Simon Bugeja

Non-transecting bulbar urethroplasty

Excision and end-to-end anastomosis (EPA) has been the preferred urethroplasty technique for short bulbar strictures and is associated with an excellent functional outcome. Driven by concerns over the potential morbidity associated with dividing the urethra, therefore compromising spongiosal blood flow, as well as spongiofibrosis being superficial in the majority of non-traumatic bulbar strictures, the non-transecting technique for bulbar urethroplasty has been developed with the aim of achieving the same success as EPA without the morbidity associated with transection. This manuscript highlights the fundamental principles underlying the ongoing debate—transection or non-transection of the strictured bulbar urethra? The potential advantages of avoiding dividing the corpus spongiosum of the urethra are discussed. The non-transecting anastomotic procedure together with its various modifications are decribed in detail. Our experience with this technique is presented. Non-transecting excision of spongiofibrosis with preservation of well vascularised underlying spongiosum provides an excellent alternative to dividing the urethra during urethroplasty for short non-traumatic proximal bulbar strictures.

The Nontransecting Approach to Bulbar Urethroplasty

The standard treatment of bulbar urethral strictures of appropriate length is excision and primary anastomosis (EPA), irrespective of the cause of the stricture. This involves transection of the corpus spongiosum (CS) and disruption of the blood flow within the CS as a consequence. The success rate of EPA in curing these strictures is very high, but there is a considerable body of evidence and of opinion to suggest that there is a significant risk of sexual dysfunction and, potentially, of other adverse consequences that occur because of transection of the CS.

V1-05 REDO BULBO-PROSTATIC ANASTOMOTIC (BPA) URETHROPLASTY FOR RECURRENT PELVIC FRACTURE-RELATED URETHRAL STRICTURES

located just at the site of the stenosis; any attempt for reconstruction may jeopardize continence. Anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. We developed a novel technique performing a meticulous dissection of this sheath to separate the muscle from the urethral wall, thus performing an intra-sphincteric anastomosis without disturbing the sphincteric function METHODS: A 67 year old patient underwent a transvesical simple prostatectomy for BPH. He developed an early bulbo-membranous stenosis managed initially with repeated dilation until he went into complete retention needing a suprapubic tube. The bulbar urethra is exposed through a vertical perineal incision with splitting of the bulbo-spongiosum muscle and then separated from the corpus cavernosum. Opening of the perineal membrane and splitting of the intercrural space in the midline, provides access to the dorsal aspect of the bulbo-membranous junction. The bulb is then mobilized to the left side, without detachment from the perineal body and the bulbar vessels are retracted. The sheath of the membranous urethra is now opened circumferentially at the bulbo-membranous junction, carefully reflecting the circular muscle fibers of the external sphincter until exposure of the urethral wall is obtained and the connecting tissue plane is identified. Gentle blunt proximal dissection along this plane allows separating the muscle away from the urethra towards the prostatic apex until healthy urethra is found to perform the bulbo-prostatic anastomosis, which is completed with a standard parachute technique. Finally the sphincteric muscle ring is anchored to the anastomosis with interrupted absorbable stitches RESULTS: The patient was discharged on PO day 3 and the urethral catheter was removed at 3 weeks. He recovered normal continent micturition and is voiding symptoms free at 3 months of follow-up CONCLUSIONS: Excision and bulbo-prostatic anastomosis with sphincter sparing for bulbo-membranous stenosis after BPH surgery is feasible and safe. Our technique allows repairing the urethra preserving continence and to our knowledge it has not been described before. A larger series and reproduction in other centers are needed to validate this technique

V1-08 SURGICAL CORRECTION OF URORECTAL FISTULA (URF) FOLLOWING RADICAL PROSTATECTOMY FOR THE TREATMENT OF PROSTATE CANCER.

