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90 CATHETERLESS SECOND STAGE URETHROPLASTY
Vol. 189, No. 4S, Supplement, Saturday, May 4, 2013
90 CATHETERLESS SECOND STAGE URETHROPLASTY Paul Bradley*, Raul Ordorica, Tampa, FL INTRODUCTION AND OBJECTIVES: A two stage approach for urethral reconstruction has been applied for complex urethral strictures such as found with Lichen Sclerosis (LS) and hypospadius with initial creation of a urethral plate using grafted oral mucosa that is subsequently tubularized to form a urethral lumen. Those methods that reduce associated morbidity and discomfort are both reasonable and preferred provided outcome is preserved. We have evaluated the completion of the second stage portion of these complex repairs without the use of an indwelling urethral catheter. METHODS: 23 patients underwent 25 first stage urethroplasty procedures utilizing oral mucosa. Mean patient age was 52 (30 to 77). Stricture length ranged from 1.5cm to 15cm (mean 6.6 cm). Etiology was LS in 15, hypospadias in 10, and epispadias in 2. First stage repair involved creation of a urethral plate using either labial (20) or lingual grafts (5). After 6 months all but one patient returned for a second stage urethroplasty. Reconstruction was completed achieving a caliber of 22 F with a 3 layer closure of mucosa, dartos, and then skin. Patients were discharged the same day voiding immediately without a catheter in place. RESULTS: Mean follow up was 29 months (6-90). Outcome was measured by complex uroflow and AUA symptoms score, with recurrence verified by cystoscopy. Stricture recurrence occurred in 5 patients (LS 3, hypospadias 1, epispadias 1) (20%), with stricture occurring proximal to the area reconstructed with oral mucosa in 2/5 patients. No fistulae were reported. CONCLUSIONS: Urethral reconstruction with creation of a single longitudinal suture line may not require an indwelling catheter to prevent cicatrix formation. Periodic voiding with low-pressure urinary flow in the absence of distal obstruction or resistance may be less inflammatory and less uncomfortable than an indwelling catheter. Second stage urethroplasty without catheter drainage is feasible with no increased risk of fistulae, urinary retention, or recurrence while improving post-operative discomfort for the patient. Source of Funding: None
91 “PSEUDOSPONGIOPLASTY” USING TUNICA DARTOS FLAPS FOR SUPPORT OF VENTRAL BUCCAL MUCOSA GRAFTS IN DISTAL URETHRA: PROMISING INITIAL RESULTS Lee C. Zhao*, J. Francis Scott, Allen F. Morey, Dallas, TX INTRODUCTION AND OBJECTIVES: For ventral buccal mucosa graft onlay during bulbar urethroplasty, spongioplasty using advancement of the corpus spongiosum is ordinarily performed to stabilize and perfuse the graft. In the pendulous and distal bulbar urethra, the spongiosum is often too scant to allow complete graft coverage. We describe the results of our “pseudospongioplasty” technique of ventral graft coverage using bilateral tunica dartos flaps and we compared these results to those of standard spongioplasty. METHODS: Retrospective review of all urethroplasties performed by a single surgeon at a tertiary care facility from July 2007 to July 2012. Single stage urethroplasty involving ventral buccal mucosa graft placement were selected for analysis. Standard spongioplasty was performed whenever possible. When spongiosal tissue was inadequate for graft coverage, usually in the pendulous and distal bulbar urethra, tunica dartos flaps were mobilized bilaterally and sutured together in the midline providing secure coverage of the buccal mucosa graft (figure). Outcomes of traditional spongioplasty were then compared to those involving pseudospongioplasty. Urethroplasty failure was defined as any subsequent operative intervention, open or endoscopic. RESULTS: Among 519 urethroplasties performed during the 5-year study period, 68 patients met inclusion criteria (13%). Pseudospongioplasty was performed predominantly in the pendulous ure-
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thra (23/35, 66%) with success in 86% (mean follow up 29 mo). Standard spongioplasty (mean follow up 32 mo) was performed in a similar number of patients (33 patients, 49%) with an identical success rate (85%). Length of stricture was comparable in the pseudospongioplasty group (mean 5.7 cm) and the traditional spongioplasty group (mean 6.2 cm, p⫽0.51). Stricture length was not significantly different between successful and failed urethroplasty (6.1 cm vs 5.1 cm, p⫽0.19). CONCLUSIONS: Ventral buccal mucosa grafts can be reliably applied to various locations throughout the anterior urethra. For distal grafts, mobilization of tunica dartos flaps appears to provide equivalent results to standard spongioplasty.
