OPEN REANASTOMOSIS FOR RECURRENT BLADDER NECK STENOSIS

Vol. 179, No. 4, Supplement, Monday, May 19, 2008

VWULFWGH¿QLWLRQRIVXFFHVV6HUXPWHVWRVHURQHOHYHOVZHUHDYDLODEOHLQ 27 of 59 patients. Twenty one of 27 (77.8%) were found to have a serum WHVWRVWHURQHQJGO7RWDOSWVWHVWRPHDQ PHGLDQ SWVZLWK WHVWRPHDQ PHGLDQSWVWHVWR!PHDQ PHGLD = 410. Systemic TRT has begun in 9 pts, 12 pts have not started TRT because they have either not returned for follow up or have declined to participate in our study. CONCLUSIONS: In BXO, low serum testoserone appears WRSOD\DVLJQL¿FDQWUROHLQWKHSURJUHVVLYHDQGUHFXUUHQWQDWXUHRIWKH disease process. Our early results have shown dramatic improvement in these men after the institution of aggressive TRT. Even the most DGYDQFHG FDVHV RI %;2 KDYH KDG QHDU QRUPDOL]DWLRQ RI WKH JODQV meatus, and prepuce with both topical and systemic replacemment of testosterone. Two-stage urethral reconstruction is preferred and also allows direct application of testosterone cream to the diseased urethra. Source of Funding: None

741 RECONSTRUCTION OF COMPLEX POSTERIOR URETHRAL AND BLADDER NECK STENOSIS AFTER PROSTATE CANCER TREATMENT Bryan B Voelzke*, Sean P Elliott, Jack W McAninch. San Francisco, CA, and Minneapolis, MN. INTRODUCTION AND OBJECTIVE: Symptomatic posterior urethral strictures (PUS) or bladder neck stenosis (BNS) after prostate surgery and/or radiation can be problematic. We reviewed our experience with management of recalcitrant PUS and BNS secondary to prostatic cancer (CaP) intervention. METHODS: We reviewed all referrals to a single surgeon (JWM) from 1991-2007 for complex PUS and BNS refractory to multiple attempts at repair. Failed reconstructions prior to referral included urethral dilation, internal urethrotomy, Urolume stent, anastomotic urethroplasty, DQGDQWHULRUEODGGHUÀDS6XFFHVVZDVGH¿QHGE\UHVROXWLRQRI386RU %16DIWHURXU¿UVWVXUJLFDOLQWHUYHQWLRQLQFOXGLQJQRVXEVHTXHQWXUHWKUDO dilations. Intervention for incontinence was not deemed a failure. Post YRLGUHVLGXDOXURÀRZPHWU\XUHWKURF\VWRJUDSK\F\VWRVFRS\DQGFOLQLFDO history were used to determine success. RESULTS: 46 patients with complex PUS and BNS were evaluated with an average follow-up of 2.6 years. CaP intervention included radical retropubic prostatectomy, cryotherapy, external radiation, brachytherapy, and combination brachytherapy/external radiation therapy. Interventions for PUS and BNS as well as subsequent DUWL¿FLDOXULQDU\VSKLQFWHU$86 LQVHUWLRQDUHGHWDLOHGEHORZ Anastomotic Urethroplasty Urolume Stent Fasciocutaneous Flap Small Bowel Interposition 1st Stage Urethroplasty TOTAL

NUMBER 26 17 1 1 1 46

SUCCESS (%) 23 (88.5) 15 (88.2) 0 (0) 0 (0) 1 (100) 39 (84.8)

SUBSEQUENT AUS 12 6 0 1 0 19

Overall success was 84.8% with subsequent AUS needed in 19/46. Six of the anastomotic urethroplasties for PUS and BNS were DVVRFLDWHG ZLWK UHFWRXUHWKUDO ¿VWXOD$OO ZHUH UHSDLUHG VXFFHVVIXOO\ Partial or total pubectomy was required for anastomotic success in eight patients. Failure of PUS and BNS intervention was not due to CaP recurrence in any of the seven failures. CONCLUSIONS: There is no absolute management option IRUFRPSOH[386DQG%16DIWHU&D3LQWHUYHQWLRQKRZHYHUDLPLQJIRU GH¿QLWLYHORZHUXULQDU\WUDFWUHKDELOLWDWLRQVKRXOGEHWKHXOWLPDWHJRDO Acceptance of new or worsened stress incontinence while surgically correcting PUS and BNS should not be regarded as failure, as additional incontinence surgery is a common requirement to achieve ¿QDOVXFFHVV Source of Funding: None