hypospadias repair, urethral reconstruction, and correction of penile curvature. We set out to develop a retractor that would improve surgeon and assistant ergonomics and provide compression at the base of the penis to reduce blood loss. We describe this novel self-retaining penile retractor and our initial experience in its use. METHODS: This retractor is made of medical grade stainless steel. It has three components e a fixed hemostatic clamp attached to a scale, with also houses an artery forceps. This forceps moves along the scale to adjust the traction on the penis. The clamp is flat and compressive. The arms are non-traumatic and do not cause circumferential constriction. A stay suture taken through the glans is engaged by the artery forceps, and the height adjusted according to the penile length. The retractor has been used by reconstructive urologists in India, Turkey, Australia, Kuwait, Indonesia, and the United States of America. RESULTS: A total of 37 reconstructive cases were performed using this penile retractor (23 redo hypospadias repairs, 7 complex penile urethroplasties, 4 penile urethrocutaneous fistula repairs, and 3 surgeries for correction of Peyronie’s disease). For each case, surgeons were asked to score the retractor on a 4 point scale: 1. Extremely Non satisfactory, 2. Not Satisfactory, 3. Satisfactory, 4. Extremely Satisfactory. The average score was 3.65. Advantages noted were ease of application, reduction of assistant fatigue, stable operative exposure and non-traumatic tissue compression conferring a bloodless field. There were no complications attributable to the device. The main limitation is that it cannot be used for hypospadias proximal to the penoscrotal junction. This retractor is inexpensive, durable and easy to sterilize and can be used on adult and pediatric patients alike. CONCLUSIONS: In our experience this retractor has high utility in reconstruction of the penis and penile urethra. It affords improved ergonomics for the surgeon and assistant, which results in shorter operative times and reduced blood loss while avoiding tissue damage.

PD64-10 LONG TERM OUTCOME FOLLOWING BLADDER NECK ARTIFICIAL URINARY SPHINCTER IMPLANTATION

day voiding diary, and urinary flow rate and post-voiding residual urine volume before and after its administration. RESULTS: Motor symptoms significantly improved after 1 year evaluating movement disorder rating scale (p<0.01). Significant improvements were also observed in the answers provided on urinary questionnaires after 1 year treatment (IPSS: 14.4 7.6 vs. 8.5 6.8, OABSS: 6.9 2.8 vs. 5.5 3.7; p<0.05) [breakdown: Table]. Data from the KHQ revealed that the domain of impact on life had significantly improved after 1 year treatment [Table]. And in 3-day voiding diary, nighttime urinary frequency (3.0 1.6 vs. 2.4 0.7; p<0.05). However, no significant changes were observed in the urinary flow rate (Qmax) or post-voiding residual urine volume (RU) between before and after 1 year administration of istradefylline (Qmax (ml/s): 10.7 3.9 vs. 8.0 2.8, RU (ml): 51.0 60.0 vs. 40.5 30.8). No adverse urological effects were observed in any patient. CONCLUSIONS: Istradefylline effectively improved not only motor symptoms, but also LUTS in patients with PD in a long-term period. And the results of the present study confirmed that adenosine A2A receptor antagonists are useful as a new pharmacological treatment for OAB in patients with PD.

PD29-07 OPEN REPAIR OF BLADDER NECK CONTRACTURES (BNC) WITH OR WITHOUT ADJUVANT RADIOTHERAPY – OUR EXPERIENCE IN 42 PATIENTS

beam radiotherapy, 38.3% had brachytherapy and 5.8% had combined radiation modalities. The most common complications were urethral stricture/stenosis (88.3%), refractory storage LUTS (88.3%), incontinence (45.8%), erectile dysfunction (60.0%), radiation cystitis (50.8%), acute urinary retention (50.0%) and hematuria (42.5%). Other notable complications included prostate necrosis/abscess (14.2%), pubic osteomyelitis/prostatosymphyseal fistula (3.3%), de novo cancer (5.8%), and rectourethral fistula (0.8%). Patients required a mean of 7.4 4.4 (130) treatments for radiation related complications over the study period and 49.2% of patients required major urologic surgery. Required procedures included urethral dilation/urethrotomy (77.5%), urethral reconstruction (44.2%), incontinence surgery (6.7%), transurethral resection (prostate, bladder, contracture) (43.3%), cystolithopaxy (11.7%) and urinary diversion (6.7%). 13.3% of patients were treated with an indwelling suprapubic catheter. Patients with complications related to combined radiotherapy had more complications (7.0 vs. 5.0; p1⁄40.016) including incontinence (85.7% vs. 44.2%; p1⁄40.04), de novo malignancy (28.6% vs. 4.4%; p1⁄40.05), pubic osteomyelitis (28.6% vs. 1.8%; p1⁄40.02), and tended to require a higher number of procedures (10.1 vs. 7.2; p1⁄40.08). CONCLUSIONS: Lower urinary tract complications related to radiotherapy are very seldom an isolated problem and require a tremendous amount of resources and urologic intervention. Patients with combined radiotherapy complications have a higher number of complications and typically require more interventions.

