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61 END-TO-END REPAIR OR BUCCAL MUCOSA GRAFT FOR SINGLE-STAGE BULBAR URETHROPLASTY?
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THE JOURNAL OF UROLOGY姞
CONCLUSIONS: A staged penile urethroplasty can be limited by the availability of buccal mucosa when excision of the urethra is performed. Our initial results show lateral native urethral plate survival and excellent buccal graft take after a first stage procedure in all cases. Our early results also show good patency rates in those who have completed the second stage procedure. Our study demonstrates the technical and anatomic feasibility of this two-stage penile urethroplasty utilizing ventral urethrotomy and dorsal buccal mucosa inlay, with lateralization and preservation of the urethral plate. Preserving the urethral plate will allow the reconstruction of longer strictures by decreasing the demand of an already limited supply of buccal mucosa graft. Source of Funding: None
61 END-TO-END REPAIR OR BUCCAL MUCOSA GRAFT FOR SINGLE-STAGE BULBAR URETHROPLASTY? Kathy Vander Eeckt*, Leuven, Belgium; Paolo Gontero, Turin, Italy; Steven Joniau, Leuven, Belgium INTRODUCTION AND OBJECTIVES: It is common practice to use an end-to-end (ETE) urethroplasty in short (ⱕ2cm) urethral strictures and a substitution urethroplasty in longer urethral strictures (⬎2cm). However, the restricture rates and functional outcomes of those 2 techniques have never been compared directly. We aimed to compare the restricture rates and erectile function changes after singlestage ETE versus buccal mucosa graft (BMG) repair for bulbar urethral stricture disease. METHODS: 103 patients underwent a single-stage bulbar urethroplasty at our institution between 2003 and 2009: 42 patients had an ETE and 61 a BMG repair. Different clinical parameters were collected: pre- and postoperative maximum flow rate (Qmax), previous urethral manipulations, stricture length, postoperative complications, remembered preoperative IIEF-5 score (r-IIEF-5) and prospectively collected IIEF-5 (p-IIEF-5) and IPSS scores at last follow-up. Any urethral instrumentation after surgery was considered a treatment failure. RESULTS: The mean stricture length was 1.34 cm in ETE versus 2.89 cm in BMG repair (p⬍0.001). 95 patients (92.2%) had undergone at least one previous urethral manipulation. Of the 17 patients who had undergone previous open surgery, 16 received a BMG repair. The mean pre- and postoperative Qmax of ETE versus BMG urethroplasty were 8.1 vs. 8.72 ml/s (p⫽0.6) and 20.4 vs. 19.9 ml/s (p⫽0.8) respectively. The mean follow-up was 25.3 months (SD ⫹/- 22.3) and this was identical for the two groups (p⫽0.99). Complication rate was 9.7%, with no significant difference between groups. The estimated failure-free rate of the ETE and the BMG repair were 79.9% and 90.2% respectively (p⫽0.3). IPSS at last follow-up was in favor of the ETE (5.4 vs 8.8, p⫽0.046). 44% of the patients had new onset postmicturation dribbling with no significant difference between the 2 groups. (p⫽0.18). There was a significant difference between overall r-IIEF-5 (mean 20.6 (SD ⫹/-5.7)) and p-IIEF-5 (mean 16.7 (SD ⫹/-8.4)) (p⫽0.0008). No difference in r-IIEF-5 (p⫽0.16) and p-IIEF-5 (p⫽0.72) was noted between groups. CONCLUSIONS: In bulbar urethral strictures, the failure-free rates and erectile function changes after end-to-end or BMG repair were comparable, even though stricture disease was more complex in the BMG group. These results have important implications for clinical practice, as when there is any doubt during surgery about the feasibility of performing an end-to-end urethroplasty, the threshold to take a BMG must be low. Source of Funding: None
Vol. 183, No. 4, Supplement, Saturday, May 29, 2010
62 PATHOLOGIC ANALYSIS OF BUCCAL MUCOSA GRAFT IN FIRST AND SECOND STAGE ADULT URETHROPLASTY Thomas Smith III*, Houston, TX; Bryan Voelzke, Hunter Wessells, Seattle, WA INTRODUCTION AND OBJECTIVES: Two stage urethroplasty is used for complex reconstruction of anterior urethral stricture disease due to failed prior urethroplasty or lichen sclerosis (LS). Buccal mucosa (BM) is non-keratinizing, squamous epithelium accepted as an excellent graft material for both single and two stage urethroplasty. Previously, we reported one case of recurrent LS in a series of three staged urethroplasty patients. We sought to describe the histologic changes of BM in two stage urethroplasty in an adult stricture population. METHODS: Thirty two consecutive patients at the University of Washington underwent two stage reconstruction of complex