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MP9-11 BULBAR URETHRAL ISCHEMIC NECROSIS
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Saturday, May 17, 2014
RESULTS: 76 TC cuffs were placed in 74 patients with mean age 74.3 years. Median cuff size was 4.5 cm. The cause of incontinence was secondary to prostate cancer (PC) treatment (96%), TURP (1.4%), pelvic tumor (1.4%) and pelvic trauma (1.4%). Prior pelvic radiation occurred in 34 (44.7%) patients. Previous surgery for stress urinary incontinence (SUI) occurred in 80.3% with either AUS (71.1%) or sling (9.2%). The mean number of prior SUI surgeries was 1.29 (04) and 36.8% had undergone 2 or more surgeries for SUI. There had been prior urethral violation with either erosion of prior device (32/74) or urethral injury (5/74) in 37 (48.7%) of cases. Twenty patients (26.3%) had undergone prior urethral reconstruction for refractory strictures. Overall complication rate at a mean follow up of 19.9 months (1.3-119) was 26.3%. The explantation rate was 14.5% at a mean of 14.2 (0.75-71) months. Revision was necessary in 9.2%. Overall and subgroup complication and continence rates are per Table 1. CONCLUSIONS: For men with sphincteric incontinence who have been radiated and/or had previous device erosion or urethral reconstruction, restoration of continence with TC AUS cuff placement is a useful salvage procedure. The complication rate is acceptable and reflects the complexity of this difficult patient population.
Incontinent Explant
Erosion
Infection
(%)
Incontinent or
N
(%)
(%)
(%)
(%)
(>1ppd)
explanted (%)
All TC cuffs
76
20 (26.3)
11 (14.5)
5 (6.6)
5 (6.6)
7/63 (11.1)
15/71 (21.2)
Previous urethral
38
11 (28.9)
7 (18.4)
2 (5.2)
4 (10.5)
2/30 (6.6)
8/36 (22.2)
20
8 (40)
6 (30)
3 (15)
2 (10)
0/14 (0)
6/20 (30)
violation Previous urethral
median pre-operative maximum flow of 4.5 mL/sec to a median postoperative maximum flow of 10.5 mL/sec. The median post-void residual was 163 mL prior to reconstruction and 25mL at follow-up. Two patients undergoing VFU underwent dilation at an average of 27 months following reconstruction for recurrent stricture with an average follow-up of 41 months. No patients undergoing dorsal BMG had a recurrent stricture or experienced urinary incontinence at an average follow-up of 24 months. CONCLUSIONS: Female urethral reconstruction, either VFU or dorsal BMG, is a safe procedure with high success and significant improvements in quality of life. Outcomes of dorsal BMG are promising, demonstrating improved clinical and physiological parameters with maintenance of urinary continence. Women should be offered urethral reconstruction as a definitive management option rather than repeated urethral dilations. Source of Funding: none
MP9-11 BULBAR URETHRAL ISCHEMIC NECROSIS
TABLE 1 Complication
e125
reconstruction
Source of Funding: none
MP9-10 ASSESSMENT OF FEMALE URETHRAL STRICTURE RECONSTRUCTION: BUCCAL MUCOSA GRAFT AND VAGINAL FLAP Casey Kowalik*, Burlington, MA; John Stoffel, Ann Arbor, MI; Leonard Zinman, Alex Vanni, Burlington, MA; Jill C. Buckley, San Diego, CA INTRODUCTION AND OBJECTIVES: The management of female urethral strictures is challenging given the variable presenting symptoms and extremely low incidence. Our objective was to evaluate the safety, operative technique and outcomes of women following urethral reconstruction with either a vaginal flap urethroplasty (VFU) or dorsal buccal mucosa graft (BMG). METHODS: We retrospectively identified 10 women undergoing