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Trauma, and Genital and Urethral Reconstruction
Urological Survey
Trauma, and Genital and Urethral Reconstruction Management of the Bladder During Surgical Treatment of Enterovesical Fistulas From Benign Bowel Disease G. G. Ferguson, E. W. Lee, S. R. Hunt, C. H. Ridley and S. B. Brandes Department of Surgery, Divisions of Urologic Surgery and Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri J Am Coll Surg 2008; 207: 569 –572.
Background: Management of the bladder in enterovesical fistulas from benign bowel disease is not well described in the literature and there is no clear consensus. Study Design: A retrospective chart review was done of all patients with benign bowel disease and an enterovesical fistula who underwent definitive surgical management between January 1993 and December 2005. Patients were excluded if they had any history of abdominal cancer or pelvic radiation. Surgical management protocol for enterovesical fistulas included a period of perioperative bowel rest, surgical exploration, separation of the fistulized bowel from the bladder, resection of the diseased bowel segment, and Foley catheter placement for 1 week. Results: Seventy-four patients were eligible for the study. The average patient age was 54.3 years (range 19 to 88 years old). Twenty-six women and 48 men underwent celiotomy and segmental resection of the offending bowel and bowel side of the fistula. The bladder side of the fistula was managed by Foley catheter alone in 68% and by surgical repair in 32%. Fifty-two patients had diverticulitis (70.3%) and 22 had Crohn’s disease (29.7%). Mean followup was 26.4 months, and median followup was 6.45 months. One patient developed a colocutaneous and vesicocutaneous fistula after celiotomy. The remaining bladder defects healed within 1 week. Conclusions: Successful surgical management of most enterovesical fistulas from diverticulitis or Crohn’s disease requires only resection of the diseased bowel, with minimal need for repair or resection of the bladder side of the fistula. Indwelling Foley catheter placement alone is typically sufficient for bladder healing. Only when there are overt defects into the bladder should formal repair be undertaken. Editorial Comment: This unique and important article reviews a 12-year experience with benign enterovesical fistulas. The diagnosis was confirmed on abdominal/pelvic computerized tomography with oral contrast as well as cystoscopy. Interestingly while all cases involved segmental resection of the diseased bowel, few required formal surgical repair of the bladder, with the bladder side of the fistula being managed by Foley catheter alone in 68%. Omental flap interposition was associated with an excellent outcome when it was necessary. Allen F. Morey, M.D.
Outcome of Dorsal Buccal Graft Urethroplasty for Recurrent Bulbar Urethral Strictures A. O’Riordan, R. Narahari, V. Kumar and R. Pickard Department of Urology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom BJU Int 2008; 102: 1148 –1151.
Objective: To audit our results of dorsal buccal mucosal graft urethroplasty for recurrent bulbar urethral stricture disease and compare them with those from specialist centres. Patients and Methods: Data were collected prospectively on 52 men who had urethroplasty with ⬎ or ⫽1 year of follow-up; failure was 0022-5347/09/1816-2588/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
2588
www.jurology.com
Vol. 181, 2588-2590, June 2009 Printed in U.S.A. DOI:10.1016/j.juro.2009.02.094
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
2589
defined as the need for further intervention. Results: The mean (range) age of the patients was 39 (19 – 61) years and 23 (45%) had an identifiable cause for their stricture. The mean (range) stricture length was 3.5 (1.5– 6) cm and was associated with moderate or severe spongiofibrosis in 38 (73%) men. Ten (19%) men had minor complications after surgery. The mean (range) follow-up was 34 (12– 80) months, with the mean maximum urinary flow rate increasing from 6 to 24 mL/s after surgery. The surgery failed, requiring dilatation or urethrotomy, in seven (14%) men at a mean (range) of 25 (15–50) months after urethroplasty, giving an overall success rate of 86%. Conclusion: This prospective audit of dorsal buccal patch augmentation urethroplasty for bulbar strictures shows an equivalent outcome to the standard set by the expert originators, suggesting that is transferable to less specialized centres. The efficacy, low complication rate, short hospital stay and general applicability of the technique encourage its use for all men with recurrent bulbar stricture disease, but formal comparison with other options in randomized trials, including cost-effectiveness analysis, is needed. Editorial Comment: This article brings up a number of interesting points about using dorsal buccal mucosa grafts for reconstruction of bulbar urethral strictures. I completely agree with the following points. The inner cheek was used uniformly as the graft donor site, and the authors changed from suture closure of the harvest site to leaving the site open after diathermy hemostasis. In addition, a clear etiological factor was identifiable in only 45% of stricture cases. Other points raised in the article also require commentary. Division of the urethral plate was not performed. Also, moderate to severe spongiofibrosis was associated with sites of failure, with the obvious conclusion being that excision of severely fibrotic stricture segments during graft only is prudent. Finally after 3 weeks of indwelling catheterization a whopping 19% of patients had radiographic extravasation after dorsal graft procedures. This rate is much higher than we have experienced with ventral graft placement (less than 5%) and suggests that the dorsal grafting compromises exposure for suturing mucosal edges to the graft (as the authors admit) . . . without any proved benefit. Allen F. Morey, M.D.
