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SECOND STAGE URETHROPLASTY AUGMENTED BY ORAL MUCOSA: AN ALTERNATIVE TO REVISION OF THE FIRST STAGE
Vol. 179, No. 4, Supplement, Saturday, May 17, 2008
32 TRANSPERINEAL ANASTOMOTIC URETHROPLASTY: EXPERIENCE IN PEDIATRIC & ADOLESCENT POPULATION VERSUS ADULT POPULATION Mohamed G ElSheikh, Ali M Ziada, Samih Z Sadek*, Ismail Shoukry. Cairo, Egypt. INTRODUCTION AND OBJECTIVE: Pediatric urethral VWULFWXUH GLVHDVH UHSUHVHQWV D VLJQL¿FDQW VXUJLFDO FKDOOHQJH EHFDXVH RIWKHVPDOOHUSHOYLFFRQ¿QHVGHFUHDVHGFDOLEHUDQGLQFUHDVHGWLVVXH fragility. We compared outcome of urethral reconstruction in the pediatric population as opposed to adults. METHODS: Between February 2002 and September 2005, 32 consecutive patients presenting with posterior urethral distraction defects, all caused by motor vehicle accidents, were included in our study. 16 pediatric patients with age range 5 and 17 years (mean 12.5) and 16 adult patients with age range 21 and 65 years (mean 40.2). We used the progressive perineal anastomotic repair in 29 patients. Two patients (an adult and a child) had extensive strictures of the bulbar and posterior urethra and were managed by substitutional urethroplasty. Scrotal inlay procedure was done in one adult patient also with extensive stricture of the bulbar and posterior urethra. RESULTS: Mean follow up was 16 months in the pediatric versus 28.5 months in the adult population. Results in both cohorts were found to be comparable. The primary and ultimate success rates were 81% and 87.5% in the pediatric population versus 69% and 100% in adults respectively. Other than re-stricture, one child had a bladder stone treated by cystolithotomy 6 months after surgery. No curvature, penile shortening or urethral diverticulae were noted during follow up. CONCLUSIONS: Comparable success could be achieved in pediatric and adult population with posterior urethral injuries. Open urethral reconstruction of adolescent and pediatric strictures provides excellent long-term results. Source of Funding: None
33 FOURNIER’S GANGRENE – CONTEMPORARY POPULATIONBASED INCIDENCE AND OUTCOMES ANALYSIS: A HCUP DATABASE STUDY Mathew D Sorensen*, Joshua A Broghammer, Frederick P Rivara, Matthew B Klein, Christopher D Mack, Hunter Wessells. Seattle, WA. INTRODUCTION AND OBJECTIVE: Fournier’s gangrene LVDUDUHDQGSRWHQWLDOO\IDWDOQHFURWL]LQJLQIHFWLRQRIWKHSHULQHXPDQG external genitalia. It is a true surgical emergency with a reported mortality rate of up to 67% in previous studies which have consisted almost exclusively of small, single institution case series. As a result, little data exist on incidence, patient characteristics or contemporary management of this complex disease. We sought to conduct a large population-based cohort study to examine the national incidence, treatment and outcomes of Fournier’s gangrene. METHODS: The State Inpatient Databases (SID) is one of WKHGDWDEDVHVFRPSULVLQJWKHQDWLRQDO+HDOWKFDUH&RVWDQG8WLOL]DWLRQ Project and includes data from 100% of admissions and discharges from participating states, representing the largest collection of longitudinal hospital care data in the United States. All patients in the SID for 2001 and 2004 with an ICD9 diagnosis code for Fournier’s gangrene (608.83) ZHUH LQFOXGHG :H UHSRUW SDWLHQW DQG KRVSLWDOL]DWLRQ GHPRJUDSKLFV including incidence, mortality rate, comorbidity frequency, insurance status, number of surgical debridements, average length of stay, discharge disposition, and complication rate. 5(68/76 $ WRWDO RI VXEMHFWV ZHUH LGHQWL¿HG ZLWK Fournier’s gangrene, representing 8.4 per 100,000 admissions with a national incidence of 1.1 cases per 100,000 persons. The case fatality rate was 5.6%. Subjects were exclusively male with a mean age of 52.2 years (SD 19.5 years). They were most commonly White and 31% had GLDEHWHV,QFRPSDULVRQWRSDWLHQWVKRVSLWDOL]HGIRUDQ\RWKHUUHDVRQ SDWLHQWVZLWK)RXUQLHU¶VZHUHVLJQL¿FDQWO\PRUHOLNHO\WRKDYHGLDEHWHV (RR 2.29), be obese (RR 2.48), and consume alcohol (RR 1.87), but were less likely to be illicit drug users (RR 0.63) (all p<0.0001). Subjects underwent a mean of 2.11 debridements per admission (SD 1.75). Mean WRWDOKRVSLWDOFKDUJHVZHUH 6' 7KHPHDQOHQJWK of stay was 11.1 days (SD 13.8 days) and while 50% of patients were
THE JOURNAL OF UROLOGY®
13
discharged home, 25% required home health care or were discharged to a short term rehabilitation facility. CONCLUSIONS: The true population based fatality rate Fournier’s gangrene is 5.6%, far less than reported in single institution studies. Nevertheless, morbidity of the disease is high. Most patients required multiple debridements while length of stay and hospital charges varied considerably. Only a minority of subjects in this study had diabetes and many required ongoing care after their discharge. Source of Funding: HIPRC: funded by R49/CE000197, CDC.
