J. Francis Scott

Poor Quality of Life in Patients with Urethral Stricture Treated with Intermittent Self-Dilation

PURPOSE We assessed patient perceptions of regular intermittent self-dilation in men with urethral stricture. MATERIALS AND METHODS We constructed and distributed a visual analog questionnaire to evaluate intermittent self-dilation via catheterization by men referred for urethral stricture management at a total of 4 institutions. Items assessed included patient duration, frequency, difficulty and pain associated with intermittent self-dilation as well as interference of intermittent self-dilation with daily activity. The primary outcome was patient perceived quality of life. Multivariate analysis was performed to assess factors that affected this outcome. RESULTS Included in the study were 85 patients with a median age of 68 years, a median of 3.0 years on intermittent self-dilation and a median frequency of 1 dilation per day. On a 1 to 10 scale the median intermittent self-dilation difficulty was 5.0 ± 2.7, the median pain score was 3.0 ± 2.7 and median interference with daily life was 2.0 ± 1.3. Overall quality of life in patients with stricture was poor (median score 7.0 ± 2.6 with poor quality of life defined as 7 or greater). On univariate analysis younger age (p <0.01), interference (p = 0.03), pain (p <0.01) and difficulty performing intermittent self-dilation (p = 0.03) correlated with poor quality of life in a statistically significant manner. On multivariate analysis only difficulty catheterizing (p <0.01) and younger age (p = 0.05) were statistically significant predictors. Patients with stricture involving the posterior urethra had a statistically significant increase in difficulty and decrease in quality of life (each p = 0.04). CONCLUSIONS Most patients with urethral stricture who are on intermittent self-dilation rate difficulty and pain as moderate, and inconvenience as low but report poor quality of life.

Outcomes after urethroplasty for radiotherapy induced bulbomembranous urethral stricture disease.

PURPOSE We recently demonstrated that radiotherapy induced urethral strictures can be successfully managed with urethroplasty. We increased size and followup in our multi-institutional cohort, and evaluated excision and primary anastomosis as treatment for radiotherapy induced urethral strictures. MATERIALS AND METHODS A retrospective review was performed of 72 patients from 3 academic institutions treated for radiotherapy induced bulbomembranous strictures. Outcome parameters of successful repair included recurrence, incontinence and erectile dysfunction. RESULTS Among the 72 men treated for radiotherapy induced strictures 66 (91.7%) underwent excision and primary anastomosis. Mean followup was 3.5 years (median 3.1, range 0.8 to 11.2). Prostate cancer was the most common reason for radiotherapy (in 64 of 66, 96.9%). External beam radiotherapy and brachytherapy were performed in 28 of 66 men (42.4%) each, and a combination of both was performed in 9 (13.6%). Mean time from radiation to excision and primary anastomosis was 6.4 years (range 1 to 20) and mean stricture length was 2.3 cm (range 1 to 6). Successful reconstruction was achieved in 46 men (69.7%). Mean time to recurrence was 10.2 months (range 1 to 64) with new onset of incontinence observed in 12 men (18.5%). This was associated with stricture length greater than 2 cm (p = 0.013) and treatment center (p <0.001). The rate of erectile dysfunction remained stable (preoperative 45.6%, postoperative 50.9%, p = 0.71). Radiotherapy type did not affect stricture length (p = 0.41), recurrence risk (p = 0.91), postoperative incontinence (p = 0.88) or erectile dysfunction (p = 0.53). CONCLUSIONS Radiotherapy induced bulbomembranous urethral strictures can be successfully managed with excision and primary anastomosis. Substitution urethroplasty with graft or flap is needed infrequently. Patients should be counseled on the potential risks of urinary incontinence and erectile dysfunction.

3.5 cm Artificial Urinary Sphincter Cuff Erosion Occurs Predominantly in Irradiated Patients

PURPOSE We analyzed our initial 100-case experience with the 3.5 cm artificial urinary sphincter cuff to identify risk factors for cuff erosion. MATERIALS AND METHODS We reviewed the records of a single surgeon, consecutive series of patients treated with 3.5 cm artificial urinary sphincter cuff placement from September 2009 to August 2013. Each patient underwent single perineal cuff placement via standardized technique. Preoperative characteristics, technical considerations and postoperative outcomes were analyzed and compared to those in a cohort of patients in whom a larger (4.0 cm or greater) artificial urinary sphincter cuff was placed during the same period. We identified clinical factors associated with an increased risk of 3.5 cm artificial urinary sphincter cuff erosion. RESULTS Of the 176 men who met study inclusion criteria during the 4-year period 100 (57%) received the 3.5 cm artificial urinary sphincter cuff and 76 (43%) received a larger cuff (4.0 cm or greater). The continence rate (83% vs 80%, p = 0.65) and mean followup (32 vs 25 months, p = 0.14) were similar in the 2 groups. Erosion developed in 16 of the 176 patients (9%) during the study period, of whom 13 had the 3.5 cm cuff. Of the 100 patients with the 3.5 cm cuff 52 (52%) had a history of radiation, including 11 (21%) with erosion. Cuff erosion developed only rarely in nonirradiated men (2 of 48 or 4%, p = 0.01). A history of radiation was the only significant risk factor associated with 3.5 cm cuff erosion (OR 6.2, 95% CI 1.3-29.5). CONCLUSIONS Men with a history of radiation who underwent placement of a 3.5 cm artificial urinary sphincter cuff experienced an increased (21%) risk of cuff erosion.

