Open urethroplasty versus endoscopic urethrotomy for recurrent urethral stricture in men: the OPEN RCT.

BACKGROUND: Men who suffer recurrence of bulbar urethral stricture have to decide between endoscopic urethrotomy and open urethroplasty to manage their urinary symptoms. Evidence of relative clinical effectiveness and cost-effectiveness is lacking. OBJECTIVES: To assess benefit, harms and cost-effectiveness of open urethroplasty compared with endoscopic urethrotomy as treatment for recurrent urethral stricture in men. DESIGN: Parallel-group, open-label, patient-randomised trial of allocated intervention with 6-monthly follow-ups over 24 months. Target sample size was 210 participants providing outcome data. Participants, clinicians and local research staff could not be blinded to allocation. Central trial staff were blinded when needed. SETTING: UK NHS with recruitment from 38 hospital sites. PARTICIPANTS: A total of 222 men requiring operative treatment for recurrence of bulbar urethral stricture who had received at least one previous intervention for stricture. INTERVENTIONS: A centralised randomisation system using random blocks allocated participants 1 : 1 to open urethroplasty (experimental group) or endoscopic urethrotomy (control group). MAIN OUTCOME MEASURES: The primary clinical outcome was control of urinary symptoms. Cost-effectiveness was assessed by cost per quality-adjusted life-year (QALY) gained over 24 months. The main secondary outcome was the need for reintervention for stricture recurrence. RESULTS: The mean difference in the area under the curve of repeated measurement of voiding symptoms scored from 0 (no symptoms) to 24 (severe symptoms) between the two groups was -0.36 [95% confidence interval (CI) -1.78 to 1.02; p = 0.6]. Mean voiding symptom scores improved between baseline and 24 months after randomisation from 13.4 [standard deviation (SD) 4.5] to 6 (SD 5.5) for urethroplasty group and from 13.2 (SD 4.7) to 6.4 (SD 5.3) for urethrotomy. Reintervention was less frequent and occurred earlier in the urethroplasty group (hazard ratio 0.52, 95% CI 0.31 to 0.89; p = 0.02). There were two postoperative complications requiring reinterventions in the group that received urethroplasty and five, including one death from pulmonary embolism, in the group that received urethrotomy. Over 24 months, urethroplasty cost on average more than urethrotomy (cost difference £2148, 95% CI £689 to £3606) and resulted in a similar number of QALYs (QALY difference -0.01, 95% CI -0.17 to 0.14). Therefore, based on current evidence, urethrotomy is considered to be cost-effective. LIMITATIONS: We were able to include only 69 (63%) of the 109 men allocated to urethroplasty and 90 (80%) of the 113 men allocated to urethrotomy in the primary complete-case intention-to-treat analysis. CONCLUSIONS: The similar magnitude of symptom improvement seen for the two procedures over 24 months of follow-up shows that both provide effective symptom control. The lower likelihood of further intervention favours urethroplasty, but this had a higher cost over the 24 months of follow-up and was unlikely to be considered cost-effective. FUTURE WORK: Formulate methods to incorporate short-term disutility data into cost-effectiveness analysis. Survey pathways of care for men with urethral stricture, including the use of enhanced recovery after urethroplasty. Establish a pragmatic follow-up schedule to allow national audit of outcomes following urethral surgery with linkage to NHS Hospital Episode Statistics. TRIAL REGISTRATION: Current Controlled Trials ISRCTN98009168. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 61. See the NIHR Journals Library website for further project information.

