Bradley A. Erickson

Prospective Analysis of Erectile Dysfunction After Anterior Urethroplasty: Incidence and Recovery of Function

PURPOSE Anterior urethroplasty has been shown to negatively impact erectile function. Recovery of function is common but the likelihood and extent of recovery have not been fully elucidated. MATERIALS AND METHODS Between October 2006 and May 2008 men undergoing anterior urethroplasty were enrolled in a prospective study to evaluate the effects of urethroplasty on erectile function. The International Index of Erectile Function was completed preoperatively and on all subsequent postoperative visits. Preoperative and postoperative erectile function was compared. RESULTS A total of 52 patients who underwent anterior urethroplasty were included in the study. Repair locations were bulbar (35) and penile (17). Of the patients undergoing bulbar urethroplasty 20 had excision and primary anastomosis, and 15 had augmented anastomotic repair. All penile repairs were ventral onlay repair (11) or inlay repair in 2 stages (6). Postoperative erectile dysfunction was noted in 20 (38%) men, of whom 18 recovered fully at a mean postoperative period of 190 days (range 92 to 398). In patients with normal preoperative erectile function bulbar urethroplasty was more likely than penile urethroplasty to cause erectile dysfunction (76% vs 38%, p = 0.05). Within the bulbar urethra excision and primary anastomosis repairs led to slightly higher erectile dysfunction rates than augmented anastomotic repairs (50% vs 26%, p = 0.16). CONCLUSIONS Anterior urethroplasty caused erectile dysfunction in approximately 40% of patients, although recovery was seen in most by 6 months. Bulbar urethroplasty appears to affect erectile function to a greater extent than penile urethroplasty, which may be explained by the proximity of the bulbar urethra to the nerves responsible for erection.

Risk Factors for Erosion of Artificial Urinary Sphincters: A Multicenter Prospective Study

OBJECTIVE To evaluate the short- to medium-term outcomes after artificial urinary sphincter (AUS) placement from a large, multi-institutional, prospective, follow-up study. We hypothesize that along with radiation, patients with any history of a direct surgery to the urethra will have higher rates of eventual AUS explantation for erosion and/or infection. MATERIALS AND METHODS A prospective outcome analysis was performed on 386 patients treated with AUS placement from April 2009 to December 2012 at 8 institutions with at least 3 months of follow-up. Charts were analyzed for preoperative risk factors and postoperative complications requiring explantation. RESULTS Approximately 50% of patients were considered high risk. High risk was defined as patients having undergone radiation therapy, urethroplasty, multiple treatments for bladder neck contracture or urethral stricture, urethral stent placement, or a history of erosion or infection in a previous AUS. A total of 31 explantations (8.03%) were performed during the follow-up period. Overall explantation rates were higher in those with prior radiation and prior UroLume. Men with prior AUS infection or erosion also had a trend for higher rates of subsequent explantation. Men receiving 3.5-cm cuffs had significantly higher explantation rates than those receiving larger cuffs. CONCLUSION This outcomes study confirms that urethral risk factors, including radiation history, prior AUS erosion, and a history of urethral stent placement, increase the risk of AUS explantation in short-term follow-up.

Erectile function, sexual drive, and ejaculatory function after reconstructive surgery for anterior urethral stricture disease

Associate Editor

Bladder neck contracture after retropubic radical prostatectomy: Incidence and risk factors from a large single-surgeon experience

To examine a large, single‐surgeon series of patients with prostate cancer who underwent retropubic radical prostatectomy (RRP) for men with postoperative bladder neck contractures (BNCs).

