Jeremy B. Myers

Multivariate Analysis of Risk Factors for Long-Term Urethroplasty Outcome

PURPOSEnWe studied the patient risk factors that promote urethroplasty failure.nnnMATERIALS AND METHODSnRecords of patients who underwent urethroplasty at the University of California, San Francisco Medical Center between 1995 and 2004 were reviewed. Cox proportional hazards regression analysis was used to identify multivariate predictors of urethroplasty outcome.nnnRESULTSnBetween 1995 and 2004, 443 patients of 495 who underwent urethroplasty had complete comorbidity data and were included in analysis. Median patient age was 41 years (range 18 to 90). Median followup was 5.8 years (range 1 month to 10 years). Stricture recurred in 93 patients (21%). Primary estimated stricture-free survival at 1, 3 and 5 years was 88%, 82% and 79%. After multivariate analysis smoking (HR 1.8, 95% CI 1.0-3.1, p = 0.05), prior direct vision internal urethrotomy (HR 1.7, 95% CI 1.0-3.0, p = 0.04) and prior urethroplasty (HR 1.8, 95% CI 1.1-3.1, p = 0.03) were predictive of treatment failure. On multivariate analysis diabetes mellitus showed a trend toward prediction of urethroplasty failure (HR 2.0, 95% CI 0.8-4.9, p = 0.14).nnnCONCLUSIONSnLength of urethral stricture (greater than 4 cm), prior urethroplasty and failed endoscopic therapy are predictive of failure after urethroplasty. Smoking and diabetes mellitus also may predict failure potentially secondary to microvascular damage.

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

OBJECTIVEnTo 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.nnnMATERIALS AND METHODSnA 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.nnnRESULTSnApproximately 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.nnnCONCLUSIONnThis 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.

Vascular endothelial growth factor (VEGF) gene therapy using a nonviral gene delivery system improves erectile function in a diabetic rat model

Erectile dysfunction (ED) is a cause of decreased quality of life in more than 70% of diabetic men. Vascular endothelial growth factor (VEGF) has shown to improve overall endothelial and smooth muscle cell dysfunction in models of ED. We describe a novel technique for nonviral, in vivo gene transfection of VEGF in the rat corpus cavernosum. Diabetic rats were transfected with DNA encoding a fusion VEGF/green fluorescent protein (GFP) complex and fluorescence microscopy was used to monitor the expression of VEGF–GFP fusion protein. Western blot and PCR analyses confirmed the expression of the GFP–VEGF fusion protein and mRNA. Functional studies using cavernous nerve stimulation revealed maximal intracavernous pressures (ICPs) of 63.1u2009mmu2009Hg, and 30.7u2009mmu2009Hg in the normal and diabetic control groups, respectively, and 47.4u2009mmu2009Hg in VEGF–GFP-transfected diabetic group. Immunohistochemical analysis of the cavernosal tissue from transfected rats showed increased smooth muscle content compared with the diabetic control group. We show for the first time in our animal model that expression of the transfected VEGF in cavernosal tissue leads to an overall improvement of maximal ICP and smooth muscle content. On the basis of these results, it is tempting to speculate that our nonviral vector system offers an excellent system for gene delivery into cavernosal tissue, and that VEGF gene therapy using this system could be useful in improving erectile function in diabetic men.

Repeat Urethroplasty After Failed Urethral Reconstruction: Outcome Analysis of 130 Patients

PURPOSEnMale urethral stricture disease accounts for a significant number of hospital admissions and health care expenditures. Although much research has been completed on treatment for urethral strictures, fewer studies have addressed the treatment of strictures in men with recurrent stricture disease after failed prior urethroplasty. We examined outcome results for repeat urethroplasty.nnnMATERIALS AND METHODSnA prospectively collected, single surgeon urethroplasty database was queried from 1977 to 2011 for patients treated with repeat urethroplasty after failed prior urethral reconstruction. Stricture length and location, and repeat urethroplasty intervention and failure were evaluated with descriptive statistics, and univariate and multivariate logistic regression.nnnRESULTSnOf 1,156 cases 168 patients underwent repeat urethroplasty after at least 1 failed prior urethroplasty. Of these patients 130 had a followup of 6 months or more and were included in analysis. Median patient age was 44 years (range 11 to 75). Median followup was 55 months (range 6 months to 20.75 years). Overall, 102 of 130 patients (78%) were successfully treated. For patients with failure median time to failure was 17 months (range 7 months to 16.8 years). Two or more failed prior urethroplasties and comorbidities associated with urethral stricture disease were associated with an increased risk of repeat urethroplasty failure.nnnCONCLUSIONSnRepeat urethroplasty is a successful treatment option. Patients in whom treatment failed had longer strictures and more complex repairs.

