Allen F. Morey

Reconstruction of Posterior Urethral Disruption Injuries: Outcome Analysis in 82 Patients

PURPOSE We sought to identify the long-term success rate of perineal anastomotic reconstruction for posterior urethral disruption. MATERIALS AND METHODS We reviewed the records of 82 patients with traumatic prostatomembranous urethral strictures who underwent perineal anastomotic urethroplasty by 1 surgeon. RESULTS Excision of fibrosis with simple perineal anastomosis was performed in 52 patients (63%), while pubectomy was required in 30 (37%) to obtain a tension-free anastomosis. Median followup was longer than 1 year. Potency improved from 46% before reconstruction to 62% postoperatively. Nine patients (11%) required 1 endoscopic urethrotomy after urethroplasty to improve flow rate and this procedure was successful in 8 (88%). In 3 patients (3%) urethroplasty ultimately failed and they remained untreated because of insurmountable co-morbidity. Overall, long-term success was observed in 79 patients (97%). CONCLUSIONS Excellent long-term results can be expected from anastomotic urethroplasty in patients with traumatic posterior urethral strictures. Subsequent urethrotomy, when required, has a high likelihood of success. A significant number of patients regain potency after urethral reconstruction. Persistent impotence probably reflects the severity of pelvic trauma.

When and how to use buccal mucosal grafts in adult bulbar urethroplasty

OBJECTIVES To evaluate the efficacy of buccal mucosa in the repair of adult urethral stricture disease, we report our experience with its use as a nontubularized onlay graft during bulbar urethral reconstruction. METHODS From June 1993 to January 1996, 75 men underwent anterior urethral reconstruction for stricture disease. Single-stage urethroplasty with an onlay patch graft of buccal mucosa was performed in 13 patients with complex, refractory strictures of the bulbar urethra. In all cases, a two-team approach was used in which one team harvested the graft from the mouth while the perineal team simultaneously exposed and calibrated the stricture. RESULTS The length of buccal mucosa ranged from 3.5 to 17 cm (average length 6.2). In 8 patients, other reconstructive techniques were used concomitantly, including fasciocutaneous penile flap or stricture excision and primary anastomosis, depending on the length and severity of the scarred area. Median follow-up time was 18 months. Excellent results were obtained in all 13 patients, and none has required urethral dilation or instrumentation subsequently. Operative time was significantly less than with other forms of substitution urethroplasty. CONCLUSIONS Excellent results can be expected when buccal mucosa is used for urethral substitution in men with refractory bulbar strictures. For patients with long or dense strictures, buccal mucosal grafts may easily be combined with other reconstructive techniques. In patients with less complex stricture disease, the reduced operative time of this two-team approach may be beneficial.

Multi-institutional experience with buccal mucosa onlay urethroplasty for bulbar urethral reconstruction.

PURPOSE Buccal mucosa has been advocated as an ideal graft material for urethral reconstruction. We report our multicenter experience with buccal mucosa ventral onlay urethroplasty for complex bulbar urethral reconstruction in adults. MATERIALS AND METHODS A retrospective analysis of patients who had undergone buccal onlay urethroplasty at 4 military medical treatment facilities participating in the Uniformed Services Urology Research Group was performed. The database generated included demographic data, genitourinary history, preoperative symptoms (American Urological Association symptom score), preoperative urinary flow rate, stricture length and operative statistics. Postoperative followup data included symptom score, flow rate, retrograde urethrogram results, and complications. RESULTS A total of 53 patients (average age 32 years, range 17 to 64) underwent buccal mucosa graft urethroplasty between January, 1996 and March, 1998 for refractory strictures. Sixteen patients had undergone an average of 2.2 prior endoscopic procedures (range 1 to 7). Average stricture length was 3.6 plus or minus standard deviation 1.8 cm. (range 2 to 7.5) as measured on preoperative retrograde urethrogram. Followup averaged 25 months (range 11 to 40 months). Average symptom scores decreased from 21.2 (range 14 to 33) preoperatively to 5.4 (range 3 to 8) postoperatively (p <0.001). Average peak urinary flow rates increased from 7.9 preoperatively to 30.1 ml. per second postoperatively (p <0.001). Postoperative retrograde urethrograms were available for 34 patients and were normal in 24. The overall complication rate was 5.4%. Three patients required endoscopic incisions. One patient has a recurrent narrowing and treatment is considered a failure. There were 4 sacculations (7.5%) and 6 narrowings, 3 of which required further treatment. Of the patients 50 required no additional procedures (94.3%). CONCLUSIONS Buccal mucosa grafts used as a ventral onlay for bulbar urethral reconstruction yield reproducibly excellent results with minimal morbidity and low complication rates. Longer followup will be required to confirm the durability of our results.

