Sachin Malde

A tertiary experience of ileal–ureter substitution: Contemporary indications and outcomes

Abstract Objective. Complex ureteric stricture disease in contemporary practice is typically related to prior pelvic surgery, radiotherapy, or complicated, repeated retrograde stone surgery, although outcomes in this group have not been well studied. The aim of this study was to report medium-term outcomes with ileal–ureter substitution for complex ureteric stricture disease. Materials and methods. All patients who had undergone ureteric reconstructive surgery using small bowel over a 5 year period between 2010 and 2015 were identified from the theatre database and their case notes reviewed. Data were collected on aetiology of ureteric stricture, prior surgery or radiotherapy, baseline renal function and comorbidity. Postoperative complications were recorded using the Clavien–Dindo classification, and overall outcome and need for further intervention were documented. Results. Nine patients underwent ileal–ureter substitution for complex ureteric stricture disease over this period, with four having bilateral ileal interpositions. Median age was 48 years (38–62 years) with a median follow-up of 17 months (1–40 months). Simple untailored ileal segments and refluxing anastomoses were used in all cases. One case of anastomotic leak and restricture required reintervention, but all others had favourable outcomes with no stricture and no requirement for further intervention. Two patients reported recurrent cystitis following surgery but there was no deterioration in renal function in any patient, with no metabolic complications reported. Conclusion. Ileal–ureter substitution surgery is a valuable option for selected patients with complex, difficult-to-treat ureteric defects that cannot be bridged by other methods. Simple onlay techniques do not seem to affect renal or metabolic function. Avoiding the extra complexity of tailored and tunnelled anastomoses may reduce the potential morbidity and reintervention rate in patients with challenging surgical fields.

Urethral diverticulectomy with Martius labial fat pad interposition improves symptom resolution and reduces recurrence.

To assess the presenting features and medium‐term symptomatic outcomes in women having excision of urethral diverticulum with Martius labial fat pad (MLFP) interposition.

Does the appearance of the urethral pressure profile trace correlate with the sphincter EMG findings in women with voiding dysfunction

Women with functional voiding dysfunction often experience a “catching” sensation when catheterising and are in general investigated with both urethral pressure profilometry (UPP) and sphincter electromyography (EMG). It is unknown whether the pattern of the UPP trace correlates with this sensation of “catching” or with sphincter EMG findings.

Buccal mucosal graft urethroplasty in men—risk factors for recurrence and complications: a third referral centre experience in anterior urethroplasty using buccal mucosal graft

Background Urethral stricture disease is a challenging condition to treat and several approaches including direct visual internal urethrotomy (DVIU) and anastomotic or augmentation urethroplasties based on the use of flaps and graft have been reported. The aim of this study is to determine risk factors for stricture recurrence and complications in patients having buccal mucosal graft (BMG) urethroplasty for anterior urethral stricture under a single surgeon in a third referral centre in UK. Methods We conducted a retrospective review of a prospectively gathered database of 128 patients having various forms of BMG urethroplasty between 2001 and 2015. Success and failure in terms of stricture recurrence, patient demographics, stricture aetiology and anatomy, and the adverse outcomes of: post-micturition dribbling (PMD), erectile dysfunction (ED) >12 months and complications were recorded in order to determine risk factors for recurrent stricture and complications. Results The mean age of all patients was 42.8 years (range, 16–74 years). Average follow-up was 45 months (range, 3–159 months). The total re-stricture rate was 19% (24 men). PMD was reported in 16% (n=20) and ED in 12.5% (n=16). All ED was none organic and responded to oral PDE5 inhibitor treatment. Post-operative complications were reported in 16 patients (12.5%). The most frequent complications recorded were urinary fistula (n=4; 3.1%), graft contracture (n=4; 3.1%) and graft failure (n=4; 3.1%), all reported after penile urethroplasty. Univariate analysis indicated that age at surgery, stricture length, site and aetiology were all significant risk factors for stricture recurrence. On multivariate analysis penile site was the only significant independent variable for restricture. Conclusions BMG urethroplasty represents a reliable therapeutic option for patient with urethral strictures with a success rate of 81% at 45 months of follow-up. Complications are more common in complex stricture of the penile urethra. On multivariate analysis penile site was the only significant independent variable for re-stricture.

