Jill C. Buckley

Revision of current American Association for the Surgery of Trauma renal injury grading system

BACKGROUND We propose a revision of the original 1989 renal organ injury system established by the American Association for the Surgery of Trauma based on our institutions>25-year longitudinal experience. Our goal is to expand the current grading system to include segmental vascular injuries and ureteral pelvic injuries and to establish a more rigorous definition of severe grade IV and V renal injuries. METHODS We retrospectively reviewed our prospectively gathered contiguous renal database of 3,580 renal injuries to describe a revised renal grading injury scale based on clinical renal salvage outcomes. We focused on the mechanism of injury, the stability of the patient, radiographic imaging, associated nonrenal injuries, and clinical salvage outcome data. RESULTS No changes were made in the definition of grade I to III injuries. The revised grade IV classification includes all collecting system, renal pelvis injuries and segmental arterial and/or venous injuries. The revised grade V classification is limited to main renal artery and/or vein injuries, including laceration, avulsion, and thrombosis. We compared the nephrectomy rate and clinical renal salvage rate between the original 1989 renal organ injury system with our revised renal injury staging classification. CONCLUSION The revised renal injury staging classification provides complete and clear definitions of renal trauma while still performing its fundamental objective to reflect increasingly complex renal injuries. Uniform language and classification of renal injuries will enhance discussion, clinical investigation, and research of renal trauma.

Management of Surgical and Radiation Induced Rectourethral Fistulas With an Interposition Muscle Flap and Selective Buccal Mucosal Onlay Graft

PURPOSE Rectourethral fistulas are a rare but devastating complication of pelvic surgery and radiation. We review, analyze and describe the management and outcomes of nonradiated and radiation/ablation induced rectourethral fistulas during a consecutive 12-year period. MATERIALS AND METHODS We performed a retrospective review of patients undergoing rectourethral fistula repair between January 1, 1998 and December 31, 2009. Patient demographics as well as preoperative, operative and postoperative data were obtained. All rectourethral fistulas were repaired using an anterior transperineal approach with a muscle interposition flap and selective use of a buccal mucosal graft urethral patch onlay. RESULTS A total of 74 patients with rectourethral fistulas underwent repair with an anterior perineal approach and muscle interposition flap (68 gracilis muscle interposition flaps, 6 other muscle interposition flaps). We compared 35 nonradiated and 39 radiated/ablation induced rectourethral fistulas. Concurrent urethral strictures were present in 11% of nonradiated and 28% of radiated/ablation rectourethral fistulas. At a mean followup of 20 months 100% of nonradiated rectourethral fistulas were closed with 1 procedure while 84% of radiated/ablation rectourethral fistulas were closed in a single stage. Of the patients with nonradiated rectourethral fistulas 97% had the bowel undiverted. Of those undiverted cases 100% were without bowel complication. Of the patients with radiated/ablation rectourethral fistulas 31% required permanent fecal diversion. CONCLUSIONS Successful rectourethral fistula closure can be achieved for nonradiated (100%) and radiation/ablation (84%) rectourethral fistulas using a standard anterior perineal approach with an interposition muscle flap and selective use of buccal mucosal graft, providing a standard for rectourethral fistula repair. Even the most complex radiation/ablation rectourethral fistula can be repaired avoiding permanent urinary and fecal diversion.

Radial Urethrotomy and Intralesional Mitomycin C for the Management of Recurrent Bladder Neck Contractures

PURPOSE We evaluated urethrotomy combined with intralesional injection of the antiproliferative agent mitomycin C for the treatment of severe, recurrent bladder neck contractures after traditional endoscopic management failed. We report our experience with radial urethrotomy and intralesional mitomycin C in patients with recurrent bladder neck contractures. MATERIALS AND METHODS A retrospective review was performed of patients evaluated for severe, recurrent bladder neck contractures between January 2007 and April 2010. All patients had at least 1 prior failed incision of a bladder neck contracture. Tri or quadrant cold knife incisions of the bladder neck were performed followed by injection of 0.3 to 0.4 mg/ml mitomycin C at each incision site. RESULTS A total of 18 patients were treated with bladder neck incision and mitomycin C injection. Preoperatively 4 (22%) patients presented with indwelling Foley catheters while 7 (39%) required a dilation schedule. At a median followup of 12 months (range 4 to 26) 13 patients (72%) had a patent bladder neck after 1 procedure, as did 3 (17%) after 2 procedures and 1 after 4 procedures. All of the patients presenting with a prior indwelling urethral catheter or requiring a dilation schedule had a stable, patent bladder neck. CONCLUSIONS Management of recurrent bladder neck contractures with radial urethrotomy combined with intralesional mitomycin C resulted in bladder neck patency in 72% of the patients after 1 procedure and in 89% after 2 procedures. Although early results are promising, longer followup and randomized, prospective studies are required to validate these findings.