Urology Resident Publication Output and Its Relationship to Future Academic Achievement

PURPOSE Scholarly research is considered by many to be an important component of residency training but little is known about the quantity and types of publications produced by urology residents. To our knowledge whether publication efforts during residency predict future academic publication performance is also unknown. We evaluated resident productivity, as measured by peer reviewed publication output, and determined its relation to future publication output as junior faculty. MATERIALS AND METHODS We assembled a list of graduating residents from 2002 to 2004 who were affiliated with the top 50 urology hospitals, as ranked in 2009 by U.S. News&World Report. PubMed® was queried to determine the publication total in the last 3 years of residency of each individual and during years 2 to 4 after residency graduation. Resident publication output was stratified by research time and fellowship training. The relationship between resident productivity and future achievement was assessed. RESULTS We assessed the publication output of 251 urologists from a total of 34 training programs affiliated with the top 50 urology hospitals. Subjects published a mean total of 3.5 and a mean of 2.0 first author papers during training. Greater research time during residency was associated with increased productivity during and after residency. Publication during training correlated with publication during the early academic career. CONCLUSIONS Publication output correlated with increasing dedicated research time and was associated with the pursuit of fellowship training and an academic career. Publication during residency predicted future academic achievement.

The Use of Uroflowmetry to Diagnose Recurrent Stricture After Urethral Reconstructive Surgery

PURPOSE The ability of uroflowmetry to diagnose recurrent stricture disease after urethroplasty has not been fully investigated. MATERIALS AND METHODS Our routine post-urethroplasty monitoring includes retrograde urethrogram and voiding cystourethrogram at 3 and 12 months, in addition to uroflowmetry at 3-month intervals for a year. All uroflowmetry data, including maximum flow rate, voided volume and voiding curve shape, as well as retrograde urethrogram/voiding cystourethrogram and voiding symptom data are stored in a prospectively maintained urethroplasty database that was analyzed for patients with postoperative retrograde urethrogram/voiding cystourethrogram and satisfactory uroflowmetry in the same period. Uroflowmetry data points and urinary symptoms were compared with corresponding findings on retrograde urethrogram/voiding cystourethrogram to determine the ability of uroflowmetry to predict recurrence. RESULTS A total of 278 men (68%) met study inclusion criteria, of whom 63 (23%) had recurrent stricture. Using a maximum flow rate of less than 10 ml per second resulted in only 54% test sensitivity to predict recurrence. The highest sensitivity and negative predictive value (each 99%) were achieved when all men with symptoms and/or obstructed flow curves were evaluated. Symptoms alone had a high specificity (87%), sensitivity (88%) and negative predictive value (95%). CONCLUSIONS Uroflowmetry is an adequate test to screen for postoperative stricture recurrence but only when the voiding curve and urinary symptoms are also evaluated. The flow rate alone does not appear to be a reliable tool to evaluate stricture recurrence.

Bladder tissue engineering through nanotechnology

The field of tissue engineering has developed in phases: initially researchers searched for “inert” biomaterials to act solely as replacement structures in the body. Then, they explored biodegradable scaffolds—both naturally derived and synthetic—for the temporary support of growing tissues. Now, a third phase of tissue engineering has developed, through the subcategory of “regenerative medicine.” This renewed focus toward control over tissue morphology and cell phenotype requires proportional advances in scaffold design. Discoveries in nanotechnology have driven both our understanding of cell–substrate interactions, and our ability to influence them. By operating at the size regime of proteins themselves, nanotechnology gives us the opportunity to directly speak the language of cells, through reliable, repeatable creation of nanoscale features. Understanding the synthesis of nanoscale materials, via “top-down” and “bottom-up” strategies, allows researchers to assess the capabilities and limits inherent in both techniques. Urology research as a whole, and bladder regeneration in particular, are well-positioned to benefit from such advances, since our present technology has yet to reach the end goal of functional bladder restoration. In this article, we discuss the current applications of nanoscale materials to bladder tissue engineering, and encourage researchers to explore these interdisciplinary technologies now, or risk playing catch-up in the future.

Multi-institutional analysis of sequential intravesical gemcitabine and mitomycin C chemotherapy for non–muscle invasive bladder cancer