urethral reconstruction between February 2007 and October 2012. All patients had active urinary symptoms and/or urodynamic study indicating bladder outlet obstruction, confirmed by cystoscopy. Recurrent stricture was defined by a urethral diameter less than 17fr. Followup included urethral calibration (>16fr), symptom assessment, voiding cystourethrogram, and cystoscopy when there was difficulty voiding or symptoms recurred. RESULTS: Mean age was 49 years (range 32-74). For urethral reconstruction, 6 patients had a VFU and 4 had a dorsal BMG. Location was mid in 6 and distal in 4 women. The indication for urethral reconstruction was urethral stricture in 9 patients. One woman had a traumatic 2 cm ventral urethral laceration associated with a pelvic fracture. Average stricture length was 1.25 cm (range 0.2-2). All patients with urethral stricture had previously undergone multiple urethral dilations. There were no major post-operative complications. Patients with available data (BMG patients) demonstrated improvement with a
Pankaj Joshi*, Shilo Rosenberg, Anna Lawrence, Faisal Alhajeri, Sandesh Surana, Sanjay Kulkarni, Pune, India INTRODUCTION AND OBJECTIVES: Management of repeatedly failed end-to-end anastomosis for posterior urethra distraction injuries, with resultant large bulbar urethral defects, is not well defined in literature. Multiple surgeries may lead to ischemic necrosis of bulbar urethra. Once bulbar urethra is transected, its vascularity is dependent on retrograde blood supply from glans which is suboptimal in vasculogenic impotence. Overzealous pubectomy may damage dorsal penile arteries adjacent to deep dorsal vein adding to ischemia. We present our retrospective data of bulbar urethral iscahemic necrosis (BUIN). METHODS: Between 1995-2012, 46 patients were referred with BUIN. On average all had >2 prior attempts at urethroplasty. RUGMCU diagnosed large defects. We performed substitution Urethroplasty (SU). It was dependant on length of neourethra to be created, presence of urethral plate, prepuce and status of scrotum. P1(long defects) were patients who underwent SU and P2 patients with narrow plate (ischemia),underwent vascularized augmentation. In P1 25 had pedicled preputial tube,4 oral mucosa flap (OMF*)and 3 had scrotal drop back (SD) procedure. 2 patients had dorsal BMG and ventral pedicled penile skin flap. In P2 requiring augmentation, 8 patients had pedicled penile flap as ventral onlay, and 4 had OMF.* In OMF, BMG is applied over dartos of scrotum through a wide elliptical incision in first stage. Once there is good graft uptake, it is mobilized on midline scrotal septum as a flap, transposed to perineum and applied as a onlay or is tubularised. Follow up ranges from 5 to 120 mths. RESULTS: 16/25 patients of preputial tube had diverticulum formation.They complained of post micturition dribble.4 had proximal anastomotic narrowing.1 had incontinence due to bladder neck incompetence. 1 developed fistula. 4/8 patients of oral mucosa flap were cured.2 patients of SD had narrowing. CONCLUSIONS: In long defects,BMG cannot be used if the patient needs inferior pubectomy to approach posterior urethra.Majority of preputial tube patients do well. Diverticulum formation, urinary leakage and anastomotic narrowing are common problems requiring attention. OMF is our new technique where vascularised buccal graft flap can be used for substitution. SD had unsatisfactory outcome. We need to protect dorsal penile arteries during inferior pubectomy.