34 SECOND STAGE URETHROPLASTY AUGMENTED BY ORAL MUCOSA: AN ALTERNATIVE TO REVISION OF THE FIRST STAGE Armine K Smith*, Kenneth W Angermeier. Cleveland, OH. ,1752'8&7,21$1' 2%-(&7,9( )ROORZLQJ ¿UVW VWDJH urethroplasty, it is not uncommon for a patient to require one or more surgical revisions prior to second stage closure. As an alternative, we have proceeded directly to second stage urethroplasty in a group of patients with suboptimal urethral plates using additional oral mucosa to augment the repair. We reviewed our experience with this surgical DSSURDFKLQRUGHUWRDVVHVVLWVHI¿FDF\LQWKLVVHWWLQJ METHODS: Eight patients with urethral strictures underwent ¿UVW VWDJH EXFFDO PXFRVD XUHWKURSODVW\ RU VWDQGDUG ¿UVW VWDJH urethroplasty (2). At the time of planning for the second stage procedure, the appearance of the urethral plate prompted consideration of additional tissue grafting to obtain an adequate urethral diameter. All patients underwent augmentation with either buccal or lingual mucosa at the WLPHRIWKHVHFRQGVWDJHWXEXODUL]DWLRQRIWKHXUHWKUD3DWLHQWVZHUH evaluated postoperatively for voiding symptoms, urethral patency and complications. Follow up included a voiding cystourethrogram at 3 weeks IROORZLQJVXUJHU\ZLWKVXEVHTXHQWXURÀRZPHWU\DQGF\VWRVFRS\DW and 12 month intervals and as needed thereafter. RESULTS: Patient age ranged from 17 to 77 years at the time of surgery. Stricture etiology included complications of previous hypospadias repair (4), unknown (3) and unoperated hypospadias (1). Seven patients had undergone multiple episodes of prior instrumentation, including direct vision internal urethrotomy and urethral dilations. The median follow up was 13.5 months (range from 2 to 28 months). All of the patients on follow-up were noted to have widely patent urethra and excellent force of stream. Complications occurred in 2 patients with a history of hypospadias. Glans separation in 1 was managed with PRELOL]DWLRQDQGGLUHFWFORVXUHRIWKHYHQWUDOJODQV,QWKHRWKHUSDWLHQW separation of his repair to the level of the corona was corrected with MAGPI type of meatal advancement. There were no other complications or reoperations. CONCLUSIONS: Augmentation of urethral plate with either lingual or buccal mucosa graft during second stage urethroplasty is a simple option, which may provide excellent cosmetic and functional results. This approach allowed 6 out of 8 patients to avoid an additional surgical procedure to complete their complex urethral reconstruction, with only a single minor corrective procedure required in the other 2. Source of Funding: None
35 LONG-TERM PATIENT SATISFACTION AND URODYNAMIC RESULTS AFTER DORSAL ONLAY URETHROPLASTY FOR RECURRENT BULBAR STRICTURES Germar M Pinggera*, Orietta Dalpiaz, Andrea Kerschbaumer, Michael Mitterberger, Jasmin Bektic, Hannes Strasser, Georg Bartsch. Innsbruck, Austria. INTRODUCTION AND OBJECTIVE: Successful outcomes in the reconstructive surgery for urethral stricture remain a challenging issue. The dorsal graft urethroplasty described by Barbagli in 1995 represents the technique of choice for repair of long stricture which may combined with various substitute materials. This procedure carries numerous advantages,such as reduction of graft shrinkage and sacculation. The aim of the present study was to evaluate the outcome of dorsal onlay skin graft urethroplasty for urethral strictures by urodynamic investigations and questionnaire on patient satisfaction.