OBJECTIVE Apart from cystectomy, few treatment options exist for the management of bacillus Calmette-Guerin refractory non-muscle invasive bladder cancer (NMIBC). We report a multi-institutional experience with sequential intravesical combination chemotherapy using gemcitabine and mitomycin C (MMC) for NMIBC in the treatment of high-risk patients. METHODS We performed a retrospective review of patients who received 6 weekly treatments with sequential intravesical gemcitabine (1g) and MMC (40 mg) chemotherapy for NMIBC. Gemcitabine was administered first and retained for 90 minutes and then drained. MMC was then administered directly after and retained for an additional 90 minutes. Forty-seven patients received treatment from 3 academic tertiary referral centers between 2000 and 2010. RESULTS Forty-seven patients (median age 70, range 32-85; 36 males, 11 females) who previously failed a median of 2 intravesical treatments were reviewed. Complete response, 1-year, and 2-year recurrence-free survival rates for all patients were 68%, 48%, and 38%, respectively. Median recurrence-free survival for all patients was 9 months (range 1-80). Fourteen of 47 patients (30%) remained free of recurrence with a median time to follow-up of 26 months (range 6-80 mo). Ten patients required cystectomy. CONCLUSION Sequential intravesical combination chemotherapy using gemcitabine and MMC appears to be a useful treatment for patients with high-grade NMIBC as well as those with prior bacillus Calmette-Guerin failure. Further prospective studies are warranted.

Changes in Uroflowmetry Maximum Flow Rates After Urethral Reconstructive Surgery as a Means to Predict for Stricture Recurrence

PURPOSE A reliable, noninvasive screening method for urethral stricture recurrence after urethroplasty is needed. We hypothesized that changes in flow rates on uroflowmetry relative to preoperative values might help predict stricture recurrence. MATERIALS AND METHODS All men who underwent urethral reconstructive surgery from 2000 to 2009 with adequate preoperative and postoperative uroflowmetry studies were included in the study. Preoperative and postoperative maximum flow rates were compared. The absolute change in maximum flow rate was compared between patients with and those without recurrence as determined by retrograde urethrogram. RESULTS A total of 125 patients treated with urethroplasty were included in the study. Mean ± SD preoperative maximum flow rate was 11.8 ± 9.1 ml per second, which did not vary by stricture length (p = 0.11), patient age (p = 0.46) or stricture location (p = 0.58). The change in maximum flow rate in men without recurrence was 19.2 ± 11.7 vs 0.2 ± 6.4 ml per second (p <0.001) in failed repairs. Setting a change in maximum flow rate of less than 10 ml per second as a screen for stricture recurrence would have resulted in a test sensitivity and specificity of 92% and 78%, respectively. There were 85 men without stricture recurrence who underwent more than 1 postoperative uroflowmetry study. Repeated maximum flow rate values achieved reasonable test reproducibility (r = 0.52), further supporting the use of uroflowmetry. CONCLUSIONS Change in flow rate after urethral reconstruction represents a promising metric to screen for stricture recurrence that is noninvasive and has a high sensitivity.

Staged Reconstruction of Long Segment Urethral Strictures in Men With Previous Pediatric Hypospadias Repair

PURPOSE Reconstruction of long segment urethral stricture disease in adults with a history of pediatric hypospadias repair remains complex secondary to poor urethral blood supply, extensive penile scarring and the need for significant amounts of graft or flap tissue. We describe our experience with staged urethroplasty in this cohort of men. MATERIALS AND METHODS A total of 15 males underwent staged urethroplasty for urethral stricture disease following previous hypospadias repair in childhood. All men underwent 2-stage repair with a minimum of 6 months separating each operation. Bulbar urethral stricture disease due to previous dilation was seen in 2 of the 15 men (14%). Graft sources included buccal mucosa in 12 cases, full-thickness hairless abdominal wall skin in 2, penile skin in 1 and posterior auricular tissue in 1. RESULTS Median patient followup was 22 months (range 5 to 62) after stage 2 closure. Median patient age at presentation was 31 years (range 19 to 57). Mean stricture length was 8 cm (range 5 to 14) and mean graft area was 22 cm(2) (range 10 to 38). There was no clinical evidence of stricture recurrence, fistula or wound dehiscence at last followup in 13 of the 15 men (86%). Two men with a congenital hypoplastic glans were left with distal hypospadias. Minor voiding symptoms were described in 3 of the 15 men (21%) with resolution in all by 6 months postoperatively. CONCLUSIONS We describe outcomes after staged reconstruction for extensive urethral stricture disease in men after previous pediatric hypospadias repair in childhood. At intermediate followup staged urethroplasty provided acceptable outcomes.