Michael A. Granieri

Prospective Analysis of Erectile Dysfunction After Anterior Urethroplasty: Incidence and Recovery of Function

PURPOSE Anterior urethroplasty has been shown to negatively impact erectile function. Recovery of function is common but the likelihood and extent of recovery have not been fully elucidated. MATERIALS AND METHODS Between October 2006 and May 2008 men undergoing anterior urethroplasty were enrolled in a prospective study to evaluate the effects of urethroplasty on erectile function. The International Index of Erectile Function was completed preoperatively and on all subsequent postoperative visits. Preoperative and postoperative erectile function was compared. RESULTS A total of 52 patients who underwent anterior urethroplasty were included in the study. Repair locations were bulbar (35) and penile (17). Of the patients undergoing bulbar urethroplasty 20 had excision and primary anastomosis, and 15 had augmented anastomotic repair. All penile repairs were ventral onlay repair (11) or inlay repair in 2 stages (6). Postoperative erectile dysfunction was noted in 20 (38%) men, of whom 18 recovered fully at a mean postoperative period of 190 days (range 92 to 398). In patients with normal preoperative erectile function bulbar urethroplasty was more likely than penile urethroplasty to cause erectile dysfunction (76% vs 38%, p = 0.05). Within the bulbar urethra excision and primary anastomosis repairs led to slightly higher erectile dysfunction rates than augmented anastomotic repairs (50% vs 26%, p = 0.16). CONCLUSIONS Anterior urethroplasty caused erectile dysfunction in approximately 40% of patients, although recovery was seen in most by 6 months. Bulbar urethroplasty appears to affect erectile function to a greater extent than penile urethroplasty, which may be explained by the proximity of the bulbar urethra to the nerves responsible for erection.

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.

Presenting symptoms of anterior urethral stricture disease: a disease specific, patient reported questionnaire to measure outcomes.

PURPOSE We evaluated the spectrum of symptoms in men with urethral stricture presenting for urethroplasty. MATERIALS AND METHODS We identified 214 men who underwent anterior urethroplasty by a single surgeon (CMG) from March 2001 to June 2010. We retrospectively reviewed the initial patient history. All voiding and sexual dysfunction symptoms were recorded. RESULTS The most common presenting voiding complaints were weak stream in 49% of cases and incomplete emptying in 27%. Overall 21% of men did not present with voiding symptoms specifically addressed by the American Urological Association symptom index. The most common of these symptoms were spraying of urinary stream in 13% of men and dysuria in 10%. No symptoms were reported in 10% of men. Men with lichen sclerosus were more likely to present with obstructive symptoms (76% vs 55%) while men with penile urethral stricture were more likely to present with urinary stream spraying (17% vs 6%, each p <0.05). Sexual dysfunction was reported by 11% of men, most commonly in those with failed hypospadias repair (23% vs 9%) and lichen sclerosus (24% vs 10%, each p <0.05). CONCLUSIONS While the American Urological Association symptom index captures the most common voiding complaints of men with urethral stricture, 21% of those who presented for urethroplasty did not have voiding symptoms assessed by the index. A validated, disease specific instrument is needed to fully capture the presenting voiding symptoms and sexual dysfunction complaints of men with urethral stricture disease.

Prospective Analysis of Ejaculatory Function After Anterior Urethral Reconstruction

PURPOSE Urethral reconstruction may improve ejaculatory function by relieving urethral obstruction but could worsen it by disrupting the bulbocavernosus muscle. We prospectively evaluated the effects of urethral reconstruction on ejaculatory function. MATERIALS AND METHODS All men who underwent anterior urethroplasty from September 2006 to June 2009 were asked to complete the ejaculatory function component of the Male Sexual Health Questionnaire (7 questions with a total of 35 points) preoperatively and postoperatively after resuming sexual activity. Postoperatively decreased and improved ejaculation was defined as an increase and a decrease of 5 or more points, respectively. RESULTS A total of 43 men were included in the study. The overall ejaculatory score did not change postoperatively (25.54 vs 26.94 points, p = 0.17) at a mean +/- SD followup of 8.1 +/- 6.0 months but men with poor preoperative function had significant improvement (15.27 vs 21.22 points, p = 0.01). Overall ejaculatory vigor (3.19 vs 3.56 points, p = 0.25) and volume (3.49 vs 3.88, p = 0.19) did not change significantly. Postoperative function was stable in 30 men (70%), improved in 8 (19%), including 7 with bulbar and 1 with penile urethroplasty, and worse in 5 (11%), including 4 with bulbar and 1 with penile urethroplasty. CONCLUSIONS Urethral reconstruction appears to have a minimal effect on ejaculatory function when evaluated by the Male Sexual Health Questionnaire. More objective testing may be necessary to fully assess the effect of urethroplasty on ejaculatory function.

Distal urethroplasty for isolated fossa navicularis and meatal strictures.