32 TRANSPERINEAL ANASTOMOTIC URETHROPLASTY: EXPERIENCE IN PEDIATRIC & ADOLESCENT POPULATION VERSUS ADULT POPULATION Mohamed G ElSheikh, Ali M Ziada, Samih Z Sadek*, Ismail Shoukry. Cairo, Egypt. INTRODUCTION AND OBJECTIVE: Pediatric urethral VWULFWXUH GLVHDVH UHSUHVHQWV D VLJQL¿FDQW VXUJLFDO FKDOOHQJH EHFDXVH RIWKHVPDOOHUSHOYLFFRQ¿QHVGHFUHDVHGFDOLEHUDQGLQFUHDVHGWLVVXH fragility. We compared outcome of urethral reconstruction in the pediatric population as opposed to adults. METHODS: Between February 2002 and September 2005, 32 consecutive patients presenting with posterior urethral distraction defects, all caused by motor vehicle accidents, were included in our study. 16 pediatric patients with age range 5 and 17 years (mean 12.5) and 16 adult patients with age range 21 and 65 years (mean 40.2). We used the progressive perineal anastomotic repair in 29 patients. Two patients (an adult and a child) had extensive strictures of the bulbar and posterior urethra and were managed by substitutional urethroplasty. Scrotal inlay procedure was done in one adult patient also with extensive stricture of the bulbar and posterior urethra. RESULTS: Mean follow up was 16 months in the pediatric versus 28.5 months in the adult population. Results in both cohorts were found to be comparable. The primary and ultimate success rates were 81% and 87.5% in the pediatric population versus 69% and 100% in adults respectively. Other than re-stricture, one child had a bladder stone treated by cystolithotomy 6 months after surgery. No curvature, penile shortening or urethral diverticulae were noted during follow up. CONCLUSIONS: Comparable success could be achieved in pediatric and adult population with posterior urethral injuries. Open urethral reconstruction of adolescent and pediatric strictures provides excellent long-term results. Source of Funding: None
33 FOURNIER’S GANGRENE – CONTEMPORARY POPULATIONBASED INCIDENCE AND OUTCOMES ANALYSIS: A HCUP DATABASE STUDY Mathew D Sorensen*, Joshua A Broghammer, Frederick P Rivara, Matthew B Klein, Christopher D Mack, Hunter Wessells. Seattle, WA. INTRODUCTION AND OBJECTIVE: Fournier’s gangrene LVDUDUHDQGSRWHQWLDOO\IDWDOQHFURWL]LQJLQIHFWLRQRIWKHSHULQHXPDQG external genitalia. It is a true surgical emergency with a reported mortality rate of up to 67% in previous studies which have consisted almost exclusively of small, single institution case series. As a result, little data exist on incidence, patient characteristics or contemporary management of this complex disease. We sought to conduct a large population-based cohort study to examine the national incidence, treatment and outcomes of Fournier’s gangrene. METHODS: The State Inpatient Databases (SID) is one of WKHGDWDEDVHVFRPSULVLQJWKHQDWLRQDO+HDOWKFDUH&RVWDQG8WLOL]DWLRQ Project and includes data from 100% of admissions and discharges from participating states, representing the largest collection of longitudinal hospital care data in the United States. All patients in the SID for 2001 and 2004 with an ICD9 diagnosis code for Fournier’s gangrene (608.83) ZHUH LQFOXGHG :H UHSRUW SDWLHQW DQG KRVSLWDOL]DWLRQ GHPRJUDSKLFV including incidence, mortality rate, comorbidity frequency, insurance status, number of surgical debridements, average length of stay, discharge disposition, and complication rate. 5(68/76 $ WRWDO RI VXEMHFWV ZHUH LGHQWL¿HG ZLWK Fournier’s gangrene, representing 8.4 per 100,000 admissions with a national incidence of 1.1 cases per 100,000 persons. The case fatality rate was 5.6%. Subjects were exclusively male with a mean age of 52.2 years (SD 19.5 years). They were most commonly White and 31% had GLDEHWHV,QFRPSDULVRQWRSDWLHQWVKRVSLWDOL]HGIRUDQ\RWKHUUHDVRQ SDWLHQWVZLWK)RXUQLHU¶VZHUHVLJQL¿FDQWO\PRUHOLNHO\WRKDYHGLDEHWHV (RR 2.29), be obese (RR 2.48), and consume alcohol (RR 1.87), but were less likely to be illicit drug users (RR 0.63) (all p<0.0001). Subjects underwent a mean of 2.11 debridements per admission (SD 1.75). Mean WRWDOKRVSLWDOFKDUJHVZHUH 6' 7KHPHDQOHQJWK of stay was 11.1 days (SD 13.8 days) and while 50% of patients were
THE JOURNAL OF UROLOGY®
13
discharged home, 25% required home health care or were discharged to a short term rehabilitation facility. CONCLUSIONS: The true population based fatality rate Fournier’s gangrene is 5.6%, far less than reported in single institution studies. Nevertheless, morbidity of the disease is high. Most patients required multiple debridements while length of stay and hospital charges varied considerably. Only a minority of subjects in this study had diabetes and many required ongoing care after their discharge. Source of Funding: HIPRC: funded by R49/CE000197, CDC.
