Prior Urethroplasty Research Articles

Urinary and Sexual Outcomes Following Bulbar Urethroplasty–An Analysis of 2 Common Approaches

ObjectiveTo report success and patient reported urinary and sexual outcomes of patients who underwent anastomotic urethroplasty and dorsal buccal onlay urethroplasty. Materials and MethodsPatients who underwent primary transecting anastomotic or dorsal buccal onlay urethroplasty for bulbar strictures at our institution between 1998 and 2015 were analyzed. Patients who had a prior urethroplasty, involvement of a different portion of the urethra, or a diagnosis of lichen sclerosis (LS) or hypospadias were excluded. Outcomes were assessed by cystoscopy at 4 months, validated questionnaires assessing urinary, erectile, and ejaculatory function at the time of their most recent assessment. ResultsA total of 40 and 139 patients were included in the dorsal buccal and anastomotic groups, respectively. Wide patency at 4-month cystoscopy was 97.5% and 100% (P= .06) and the long-term success was 95% and 99.3% (P= .06) with a mean follow-up of 51.4 and 63.3 months. Patient reported outcomes were similar with 2 exceptions: postvoid dribbling was reported more often in the onlay group (28.1% vs 8.3%, P< .0001), and tethering with erections in the anastomotic group (23.4% vs 3.1%, P= .008). Ninety-eight percent of patients in the anastomotic group and 91% in the dorsal buccal onlay group would choose their surgery again (P= .07). ConclusionBoth anastomotic urethroplasty and dorsal onlay graft are associated with high success with comparable satisfaction. Patient reported outcome measures were similar regardless of approach, despite inherent differences in stricture length. Our data indicates that anastomotic urethroplasty should not be avoided due to concerns of sexual side effects.

PD33-05 INITIAL EXPERIENCE OF INJECTION OF DEHYDRATED HUMAN AMNION/CHORION ON OUTCOMES OF URETHROTOMY FOR RECURRENT URETHRAL STRICTURES

You have accessJournal of UrologyStem Cell Research: Stem Cell Research I1 Apr 2018PD33-05 INITIAL EXPERIENCE OF INJECTION OF DEHYDRATED HUMAN AMNION/CHORION ON OUTCOMES OF URETHROTOMY FOR RECURRENT URETHRAL STRICTURES Joseph Pariser, Maha Husainat, Omar Soto-Aviles, and Richard Santucci Joseph PariserJoseph Pariser More articles by this author , Maha HusainatMaha Husainat More articles by this author , Omar Soto-AvilesOmar Soto-Aviles More articles by this author , and Richard SantucciRichard Santucci More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1560AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recurrent urethral strictures can be managed endoscopically, but success rates approach 0% after 3 or more procedures. Scar modulation has the potential to be a therapeutic target for these patients. Amniofix (MiMedex, Marietta, GA) is a dehydrated human amnion/chorion membrane (dHACM) allograft designed to reduce scar tissue formation and promote healing, with a robust supportive literature in other body systems. We report the first clinical experience of adjuvant injectable dHACM placed at the time of urethrotomy in a population with otherwise high expected failure rates with urethrotomy alone. METHODS Between July 2016 and December 2016, a select group of patients with urethral stricture underwent urethrotomy and injection of dHACM into the incised scar tissue. Baseline demographics were collected. Patients were followed postoperative by symptoms, uroflowmetry (UF) and post-void residual (PVR) at least every 4 months. Successful treatment consisted of lack of additional procedures or self-catheterization for the treated stricture. RESULTS Twelve patients with median age 73 years were treated. Seven patients (58%) had prior pelvic radiation, and five patients (42%) had prior urethroplasty. The mean number of endoscopic procedures prior to injection was 2.5 (range 0-7). Successful treatment for the individual stricture was seen in 8 patients (67%) over the observation period. However, 2 of these patients developed other strictures requiring surgical intervention, one at the fossa navicularis and one in the prostatic urethra. There were no adverse effects noted from treatment. Median followup was 299 days (IQR 226-317). CONCLUSIONS Despite a heavily pretreated patient population including prior endoscopic treatments, radiation and/or urethroplasty, strictures treated with urethrotomy and adjuvant dHACM injection had a higher rate of success than expected with urethrotomy alone. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e652 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Joseph Pariser More articles by this author Maha Husainat More articles by this author Omar Soto-Aviles More articles by this author Richard Santucci More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD63-01 STENOSIS LENGTH IS INDEPENDENTLY ASSOCIATED WITH POSTERIOR URETHROPLASTY FAILURE: STRENGTHENING THE CASE FOR ACCURATE PREOPERATIVE STAGING OF POSTERIOR URETHRAL STENOSES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) III1 Apr 2018PD63-01 STENOSIS LENGTH IS INDEPENDENTLY ASSOCIATED WITH POSTERIOR URETHROPLASTY FAILURE: STRENGTHENING THE CASE FOR ACCURATE PREOPERATIVE STAGING OF POSTERIOR URETHRAL STENOSES Keith Rourke and Danielle Thiel Keith RourkeKeith Rourke More articles by this author and Danielle ThielDanielle Thiel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2961AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Posterior urethroplasty is generally recognized as a unique and challenging aspect of reconstructive urology but little data exists on what determines posterior urethroplasty success. Our aim is to examine factors associated with posterior urethroplasty failure. METHODS A retrospective review of 140 patients undergoing posterior urethroplasty over a 13-year period at a single center was performed. Urethroplasty failure was defined as stricture <16Fr identified on cystoscopy with a minimum of 12 months' follow-up. Clinical covariates included patient age, obesity (BMI>35), smoking, Charlson comorbidity index, etiology (pelvic fracture, radiation, or iatrogenic), stricture length, previous endoscopic treatments, previous urethroplasty and type of urethroplasty (anastomotic or tissue transfer with onlay). All patients underwent preoperative staging with retrograde urethrography, voiding cystourethrogram and cystoscopy. Descriptive statistics were used to summarize data while univariate and multivariate Cox regression analyses were used to delineate clinical associations. RESULTS Average stenosis length was 2.2 cm with a mean patient age of 52.1 years. Overall urethral patency was 86.4% with a mean follow-up of 61.6 months (12-156). 63.6% of patients failed previous endoscopic treatment, while 6.4% failed previous urethroplasty. 91.4%% of patients underwent anastomotic urethroplasty with the remaining required tissue transfer with onlay using either a buccal mucosal graft or penile island flap. On univariate Cox regression analysis stricture length (p<0.0001) and tissue transfer (p=0.008) were associated with stricture recurrence while patient age (p=0.85), smoking (p=0.11), obesity (p=0.57), overall comorbidity (p=0.21), stricture etiology (p=0.57), prior endoscopic treatment (p=0.54) and prior urethroplasty (p=0.83) were not. On multivariate assessment stricture length remained independently associated with stricture recurrence (p=0.03; H.R. 1.4; 95%CI 1.1-1.9) while tissue transfer was not (p=0.73). CONCLUSIONS Although without the variability in length found in anterior urethral strictures, stricture length is independently associated with recurrence stenosis after posterior urethroplasty. This emphasizes the importance of accurate preoperative staging preoperatively in order to determine accurate stricture length and thus provide appropriate preoperative patient counselling. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1213-e1214 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Keith Rourke More articles by this author Danielle Thiel More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Technique for single-stage reconstruction of obliterative or near-obliterative long urethral strictures in circumcised patients.

