Timothy O. Davies

Primary Realignment vs Suprapubic Cystostomy for the Management of Pelvic Fracture–associated Urethral Injuries: A Systematic Review and Meta-analysis

OBJECTIVE To compare primary urethral realignment (PR) with suprapubic cystostomy (SPC) for the management of pelvic fracture-associated posterior urethral injuries with regards to rates of stricture, erectile dysfunction, and urinary incontinence. METHODS Two electronic databases (MEDLINE and EMBASE) were searched with the assistance of a librarian. Title, abstract, and full text screening was carried out by 2 independent reviewers, with discrepancies resolved by consensus. Narrative reviews, surveys, and historical articles were excluded. Only studies reporting a direct comparison of PR vs SPC for the management of posterior urethral injuries associated with blunt trauma in adults were included. Quality assessment of the included articles was performed in duplicate. Stricture incidence was evaluated for all included studies, as were erectile dysfunction and incontinence rates when reported. All outcomes were treated as dichotomous data with calculation of odds ratio and were pooled using a random effects model with Review Manager 5.1. RESULTS Our comprehensive search yielded 161 unique articles. Nine articles were included in the final meta-analysis. Stricture rate was significantly lower in the PR group (odds ratio [OR] = 0.12, 95% confidence interval [CI] 0.04-0.41, P <.001). There was no significant difference between the 2 interventions with regards to erectile dysfunction (OR = 1.19, 95% CI 0.73-1.92, P = .49) or incontinence (OR = 0.75, 95% CI 0.38-1.48, P = .41). CONCLUSION PR appears to reduce the incidence of stricture formation after pelvic fracture-associated posterior urethral injuries as compared with SPC.

Buried penis: An unrecognized risk factor in the development of invasive penile cancer.

One of the documented benefits of neonatal circumcision is protection against invasive penile cancer. To date there have been a handful of published cases of invasive penile cancer in men circumcised as neonates. We report a case of a 73-year-old man, with a history of neonatal circumcision with no evidence of previous human papillomavirus exposure, who developed a buried penis secondary to obesity. He was diagnosed with Grade 2, pT3N0 squamous cell carcinoma of the penis. This report suggests that buried penis may pose a risk factor for the development of penile cancer despite the protective effects of neonatal circumcision. Thus periodic examination of a buried penis is warranted even in patients with no risk factors for penile cancer. A review of the literature is provided.

The urachal flap: a previously unreported tissue flap in vesicovaginal fistula repair.

Objectives Tissue interposition is an important part of vesicovaginal fistula (VVF) repair that has been shown to improve success rates. The most common interpositional flap used during a transabdominal VVF repair is the omental flap; however, in some cases, it cannot be used. The urachus is a well-vascularized tissue that is easily mobilized for interposition. We describe our experience using a urachal flap in VVF repair. Methods Patients undergoing VVF repair at our center were identified, and a retrospective chart review was performed. Patients who underwent a transabdominal repair with interposition of a urachal flap were included. Results Thirteen patients were identified between 2005 and 2009. All were evaluated with a history, physical, upper and lower tract imaging, and cystoscopy. Median patient age was 49 years (range, 31–88 years). Fistula etiology was hysterectomy in 11 and prolapse repair in 2. Five patients presented with recurrent fistulas having failed previous repair. Of 13 patients, 12 had successful repairs with our described technique, including 4 patients who failed previous repairs. There was no recurrence of fistula after median follow-up of 6 months (range, 2 weeks to 4 years). Two patients had preoperative and postoperative complaints of stress urinary incontinence that was mild and did not require surgery. Conclusions Vesicovaginal fistulas can be a difficult challenge for the reconstructive surgeon. The urachal flap is a well-vascularized tissue flap that can be easily mobilized and interposed for VVF repair. Of 13 patients in this series, 12 were successfully repaired using this technique. We feel that further evaluation and usage of this tissue flap are indicated.

