Effect of a temporary thermo-expandable stent on urethral patency after dilation or internal urethrotomy for recurrent bulbar urethral stricture: results from a 1-year randomized trial.

PURPOSE: The long-term success rate of dilation and/or internal urethrotomy is low in cases of recurrent urethral stricture. We investigated the ability of the Memokath™ 044TW stent to maintain urethral patency after dilation or internal urethrotomy for recurrent urethral stricture. MATERIALS AND METHODS: A total of 92 patients with recurrent bulbar urethral strictures (mean length 2.7 cm) were treated with dilation or internal urethrotomy and randomized to short-term urethral catheter diversion (29) or insertion of a Memokath 044TW stent (63). The primary end point was urethral patency, as assessed by passage of a calibrated endoscope. Secondary end points included urinary symptoms and uroflowmetry parameters. Stents were scheduled to remain in situ for 12 months. RESULTS: The rate of successful stent insertion was 93.6% (59 of 63 patients). In stented patients patency was maintained significantly longer than controls (median 292 vs 84 days, p <0.001). Patency was reflected in significantly improved uroflowmetry and symptom scores. The stent was removed in 100% of patients. The most frequently noted side effects in stented patients were bacteriuria, hematuria and penile pain, which were usually mild and transient. There was no difference in sexual function between stented and control patients. Stent dislocation and occlusion were observed in 8 and 3 patients, respectively. CONCLUSIONS: Patients with recurrent bulbar urethral strictures treated with dilation or urethrotomy and a Memokath 044TW stent maintained urethral patency significantly longer than those treated with dilation or urethrotomy alone. The stent side effect profile was favorable. The stent was straightforward to insert and it was removed without difficulty even after long-term placement.

Bilateral Ureteropelvic Junction Disruptions in a 17-Year-Old With Bilateral Ureteral Duplications: Impact of Unrecognized Duplications and Unique Management of Nephrocutaneous Fistula.

A case of bilateral ureteropelvic junction (UPJ) disruptions in a patient with bilateral duplication anomalies is presented. A UPJ disruption with a duplication anomaly has not been reported let alone bilateral duplication anomalies. The unrecognized duplication anomalies led to isolated and obstructed upper pole segments that were managed by bilateral heminephrectomies. A nephrocutaneous fistula developed after one of the heminephrectomies that was successfully managed using a method of percutaneous fulguration and fibrin sealant. In UPJ disruption cases, the possibility of a duplicated collecting system should be considered as an unrecognized duplication may complicate management and prolong recovery.

Staged urethroplasty: indications and techniques.

There is still a place for staged urethroplasty. There are some indications for staged urethral reconstruction such as strictures associated with chronic inflammation, fistula, false passage, urethral stones, urethral diverticula, abscess, failed prior repair, complicated hypospadias, severe trauma, neurologic diseases, extensive BXO strictures and long strictures. Staging a urethroplasty should not be considered a step backwards rather instead we should learn from experience and realize there are some patients who are too complex to reconstruct in a single stage.

Large cystocele with spontaneous vesicovaginal fistula.

Vesicovaginal fistulae (VVF) caused by cystoceles are very rare. To date, there are no documented cases in English literature. A 77-year-old woman presented with near total incontinence. On physical examination, she was found to have severe vaginal atrophy and pressure necrosis of the anterior vaginal wall, which caused partial thickness erosion and breakdown of the mucosa. A fistula had formed but there was no obvious full thickness necrosis. She underwent a combined vesicovaginal fistula repair with pubovaginal sling.

Periurethral mass formations following bulking agent injection for the treatment of urinary incontinence.

PURPOSE: Durasphere is gaining popularity as a bulking agent for treating women with stress urinary incontinence. We present a series of patients with periurethral mass formation following Durasphere injection. MATERIALS AND METHODS: The charts of 135 women with a mean age of 69.4 years (range 46 to 83) who underwent Durasphere periurethral injections were retrospectively reviewed. Patients who had a periurethral mass were identified and their clinical data were collected and analyzed. RESULTS: Four patients (2.9%) were diagnosed with periurethral mass formation 12 to 18 months (average 14.7) following a Durasphere injection. Clinical presentation varied, including irritative voiding symptoms, pelvic pain and urinary incontinence. All patients were found to have a tender and tense periurethral mass. A radiopaque mass was revealed during videourodynamic study in 1 patient. Incision, and transvaginal and endoscopic drainage or transvaginal excision were used to treat these masses. Intraoperative and pathological findings as well as operative outcomes are presented. CONCLUSIONS: Irritative or obstructing voiding symptoms, pelvic pain or a periurethral mass in patients with a history of Durasphere or other periurethral bulking agent injection should alert the physician to the possibility of periurethral mass formation. The true incidence of this late complication remains to be determined.

