Joel Gelman

1-Stage Repair of Obliterative Distal Urethral Strictures With Buccal Graft Urethral Plate Reconstruction and Simultaneous Onlay Penile Skin Flap

PURPOSE When penile skin is available, onlay flap reconstruction is an excellent choice for 1-stage repair of complex hypospadias and strictures involving the glans, fossa navicularis and penile urethra. When the urethra is deficient circumferentially, tube flaps are an option but there is a high failure rate. We report our 8-year experience with 1-stage reconstruction using a dorsal buccal mucosa graft to reconstruct the deficient urethral plate with repair completed using an onlay penile skin flap. MATERIALS AND METHODS A total of 12 patients with a mean age of 42.8 years (range 16 to 77) underwent dorsal buccal grafting with ventral skin flap repair. Buccal mucosa was quilted to the penile ventral corpora to reconstruct the dorsal urethral aspect. Most surgeries included buccal graft reconstruction of the glans and fossa navicularis. Onlay penile skin flap repair was then performed to complete the reconstruction. RESULTS All 12 patients were free of disabling chordee or urethral stricture disease at a mean 39-month followup (range 7 to 96). In 1 patient a small urethrocutaneous fistula developed, which was repaired. In another patient a fistula and medium caliber fossa navicularis narrowing developed with associated chordee, which were successfully repaired. CONCLUSIONS Dorsal buccal grafting with ventral flap reconstruction appears to be an excellent option to repair circumferential urethral deficiency when penile skin is available, especially when chordee correction with distal urethral plate reconstruction is required.

Composite thin film and electrospun biomaterials for urologic tissue reconstruction.

A replacement material for autologous grafts for urinary tract reconstruction would dramatically reduce the complications of surgery for these procedures. However, acellular materials have not proven to work sufficiently well, and cell‐seeded materials are technically challenging and time consuming to generate. An important function of the urinary tract is to prevent urine leakage into the surrounding tissue—a function usually performed by the urothelium. We hypothesize that by providing an impermeable barrier in the acellular graft material, urine leakage would be minimized, as the urothelium forms in vivo. However, since urothelial cells require access to nutrients from the supporting vasculature, the impermeable barrier must degrade over time. Here we present the development of a novel biomaterial composed of the common degradable polymers, poly(ε‐caprolactone) and poly(L‐lactic acid) and generated by electrospinning directly onto spin‐coated thin films. The composite scaffolds with thin films on the luminal surface were compared to their electrospun counterparts and commercially available small intestinal submucosa by surface analysis using scanning electron microscopy and by analysis of permeability to small molecules. In addition, the materials were examined for their ability to support urothelial cell adhesion, proliferation, and multilayered urothelium formation. We provide evidence that these unique composite scaffolds provide significant benefit over commonly used acellular materials in vitro and suggest that they be further examined in vivo. Biotechnol. Bioeng. 2011; 108:207–215.

Posterior Urethral Strictures

Pelvic fracture urethral injuries are typically partial and more often complete disruptions of the most proximal bulbar and distal membranous urethra. Emergency management includes suprapubic tube placement. Subsequent primary realignment to place a urethral catheter remains a controversial topic, but what is not controversial is that when there is the development of a stricture (which is usually obliterative with a distraction defect) after suprapubic tube placement or urethral catheter removal, the standard of care is delayed urethral reconstruction with excision and primary anastomosis. This paper reviews the management of patients who suffer pelvic fracture urethral injuries and the techniques of preoperative urethral imaging and subsequent posterior urethroplasty.

The Use of Flaps and Grafts in the Treatment of Urethral Stricture Disease

The use of various grafts and flaps plays a critical role in the successful surgical management of urethral stricture disease. A thorough comprehension of relevant anatomy and principles of tissue transfer techniques are essential to understanding the appropriate use of grafts or flaps to optimize outcomes. We briefly review these principles and discuss which technique may be best suited for a given anterior urethral stricture, depending on the location and length of the stricture, the presence or absence of an intact corpus spongiosum, and the availability of adequate and healthy penile skin.