anterior urethral stricture disease from 2002-2009. First stage urethroplasty was completed in all patients using BM. Biopsy of the urethra or urethral plate was performed at time of first stage in 30 and of the harvested BM in 21. Second stage urethroplasty was completed a mean of 12.8 months later in 26, of whom 25 underwent biopsy of the BM graft. Pathologic analysis was performed in all biopsies. RESULTS: Urethral biopsies showed LS or chronic inflammation in 13, fibrosis in 5, and urothelium or epithelium in the remainder. BM analysis at harvest was normal (17), chronically inflamed (2), and minor histologic variant (2). Of the 25 second stage patients, pathologic findings on BM graft site included recurrent LS or chronic inflammation in 4 and fibrosis in 2. No patient’s first stage graft failed due to BM pathology at time of harvest. Of the 6 patients who did not proceed to second stage, 3 had recurrent LS and 1 had graft fibrosis. Second stage procedures failed in 2 patients due to pathologic changes of the grafted BM including 1 due to recurrent LS. Overall, 24 of 26 patients who proceeded to second stage repair had urethral patency. CONCLUSIONS: BM is a robust epithelium which maintains squamous epithelial histologic anatomy despite use as a free graft and change in environment from moist to dry. It appears to be resistant to the pathologic changes of LS, although 4 of 12 showed recurrence in the graft, usually detectable prior to second stage closure. Pathology of buccal mucosa graft bed at 2nd stage urethroplasty Pathologic Diagnosis Patients Normal Squamous Epithelium 15 Mild Chronic Inflammation/Normal Epithelium
4
Fibrosis
2
Chronic Inflammation
2
Lichen sclerosis Total
2 25
Pathology of urethra at 1st stage urethroplasty Pathologic Diagnosis Lichen Sclerosis
Patients 7
Chronic Inflammation/Squamous Chronic Inflammation
6
Fibrous/Fibrovascular tissue
5
Keratinized Squamous/Skin
4
Nonkeratinized squamous
5
Normal Urethra
2
Chronic Urethral Inflammation Total
1 30
Source of Funding: None
63 SINGLE-STAGE SALVAGE URETHROPLASTY AFTER PREVIOUS OPEN SURGERY. Kathy Vander Eeckt*, Steven Joniau, Leuven, Belgium INTRODUCTION AND OBJECTIVES: There is no common practice in the treatment of urethral strictures after previous open urethral reconstruction in adults. We aimed to assess the results of single-stage salvage urethroplasty after previous open surgery.
THE JOURNAL OF UROLOGY姞
CONCLUSIONS: A staged penile urethroplasty can be limited by the availability of buccal mucosa when excision of the urethra is performed. Our initial results show lateral native urethral plate survival and excellent buccal graft take after a first stage procedure in all cases. Our early results also show good patency rates in those who have completed the second stage procedure. Our study demonstrates the technical and anatomic feasibility of this two-stage penile urethroplasty utilizing ventral urethrotomy and dorsal buccal mucosa inlay, with lateralization and preservation of the urethral plate. Preserving the urethral plate will allow the reconstruction of longer strictures by decreasing the demand of an already limited supply of buccal mucosa graft. Source of Funding: None
61 END-TO-END REPAIR OR BUCCAL MUCOSA GRAFT FOR SINGLE-STAGE BULBAR URETHROPLASTY? Kathy Vander Eeckt*, Leuven, Belgium; Paolo Gontero, Turin, Italy; Steven Joniau, Leuven, Belgium INTRODUCTION AND OBJECTIVES: It is common practice to use an end-to-end (ETE) urethroplasty in short (ⱕ2cm) urethral strictures and a substitution urethroplasty in longer urethral strictures (⬎2cm). However, the restricture rates and functional outcomes of those 2 techniques have never been compared directly. We aimed to compare the restricture rates and erectile function changes after singlestage ETE versus buccal mucosa graft (BMG) repair for bulbar urethral stricture disease. METHODS: 103 patients underwent a single-stage bulbar urethroplasty at our institution between 2003 and 2009: 42 patients had an ETE and 61 a BMG repair. Different clinical parameters were collected: pre- and postoperative maximum flow rate (Qmax), previous urethral manipulations, stricture length, postoperative complications, remembered preoperative IIEF-5 score (r-IIEF-5) and prospectively collected IIEF-5 (p-IIEF-5) and IPSS scores at last follow-up. Any urethral instrumentation after surgery was considered a treatment failure. RESULTS: The mean stricture length was 1.34 cm in ETE versus 2.89 cm in BMG repair (p⬍0.001). 