Anastasia Frost

Urethral atrophy after implantation of an artificial urinary sphincter: fact or fiction?

To investigate the concept of ‘urethral atrophy’, which is often cited as a cause of recurrent incontinence after initially successful implantation of an artificial urinary sphincter (AUS); and to investigate the specific cause of the malfunction of the AUS in these patients and address their management.

V1-05 REDO BULBO-PROSTATIC ANASTOMOTIC (BPA) URETHROPLASTY FOR RECURRENT PELVIC FRACTURE-RELATED URETHRAL STRICTURES

located just at the site of the stenosis; any attempt for reconstruction may jeopardize continence. Anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. We developed a novel technique performing a meticulous dissection of this sheath to separate the muscle from the urethral wall, thus performing an intra-sphincteric anastomosis without disturbing the sphincteric function METHODS: A 67 year old patient underwent a transvesical simple prostatectomy for BPH. He developed an early bulbo-membranous stenosis managed initially with repeated dilation until he went into complete retention needing a suprapubic tube. The bulbar urethra is exposed through a vertical perineal incision with splitting of the bulbo-spongiosum muscle and then separated from the corpus cavernosum. Opening of the perineal membrane and splitting of the intercrural space in the midline, provides access to the dorsal aspect of the bulbo-membranous junction. The bulb is then mobilized to the left side, without detachment from the perineal body and the bulbar vessels are retracted. The sheath of the membranous urethra is now opened circumferentially at the bulbo-membranous junction, carefully reflecting the circular muscle fibers of the external sphincter until exposure of the urethral wall is obtained and the connecting tissue plane is identified. Gentle blunt proximal dissection along this plane allows separating the muscle away from the urethra towards the prostatic apex until healthy urethra is found to perform the bulbo-prostatic anastomosis, which is completed with a standard parachute technique. Finally the sphincteric muscle ring is anchored to the anastomosis with interrupted absorbable stitches RESULTS: The patient was discharged on PO day 3 and the urethral catheter was removed at 3 weeks. He recovered normal continent micturition and is voiding symptoms free at 3 months of follow-up CONCLUSIONS: Excision and bulbo-prostatic anastomosis with sphincter sparing for bulbo-membranous stenosis after BPH surgery is feasible and safe. Our technique allows repairing the urethra preserving continence and to our knowledge it has not been described before. A larger series and reproduction in other centers are needed to validate this technique

V1-08 SURGICAL CORRECTION OF URORECTAL FISTULA (URF) FOLLOWING RADICAL PROSTATECTOMY FOR THE TREATMENT OF PROSTATE CANCER.

hypospadias repair, urethral reconstruction, and correction of penile curvature. We set out to develop a retractor that would improve surgeon and assistant ergonomics and provide compression at the base of the penis to reduce blood loss. We describe this novel self-retaining penile retractor and our initial experience in its use. METHODS: This retractor is made of medical grade stainless steel. It has three components e a fixed hemostatic clamp attached to a scale, with also houses an artery forceps. This forceps moves along the scale to adjust the traction on the penis. The clamp is flat and compressive. The arms are non-traumatic and do not cause circumferential constriction. A stay suture taken through the glans is engaged by the artery forceps, and the height adjusted according to the penile length. The retractor has been used by reconstructive urologists in India, Turkey, Australia, Kuwait, Indonesia, and the United States of America. RESULTS: A total of 37 reconstructive cases were performed using this penile retractor (23 redo hypospadias repairs, 7 complex penile urethroplasties, 4 penile urethrocutaneous fistula repairs, and 3 surgeries for correction of Peyronie’s disease). For each case, surgeons were asked to score the retractor on a 4 point scale: 1. Extremely Non satisfactory, 2. Not Satisfactory, 3. Satisfactory, 4. Extremely Satisfactory. The average score was 3.65. Advantages noted were ease of application, reduction of assistant fatigue, stable operative exposure and non-traumatic tissue compression conferring a bloodless field. There were no complications attributable to the device. The main limitation is that it cannot be used for hypospadias proximal to the penoscrotal junction. This retractor is inexpensive, durable and easy to sterilize and can be used on adult and pediatric patients alike. CONCLUSIONS: In our experience this retractor has high utility in reconstruction of the penis and penile urethra. It affords improved ergonomics for the surgeon and assistant, which results in shorter operative times and reduced blood loss while avoiding tissue damage.