PurposeTo report our initial experience with urethral reconstruction using a combined dorsal lingual mucosal graft (LMG) and ventral onlay preputial flap for long obliterative or near-obliterative strictures in circumcised patients.Materials and MethodsThis was a retrospective study of 10 patients from January 2015 to June 2017 with long obliterative or near-obliterative anterior urethral strictures and circumcised prepuces. All patients underwent a combined approach using a dorsally LMG and a narrow preputial onlay flap ventrally to create a 26–30 Fr. neourethra over a 14-Fr Foley catheter. Success was defined as no requirement for additional urethral instrumentation. The follow-up period ranged from 6 to 32 months.ResultsThe patients ranged in age from 17 to 44 years (mean, 32.3±9.59 years) and stricture length ranged from 9 to 12.5 cm (mean, 10.77±1.15 cm). Four strictures were obliterative and six were near-obliterative. Two patients had a history of prior urethroplasty. The length of the LMGs harvested ranged from 11 to 14 cm (mean, 12.8±1.03 cm). The preputial flaps available were from 1 to 1.5 cm in width (1.29±0.16 cm) and the desired length. Maximum urinary flow rate (Qmax) achieved ranged from 12 to 26 mL/s (mean, 20.46±3.71 mL/s) after 3 months. One patient needed a single direct visualized internal urethrotomy and another patient develop temporary superficial penile necrosis. The success rate was 90%.ConclusionsLong obliterative and near-obliterative penile and penobulbar urethral strictures can still be treated in circumcised patients using available preputial skin along with lingual mucosa with good outcomes.

Incidence and Predictors of Complications due to Urethral Stricture in Patients Awaiting Urethroplasty

We examined the incidence and predictors of complications due to urethral stricture in patients awaiting urethroplasty. We retrospectively reviewed the charts of patients who underwent urethroplasty from 2009 to 2013. The primary outcome was complications, defined as any unplanned interaction with the health care system due to urethral stricture during the period between the decision to perform surgery and urethroplasty. A total of 276 patients were identified for analysis. Median stricture length was 4.0 cm and 67.4% of strictures were in the bulbar urethra. The most common stricture etiologies were idiopathic in 47.8% of cases and traumatic in 15.9%. Overall 15.9% of patients presented with a complication with a median time to complication of 43 days. Median surgical wait time was 151 days. Complications included urinary tract infections in 56.8% of patients, acute urinary retention in 20.5%, genitourinary pain in 5.8% and catheter related issues in 15.9%. Univariate analysis suggested that catheter dependent status, number of prior endoscopic treatments, a hypospadias and/or trauma etiology, and prior urethroplasty were potential significant predictors of complications. Multivariate analysis yielded only catheter dependent status (HR 5.2, 95% CI 2.4-11.3, p<0.0001) and prior failed urethroplasty (HR 1.6, 95% CI 1.1-2.3, p = 0.03) as significantly associated with complications. To our knowledge our study is the first to examine and quantify the morbidity of urethroplasty wait time. Approximately 16% of patients experienced a complication while awaiting urethroplasty. The optimal wait time should be less than 43 days. Patients with prior urethroplasty and catheters at the time of the surgical decision should be prioritized as they may be more likely to experience complications.

Do Transurethral Treatments Increase the Complexity of Urethral Strictures?

We examined the impact on urethral stricture complexity at urethroplasty of previous transurethral treatments such as dilation, urethrotomy and stenting, which are most commonly performed when treating male urethral stricture. We retrospectively reviewed the records of 45 males who had undergone transurethral treatments before urethroplasty. We compared urethrography findings at initial diagnosis with those at urethroplasty. Males with failed hypospadias repair, lichen sclerosis or a history of prior urethroplasty were excluded from analysis. We considered stricture complexity increased if the number and/or length of strictures on urethrography at urethroplasty was greater than that at initial diagnosis or false passage was newly identified. Of the patients 39 (87%), 32 (71%) and 13 (29%) had undergone urethral dilation, urethrotomy and urethral stenting, respectively, and 39 (87%) had undergone repeat or multiple kinds of transurethral treatments. Stricture complexity was increased in 22 men (49%) while 7 (16%) required urethroplasty more complex than that anticipated from urethrography findings at initial diagnosis. Increased stricture complexity was significantly associated with a history of urethrotomy (p = 0.03), urethral stenting (p = 0.0002) and repeat transurethral treatments (p = 0.01). Multivariate analysis revealed that urethral stenting (p = 0.01) and repeat transurethral treatments (p = 0.01) were independent predictors of increased stricture complexity. Repeat transurethral treatments increase stricture complexity and are potentially counterproductive. Even a single application of temporary urethral stenting carries a high risk of complicating the stricture and requiring complex urethroplasty.