The Continent, Catheterizable Abdominal Conduit in Adult Urological Practice B. D. Gowda, V. Agrawal and S. C. Harrison Department of Urology, James Cook University Hospital, Middlesbrough, Cleveland, United Kingdom BJU Int 2008; 102: 1688 –1692.
Objective: To report a large, single-centre experience with a continent, catheterizable abdominal conduit in adult patients. Patients and Methods: We retrospectively reviewed the case notes of all 65 patients who had surgery to create a continent catheterizable conduit based on the Mitrofanoff principle. Operations were carried out over a 13-year period. Data on surgical procedure, complications and final outcome were collected and analysed. Results: The mean age of the patients was 38.4 years and mean follow-up interval was 75.2 months. Patients with neuropathic lower urinary tracts accounted for the largest single indication for reconstruction (36 patients). The appendix was the conduit of choice and was available and suitable for use in 37 patients. There were 57 patients who continued to use their native bladder or had undergone an augmentation or substitution cystoplasty; 24.5% of these 57 individuals had also undergone closure of the bladder neck or urethra. There were postoperative complications requiring laparotomy in five (8%) patients. In all, 30 patients (46%) had catheterization problems, but most of these were easy to treat. Five patients (8%) had an incontinent conduit which was a more difficult problem to deal with. Two patients have died of unrelated cause and five patients have been converted to an ileal conduit. In all, 58 patients (92%) now have a Mitrofanoff conduit, of which 97% are catheterizable and 95% are continent. Conclusions: Continent urinary diversion, based on the Mitrofanoff principle, has similar outcomes in adult urological practice to those described in published paediatric case series. There is good evidence to suggest that Mitrofanoff conduits are durable. However, patients should be aware of complications and the need for long-term follow-up.
2590
DIAGNOSTIC UROLOGY, URINARY DIVERSION AND PERIOPERATIVE CARE
Editorial Comment: Although the Mitrofanoff principle theoretically provides an attractive technique for achieving a continent, catheterizable conduit, I am not a big fan of this procedure. For adults with lower tract trauma or urethral stricture orthotopic reconstruction is almost always achievable. The problems of obesity, radiation damage to surrounding tissues, stone formation, difficult catheterization and intractable incontinence limit the applicability of this technique in adults. In this series of 57 adult patients 54% had long-term Mitrofanoff conduit related complications requiring surgical revision. Caution is advised. Allen F. Morey, M.D.
Diagnostic Urology, Urinary Diversion and Perioperative Care Continent Cutaneous Diversion M. Fisch and J. W. Thuroff Center of Urology and Paediatric Urology, Asklepios Klinik Harburg, Hamburg, Germany BJU Int 2008; 102: 1314 –1319.
Continent urinary diversion requires the creation of a reservoir, ureteric implantation and establishment of a continence mechanism in the efferent segment. This review is a short overview on the history of different techniques in current use. Reservoirs with high volume and low pressure can be fashioned by antimesenteric opening and spherical reconfiguration of the bowel. Previously, techniques for ureteric implantation were simply transferred to continent urinary diversion. Currently the need for antirefluxive ureteric implantation techniques is questioned and there is a trend towards refluxive implantation. To create a continence mechanism, simple and reproducible procedures. e.g. the incorporation of the efferent segment into the pouch wall (e.g. appendix stoma, flap valve T mechanism, serosal-lined extramural tunnel) have been developed. Long-term data for different surgical techniques show excellent continence and acceptable complication rates. Editorial Comment: This excellent review article outlines the history of different techniques to achieve continence, as well as the current method used by the authors. The references are up to date and useful, providing historical perspective on what has become a common urological procedure. Richard K. Babayan, M.D.