Can it wait? A systematic review of immediate vs. delayed surgical repair of penile fractures

INTRODUCTION Penile fractures have classically been thought to require immediate surgical intervention; however, recent series have described acceptable outcomes with delayed repair. In this systematic review, we compared complication rates between immediate and delayed repair of penile fractures. METHODS A systematic search of MEDLINE, Embase, CENTRAL, and Web of Science was performed with predefined search terms between 1974 and 2015. Titles and abstracts were screened prior to full-text review and quality appraisal by two independent investigators. Abstracted outcomes included postoperative erectile dysfunction (ED), tunical scar formation, and penile curvature. Only studies reporting a direct comparison of complications following immediate (<24 hours from injury to presentation/surgery) and delayed (>24 hours) repair of penile fractures were included. RESULTS A total of 12 studies met inclusion criteria. All were retrospective, observational studies of low or moderate methodological quality. Of the reported 502 patients, 391 underwent immediate repair and 111 delayed repair. In the immediate repair group, the percent of patients with postoperative ED, tunical scars, and curvature were 6.6%, 5.4%, and 1.8%, respectively, while in the delayed group, the rates of ED, tunical scars, and curvature were 4.5% across the board. Rates of ED and tunical scar formation following immediate compared to delayed repair trended towards favouring immediate repair, but did not differ significantly, while rates of curvature significantly favoured immediate repair. However, cases of curvature were typically reported as mild and none affected sexual functioning. CONCLUSIONS In this systematic review, we demonstrated that ED and tunical scar formation rates between immediate and delayed repair of penile fractures were statistically similar, while immediate repair had a lower rate of penile curvature. Although this suggests that a brief delay in repair may be acceptable in select patients, the results should be interpreted with caution, as the included studies were of low or moderate methodological quality. Most importantly, this review highlights the deficiencies in the current penile fracture literature, setting the stage to improve the quality of future studies.

Urothelial carcinoma involving the distal penis

Urothelial carcinoma (UC) rarely metastasizes to the penis and skin. We report the case of a 73-year-old man with UC metastases to the corpus spongiosum and dermis of the distal penis. We also review the clinicopathologic characteristics and management options for UC metastasizing to the penis. The patient presented with priapism and edema of the genital region. This follows a 5-year history of urothelial carcinoma in situ that progressed to invasive cancer despite intravesical immunotherapy. Seventeen months prior to presentation, the patient underwent a radical cystectomy with adjuvant chemotherapy. The cystectomy specimen demonstrated a pT4a N2 M0 G3 UC and margins were positive for carcinoma in situ. Follow-up had been negative for recurrence until his presentation with priapism. Incisional biopsy of the glans revealed UC and radical penectomy was performed with negative margins. The penile specimen demonstrated extensive involvement of the corpus spongiosum by UC with lymphovascular invasion and subepidermal involvement. Three months after penectomy, the patient presented with inguinal nodal recurrence. Palliative radiotherapy was administered and the patient passed away eight months after surgery.

Urethral stricture disease: Measuring success in treatment.

Urethral stricture disease and its management are complex. The UREThRAL stricture score (USS) as described by Wiegand and Brandes is a novel method to describe and quantify urethral stricture disease.1 To develop the USS, they chose factors they believed to be important and assigned a point value to each domain. The appealing UREThRAL acronym was used to recall the domains of etiology, number of strictures, luminal obliteration, location and length. Retrospectively they analyzed a group of postoperative urethral reconstructive patients to see if the score correlated with a subjective surgical complexity score. As they point out, there would be some debate as to the value of the surgical complexity score. Excision and primary anastomosis is doubtlessly the simplest of the open urethral reconstructive techniques and most would agree that combined graft and flap tissue transfer is used for the most complex stricture disease. Variability in surgical training and surgeon preference would be a significant confounder to the treatment complexity score. The value of a quantifiable urethral stricture score would be in comparing the scores to patient outcomes. Outcome measures continue to be one of the major hurdles to overcome in providing good quality research in reconstructive urology. Measurement of patient outcomes following urethral reconstructive surgery is not standardized. Many different methods have been used in the past to evaluate “success” following urethroplasty. Cystoscopy, urethral x-ray studies, uroflow and post-void residuals have been used to capture outcomes. Assessing the quality of life – the most important outcome – has yet to be standardized. Investigators have used non-validated questionnaires (like the AUA symptom score). Recently, Jackson and colleagues have taken a first step to develop a stricture specific health related quality of life questionnaire.2 The current challenge facing reconstructive urology is to develop a validated and standardized method of assessing patients pre- and postoperatively. In the development of The UREThRAL stricture score, the authors have delineated the important factors in determining the complexity of a stricture. This is valuable reminder to all urologists. At the initial evaluation of stricture disease, the factors pointed out by the authors (etiology, number of strictures, luminal obliteration, location and length) are the keys to determine the severity of the stricture itself. The length, as the authors point out, is heavily weighted and it is accepted to be the most likely determinant of both outcome and treatment.3,4 Longer and more complex strictures should signal the urologist to consider early open surgical intervention rather than pursuing futile and repeated endoscopic management (urethrotomy/dilatation). The poor outcomes5 and cost ineffectiveness6 of repeated endoscopic treatment of urethral strictures are well-described in the literature. Failed endoscopic treatment may be a useful additional factor in the USS. This may encourage earlier consideration for urethral reconstruction, which would benefit the patient and the health care system.