Treatment of Adults with Complications from Previous Hypospadias Surgery

PURPOSEnAdults with complications from previous hypospadias surgery experience various problems, including urethral stricture, persistent hypospadias and urethrocutaneous fistula. Innate deficiencies of the corpus spongiosum and multiple failed operations makes further management challenging.nnnMATERIALS AND METHODSnWe reviewed our prospective urethroplasty database of men who presented with complications of previous hypospadias surgery. Patients were included in study if they had greater than 6 months of followup. Our surgical management was defined as an initial success if there were no urethral complications. The overall success rate included men with the same result after additional treatment.nnnRESULTSnA total of 50 men had followup greater than 6 months (median 89) and were included in study. These 50 patients presented with urethral stricture (36), urethrocutaneous fistula (12), persistent hypospadias (7), hair in the urethra (6) and severe penile chordee (7). Patients underwent a total of 74 urethroplasties, including stage 1 urethroplasty in 19, a penile skin flap in 11, stage 2 urethroplasty in 11, urethrocutaneous fistula closure in 9, permanent perineal urethrostomy in 6, excision and primary anastomosis in 6, a 1-stage buccal mucosa onlay in 4, tubularized plate urethroplasty in 3, combined techniques in 3 and chordee correction in 1. In 25 men (50%) treatment was initially successfully. Of the 25 men in whom surgery failed 18 underwent additional procedures, including 13 who were ultimately treated successfully for an overall 76% success rate (38 of 50).nnnCONCLUSIONSnManaging problems from previous hypospadias surgery is difficult with a high initial failure rate. Additional procedures are commonly needed.

Urologic problems in spina bifida patients transitioning to adult care.

OBJECTIVEnTo identify the urologic needs of adult patients with spina bifida (SB) at the time of their transition from pediatric to adult care. We hypothesized that delays in transition to adult care would be associated with higher rates of active problems.nnnMETHODSnWe retrospectively reviewed patients seen at adult dedicated SB clinics at the Universities of Utah and Minnesota from April 2011 to April 2012. We reviewed bladder management, urologic problems, time from last urologic care, and necessary interventions.nnnRESULTSnWe identified 65 patients from these clinics with SB. The mean age was 30.6xa0years (standard deviation, 11.3). The median time since last urologic evaluation at Utah and Minnesota was 17xa0months and 12xa0months, respectively (range 1xa0month-10xa0years). Fifty-five patients (85%) reported a urologic problem at the time of their visit. Urinary incontinence was most common in 34 (52%), followed by recurrent urinary tract infection in 22 (34%), catheterization troubles in 8 (12%), and calculi in 6 (9%). Sixty-three patients (97%) required some sort of intervention. These were diagnostic (cystoscopy, ultrasonography, computed tomography scan, urodynamics) in 50 patients (77%), surgical (urinary diversion, onabotulinum toxin A injection, stone surgery, and so forth) in 22 (34%), and medical (antimicrobial prophylaxis, bladder irrigations, anticholinergics, self-catheterization) in 16 (25%). There was no association between longer transition times and higher rates of active problems.nnnCONCLUSIONnOn presentation to adult SB clinics, patients had many active urologic problems and operative management was often needed; however, there was no association between longer transition times and higher rates of active problems.

High grade renal injuries: Application of parkland hospital predictors of intervention for renal hemorrhage

