726 LATISSIMUS DORSI DETRUSOR MYOPLASTY IN PATIENTS WITH ACONTRACTILE BLADDER: LONG-TERM RESULTS OF A MULTICENTER STUDY

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Urostomy and quality of life in patients with disabling lower urinary tract dysfunction: A prospective study Schultz A.1, Boye B.2, Thind P.3, Jonsson O.4, Mansson W.5 Rikshospitalet, Dept. of Urology, Oslo, Norway, 2Rikshospitalet University Hospital, Dept. of Psychosomatic Diseases, Oslo, Norway, 3State University Hospital, Dept. of Urology, Copenhagen, Denmark, 4Sahlgrenska University Hospital, Dept. of Urology, Gothenburg, Sweden, 5University Hospital, Dept. of Urology, Lund, Sweden 1

Introduction & Objectives: Urinary diversion might be an option in patients with disabling lower urinary tract dysfunction, refractory to conservative treatment. However, it involves major surgery. The aim of this study was to evaluate whether urostomy improves quality of life in these patients and the cost of surgery in terms of complications and hospital stay. Material & Methods: 52 consecutive patients, 9 men and 43 women, were included in the study; 12 with multiple sclerosis, 11 with spinal cord injury, 8 with interstitial cystitis, 6 with detrusor overactivity, 3 with myelomeningocele, and 12 with other disorders. 26 patients received an ileal conduit and 26 a continent cutaneous diversion. The patients completed the generic quality of life instrument WHOQOL-BREF (comprising 26 items measuring the following domains: physical health, psychological health, social relationships, and environment) and a bladder/urostomy specific quality of life instrument ( comprising 13 items measuring physical, psychological, and future perspective domains) preoperatively, and 6, and 12 months after surgery. In addition, hospital stay and complications were registered. Intravenous urography and determination of GFR were performed preoperatively and 12 months postoperatively. Results: One patient died of unrelated cause 12 months after surgery. The patients improved in all domains but social relationship on the generic quality of life instrument (p<0.05) and in all domains on the disease specific quality of life instrument (p<0.0005) from baseline to 12 months follow-up. For the question on future perspective, improvement from 5.2 to 1.4 (1 indicating “satisfaction” and 7 indicating “worst possible”) was seen. The improvement was reported during the first 6 months, with no further improvement thereafter. There were no significant differences in degree of improvement between patients with different diagnosis, but men improved more than women on the general psychological dimension on quality of life (p=0.013). There was no difference in improvements between patients with conduits and those with continent reservoirs. Mean hospital stay was 14 days. Early and late complications required open surgery in 12 patients (23%). Out of 41 patients who had GFR determination both preoperatively and a year after surgery, 3 had reduction in GFR of >25%. Conclusions: Urostomy improves both general and disease specific quality of life in patients with disabling lower urinary tract dysfunction. However, the risk of complications is not negligible.



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Outcome of different management options for fulllength anterior urethral strictures Andrich D.E., Mundy A.R. Institute of Urology, Dept. of Urology, London, United Kingdom Introduction & Objectives: Full length anterior strictures are a challenging problem. To compare the outcome of 3 different surgical management options for full-length anterior urethral strictures. Material & Methods: Over the last 5 years 61 men with full-length anterior strictures of various aetiologies were managed with 3 different surgical approaches taking into account aetiology, number of previous urethral reconstruction, age and co-morbidities of the patient with a minimum follow-up of 1 year. Group 1: 30/61 men, 28-79y, median 66, underwent perineal urethrostomy. The underlying aetiology was 11 BXO; 8 failed multi-stage urethroplasty; 6 Iatrogenic; 3 Idiopathic; 1 penile trauma. Group 2: 20/61 men, 24-72y, median 43, underwent staged peno-bulbar urethroplasty, whereby the penile and bulbar urethra were marsupialised at the 1st stage and closed in 3 layers at the 2nd stage. A buccal mucosal graft (BMG) was placed when the glans cleft required reconstruction in BXO or Hypospadias. The aetiology was 6 BXO, 8 failed multi-stage urethroplasty; 4 Iatrogenic; 1 Idiopathic; 1 Infective. Group 3: More recently, 11/61 men, 26-60y, median 44, underwent a hybrid staged/one stage graft procedure, whereby the bulbar urethra was augmented in one stage with a long BMG graft but the penile urethra was marsupialised in the 1st stage and a BMG placed distally as required. The second stage involved closing the penile urethra in 3 layers. The aetiology was 5 BXO, 1 failed multi-stage urethroplasty; 4 Iatrogenic; 1 Idiopathic. Results: 7% (2/30) of Group 1 failed; one patient was revised, the other managed with suprapubic diversion. There were 2 (7%) adverse events (1 orchitis and 1 profuse bleeding from the spongiosum settling with pressure drainage). 30%(6/20) of Group 2 failed (3 in multistage urethroplasty and 2 in BXO patients). 4 of them were managed with urethral dilatation and 1 underwent revision urethroplasty. 1 hypospadias salvage patient has an asymptomatic radiological stricture affecting the interscrotal segment. There were 5 (25%) adverse events (2 urethrocutaneous fistulae, 1 partial BMG contracture, 1 urethral diverticulum and 1 self-limiting foot drop 2nd lithotomy position). 18% (2/11) of Group 3 failed (both in BXO, one of which required dilatation and the other radiological recurrence is still asymptomatic at 1 year followup). There was 1 wound infection (9%). Conclusions: Surgical reconstruction of full-length urethral stricture disease, irrespective of surgical technique, carries a high failure rate. In this series, BXO patients developed their recurrence in the marsupialised segment and multi-stage salvage urethroplasty patients developed their recurrence at the peno-scrotal junction. Perineal urethrostomy is a more reliable management of full-length urethral strictures and not surprisingly more often used in elderly patients.

