Celeste Valadez

Urethroplasty for Radiotherapy Induced Bulbomembranous Strictures: A Multi-Institutional Experience

PURPOSE Radiotherapy induced urethral strictures are often difficult to manage due to proximal location, compromised vascular supply and poor wound healing. To determine the success of urethroplasty for radiation induced strictures we performed a multi-institutional review of men who underwent urethroplasty for urethral obstruction. MATERIALS AND METHODS A total of 30 men (mean age 67 years) underwent urethroplasty at 3 separate institutions. Excision with primary anastomosis was used in 24 of 30 patients (80%), with 4 of 30 requiring a genital fasciocutaneous skin flap and 2 a buccal graft. Hospitalization was less than 23 hours for 70% of the patients. Recurrence was defined as cystoscopic identification of urethral narrowing to less than 16Fr in diameter. RESULTS All strictures were located in the bulbomembranous region. Mean stricture length was 2.9 cm (range 1.5 to 7). External beam radiotherapy for prostate cancer was the etiology of stricture disease in 15 men (50%), with brachytherapy in 7 (24%) and a combination of the 2 modalities in 8 (26%). Successful urethral reconstruction was achieved in 22 men (73%) at a mean of 21 months. Mean time to stricture recurrence was 5.1 months (range 2 to 8). Two men required balloon dilation after stricture recurrence and none required urinary diversion. Incontinence was transient in 10% and persistent in 40%, with 13% requiring an artificial urinary sphincter. The rate of erectile dysfunction was unchanged following urethroplasty (47% preoperative, 50% postoperative). CONCLUSIONS Urethroplasty for radiation induced strictures has an acceptable rate of success and can be performed without tissue transfer techniques in most cases. Almost half of men will experience some degree of incontinence as a result of surgery but erectile function appears to be preserved.

Grafts are Unnecessary for Proximal Bulbar Reconstruction

PURPOSE We compared our experience with the reconstruction of proximal vs distal bulbar stricture to assess the role of excision and primary anastomosis vs graft procedures at each site. MATERIALS AND METHODS We reviewed all urethroplasties done by a single surgeon during a 2-year period. Data analyzed included patient history and demographics, operative details, stricture length and site, and clinical outcome. The proximal bulbar urethra was defined as the segment within 5 cm of the membranous urethra and the distal bulb was defined as the adjoining segment extending to the penoscrotal junction. Cases involving the pendulous or posterior urethra were excluded from study. RESULTS Of 210 urethroplasties from 2007 to 2009, 112 were done for bulbar strictures, including 72 (64%) for proximal bulbar strictures. All 72 cases were treated with excision and primary anastomosis. Median stricture length was 2 cm (range 1 to 5), although 31 of 72 strictures (43%) were of intermediate length (2.5 to 5 cm). Recurrence developed in 1 case (1.4%). Distal bulbar strictures in 40 of the 112 cases (36%) were treated predominantly with substitution urethroplasty in 36 (90%), and with excision and primary anastomosis in 4 (10%). Median stricture length was 3.75 cm (range 1.5 to 20). We noted intermediate length stricture in 18 of 40 cases (45%) and recurrence in 11 (28%). Of intermediate length strictures recurrence was much rarer after excision and primary anastomosis than after graft procedures (1 of 33 or 3.0% vs 6 of 16 or 38%, p<0.05). CONCLUSIONS Location is critical when selecting an appropriate technique for bulbar urethral reconstruction. Excision and primary anastomosis are superior to grafts in the proximal bulb. Grafts are often unnecessary for reconstructing proximal bulbar strictures 5 cm or less.

Urethral Rest: Role and Rationale in Preparation for Anterior Urethroplasty

OBJECTIVES To report the outcomes of men treated initially with a period of urethral rest to allow tissue recovery before anterior urethroplasty. Many men referred to referral centers for anterior urethral reconstruction often present soon after the endoscopic manipulation of severe strictures. METHODS We reviewed our database of all anterior urethroplasties performed by a single surgeon from 2007 to 2009. Urethral rest was accomplished by removal of the indwelling catheter, cessation of self-catheterization, and/or suprapubic urinary diversion before urethral reconstruction. RESULTS During the study period, 210 patients underwent urethral reconstruction at our center. Men who had undergone meatoplasty or posterior urethroplasty were excluded, leaving 128 anterior urethroplasty patients available for analysis. Of these men, 28 (21%) were preoperatively given an initial period of urethral rest (median duration 3 months) because of recent urologic manipulation occurring immediately before referral. Of the 28 patients, 15 (54%) received suprapubic catheters. Urethral rest promoted identification of severely fibrotic stricture segments, enabling focal or complete excision in 75% (excision and primary anastomosis in 12 [43%] and augmented anastomosis in 9 [32%]), a percentage similar to that for those undergoing reconstruction without preliminary manipulation mandating urethral rest (82%). Stricture recurrence developed in 4 (14%) of the 28 rest patients, a rate again similar to that for the remainder of the urethroplasty population (10%). CONCLUSIONS The results of our study have shown that recently manipulated anterior urethral strictures often declare themselves to be obliterative within several months of urethral rest, thus enabling successful urethroplasty by focal or complete excision.

Correlation of Penile and Bulbospongiosus Measurements: Implications for Artificial Urinary Sphincter Cuff Placement

PURPOSE We assessed penile and bulbospongiosus measurements to develop a quantitative guide to select the surgical approach (perineal vs transscrotal vs transcorporeal) to artificial urinary sphincter cuff placement. MATERIALS AND METHODS We retrospectively reviewed the intraoperative records of 100 men who underwent artificial urinary sphincter placement (43) or anastomotic urethroplasty (57) from February 2008 to June 2009. Correlations between penile (stretched length and circumference at the shaft base) and bulbospongiosus (distal and proximal circumference) measurements were assessed. Cases were analyzed according to 2 penile circumference groups, including group 1-8.0 cm or less and group 2-8.5 or more. RESULTS Mean proximal bulbospongiosus circumference was uniformly larger than distal bulbospongiosus circumference (4.5 vs 3.9 cm). It was about 50% of the penile shaft circumference (mean 8.9 cm, r = 0.70). In group 1 men the average distal bulbospongiosus circumference was 3.4 cm. They were more likely to undergo transcorporeal artificial urinary sphincter cuff placement than those in group 2, who had an average distal bulbospongiosus circumference of 4.1 cm (8 of 22 or 36% vs 1 of 21 or 5%, OR 11.4). Penile length correlated less robustly with distal and proximal bulbospongiosus circumference (r = 0.39 and 0.43, respectively). Patients with urethroplasty had significantly larger urethral measurements than those with the artificial urinary sphincter (proximal and distal bulbospongiosus circumference 4.9 vs 3.7 and 4.1 vs 3.2, respectively) but were significantly younger (47 vs 67 years), and less likely to have erectile dysfunction (11 of 57 vs 34 of 43) or to have undergone radical prostatectomy (0 of 57 vs 37 of 43). CONCLUSIONS Bulbospongiosus circumference appears to be proportional to penile circumference. The distal bulbospongiosus is uniformly smaller than the proximal bulbospongiosus. The potential need for a perineal or transcorporeal approach to artificial urinary sphincter placement can be anticipated by penile circumference measurements and a combination of clinical factors, such as older patient age, history of radical prostatectomy and impotence.