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VID-2.06: Combined perineal-prerectal approach and pedunculated penile skin flap autoplasty for complex bulbar-membranous urethral strictures
VIDEO SESSIONS
porcine intestine submucosa in urethroplastic surgery. Materials and Methods: After coronal incision and penile degloving (when necessary the incision is prolonged in perineal-scrotal region), the urethra is rotated 180°, opened through the entire restricted tract, where the graft will be sutured resulting dorsal and reinforced by contact with the cavernous bodies to prevent pouching. From 1999 to 2005 we performed this grafting procedure in 36 men and 4 women (by transvaginal approach) affected with urethral stricture. It is far more difficult to be operated on by traditional methods and not in a single step. Then we stopped with this technique to evaluate our results. Sixteen more operations were performed in the following years, but with direct ventral graft procedure, without urethra isolation, rotation, and de-rotation with effective, worthy simplification. Results: The up-to-date overall follow-up is 10 years with satisfactory urodynamic and subjective outcomes for both procedures assessed by voiding urethrography and uroflowmetry with a mean flow value of 18 ml/s and max flow time inferior than 10 seconds, as well as an improvement in the International Prostate Symptom Score (IPSS) and in quality of life (QoL). Moreover at urethroscopy the graft and the native tissue appeared completely homogeneous, confirmed by the histological examination of the bioptic sample at the beginning of our experience. Conclusions: Positive results encourage us to continue this experience to further verify its possibilities and limits. Particularly the ventral direct graft represents the more consistent evolution of this surgery; we didn’t observe pouching and the results remained effective. Even if for penile urethra, in a restricted number of patients, periodic dilatations were necessary to preserve patency. According to our experience, S.I.S. must be considered an alternative to more complicated techniques and more difficult grafting procedures, which are probably not more indispensable—according to our functional results—in urethral enlargement, even for critical strictures. VID-2.04 Purely transvaginal excision of mesh erosion involving the bladder Firoozi F, Goldman H Cleveland Clinic, Cleveland, OH, USA Introduction and Objectives: We present a pure transvaginal approach to the removal of eroded mesh involving the
bladder secondary to placement of transvaginal mesh for management of pelvic organ prolapse using a mesh kit. Materials and Methods: Transvaginal excision of mesh erosion involving the bladder after mesh placement using a prolapse kit was performed. A reverse C-shaped incision was made in the anterior vaginal wall; mesh arms were identified laterally, divided, and then dissected from the bladder. The bladder was closed in 3 layers transvaginally, followed by closure of the vaginal wall as a fourth layer. Results: Removal of eroded mesh within the bladder was completed with all operative steps performed transvaginally. The patient was discharged home within 23 hours. There were no postoperative complications. Conclusions: Transvaginal removal of mesh erosion involving the bladder is safe, technically feasible, and allows forrapid return to normal function. VID-2.05 Tissue activated laser beam in the treatment of urethral stricture Flamand V, Sanchez Salas R, De Fourmestraux A, Barret E, Rozet F, Cathelineau X, Galiano M, Vallancien G Dept. of Urology, Institut Montsouris, Paris, France Introduction and Objective: Urethral stricture (US) management is a challenging surgical procedure. Success rate remains low and a high recurrence negatively impacts a patient’s quality of life. Main etiology for US is radical or simple prostatectomy followed by infectious or congenital disease. Material and Methods: Six patients were operated in a prospective feasibility study of Revolix®. Five patients presented with US after radical or simple prostatectomy and one harbored a congenital US (Primary US n⫽4, recurrent US n⫽2). Revolix® features a continuous wave DPSS laser beam which works with a 2 m wavelength and activates in contact with the tissue. All patients underwent conventional endoscopic procedure under general anesthesia. US were endoscopically incised (twelve, five and seven o’clock) with the laser in order to reach clear access to the bladder. Accurate hemostasis was achieved. A 20 french catheter was placed in every case. Results: In our initial experience, 6 patients have been successfully treated. The indwelling catheter was removed after a mean of 1,5 [1-2] days. No perioperative complication occurred. Only one patient needed urethral dilatation at 3 months
UROLOGY 76 (Supplement 3A), September 2010
after surgery, with an uneventful evolution afterwards. At 6 months’ follow-up, 5 patients remain stricture free with no need for adjuvant intervention and without urological symptoms. Conclusion: In the short-term, management of US using the Revolix® laser seems safe and effective. The procedure allows for a perfect control of the urethral section with precise preservation of the sphincter.