Acquired rectourethral fistulas in adults: a systematic review of surgical repair techniques and outcomes.

BACKGROUND: Rectourethral fistulas are uncommon. Retrospective studies and case reports have highlighted various approaches for surgical repair. Because clinical presentations and technical expertise vary widely, no single procedure has been universally adopted. OBJECTIVE: We sought to qualitatively analyze studies describing surgical techniques and outcomes in adult acquired rectourethral fistulas to outline universal approaches for evaluation and management. DATA SOURCES: MEDLINE (PubMed, Ovid) and the Cochrane Library were searched by using the terms rectourethral fistulas, recto-urethral fistulas, urethrorectal fistulas, and prostatourethral-rectal fistulas. STUDY SELECTION: All studies were retrospective, in English, and reported at least 4 cases. Any series with >50% congenital cases or <50% adults (19+ years) was excluded. Of the 569 records identified, 26 articles were included. INTERVENTION: The intervention was surgical repair of rectourethral fistula. MAIN OUTCOME MEASURES: The main outcome measures were successful fistula closure, fistula recurrence or persistence, and permanent fecal and/or urinary diversion. RESULTS: Four hundred sixteen patients were identified, including 169 (40%) who had previous pelvic irradiation and/or ablation. Most patients (90%) underwent 1 of 4 categories of repair: transanal (5.9%), transabdominal (12.5%), transsphincteric (15.7%), and transperineal (65.9%). Tissue interposition flaps, predominantly gracilis muscle, were used in 72% of repairs. The fistula was successfully closed in 87.5%. Overall permanent fecal and/or urinary diversion rates were 10.6% and 8.3%. Most high-volume centers (≥25 patients) performed transperineal repairs with tissue flaps in 100% of cases. LIMITATIONS: This review was limited by the heterogeneity of repairs and bias toward preferred surgical approaches in single-center studies. CONCLUSIONS: Regardless of complexity, rectourethral fistulas have an initial closure rate approaching 90% when the transperineal approach is used. Permanent fecal and/or urinary diversion should be a last resort in patients with devastated, nonfunctional fecal and urinary systems.

Embryonic exposure to the fungicide vinclozolin causes virilization of females and alteration of progesterone receptor expression in vivo: an experimental study in mice

BackgroundVinclozolin is a fungicide that has been reported to have anti-androgenic effects in rats. We have found that in utero exposure to natural or synthetic progesterones can induce hypospadias in mice, and that the synthetic progesterone medroxyprogesterone acetate (MPA) feminizes male and virilizes female genital tubercles. In the current work, we selected a relatively low dose of vinclozolin to examine its in utero effects on the development of the genital tubercle, both at the morphological and molecular levels.MethodsWe gave pregnant dams vinclozolin by oral gavage from gestational days 13 through 17. We assessed the fetal genital tubercles from exposed fetuses at E19 to determine location of the urethral opening. After determination of gonadal sex, either genital tubercles were harvested for mRNA quantitation, or urethras were injected with a plastic resin for casting. We analyzed quantified mRNA levels between treated and untreated animals for mRNA levels of estrogen receptors α and β, progesterone receptor, and androgen receptor using nonparametric tests or ANOVA. To determine effects on urethral length (males have long urethras compared to females), we measured the lengths of the casts and performed ANOVA analysis on these data.ResultsOur morphological results indicated that vinclozolin has morphological effects similar to those of MPA, feminizing males (hypospadias) and masculinizing females (longer urethras). Because these results reflected our MPA results, we investigated the effects of in utero vinclozolin exposure on the mRNA expression levels of androgen, estrogen α and β, and progesterone receptors. At the molecular level, vinclozolin down-regulated estrogen receptor α mRNA in females and up-regulated progesterone receptor mRNA. Vinclozolin-exposed males exhibited up-regulated estrogen receptor α and progesterone receptor mRNA, effects we have also seen with exposure to the synthetic estrogen, ethinyl estradiol.ConclusionThe results suggest that vinclozolin virilizes females and directly or indirectly affects progesterone receptor expression. It also affects estrogen receptor expression in a sex-based manner. We found no in vivo effect of vinclozolin on androgen receptor expression. We propose that vinclozolin, which has been designated an anti-androgen, may also exert its effects by involving additional steroid-signaling pathways.

SIU/ICUD Consultation on Urethral Strictures: Dilation, internal urethrotomy, and stenting of male anterior urethral strictures.

Male urethral stricture is one of the oldest known urologic diseases, and continues to be a common and challenging urologic condition. Our objective was to review all contemporary and historial articles on the topic of dilation, internal urethrotomy, and stenting of male anterior urethral strictures. An extensive review of the scientific literature concerning anterior urethral urethrotomy/dilation/stenting was performed. Articles were included that met the criteria set by the International Consultation on Urological Diseases (ICUD) urethral strictures committee and were classified by level of evidence using the Oxford Centre for Evidence-Based Medicine criteria adapted from the work of the Agency for Health Care Policy and Research as modified for use in previous ICUD projects. Using criteria set forth by the ICUD, a committee of international experts in urethral stricture disease reviewed the literature and created a consensus statement incorporating levels of evidence and expert opinion in regard to dilation, internal urethrotomy, and stenting of male anterior urethral strictures.