THE JOURNAL OF UROLOGYâ
e126
Vol. 191, No. 4S, Supplement, Saturday, May 17, 2014
while of 30 patients having superior prostatic displacement 6 (20%) had ED. The mean length of urethral gap of patients with normal EF was 1.8 cm (range 1 e 2.5), while that of impotent patients was 3.9 cm (range 2.5 e 6). CONCLUSIONS: The prognosis to the parents of a child who sustains a PFUI must remain guarded until the patient attains a postpubertal status. About half of the patients exhibit ED at puberty. The risk of ED is increased in the presence of a long urethral gap, bilateral pubic rami fracture, Malgaigne’s fracture, pubic diastasis, and lateral prostatic displacement. Source of Funding: none
MP9-13 NEW INSIGHT INTO POST-ROBOTIC PROSTATECTOMY BLADDER NECK CONTRACTURE: THE ROLE OF EXTRUDED HEMOLOCK CLIPS Alla Hamada*, Sanjay Razdan, Miami, FL
Source of Funding: none
MP9-12 PREDICTING RISK OF ERECTILE DYSFUNCTION FOLLOWING PELVIC FRACTURE URETHRAL INJURY DURING CHILHOOD Mamdouh Koraitim*, Alexandria, Egypt INTRODUCTION AND OBJECTIVES: It has been reported that erectile dysfunction (ED) is a common complication after pelvic fracture urethral injury (PFUI). However, almost all studies have been concerned with adult patients at the time of injury. We thought to study the incidence of postpubertal ED following PFUI during childhood, as well as to identify the related risk factors. METHODS: All patients who had undergone repair of a PFUI from 1980 to 2010, and aged <15 years at the time of injury and aged >18 years at the time of assessment, were identified from our database. Patients were invited by mail to participate in the study. Responding patients were asked to answer a brief questionnaire consisting of 6 questions that were designed to assess erectile experience within the past 4 weeks. This questionnaire is the erectile function (EF) domain of the International Index of Erectile Function (IIEF). Based on the total score of 30 of the EF domain, the score was calculated for every patient. Medical records and imaging studies were reviewed with a focus on 4 variables: pattern of pelvic fracture, presence of pubic diastasis, displacement of the prostate, and length of urethral gap. RESULTS: Overall, 51 patients participated in the study. The mean age of patients at the time of pelvic trauma was 10 years (range 3 to <15). Of the patients, 24 (47%) exhibited ED at puberty with the majority (21 patients, 88%) reporting severe ED (score 6 -10). Single ramus fracture was found in 18 patients and ipsilateral ischiopubic rami fracture in 21, of whom 3 (17%) and 9 (43%) exhibited ED, respectively. Bilateral 2 or more rami fracture and ipsilateral rami fracture associated with disruption of sacroiliac joint (Malgaigne’s fracture) was found in 6 patients each, all 12 (100%) exhibited ED. Of 12 patients with pubic diastasis 9 (75%) developed ED, and of 39 patients with intact symphysis pubis 15 (38%) developed ED. Of 21 patients having prostatic displacement in superior and lateral directions 18 (86%) exhibited ED,
INTRODUCTION AND OBJECTIVES: Post radical prostatectomy bladder neck contracture (BNC) is moderate to severe scarring process involving urethrovesical (U-V) anastomosis resulting in bladder outlet obstruction. Its incidence has been notably reduced with use of robotic assisted laparoscopic prostatectomy (RALP). Weck clips have been used to ligate lateral vascular pedicles and aid in dissection of neurovascular bundles. OBJECTIVE: To examine BNC developed after RALP in terms of prevalence, clinical presentation pattern, cystoscopic findings, possible associated risk factors and response to treatment. METHODS: After obtaining IRB approval, the retrospective data of 1718 men with prostate cancer who underwent RALP by a high volume surgeon in the period between May, 2004 and June, 2012 were prospectively analyzed to investigate prevalence and risk factors of BNC. The recorded data included clinical, laboratory perioperative, cystoscopic findings (presence of stricture, extruded Weck Hemolock clips and associated bladder stone), number of contemplated laser bladder neck incision (BNI) procedures and rate of recurrence. In all patients, urethrovesical (U-V) anastomosis was performed using VanVelthoven technique, utilizing running double-armed 3-0 Monocryl suture. RESULTS: Prevalence of post-RALP BNC after a median follow-up period of 24 months, was 43/1718 (2.5%). BNC developed after a mean and median period of 9.9 and 6 months, respectively. Within patients with BNC, two categories were identified based on cystoscopic findings: a) 23 patients (53%) had pure U-V anastomotic stricture related BNC (SRBNC) and b) 20 patients (46.5%) had stricture-Weck clip related BNC (SCRBNC), in which single or multiple Hemolock Weck clips were extruded into the U-V anastomotic region resulting into anastomotic stricture. By comparing both groups, no differences were seen in the analyzed parameters. After undergoing laser BNI and removal of extruded clips, recurrence rates of BNC was higher in the SCRBNC (60%) than in SRBNC group (26%) (p¼0.025). Patients with SCRBNC required at least 2.2 procedure per patient vs. 1.3 laser BNI procedure in the SRBNC group (P¼0.015). CONCLUSIONS: Extruded Hemolock Weck clips into vesicourethral anastomosis in patients who underwent RALP, constitute significant predisposing factor for nearly half of cases of bladder neck contracture and is responsible for its recurrence. Use of biodegradable clips are encouraged to minimize BNC.