Delayed Reconstruction of Bulbar Urethral Strictures is Associated with Multiple Interventions, Longer Strictures and More Complex Repairs

Prior to urethral reconstruction many patients with stricture undergo a variable period during which endoscopic treatments are performed for recurrent obstructive symptoms. We evaluated the association among urethroplasty delay, endoscopic treatments and subsequent reconstructive outcomes. We reviewed the records of men who underwent primary bulbar urethroplasty from 2007 to 2014. Those with prior urethroplasty, penile and/or membranous strictures and incomplete data were excluded from analysis. Men were stratified by a urethroplasty delay of less than 5, 5 to 10 or greater than 10 years from diagnosis. A total of 278 primary bulbar urethroplasty cases with complete data were evaluated. Median time between stricture diagnosis and reconstruction was 5 years (IQR 2-10). Patients underwent an average ± SD of 0.9 ± 2.4 endoscopic procedures per year of delay. Relative to less than 5 and 5 to 10 years a delay of greater than 10 years was associated with more endoscopic treatments (median 1vs 2 vs 5), repeat self-dilations (13% vs 14% vs 34%), strictures longer than 2 cm (40% vs 39% vs 56%) and complex reconstructive techniques (17% vs 17% vs 34%). An increasing number of endoscopic treatments was independently associated with strictures longer than 2 cm (OR 1.06, p = 0.003), which had worse 24-month stricture-free survival than shorter strictures (83% vs 96%, p = 0.0003). Each consecutive direct vision internal urethrotomy was independently associated with the risk of urethroplasty failure (HR 1.19, p = 0.02). Urethroplasty delay is common and often associated with symptomatic events managed by repeat urethral manipulations. Endoscopic treatments appear to lengthen strictures and increase the complexity of repair.

PD60-03 PRE- AND POST-TREATMENT URETHROGRAMS SHOW THAT TRANSURETHRAL TREATMENTS INCREASE THE COMPLEXITY OF URETHRAL STRICTURES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) IV1 Apr 2017PD60-03 PRE- AND POST-TREATMENT URETHROGRAMS SHOW THAT TRANSURETHRAL TREATMENTS INCREASE THE COMPLEXITY OF URETHRAL STRICTURES AKIO HORIGUCHI, MASAYUKI SHINCHI, KEIICHI ITO, RYUICHI AZUMA, and TOMOHIKO ASANO AKIO HORIGUCHIAKIO HORIGUCHI More articles by this author , MASAYUKI SHINCHIMASAYUKI SHINCHI More articles by this author , KEIICHI ITOKEIICHI ITO More articles by this author , RYUICHI AZUMARYUICHI AZUMA More articles by this author , and TOMOHIKO ASANOTOMOHIKO ASANO More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2749AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We examined the association of urethral stricture complexity at urethroplasty with previous transurethral manipulation including urethral dilation, urethrotomy, and urethral stenting, which are the most commonly performed procedures for treating male urethral strictures but have alarmingly high failure rates. METHODS We retrospectively reviewed the records of 249 patients with urethral stricture disease who had undergone urethroplasty between 2004 and 2015. Patients with a history of lichen sclerosus, hypospadias, phalloplasty, and/or prior urethroplasty were excluded from analysis. Of the remaining 197 patients, we analyzed the records of 45 patients who had a history of transurethral treatments including self- or office-dilation, urethrotomy with a cold knife or laser, and/or urethral stenting using temporary thermo-expandable stents at least once and whose urethrography results at initial stricture diagnosis and at urethroplasty were available. We considered stricture complexity increased if the number of strictures and/or stricture length on the urethrography at urethroplasty was greater than that at initial diagnosis, and/or if a false passage was newly identified. RESULTS Thirty-nine of the patients (87%) had been subjected to urethral dilation, 32 (71%) to urethrotomy, and 13 (29%) to temporary urethral stenting, and 39 (87%) had received repeated and/or multiple kinds of transurethral treatments. Disease duration (defined as the period between the initial stricture diagnosis and urethroplasty) in patients with repeated transurethral treatments (mean 102 months) was more than four times that in patients with a single transurethral treatment (mean 24 months, p = 0.006). Stricture complexity was increased in 22 (49%) and was significantly associated with a history of urethrotomy (p = 0.03), urethral stenting (p = 0.0002), and repeated transurethral treatments (p = 0.01). Notably, twelve (92%) of 13 patients with history of urethral stenting showed increased stricture complexity, and multivariate logistic regression analysis revealed that history of urethral stenting was an independent predictor of increased stricture complexity (OR 13.7, p = 0.01). Of the 22 patients with increased stricture complexity, seven (32%) were forced to change the type of urethroplasty to one more complex than the predicted repair type based on the urethrography at initial diagnosis. CONCLUSIONS Repeated transurethral manipulation is associated with increased stricture complexity and is potentially counterproductive. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1183-e1184 Advertisement Copyright & Permissions© 2017MetricsAuthor Information AKIO HORIGUCHI More articles by this author MASAYUKI SHINCHI More articles by this author KEIICHI ITO More articles by this author RYUICHI AZUMA More articles by this author TOMOHIKO ASANO More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD34-01 ANASTOMOTIC BULBAR URETHROPLASTY: TO TRANSECT OR NOT TO TRANSECT?

