulation in terms of treatment success outcome.

Grafts are Unnecessary for Proximal Bulbar Reconstruction

We compared our experience with the reconstruction of proximal vs distal bulbar stricture to assess the role of excision and primary anastomosis vs graft procedures at each site. We reviewed all urethroplasties done by a single surgeon during a 2-year period. Data analyzed included patient history and demographics, operative details, stricture length and site, and clinical outcome. The proximal bulbar urethra was defined as the segment within 5 cm of the membranous urethra and the distal bulb was defined as the adjoining segment extending to the penoscrotal junction. Cases involving the pendulous or posterior urethra were excluded from study. Of 210 urethroplasties from 2007 to 2009, 112 were done for bulbar strictures, including 72 (64%) for proximal bulbar strictures. All 72 cases were treated with excision and primary anastomosis. Median stricture length was 2 cm (range 1 to 5), although 31 of 72 strictures (43%) were of intermediate length (2.5 to 5 cm). Recurrence developed in 1 case (1.4%). Distal bulbar strictures in 40 of the 112 cases (36%) were treated predominantly with substitution urethroplasty in 36 (90%), and with excision and primary anastomosis in 4 (10%). Median stricture length was 3.75 cm (range 1.5 to 20). We noted intermediate length stricture in 18 of 40 cases (45%) and recurrence in 11 (28%). Of intermediate length strictures recurrence was much rarer after excision and primary anastomosis than after graft procedures (1 of 33 or 3.0% vs 6 of 16 or 38%, p<0.05). Location is critical when selecting an appropriate technique for bulbar urethral reconstruction. Excision and primary anastomosis are superior to grafts in the proximal bulb. Grafts are often unnecessary for reconstructing proximal bulbar strictures 5 cm or less.

Improved Continence in Patients With Neurogenic Sphincteric Incompetence With Combination Tubularized Posterior Urethroplasty and Fascial Wrap: The Lengthening, Narrowing and Tightening Procedure

We evaluated the outcome in 19 patients who underwent bladder neck reconstruction by lengthening, narrowing and tightening the bladder neck with a combined tubularized posterior urethroplasty and circumferential fascial wrap. We reviewed the records of all patients who underwent bladder neck lengthening, narrowing and tightening between April 1996 and November 2002. Preoperative urodynamic and radiographic data were available on all patients. The surgical technique involved retroperitoneal exposure of the bladder neck with a tubularized posterior urethroplasty over a urethral catheter. The reconstructed urethra was then circumferentially wrapped with a fitted piece of cadaveric fascia. Of the 19 patients 15 remain completely continent at a mean ± SD followup of 35.5 ± 29.1 months. Three patients underwent secondary reconstruction, including bladder neck ligation in all 3 and secondary enterocystoplasty in 2. No patient experienced difficult intermittent catheterization via the urethra postoperatively. Bladder neck lengthening, narrowing and tightening is effective for managing neurogenic sphincteric incontinence. Outcomes are comparable with those of other reconstructive procedures.

1227 REDO POSTERIOR URETHROPLASTY IN CHILDREN: A RETROSPECTIVE STUDY

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery IV1 Apr 20101227 REDO POSTERIOR URETHROPLASTY IN CHILDREN: A RETROSPECTIVE STUDY Samir Orabi Samir OrabiSamir Orabi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.750AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Management of children with failed posterior urethroplasty is a challenge for both surgeon and parents. Objective: A retrospective evaluation of different line of management of redo posterior urethroplasty in children METHODS 19 out of 96 (19.79 %) children that subjective to posterior urethroplasty surgery for pelvic fracture urethral distraction defect(PFUDD) were suffered from failed posterior urethroplasty and were admitted to our department between January 1998 to March 2008. Age ranged between 4 -16 y with a mean of 10.7y. The surgery was done as a second in 10 out 19 (52.6 %), as third in 6 (31, 6 %) and in 3 (15.8 %) as a fourth surgery. All patients were subjective to a thorough history taken, urine culture and sensitivity, ascending urethrogram, combined cysto-urethrogram and endoscopy. To achieve a tension free anastomosis, partial pubectomy was done in 11 out of 19 (57.9%) children, total perineal pubectomy in 6 (31.6 %) and tubed penile skin flap for a long distraction defect (> 5 cm) in 2 (10.5 %). Follow up ranged from 13 months to 7 y with a mean of 35 months in the form of subjective parameters as straining, recurrent UTI, stress or total urinary incontinence and objective parameters as urine culture and sensitivity, ascending urethrogram and endoscopy if needed. RESULTS 11 out of 19 children (57.9 %) had complications with a success rate of 36.8%. Stress urinary incontinence was encountered in 6 (31.6%), 4 children response to conservative treatment in the form anticholinergic drugs and other 2 children need microplastique injection. 3 (15.8 %) had anastomotic strictures and were treated by EVU. Urethral diverticulae with stones and strictures were encountered in two patients with penile skin flap. CONCLUSIONS The best chance of success of posterior urethroplasty in children is the first surgery and it must be done by expertise in a special center. In redo surgery, the surgeon must be aware of all kinds of urethroplasty and skin substitution must be avoided. Alexandria, Egypt© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e475 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samir Orabi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...