Autologous mid-urethral sling for stress urinary incontinence: Preliminary results and description of a contemporary technique

Objective: The objective of this article is to describe the preliminary results of a contemporary technique for autologous rectus fascial sling insertion for stress urinary incontinence (SUI). Methods: We retrospectively reviewed the case notes of all patients who underwent autologous mid-urethral sling (aMUS) insertion by a single surgeon at our institution over a four-year period (2008–2012). Our novel technique utilises a minimal suprapubic incision, a specially designed reusable retropubic needle and mid-urethral sling positioning in a tension-free fashion as opposed to a tensioned bladder neck sling. Results: Thirty-eight patients were identified. Fifty per cent reported pure SUI whilst 47% had mixed urinary incontinence. Patients used an average of four pads per day (one to eight), and 26% of patients had at least one previously failed SUI procedure. Post-operative symptom questionnaires revealed mean Patient Global Impression of Improvement (PGI) scores of 1.8 (1–4), indicating that the majority of patients were very much or much improved. Only 8% of patients reported de novo OAB symptoms. Intraoperative bladder perforation occurred in only two patients. There was no incidence of chronic pain, sexual dysfunction or erosion. Conclusion: In a heterogeneous group of women with primary or recurrent stress urinary incontinence, the aMUS was found to have good subjective short-term cure rates with acceptable patient-reported satisfaction scores. We report a low rate of de novo OAB symptoms, no cases of erosion and no chronic pelvic, groin, or vaginal pain. We believe that aMUS is a good alternative to synthetic mid-urethral sling surgery and could be offered to women contemplating surgery for SUI.

Can filling phase urodynamic parameters predict the success of the bulbar artificial urinary sphincter in treating post‐prostatectomy incontinence?

To evaluate whether filling phase urodynamic parameters can predict the success of the artificial urinary sphincter (AUS) in treating post‐prostatectomy incontinence (PPI).

OnabotulinumtoxinA injections in men with refractory idiopathic detrusor overactivity

OBJECTIVE To establish the effectiveness and safety profile of Onaboulinum toxin A (BTX-A) in men with idiopathic detrusor overactivity and compare with the outcomes observed in women. Several randomized trials have demonstrated the effectiveness of intradetrusor BTX-A injections in improving symptoms and quality of life in patients with overactive bladder (OAB) symptoms. Most trials however contained relatively few men or excluded men altogether. MATERIALS AND METHODS Data patient undergoing BTX-A for refractory OAB with idiopathic detrusor overactivity on urodynamics were extracted from our centers prospectively maintained database. Incontinence impact questionnaire-7 and urogenital distress inventory-6 scores were collected at baseline and 4-12 weeks together with data regarding urinary retention requiring clean intermittent self-catheterization (CISC) and urinary tract infection (UTI). Urodynamic studies were assessed where available to see if voiding dysfunction and CISC were predictable. RESULTS Sixty-five men received 133 BoNT-A treatments in the 15-year period representing 27.8% of those with refractory OAB. Baseline urogenital distress inventory-6 and incontinence impact questionnaire-7 fell by 4.2 (P = .00) and 6.0 (P = .00) points for men and by 6.0 (P = .00) and 11.1 (P = .00) for women, respectively. De novo CISC was required in 46 (42.6%) men and 107 (35.3%) women (P = .10). UTI was reported in 36 (29.0%) men and 86 (27.0%) women (P = .73). The bladder outflow obstruction index and the bladder contractility index did not reliably predict CISC requirement. CONCLUSION Men with refractory OAB experience significant improvement in quality of life scores following BTX-A, though the benefit appears greater in women. The requirements for CISC and UTI rates were similar between sexes.

Preliminary report on the effect of urethral diverticulum magnetic resonance imaging configuration on the incidence of new onset urodynamic stress urinary incontinence following excision

