Brendan Browne

Management of Radiation Anterior Prostato-symphyseal Fistulas With Interposition Rectus Abdominis Muscle Flap

OBJECTIVE To describe a novel, organ-sparing approach for reconstruction of radiation-induced anterior prostato-symphyseal fistulas (PSFs) at our institution over a consecutive 10-year period. MATERIALS AND METHODS We performed a retrospective review of patients undergoing surgical reconstruction for anterior PSF between January 1, 2006 and October 31, 2015. Patient demographics as well as preoperative, operative, and postoperative data were reviewed, including etiology of fistula, surgical management, and outcomes. RESULTS A total of 4 patients with anterior PSF underwent organ-sparing reconstruction. All fistulas were the result of previous pelvic radiation. All 4 patients presented with pubic osteomyelitis. Patients underwent pubic symphysis debridement, fistula closure, and placement of an interposition rectus abdominis muscle flap. At a median follow-up of 27 months, 100% of the patients undergoing repair with interposition rectus flap were closed with 1 procedure. CONCLUSION Radiation-induced PSF can be successfully reconstructed with pubic symphysis debridement and fistula closure using an adjunct rectus abdominis interposition flap, avoiding prostatectomy and urinary diversion.

An analysis of staging and treatment trends for upper tract urothelial carcinoma in the National Cancer Database

Micro‐Abstract Kidney‐sparing surgery for upper tract urothelial carcinoma (UTUC) has recently shown good outcomes for low‐risk patients in lieu of nephroureterectomy. We used the National Cancer Database to analyze trends in practice patterns for UTUC. Use of ureteroscopic biopsy and laser ablation has increased over the past decade with decreases in nephroureterectomy as clinicians increasingly use these techniques. Background: The purpose of this study was to analyze contemporary trends for diagnosis and treatment of upper tract urothelial carcinoma (UTUC). Patients and Methods: We identified all cases of UTUC in the National Cancer Database (NCDB) between 2004 and 2013. Data comprising tumor, patient, and facility factors were extracted. Treatment data for surgery and chemotherapy were also collected. Comparisons used χ2 testing. Results: Over this 10‐year period, the sex and age distribution of UTUC was stable at 60% male and median age of 72 years. Most tumors were < cT2 at diagnosis, with an upward trend over 10 years (66% to 72%; P < .001). However, presentation with clinical metastatic disease also rose, from 4.6% to 8.9% (P < .001). Primary tumor biopsy increased from 37% to 50%. Overall rate of nephroureterectomy decreased from 59.6% to 56.7% whereas endoscopic ablation increased from 9.8% to 11.5%. Ablation was much more common in < cT2 tumors than ≥ cT2 (18.3% vs. 3.7%) and for low‐grade tumors than high‐grade (22.6% vs. 5.9%). Neoadjuvant chemotherapy was significantly more used, but still at a low rate. Conclusion: Treatment of UTUC appears to be shifting toward conservative surgical management with tumor ablation, and increasing neoadjuvant chemotherapy use. More primary tumor biopsies are being performed, likely reflecting improved ureteroscopic instruments and training. The NCDB also reports an increase in metastatic disease, which must be interpreted cautiously and might be artifactual.

Use of Alternative Techniques and Grafts in Urethroplasty

The current management for complex urethral strictures commonly uses open reconstruction with buccal mucosa urethroplasty. However, there are multiple situations whereby buccal mucosa is inadequate (eg, pan-urethral stricture or prior buccal harvest) or inappropriate for utilization (eg, heavy tobacco use or oral radiation). Multiple options exist for use as alternatives or adjuncts to buccal mucosa in complex urethral strictures. This article reviews the current state of alternate techniques for urethral stricture treatment besides buccal mucosa, including injectable antifibrotic agents, augmentation urethroplasty with skin flaps, lingual mucosa, colonic mucosa, and new developments in tissue engineering for urethral graft material.