Technique of harvesting buccal mucosa for urethral reconstruction

PURPOSE Buccal mucosa has been used increasingly by urologists for urethral substitution in complex hypospadias repair. We have found buccal mucosa to be useful in reconstruction of bulbar urethral strictures, and describe a simple and reliable technique for harvest. MATERIALS AND METHODS In 11 patients with refractory bulbar urethral strictures a nontubularized onlay patch of buccal mucosa was used for urethral reconstruction. All procedures were done with a 2-team approach in which 1 team (usually an oral surgeon and urologist) harvested the graft from the mouth, while the perineal team simultaneously exposed and calibrated the stricture. RESULTS The length of buccal mucosa used ranged from 3.5 to 17 cm. (average 6.4). All patients achieved excellent results. No oral complications were noted, even in patients in whom multiple buccal mucosal grafts were obtained. CONCLUSIONS With the technique reported, buccal mucosa is a reliable, easily obtained tissue for patch graft urethroplasty. Our 2-team approach decreased operative time considerably.

ERECTILE FUNCTION AFTER ANTERIOR URETHROPLASTY

PURPOSE We ascertained the impact of anterior urethroplasty on male sexual function. MATERIALS AND METHODS A validated questionnaire was mailed to 200 men who underwent anterior urethroplasty to evaluate postoperative sexual function. Questions addressed the change in erect penile length and angle, patient satisfaction with erection, preoperative and postoperative coital frequency, and change in erection noted by the sexual partner. Results were stratified by the urethral reconstruction method, namely anastomosis, buccal mucosal graft, penile flap and all others, and compared with those in a similar group of men who underwent circumcision only. RESULTS Of the 200 men who underwent urethroplasty 152 who were 17 to 83 years old (mean age 45.7) completed the questionnaire. Average followup was 36 months (range 3 to 149). Overall there was a similar incidence of sexual problems after urethroplasty and circumcision. Penile skin flap urethroplasty was associated with a slightly higher incidence of impaired sexual function than other procedures (p >0.05). Men with a longer stricture were most likely to report major changes in erectile function and penile length (p <0.05) but improvement was evident with time in 61.8%. CONCLUSIONS Overall anterior urethral reconstruction appears no more likely to cause long-term postoperative sexual dysfunction than circumcision. Men with a long stricture may be at increased risk for transient erectile changes.

Efficacy of Radiographic Imaging in Pediatric Blunt Renal Trauma

PURPOSE We sought to determine whether radiographic imaging can effectively detect significant renal injuries in children with blunt trauma who do not have significant hematuria. MATERIALS AND METHODS We reviewed the records of 180 children who presented to our hospital for suspected renal trauma between 1977 and 1995. Results of excretory urography or abdominal computerized tomography were correlated with urinalysis findings and clinical outcome. RESULTS Of 147 patients with microscopic hematuria after blunt trauma 77 underwent imaging. Only 1 patient had a significant renal injury (grade 2 or greater) and 76 had normal findings or renal contusions only, including 11 with microscopic hematuria and shock. Of the 74 patients who did not undergo imaging a clinical diagnosis of renal contusion was made and followup was available for 57 (77%). All patients healed without adverse sequelae. Of 33 patients with gross hematuria significant renal injuries were found in 9, including 3 who required immediate surgical repair of a major renal laceration or vascular injury. Combining our results with those of other reported series revealed significant renal injuries in only 11 of 548 children (2%) with less than 50 red blood cells per high power field on presenting urinalysis after blunt abdominal trauma. These patients were likely to have multiple associated injuries. CONCLUSIONS Significant renal injuries are unlikely in pediatric patients with blunt renal trauma but no gross or substantial microscopic hematuria. Shock does not appear to be a clinically useful indicator.

Bladder rupture after blunt trauma: guidelines for diagnostic imaging.