Source of Funding: None
92 A MULTI-INSTITUTIONAL COMPARISON OF MEDIUM-TERM SEVERE COMPLICATIONS IN HIGH RISK PATIENTS UNDERGOING TRANSCORPORAL VERSUS 3.5 CM CUFF SIZE ARTIFICIAL URINARY SPHINCTER PLACEMENT William Brant*, Salt Lake City, UT; Christopher Powell, Kansas City, KS; Nejd Alsikafi, Chicago, IL; Sean Elliott, Minneapolis, MN; Bradley Erickson, Iowa City, IA; Christopher McClung, Columbus, OH; Jeremy Myers, Salt Lake City, UT; Thomas Smith, Houston, TX; Bryan Voelzke, Seattle, WA; Joshua Broghammer, Kansas City, KS INTRODUCTION AND OBJECTIVES: Limited data exist regarding the 3.5cm artificial urinary sphincter (AUS). Previous publications show comparable complications to traditional cuff sizes when placed conventionally (around the urethra). Theoretical benefits of the 3.5cm cuff size include decreased utilization of more complex procedures such as tandem cuff placement and transcorporal cuff (TC) placement. We compared our multi-institutional outcomes of 3.5cm cuff AUS placement and transcorporal cuff placement at 8 academic medical centers. METHODS: A retrospective analysis was performed of 303 patients treated with AUS placement from April 2009 to February 2012 at 8 institutions with at least 3 months followup. 51 and 97 patients were found to have undergone AUS placement using the 3.5cm cuff size and transcorporal technique respectively. Three patients underwent 3.5cm cuff AUS placement in conjunction with TC technique. All patients receiving these treatments were included regardless of incontinence etiology. Charts were analyzed for pre-operative risk factors and postoperative complications requiring explantation. RESULTS: 67 of 97 (69%) patients undergoing TC AUS placement and 16/51 (31%) of patients undergoing 3.5 cm cuffs were considered high-risk. High-risk was defined as patients having undergone radiation therapy, urethroplasty, multiple treatments for bladder neck contracture or urethral stricture, urethral stent placement, or a history of erosion or infection in a previous AUS. Replacement of AUS for mechanical failure or subcuff atrophy was not considered high-risk.
90 CATHETERLESS SECOND STAGE URETHROPLASTY Paul Bradley*, Raul Ordorica, Tampa, FL INTRODUCTION AND OBJECTIVES: A two stage approach for urethral reconstruction has been applied for complex urethral strictures such as found with Lichen Sclerosis (LS) and hypospadius with initial creation of a urethral plate using grafted oral mucosa that is subsequently tubularized to form a urethral lumen. Those methods that reduce associated morbidity and discomfort are both reasonable and preferred provided outcome is preserved. We have evaluated the completion of the second stage portion of these complex repairs without the use of an indwelling urethral catheter. METHODS: 23 patients underwent 25 first stage urethroplasty procedures utilizing oral mucosa. Mean patient age was 52 (30 to 77). Stricture length ranged from 1.5cm to 15cm (mean 6.6 cm). Etiology was LS in 15, hypospadias in 10, and epispadias in 2. First stage repair involved creation of a urethral plate using either labial (20) or lingual grafts (5). After 6 months all but one patient returned for a second stage urethroplasty. Reconstruction was completed achieving a caliber of 22 F with a 3 layer closure of mucosa, dartos, and then skin. Patients were discharged the same day voiding immediately without a catheter in place. RESULTS: Mean follow up was 29 months (6-90). Outcome was measured by complex uroflow and AUA symptoms score, with recurrence verified by cystoscopy. Stricture recurrence occurred in 5 patients (LS 3, hypospadias 1, epispadias 1) (20%), with stricture occurring proximal to the area reconstructed with oral mucosa in 2/5 patients. No fistulae were reported. CONCLUSIONS: Urethral reconstruction with creation of a single longitudinal suture line may not require an indwelling catheter to prevent cicatrix formation. Periodic voiding with low-pressure urinary flow in the absence of distal obstruction or resistance may be less inflammatory and less uncomfortable than an indwelling catheter. Second stage urethroplasty without catheter drainage is feasible with no increased risk of fistulae, urinary retention, or recurrence while improving post-operative discomfort for the patient. Source of Funding: None