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) III1 Apr 2017PD34-01 ANASTOMOTIC BULBAR URETHROPLASTY: TO TRANSECT OR NOT TO TRANSECT? Dave Chapman, Adam Kinnaird, Jon Witten, and Keith Rourke Dave ChapmanDave Chapman More articles by this author , Adam KinnairdAdam Kinnaird More articles by this author , Jon WittenJon Witten More articles by this author , and Keith RourkeKeith Rourke More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1524AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Anastomotic urethroplasty is an effective but occasionally controversial treatment for short bulbar urethral strictures. Non-transecting variations of anastomotic urethroplasty were created in part to address this controversy. The objective of this study is to assess current outcomes of anastomotic urethroplasty and compare outcomes of transecting and non-transecting techniques. METHODS 171 patients with complete follow-up underwent anastomotic bulbar urethroplasty from September 2003 to May 2016. Patient age, stricture length, location, etiology, 90-day complications and semi-quantitative assessment of sexual dysfunction were recorded. The primary (objective) outcome was success defined as urethral patency >16Fr on routine follow-up cystoscopy. Secondary outcome measures included 90-day complications (Clavien ≥2) and de novo sexual dysfunction assessed at 6 months. Statistical comparison between transecting and non-transecting cohorts was made using Cox Regression Analysis and Chi-square when appropriate. RESULTS One hundred and thirty patients underwent transecting anastomotic urethroplasty while 41 had a non-transecting anastomotic urethroplasty. Mean stricture length was 1.5±0.5cm (range 1-3) with a mean patient age of 43.0±18.0 years. 78.9% of patients failed prior endoscopic treatment (135/171) and 2.4% failed prior urethroplasty (4). Overall there was a 98.2% (168/171) success rate with a mean follow-up of 74.9(±46.7) months. 7.0% (12/171) of patients experienced a 90-day postoperative complication of Clavien ≥2 including 2.9% wound-related complications (5), 1.8% scrotal hematomas (3), 1.8% UTI (3), and 0.6% urethral bleeding (1). 9.9% reported an adverse change in sexual function including 6.4% erectile dysfunction (11), 1.8% ejaculatory dysfunction (3), 1.2% painful erection (2), and 0.6% chordee (1). When comparing transecting and non-transecting technique success using Cox Regression analysis there was no difference in urethroplasty success (97.7% vs. 100%; p=0.63) and no difference in postoperative complications (7.7% vs. 4.9%; p=0.73) but patients undergoing transecting anastomotic urethroplasty were more likely to report an adverse change in sexual function (13.1%; vs. 0%; p=0.013). CONCLUSIONS Anastomotic urethroplasty remains a highly effective treatment for short-segment bulbar urethral strictures with relatively minimal associated morbidity. Newer non-transecting anastomotic urethroplasty techniques appear to compare favorably in the short-term and may reduce the risk of associated sexual dysfunction. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e657 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Dave Chapman More articles by this author Adam Kinnaird More articles by this author Jon Witten More articles by this author Keith Rourke More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Re-operative urethroplasty after failed hypospadias repair: how prior surgery impacts risk for additional complications

The primary aim of this report was to compare urethroplasty complications for primary distal and proximal repairs with those after 1, 2, 3, and 4 or more re-operations. Prospectively collected data on consecutive hypospadias repairs (tubularized incised plate (TIP), inlay, two-stage graft) from 2000 to 2015 were reviewed. Isolated fistula closures were excluded. Extracted information included patient age, meatal location, repair type, primary vs. re-operative surgery, number of prior operations, any testosterone use, glans width, and urethroplasty complications. Pre-operative testosterone stimulation was used during the study period until 2012. Initially, it was given for a subjectively small-appearing glans, but from 2008 to 2012 use was determined by glans width <14mm. Patients initially managed elsewhere were queried for any testosterone treatment. The number of prior operations was determined by patient history and confirmed by review of records. Calibrations, dilations, cystoscopies, and/or isolated skin revisions were not considered as prior urethroplasty operations. Multiple logistic regression was performed for all patients, and for the subset of patients undergoing re-operation, using stepwise regression for the following potential risk factors: meatal location (distal vs. midshaft/proximal), number of prior surgeries (0, 1, 2, 3, ≥4), pre-operative testosterone use (yes/no), small glans (<14 vs. ≥14), surgery type (TIP, inlay and two-stage graft), and age (continuous in months), with P-values <0.05 considered statistically significant. In contrast to the 135/1085 (12%) complication rate in patients undergoing primary distal and proximal TIP repair, re-operative urethroplasty complications occurred in 61/191 (32%) TIP, 16/46 (35%) inlay, and 49/124 (40%) two-stage repairs, P<0.0001. Data regarding testosterone use was available for 1490 (96%) patients. A total of 139 received therapy, of which 65 (46%) had urethroplasty complications vs. 229 of 1351 (16%) without treatment, P=0.0001. Logistic regression in 1536 patients demonstrated that each prior surgery increased the odds of subsequent urethroplasty complications 1.5-fold (OR 1.51, 95% CI 1.25-1.83), along with small glans <14mm (OR 2.40, 95% CI 1.48-3.87), mid/proximal meatal location (OR 2.54, 95% CI 1.65-3.92), and use of pre-operative testosterone (OR 2.57, 95% CI 1.53-4.31); age and surgery type did not increase odds (AUC=0.739). Urethroplasty complications doubled in people undergoing a second hypospadias urethroplasty compared with those undergoing primary repair. This risk increased to 40% with three or more re-operations. Logistic regression demonstrates that each surgery increases the odds for additional complications 1.5-fold. Mid/proximal meatal location, small glans <14mm, and use of pre-operative testosterone also significantly increase odds for complications. These observations support the theory that previously operated tissues have less robust vascularity than assumed in a primary repair, and suggest additional adjunctive therapies are needed to improve wound healing in re-operations. The finding that even a single re-operative urethroplasty has twice the risk for additional complications vs. a primary repair emphasizes the need for hypospadias surgeons to 'get it right the first time'. The fact that 40% of the re-operative urethroplasties in this series followed distal repairs emphasizes that there is no 'minor' hypospadias. A single re-operative hypospadias urethroplasty has twice the risk for additional complications vs. the primary repair, which increases to 40% with three or more re-operations. These results support a theory that vascularity of penile tissues decreases with successive operations, and suggest the need for treatments to improve vascularity. The higher risk for complications during re-operative urethroplasties also emphasizes the need to get the initial repair correct.