Vol. 191, No. 4S, Supplement, Saturday, May 17, 2014
RESULTS: 76 TC cuffs were placed in 74 patients with mean age 74.3 years. Median cuff size was 4.5 cm. The cause of incontinence was secondary to prostate cancer (PC) treatment (96%), TURP (1.4%), pelvic tumor (1.4%) and pelvic trauma (1.4%). Prior pelvic radiation occurred in 34 (44.7%) patients. Previous surgery for stress urinary incontinence (SUI) occurred in 80.3% with either AUS (71.1%) or sling (9.2%). The mean number of prior SUI surgeries was 1.29 (04) and 36.8% had undergone 2 or more surgeries for SUI. There had been prior urethral violation with either erosion of prior device (32/74) or urethral injury (5/74) in 37 (48.7%) of cases. Twenty patients (26.3%) had undergone prior urethral reconstruction for refractory strictures. Overall complication rate at a mean follow up of 19.9 months (1.3-119) was 26.3%. The explantation rate was 14.5% at a mean of 14.2 (0.75-71) months. Revision was necessary in 9.2%. Overall and subgroup complication and continence rates are per Table 1. CONCLUSIONS: For men with sphincteric incontinence who have been radiated and/or had previous device erosion or urethral reconstruction, restoration of continence with TC AUS cuff placement is a useful salvage procedure. The complication rate is acceptable and reflects the complexity of this difficult patient population.
Incontinent Explant
Erosion
Infection
(%)
Incontinent or
N
(%)
(%)
(%)
(%)
(>1ppd)
explanted (%)
All TC cuffs
76
20 (26.3)
11 (14.5)
5 (6.6)
5 (6.6)
7/63 (11.1)
15/71 (21.2)
Previous urethral
38
11 (28.9)
7 (18.4)
2 (5.2)
4 (10.5)
2/30 (6.6)
8/36 (22.2)
20
8 (40)
6 (30)
3 (15)
2 (10)
0/14 (0)
6/20 (30)
violation Previous urethral
median pre-operative maximum flow of 4.5 mL/sec to a median postoperative maximum flow of 10.5 mL/sec. The median post-void residual was 163 mL prior to reconstruction and 25mL at follow-up. Two patients undergoing VFU underwent dilation at an average of 27 months following reconstruction for recurrent stricture with an average follow-up of 41 months. No patients undergoing dorsal BMG had a recurrent stricture or experienced urinary incontinence at an average follow-up of 24 months. CONCLUSIONS: Female urethral reconstruction, either VFU or dorsal BMG, is a safe procedure with high success and significant improvements in quality of life. Outcomes of dorsal BMG are promising, demonstrating improved clinical and physiological parameters with maintenance of urinary continence. Women should be offered urethral reconstruction as a definitive management option rather than repeated urethral dilations. Source of Funding: none
MP9-11 BULBAR URETHRAL ISCHEMIC NECROSIS
TABLE 1 Complication
e125
reconstruction
Source of Funding: none
MP9-10 ASSESSMENT OF FEMALE URETHRAL STRICTURE RECONSTRUCTION: BUCCAL MUCOSA GRAFT AND VAGINAL FLAP Casey Kowalik*, Burlington, MA; John Stoffel, Ann Arbor, MI; Leonard Zinman, Alex Vanni, Burlington, MA; Jill C. Buckley, San Diego, CA INTRODUCTION AND OBJECTIVES: The management of female urethral strictures is challenging given the variable presenting symptoms and extremely low incidence. Our objective was to evaluate the safety, operative technique and outcomes of women following urethral reconstruction with either a vaginal flap urethroplasty (VFU) or dorsal buccal mucosa graft (BMG). METHODS: We retrospectively identified 10 women undergoing urethral reconstruction between February 2007 and October 2012. All patients had active urinary symptoms and/or urodynamic study indicating bladder outlet obstruction, confirmed by cystoscopy. Recurrent stricture was defined by a urethral diameter less than 17fr. Followup included urethral calibration (>16fr), symptom assessment, voiding cystourethrogram, and cystoscopy when there was difficulty voiding or symptoms recurred. RESULTS: Mean age was 49 years (range 32-74). For urethral reconstruction, 6 patients had a VFU and 4 had a dorsal BMG. Location was mid in 6 and distal in 4 women. The indication for urethral reconstruction was urethral stricture in 9 patients. One woman had a traumatic 2 cm ventral urethral laceration associated with a pelvic fracture. Average stricture length was 1.25 cm (range 0.2-2). All patients with urethral stricture had previously undergone multiple urethral dilations. There were no major post-operative complications. Patients with available data (BMG patients) demonstrated improvement with a
