Trauma, and Genital and Urethral Reconstruction

Urological Survey TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION The Penile Suspensory Ligament: Abnormalities and Repair C. Y. Li, V. Agrawal, S. Minhas and D. J. Ralph, St. Peter’s Hospital and Institute of Urology, London, United Kingdom BJU Int 2007; 99: 117–120. Objective: To assess men presenting with abnormalities of the penile suspensory ligament (PSL) and its correction. Patients and Methods: In all, 35 men presenting with abnormalities of the PSL that were subsequently repaired were included in this series. The causes included; sexual trauma (15 men), congenital absence of the PSL/congenital penile curvature (14), and two each with venogenic erectile dysfunction, Peyronie’s disease and penile dysmorphic disorder. The diagnosis was made clinically by the presence of a palpable gap between the symphysis pubis and the penis, together with medical history and examination of penile torsion or instability. The surgical repair used nonabsorbable sutures placed between the symphysis pubis and the tunica albuginea of the penis. Results: A ‘good’ surgical outcome was defined as correction of the penile deformity or instability and achieving normal sexual function. There was a good surgical outcome in 91% of men as defined, and 86% of the men were happy with the outcome. There were no significant complications, but three men needed a repeat PSL repair. Conclusion: Men with abnormalities of the PSL can present with a variety of clinical symptoms, but when correctly diagnosed the repair is a simple technique with a successful cosmetic and functional outcome. Editorial Comment: The PSL acts to maintain the base of the penis in front of the pubis, thus, providing a major point of support during sexual intercourse. This is a fascinating series of cases from London in which PSL repair was performed for a variety of complex rotational and lateral penile deformities, roughly half of which were due to trauma. Surgical technique involves placement of a large nonabsorbable suture (eg No. 1 nylon) from the midline tunica albuginea to the symphysis pubis via a transverse suprapubic incision, with optimal penile position ascertained by artificial erection. Results in 35 men were promising, with 86% satisfied with the outcome. I am not sure that this procedure is ready for prime time, but reinforced fixation of the proximal penile shaft would undoubtedly be of benefit in a selected group of men with penile deformities. Allen F. Morey, M.D.

Pelvic Fracture-Associated Urethral Injuries in Girls: Experience With Primary Repair L. N. Dorairajan, H. Gupta and S. Kumar, Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India BJU Int 2004; 94: 134 –136. Objective: To present our experience with four urethral injuries in females accompanying a pelvic fracture, managed with primary repair or realignment of the urethra. Patients and Methods: There were three teenage girls and one adult (22 years old). All the patients had complete urethral injuries associated with a pelvic fracture from accidents. They were managed by immediate suprapubic cystostomy followed by repair or realignment of the urethra over a catheter on the same day. The catheter was removed after 3 weeks and a voiding cysto-urethrogram taken. Thereafter they were followed with regular urethral calibration. Results: All patients voided satisfactorily with a good stream; three were fully continent and the fourth had transient stress urinary incontinence. One patient needed dilatation at 2 months and another visual internal urethrotomy at 5 months. At a mean (range) follow-up of 33 (9 – 60) months all the patients had a normal voiding pattern and were continent; none developed vaginal stenosis. Conclusion: Primary repair of the urethra, and if that is impossible, simple urethral realignment over a catheter, is the procedure of choice for managing female urethral injury associated with a pelvic fracture. The procedure has the additional advantage of reducing the risk of vaginal stenosis. 0022-5347/07/1785-2016/0 THE JOURNAL OF UROLOGY® Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION

2016

Vol. 178, 2016-2019, November 2007 Printed in U.S.A. DOI:10.1016/j.juro.2007.07.094

TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION Editorial Comment: Traumatic disruption of the female urethra is rare due to the lower incidence of trauma in females. The typical presentation is that of traumatic vaginal laceration, with labial edema and genital bleeding noted after pelvic crush injury. Because of the unusual nature of this injury, no large series exist and management remains controversial. Delayed repair is difficult in females compared to males due to the negligible amount of urethra available for mobilization. As a result, many experts have now shifted toward a more aggressive approach, consisting of attempted acute primary urethral repair or realignment in conjunction with vaginal repair. In this series of 4 patients all were able to void successfully after primary repair (achievable in only 2) or realignment, and none had vaginal stenosis. Allen F. Morey, M.D.

Erectile Function, Sexual Drive, and Ejaculatory Function After Reconstructive Surgery for Anterior Urethral Stricture Disease B. A. Erickson, J. S. Wysock, K. T. McVary and C. M. Gonzalez, Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois BJU Int 2007; 99: 607– 611. Objective: To evaluate the effect of urethral reconstructive surgery on sexual drive, erectile function and ejaculation. Patients and Methods: The study group consisted of 52 men with a median (range) age of 44 (18 –79) years who underwent 59 urethral reconstructive procedures for anterior urethral stricture disease between 2001 and 2004. We evaluated sexual functioning using the O’Leary Brief Male Sexual Function Inventory (BMSFI) before and after surgery. Results: The mean (sd) follow-up was 22.3 (14.8) months. The mean BMSFI scores were only statistically significantly different for an improvement in ejaculation after surgery (P ⫽ 0.04). When separated by age, only the men aged 50 –59 years reported decreased erectile function after surgery (P ⬍ 0.001) and only those aged ⬍40 – 49 years reported an improvement in ejaculatory function (P ⫽ 0.05). Men at ⬍1 year after surgery reported lower sexual drive (P ⫽ 0.025) and erectile function (P ⫽ 0.05) than men with longer periods of recovery. Conclusions: The BMFSI is useful for evaluating sexual function after urethroplasty. Overall, the men did not report a decline in erectile function or sexual drive after surgery; however, older men might have a higher incidence of erectile dysfunction after surgery. Erectile function might recover with time. Younger men had the most pronounced improvement in ejaculatory function, but further studies are necessary to evaluate the clinical significance of this. Editorial Comment: This study provides further documentation that sexual function tends to remain intact after anterior urethroplasty in most men, although those older than 50 years may be prone to some degree of decline. Mild changes that may occur in the initial postoperative period due to swelling, pain or changes in sensitivity can be expected to improve during the first 12 months postoperatively. Interestingly, in this study ejaculatory function improved after urethral reconstruction, likely due to the amelioration of urethral obstruction. Allen F. Morey, M.D.