Direct visual internal urethrotomy for isolated, post-urethroplasty strictures: a retrospective analysis.

Urethroplasty is often successful for the treatment of male urethral stricture disease, but limited data exists on recurrence management. Our goal was to evaluate direct visual internal urethrotomy (DVIU) as a treatment option for isolated, recurrent strictures after urethroplasty. We retrospectively identified male patients who underwent urethroplasty from 1999 to 2013 and developed an isolated, recurrent stricture at the urethroplasty site treated with DVIU. Success was defined as lack of symptomatology and no subsequent intervention. Comparative analysis identified characteristics and stricture properties associated with success. A total of 436 urethroplasties were performed in 401 patients at our institution between 1999 and 2013. Stricture recurrence was noted in 64 (16%) patients. Of these, 47 (73%) underwent a DVIU. A total of 37 patients met inclusion criteria and underwent 50 DVIU procedures at the urethroplasty site. A single DVIU was successful in 13 of 37 patients (35%). A total of 4 of 6 patients required a second DVIU (67%). Overall, 17 of 43 (40%) of the total DVIUs were successful after urethroplasty. Success did not differ by age, stricture length or location, surgical technique, radiation history, prior urethroplasty or DVIU, time to failure, or etiology. Post-urethroplasty DVIU for isolated, recurrent strictures may be offered as a minimally invasive treatment option. Approximately 40% of patients were spared further intervention.

Urethral Reconstruction with Rectal Mucosa Graft Onlay: A Novel, Minimally Invasive Technique

Alternative grafts are needed for patients who are not suitable candidates for oral mucosa graft harvest or who have a paucity of oral mucosa graft available for reconstruction. Circumferential colonic mucosal grafts have demonstrated feasibility for urethral reconstruction, although sigmoid resection has been required for graft retrieval. We report the feasibility and short-term outcomes of urethral reconstruction using a rectal mucosa graft harvested by a novel, minimally invasive, transanal endoscopic microsurgical technique. We retrospectively reviewed the records of all patients who underwent transanal endoscopic microsurgical rectal mucosa graft harvest and onlay urethroplasty since the technique was first implemented in 2013. Graft failure was defined as inability to pass a 16Fr cystoscope in the grafted urethra. All 4 strictures were bulbopendulous with a median length of 13.5 cm (range 10 to 21). Median followup was 18 months (range 12 to 28). Stricture etiology was lichen sclerosus in 3 patients and failed hypospadias interventions in 1. Three patients had undergone at least 1 prior urethroplasty. In 1 patient stricture recurred in the graft 10 months following reconstruction. There were no colorectal complications. To our knowledge this is the first study demonstrating urethral reconstruction using a rectal mucosa graft harvested by the transanal endoscopic microsurgical technique. Initial data revealed that this technique is feasible and safe, and minimizes graft harvest morbidity. Transanal endoscopic microsurgical harvest of a rectal mucosa graft may provide an alternative graft material for patients with long segment urethral strictures who are not candidates for oral mucosa graft harvest. Further experience and longer followup are needed to validate these findings.

Artificial Urinary Sphincter Outcomes in the “Fragile Urethra”

To assess artificial urinary sphincter (AUS) outcomes in challenging post-prostatectomy patients with a "fragile urethra" at risk for urethral erosion. An institutional retrospective review of all AUS placements between August 2004 and March 2014 was performed. A "fragile urethra" was defined as a history of pelvic radiation, previous failed AUS, previous urethroplasty, or cystoscopic and/or clinical findings of urethral atrophy. The primary outcome was continence, defined as requiring ≤1 pad per day. Secondary outcomes included 90-day complications, need for further treatment, change in continence pads, and patient-reported satisfaction. Thirty patients were identified as having a "fragile urethra." Thirteen of these patients underwent a transcorporal AUS (TCAUS) and 17 had a standard AUS cuff placement. Seventeen patients had radiation, 8 had a previous eroded AUS, and 10 had a prior urethroplasty. Five patients had multiple risk factors for urethral erosion. Continence was achieved in 77% (23/30), 97% (29/30) were improved, and the mean change in pads was 6.0 ± 2.8. Only 7% (2/30) required explantation, both for erosion. When the TCAUS and standard AUS groups were compared, no differences were noted in continence rates (P = .43), improvement (P = 1.00), explantation rates (P = .18), or erosion rates (P = .18), despite TCAUS having a higher proportion of previous urethroplasties. AUS is a viable treatment option for post-prostatectomy incontinence, even in the fragile urethra. TCAUS may be utilized in patients with a very high risk for atrophy with similar continence and complication rates compared with standard AUS.