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259

742 MANAGEMENT OF THE DEVASTATED OUTLET FOLLOWING THERAPY FOR PROSTATE CANCER USING A UROLUME STENT AND AN ARTIFICIAL URINARY SPHINCTER: LONG-TERM FOLLOW-UP Jack R Walter*, Neil H Grafstein, Kristy M Borawski, George D Webster. Durham, NC. INTRODUCTION AND OBJECTIVE: Management of recalcitrant bladder neck/prostatic obstruction and urinary incontinence following therapy for prostate cancer is a reconstructive dilemma. We SUHVHQW RXU ORQJ WHUP IROORZ XS RI WKH PDQDJHPHQW RI WKLV GLI¿FXOW SUREOHPXVLQJD8UROXPHVWHQWDQGLQPRVWFDVHVDVXEVHTXHQWDUWL¿FLDO urinary sphincter (AUS) implantation for continence. METHODS: This is a retrospective study of all men who underwent placement of Urolume stents for recalcitrant obstruction following management of prostate cancer between January 1, 2000 and October 1, 2007. Etiology, reoperative rates, and delayed complicationswere recorded. Patients unable to void per urethra and or having total incontinence with no other local surgical options were considered failures. RESULTS: Forty consecutive men with intractable recurrent obstruction were implanted with a Urolume stent. Average age at implant was 67.1 years (range 33-87). Patient characteristics are:

Surgery Radiation +/Surgery

Etiology Surgery Radiation +/Surgery

16

46.8

25

Average post Subsequent op AUS implant pad per 24hours 15 of 16 0.6

24

33.0

66

21 of 24

Average Subjects followup (months)

Etiology

Average delay to intervention (months)

0.7

Men requiring second stents

Stent ingrowth requiring endoscopic clearance (subjects/surgeries)

Urolume stents requiring clearance of calculi.

AUS AUS mechanical erosions failure

2

5/8

0

1

0/15

1

7/9

2

1

2/24

In the radiation naive group, no man has failed. In those with UDGLDWLRQRIKDYHIDLOHGZLWKXUHWKURFXWDQHRXV¿VWXODPDQDJHG with urethral catheter, 1 with recurrent clot retention from radiation cystitis managed with suprapubic tube, 1 incontinent with eroded aus x 2, and 1 with recalcitrant contracture and eroded aus (p=0.21). &21&/86,2167KHUHLVQRSHUIHFWVROXWLRQIRUWKLVGLI¿FXOW situation however the staged use of a urethral stent and an AUS delivers a functional result for most men requiring an acceptable rate of need for later endoscopic clearance of tissue ingrowth or calculus encrustation of the stent. There is no statistical difference in overall failure for radiated versus non-radiated men. Timing and techniques of implants will be discussed. Continued observation will be required to assess long term stability of this complex, reconstructive patient population. Source of Funding: None

743 OPEN REANASTOMOSIS FOR RECURRENT BLADDER NECK STENOSIS Maike B Beuke*, Daniel Pfalzgraf, Margit Fisch. Hamburg, Germany. INTRODUCTION AND OBJECTIVE: The incidence of bladder neck stricture after radical prostatectomy ranges from 0.5 to 21%. Treatment options described are dilatations, cold knife incisions, stent placement and transurethral resections. The initial management at our hospital is transurethral resection up to three times (except for severely scarred strictures). If stenosis has recurred thereafter or massive scar is present, an open reanatomosis is performed. METHODS: From 1998 to 2007 a total of 158 patients presented with the diagnosis of recurrent bladder neck stenosis. In 118 patients the stenosis was located at the site of anastomosis after radical prostatectomy. In 26 out of these an open reanastomosis via a retropubic approach was performed. Mean patient age was 66 (55-77) years. Patients had a mean of 4 (0-10) previous interventions for treatment of stenosis. Follow-up is 53 (8 - 102) months.