Management of Urethral Stricture and Bladder Neck Contracture Following Primary and Salvage Treatment of Prostate Cancer

Purpose of ReviewThis article discusses the incidence, evaluation, and treatment of bladder outlet obstruction from urethral stricture, vesicourethral anastomotic stricture, and bladder neck contracture following primary and salvage treatment of prostate cancer.Recent FindingsRates of stenosis after prostate cancer treatment appear similar across all primary treatment modalities including radical prostatectomy, radiation therapy, cryoablation, and high-intensity focused ultrasound in contemporary series. Urethral dilation and urethrotomy continue to report moderate patency rates. Urethroplasty achieves high patency rates even for long strictures, but more extensive reconstruction increases the risk of postoperative urinary incontinence. Recent AUA guidelines on urethral strictures provide new recommendations for management of these patients.SummaryAll treatment options for prostate cancer carry a risk for bladder outlet obstruction, and intervention is often necessary to relieve long-lasting morbidity. Careful preoperative evaluation should be completed to assess location and extent of the stricture in order to choose optimal therapy. Endoscopic treatments, open reconstruction, and urinary diversion all play a role in relief of stenosis depending on stricture length, location, characteristics, and patient comorbidities.

Short- and Long-term Complications and Outcomes of Radiation and Surgically Induced Rectourethral Fistula Repair With Buccal Mucosa Graft and Muscle Interposition Flap

OBJECTIVE To analyze and report 30-day, 90-day, and long-term complications and surgical outcomes over a 17-year period for anterior transperineal repair of rectourethral fistulas (RUFs) resulting from pelvic radiation and surgery. MATERIALS AND METHODS We performed a retrospective review of patients undergoing RUF repair between January 1, 1998 and February 28, 2015, at a single institution. All RUF were repaired using an anterior transperineal approach with an interposition muscle flap and selective use of a buccal mucosa graft onlay. RESULTS Ninety-eight patients underwent repair with an anterior transperineal approach and muscle interposition flap (49 non-radiation induced and 49 radiation or ablation induced). Thirty- and 90-day complication rates were 29% and 2%, respectively, for non-radiated RUF, and 29% and 24%, respectively, for radiated RUF. Urethral diverticula, urinary incontinence, urethral stricture, and bowel problems were delayed complications requiring surgery. At a median follow-up of 14.5 months (range 3-144), 98% (48 of 49) of non-radiated RUF were closed with 1 procedure, whereas 86% (42 of 49) of radiated RUF were closed with 1 procedure. Gastrointestinal tract continuity was restored in 94% (45 of 48) of non-radiated RUF and in 65% (30 of 46) of radiated RUF. CONCLUSION Successful RUF closure is possible in 98% of non-radiated and in 86% of radiated or ablated patients with 1 procedure. Most radiation-induced RUF, regardless of size, can be successfully repaired with minimal short-term complications. Delayed complications may arise and require surgery, and thus continued surveillance is recommended.

MicroRNA expression profiles in upper tract urothelial carcinoma differentiate tumor grade, stage and survival: implications for clinical decision-making

OBJECTIVE To evaluate microRNA (miRNA) biomarkers for upper tract urothelial carcinoma (UTUC) to improve risk stratification. METHODS miRNA was isolated from 157 radical nephroureterectomy specimens from 2 institutions. The relative expression of miRNA was examined for high grade vs low grade tumors as well as muscle invasive vs nonmuscle invasive tumors. Recurrence free survival (RFS) and overall survival (OS) were also stratified using relative expression of specific miRNA. RESULTS The optimized model to identify high grade UTUC included miR-29b-2-5p, miR-18a-5p, miR-223-3p, and miR-199a-5p, generating a sensitivity of 83%, specificity of 85%, and generated a receiver operating characteristic (ROC) curve with area-under-the-curve of 0.86. Similarly, the model classifier for predicting ≥pT2 disease incorporated miR-10b-5p, miR-26a-5p-5p, miR-31-5p, and miR-146b-5p, producing a sensitivity of 64%, specificity of 96%, and area-under-the-curve of 0.90. RFS was best reflected by a combination of miR-10a-5p, miR-30c-5p, and miR-10b-5p, while OS was best predicted by miR-10a-5p, miR-199a-5p, miR-30c-5p, and miR-10b-5p. CONCLUSION High-grade vs low-grade as well as muscle invasive vs nonmuscle invasive UTUC can be reliable distinguished with unique miRNA signatures. Furthermore, differential expression of UTUC miRNA produces robust classifiers for predicting RFS and OS that may help identify patients who would most benefit from adjuvant therapies.