The urethra carries urine from the bladder to the tip of the penis. Men can develop a condition called urethral stricture when part of the urethra narrows due to scarring. This can lead to difficulties in passing urine and can recur. There are two operations for urethral stricture. The standard approach is endoscopic urethrotomy. The alternative is open urethroplasty. This study wanted to find out which operation was preferable in terms of symptom control, time before further surgery and which operation was best value for the NHS. All aspects of the study were informed by patients. Two hundred and twenty-two men who had received at least one previous operation for stricture took part. The choice of operation was decided by chance (randomisation). Of these men, 113 were randomised to urethrotomy and 109 were randomised to urethroplasty. Following their operation, the men filled in questionnaires every 3­6 months for 2 years about their symptoms and if any further surgery was needed. The two groups were then compared. Of the 222 men who took part, 159 provided enough information for inclusion in the comparison (90 were in the urethrotomy group and 69 were in the urethroplasty group). The improvement over time in urinary symptoms was similar for the two groups. Men in the urethrotomy group were twice as likely to need a further operation over the 2-year study period. Very few men experienced serious complications. This study showed that both operations led to symptom improvement for men with recurrent urethral stricture. Urethroplasty, however, appears unlikely to offer good value for money for the NHS. Men needing treatment for recurrent urethral stricture can use this information to weigh up the pros and cons of each operation to decide with their clinical team which one to undergo.

Surgical Treatment for Recurrent Bulbar Urethral Stricture: A Randomised Open-label Superiority Trial of Open Urethroplasty Versus Endoscopic Urethrotomy (the OPEN Trial).

BACKGROUND: Urethral stricture affects 0.9% of men. Initial treatment is urethrotomy. Approximately, half of the strictures recur within 4 yr. Options for further treatment are repeat urethrotomy or open urethroplasty. OBJECTIVE: To compare the effectiveness and cost-effectiveness of urethrotomy with open urethroplasty in adult men with recurrent bulbar urethral stricture. DESIGN, SETTING, AND PARTICIPANTS: This was an open label, two-arm, patient-randomised controlled trial. UK National Health Service hospitals were recruited and 222 men were randomised to receive urethroplasty or urethrotomy. INTERVENTION: Urethrotomy is a minimally invasive technique whereby the narrowed area is progressively widened by cutting the scar tissue with a steel blade mounted on a urethroscope. Urethroplasty is a more invasive surgery to reconstruct the narrowed area. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the profile over 24 mo of a patient-reported outcome measure, the voiding symptom score. The main clinical outcome was time until reintervention. RESULTS AND LIMITATIONS: The primary analysis included 69 (63%) and 90 (81%) of those allocated to urethroplasty and urethrotomy, respectively. The mean difference between the urethroplasty and urethrotomy groups was -0.36 (95% confidence interval [CI] -1.74 to 1.02). Fifteen men allocated to urethroplasty needed a reintervention compared with 29 allocated to urethrotomy (hazard ratio [95% CI] 0.52 [0.31-0.89]). CONCLUSIONS: In men with recurrent bulbar urethral stricture, both urethroplasty and urethrotomy improved voiding symptoms. The benefit lasted longer for urethroplasty. PATIENT SUMMARY: There was uncertainty about the best treatment for men with recurrent bulbar urethral stricture. We randomised men to receive one of the following two treatment options: urethrotomy and urethroplasty. At the end of the study, both treatments resulted in similar and better symptom scores. However, the urethroplasty group had fewer reinterventions.

Single-stage tubular urethral reconstruction using oral grafts is an alternative to classical staged approach for selected penile urethral strictures.

Penile urethral strictures have been managed by a staged surgical approach. In selected cases, spongiofibrosis can be excised, a neo-urethral plate created using buccal mucosa graft (BMG) and tubularized during the same procedure, performing a "two-in-one" stage approach. We aim to identify stricture factors which indicate suitability for this two-in-one stage approach. We assess surgical outcome and compare with staged reconstruction. We conducted an observational descriptive study. The data were prospectively collected from two-in-one stage and staged penile urethroplasties using BMG in a single center between 2007 and 2017. The minimum follow-up was 6 months. Outcomes were assessed clinically, radiologically, and by flow-rate analysis. Failure was defined as recurrent stricture or any subsequent surgical or endoscopic intervention. Descriptive analysis of stricture characteristics and statistical comparison was made between groups. Of 425 penile urethroplasties, 139 met the inclusion criteria: 59 two-in-one stage and 80 staged. The mean stricture length was 2.8 cm (single stage) and 4.5 cm (staged). Etiology was lichen sclerosus (LS) 52.5% (single stage) and 73.8% hypospadias related (staged). 40.7% of patients had previous failed urethroplasties in the single-stage group and 81.2% in the staged. The most common stricture locations were navicular fossa (39.0%) and distal penile urethra (59.3%) in the single-stage group and mid or proximal penile urethra (58.7%) in the staged group. Success rates were 89.8% (single stage) and 81.3% (staged). A trend toward a single-stage approach for select penile urethral strictures was noted. We conclude that a single-stage substitution penile urethroplasty using BMG as a "two-in-one" approach is associated with excellent functional outcomes. The most suitable strictures for this approach are distal, primary, and LS-related 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.