Study Type – Therapy (case series)

Critical Analysis of Patient-reported Complaints and Complications After Urethroplasty for Bulbar Urethral Stricture Disease

OBJECTIVE To evaluate the full spectrum of postoperative complications and patient-reported complaints after urethroplasty for bulbar urethral stricture disease. MATERIALS AND METHODS We performed a retrospective review of our institutional database for all patients who underwent urethroplasty from January 1, 2002 to December 1, 2012. We recorded all postoperative complications and patient-reported complaints and grouped them by the Clavien-Dindo classification of surgical complications and into the following categories: perioperative, infectious, anatomic, sexual dysfunction, and voiding related. The Fisher exact test was used to calculate statistical differences among repair types and etiology. RESULTS Three hundred twenty-five men underwent urethroplasty by 2 surgeons (G.D.W. and A.C.P.) during the period reviewed. Two hundred ninety-two of 325 men (90%) had sufficient follow-up data available. One hundred eleven of 292 men (38%) reported a total of 146 postoperative complications or complaints. Forty-seven of 111 men (42%) were classified as having a perioperative complication, 17 of 111 (15.3%) as infectious, 8 of 111 (7.2%) as anatomic, 29 of 111 (26.1%) as sexual dysfunction, and 32 of 111 (28.8%) as voiding related. The majority of complications were classified as Clavien grade I (87 of 146, 60%). Forty-seven of 146 men (32%) were classified as having Clavien grade II, 9 of 146 (6%) as grade III, and 3 of 146 (2%) as grade IV. There were no grade V complications. Patients with iatrogenic etiology had a higher rate of infectious-related complications when compared with idiopathic or traumatic (17.5% vs 3.7%, 4.8%, respectively; P = .008). CONCLUSION Urethroplasty continues to have excellent outcomes with acceptable complication rates, the majority of which are self-reported complaints about voiding, scrotal and/or perineal neuralgia, and sexual dysfunction and appear to have minimal long-term sequelae.

Scrotal and Perineal Sensory Neuropathy After Urethroplasty for Bulbar Urethral Stricture Disease: An Evaluation of the Incidence, Timing, and Resolution

OBJECTIVE To examine the timing, incidence, and resolution of scrotal and perineal sensory neuropathy after urethroplasty for bulbar urethral stricture disease. MATERIALS AND METHODS We performed an institutional review board--approved retrospective review of our urethroplasty database with specific attention paid to patient demographics, stricture location, repair type, and postoperative sensory neuropathy defined as the complaint of hypesthesia, anesthesia, paresthesia, hyperesthesia, and pain in the scrotal and perineal region after surgery. Incidence and reported times to onset and resolution of sensory neuropathy were compared among our cohort. RESULTS A total of 155 men underwent urethroplasty for bulbar urethral stricture disease from January 2007 to December 2012. One hundred forty-three of 155 men (92%) had postoperative data available for analysis. The average age at surgery was 47 ± 15 years and average stricture length was 2.1 ± 1.4 cm. Repair types were excision and primary anastomosis (101 of 143; 71%), augmented anastomotic repair (31 of 143; 22%), onlay repair (4 of 143; 3%), and perineal urethrostomy (7/143, 5%). Twenty of 143 men (14%) experienced postoperative scrotal and perineal neuralgia at a median time of 108 days (range, 18-160 days) from surgery. Fourteen of 20 men (70%) had subsequent follow-up visits, and all of these men had resolution of the pain, without treatment, at a median reported time of 271 days from surgery. There were no significant differences in incidence, resolution, or timing of sensory neuropathy among repair types. CONCLUSION Our findings indicate that approximately 14% of men who undergo urethroplasty for bulbar urethral stricture disease experience postoperative scrotal and perineal sensory neuropathy. This appears to be transient with 100% resolution in our patients with available follow-up.

The Management of Bulbar Urethral Stricture Disease Before Referral for Definitive Repair: Have Practice Patterns Changed?

OBJECTIVE To describe the management of patients with bulbar urethral stricture disease before referral for definitive urethroplasty and determine if practice patterns have changed with respect to endoscopic interventions. MATERIALS AND METHODS We performed an institutional review board-approved retrospective review and recorded patient demographics, stricture-related information, and all procedures performed for bulbar urethral stricture disease before initial presentation at our institution. Included procedures were: UroLume stent (AMS, Minnetonka, MN), laser urethrotomy, direct visual urethrotomy (DVIU), and dilation of urethral stricture. Patients with prior urethroplasty were excluded. We compared the differences between procedures when stratified by stricture length. RESULTS We identified 363 men who underwent urethroplasty for bulbar urethral stricture disease from January 1996 to September 2011. Of the total, 235 men (65%) had a prior DVIU, whereas 65 of these men (28%) had multiple DVIUs. One hundred ninety-nine men (55%) had a prior dilation and 155 of these men (78%) had multiple dilations. The remaining procedures consisted of laser urethrotomy (6; 2%), and UroLume stent (4; 1%). Twenty-four patients (6%) had no procedures before referral. There was no statistically significant difference between numbers of prior procedures when stratified by stricture length. From 1996 to 2010, there was no appreciable change in number of procedures before referral, with ∼ 70% of patients with ≥ 2 prior procedures. CONCLUSION Our institution has not seen a measurable change in practice patterns before referral from 1996 to 2010. Future studies are needed to determine if the change in referral patterns in 2011 represents a future trend.