Repeat Excision and Primary Anastomotic Urethroplasty for Salvage of Recurrent Bulbar Urethral Stricture

We compared the results of initial excision and primary anastomosis urethroplasty to the excision and primary anastomosis outcomes of other challenging reoperative clinical settings, including secondary cases (prior urethroplasty of any technique other than excision and primary anastomosis) and repeat cases (prior excision and primary anastomosis). We reviewed our database of patients who underwent excision and primary anastomosis urethroplasty for bulbar urethral stricture atour tertiary referral center from 2007 to 2014. Patients without available dataand those with a history of lichen sclerosus, radiation, pelvic fracture urethral injuries, distal strictures and/or hypospadias were excluded from analysis. Patient characteristics and outcomes were compared between those undergoing initial, secondary, and repeat excision and primary anastomosis urethroplasty for bulbar urethral stricture. Among 898 urethroplasties performed during the study period we identified 305 men who underwent excision and primary anastomosis urethroplasty ofthe bulbar urethra, including an initial procedure in 268 of 305 (88%) and reoperation in 37 (12%). Of patients with reoperation 18 of 37 (49%) underwent secondary excision and primary anastomosis following a different type of prior urethroplasty and 19 (51%) underwent repeat excision and primary anastomosis. Repeat excision and primary anastomosis in the bulbar urethra was successful in18 of 19 patients (95%), which was comparable to the success rate of initial bulbar excision and primary anastomosis (251 of 268 or 94%) as well as secondary bulbar excision and primary anastomosis (17 of 18 or 94%, p = 0.975) with a similar mean stricture length. Mean followup for all patients was 41.5 months (range 6 to 90) and mean followup in each group was greater than 30 months. Repeat excision and primary anastomosis urethroplasty has excellent results for short bulbar strictures, comparable to those achieved in the initial and secondary setting.

Risk of urethral stricture recurrence increases over time after urethroplasty.

To report a single institutional experience with urethroplasty outcomes and success rates at long-term follow up. A retrospective review was carried out of all urethroplasties performed by a single surgeon from 2000 to 2010. A total of 347 patients underwent urethroplasty during this time period, of which 227 had minimum 1-year follow-up data available. Demographic, clinical, pathological and outcome data were reviewed. Recurrence was defined by patient reported urinary symptoms or need for subsequent intervention. Statistical analyses were carried out using SPSS statistical software. A total of 26% of all patients had a recurrence at a mean follow up of 62 months (range 13-147 months). The recurrence rate after anastomotic urethroplasty was 18%, as compared with 31% after substitution urethroplasty. Mean time to recurrence was 34 months (range 5-87). On univariate analysis, use of abdominal skin graft, history of prior urethroplasty, lichen sclerosus and length of follow up were statistically significant predictors of recurrence. On multivariate analysis, only history of prior urethroplasty and length of follow-up time exceeding 48 months were statistically significant predictors of recurrence. Urethroplasty for urethral stricture is the most durable treatment modality, regardless of surgical approach. However, there is an ongoing risk of recurrence with the passage of time. Patients should be counseled appropriately on the potential for late recurrence of stricture disease after urethroplasty.

V12-12 TWO-STAGE URETHROPLASTY WITH PREFABRICATED GRACILIS-BUCCAL MUCOSA COMPOSITE FLAP

You have accessJournal of UrologyReconstruction1 Apr 2015V12-12 TWO-STAGE URETHROPLASTY WITH PREFABRICATED GRACILIS-BUCCAL MUCOSA COMPOSITE FLAP Stephen Blakely, Henry Okafor, and Dmitriy Nikolavsky Stephen BlakelyStephen Blakely More articles by this author , Henry OkaforHenry Okafor More articles by this author , and Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2782AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In patients with devastated bulbous urethra (i.e. spongionecrosis, failed skin tube repairs, watering can perineum) repair options include buccal mucosa-dartos composit flap, enterourethroplasty, perineal urethrostomy or diversions. Here we demonstrate a novel technique to reconstruct a devastated bulbous urethra. This 2-stage technique involves creation of two independently vascularized urethral hemi-plates lined with buccal mucosa (BMG). In the first stage the dorsal plate is created by quilting BMG onto corpora cavernosa and the future ventral plate is grafted onto exposed distal gracilis muscle. During the second stage the two fabricated plates are anastomosed by bringing gracilis into perineum. To our knowledge this is the first report of reconstructing entire segment of devastated urethra in such manner. METHODS A 57 year old male with prior urethroplasty had a new penetrating injury to perineum. He presented with perineal abscess and fistula, underwent incision and drainage and suprapubic tube placement. Three months later he presented for reconstruction. In the stage 1 the affected urethra is dissected and removed leading to a 5cm defect. Two 6x2.5 cm BMG harvested, defatted and fenestrated. One graft was quilted on corpora cavernosa and anastomosed to the spatulated urethral stumps. Perineal urethrostomy was created by approximating edges of skin to the edges of urethral plate. A catheter is placed in the urethrostomy and a tie-over dressing applied. Next, Gracilis tendon is identified. A 6-cm skin defect was created and muscle sutured to the skin edges. The second BMG was quilted on the muscle and a tie-over dressing applied. 8 weeks later, stage 2, the gracilis-BMG composite is harvested. The muscle is passed into the perineal incision and the BMG edges on the flap are anastomosed the edges of the dorsal graft. The gracilis muscle is sutured to corpora cavernosa. RESULTS Patient underwent a 2-stage repair w/o complications and was sent home on day 1 each time. VCUG demonstrated patent urethra with reconstructed bulbous fragment similar to native urethra. Maximum uroflow was 18 cc/sec. CONCLUSIONS We demonstratedthe feasibility of using prefabricated BMG- gracilis composite flap for repair of devastated urethra. This technique avoids use of hair-bearing skin or GI segments. Gracilis muscle provides vascular bed ventrally and reduces the risk of developing ventral diverticulum. Independently vascularized urethral hemi-plates require minimal dissection to achieve tension-free anastomosis. Additional two patients are awaiting the second stage of this operation. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e980 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Stephen Blakely More articles by this author Henry Okafor More articles by this author Dmitriy Nikolavsky More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD22-02 TRANSECTED VS NON-TRANSECTED BULBAR URETHROPLASTY RESULTS IN SIMILAR STRICTURE RESOLUTION RATE IN PRIMARY REPAIR OF BULBAR URETHRAL STRICTURES