Tips for Successful Open Surgical Reconstruction of Posterior Urethral Disruption Injuries

This article provides an overview of the open surgical management of posterior urethral disruption injuries. The discussion includes the evaluation of the patient before surgery with a focus on urethral imaging and details of posterior urethroplasty surgical technique.

Reconstruction of Massive Localized Lymphedema of the Scrotum: Results, Complications and Quality of Life Improvements

OBJECTIVE To review the surgical technique, outcomes, and complications of surgical excision of massive localized lymphedema (MLL) of the scrotum, and to determine changes in weight and quality of life (QOL) after excision. METHODS A retrospective review was performed for all patients who have undergone excision of MLL of the scrotum at our institution between 2008 and 2014. Standard baseline characteristics, complications, pre- and postoperative weight, and QOL data were recorded. RESULTS Eleven patients were included, with a mean follow-up of 26 months after surgery. The mean preoperative body mass index was 60, and the mean weight of resected tissue was 21 kg. No patient required an orchiectomy for completion of the resection. Skin grafting was performed in 1 patient, and the rest were closed primarily. Wound complications were common but generally managed successfully with local wound care. At the time of most recent follow-up, most patients had actually gained weight since surgery (mean weight change of +5.2 kg). However, QOL scores improved across all domains, and overall QOL improved from a mean of 1.3 preoperatively to 7.7 postoperatively (where 1 is poor, and 10 is excellent). CONCLUSION Surgical treatment of MLL of the scrotum can be performed successfully for masses even up to 61 kg (134 lbs). Short-term wound complications are common, but subjective QOL scores improve dramatically. Despite expectations, most patients gained weight after mass removal, which indicates that they would benefit from a comprehensive weight loss plan that includes, but is not limited to, scrotal surgery.

Men with Anterior Urethral Strictures are Often Treated without Imaging or Discussion of all Treatment Options

Introduction: We determined how men presenting to our institution with anterior urethral strictures and recurrent strictures after treatment were evaluated, counseled and treated. Methods: A prospective study was performed of all patients presenting to our institution with recurrent anterior urethral stricture disease between 2011 and 2014. Outside records were reviewed and all patients were queried to determine if they had any urethral imaging before treatment, what treatment was given and what other options were discussed. Patients were excluded from the study if they had a history of hypospadias, or if they were initially treated more than 10 years ago or treated outside of the United States. Results: A total of 100 men were included in the study, of whom 89 (89%) had prior treatment with urethral dilation or endoscopic incision. Of these patients 81 (91%) were treated without prior urethral imaging. Of the 90 patients who were treated or advised to have treatment with direct visual internal urethrotomy or dilation, 81 (90%) were not offered urethroplasty as an option. There were 66 patients who had multiple such treatments and of this group only 6 (9%) were offered urethroplasty before subsequent treatment. Conclusions: In this study the majority of men with urethral strictures were treated without urethral imaging. Furthermore, most men were not offered urethroplasty as an option before undergoing 1 or more urethral dilations or internal urethrotomies.

PD34-04 ONE-STAGE URETHROPLASTY USING DORSAL AND VENTRAL BUCCAL MUCOSAL GRAFT: LONG-TERM VALIDATED OUTCOMES

urethroplasty is 3.6 (range 0-36). Urethroplasty techniques were: anastomotic (33%, n1⁄443), dorsal graft (39%, n1⁄451), ventral graft (15%, n1⁄419), flap (6%, n1⁄48), perineal urethrostomy (2%, n1⁄43). 5% of patients underwent advanced reconstructive techniques such as: double graft, augmented dorsal anastomotic, Duckett, or first stage Johanson (n1⁄46). Overall success rate was 85% with an average time-to-failure of 23 months (range 2-151 months). Success rates for patients who had prior endoscopic intervention (urethrotomy or dilation) was 83% versus those with no prior endoscopic intervention who had a success rate of 100%, p> 0.05. Complications were reported in 17% of patients, including recurrent UTI, erectile dysfunction, urinary incontinence, and penile shortening. CONCLUSIONS: Our study represents the first multi-institutional report on the severity and management of post-TURP urethral strictures. Our data shows that the majority of post-TURP strictures are successfully managed with urethroplasty, with 85% success. Better success rates are seen in patients with no prior endoscopic intervention, suggesting early urethroplasty or referral to a reconstructive urology center is warranted.