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RESULTS: A restricture occurred in 8 patients (31%) after open reconstruction requiring further interventions (one endoscopic intervention in 5 patients, up to 5 interventions in the remaining 3). After the additional procedures anastomosis remained open in 7, one patient required a continent vesicostomy (Overall success rate 96%). Before surgery 14 patients were continent, 9 were known to be incontinent and information was lacking in 3. Out of the 14 continent patients 10 remained continent after open reanastomosis thus leaving a total of 16 LQFRQWLQHQW SDWLHQWV$Q DUWL¿FLDO VSKLQFWHU ZDV LPSODQWHG LQ   DUH waiting for implantation and 3 refused any therapy. One patinet has an urinal condom. Urinary diversion had to be performed in 1. The patient with failed stricture management who was also incontinent received a continent vesicostomy. CONCLUSIONS: Open reanastomosis is a valuable treatment option in patients with recurrent stricture of the anastomosis after radical prostatectomy. Initial success rate is 69%, overall success rate 96%. The risk to become incontinent by the procedure is 42%. With implantation RIDQDUWL¿FLDOVSKLQFWHUDWVHFRQGVWDJHFRQWLQHQFHZDVDFKLHYHGLQ 73% of our patients. Source of Funding: None

744 TRANSPUBIC URETHROPLASTY FOR COMPLEX POSTERIOR URETHRAL STRICTURES: A SINGLE CENTER EXPERIENCE Narmada P Gupta*. New Delhi, India. INTRODUCTION AND OBJECTIVE: Complex post traumatic posterior urethral strictures account for 5% of the urethral injuries. 9DULRXUIDFWRUVFRQWULEXWHWRWKHFRPSOH[LW\DQGGLI¿FXOW\LQGHDOLQJZLWK some of these cases. The factors include stricture length more than 3 FPDVVRFLDWHGSHULQHDORUUHFWRXUHWKUDO¿VWXODVSHULXUHWKUDOFDYLWLHV osteomyelitis, false passages, incompetent bladder neck or previously failed repair. At present progressive perineal approach is prefered in most cases of posterior urethral strictures however complex posterior urethral strictures can not be managed through this approach and transpbuic urethroplasty is preferred. We review our experience of 19 cases of transpubic urethroplasty performed for complex posterior urethral strictures. METHODS: A total of 19 patients with mean age 17.8 years (6-35 years) with complex posterior urethral strictures were treated by end to end urethroplasty through transpubic approach in last 6 years. All KDGDVVRFLDWHGSHOYLFIUDFWXUHGXHWRURDGWUDI¿FDFFLGHQWDQGGXH to fall from height). Mean stricture length was 4.4 cm (3.0 - 6.0 cm). All had obliterative stricture and had history of some intervention earlier. 3 SDWLHQWVKDGUHFWRXUHWKUDO¿VWXODWZRKDGVLQXVWUDFWLQSHULQHXPZKLFK ZDVFRPPXQLFDWLQJZLWKSHULXUHWKUDOFDYLW\2QHSDWLHQWKDGORQJ¿VWORXV tract communicating through anus to anterior abdominal wall. One patient HDFKKDGXUHWKRFXWDQHRXV¿VWXODSHULXUHWKUDOFDYLW\DQGRVWHRP\OLWLV of pubic bone. 10 had associated erectile dysfunction. RESULTS: 16 patients out of 19 (84.2%) had excellent outcome with no evidence of stricture. 3 had acceptable outcome with some evidence of stricture. One patient had failure. Mean operative time was 3.2 hours (2.5-4.0) and average blood loss was 650 ml (500-900). Mean hospital stay was 7.6 days (6-12) and average follow up was 30 months (7-60). Two patients developed mild wound infection. One HDFKGHYHORSHGHSLGLG\PRUFKLWLVSHULQHDOKHPDWRPDIHFDO¿VWXODDQG urine leak. One patient failed to void after catheter removal. One patient developed erectile dysfunction following urethroplasty. CONCLUSIONS: Transpubic approach is an excellent approach to perform end to end anastomotic urethroplasty for patients having complex posterior urethral strictures with good result Source of Funding: None

745 RE-DO POSTERIOR URETHROPLASTY: STEPS TO ACHIEVE A SUCCESS Samir S Orabi*. Alexandria, Egypt. INTRODUCTION AND OBJECTIVE: End-to end bulboprostatic anastomosis is considered as a gold standard treatment for pelvic fracture urethral distraction defect (PFUDD) with a success rate of 98%. In 2-3% of cases, a revision is mandatory due to failure of primary