PD38-12 THE EFFECT OF RADIOTHERAPY ON THE OUTCOME OF THE REPAIR OF URORECTAL FISTULAE

INTRODUCTION AND OBJECTIVES: The aim of this study was to assess the results of kidney transplant (KT) in patients with bladder augmentation (BA). METHODS: Between 1988 and 2015, 64 patients with BA (3 after KT) underwent kidney transplantation, due to significant lower urinary tract dysfunction. There were 40 males and 24 females. Ten second and 1 third KT were performed, comprising 75 KT in 64 patients. 44 were from living donor and 31 from deceased donor. Mean age at first KT was 22.54 15.09 (3-64) years and mean age at first bladder augmentation was 18.31 13.83 (2-64) years. The etiology of bladder dysfunction was neurogenic bladder due to spina bifida (23 patients), posterior urethral valve (12 patients), vesico-urethral reflux (6 patients), tuberculosis (8 patients) and other causes (14 patients). The bowel segments used in the augmentation included ileum in 45(70.3%) patients, ileocecal in 3(4.7%) patients and sigmoid in 4(6.3%) patients. The ureter was used in 12 (18.8%) patients. Redo BA was performed in 4 patients (1 ureterocistoplasty and 3 ileocistoplasty), all after ureterocistoplasty. In 2 patients, it was performed before the first kidney transplant. RESULTS: Mean follow-up after first BA was 172.47 112,07 (11-522) months. Overall patient survival was 77.6% and actuarial graft survival at 1,2,5,7,9 and 10 years was 92%, 87.6%, 81.2%, 67.8%, 65.7% and 53.9%, respectively. Surgical complications included 1 vesicocutaneous fistula and 1 stenosis of ureteral reimplant. 51(79.7%) patients were in clean intermittent catheterization. Symptomatic or febrile urinary tract infections (UTI) occurred at least 1 episode in 79.3% of patients. Ten (62.5%) patients died of unrelated cause and 6 (37.5%) patients died due to related causes. The main cause of graft loss was chronic allograft nephropaty in 21 (77.7%) patients. CONCLUSIONS: Augmentation cystoplasty is a safe and effective treatment for lower urinary dysfunction. Patients must be followed up closely with special attention to UTIs. Survival graft after 10 years seems to similar to regular KT recipients.