Rectourethral Fistulas Secondary to Prostate Cancer Treatment: Management and Outcomes from a Multi-Institutional Combined Experience.

PURPOSE: Rectourethral fistula is a known complication of prostate cancer treatment. Reports in the literature on rectourethral fistula repair technique and outcomes are limited to single institution series. We examined the variations in technique and outcomes of rectourethral fistula repair in a multi-institutional setting. MATERIALS AND METHODS: We retrospectively identified patients who underwent rectourethral fistula repair after prostate cancer treatment at 1 of 4 large volume reconstructive urology centers, including University of California-San Francisco, University College London Hospitals, Lahey Clinic and Devine-Jordan Center for Reconstructive Surgery, in a 15-year period. We examined the types of prostate cancer treatment, technical aspects of rectourethral fistula repair and outcomes. RESULTS: After prostate cancer treatment 201 patients underwent rectourethral fistula repair. The fistula developed in 97 men (48.2%) after radical prostatectomy alone and in 104 (51.8%) who received a form of energy ablation. In the ablation group 84% of patients underwent bowel diversion before rectourethral fistula repair compared to 65% in the prostatectomy group. An interposition flap or graft was placed in 91% and 92% of the 2 groups, respectively. Concomitant bladder neck contracture or urethral stricture developed in 26% of patients in the ablation group and in 14% in the prostatectomy group. Postoperatively the rates of urinary incontinence and complications were higher in the energy ablation group at 35% and 25% vs 16% and 11%, respectively. The ultimate success rate of fistula repair in the energy ablation and radical prostatectomy groups was 87% and 99% with 92% overall success. CONCLUSIONS: Rectourethral fistulas due to prostate cancer therapy can be reconstructed successfully in a high percent of patients. This avoids permanent urinary diversion in these complex cases.

Urethral atrophy after implantation of an artificial urinary sphincter: fact or fiction?

OBJECTIVES: To investigate the concept of 'urethral atrophy', which is often cited as a cause of recurrent incontinence after initially successful implantation of an artificial urinary sphincter (AUS); and to investigate the specific cause of the malfunction of the AUS in these patients and address their management. PATIENTS AND METHODS: Between January 2006 and May 2013, 50 consecutive patients (mean age 54.3 years) with recurrent incontinence had their AUS explored for malfunction and replaced with a new device with components of exactly the same size, unless there was a particular reason to use something different. Average time to replacement of the device was 10.1 years. The mean follow-up after replacement of the device was 24.7 months. All patients without an obvious cause for their recurrent incontinence had preoperative urodynamic evaluation, including measurement of the Valsalva leak point pressure (VLPP) and the retrograde cuff occlusion pressure (RCOP). After explantation of the AUS in patients without any apparent abnormality of the device at the time of replacement, the pressure generated by the explanted pressure-regulating balloon (PRB) was measured manometrically, when this was possible. In a select group of six consecutive patients of this type, the fibrous capsule surrounding the old cuff was incised then excised to expose and evaluate the underlying corpus spongiosum. RESULTS: In 31 of the 50 patients (62%) undergoing exploration, a specific cause for the malfunction of their AUS was defined. In the other 19 patients (38%) no cause was found, either preoperatively or at the time of exploration, other than a low VLPP and RCOP. A typical 'waisted' or 'hour-glass' appearance of the underlying corpus spongiosum was demonstrable, to some degree, on explanting the cuff in all cases. In the six patients in whom the restrictive sheath surrounding the cuff was excised, the urethral circumference immediately returned to normal after the compressive effect of the sheath was released. Manometry of the explanted PRBs, when this was possible, showed a loss of pressure in all instances. Replacement of the explanted AUS with a new device with the same size cuff and PRB in 14 of these 19 patients was successful in 12 (85.7%). CONCLUSIONS: These results, and other theoretical considerations, suggest that recurrent incontinence, years after initially successful implantation of an AUS, is because of material failure of the PRB, probably attributable to its age and consequent loss of its ability to generate the pressure it was designed to produce, and that urethral atrophy does not occur. Simply replacing the old device with a new one with the same characteristics, unless there is a particular reason to do otherwise, is usually successful and avoids the complications of alternatives such as as cuff downsizing, implanting a PRB with a higher pressure range, implantation of a second cuff or transcorporeal cuff placement, all of which have been advocated in these patients.

