Britton E. Tisdale

Outcome of Penile Revascularization for Arteriogenic Erectile Dysfunction After Pelvic Fracture Urethral Injuries

OBJECTIVE To review our experience with penile revascularization for patients with bilateral occlusion of the deep internal pudendal arteries after pelvic fracture urethral injury (PFUI). MATERIALS AND METHODS We identified 17 patients who had undergone penile revascularization with end-to-side anastomosis of the deep inferior epigastric artery to the dorsal penile artery from July 1991 to December 2010. Success was defined as achieving erections sufficient for intercourse with or without pharmacologic assistance. RESULTS All patients had had a PFUI causing arterial insufficiency and erectile dysfunction not responsive to pharmacologic intervention. Of the 17 patients, 4 (24%) underwent revascularization before and 13 (76%) after PFUI repair. The mean age at revascularization was 32.7 years (range 17-54). At an average follow-up of 3.1 years, the surgery was successful in 14 of the 17 patients (82%). In patients with erectile dysfunction as an indication for surgery, successful erections were achieved in 11 of 13. For those who underwent revascularization to prevent ischemic stenosis of the urethral repair, 3 of 4 achieved successful erections, and all subsequent urethral surgeries were successful. The penile duplex ultrasound parameters showed clinically and statistically significant improvements after revascularization. No operative complications developed. The average hospital length of stay was 4.7 days. Four patients experienced early postoperative complications, including an abdominal wall hematoma requiring evacuation in one, penile edema in two, and a superficial surgical site infection in one. No late complications occurred. CONCLUSION Penile arterial revascularization in select patients can allow for successful treatment of PFUIs and the refractory erectile dysfunction caused by them.

Renal histopathology features according to various warm ischemia times in porcine laparoscopic and open surgery model

BACKGROUND Thirty minutes has been considered as the threshold for tolerable warm ischemic time (WIT). Recent reports demonstrate recovery of renal function after longer WIT. We assessed renal histology according to different WIT in a 2-kidney porcine model. METHODS Twelve female pigs were randomized to an open or laparoscopic group. Each pig was further randomized within each group to clamping the left renal artery for 5, 15, 30, 45, 60 or 180 minutes. Preclamping left renal biopsies were performed on each pig. The contralateral kidney in each animal was used as an individual control. On postoperative day 14, all animals underwent bilateral nephrectomies. Preclamping left renal biopsies and all renal specimens were evaluated by a blinded veterinary pathologist. RESULTS One pig died in the open group after 180 minutes of clamping. Histopathology did not show any significant changes between the two groups and across clamp times from 5 to 60 minutes. After 180 minutes of laparoscopic clamping, there was evidence of diffuse necrosis. INTERPRETATION Sixty minutes of ischemia did not show any permanent renal damage in both groups. Further studies are needed to verify these findings in humans. A prolonged ischemic time without permanent renal damage would be helpful in partial nephrectomy. Warm ischemic time of 180 minutes exceeded the renal ischemic burden based on histological features.

The urachal flap: a previously unreported tissue flap in vesicovaginal fistula repair.

Objectives Tissue interposition is an important part of vesicovaginal fistula (VVF) repair that has been shown to improve success rates. The most common interpositional flap used during a transabdominal VVF repair is the omental flap; however, in some cases, it cannot be used. The urachus is a well-vascularized tissue that is easily mobilized for interposition. We describe our experience using a urachal flap in VVF repair. Methods Patients undergoing VVF repair at our center were identified, and a retrospective chart review was performed. Patients who underwent a transabdominal repair with interposition of a urachal flap were included. Results Thirteen patients were identified between 2005 and 2009. All were evaluated with a history, physical, upper and lower tract imaging, and cystoscopy. Median patient age was 49 years (range, 31–88 years). Fistula etiology was hysterectomy in 11 and prolapse repair in 2. Five patients presented with recurrent fistulas having failed previous repair. Of 13 patients, 12 had successful repairs with our described technique, including 4 patients who failed previous repairs. There was no recurrence of fistula after median follow-up of 6 months (range, 2 weeks to 4 years). Two patients had preoperative and postoperative complaints of stress urinary incontinence that was mild and did not require surgery. Conclusions Vesicovaginal fistulas can be a difficult challenge for the reconstructive surgeon. The urachal flap is a well-vascularized tissue flap that can be easily mobilized and interposed for VVF repair. Of 13 patients in this series, 12 were successfully repaired using this technique. We feel that further evaluation and usage of this tissue flap are indicated.