The Effect of Male Circumcision on Sexuality D. Kim and M. G. Pang, Department of Physics and Astronomy, Seoul National University, Seoul, Korea BJU Int 2007; 99: 619 – 622. Objective: To prospectively study, using a questionnaire, the sexuality of men circumcised as adults compared to uncircumcised men, and to compare their sex lives before and after circumcision. Subjects and Methods: The study included 373 sexually active men, of whom 255 were circumcised and 118 were not. Of the 255 circumcised men, 138 had been sexually active before circumcision, and all were circumcised at ⬎20 years of age. As the Brief Male Sexual Function Inventory does not specifically address the quality of sex life, questions were added to compare sexual and masturbatory pleasure before and after circumcision. Results: There were no significant differences in sexual drive, erection, ejaculation, and ejaculation latency time between circumcised and uncircumcised men. Masturbatory pleasure decreased after circumcision in 48% of the respondents, while 8% reported increased pleasure. Masturbatory difficulty increased after circumcision in 63% of the respondents but was easier in 37%. About 6% answered that their sex lives improved, while 20% reported a worse sex life after circumcision. Conclusion: There was a decrease in masturbatory pleasure and sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings.

2017

2018

DIAGNOSTIC UROLOGY, URINARY DIVERSION AND PERIOPERATIVE CARE Editorial Comment: What is the effect of male circumcision on sexuality? This South Korean study provides a unique perspective because most patients evaluated were sexually active before circumcision. While erectile function was again shown to be unchanged, 20% of men reported reduced sexual pleasure after circumcision, usually due to lost sensation. Problems involving scar formation, uneven skin loss and uncomfortable erections were also reported. Obviously, full counseling is imperative before undertaking circumcision in adults. Allen F. Morey, M.D.

Combined Buccal Mucosa Graft and Genital Skin Flap for Reconstruction of Extensive Anterior Urethral Strictures R. K. Berglund and K. W. Angermeier, Section of Prosthetic Surgery and Genitourethral Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio Urology 2006; 68: 707–710. Objectives: Buccal mucosa has become the graft material of choice for substitution urethroplasty, but the tissue may be insufficient to completely reconstruct an extensive or panurethral stricture. We reviewed our experience with the combination of buccal mucosa and a genital skin flap to assess the efficacy of this approach in this setting. Methods: Eighteen patients underwent single-stage urethral reconstruction at our institution from November 1997 to May 2003 using a buccal mucosa onlay graft and a penile and/or scrotal island flap. After surgery, patients were evaluated with voiding urethrography at 3 weeks, followed by flexible cystoscopy at 6 and 12 months and as needed thereafter. Results: The mean stricture length was 15.1 cm (range 9.5 to 22), with an average graft length of 6.3 cm and flap of 8.5 cm. The stricture etiology included multiple hypospadias repair failures in 4 (22.2%), prior instrumentation in 4 (22.2%), pelvic trauma in 3 (16.7%), balanitis xerotica obliterans in 3 (16.7%), and unknown in 4 (22.2%) of the 18 patients. At the last follow-up visit, 3 patients (16.7%) had had recurrent stricture noted on follow-up cystoscopy. Conclusions: In this series, the combination of buccal mucosa and a genital skin flap proved to be a reliable and durable method of single-stage repair for extensive and panurethral stricture disease. The use of longitudinal island flaps and patient repositioning during surgery seemed to contribute to a decreased incidence of local and systemic morbidity. Editorial Comment: The 80% success rate reported in this 6-year experience with men who had an average stricture length of greater than 15 cm supports a creative, aggressive, single stage reconstructive approach. To prevent troublesome lower extremity complications, such repairs should be conducted in a distal-to-proximal manner, beginning with the patient in the supine position, with repositioning into the high lithotomy position only as necessary for perineal urethral access. Allen F. Morey, M.D.

DIAGNOSTIC UROLOGY, URINARY DIVERSION AND PERIOPERATIVE CARE Orthotopic Ileal Neobladder Reconstruction for Bladder Cancer: Is Adjuvant Chemotherapy Safe? M. Manoharan, M. A. Reyes, R. Singal, B. R. Kava, A. M. Nieder and M. S. Soloway, Department of Urology, University of Miami School of Medicine, Miami, Florida Int Braz J Urol 2006; 32: 529 –535. Objective: We examined our database of patients undergoing radical cystectomy (RC) with orthotopic neobladder (NB) to determine whether adjuvant chemotherapy in this group is safe. Materials and Methods: We performed a retrospective analysis of patients who underwent radical cystectomy and urinary diversion between 1992 and 2004. Relevant clinical and therapeutic data were entered into a database. High-risk bladder cancer patients who underwent NB were identified. They were stratified into 2 groups, those who received adjuvant chemotherapy and those who did not. The incidence of complications between the 2 groups was analyzed and compared. Results: Over the 12-year period, 136 patients underwent RC and NB construction for bladder cancer. Of these, 83 patients were at high risk for recurrence. Nineteen patients