Management of Complex Anterior Urethral Strictures With Multistage Buccal Mucosa Graft Reconstruction

OBJECTIVE To describe the indications and outcomes of salvage urethral reconstruction using the combination of urethrectomy and buccal graft replacement. MATERIALS AND METHODS We retrospectively identified 91 consecutive patients who had undergone multistage urethral reconstruction from 2003 to 2009. The demographic and surgical outcomes data, including the need for first stage revision, pre- and postoperative urine flow rates, and reconstruction failure was collected for all patients. RESULTS Of the 91 patients, 51 (56%) subsequently underwent urethral tubularization, 17 (19%) were pending closure, and 23 (25%) had undergone the first stage only, with no plan for completion. The stricture etiology included hypospadias in 41 (45.1%), lichen sclerosus in 29 (31.9%), and a combination of the 2 in 10 (11%). Of the 91 patients, 54.9% had panurethral disease, with the remaining involving varying lengths of the anterior urethra. The mean follow-up was 15 months (range 12-69). A total of 17 patients (18.7%) required revision of their first stage, with 4 requiring ≥2 repairs. Seven patients (7.7%) required revision of their second stage, with 2 undergoing multiple revisions. The urine flow rates increased on average from 6.7 mL/s preoperatively to 21.5 mL/s postoperatively (P <.00001). In 9 patients (9.9%) reconstruction failed, and they required scheduled balloon dilation or a chronic indwelling catheter to maintain urethral patency. CONCLUSION Urethrectomy with salvage reconstruction using buccal mucosal grafts in a staged fashion is the optimal option for complex anterior urethral stricture resolution in these challenging patients. Surgical revision of the first or second stage could be required in up to 25% of challenging patients. Despite the high complexity and severity of the urethral stricture burden, a 90% success rate was achieved.

Urethroplasty for High Risk, Long Segment Urethral Strictures with Ventral Buccal Mucosa Graft and Gracilis Muscle Flap

PURPOSE Long segment urethral strictures with a compromised graft bed and poor vascular supply are unfit for standard repair and at high risk for recurrence. We assessed the success of urethral reconstruction in these patients with a ventral buccal mucosa graft and gracilis muscle flap. MATERIALS AND METHODS We retrospectively reviewed the records of 1,039 patients who underwent urethroplasty at Lahey Hospital and Medical Center between 1999 and 2014. We identified 20 patients who underwent urethroplasty with a ventral buccal mucosa graft and a gracilis muscle flap graft bed. Stricture recurrence was defined as the inability to pass a 16Fr cystoscope. RESULTS Mean stricture length was 8.2 cm (range 3.5 to 15). Strictures were located in the posterior urethra with or without involvement of the bulbar urethra in 50% of cases, and in the bulbomembranous urethra in 35%, the bulbar urethra in 10% and the proximal pendulous urethra in 5%. Stricture etiology was radiation therapy in 45% of cases, followed by an idiopathic cause in 20%, trauma in 15%, prostatectomy in 10%, and hypospadias failure and transurethral surgery in 5% each. Nine patients (45%) were previously treated with urethroplasty and 3 (15%) previously underwent UroLume® stent placement. Urethral reconstruction was successful in 16 cases (80%) at a mean followup of 40 months. One of the patients in whom treatment failed had an ileal loop, 2 had a suprapubic tube and urethral dilatation had been done in 1. Mean time to recurrence was 10 months (range 2 to 17). Postoperatively 5 patients (25%) had incontinence requiring an artificial urinary sphincter. CONCLUSIONS Urethroplasty for high risk, long segment urethral strictures can be successfully performed with a ventral buccal mucosa graft and a gracilis muscle flap, avoiding urinary diversion in most patients.

Impact of urethral ultrasonography on decision-making in anterior urethroplasty

Study Type – Diagnostic (Exploratory cohort)

Distal penile circular fasciocutaneous flap for complex anterior urethral strictures

Complex anterior urethral strictures represent challenging cases even for the experienced reconstructive urologist. Urethral trauma is the most common reported cause ( ≈ 50%) with the remainder being idiopathic. Risk factors are long-term urethral catheterization, previous urethral instrumentation, unrecognised urethral trauma, chronic urethritis, and compromised urethral blood flow. Scar excision and anastomotic urethroplasty is reserved for short bulbar urethral strictures ( < 2.0–2.2 cm) due to the risk of penile shortening and tissue ischaemia with more extensive resections [1].