Vol. 179, No. 4, Supplement, Monday, May 19, 2008

anastomosis. Objective: Evaluation of different steps of management of recurrent failed posterior urethroplasty that suggested to increase the success rate. METHODS: Between 1996 and 2007, Fifty one patients with failed posterior urethroplasty were referred to our institute. Cases treated by substitution urethroplasty were excluded. All patients had a patent supra-pubic tube. For all cases, urine analysis and culture sensitivity, SODLQ;UD\SHOYLVFRPELQHGF\VWRXUHWKURJUDPZLWKVWUDLQLQJ¿OPDQG ante-grade endoscopy were done. Urethral catheter was inserted from WKHVWDUWWRLGHQWLI\WKHXUHWKUDDURXQGGHQVH¿EURVLV0LGOLQHSHULQHDO LQFLVLRQZDVXVXDOO\VXI¿FLHQWZLWKVKDUSGLVVHFWLRQWKDWGRQHEH\RQGWKH DUHDRI¿EURVLVRUWLOOWKHDQWHULRUVXUIDFHRIWKHSURVWDWHZLWKFRPSOHWH H[FLVLRQRIDOO¿EURXVWLVVXHV5HURXWLQJRIWKHXUHWKUDZDVQRWGRQHLQ any case. Intra-operative antegrade endoscopy was performed to be sure from absence of bladder stones and to exclude anastomosis to a false passage. End-to end anastomosis was done in 25 out of 51 cases (49 %), inferior pubectomy in 20 out 51 cases (39.2 %), and transpubic approach in 6 cases (11.8 %). Urethral catheter was left for 3 weeks & DSHULFDWKHWHUUHWURJUDGHXUHWKURJUDPZDVGRQHWRFRQ¿UPWKHKHDOLQJ at the anastomotic site. The supra-pubic tube was left for another 7 days to be sure from good urinary stream. If there is any doubt, immediate endoscopy was done to evaluate the site of anastomosis. RESULTS: Redo posterior urethroplasty was done as second surgery in 31 cases, as a third surgery in 12 cases and a fourth surgery in the remaining 8 cases. The success rate of redo urethroplasty was ranged from 100% in cases of trans-pubic as well as inferior pubectomy approach to 97 % in cases of end-to end anastomosis. Endoscope visual urethrotomy was done for 3 cases while immediate resection of excess granulation tissues at the site of anastomosis was performed for 2 cases. Two children suffered from stress urinary incontinence and one adult had a perineal abscess and were managed by conservative treatment. CONCLUSIONS: Redo posterior urethroplasty is a mandatory procedure after failure of primary surgery. It must be done by an expertise urologist and many steps must be followed to increase the success rate. Source of Funding: None

746 A NEW INDEX FOR ELASTIC LENGTHENING OF ANTERIOR URETHRA IN REPAIR OF POSTTRAUMATIC POSTERIOR URETHRAL DEFECTS Mamdouh M Koraitim*. Alexandria, Egypt. INTRODUCTION AND OBJECTIVE: Anastomotic repair of posttraumatic posterior urethral defects depends largely on the elastic OHQJWKHQLQJSURYLGHGE\WKHPRELOL]HGDQWHULRUXUHWKUD7KLVXVXDOO\LV VXI¿FLHQWWRDFKLHYHDWHQVLRQIUHHDQDVWRPRVLVDIWHUEULGJLQJWKHEXOER prostatic gap via a simple perineal approach. Otherwise, an elaborated perineal or a transpubic procedure has to be resorted to. We attempted WRGHWHUPLQHWKHLQÀXHQFHRIWKHOHQJWKRIXUHWKUDOGHIHFWDQGRIEXOEDU urethra on the surgical repair approach of these cases. METHODS: We reviewed the medical records and radiographic studies of 120 patients, 6 to 52 years old, who had undergone anastomotic repair of bulbo-prostatic urethral defects complicating pelvic fracture urethral disruption. Repair was accomplished by a “simple” perineal operation in 84 patients (Group 1) and by either an elaborated perineal or a transpubic procedure in 36 (Group 2). The length of urethral defect and of bulbar urethra were measured on the preoperative urethrogram. Also, the length of urethral defect as a portion of the bulbar urethral length (index of elastic lengthening) was calculated. RESULTS: The mean length of urethral defect was 1.5 cm in Group 1 versus 4.2 cm in Group 2 (p < 0.001). The mean length of bulbar urethra was 7.3 cm in Group 1 versus 6.6 cm in Group 2 (p >0.05). The mean index of elastic lengthening was 0.21 (range 0.06 to 0.34) in Group 1 versus 0.64 (range 0.38 to 0.88) in Group 2 (p <0.001). The difference in the mean length of urethral defect between children and DGXOWVLQERWKJURXSVZDVQRWVWDWLVWLFDOO\VLJQL¿FDQWFPYVFP p > 0.05) while the difference in the mean length of bulbar urethra was KLJKO\VLJQL¿FDQWFPYVFPS  CONCLUSIONS: The surgical approach for posterior urethroplasty is largely determined by a concomitant measurement of the length of both urethral defect and bulbar urethra as represented