Fistulation into the Pubic Symphysis after Treatment of Prostate Cancer: An Important and Surgically Correctable Complication.

PURPOSE: Chronic pubic pain after the treatment of prostate cancer is often attributed to osteitis pubis. We have become aware of another complication, namely fistulation into the pubic symphysis, which is more serious and more common than previously thought. MATERIALS AND METHODS: A total of 16 patients were treated for urosymphyseal fistulas after the treatment of prostate cancer between January 2011 and April 2014. Clinical presentation was characterized by chronic, debilitating pubic/pelvic/groin pain in all patients. Diagnosis was confirmed by magnetic resonance imaging. Conservative management was successful in only 1 patient. The remaining patients were treated surgically with excision of the fistulous track and involved symphyseal bone and omentoplasty, followed by reconstruction when feasible. RESULTS: All 16 patients had had radiotherapy as primary treatment (8) or after prostatectomy (8). There were 5 patients (31.3%) who underwent various combinations of brachytherapy, external beam radiotherapy and cryotherapy. Bladder neck contractures developed in 13 patients (81.3%), whose treatment (endoscopic or open reconstruction) resulted in urinary leak leading to urosymphyseal fistulas. Reconstruction was possible in 7 of 15 patients (46.7%) with salvage radical prostatectomy and substitution/augmentation cystoplasty. The other 8 patients (53.3%) underwent cystectomy and ileal conduit diversion. All patients experienced resolution of symptoms, most significantly the almost immediate resolution of pain. CONCLUSIONS: A high index of suspicion must be maintained in irradiated patients presenting with symptoms suggestive of urosymphyseal fistulas, especially after having undergone treatment of bladder neck contractures or prostatic urethral stenoses. Although extensive, surgery for urosymphyseal fistulas, with a high risk of morbidity and mortality and a protracted recovery, leads to immediate and dramatic improvement in symptoms.

Surgical correction of bladder neck contracture following prostate cancer treatment.

The surgical and non-surgical treatment of localised prostate cancer may be complicated by bladder neck contractures, prostatic urethral stenoses and bulbomembranous urethral strictures. In general, such complications following radical prostatectomy are less extensive, easier to treat and associated with a better outcome and more rapid recovery than the same complications following radiotherapy, high-intensity focussed ultrasound and cryotherapy. Treatment options range from minimally invasive endoscopic procedures to more complex and specialised open surgical reconstruction.In this chapter the surgical management of bladder neck contractures following the treatment of prostate cancer is described together with the management of prostatic urethral stenoses and bulbomembranous urethral strictures, given the difficulty in distinguishing them from one another clinically.

SIU/ICUD Consultation on Urethral Strictures: The management of anterior urethral stricture disease using substitution urethroplasty.