Pankaj Joshi*, Shilo Rosenberg, Anna Lawrence, Faisal Alhajeri, Sandesh Surana, Sanjay Kulkarni, Pune, India INTRODUCTION AND OBJECTIVES: Management of repeatedly failed end-to-end anastomosis for posterior urethra distraction injuries, with resultant large bulbar urethral defects, is not well defined in literature. Multiple surgeries may lead to ischemic necrosis of bulbar urethra. Once bulbar urethra is transected, its vascularity is dependent on retrograde blood supply from glans which is suboptimal in vasculogenic impotence. Overzealous pubectomy may damage dorsal penile arteries adjacent to deep dorsal vein adding to ischemia. We present our retrospective data of bulbar urethral iscahemic necrosis (BUIN). METHODS: Between 1995-2012, 46 patients were referred with BUIN. On average all had >2 prior attempts at urethroplasty. RUGMCU diagnosed large defects. We performed substitution Urethroplasty (SU). It was dependant on length of neourethra to be created, presence of urethral plate, prepuce and status of scrotum. P1(long defects) were patients who underwent SU and P2 patients with narrow plate (ischemia),underwent vascularized augmentation. In P1 25 had pedicled preputial tube,4 oral mucosa flap (OMF*)and 3 had scrotal drop back (SD) procedure. 2 patients had dorsal BMG and ventral pedicled penile skin flap. In P2 requiring augmentation, 8 patients had pedicled penile flap as ventral onlay, and 4 had OMF.* In OMF, BMG is applied over dartos of scrotum through a wide elliptical incision in first stage. Once there is good graft uptake, it is mobilized on midline scrotal septum as a flap, transposed to perineum and applied as a onlay or is tubularised. Follow up ranges from 5 to 120 mths. RESULTS: 16/25 patients of preputial tube had diverticulum formation.They complained of post micturition dribble.4 had proximal anastomotic narrowing.1 had incontinence due to bladder neck incompetence. 1 developed fistula. 4/8 patients of oral mucosa flap were cured.2 patients of SD had narrowing. CONCLUSIONS: In long defects,BMG cannot be used if the patient needs inferior pubectomy to approach posterior urethra.Majority of preputial tube patients do well. Diverticulum formation, urinary leakage and anastomotic narrowing are common problems requiring attention. OMF is our new technique where vascularised buccal graft flap can be used for substitution. SD had unsatisfactory outcome. We need to protect dorsal penile arteries during inferior pubectomy.
THE JOURNAL OF UROLOGYâ
e126
Vol. 191, No. 4S, Supplement, Saturday, May 17, 2014
while of 30 patients having superior prostatic displacement 6 (20%) had ED. The mean length of urethral gap of patients with normal EF was 1.8 cm (range 1 e 2.5), while that of impotent patients was 3.9 cm (range 2.5 e 6). CONCLUSIONS: The prognosis to the parents of a child who sustains a PFUI must remain guarded until the patient attains a postpubertal status. About half of the patients exhibit ED at puberty. The risk of ED is increased in the presence of a long urethral gap, bilateral pubic rami fracture, Malgaigne’s fracture, pubic diastasis, and lateral prostatic displacement. Source of Funding: none
MP9-13 NEW INSIGHT INTO POST-ROBOTIC PROSTATECTOMY BLADDER NECK CONTRACTURE: THE ROLE OF EXTRUDED HEMOLOCK CLIPS Alla Hamada*, Sanjay Razdan, Miami, FL
Source of Funding: none