34 SECOND STAGE URETHROPLASTY AUGMENTED BY ORAL MUCOSA: AN ALTERNATIVE TO REVISION OF THE FIRST STAGE Armine K Smith*, Kenneth W Angermeier. Cleveland, OH. ,1752'8&7,21$1' 2%-(&7,9( )ROORZLQJ ¿UVW VWDJH urethroplasty, it is not uncommon for a patient to require one or more surgical revisions prior to second stage closure. As an alternative, we have proceeded directly to second stage urethroplasty in a group of patients with suboptimal urethral plates using additional oral mucosa to augment the repair. We reviewed our experience with this surgical DSSURDFKLQRUGHUWRDVVHVVLWVHI¿FDF\LQWKLVVHWWLQJ METHODS: Eight patients with urethral strictures underwent ¿UVW VWDJH EXFFDO PXFRVD XUHWKURSODVW\ RU VWDQGDUG ¿UVW VWDJH urethroplasty (2). At the time of planning for the second stage procedure, the appearance of the urethral plate prompted consideration of additional tissue grafting to obtain an adequate urethral diameter. All patients underwent augmentation with either buccal or lingual mucosa at the WLPHRIWKHVHFRQGVWDJHWXEXODUL]DWLRQRIWKHXUHWKUD3DWLHQWVZHUH evaluated postoperatively for voiding symptoms, urethral patency and complications. Follow up included a voiding cystourethrogram at 3 weeks IROORZLQJVXUJHU\ZLWKVXEVHTXHQWXURÀRZPHWU\DQGF\VWRVFRS\DW and 12 month intervals and as needed thereafter. RESULTS: Patient age ranged from 17 to 77 years at the time of surgery. Stricture etiology included complications of previous hypospadias repair (4), unknown (3) and unoperated hypospadias (1). Seven patients had undergone multiple episodes of prior instrumentation, including direct vision internal urethrotomy and urethral dilations. The median follow up was 13.5 months (range from 2 to 28 months). All of the patients on follow-up were noted to have widely patent urethra and excellent force of stream. Complications occurred in 2 patients with a history of hypospadias. Glans separation in 1 was managed with PRELOL]DWLRQDQGGLUHFWFORVXUHRIWKHYHQWUDOJODQV,QWKHRWKHUSDWLHQW separation of his repair to the level of the corona was corrected with MAGPI type of meatal advancement. There were no other complications or reoperations. CONCLUSIONS: Augmentation of urethral plate with either lingual or buccal mucosa graft during second stage urethroplasty is a simple option, which may provide excellent cosmetic and functional results. This approach allowed 6 out of 8 patients to avoid an additional surgical procedure to complete their complex urethral reconstruction, with only a single minor corrective procedure required in the other 2. Source of Funding: None
35 LONG-TERM PATIENT SATISFACTION AND URODYNAMIC RESULTS AFTER DORSAL ONLAY URETHROPLASTY FOR RECURRENT BULBAR STRICTURES Germar M Pinggera*, Orietta Dalpiaz, Andrea Kerschbaumer, Michael Mitterberger, Jasmin Bektic, Hannes Strasser, Georg Bartsch. Innsbruck, Austria. INTRODUCTION AND OBJECTIVE: Successful outcomes in the reconstructive surgery for urethral stricture remain a challenging issue. The dorsal graft urethroplasty described by Barbagli in 1995 represents the technique of choice for repair of long stricture which may combined with various substitute materials. This procedure carries numerous advantages,such as reduction of graft shrinkage and sacculation. The aim of the present study was to evaluate the outcome of dorsal onlay skin graft urethroplasty for urethral strictures by urodynamic investigations and questionnaire on patient satisfaction.