VID-2.06 Combined perineal-prerectal approach and pedunculated penile skin flap autoplasty for complex bulbar-membranous urethral strictures Austoni E1,3, Pini G2 1 University of Milan, Milan; 2University of Modena and Reggio Emilia, Modena and Reggio Emilia; 3GVM Group Lecco, Reggio Emilia, Bologna, Italy Introduction and Objective: The prerectal approach, performed in perineal radical prostatectomy (PRP), has been adopted for 10 years to treat complex membranous postraumatic stenosis with upwards dislocation of the prostate. We describe the combination of this procedure with a peduncolated penile skin flap autoplasty applied in 4 cases of complex and large bulbar-membranous strictures. Materials and Methods: From 19962006, 13 patients with multi-recurrent membranous postraumatic stenosis, secondary erectile dysfunction and permanent cystostomy underwent to a “prerectal intrasfinteric approach” urethroplasty. Four of them with associated large bulbarurethral and subsequent perivescical fibrosis underwent a combined retropubic prerectal cistolysis and a bulbar reconstruction with penile skin autoplasty. A dorsal penile skin vascularized tube-flap is slid laterally via an infrapubic route down to the perineum. The tube penile skin flap is anastomosed proximally with the prostatic apex mobilized by a prerectal route and distally with the intact bulbar uretra. A full-thickness dermal-epidermal graft is used to cover the penis. Results: There were no intraoperatory and postoperatory complications and no rectal lesion. Qmedium in 11 patients were 20 ml/sec. The only one stricture recurrence was managed with endoscopic urethrotomy. Incontinence was present in 2 of the “combined approach” patients. Two patients recovered from preoperatory erectile dysfunction. Prostate isola-
S51
VIDEO SESSIONS
tion could explain a recanalization of nervi erigentes damaged by trauma and fibrous block. Conclusions: In case of complex and large bulbo-mebranous postraumatic stenosis with upwards dislocation of the prostate we suggest an alternative to the transperineal-transpubic (Waterhouse) or partial pubic resection (Lenzi-Barbagli) approaches. The “perineal-prerectal” approach, developed as result of our extensive experience with PRP, allows for an easy mobilization of the prostatic apex and a ‘tension-free’ anastomosis. In cases of such lesions associated with urethral bulb lesions, a skin bulbar-membranous autoplasty is indicated. The dorsal penile skin vascularized tube-flap is an alternative to the multistaged surgery as scrotal inlay (Blandy-Turner Warwich) or mesh graft (Schreiter-Jordan). It should be emphasized that prerectal approaches combined with autoplasty is to be considered an extreme urethral surgery for the management of very severe posterior strictures. The procedure is challenging but offers good and stable results.
S52
VID-2.07 Free preputial skin dorsal onlay urethroplasty: our experience in 104 patients Bapat S, Mulay A, Sharma R, Sovani Y, Kshirsagar Y, Paramne V, Choudhary H Maharashtra Medical Research Society and Ratna Memorial Hospital, Pune, India Introduction and Objective: To present the outcome of free preputial skin dorsal onlay urethroplasty in 104 patients for stricture urethra over a period of 11 years. Materials and Methods: There were 104 patients of stricture urethra who underwent free preputial skin dorsal onlay urethroplasty from Jan 1998 to Dec 2009. Age distribution: 14-68 years. Aetiology: Trauma 30(28.84%), Balanitis Xerotica Obliterans 6(5.76%), Iatrogenic 34(32.69%), Infection 16(15.38%), Idiopathic 18(17.30%). Site: Penobulbar– 44(42.3%), bulbar-52(50%), membranous-6(5.7%) and full length-2(1.9%). Suprabubic cystostomy was performed earlier in 31patients. Preputial or distal penile skin in circumcised patients was used in all patients. Buccal
mucosa was not used in any patient. Hospitalization was for 4-5 days. Catheter was removed after 21 days. All patients had their first uroflowmetry and endoscopic checkup after 3 months of catheter removal. Subsequent follow up was by uroflometry. Routine imaging of urethra for follow up was not carried out. Results: There were 88(84.61%) patients who had a satisfactory outcome not requiring any further treatment; 16 (15.38%) developed anastomotic stricture (6/16-optical internal urethrotomy, 10/16 Dilatation alone); 4/104(4.16%) developed external meatal stenosis. None had urinary fistula and required repeat urethroplasty. Follow up ranged from 3 months to 11 years. Conclusion: Dorsal onlay urethroplasty using preputial/distal penile skin is a satisfactory procedure. Preputial/distal penile skin is very thin, supple, devoid of fat and hair hence, an ideal graft material for urethroplasty. In circumcised patients distal penile skin can be harvested without interfering with sexual life. Long-term follow up is required in judging results of patients with stricture urethra.