PD34-02 HE LONG-TERM RESULTS OF NON-TRANSECTING BULBAR URETHROPLASTY

INTRODUCTION AND OBJECTIVES: Anastomotic urethroplasty is an effective but occasionally controversial treatment for short bulbar urethral strictures. Non-transecting variations of anastomotic urethroplasty were created in part to address this controversy. The objective of this study is to assess current outcomes of anastomotic urethroplasty and compare outcomes of transecting and non-transecting techniques. METHODS: 171 patients with complete follow-up underwent anastomotic bulbar urethroplasty from September 2003 to May 2016. Patient age, stricture length, location, etiology, 90-day complications and semi-quantitative assessment of sexual dysfunction were recorded. The primary (objective) outcome was success defined as urethral patency >16Fr on routine follow-up cystoscopy. Secondary outcome measures included 90-day complications (Clavien 2) and de novo sexual dysfunction assessed at 6 months. Statistical comparison between transecting and non-transecting cohorts was made using Cox Regression Analysis and Chi-square when appropriate. RESULTS: One hundred and thirty patients underwent transecting anastomotic urethroplasty while 41 had a non-transecting anastomotic urethroplasty. Mean stricture length was 1.5 0.5cm (range 1-3) with a mean patient age of 43.0 18.0 years. 78.9% of patients failed prior endoscopic treatment (135/171) and 2.4% failed prior urethroplasty (4). Overall there was a 98.2% (168/171) success rate with a mean follow-up of 74.9( 46.7) months. 7.0% (12/171) of patients experienced a 90-day postoperative complication of Clavien 2 including 2.9% wound-related complications (5), 1.8% scrotal hematomas (3), 1.8% UTI (3), and 0.6% urethral bleeding (1). 9.9% reported an adverse change in sexual function including 6.4% erectile dysfunction (11), 1.8% ejaculatory dysfunction (3), 1.2% painful erection (2), and 0.6% chordee (1). When comparing transecting and non-transecting technique success using Cox Regression analysis there was no difference in urethroplasty success (97.7% vs. 100%; p1⁄40.63) and no difference in postoperative complications (7.7% vs. 4.9%; p1⁄40.73) but patients undergoing transecting anastomotic urethroplasty were more likely to report an adverse change in sexual function (13.1%; vs. 0%; p1⁄40.013). CONCLUSIONS: Anastomotic urethroplasty remains a highly effective treatment for short-segment bulbar urethral strictures with relatively minimal associated morbidity. Newer non-transecting anastomotic urethroplasty techniques appear to compare favorably in the short-term and may reduce the risk of associated sexual dysfunction.

Pelvic fracture urethral injury – the nature of the causative injury correlates strongly with surgical treatment and outcome

It is well recognised that pelvic fracture urethral injury (PFUI) is related to pelvic ring disruption. The usual causes of disruption of the pelvic ring are a lateral compression, an antero-posterior compression or a vertical shear force. The lateral compression injury causes the pelvis to be crushed inwards; the anteroposterior compression tends to cause an “open book” which opens the pelvis up; and the vertical shear force causes upward displacement of one hemi-pelvis in relation to the other side.

Re-operative abdomino-perineal reconstructive surgery

INTRODUCTION AND OBJECTIVES: While the perineal urethrostomy (PU) has proven to be a highly successful option for patients with complex urethral stricture disease, it is often utilized as a last resort. The perceived disadvantages of this procedure include the loss of normal anatomy, need to sit to urinate, and concerns about potency and sexual function. We aim to describe our contemporary series of patients treated with perineal urethrostomy. METHODS: We conducted an IRB approved, retrospective review of all patients who underwent PU from 1996 to 2012. Inclusion criteria were age > 18 and male gender. Patients with a temporary PU as part of a staged repair were excluded. Data extracted included patient demographics, stricture etiology, comorbidities, previous therapies, and need for subsequent interventions. All patients who received perineal urethrostomy as definitive management were included in the analysis. PU was considered successful if there was no need for subsequent interventions including dilations, self-calibration or surgical revision. RESULTS: A total of 718 patients underwent urethral reconstruction in the studied time period. Of these, 56 received a PU (7.8%). Etiology was lichen sclerosus in 20 (36%), hypospadias in 10 (18%), and trauma or idiopathic in 26 (46%). Mean follow-up was 21 months. All of these cases consisted of creation of a posteriorly based flap perineal urethrostomy as described by Barbagli. Eight out of 56 patients received a PU after electing not to proceed with a planned second stage urethroplasty. Twenty-eight of the 48 (58%) patients who intended to have definitive PU had failed at least one previous urethroplasty compared with 2 of 8 (25%) patients intending to have staged repair (p1⁄40.1). Of the 56 patients, two patients (3.6%) developed stenosis of the PU. One patient underwent a successful revision of the perineal urethrostomy and the other was placed on self-dilations. Prior radiation, stricture etiology, BMI, diabetes, prior urethroplasty, and stricture length were not predictive of failure. CONCLUSIONS: Perineal urethrostomy is a highly successful technique for severe urethral stricture disease that arrests the need for further interventions in the vast majority of cases with a very low complication or revision rate.