95 patients (92.2%) had undergone at least one previous urethral manipulation. Of the 17 patients who had undergone previous open surgery, 16 received a BMG repair. The mean pre- and postoperative Qmax of ETE versus BMG urethroplasty were 8.1 vs. 8.72 ml/s (p⫽0.6) and 20.4 vs. 19.9 ml/s (p⫽0.8) respectively. The mean follow-up was 25.3 months (SD ⫹/- 22.3) and this was identical for the two groups (p⫽0.99). Complication rate was 9.7%, with no significant difference between groups. The estimated failure-free rate of the ETE and the BMG repair were 79.9% and 90.2% respectively (p⫽0.3). IPSS at last follow-up was in favor of the ETE (5.4 vs 8.8, p⫽0.046). 44% of the patients had new onset postmicturation dribbling with no significant difference between the 2 groups. (p⫽0.18). There was a significant difference between overall r-IIEF-5 (mean 20.6 (SD ⫹/-5.7)) and p-IIEF-5 (mean 16.7 (SD ⫹/-8.4)) (p⫽0.0008). No difference in r-IIEF-5 (p⫽0.16) and p-IIEF-5 (p⫽0.72) was noted between groups. CONCLUSIONS: In bulbar urethral strictures, the failure-free rates and erectile function changes after end-to-end or BMG repair were comparable, even though stricture disease was more complex in the BMG group. These results have important implications for clinical practice, as when there is any doubt during surgery about the feasibility of performing an end-to-end urethroplasty, the threshold to take a BMG must be low. Source of Funding: None
Vol. 183, No. 4, Supplement, Saturday, May 29, 2010
62 PATHOLOGIC ANALYSIS OF BUCCAL MUCOSA GRAFT IN FIRST AND SECOND STAGE ADULT URETHROPLASTY Thomas Smith III*, Houston, TX; Bryan Voelzke, Hunter Wessells, Seattle, WA INTRODUCTION AND OBJECTIVES: Two stage urethroplasty is used for complex reconstruction of anterior urethral stricture disease due to failed prior urethroplasty or lichen sclerosis (LS). Buccal mucosa (BM) is non-keratinizing, squamous epithelium accepted as an excellent graft material for both single and two stage urethroplasty. Previously, we reported one case of recurrent LS in a series of three staged urethroplasty patients. We sought to describe the histologic changes of BM in two stage urethroplasty in an adult stricture population. METHODS: Thirty two consecutive patients at the University of Washington underwent two stage reconstruction of complex anterior urethral stricture disease from 2002-2009. First stage urethroplasty was completed in all patients using BM. Biopsy of the urethra or urethral plate was performed at time of first stage in 30 and of the harvested BM in 21. Second stage urethroplasty was completed a mean of 12.8 months later in 26, of whom 25 underwent biopsy of the BM graft. Pathologic analysis was performed in all biopsies. RESULTS: Urethral biopsies showed LS or chronic inflammation in 13, fibrosis in 5, and urothelium or epithelium in the remainder. BM analysis at harvest was normal (17), chronically inflamed (2), and minor histologic variant (2). Of the 25 second stage patients, pathologic findings on BM graft site included recurrent LS or chronic inflammation in 4 and fibrosis in 2. No patient’s first stage graft failed due to BM pathology at time of harvest. Of the 6 patients who did not proceed to second stage, 3 had recurrent LS and 1 had graft fibrosis. Second stage procedures failed in 2 patients due to pathologic changes of the grafted BM including 1 due to recurrent LS. Overall, 24 of 26 patients who proceeded to second stage repair had urethral patency. CONCLUSIONS: BM is a robust epithelium which maintains squamous epithelial histologic anatomy despite use as a free graft and change in environment from moist to dry. It appears to be resistant to the pathologic changes of LS, although 4 of 12 showed recurrence in the graft, usually detectable prior to second stage closure. Pathology of buccal mucosa graft bed at 2nd stage urethroplasty Pathologic Diagnosis Patients Normal Squamous Epithelium 15 Mild Chronic Inflammation/Normal Epithelium
4
Fibrosis
2
Chronic Inflammation
2
Lichen sclerosis Total
2 25
Pathology of urethra at 1st stage urethroplasty Pathologic Diagnosis Lichen Sclerosis
Patients 7
Chronic Inflammation/Squamous Chronic Inflammation
6
Fibrous/Fibrovascular tissue
5
Keratinized Squamous/Skin
4
Nonkeratinized squamous
5
Normal Urethra
2
Chronic Urethral Inflammation Total
1 30
Source of Funding: None
63 SINGLE-STAGE SALVAGE URETHROPLASTY AFTER PREVIOUS OPEN SURGERY. Kathy Vander Eeckt*, Steven Joniau, Leuven, Belgium INTRODUCTION AND OBJECTIVES: There is no common practice in the treatment of urethral strictures after previous open urethral reconstruction in adults. We aimed to assess the results of single-stage salvage urethroplasty after previous open surgery.