Eur Urol Suppl 2009;8(4):302



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Latissimus Dorsi Detrusor Myoplasty in patients with acontractile bladder: Long-term results of a multicenter study Gakis G.1, Van Koeveringe G.2, Raina S.3, Lorenz S.4, Rahnama’i M.S.2, Sievert K.D.1, Ninkovic M.4, Stenzl A.1 1 Eberhard-Karls University, Dept. of Urology, Tübingen, Germany, 2Maastricht University Medical Centre, Dept. of Urology, Maastricht, The Netherlands, 3Jaslok Hospital & Research Centre, Dept. of Urology, Mumbai, India, 4Hospital Munich-Bogenhausen, Dept. of Plastic Surgery, Munich, Germany

Introduction & Objectives: Latissimus Dorsi Detrusor Myoplasty (LDDM) has been proven to be a viable option for the treatment of patients with an acontractile bladder due to traumatic, idiopathic or congenital lower motor neuropathy (Lancet, 1998, 16; 351(9114):1483-5 and J Urol, 2003, 169(4): 1370-83). We report the clinical long-term results of our multicenter study. Material & Methods: From 05/2001 until 02/2008, a total of 21 patients (mean age: 38 years; range: 14-63; 12 males, 9 females) in four clinical centers were enrolled. Preoperative evaluation of the patients included urethrocystoscopy, intravenous pyelography and electromyography of the rectus abdominis muscle. Preoperative urodynamic assessment showed acontractile bladder in all patients requiring complete clean intermittent catheterization (CIC) 4-8 times per day. Postoperative follow-up ranged from 8-89 months (mean: 45 months) and was carried out by questionnaire and measurement of post-voided residual urine volume. Results: 13 of 21 patients gained complete control of spontaneous micturition and do not require CIC anymore with postvoided residual urine volumes from 0-100ml. In 3 patients, the frequency of CIC was reduced from 5-6 times per day preoperatively to 2-3 times per day postoperatively with postvoided residual urine volumes from 150-250ml. In one female patient with spontaneous micturition three months postoperatively, CIC is currently required 5 times per day due to recurrent urinary tract infections and persistent urethral pain. At present, 4 patients need CIC 4-6 times per day as preoperatively. Two of them do not suffer from recurrent urinary tract infections anymore. No functional restrictions or chronic pain of the upper extremity were observed in any patient. Conclusions: This multicenter study confirms that LDDM is an effective treatment option in patients with acontractile bladder and can restore bladder function completely.



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Comparative retrospective outcome analysis of 375 patients who underwent one-stage repair of bulbar urethral strictures in a single referral center experience Barbagli G.1, Romano G.2, De Angelis M.2, Lazzeri M.3 Center for Reconstructive Urethral Surgery, Dept. of Urology, Arezzo, Italy, 2San Donato Hospital, Dept. of Urology, Arezzo, Italy, 3Center Santa Chiara GIOMI Group, Dept. of Urology, Florence, Italy 1

Introduction & Objectives: To compare the outcome of one-stage bulbar urethral reconstruction using various surgical techniques. Material & Methods: Three hundred seventy-five patients, with an average age of 39 years (range 14 to 80 years), underwent bulbar urethral reconstruction using one-stage techniques. One hundred sixty-five patients (44%) underwent end-to-end anastomosis, 40 patients (10.7%) underwent augmented anastomotic repair using penile skin (9 cases) or oral mucosa (31 cases) as substitute graft material, and 170 patients (45.3%) underwent onlay graft procedures using penile skin (38 cases) or oral mucosa (132 cases) as substitute graft material. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilation. Uroflowmetry and urine culture were repeated every 4 months in the first year and annually thereafter. When symptoms of decreased force of stream were present and the uroflowmetry was less than 14 ml/ sec., urethrography, urethral ultrasound and urethroscopy were repeated. Results: The average follow-up was 53 months (range 12 to 218 months). The stricture etiology was unknown in 245 (65.3%) cases, catheter in 52 (13.9%), trauma in 38 (10.1%), instrumentation in 29 (7.8%), infection in 7 (1.9%), radiotherapy in 2 (0.5%), congenital in 2 (0.5%). Stricture length was: 1<2cm in 104 (27.7%) cases, 2-<3 cm in 74 (19.7%), 3-<4 cm in 65 (17.3%), 4-<5 cm in 87 (23.2%), 5-<6 cm in 35 (9.4%), >6 cm in 10 (2.7%). Two hundred-sixty patients (69.3%) underwent dilation (3.2%), internal urethrotomy (36%), urethroplasty (2.4%) or multiple treatments (27.7%) before referral to our center. Out of 375 cases, 313 (83.5%) were successful and 62 (16.5%) failures. Out of 165 cases that underwent end-to-end anastomosis, 150 (90.9%) were successful and 15 (9.1%) failures. Out of 40 cases that underwent augmented anastomotic repair, 24 (60%) were successful and 16 (40%) failures. Out of 170 cases that underwent onlay graft procedures, 139 (81.8%) were successful and 31 (18.2%) failures. The end-to-end anastomosis showed significant higher success rate compared to the onlay graft procedures and augmented anastomotic repair. Out of 47 penile skin grafts, 28 (59.6%) were successful and 19 (40.4%) failures. Out of 163 oral mucosal grafts, 135 (82.8%) were successful and 28 (17.2%) failures. Conclusions: In our center, one-stage bulbar urethroplasties showed an overall 83.5% success rate. The end-to-end anastomosis showed the higher success rate (90.9%) compared to the onlay graft procedures (81.8%) or augmented anastomotic repair (60%). The difference in the outcome between the use of oral mucosal (82.8% success rate) or penile skin grafts (59.6% success rate) is significant.