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BULBAR URETHRAL RECONSTRUCTION: DOES ULTRASOUND ADD TO PREOPERATIVE PLANNING?
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THE JOURNAL OF UROLOGY®
sexual functioning was compared using paired T-tests. Post-op ED was defined as a decrease in score of > 10%. RESULTS: Anterior urethroplasty was performed on 65 patients, 60 of which had sufficient post-op data for analysis. Repair locations were bulbar (n=34) and penile (n=31). Type of repair was EPA (n=17) and onlay repair (n=38). Median follow-up time was 6.5 months. Significant decreases were seen in all domains of sexual functioning with the exception of SD (Table 1). Significant recovery was noted in all domains by last follow-up (Table). Overall, 26 patients had initial post-op ED (43%), of which only 5 (19%) were in men with penile repairs (p = 0.07). Lasting ED was noted in 8 (13%) men (median f/u time 8.3 months; 6 bulbar, 2 penile). Median time to full recovery was 6.8 months. CONCLUSIONS: Anterior urethroplasty adversely affects all domains of sexual function. Bulbar urethroplasty may affect ED greater than penile repairs. Most men with post-op ED had full recovery by 7 months though persistent ED was seen. Longer follow-up will be needed to assess if permanent ED is present in this population.
Vol. 181, No. 4, Supplement, Saturday, April 25, 2009
urethral blood supply was compromised (ie. hypospadias), pan-urethral stricture disease was present, or there was concurrent urethral cancer. The preoperative discussion and booked procedure were reviewed along with the pertinent clinical data. RESULTS: We identified 87 patients who met the above criteria. The median age of the patients was 44 years (14-72). 37 patients underwent EPA BUR. 50 patients underwent BUR using buccal mucosal (Augmented anastomosis, or Dorsal/Ventral Onlay). The mean length of stricture was estimated to be 4.76cm (0.5-13), without the use of U/S. All patients underwent the planned procedure. In 3 cases, preoperative planning called for 2 buccal grafts, but only 1 graft was necessary. 96.5% of patients were successfully treated with a single procedure. 3 patients required 1 further DVIU, or dilation at a median followup of 38 months (10-68). CONCLUSIONS: At our center, we have excellent surgical results with BUR using RUG, VCUG, and endoscopy for preoperative evaluation. The addition of ultrasound to our diagnostic armamentarium does not seem to improve our decision making. Source of Funding: None
44 DEFINING STRICTURE RECURRENCE AFTER URETHROPLASTY: A SYSTEMATIC REVIEW Joshua J Meeks*, Bradley A Erickson, Michael A Granieri, Christopher M Gonzalez, Chicago, IL
Source of Funding: None
43 BULBAR URETHRAL RECONSTRUCTION: DOES ULTRASOUND ADD TO PREOPERATIVE PLANNING? Timothy O Davies*, Kurt A McCammon, Gerald H Jordan, Norfolk, VA INTRODUCTION AND OBJECTIVE: Decision-making and preoperative planning are of paramount importance in urethral reconstructive surgery. The decision to perform excision and primary anastomosis (EPA), or to use tissue transfer techniques in bulbar urethral reconstruction (BUR) is based primarily on the anatomy of the stricture, with length of stricture being a most important variable. Traditionally, this has been evaluated by retrograde urethrogram (RUG), voiding cystourethrogram (VCUG) and endoscopy. Some have advocated for perineal ultrasound (either preoperatively, or intraoperatively) to determining whether a tissue transfer technique was necessary, feeling that length is more accurately assessed by that modality. We review our recent experience with BUR to determine the accuracy of our preoperative assessment and the usefulness of ultrasound in evaluating these patients. METHODS: Retrospective chart review was performed from 2003-2006 for those patients who had undergone BUR at our center. Patients were excluded if: less than 14 years of age, urethral distal
INTRODUCTION AND OBJECTIVE: Urethral reconstruction has become the gold-standard for the management of urethral strictures, with high rates of long-term success. Despite advances in the development of tissue graft sources and surgical technique, the standards by which recurrence is defined after urethroplasty is widely variable. To determine the completeness and quality of published literature on success and stricture recurrence after urethroplasty, we conducted a systematic review of the urologic literature to determine how stricture recurrence is defined in order to guide further studies in urethral reconstruction. METHODS: A literature review was conducted to compile all urethroplasty manuscripts published between 2000 and 2008. Using the term “urethroplasty”, 287 manuscripts were identified and evaluated. From the initial screen, 80 manuscripts were included that were original reports of urethroplasty in adult males. RESULTS: The overall recurrence rate for all reconstructive procedures was 15.8%. This rate has not changed over time (range 8-22% between 2000 and 2008). Anterior urethral (non-bulbar) strictures were evaluated in 38% of manuscripts, posterior urethral strictures in 20% and bulbar urethral strictures in 42%. Recurrence was evaluated by a mean of three diagnostic tests (range 1 to 8 procedures). Questionnaires were utilized as a primary screen for recurrence in 40%. The most common primary diagnostic tests were uroflowmetry (54% of manuscripts) and retrograde urethrography (48%). Cystoscopy, was a diagnostic screen in 21%, yet was utilized as a secondary procedure to evaluate recurrence in 22%, for 43% overall. While most manuscripts defined recurrence as strictures identified on a diagnostic screen, 21% and 29% of manuscripts defined recurrence solely as the need for further surgical procedure or stricture requiring dilation in 21% and 29% respectively. CONCLUSIONS: Various methods are utilized to screen and diagnose recurrence after urethral stricture reconstruction. Clear descriptions of diagnostic procedures used to identify stricture recurrence will contribute to a more comprehensive evaluation of new techniques used for urethroplasty. Source of Funding: None
THE JOURNAL OF UROLOGY®
sexual functioning was compared using paired T-tests. Post-op ED was defined as a decrease in score of > 10%. RESULTS: Anterior urethroplasty was performed on 65 patients, 60 of which had sufficient post-op data for analysis. Repair locations were bulbar (n=34) and penile (n=31). Type of repair was EPA (n=17) and onlay repair (n=38). Median follow-up time was 6.5 months. Significant decreases were seen in all domains of sexual functioning with the exception of SD (Table 1). Significant recovery was noted in all domains by last follow-up (Table). Overall, 26 patients had initial post-op ED (43%), of which only 5 (19%) were in men with penile repairs (p = 0.07). Lasting ED was noted in 8 (13%) men (median f/u time 8.3 months; 6 bulbar, 2 penile). Median time to full recovery was 6.8 months. CONCLUSIONS: Anterior urethroplasty adversely affects all domains of sexual function. Bulbar urethroplasty may affect ED greater than penile repairs. Most men with post-op ED had full recovery by 7 months though persistent ED was seen. Longer follow-up will be needed to assess if permanent ED is present in this population.