UROLOGY 76 (Supplement 3A), September 2010
porcine intestine submucosa in urethroplastic surgery. Materials and Methods: After coronal incision and penile degloving (when necessary the incision is prolonged in perineal-scrotal region), the urethra is rotated 180°, opened through the entire restricted tract, where the graft will be sutured resulting dorsal and reinforced by contact with the cavernous bodies to prevent pouching. From 1999 to 2005 we performed this grafting procedure in 36 men and 4 women (by transvaginal approach) affected with urethral stricture. It is far more difficult to be operated on by traditional methods and not in a single step. Then we stopped with this technique to evaluate our results. Sixteen more operations were performed in the following years, but with direct ventral graft procedure, without urethra isolation, rotation, and de-rotation with effective, worthy simplification. Results: The up-to-date overall follow-up is 10 years with satisfactory urodynamic and subjective outcomes for both procedures assessed by voiding urethrography and uroflowmetry with a mean flow value of 18 ml/s and max flow time inferior than 10 seconds, as well as an improvement in the International Prostate Symptom Score (IPSS) and in quality of life (QoL). Moreover at urethroscopy the graft and the native tissue appeared completely homogeneous, confirmed by the histological examination of the bioptic sample at the beginning of our experience. Conclusions: Positive results encourage us to continue this experience to further verify its possibilities and limits. Particularly the ventral direct graft represents the more consistent evolution of this surgery; we didn’t observe pouching and the results remained effective. Even if for penile urethra, in a restricted number of patients, periodic dilatations were necessary to preserve patency. According to our experience, S.I.S. must be considered an alternative to more complicated techniques and more difficult grafting procedures, which are probably not more indispensable—according to our functional results—in urethral enlargement, even for critical strictures. VID-2.04 Purely transvaginal excision of mesh erosion involving the bladder Firoozi F, Goldman H Cleveland Clinic, Cleveland, OH, USA Introduction and Objectives: We present a pure transvaginal approach to the removal of eroded mesh involving the
bladder secondary to placement of transvaginal mesh for management of pelvic organ prolapse using a mesh kit. Materials and Methods: Transvaginal excision of mesh erosion involving the bladder after mesh placement using a prolapse kit was performed. A reverse C-shaped incision was made in the anterior vaginal wall; mesh arms were identified laterally, divided, and then dissected from the bladder. The bladder was closed in 3 layers transvaginally, followed by closure of the vaginal wall as a fourth layer. Results: Removal of eroded mesh within the bladder was completed with all operative steps performed transvaginally. The patient was discharged home within 23 hours. There were no postoperative complications. Conclusions: Transvaginal removal of mesh erosion involving the bladder is safe, technically feasible, and allows forrapid return to normal function. VID-2.05 Tissue activated laser beam in the treatment of urethral stricture Flamand V, Sanchez Salas R, De Fourmestraux A, Barret E, Rozet F, Cathelineau X, Galiano M, Vallancien G Dept. of Urology, Institut Montsouris, Paris, France Introduction and Objective: Urethral stricture (US) management is a challenging surgical procedure. Success rate remains low and a high recurrence negatively impacts a patient’s quality of life. Main etiology for US is radical or simple prostatectomy followed by infectious or congenital disease. Material and Methods: Six patients were operated in a prospective feasibility study of Revolix®. Five patients presented with US after radical or simple prostatectomy and one harbored a congenital US (Primary US n⫽4, recurrent US n⫽2). Revolix® features a continuous wave DPSS laser beam which works with a 2 m wavelength and activates in contact with the tissue. All patients underwent conventional endoscopic procedure under general anesthesia. US were endoscopically incised (twelve, five and seven o’clock) with the laser in order to reach clear access to the bladder. Accurate hemostasis was achieved. A 20 french catheter was placed in every case. Results: In our initial experience, 6 patients have been successfully treated. The indwelling catheter was removed after a mean of 1,5 [1-2] days. No perioperative complication occurred. Only one patient needed urethral dilatation at 3 months
UROLOGY 76 (Supplement 3A), September 2010
after surgery, with an uneventful evolution afterwards. At 6 months’ follow-up, 5 patients remain stricture free with no need for adjuvant intervention and without urological symptoms. Conclusion: In the short-term, management of US using the Revolix® laser seems safe and effective. The procedure allows for a perfect control of the urethral section with precise preservation of the sphincter.