PURPOSEnInvestigators from Parkland Hospital proposed substratification of the AAST (American Association for the Surgery of Trauma) grading scale based on 3 risk factors, including active vascular extravasation, a medial laceration and a perinephric hematoma of greater than 3.5 cm. We hypothesized that these characteristics would also be associated with intervention for renal hemorrhage in our large trauma series.nnnMATERIALS AND METHODSnFrom January 2005 to January 2011 we retrospectively reviewed the renal trauma records at adult level 1 trauma centers in Utah. AAST grade 3 and 4 injuries were characterized based on the mentioned 3 risk factors. Our primary outcome was intervention to control renal hemorrhage.nnnRESULTSnAAST grade 3 or greater injury was identified in 147 patients, including 115 who had grade 3 and 4 injuries as well as imaging available for review. There were 63 grade 3 (53%) and 52 grade 4 (43%) renal injuries. Eight patients (7%) underwent intervention for renal hemorrhage. Vascular extravasation (OR 16.4, 95% CI 2.6-179.8, p <0.001) and perinephric hematoma greater than 3.5 cm (OR 8.4, 95% CI 1.4-52.5, p = 0.0099) were associated with intervention, while a medial laceration was not (p = 0.454). Patients with 1 or fewer, 2 and 3 risk factors had an intervention rate of less than 2.9%, 18% and 50%, respectively (p <0.001).nnnCONCLUSIONSnVascular extravasation, a perinephric hematoma greater than 3.5 cm and the number of risk factors (0 to 3) were associated with intervention for renal hemorrhage. Our findings are similar to those at Parkland Hospital. These imaging features may serve as useful prognostic indicators for renal trauma.

Management of posterior urethral disruption injuries

Posterior urethral disruption is a traumatic injury to the male urethra, which most often results from pelvic fracture. After trauma, the distraction defect between the two ends of the urethra often scars and becomes fibrotic, blocking the urethra and bladder emptying. Increasing evidence suggests that many posterior urethral disruptions occur at the junction between the membranous urethra and the bulbar urethra, which is distal to the rhabdosphincter. In the acute setting, when a posterior urethral disruption is suspected, retrograde urethrography should be performed. Posterior urethral disruptions can be managed acutely by realignment of the urethra over a urethral catheter or by placement of a suprapubic catheter for bladder drainage only. Once fibrosis has stabilized, the patient can undergo posterior urethroplasty. In most cases, this procedure can be performed via a perineal approach in a single-stage surgery. The results of this single-stage perineal urethroplasty are excellent, and a patent urethra can be re-established in the majority of men who undergo surgery.

Current Management of Penile Implant Infections, Device Reliability, and Optimizing Cosmetic Outcome

Penile implants hold a major position in the treatment algorithm for patients with erectile dysfunction who find medications and vacuum erection devices ineffective or unsatisfactory. As with any surgical procedure, adverse events may occur. The infection rate associated with implant placement has been lowered to the range of 1xa0% or less due to multifactorial improvements including no-touch techniques, the use of antibiotic-coated devices, and improved quality measures in the operating room. Urologists have been proactive in employing techniques and procedures which minimize loss of erectile length, hence enhancing patient satisfaction. Flat reservoirs have been developed and techniques of placing these to avoid problems in the space of Retzius have reduced complication rates as well. Device reliability has improved to the point that penile implants are among the most durable mechanical surgical products that contribute to patient and partner satisfaction, which is by far the greatest among all the treatments of erectile dysfunction.

The Outcomes of Perineal Urethrostomy With Preservation of the Dorsal Urethral Plate and Urethral Blood Supply

OBJECTIVESnTo describe the surgical technique and outcomes for perineal urethrostomy. We sought to identify factors that predicted surgery failure within our patient cohort and to describe key aspects of the operation aimed at preservation of the dorsal urethral plate and longitudinal blood supply within the urethra.nnnMETHODSnWe reviewed our prospectively collected database and identified 45 men who underwent definitive perineal urethrostomy from 1989 to 2009. Primary success was defined as no need for additional treatment. If 1 urethral dilation was performed, outcome was defined as a secondary success. Statistical analyses were performed to determine variables associated with failure.nnnRESULTSnUrethral pathology was varied and included idiopathic strictures (20%), lichen sclerosis (20%), infection (16%), radiation for prostate cancer (13%), prior hypospadias repair (11%), instrumentation or catheter trauma (11%), and penile cancer or condyloma (9%). Of these men, 21 (48%) had prior urethroplasty. Forty patients had follow-up greater than 3 months (median, 31 months). Postoperative stenosis occurred in 7 (18%) patients. Previous radiation therapy was a significant risk factor for postoperative stenosis on univariate (OR 12.4, 95% CI 1.8-84.3, P <.01) and multivariate analysis (OR 11.2, 95% CI 1.4-87.2, P <.02). Primary success rate for perineal urethrostomy was 83% (33/40 patients) and secondary success rate was 93% (37/40).nnnCONCLUSIONSnDuring creation of perineal urethrostomy, when the longitudinal blood supply within the bulbar urethra is preserved rather than transected, stenosis of the perineal urethrostomy is a rare complication primarily in patients who have a history of radiation therapy.