Vol. 181, No. 4, Supplement, Saturday, April 25, 2009
urethral blood supply was compromised (ie. hypospadias), pan-urethral stricture disease was present, or there was concurrent urethral cancer. The preoperative discussion and booked procedure were reviewed along with the pertinent clinical data. RESULTS: We identified 87 patients who met the above criteria. The median age of the patients was 44 years (14-72). 37 patients underwent EPA BUR. 50 patients underwent BUR using buccal mucosal (Augmented anastomosis, or Dorsal/Ventral Onlay). The mean length of stricture was estimated to be 4.76cm (0.5-13), without the use of U/S. All patients underwent the planned procedure. In 3 cases, preoperative planning called for 2 buccal grafts, but only 1 graft was necessary. 96.5% of patients were successfully treated with a single procedure. 3 patients required 1 further DVIU, or dilation at a median followup of 38 months (10-68). CONCLUSIONS: At our center, we have excellent surgical results with BUR using RUG, VCUG, and endoscopy for preoperative evaluation. The addition of ultrasound to our diagnostic armamentarium does not seem to improve our decision making. Source of Funding: None
44 DEFINING STRICTURE RECURRENCE AFTER URETHROPLASTY: A SYSTEMATIC REVIEW Joshua J Meeks*, Bradley A Erickson, Michael A Granieri, Christopher M Gonzalez, Chicago, IL
Source of Funding: None
43 BULBAR URETHRAL RECONSTRUCTION: DOES ULTRASOUND ADD TO PREOPERATIVE PLANNING? Timothy O Davies*, Kurt A McCammon, Gerald H Jordan, Norfolk, VA INTRODUCTION AND OBJECTIVE: Decision-making and preoperative planning are of paramount importance in urethral reconstructive surgery. The decision to perform excision and primary anastomosis (EPA), or to use tissue transfer techniques in bulbar urethral reconstruction (BUR) is based primarily on the anatomy of the stricture, with length of stricture being a most important variable. Traditionally, this has been evaluated by retrograde urethrogram (RUG), voiding cystourethrogram (VCUG) and endoscopy. Some have advocated for perineal ultrasound (either preoperatively, or intraoperatively) to determining whether a tissue transfer technique was necessary, feeling that length is more accurately assessed by that modality. We review our recent experience with BUR to determine the accuracy of our preoperative assessment and the usefulness of ultrasound in evaluating these patients. METHODS: Retrospective chart review was performed from 2003-2006 for those patients who had undergone BUR at our center. Patients were excluded if: less than 14 years of age, urethral distal
INTRODUCTION AND OBJECTIVE: Urethral reconstruction has become the gold-standard for the management of urethral strictures, with high rates of long-term success. Despite advances in the development of tissue graft sources and surgical technique, the standards by which recurrence is defined after urethroplasty is widely variable. To determine the completeness and quality of published literature on success and stricture recurrence after urethroplasty, we conducted a systematic review of the urologic literature to determine how stricture recurrence is defined in order to guide further studies in urethral reconstruction. METHODS: A literature review was conducted to compile all urethroplasty manuscripts published between 2000 and 2008. Using the term “urethroplasty”, 287 manuscripts were identified and evaluated. From the initial screen, 80 manuscripts were included that were original reports of urethroplasty in adult males. RESULTS: The overall recurrence rate for all reconstructive procedures was 15.8%. This rate has not changed over time (range 8-22% between 2000 and 2008). Anterior urethral (non-bulbar) strictures were evaluated in 38% of manuscripts, posterior urethral strictures in 20% and bulbar urethral strictures in 42%. Recurrence was evaluated by a mean of three diagnostic tests (range 1 to 8 procedures). Questionnaires were utilized as a primary screen for recurrence in 40%. The most common primary diagnostic tests were uroflowmetry (54% of manuscripts) and retrograde urethrography (48%). Cystoscopy, was a diagnostic screen in 21%, yet was utilized as a secondary procedure to evaluate recurrence in 22%, for 43% overall. While most manuscripts defined recurrence as strictures identified on a diagnostic screen, 21% and 29% of manuscripts defined recurrence solely as the need for further surgical procedure or stricture requiring dilation in 21% and 29% respectively. CONCLUSIONS: Various methods are utilized to screen and diagnose recurrence after urethral stricture reconstruction. Clear descriptions of diagnostic procedures used to identify stricture recurrence will contribute to a more comprehensive evaluation of new techniques used for urethroplasty. Source of Funding: None