New periurethral bulking agent for stress urinary incontinence: modified technique and early results.

PURPOSE: Durasphere (Carbon Medical Technologies, St. Paul, Minnesota) is a newly approved injectable agent for stress urinary incontinence. Proven and potential advantages include nonimmunogenicity, tissue nonreactivity, efficacy at low injectable volume and durability. A concern regarding use is difficulty involved with application. A modified technique for easier implantation of this agent is described and early results are reported. MATERIALS AND METHODS: The surgical technique follows the standard technique for transurethral implantation of bulking agents. Steps modified to allow easier implantation of Durasphere beads include a single needle stick at the 4 o'clock position, hydrodissection with 1.5 ml 1% lidocaine into the submucosa, gradual withdrawal/advancement or rotation of the needle tip after resistance is noted and holding the needle in position for an additional 10 seconds after proper coaptation is achieved to prevent the beads from leaking out of the needle puncture site. Patient charts were retrospectively reviewed. Patient perception of treatment outcomes, a 24-hour pad test and a voiding diary were obtained and analyzed. The strict criteria of the Groutz-Blaivas score were applied as an additional measure of outcome. RESULTS: Of 70 patients 46 (65.7%) for whom full contact information was available responded. Patient age was 46 to 83 years (mean 69.4). A history of a failed prior anti-incontinence procedure was recorded in 15 patients (32.6%) and coexisting symptoms of urge incontinence or urodynamically proven detrusor instability was evident in 29 (63%) and 5 (10.8%), respectively. Bulking agent was delivered at 1 to 3 sessions (mean 1.52) 1 to 3 months apart with 2 to 6 ml (3.2 ml) injected per session. Excellent or good coaptation was achieved in 92% of injections. At a followup of up to 18 months (mean 9.4) 6 (13%), 24 (52.2%) and 16 (34.7%) patients considered themselves cured or improved, or treatment to have failed, respectively. Of the 36 patients who completed a 24-hour pad test 18 (50%), 2 (5.5%) and 16 (44.4%) had a urine loss of 8 or less, 9 to 20 and greater than 20 gm, respectively. Results of the voiding diary and the Groutz-Blaivas score are provided. CONCLUSIONS: The modified technique of Durasphere injection allows easy implantation with good coaptation in the majority of patients. Early results are encouraging. Further research may reveal whether the improved delivery techniques translate into improved outcomes with more durable results compared with other approved bulking agents.

Urethral reconstruction in spinal cord injury patients.

PURPOSE: Bladder management programs for patients with spinal cord injury and neurological disease (SCIND) include intermittent catheterization and sphincterotomy with external catheter drainage. These programs depend on maintaining a patent urethra. Once urethral stricture, erosion, diverticulum or urethrocutaneous fistula occurs, the only treatments available are urethral reconstruction and urinary diversion. We evaluate the role of urethral reconstruction in this subset of patients. MATERIALS AND METHODS: The charts of 18 patients with SCIND (spinal cord injury 16, cerebral palsy 1, meningomyelocele 1) were retrospectively analyzed. Different surgical procedures had been performed according to the presenting pathology and tissue availability. RESULTS: Urethral reconstruction was performed in 17 patients with a mean age of 42.2 years (range 27 to 60). Of the patients 13 are paraplegic and 4 are quadriplegic. Urethral defects included urethral stricture in 6 cases, urethral erosion in 4, urethrocutaneous fistula in 3, urethral diverticula in 1 and combined defects in 3. Mean followup is 3.7 years (range 1 to 13) and the mean number of reoperations was 1.4 (range 0 to 4). Of the 17 patients 11 (64.7%) who underwent urethral reconstruction eventually required urinary diversion for end stage urethral pathology (incontinent ileovesicostomy 5, right colon pouches 2, other procedures 4). The mean time from first urethral reconstruction to eventual urinary diversion was 3.3 years (range 0.7 to 7). Four patients maintain a patent urethra while 1 patient was lost to followup. CONCLUSIONS: Patients with SCIND in whom urethral reconstruction is considered should be advised that urethral surgery carries a high risk of reoperation and eventual need for urinary diversion. Clearly, many patients with neurological disease and severe urethral pathology are best treated with urinary diversion.