MP9-12 PREDICTING RISK OF ERECTILE DYSFUNCTION FOLLOWING PELVIC FRACTURE URETHRAL INJURY DURING CHILHOOD Mamdouh Koraitim*, Alexandria, Egypt INTRODUCTION AND OBJECTIVES: It has been reported that erectile dysfunction (ED) is a common complication after pelvic fracture urethral injury (PFUI). However, almost all studies have been concerned with adult patients at the time of injury. We thought to study the incidence of postpubertal ED following PFUI during childhood, as well as to identify the related risk factors. METHODS: All patients who had undergone repair of a PFUI from 1980 to 2010, and aged <15 years at the time of injury and aged >18 years at the time of assessment, were identified from our database. Patients were invited by mail to participate in the study. Responding patients were asked to answer a brief questionnaire consisting of 6 questions that were designed to assess erectile experience within the past 4 weeks. This questionnaire is the erectile function (EF) domain of the International Index of Erectile Function (IIEF). Based on the total score of 30 of the EF domain, the score was calculated for every patient. Medical records and imaging studies were reviewed with a focus on 4 variables: pattern of pelvic fracture, presence of pubic diastasis, displacement of the prostate, and length of urethral gap. RESULTS: Overall, 51 patients participated in the study. The mean age of patients at the time of pelvic trauma was 10 years (range 3 to <15). Of the patients, 24 (47%) exhibited ED at puberty with the majority (21 patients, 88%) reporting severe ED (score 6 -10). Single ramus fracture was found in 18 patients and ipsilateral ischiopubic rami fracture in 21, of whom 3 (17%) and 9 (43%) exhibited ED, respectively. Bilateral 2 or more rami fracture and ipsilateral rami fracture associated with disruption of sacroiliac joint (Malgaigne’s fracture) was found in 6 patients each, all 12 (100%) exhibited ED. Of 12 patients with pubic diastasis 9 (75%) developed ED, and of 39 patients with intact symphysis pubis 15 (38%) developed ED. Of 21 patients having prostatic displacement in superior and lateral directions 18 (86%) exhibited ED,
INTRODUCTION AND OBJECTIVES: Post radical prostatectomy bladder neck contracture (BNC) is moderate to severe scarring process involving urethrovesical (U-V) anastomosis resulting in bladder outlet obstruction. Its incidence has been notably reduced with use of robotic assisted laparoscopic prostatectomy (RALP). Weck clips have been used to ligate lateral vascular pedicles and aid in dissection of neurovascular bundles. OBJECTIVE: To examine BNC developed after RALP in terms of prevalence, clinical presentation pattern, cystoscopic findings, possible associated risk factors and response to treatment. METHODS: After obtaining IRB approval, the retrospective data of 1718 men with prostate cancer who underwent RALP by a high volume surgeon in the period between May, 2004 and June, 2012 were prospectively analyzed to investigate prevalence and risk factors of BNC. The recorded data included clinical, laboratory perioperative, cystoscopic findings (presence of stricture, extruded Weck Hemolock clips and associated bladder stone), number of contemplated laser bladder neck incision (BNI) procedures and rate of recurrence. In all patients, urethrovesical (U-V) anastomosis was performed using VanVelthoven technique, utilizing running double-armed 3-0 Monocryl suture. RESULTS: Prevalence of post-RALP BNC after a median follow-up period of 24 months, was 43/1718 (2.5%). BNC developed after a mean and median period of 9.9 and 6 months, respectively. Within patients with BNC, two categories were identified based on cystoscopic findings: a) 23 patients (53%) had pure U-V anastomotic stricture related BNC (SRBNC) and b) 20 patients (46.5%) had stricture-Weck clip related BNC (SCRBNC), in which single or multiple Hemolock Weck clips were extruded into the U-V anastomotic region resulting into anastomotic stricture. By comparing both groups, no differences were seen in the analyzed parameters. After undergoing laser BNI and removal of extruded clips, recurrence rates of BNC was higher in the SCRBNC (60%) than in SRBNC group (26%) (p¼0.025). Patients with SCRBNC required at least 2.2 procedure per patient vs. 1.3 laser BNI procedure in the SRBNC group (P¼0.015). CONCLUSIONS: Extruded Hemolock Weck clips into vesicourethral anastomosis in patients who underwent RALP, constitute significant predisposing factor for nearly half of cases of bladder neck contracture and is responsible for its recurrence. Use of biodegradable clips are encouraged to minimize BNC.