MP79-16 COMPLICATIONS OF GENITAL ENLARGEMENT SURGERY

compliance was defined as surgical management or non-surgical management only if imaging was performed. Incidence was calculated from New York census data. Patients were tracked for PFx sequelae. RESULTS: 711 men presented with PFx with mean age 38 years (Range 18-81). PFx accounted for 6.2% of all GT over this time. The incidence rate was 0.83 cases/100,000 person-years (p-y) with a peak in men 30-39 years old (1.31 cases/100,000 p-y). Eighty men (11.3%) underwent urethral evaluation, 15 (2.1%) had diagnostic ultrasound and 397 (55.8%) underwent surgery (Figure 1). All men with ultrasound were managed conservatively. The AUA guideline compliance rate was 58%. On multivariate logistic regression, high comorbidity burden was associated with low compliance (OR [95% CI]: 0.35 [0.16-0.73], p<0.01) whereas non-White race (1.58 [1.16-2.16], p<0.01) and academic centers (1.53 [1.11-2.11], p1⁄40.01) were associated with high compliance. PFx sequelae (erectile dysfunction, urethral stricture, Peyronie0s disease) developed in 12 patients (1.7%). CONCLUSIONS: This is the largest report of PFx incidence and management in the literature to date. PFx is rare with peak rate in men 30-39 years old. About half of cases were managed surgically with overall guideline compliance rate of only 58%. This may reflect suboptimal management or incorrect diagnostic coding of non-fracture injuries. Efforts to improve physician education on the management of suspected PFx is crucial given its potential for long term morbidity.

MP52-08 EXCISION AND PRIMARY ANASTOMOSIS VS. DORSAL BUCCAL GRAFTING FOR BULBAR URETHRAL STRICTURES: COMPARISON OF OUTCOMES AND QUALITY OF LIFE

INTRODUCTION AND OBJECTIVES: Excision and primary anastomosis (EPA) with urethral transection has historically been favored as the procedure of choice for short bulbar urethral strictures due to excellent success rates. However, buccal graft onlay repair without transection is gaining favor because of potential long-term sexual complications that may result from EPA. We aim to compare short and long-term urinary and sexual outcomes of both procedures. METHODS: A retrospective analysis was performed of all EPA and dorsal buccal (DB) urethroplasties performed for bulbar urethral strictures at our institution between 1998 and 2015. Exclusion criteria included prior urethroplasty, simultaneous reconstruction of a separate part of the urethra, need for a 2nd buccal graft harvest, hypospadias or lichen sclerosis. Our protocol includes cystoscopy 4 months after surgery to ensure a technical success and subsequent annual symptom, flow rate, and post-void residual assessment. All patients included in the study who were contacted during the month prior to abstract submission completed validated questionnaires to assess voiding, erectile, and ejaculatory function and other urethroplasty specific outcomes including glans sensitivity and engorgement. RESULTS: After exclusion criteria were applied, a total of 130 (EPA) and 38 (DB) patients were included in the study. Technical success at 4 months, success at last evaluation, length of stricture and length of follow-up for EPA vs DB was 100% vs. 97.4% (NS), 99.2% vs. 94.7% (p1⁄40.07), 1.7cm vs. 3.95cm (p<0.0001) and 42.3 vs. 39.8 months respectively. Thirty-one EPA and twenty-one DB patients responded to the survey. Of these, ejaculatory bother and post-void dribbling were significantly worse in the DB group. Six patients in the EPA group complained of a pulling sensation or curvature during erection compared to one in the DB group (p1⁄40.21, the average stricture length was 1.4 cm in this group). DB grafting was associated with worse pot-void dribbling and ejaculatory bother. There were otherwise no significant differences in patient reported outcome measures related to quality of life, urinary function, erectile function, sexual activity, or penile sensitivity between groups. No patients complained of a cold glans. CONCLUSIONS: EPA and DB grafting are both highly successful techniques for strictures isolated to the bulbar urethra with low sexual complications. Our data does not suggest that EPA for short bulbar strictures should be avoided in favor of DB due to a concern of an increased risk of sexual side effects with EPA.