91 “PSEUDOSPONGIOPLASTY” USING TUNICA DARTOS FLAPS FOR SUPPORT OF VENTRAL BUCCAL MUCOSA GRAFTS IN DISTAL URETHRA: PROMISING INITIAL RESULTS Lee C. Zhao*, J. Francis Scott, Allen F. Morey, Dallas, TX INTRODUCTION AND OBJECTIVES: For ventral buccal mucosa graft onlay during bulbar urethroplasty, spongioplasty using advancement of the corpus spongiosum is ordinarily performed to stabilize and perfuse the graft. In the pendulous and distal bulbar urethra, the spongiosum is often too scant to allow complete graft coverage. We describe the results of our “pseudospongioplasty” technique of ventral graft coverage using bilateral tunica dartos flaps and we compared these results to those of standard spongioplasty. METHODS: Retrospective review of all urethroplasties performed by a single surgeon at a tertiary care facility from July 2007 to July 2012. Single stage urethroplasty involving ventral buccal mucosa graft placement were selected for analysis. Standard spongioplasty was performed whenever possible. When spongiosal tissue was inadequate for graft coverage, usually in the pendulous and distal bulbar urethra, tunica dartos flaps were mobilized bilaterally and sutured together in the midline providing secure coverage of the buccal mucosa graft (figure). Outcomes of traditional spongioplasty were then compared to those involving pseudospongioplasty. Urethroplasty failure was defined as any subsequent operative intervention, open or endoscopic. RESULTS: Among 519 urethroplasties performed during the 5-year study period, 68 patients met inclusion criteria (13%). Pseudospongioplasty was performed predominantly in the pendulous ure-
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thra (23/35, 66%) with success in 86% (mean follow up 29 mo). Standard spongioplasty (mean follow up 32 mo) was performed in a similar number of patients (33 patients, 49%) with an identical success rate (85%). Length of stricture was comparable in the pseudospongioplasty group (mean 5.7 cm) and the traditional spongioplasty group (mean 6.2 cm, p⫽0.51). Stricture length was not significantly different between successful and failed urethroplasty (6.1 cm vs 5.1 cm, p⫽0.19). CONCLUSIONS: Ventral buccal mucosa grafts can be reliably applied to various locations throughout the anterior urethra. For distal grafts, mobilization of tunica dartos flaps appears to provide equivalent results to standard spongioplasty.
Source of Funding: None
92 A MULTI-INSTITUTIONAL COMPARISON OF MEDIUM-TERM SEVERE COMPLICATIONS IN HIGH RISK PATIENTS UNDERGOING TRANSCORPORAL VERSUS 3.5 CM CUFF SIZE ARTIFICIAL URINARY SPHINCTER PLACEMENT William Brant*, Salt Lake City, UT; Christopher Powell, Kansas City, KS; Nejd Alsikafi, Chicago, IL; Sean Elliott, Minneapolis, MN; Bradley Erickson, Iowa City, IA; Christopher McClung, Columbus, OH; Jeremy Myers, Salt Lake City, UT; Thomas Smith, Houston, TX; Bryan Voelzke, Seattle, WA; Joshua Broghammer, Kansas City, KS INTRODUCTION AND OBJECTIVES: Limited data exist regarding the 3.5cm artificial urinary sphincter (AUS). Previous publications show comparable complications to traditional cuff sizes when placed conventionally (around the urethra). Theoretical benefits of the 3.5cm cuff size include decreased utilization of more complex procedures such as tandem cuff placement and transcorporal cuff (TC) placement. We compared our multi-institutional outcomes of 3.5cm cuff AUS placement and transcorporal cuff placement at 8 academic medical centers. METHODS: A retrospective analysis was performed of 303 patients treated with AUS placement from April 2009 to February 2012 at 8 institutions with at least 3 months followup. 51 and 97 patients were found to have undergone AUS placement using the 3.5cm cuff size and transcorporal technique respectively. Three patients underwent 3.5cm cuff AUS placement in conjunction with TC technique. All patients receiving these treatments were included regardless of incontinence etiology. Charts were analyzed for pre-operative risk factors and postoperative complications requiring explantation. RESULTS: 67 of 97 (69%) patients undergoing TC AUS placement and 16/51 (31%) of patients undergoing 3.5 cm cuffs were considered high-risk. High-risk was defined as patients having undergone radiation therapy, urethroplasty, multiple treatments for bladder neck contracture or urethral stricture, urethral stent placement, or a history of erosion or infection in a previous AUS. Replacement of AUS for mechanical failure or subcuff atrophy was not considered high-risk.