A. Frost

Pelvic fracture urethral injury – the nature of the causative injury correlates strongly with surgical treatment and outcome

It is well recognised that pelvic fracture urethral injury (PFUI) is related to pelvic ring disruption. The usual causes of disruption of the pelvic ring are a lateral compression, an antero-posterior compression or a vertical shear force. The lateral compression injury causes the pelvis to be crushed inwards; the anteroposterior compression tends to cause an “open book” which opens the pelvis up; and the vertical shear force causes upward displacement of one hemi-pelvis in relation to the other side.

Re-operative abdomino-perineal reconstructive surgery

INTRODUCTION AND OBJECTIVES: While the perineal urethrostomy (PU) has proven to be a highly successful option for patients with complex urethral stricture disease, it is often utilized as a last resort. The perceived disadvantages of this procedure include the loss of normal anatomy, need to sit to urinate, and concerns about potency and sexual function. We aim to describe our contemporary series of patients treated with perineal urethrostomy. METHODS: We conducted an IRB approved, retrospective review of all patients who underwent PU from 1996 to 2012. Inclusion criteria were age > 18 and male gender. Patients with a temporary PU as part of a staged repair were excluded. Data extracted included patient demographics, stricture etiology, comorbidities, previous therapies, and need for subsequent interventions. All patients who received perineal urethrostomy as definitive management were included in the analysis. PU was considered successful if there was no need for subsequent interventions including dilations, self-calibration or surgical revision. RESULTS: A total of 718 patients underwent urethral reconstruction in the studied time period. Of these, 56 received a PU (7.8%). Etiology was lichen sclerosus in 20 (36%), hypospadias in 10 (18%), and trauma or idiopathic in 26 (46%). Mean follow-up was 21 months. All of these cases consisted of creation of a posteriorly based flap perineal urethrostomy as described by Barbagli. Eight out of 56 patients received a PU after electing not to proceed with a planned second stage urethroplasty. Twenty-eight of the 48 (58%) patients who intended to have definitive PU had failed at least one previous urethroplasty compared with 2 of 8 (25%) patients intending to have staged repair (p1⁄40.1). Of the 56 patients, two patients (3.6%) developed stenosis of the PU. One patient underwent a successful revision of the perineal urethrostomy and the other was placed on self-dilations. Prior radiation, stricture etiology, BMI, diabetes, prior urethroplasty, and stricture length were not predictive of failure. CONCLUSIONS: Perineal urethrostomy is a highly successful technique for severe urethral stricture disease that arrests the need for further interventions in the vast majority of cases with a very low complication or revision rate.

957 The non-transecting technique for bulbar urethral strictures

METHODS: A retrospective chart review of all RALPs at Indiana University from October 2002 to July 2014 was performed. RALP success was defined as resolution of symptoms of UPJ obstruction, improved hydronephrosis radiographically, or resolution of obstruction on follow-up Lasix renogram, IVP, or Whitaker test. RALP failure was defined as persistence of symptoms with obstruction demonstrated on functional imaging or requirement for a subsequent UPJ procedure. RESULTS: A total of 133 evaluable patients were identified with an average age of 34 years. 12% had undergone previous failed UPJ procedure (including balloon dilation, endopyelotomy, or pyeloplasty) and 48% had a ureteral stent or nephrostomy placed prior to surgery. Stented RALP was performed in 81.2% of cases while 18.8% were stentless repairs. 89.5% of pyeloplasties were performed with a dismembered technique, while 10.5% were nondismembered Fenger, Y-V, or flap pyeloplasties. 5 intraoperative complications (Clavien I-IIIb) and 18 postoperative complications (Clavien I-IIIa) were described. 129 patients received follow up for an average of 15.7 months (range 1-115 months). 98.3% of patients who were followed for at least twelve months underwent postoperative Lasix renogram. The average increase in split renal function was 1.7% and average decrease in clearance half-time was 23.2 minutes for the ipsilateral kidney in all patients who received preand postoperative Lasix renograms. RALP was determined to be successful in 97.7% of cases. Three failures were noted, all were symptomatic with continued obstruction on functional imaging. Of these failures, one was managed with long-term ureteral stent placement and two required ipsilateral nephrectomy. CONCLUSIONS: Robot-assisted laparoscopic pyeloplasty is an excellent minimally invasive method for correction of UPJ obstruction, resulting in lasting improvement in symptoms and resolution of obstruction for most patients.