Survey on the Contemporary Management of Intraoperative Urethral Injuries During Penile Prosthesis Implantation

BACKGROUND Intraoperative urethral injury is an uncommon event during the placement of a penile prosthesis, and alternative management strategies have been proposed with continuation of implantation after urethral injury. AIM To evaluate surgeon practices in the management of intraoperative urethral injury. METHODS An online survey was sent to the society listservs of the Genitourinary Reconstructive Surgeons (GURS) and the Sexual Medicine Society of North America (SMSNA). Physicians were queried on their fellowship training, experience with penile prosthesis implantation, and management of urethral injuries during prosthesis placement. The response data were analyzed using SAS 9.4 (SAS Institute, Cary, NC, USA). The χ2 test and Fisher exact test were used to determine associations between variables. OUTCOMES Survey responses. RESULTS 131 survey responses were analyzed. Of the responders, 41.2% were GURS fellowship trained, 19.1% were SMSNA trained, 30.5% were non-fellowship trained, and 9.2% were trained in other fellowships. 25.4% of participants performed more than 50 implantations per year, 37.7% performed 20 to 50 per year, and 36.9% performed fewer than 20 per year. Urethral injury during prosthesis implantation was uncommon, with 26.2% reporting 0 injury, 58.5% reporting 1 to 3 injuries, and 15.4% reporting more than 3 career injuries. Injuries were most commonly encountered during corporal dilation (71.1%) compared with corporal exposure (12.5%) or penile straightening maneuvers (7.0%). There was no statistically significant difference with aborting or continuing implantation among GURS-trained, SMSNA-trained, other fellowship-trained, and non-fellowship-trained surgeons. Of all responders, 55% would abort the procedure after distal urethral injury, whereas 45% would continue the procedure with unilateral or bilateral insertion of cylinders. Patient factors that increased likelihood of terminating the procedure in the case of urethral injury included immunosuppression, spinal cord injury, and clean intermittent catheterization dependence. CLINICAL IMPLICATIONS A urethral injury during penile prosthesis implantation might not mandate termination of the procedure despite classic teaching. STRENGTHS AND LIMITATIONS The strength of this study is that it provides difficult to obtain epidemiologic data on the frequency and management of this clinically significant injury. Limitations include the inherent biases from a survey-based study including response bias and recall bias. The survey response rate could not be obtained. CONCLUSION Urethral injury during penile prosthesis implantation is a rare but clinically significant risk of the procedure, with many variations in management of the injury. Termination and delayed implantation might not be necessary after injury, although long-term outcome data are difficult to obtain. Sexton SJ, Granieri MA, Lentz AC. Survey on the Contemporary Management of Intraoperative Urethral Injuries During Penile Prosthesis Implantation. J Sex Med 2018;15:576-581.

A Critical Evaluation of the Utility of Imaging After Urethroplasty for Bulbar Urethral Stricture Disease

OBJECTIVE To determine the incidence of extravasation on initial postoperative pericatheter retrograde urethrogram (pcRUG) after bulbar urethroplasty and the relationship to repair type. MATERIALS AND METHODS We performed a retrospective review to collect stricture-related and postoperative information with emphasis on pcRUGs. All men had a pcRUG at the initial follow-up appointment. The Foley catheter was removed if no extravasation was seen and left in place for an extra week, with a repeat pcRUG if extravasation was noted. RESULTS We limited our analysis to men who underwent bulbar urethroplasty from January 1996 to December 2012 (by two surgeons: GDW, ACP). We identified 437 patients and 407 (93%) had follow up data. The mean stricture length was 1.97 cm ± 1.2 cm. In those patients who underwent excision and primary anastomosis (EPA) (n = 232, 57%), we performed the1st pcRUG 1 week earlier compared to those who underwent augmented anastomotic repair (n = 150, 37%) or onlay repair (n = 25, 6%). There was no difference in extravasation rates among all repair types at first pcRUG. The overall rate of extravasation on the first postoperative pcRUG significantly decreased in all patients (0.98% vs 5%, P = .0008) and in those who underwent EPA (5.6% vs 0.4%, P = .0016) when the Foley catheter remained for an extra week. CONCLUSION Men who undergo bulbar urethroplasty have a low extravasation rate (2.2%) 3 weeks postoperatively and those who underwent EPA benefited from an additional week of catheterization.