Complex Fistula Disease in the Pelvic Malignancy Cancer Survivor Who Has Been Treated with Radiation

Fistulation is a relatively uncommon complication resulting from the treatment of pelvic malignancy but one which is associated with significant patient morbidity. Fistulae complicating treatment with radiation, when compared to those arising from surgical management alone, are usually more difficult to treat by virtue of tissue ischaemia and fibrosis. They are also commonly associated with other complications resulting from the effect of radiation on adjacent organs such as the bladder, lower intestinal tract and pelvic bones as well as the frequent occurrence of intervening cavitation and chronic pelvic sepsis, all of which render these fistulae complex. Complex radiotherapy fistulae necessitate a change in the standard approach to fistula management. In a non-tertiary setting, they are often treated by urinary or bowel diversion (or both). Surgical correction of complex fistulae following radiotherapy is nonetheless possible in experienced hands but commonly requires extensive reconstructive procedures via an abdominoperineal approach with a protracted recovery and reduced potential for return to complete functional normality.

MP29-07 COMPLICATIONS ASSOCIATED WITH CLEAN INTERMITTENT SELF CATHETERISATION IN PATIENTS WITH ARTIFICIAL URINARY SPHINCTER FOR THE TREATMENT OF NEUROPATHIC BLADDER DYSFUNCTION.

INTRODUCTION AND OBJECTIVES: Augmentation cystoplasty has been used for over 50 years as a surgical treatment for patients with dysfunctional bladder disorders. Some of these patients may require an artificial urinary sphincter (AUS) to maintain continence; and to perform clean intermittent self-catheterisation (CISC) to ensure bladder emptying. This study reviews outcomes of patients with neuropathic bladder disorders who have had both cystoplasty and AUS implantation. We compare the outcomes of those that regularly CISC with those that do not. METHODS: In this retrospective cohort study, 123 patients (77 male, 46 female) underwent augmentation cystoplasty, by a single surgeon, with implantation of an AUS. The cohort was divided into 2 groups. Group 1 (n1⁄467) performed CISC and group 2 (n1⁄456) did not. Mean age at time of initial surgery was 22 years (4.3-73 years). Mean follow up was 25 years (12-32 years). RESULTS: Of 123 patients, 85 (group 1 n1⁄442 vs. group 2 n1⁄443) had the AUS removed after a mean of 6.3 years (2 days 23.4 years). The mean time to explant was equal in groups 1 and 2 (6.4 years vs 6.2 years). In group 1, erosion occurred in 48.8%, infection in 2.4%, and malfunction 48.8%. The mean time to explant was 4.95 years (42 days 18 years) for erosion and 8.2 years (85 days 23.5 years) for malfunction. 1 patient had infection at 2 days. In group 2 the devices were removed due to erosion in 53.4%, and malfunction in 44.3%; after a mean of 5.1 years (60 days 21.4 years), and 9.6 years (0.7 23.5 years) respectively. There was 1 AUS removed for infection after 23 days. 51 patients went on to have a second AUS implanted with 28 (55%) being removed after a mean of 4.9 years, with 14 patients in each group. Erosion occurred in 39.2%, infection in 3.7%, and malfunction in 57.1%. The mean time to explant following erosion was similar in groups 1 and 2 (4.04 vs. 4.05 years). In group 1 there was one patient with infection at 91 days. There were no early infections in group 2. CONCLUSIONS: Patients with augmentation cystoplasty and an AUS developed erosion and infection at equal rates and mean time whether they performed CISC or not.