Management of pelvic fracture-associated urethral injuries: A survey of Canadian urologists

INTRODUCTION The management of pelvic fracture-associated urethral injuries (PFUI) is not standardized and optimal management is controversial. We surveyed Canadian urologists about their experiences and opinions regarding optimal management of PFUI. METHODS Canadian urologists were surveyed via an anonymous, bilingual, web-based, 12-item questionnaire. A total of 735 Canadian urologists were invited to participate via email distributed by the Canadian Urological Association. RESULTS Of the 146 urologists who participated (19.9% response rate), the majority practice at a trauma centre (53.2%), but manage only 1-5 PFUI/year (71.5%). Most participants (82.6%) favour primary realignment compared to suprapubic (SP) tube with delayed repair (15.3%) and immediate reconstruction (2.1%). Compared to SP diversion and delayed repair, the majority of participants believe primary realignment is associated with equivocal incontinence (61.2%) and erectile dysfunction rates (75.8%), but has lower stricture rates (73.0%). Among respondents who perform primary realignment, 45.4% concurrently place a SP tube, while 54.6% do not. While 91% believe SP tubes do not increase the risk of pelvic hardware infections, 31.6% report that orthopedic surgeons alter their management of pelvic fractures in the presence of a SP tube. CONCLUSIONS Most Canadian urologist respondents - even those practicing at trauma centres - manage very few PFUIs/year. There is reasonable consensus among respondents that primary realignment is favourable to delayed or immediate reconstruction, but discordance on whether or not to place concurrent SP tubes. The urological and orthopedic consequences of SP tubes in the management of traumatic urological injuries warrant further investigation.

Exploring the business of urology: Change management

Change is inevitable. All organizations need to change to maintain relevance and to successfully adapt to varying external forces. Change is a challenge for those involved in it. It is the antithesis of consistency and at its core requires a shift in behaviour that is reflexic and instinctual. The authors of this paper would suggest that given the nature of healthcare, its evolving research, its social value/importance, and its cost, that no other profession is more subject to change than medicine. Change is necessary, inevitable, and difficult. A solid understanding of change and its management process is a prerequisite for professional survival. Preparation, conviction, purpose, and clarity are the core values of change. Physicians, more than any other profession, have been driven to and exposed to change. Physicians are in a position to distill its process to a level of understanding that would serve as a model for others to follow. The goals of this paper are to outline the rationale of change, as well as to review change management options and strategies to increase successful change.

A novel approach to the repair of urethrocutaneous fistulae arising after abdominoperineal anorectal resection

This case report describes a novel approach to the repair of perineal urethrocutaneous fistulae (UCF) after abdominoperineal resection (APR). A 62-year-old patient developed a UCF after an APR for rectal cancer complicated by perineal abscess formation. The patient presented with continuous urinary drainage from the fistula that persisted despite a number of conservative and surgical measures. The patient underwent successful repair of the urethrocutaneous fistula in prone position-an approach that has not previously been described in the literature. Repair was performed by the multi-disciplinary team of a reconstructive urologist, colorectal surgeon, and plastic surgeon. Post-operative retrograde urethrogram demonstrated the absence of a persistent fistula tract and the patient has been continent for 18 months. The prone approach for UCF repair allows for excellent access to the fistula tract for posterior urethroplasty in a patient that has had prior APR.

Wound Healing and Principles of Plastic Surgery

Wound healing is the natural restorative response to tissue injury. Essential to optimizing surgical procedures and evolving novel techniques, a basic understanding of the basic principles of wound healing is necessary. Types of wound closure are classified as primary, secondary, and tertiary. Primary wound healing refers to those wounds which are immediately closed with direct epithelial/mucosal approximation. Secondary wound healing refers to those wounds that all or a portion are left open to heal, without any attempt at closure. These will heal by granulation, reepithelialization, and wound contraction. Tertiary wound healing refers to wounds closed by delayed primary closure.