You have accessJournal of UrologyTrauma/Reconstruction: Urethral Reconstruction (including Stricture) III1 Apr 2015PD22-02 TRANSECTED VS NON-TRANSECTED BULBAR URETHROPLASTY RESULTS IN SIMILAR STRICTURE RESOLUTION RATE IN PRIMARY REPAIR OF BULBAR URETHRAL STRICTURES Kirk Anderson, Catherine Cooper, Dmitriy Nikolavsky, and Brian Flynn Kirk AndersonKirk Anderson More articles by this author , Catherine CooperCatherine Cooper More articles by this author , Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author , and Brian FlynnBrian Flynn More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1444AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There are a wide variety of techniques used in the repair of bulbar urethral strictures. The decision to perform transection vs. non-transection of the corpus spongiosum during urethoplasty is based on stricture characteristics and surgeon preference. A potential benefit of non-transecting technique is preservation of blood supply distal to the site of stricture. The purpose of this study is to review the stricture resolution rate of transecting vs non-transecting urethroplasty utilized by a single surgeon (BJF) to repair bulbar urethral strictures. METHODS A retrospective review was done of 342 patients who underwent anterior urethroplasty performed by a single surgeon over the previous 11 years. Patients were then excluded from further analysis if there had been prior urethroplasty, stricture location outside the bulbous urethra, or age <18 years. In the transected group, surgical techniques used included excision and primary anastomosis (EPA) and augmented anastomosis. In the non-transected group, surgical techniques used included non-transecting anastomotic urethroplasty and dorsal, ventral, or combination dorsal-ventral buccal grafting. The decision which surgical technique to employ was based on stricture etiology, length and surgeon preference. The primary end-point was stricture resolution in transected vs. non-transected bulbar urethroplasty. Success was defined as freedom from secondary procedures including dilation, urethrotomy, or repeat urethroplasty. RESULTS One-hundred and fifty-two patients met inclusion criteria. Mean patient age is 42 years and mean follow-up is 63 months. Primary and secondary outcomes are summarized in Table 1. The most common etiologies are idiopathic and trauma occurring in 59% and 30%, respectively, in the transected group and 60% and 32%, respectively, in the non-transected group. CONCLUSIONS Urethroplasty can be accomplished utilizing a variety of surgical techniques with durable success rates. In this series, transecting and non-transecting bulbar urethroplasty resulted in similar stricture resolution rate. Additional studies are needed to determine if differences may exist in sexual function outcomes and long-term success. Transected Non-Transected p-value Number 102 50 Success 83% 84% 0.92 Stricture Length (range) 2.3cm (0.3-8cm) 3.9 (1-10cm) <0.01 Prior DVIU 51% 54% 0.49 Mean f/u (months, range) 72 (18-137) 45 (2-135) <0.01 © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e476-e477 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kirk Anderson More articles by this author Catherine Cooper More articles by this author Dmitriy Nikolavsky More articles by this author Brian Flynn More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD14-10 A MULTIINSTITUTIONAL EVALUATION OF THE MANAGEMENT AND OUTCOMES OF LONG SEGMENT AND PANURETHRAL STRICTURES

You have accessJournal of UrologyTrauma/Reconstruction: Urethral Reconstruction (including Stricture) II1 Apr 2015PD14-10 A MULTIINSTITUTIONAL EVALUATION OF THE MANAGEMENT AND OUTCOMES OF LONG SEGMENT AND PANURETHRAL STRICTURES Jonathan Warner, Ibraheem Malkawi, Panjak Joshi, Sanjay Kulkarni, Guido Barbagli, Massimo Lazzeri, Ryan Mori, Kenneth Angermeier, Justin Han, Christopher Gonzalez, Fransisco Martins, Reynaldo Gomez, and Richard Santucci Jonathan WarnerJonathan Warner More articles by this author , Ibraheem MalkawiIbraheem Malkawi More articles by this author , Panjak JoshiPanjak Joshi More articles by this author , Sanjay KulkarniSanjay Kulkarni More articles by this author , Guido BarbagliGuido Barbagli More articles by this author , Massimo LazzeriMassimo Lazzeri More articles by this author , Ryan MoriRyan Mori More articles by this author , Kenneth AngermeierKenneth Angermeier More articles by this author , Justin HanJustin Han More articles by this author , Christopher GonzalezChristopher Gonzalez More articles by this author , Fransisco MartinsFransisco Martins More articles by this author , Reynaldo GomezReynaldo Gomez More articles by this author , and Richard SantucciRichard Santucci More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1339AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES This study presents the results of an international multi-institutional collaborative review of the largest available series of long segment and panurethral stricture repairs. The authors seek to better understand the management of long segment and panurethral strictures. METHODS A retrospective review was performed of patients treated with strictures longer than 8 cm at 8 different international tertiary referral centers. Data collected included demographics, cause of stricture, prior dilation or DVIU, prior urethroplasty, length of stricture, and surgical approach. Endpoints analyzed included surgical complications and recurrence. RESULTS 466 patients were identified. Treatment intervals ranged from 12/27/1984 to 11/9/2013 and included the experience of 8 experts in the field. Dorsal onlay buccal mucosa graft was the most common procedure utilized (223, 47.9%) while other techniques included first stage Johanson (including perineal urethrostomy) (162, 34.8%), second stage Johanson (56, 12%), fasciocutaneous flaps (8, 1.7%) and a combination flap and graft (17, 3.6%). Overall success was achieved in 361 patients (77.5%) with a mean follow up of 20 months. Recurrences of the various surgical types were similar; however, second stage Johanson urethroplasty was found to have a higher recurrence rate compared to one-stage buccal mucosal graft urethroplasty (35.7% versus 17.5%, respectively, p <0.01). In cases of lichen sclerosis, the recurrence rate was higher after second stage Johanson versus after a one-stage buccal graft procedure (14.0% versus 47.8% respectively, p <0.01). Those urethroplasties performed with a fasciocutaneous flap had a higher complication rate compared to those performed without (32% versus 14%, respectively, p =0.02). Prior dilation or urethrotomy, higher number of prior dilations or urethrotomies, abnormal postoperative voiding cystourethrogram, and skin grafts all portend a higher recurrence rate. Stricture length and location of buccal mucosal graft appear to have no impact on recurrence. On logistic regression analysis, only second stage Johanson had an increased odds ratio of recurrence compared to BMG, at 2.82 (1.41-5.86). CONCLUSIONS Panurethral and long segment strictures can be treated with high success rates. Considering all techniques, a 77.5% success rate was noted. Buccal grafts were particularly more successful than second stage Johanson urethroplasty. Fasciocutaneous flaps, while successful, had high complication rates. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e322 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan Warner More articles by this author Ibraheem Malkawi More articles by this author Panjak Joshi More articles by this author Sanjay Kulkarni More articles by this author Guido Barbagli More articles by this author Massimo Lazzeri More articles by this author Ryan Mori More articles by this author Kenneth Angermeier More articles by this author Justin Han More articles by this author Christopher Gonzalez More articles by this author Fransisco Martins More articles by this author Reynaldo Gomez More articles by this author Richard Santucci More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