In this systematic review of the literature, a search of the PubMed database was conducted to identify articles dealing with augmentation/substitution urethral reconstruction of the anterior urethral stricture. The evidence was categorized by stricture site, surgical technique, and the type of tissue used. The committee appointed by the International Consultation on Urological Disease reviewed this data and produced a consensus statement relating to the augmentation and substitution of the anterior urethra. In this review article, the background pathophysiology is discussed. Most cases of urethral stricture disease in the anterior urethra are consequent on an ischemic spongiofibrosis. The choice of technique and the surgical approach are discussed along with the potential pros and cons of the use of a graft vs a flap. There is research potential for tissue engineering. The efficacy of the surgical approach to the urethra is reviewed. Whenever possible, a 1-stage approach is preferable from the patient's perspective. In some cases, with complex penile urethral strictures, a 2-stage procedure might be appropriate, and there is an important potential role for the use of a perineal urethrostomy in cases where there is an extensive anterior urethral stricture or where the patient does not wish to undergo complex surgery, or medical contraindications make this hazardous. It is important to have accurate outcome measures for the follow-up of patients, and in this context, a full account needs to be taken of patients' perspectives by the use of appropriate patient-reported outcome measures. The use of symptoms and a flow rate can be misleading. It is well established that with a normally functioning bladder, the flow rate does not diminish until the caliber of the urethra falls below 10F. The most accurate means of following up patients after stricture surgery are by the use of endoscopy or visualization by urethrography. Careful consideration needs to be made of the outcomes reported in the world literature, bearing in mind these aforementioned points. The article concludes with an overview of the key recommendations provided by the committee.

A prospective patient-centred evaluation of urethroplasty for anterior urethral stricture using a validated patient-reported outcome measure.

BACKGROUND: Studies of interventions for urethral stricture have inferred patient benefit from clinician-driven outcomes or questionnaires lacking scientifically robust evidence of their measurement properties for men with this disease. OBJECTIVE: To evaluate urethral reconstruction from the patients' perspective using a validated patient-reported outcome measure (PROM). DESIGN, SETTING, AND PARTICIPANTS: Forty-six men with anterior urethral stricture at four UK urology centres completed the PROM before (baseline) and 2 yr after urethroplasty. INTERVENTION: A psychometrically robust PROM for men with urethral stricture disease. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Lower urinary tract symptoms (LUTS), health status, and treatment satisfaction were measured, and paired t and Wilcoxon matched-pairs tests were used for comparative analysis. RESULTS AND LIMITATIONS: Thirty-eight men underwent urethroplasty for bulbar stricture and eight for penile stricture. The median (range) follow-up was 25 (20-30) mo. Total LUTS scores (0 = least symptomatic, 24 = most symptomatic) improved from a median of 12 at baseline to 4 at 2 yr (mean [95% confidence interval (CI)] of differences 6.6 [4.2-9.1], p < 0.0001). A total of 33 men (72%) felt their urinary symptoms interfered less with their overall quality of life, 8 (17%) reported no change, and 5 (11%) were worse 2 yr after urethroplasty. Overall, 40 men (87%) remained "satisfied" or "very satisfied" with the outcome of their operation. Health status visual analogue scale scores (100 = best imaginable health, 0 = worst) 2 yr after urethroplasty improved from a mean of 69 at baseline to 79 (mean [95% CI] of differences 10 [2-18], p = 0.018). Health state index scores (1 = full health, 0 = dead) improved from 0.79 at baseline to 0.89 at 2 yr (mean [95% CI] of differences 0.10 [0.02-0.18), p = 0.012]). CONCLUSIONS: This is the first study to prospectively evaluate urethral reconstruction using a validated PROM. Men reported continued relief from symptoms with related improvements in overall health status 2 yr after urethroplasty. These data can be used as a provisional reference point against which urethral surgeons can benchmark their performance.

Conservative management of urorectal fistulae.