VID-2.06 Combined perineal-prerectal approach and pedunculated penile skin flap autoplasty for complex bulbar-membranous urethral strictures Austoni E1,3, Pini G2 1 University of Milan, Milan; 2University of Modena and Reggio Emilia, Modena and Reggio Emilia; 3GVM Group Lecco, Reggio Emilia, Bologna, Italy Introduction and Objective: The prerectal approach, performed in perineal radical prostatectomy (PRP), has been adopted for 10 years to treat complex membranous postraumatic stenosis with upwards dislocation of the prostate. We describe the combination of this procedure with a peduncolated penile skin flap autoplasty applied in 4 cases of complex and large bulbar-membranous strictures. Materials and Methods: From 19962006, 13 patients with multi-recurrent membranous postraumatic stenosis, secondary erectile dysfunction and permanent cystostomy underwent to a “prerectal intrasfinteric approach” urethroplasty. Four of them with associated large bulbarurethral and subsequent perivescical fibrosis underwent a combined retropubic prerectal cistolysis and a bulbar reconstruction with penile skin autoplasty. A dorsal penile skin vascularized tube-flap is slid laterally via an infrapubic route down to the perineum. The tube penile skin flap is anastomosed proximally with the prostatic apex mobilized by a prerectal route and distally with the intact bulbar uretra. A full-thickness dermal-epidermal graft is used to cover the penis. Results: There were no intraoperatory and postoperatory complications and no rectal lesion. Qmedium in 11 patients were 20 ml/sec. The only one stricture recurrence was managed with endoscopic urethrotomy. Incontinence was present in 2 of the “combined approach” patients. Two patients recovered from preoperatory erectile dysfunction. Prostate isola-
S51
VIDEO SESSIONS
tion could explain a recanalization of nervi erigentes damaged by trauma and fibrous block. Conclusions: In case of complex and large bulbo-mebranous postraumatic stenosis with upwards dislocation of the prostate we suggest an alternative to the transperineal-transpubic (Waterhouse) or partial pubic resection (Lenzi-Barbagli) approaches. The “perineal-prerectal” approach, developed as result of our extensive experience with PRP, allows for an easy mobilization of the prostatic apex and a ‘tension-free’ anastomosis. In cases of such lesions associated with urethral bulb lesions, a skin bulbar-membranous autoplasty is indicated. The dorsal penile skin vascularized tube-flap is an alternative to the multistaged surgery as scrotal inlay (Blandy-Turner Warwich) or mesh graft (Schreiter-Jordan). It should be emphasized that prerectal approaches combined with autoplasty is to be considered an extreme urethral surgery for the management of very severe posterior strictures. The procedure is challenging but offers good and stable results.
S52
VID-2.07 Free preputial skin dorsal onlay urethroplasty: our experience in 104 patients Bapat S, Mulay A, Sharma R, Sovani Y, Kshirsagar Y, Paramne V, Choudhary H Maharashtra Medical Research Society and Ratna Memorial Hospital, Pune, India Introduction and Objective: To present the outcome of free preputial skin dorsal onlay urethroplasty in 104 patients for stricture urethra over a period of 11 years. Materials and Methods: There were 104 patients of stricture urethra who underwent free preputial skin dorsal onlay urethroplasty from Jan 1998 to Dec 2009. Age distribution: 14-68 years. Aetiology: Trauma 30(28.84%), Balanitis Xerotica Obliterans 6(5.76%), Iatrogenic 34(32.69%), Infection 16(15.38%), Idiopathic 18(17.30%). Site: Penobulbar– 44(42.3%), bulbar-52(50%), membranous-6(5.7%) and full length-2(1.9%). Suprabubic cystostomy was performed earlier in 31patients. Preputial or distal penile skin in circumcised patients was used in all patients. Buccal
mucosa was not used in any patient. Hospitalization was for 4-5 days. Catheter was removed after 21 days. All patients had their first uroflowmetry and endoscopic checkup after 3 months of catheter removal. Subsequent follow up was by uroflometry. Routine imaging of urethra for follow up was not carried out. Results: There were 88(84.61%) patients who had a satisfactory outcome not requiring any further treatment; 16 (15.38%) developed anastomotic stricture (6/16-optical internal urethrotomy, 10/16 Dilatation alone); 4/104(4.16%) developed external meatal stenosis. None had urinary fistula and required repeat urethroplasty. Follow up ranged from 3 months to 11 years. Conclusion: Dorsal onlay urethroplasty using preputial/distal penile skin is a satisfactory procedure. Preputial/distal penile skin is very thin, supple, devoid of fat and hair hence, an ideal graft material for urethroplasty. In circumcised patients distal penile skin can be harvested without interfering with sexual life. Long-term follow up is required in judging results of patients with stricture urethra.
UROLOGY 76 (Supplement 3A), September 2010