Trauma, and Genital and Urethral Reconstruction Management of the Bladder During Surgical Treatment of Enterovesical Fistulas From Benign Bowel Disease G. G. Ferguson, E. W. Lee, S. R. Hunt, C. H. Ridley and S. B. Brandes Department of Surgery, Divisions of Urologic Surgery and Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri J Am Coll Surg 2008; 207: 569 –572.
Background: Management of the bladder in enterovesical fistulas from benign bowel disease is not well described in the literature and there is no clear consensus. Study Design: A retrospective chart review was done of all patients with benign bowel disease and an enterovesical fistula who underwent definitive surgical management between January 1993 and December 2005. Patients were excluded if they had any history of abdominal cancer or pelvic radiation. Surgical management protocol for enterovesical fistulas included a period of perioperative bowel rest, surgical exploration, separation of the fistulized bowel from the bladder, resection of the diseased bowel segment, and Foley catheter placement for 1 week. Results: Seventy-four patients were eligible for the study. The average patient age was 54.3 years (range 19 to 88 years old). Twenty-six women and 48 men underwent celiotomy and segmental resection of the offending bowel and bowel side of the fistula. The bladder side of the fistula was managed by Foley catheter alone in 68% and by surgical repair in 32%. Fifty-two patients had diverticulitis (70.3%) and 22 had Crohn’s disease (29.7%). Mean followup was 26.4 months, and median followup was 6.45 months. One patient developed a colocutaneous and vesicocutaneous fistula after celiotomy. The remaining bladder defects healed within 1 week. Conclusions: Successful surgical management of most enterovesical fistulas from diverticulitis or Crohn’s disease requires only resection of the diseased bowel, with minimal need for repair or resection of the bladder side of the fistula. Indwelling Foley catheter placement alone is typically sufficient for bladder healing. Only when there are overt defects into the bladder should formal repair be undertaken. Editorial Comment: This unique and important article reviews a 12-year experience with benign enterovesical fistulas. The diagnosis was confirmed on abdominal/pelvic computerized tomography with oral contrast as well as cystoscopy. Interestingly while all cases involved segmental resection of the diseased bowel, few required formal surgical repair of the bladder, with the bladder side of the fistula being managed by Foley catheter alone in 68%. Omental flap interposition was associated with an excellent outcome when it was necessary. Allen F. Morey, M.D.
Outcome of Dorsal Buccal Graft Urethroplasty for Recurrent Bulbar Urethral Strictures A. O’Riordan, R. Narahari, V. Kumar and R. Pickard Department of Urology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom BJU Int 2008; 102: 1148 –1151.
Objective: To audit our results of dorsal buccal mucosal graft urethroplasty for recurrent bulbar urethral stricture disease and compare them with those from specialist centres. Patients and Methods: Data were collected prospectively on 52 men who had urethroplasty with ⬎ or ⫽1 year of follow-up; failure was 0022-5347/09/1816-2588/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
2588
www.jurology.com
Vol. 181, 2588-2590, June 2009 Printed in U.S.A. DOI:10.1016/j.juro.2009.02.094
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
2589
defined as the need for further intervention. Results: The mean (range) age of the patients was 39 (19 – 61) years and 23 (45%) had an identifiable cause for their stricture. The mean (range) stricture length was 3.5 (1.5– 6) cm and was associated with moderate or severe spongiofibrosis in 38 (73%) men. Ten (19%) men had minor complications after surgery. The mean (range) follow-up was 34 (12– 80) months, with the mean maximum urinary flow rate increasing from 6 to 24 mL/s after surgery. The surgery failed, requiring dilatation or urethrotomy, in seven (14%) men at a mean (range) of 25 (15–50) months after urethroplasty, giving an overall success rate of 86%. Conclusion: This prospective audit of dorsal buccal patch augmentation urethroplasty for bulbar strictures shows an equivalent outcome to the standard set by the expert originators, suggesting that is transferable to less specialized centres. The efficacy, low complication rate, short hospital stay and general applicability of the technique encourage its use for all men with recurrent bulbar stricture disease, but formal comparison with other options in randomized trials, including cost-effectiveness analysis, is needed. Editorial Comment: This article brings up a number of interesting points about using dorsal buccal mucosa grafts for reconstruction of bulbar urethral strictures. I completely agree with the following points. The inner cheek was used uniformly as the graft donor site, and the authors changed from suture closure of the harvest site to leaving the site open after diathermy hemostasis. In addition, a clear etiological factor was identifiable in only 45% of stricture cases. Other points raised in the article also require commentary. Division of the urethral plate was not performed. Also, moderate to severe spongiofibrosis was associated with sites of failure, with the obvious conclusion being that excision of severely fibrotic stricture segments during graft only is prudent. Finally after 3 weeks of indwelling catheterization a whopping 19% of patients had radiographic extravasation after dorsal graft procedures. This rate is much higher than we have experienced with ventral graft placement (less than 5%) and suggests that the dorsal grafting compromises exposure for suturing mucosal edges to the graft (as the authors admit) . . . without any proved benefit. Allen F. Morey, M.D.