OBJECTIVE: To characterize conservative management of urorectal fistulae (URF). METHODS: URF are a recognized but rare complication of treatments for prostate and rectal cancers. URF can lead to incontinence, fecaluria, pain, urinary infection, and sepsis, and thus are usually treated surgically. We present a series of 3 patients whose complex URF were managed conservatively. Between 2004 and 2010, 43 patients were diagnosed with URF resulting from treatment for prostate or rectal cancer. All patients were evaluated and offered surgical treatment; 40 patients elected surgical therapy, and 3 patients chose conservative, nonoperative management of the URF. The primary outcome was the patient choosing or needing formal surgical URF closure. Because this was not a comparative study, no formal statistical analysis was undertaken. RESULTS: The 3 patients have been regularly monitored and have required symptomatic and episodic care. None, however, has opted for formal surgical fistula repair, and to date, all continue in conservative management of their URF. CONCLUSION: Spontaneous URF closure is uncommon and is unknown to occur in complex URF. Surgery is the mainstay of treatment. Patients should consider treatment options, potential outcomes, and their quality of life when choosing or not choosing treatment. The applicability and durability of conservative management of URF remains unclear.

Posterior urethral complications of the treatment of prostate cancer.

• To review the less common and not widely discussed, but much more serious complications of prostate cancer treatment of: urethral stricture, bladder neck contracture and urorectal fistula. • The treatment options for patients with organ-confirmed prostate cancer include: radical prostatectomy (RP), brachytherapy (BT), external beam radiotherapy (EBRT), high-intensity focussed ultrasound (HIFU) and cryotherapy; with each method or combination of methods having associated complications. • Complications resulting from RP are relatively easy to manage, with rapid recovery and return to normal activities, and usually a return to normal bodily functions. • However, after non-surgical treatments, i.e. BT, EBRT, HIFU and cryotherapy, these same problems are more difficult to treat with a much slower return to a much lower level of function. • When counselling patients about the primary treatment of prostate cancer they should be advised that although the same type of complication may occur after surgical or non-surgical treatment, the scope and scale of that complication, the ease with which it is treated and the degree of restoration of normality after treatment, is altogether in favour of surgery in those for whom surgery is appropriate and who are fit for surgery.

What's new in urethroplasty?

PURPOSE OF REVIEW: This study provides an overview of current thinking about urethroplasty. RECENT FINDINGS: There have been a number of recent developments, principally to minimize the trauma of anterior urethroplasty and to address the posterior urethral complications of the treatment of prostate cancer. There also have been significant developments in the assessment of the outcome of urethroplasty and specifically of patient reported outcome measures. SUMMARY: These trends are likely to continue. There also seems to be a real possibility that cell culture techniques may finally produce clinically useful material for surgical practice.

Defining a patient-reported outcome measure for urethral stricture surgery.

BACKGROUND: A systematic literature review did not identify a formally validated patient-reported outcome measure (PROM) for urethral stricture surgery. OBJECTIVE: Devise a PROM for urethral stricture surgery and evaluate its psychometric properties in a pilot study to determine suitability for wider implementation. DESIGN, SETTING, AND PARTICIPANTS: Constructs were identified from existing condition-specific and health-related quality of life (HRQoL) instruments. Men scheduled for urethroplasty were prospectively enrolled at five centres. INTERVENTION: Participants self-completed the draft PROM before and 6 mo after surgery. MEASUREMENTS: Question sets underwent psychometric assessment targeting criterion and content validity, test-retest reliability, internal consistency, acceptability, and responsiveness. RESULTS AND LIMITATIONS: A total of 85 men completed the preoperative PROM, with 49 also completing the postoperative PROM at a median of 146 d; and 31 the preoperative PROM twice at a median interval of 22 d for test-retest analysis. Expert opinion and patient feedback supported content validity. Excellent correlation between voiding symptom scores and maximum flow rate (r = -0.75), supported by parallel improvements in EQ-5D visual analogue and time trade-off scores, established criterion validity. Test-retest intraclass correlation coefficients ranged from 0.83 to 0.91 for the total voiding score and 0.93 for the construct overall; Cronbach's α was 0.80, ranging from 0.76 to 0.80 with any one item deleted. Item-total correlations ranged from 0.44 to 0.63. These values surpassed our predefined thresholds for item inclusion. Significant improvements in condition-specific and HRQoL components following urethroplasty demonstrated responsiveness to change (p < 0.0001). Wider implementation and review of the PROM will be required to establish generalisability across different disease states and for more complex interventions. CONCLUSIONS: This pilot study has defined a succinct, practical, and psychometrically robust PROM designed specifically to quantify changes in voiding symptoms and HRQoL following urethral stricture surgery.