PD14-04 REPEAT ENDOSCOPIC MANIPULATION FOR BULBAR URETHRAL STRICTURES INCREASES STRICTURE LENGTH AND URETHROPLASTY COMPLEXITY BUT DOES NOT AFFECT URETHROPLASTY OUTCOMES

You have accessJournal of UrologyTrauma/Reconstruction: Urethral Reconstruction (including Stricture) II1 Apr 2015PD14-04 REPEAT ENDOSCOPIC MANIPULATION FOR BULBAR URETHRAL STRICTURES INCREASES STRICTURE LENGTH AND URETHROPLASTY COMPLEXITY BUT DOES NOT AFFECT URETHROPLASTY OUTCOMES David W. Chapman, Abhaya Prasad, Adam Kinnaird, and Keith Rourke David W. ChapmanDavid W. Chapman More articles by this author , Abhaya PrasadAbhaya Prasad More articles by this author , Adam KinnairdAdam Kinnaird More articles by this author , and Keith RourkeKeith Rourke More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1333AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Endoscopic procedures, in the form of dilation or direct vision urethrotomy remain the most commonly used treatments for urethral stricture. Repeat endoscopic procedures, however, do not typically offer cure and may increase stricture complexity, threatening urethroplasty outcomes. Our objective was to evaluate the association between the number of endoscopic procedures with stricture length, urethroplasty complexity and urethroplasty outcomes. METHODS A retrospective review of 840 consecutive urethral reconstructions performed by a single surgeon between August 2003 and May 2014 was completed. Exclusion criteria were prior urethroplasty, penile or panurethral strictures, posterior stenosis, staged repair or incomplete datasets. Number of endoscopic treatments were analysed as an ordinal variable by dividing the number of endoscopic treatments into 4 groups (group 1 = 0 treatments, group 2= 1-2, group 3 = 3-5, group 4 = greater than 5) and as a continuous variable. Preoperative patient demographics and postoperative outcomes were first compared using univariate binary regression, followed by multivariate binary regression. Outcomes measures were stricture length (measured intra-operatively), complexity of urethroplasty (either an anastomotic technique or a more complex tissue substitution), urethroplasty success (defined as the easy passage of a 16Fr cystoscope), and Clavien complications. RESULTS Of the 430 patients with bulbar urethral strictures eligible for analysis, 49 were in group 1, 182 were group 2, 141 in group 3, and 58 were group 4. Using linear regression as both an ordinal and continuous variable, an increase in the number of endoscopic manipulations was strongly associated with increased stricture length (p<0.001 and p=0.01) and urethroplasty complexity (p<0.001 and p=0.02). Using multivariate binary regression, no association of urethroplasty success or complications were found with number of endoscopic treatments (p=0.85 and p=0.56, respectively). Urethroplasty failed in 2% of group 0 (1/50), 6.6% of group 1 (12/182), 9.0% of group 3 (13/143), and 8.6% of group 4 (5/65). CONCLUSIONS Temporizing patients with repeat endoscopic procedures is associated with increasing stricture length and urethroplasty complexity. Despite this, no association was found between the rate of stricture recurrence or accompanying urethroplasty complications. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e320 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information David W. Chapman More articles by this author Abhaya Prasad More articles by this author Adam Kinnaird More articles by this author Keith Rourke More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

7-flap perineal urethrostomy.

Perineal urethrostomy (PU) has been performed with success for the treatment of refractory and advanced urethral stricture disease for at least the past six decades. Here, we review the indications and outcomes of PU for indications such as complex hypospadias repair and urethral stricture disease resulting from trauma, infection, and failure of prior urethroplasty. We also describe the role of 7-flap PU, a novel alternative to the conventional approach that offers the surgeon added flexibility in tailoring urethrostomy creation based on intraoperative findings. The authors’ updated experience with 7-flap PU demonstrates a comparable 95% success rate in patients with a wide variety of stricture etiology. PU through either a conventional approach or a 7-flap technique is a valuable option for improving the quality of life in patients with debilitating urethral stricture disease.