Immediate Urethral Repair during Explantation Prevents Stricture Formation after Artificial Urinary Sphincter Cuff Erosion

PURPOSE We compare stricture outcomes in patients with artificial urinary sphincter cuff erosion managed with and without synchronous urethral repair. MATERIALS AND METHODS Records of patients who underwent artificial urinary sphincter removal for cuff erosion from 2007 to 2013 were retrospectively reviewed. Two cohorts of patients were evaluated, with those in group 1 treated with in situ urethroplasty and those in group 2 treated with a Foley catheter only. We compared demographic, clinical and radiological data to assess resultant stricture disease, and compared operative times between the cohorts. RESULTS Of the 26 artificial urinary sphincter cuff erosion cases identified 13 underwent in situ urethroplasty while 13 did not. Mean patient age was 73 years (range 61 to 83) with a mean followup of 24 months (range 8 to 69). The rate of urethral stricture formation after artificial urinary sphincter explantation was significantly reduced among patients treated with in situ urethroplasty (5 of 13, 38%) compared to those treated with Foley catheter only (11 of 13, 85%; p=0.047). Mean operative times were similar at 78 minutes (50 to 133) for the in situ urethroplasty group vs 70 minutes (51 to 92) for the Foley catheter only group (p=0.39). Those treated with in situ urethroplasty underwent significantly fewer procedures per patient before artificial urinary sphincter replacement (0.4 vs 1.1, p=0.004) and had a much higher rate of eventually undergoing secondary artificial urinary sphincter implantation (7 of 13, 54% vs 2 of 13, 15%, p=0.04) compared to those with cuff erosion treated with Foley catheter only. CONCLUSIONS Urethral repair at the time of artificial urinary sphincter explantation for cuff erosion appears to prevent stricture development, thus facilitating successful artificial urinary sphincter replacement.

PD20-05 COST EFFECTIVENESS OF ACUTE INSERTION OF MALLEABLE PENILE PROSTHESIS FOR REFRACTORY ISCHEMIC PRIAPISM IN PUBLIC HOSPITAL SETTING

METHODS: At eight centers a total of fifteen patients with locally positive, but no systemic signs and symptoms of wound / IPP infection were reviewed. If the patient had systemic / septic symptoms, immediate surgical treatment was performed. Basic patient demographics and post-operative data were acquired. All patients were carefully and frequently followed on one to two oral antibiotics. RESULTS: Fifteen patients were retrospectively reviewed. Demographics reveal age of 47 to 70 (mean 59.4), 7 of 15 (47%) being diabetic, 12 Titans / 1 700 / 1 Genesis / 1 Ambicor [has no infection retardant coating] and 11 (73%) were primary implantation with 3 (20%) being replacements and 1 (6.7%) into previous infected IPP scarred corporal bodies. Time to local wound / IPP infection after implantation was 7 to 40 days (mean 20.4 days), 14 (93 %) had incisional wound drainage with some described as large quality of fluid, 3 (20%) had significant swelling, 1 (6.7%) had device skin fixation and 4 (27%) of the 15 patients had significant increase in IPP pain / tenderness. 9 different bacteria isolates were cultured out of the incisional drainage of 7 patients with 3 Staph Epi, 2 pseudomonas, 1 enterococcus, 2 E. coli, 1 staph aurerus, 1 alpha streptococcus and 1 proteus growths. Time to total resolution of symptoms was 21 to 141 (mean 76.2) days with 13 patients having total resolution of symptoms and two currently under observation. CONCLUSIONS: Observation maybe an option for patients with local signs / symptoms of IPP infection, even with incisional drainage of culture positive bacteria, that traditionally indicated immediate surgical intervention. The authors strongly feel that from a medical legal issue this information is important to get into the literature.

V1584 TRANS-SCROTAL PLICATION FOR PEYRONIE'S DISEASE WITH SYNCHRONOUS PENILE IMPLANT

INTRODUCTION AND OBJECTIVES: Current standard management of Peyronie’s disease with erectile dysfunction involves penile prosthesis placement with manual modeling. We report an alternative technique utilizing synchronous penile plication and inflatable penile prosthesis (IPP) placement. METHODS: An artificial erection is induced with injectable saline and a penile tourniquet to identify the nature of the penile curvature. A 2 cm penoscrotal incision is made and mobilized over the convex aspect of the penile curvature. The dissection is carried down through dartos and Buck’s fascia. The incision is then mobilized distally along the shaft to allow placement of multiple parallel plicating sutures (braided, nonabsorbable polyester) in the tunica albuginea until the curvature is completely corrected. IPP placement is then immediately performed through the same incision in a standard fashion. Patients were administered a postoperative survey to identify functional outcomes and patient satisfaction. RESULTS: Sixteen patients have undergone synchronous penile plication with IPP placement. Preoperative penile curvature was a mean of 43 degrees compared with 4 degrees post-procedure. We achieved approximately 8 degrees of correction with each plication suture. Of the 10 patients who completed the survey, 90% described their penile curvature as much better and 10% as slightly better. No patients have had infection or have required reoperation. CONCLUSIONS: Penile plication with concomitant IPP placement is an effective, safe, and controlled method for treatment of Peyronie’s disease with erectile dysfunction.