PURPOSE The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome. METHODS We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series. RESULTS Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates. CONCLUSION The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.

Sonographic staging of anterior urethral strictures

PURPOSE Although radiographic retrograde urethrography has traditionally been the gold standard for imaging the anterior urethra, sonourethrography has proved to be precise and effective for evaluating urethral strictures. We review the evolution of sonourethrography and demonstrate its practical contemporary applications. MATERIALS AND METHODS We performed literature reviews on MEDLINE and chart reviews of our patient records from 1988 to 1998. RESULTS Sonourethrography measures stricture length in the bulbar urethra more accurately than conventional retrograde urethrography. Spongiofibrosis is manifested sonographically by a lack of urethral distensibility during retrograde instillation of saline solution. Posterior shadowing is noted in severe posttraumatic cases. Sonographic staging before treatment of complex or reoperative anterior strictures elucidates complicating features, such as calculi, urethral hair, false passage and stent encrustation. CONCLUSIONS Sonographic staging of anterior urethral strictures offers clinically important information that may be useful in guiding reconstructive therapy.

Proximal Bulbar Urethroplasty Via Extended Anastomotic Approach—What Are the Limits?

PURPOSE We report our initial experience with men who underwent EAU for strictures greater than 2.5 cm involving the proximal bulbar urethra. MATERIALS AND METHODS Of the more than 250 men who underwent urethral reconstruction at our institution during 1997 to 2005 a select consecutive group of 22 in whom proximal bulbar urethral strictures were treated with primary bulbomembranous anastomosis were evaluated. Outcomes in men with strictures greater than 2.5 cm long (EAU) were compared to those in men with shorter strictures in the same proximal bulbar location. Cases of post-traumatic urethral disruption related to pelvic fractures were omitted. American Urological Association symptom index scores and erectile function questionnaires were completed more than 6 months postoperatively. Results of a prior study using the same erectile function questionnaire after various types of urethroplasty and circumcision were then compared to those of our series. RESULTS Patients with EAU had an average stricture length of 3.78 cm (range 2.6 to 5.0) and 10 of 11 procedures (91%) were successful. Anastomotic urethroplasty performed for similar proximal bulbar strictures less than 2.5 cm (mean 1.5, range 1.0 to 2.3) was successful in 10 of 11 cases (91%). Mean followup was 22.1 months and all followups were more than 1 year. Men treated with EAU had no increased rate of stricture recurrence or erectile complaints compared to men in whom shorter proximal bulbar strictures were repaired using an identical surgical technique. Similarly no increased rate of erectile problems was identified compared to other types of urethroplasty and circumcision using an identical questionnaire. CONCLUSIONS Urethral reconstructability is proportional to the length and elasticity of the distal urethral segment. Defects up to 5 cm may be successfully excised and primarily reconstructed in select young men with proximal bulbar strictures.

PENILE CIRCULAR FASCIOCUTANEOUS SKIN FLAP IN 1-STAGE RECONSTRUCTION OF COMPLEX ANTERIOR URETHRAL STRICTURES

PURPOSE We review the applications and outcomes of penile circular fasciocutaneous flap urethroplasty in 66 patients at our institution. MATERIALS AND METHODS We used a circular distal penile skin flap for urethral reconstruction in 66 men with complex urethral strictures. Average stricture length in this series was 9.08 cm. and mean followup was 41 months (range 1 to 7 years). RESULTS The initial overall success rate was 79% (52 of 66 cases). Recurrent stenosis was noted in 7 of the 54 onlay (13%) and 7 of the 12 tubularized repairs (58%). Most recurrent strictures were successfully treated with a single subsequent procedure, including repeat urethroplasty in 5 cases and optical urethrotomy or dilation in 6. Two patients required perineal urethrostomy and 1 awaits further reconstruction. Including subsequent procedures, the overall long-term followup success rate was 95%. Neurovascular lower extremity complications developed in 4 patients after prolonged high lithotomy positioning. CONCLUSIONS Circular fasciocutaneous flap urethroplasty is a highly effective 1-stage method of reconstructing complex urethral strictures. Onlay repairs appear to be more successful than those involving flap tubularization. Limiting the time that the patient spends in the high lithotomy position appears to prevent neurovascular extremity complications.