Context: Excision of urethral diverticulum in females has been reported to be associated with new onset urodynamic stress urinary incontinence (USUI) in up to 49%. Aims: We have assessed the incidence of new onset USUI in all patients having urethral diverticulum excision with Martius fat pad interposition under the care of a single surgeon between May 1, 2007, and December 1, 2011. The incidence of new onset USUI has been correlated with the preoperative magnetic resonance imaging (MRI) appearance of the urethral diverticulum. Patients and Methods: All 33 patients (mean age 42) having urethral diverticulum with Martius fat pad interposition had prospective data tabulated on demographics, preoperative MRI appearance, and pre- and post-operative videocystometrogram. Statistical Analysis Used: Statistical analysis was performed by Chi-squared and Fishers exact. Results: Of the 33 patients, 10 (30%) had preoperative USUI and have been excluded from this study. Other preoperative urodynamic findings included idiopathic detrusor overactivity in ten (30%) and bladder outflow obstruction in five (16%). Two (10%) of the patients had a simple diverticulum, 16 (73%) had a horseshoe diverticulum, and 5 (17%) had a circumferential diverticulum. The rate of new onset USUI was 0% for simple, 6% for saddle, and 20% for circumferential. Conclusions: New onset USUI occurs in 9% of patients having excision of urethral diverticulum with Martius fat pad interposition. The incidence appears to increase with increasing complexity of urethral diverticulum on preoperative MRI – rising from 0% following simple urethral diverticulum excision to 20% following circumferential diverticulum excision.

Describing the learning curve for bulbar urethroplasty

Background Learning curves have been described for a number of urological procedures including radical prostatectomy and laparoscopic nephrectomy but rarely for urethroplasty. We describe the learning curve for bulbar urethroplasty in a single surgeon series. Methods A retrospective case note review was performed of 91 consecutive men median age 32 years (range, 15–66 years) having bulbar urethroplasty performed by a single surgeon. Data was collected on type of urethroplasty, restricture rate (as defined by urethrogram and/or flow rate) and duration of follow up. The restricture rates were compared by quartiles and statistical analysis was by ¦Ö2 between the first and fourth quartiles. Results The 91 men had 42 dorsal onlay buccal mucosal graft (Dorsal BMG), 20 BMG augmented bulbobulbar anastomotic (Augmented Rooftop) and 29 bulbobulbar anastomotic (BBA) urethroplasties performed. Median follow up was 39 months for the first quartile, 42 months for the second, 36 months for the third, and 35 months for the fourth. The restricture rate was 17% in the first quartile, 8.7% in the second and third quartiles and 4.5% in the fourth quartile. There were no restrictures noted after 24 months. There were 4 restrictures in the first quartile and 1 restricture in the fourth quartile (¦Ö2 P<0.01). Conclusions There is a statistically and clinically significant difference in restricture rates between first and fourth quartiles with rates falling from 17% to 4.5%. There is a learning curve for bulbar urethroplasty with a reduced restricture rate each quartile and it may take as many as 90 cases to reach optimum restricture rates.

MP63-15 CONCORDANCE OF URODYNAMIC DEFINITIONS OF FEMALE BLADDER OUTLET OBSTRUCTION

METHODS: Twenty patients whose most bothersome symptoms were nocturia and/or nocturnal enuresis underwent overnight ambulatory urodynamic studies. All patients had undergone prior undiagnostic standard filling cystometry. Traces were reviewed and it was documented if detrusor overactivity (DO) +/-leakage was demonstrated, as well as the maximum voided volume and nocturnal urine output. RESULTS: The mean ( SD) agewas 45.1 19.9 years, comprising 14 female and 6 male patients All patients presented with nocturia with 17 patients additionally complaining of nocturnal enuresis. Only 5 patients reported bothersome day time symptoms. The mean duration for the overnight ambulatory urodynamic studies was 14.5 hours (range 12 to 16.6 hours). DO was demonstrated in 80% (n1⁄416) of patients. 15 out of the 17 (88.3%) patients with nocturnal enuresis demonstrated DO. Small volume SUI was demonstrated in 4 out the 17 (23.5%) patients with nocturnal enuresis. The mean and median peak DO pressure was 68.3 ( 50.9) and 50 cmH2O. There appears to be no significant difference in the maximum voided volume and nocturnal urine output between the two DO groups (NB: small sample DO -ve patients). Incontinence was observed in 15 out of 16 (93%) patients with DO. CONCLUSIONS: 80.0% of patients who present with nocturia and 88% with nocturnal enuresis demonstrate detrusor overactivity on overnight ambulatory urodynamics tests. The DO pressures demonstrated were large amplitude and resulted in incontinence by overcoming in most cases an otherwise competent outlet. Nocturnal ambulatory urodynamics are a useful clinical adjunct for assessing night time urinary symptoms.