The Continent, Catheterizable Abdominal Conduit in Adult Urological Practice B. D. Gowda, V. Agrawal and S. C. Harrison Department of Urology, James Cook University Hospital, Middlesbrough, Cleveland, United Kingdom BJU Int 2008; 102: 1688 –1692.
Objective: To report a large, single-centre experience with a continent, catheterizable abdominal conduit in adult patients. Patients and Methods: We retrospectively reviewed the case notes of all 65 patients who had surgery to create a continent catheterizable conduit based on the Mitrofanoff principle. Operations were carried out over a 13-year period. Data on surgical procedure, complications and final outcome were collected and analysed. Results: The mean age of the patients was 38.4 years and mean follow-up interval was 75.2 months. Patients with neuropathic lower urinary tracts accounted for the largest single indication for reconstruction (36 patients). The appendix was the conduit of choice and was available and suitable for use in 37 patients. There were 57 patients who continued to use their native bladder or had undergone an augmentation or substitution cystoplasty; 24.5% of these 57 individuals had also undergone closure of the bladder neck or urethra. There were postoperative complications requiring laparotomy in five (8%) patients. In all, 30 patients (46%) had catheterization problems, but most of these were easy to treat. Five patients (8%) had an incontinent conduit which was a more difficult problem to deal with. Two patients have died of unrelated cause and five patients have been converted to an ileal conduit. In all, 58 patients (92%) now have a Mitrofanoff conduit, of which 97% are catheterizable and 95% are continent. Conclusions: Continent urinary diversion, based on the Mitrofanoff principle, has similar outcomes in adult urological practice to those described in published paediatric case series. There is good evidence to suggest that Mitrofanoff conduits are durable. However, patients should be aware of complications and the need for long-term follow-up.
2590
DIAGNOSTIC UROLOGY, URINARY DIVERSION AND PERIOPERATIVE CARE
Editorial Comment: Although the Mitrofanoff principle theoretically provides an attractive technique for achieving a continent, catheterizable conduit, I am not a big fan of this procedure. For adults with lower tract trauma or urethral stricture orthotopic reconstruction is almost always achievable. The problems of obesity, radiation damage to surrounding tissues, stone formation, difficult catheterization and intractable incontinence limit the applicability of this technique in adults. In this series of 57 adult patients 54% had long-term Mitrofanoff conduit related complications requiring surgical revision. Caution is advised. Allen F. Morey, M.D.
Diagnostic Urology, Urinary Diversion and Perioperative Care Continent Cutaneous Diversion M. Fisch and J. W. Thuroff Center of Urology and Paediatric Urology, Asklepios Klinik Harburg, Hamburg, Germany BJU Int 2008; 102: 1314 –1319.
Continent urinary diversion requires the creation of a reservoir, ureteric implantation and establishment of a continence mechanism in the efferent segment. This review is a short overview on the history of different techniques in current use. Reservoirs with high volume and low pressure can be fashioned by antimesenteric opening and spherical reconfiguration of the bowel. Previously, techniques for ureteric implantation were simply transferred to continent urinary diversion. Currently the need for antirefluxive ureteric implantation techniques is questioned and there is a trend towards refluxive implantation. To create a continence mechanism, simple and reproducible procedures. e.g. the incorporation of the efferent segment into the pouch wall (e.g. appendix stoma, flap valve T mechanism, serosal-lined extramural tunnel) have been developed. Long-term data for different surgical techniques show excellent continence and acceptable complication rates. Editorial Comment: This excellent review article outlines the history of different techniques to achieve continence, as well as the current method used by the authors. The references are up to date and useful, providing historical perspective on what has become a common urological procedure. Richard K. Babayan, M.D.