Urorectal fistulae following the treatment of prostate cancer.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? It is known that urorectal fistulae is a serious but rare complication of the treatment of carcinoma of the prostate. This study adds a distinction between post-surgical fistulate and post-irradiation fistulae. Essentially most post-surgical fistulae are simple and relatively easily dealt with: the expectation is that the patient will return to normality; whereas post-irradiation fistulate are by their nature complex and much more difficult to treat with a much more uncertain long-term outcome. Complexity is discussed and defined. OBJECTIVE: • To evaluate the management of urorectal fistulae (URF) in light of new technology in prostate cancer treatment, which has changed the nature of these URF and, therefore, the approach to treatment. PATIENTS AND METHODS: • Between 2004 and 2009 we repaired URF after treatment for prostate cancer in 40 patients with a minimum of 1-year follow-up since their last intervention. • In 23 patients (post-surgical group) the URF resulted from open, laparoscopic or robotic radical prostatectomy. In the other 17 patients (post-irradiation group) the URF resulted from either external beam radiation (EBRT) or brachytherapy (BT), or both, salvage cryotherapy or salvage high-intensity focused ultrasound (sHIFU). • In the 23 patients in the post-surgical group a transperineal repair was performed. In the post-irradiation group a transperineal repair was performed in three of the 17 patients. A transabdominal or abdominoperineal repair was performed in the remaining 14 patients, combined with salvage radical prostatectomy in those eight patients in whom a discrete prostate still existed, and in whom this was possible. RESULTS: • The URF were cured in all patients. • A bladder-neck contracture (BNC) developed in two patients, one of whom is being managed by interval dilatation and the other of whom had a revision of his vesico-urethral anastomosis. Sphincter weakness incontinence required further treatment in eight patients by implantation of an artificial urinary sphincter. • A specific category of complex URF with cavitation was identified, which is particularly common after sHIFU following the combination of previous EBRT and BT, but which may result from the sequential application of any 'new technology'. CONCLUSIONS: • URF of any degree of complexity can be managed without the need for a transanorectal sphincter-splitting approach or a covering colostomy and without the need for an interposition flap when the circumstances are appropriate and the surgeon is sufficiently experienced. URF with cavitation and in the post-irradiation group are an exception and do require an interposition flap. • The role of salvage radical prostatectomy in patients with a URF who still have a prostate, needs to be defined. • We suggest that cavitation, BNC and extensive ischaemia due to the serial application of external energy sources confer 'complexity'. Post-surgical URF are simple except for those with cavitation or a BNC. Most post-irradiation URF are complex even in the absence of cavitation or a BNC.

Urethral strictures.

What's known on the subject? and What does the study add? Urethral strictures are common and increasingly common in an ageing population. The treatment is controversial and particularly the relative roles of urethrotomy or urethral dilatation on the one hand and urethroplasty on the other. This review aims to provide a comprehensive overview of the subject including less commonly discussed issues such as the history and pathology of stricture disease. We would hope that a comprehensive overview of the subject will give a sharper perspective to aid the investigation and management of patients with urethral strictures.

A Fellowship programme in reconstructive urological surgery: what is it and what is it for?

OBJECTIVE: To report our experience of a 3-year Fellowship in reconstructive urology for its content and duration, with particular reference to what can be achieved each year. METHODS: Over the 3-year period October 2004 to October 2007 the Fellow worked full-time in a specialist reconstructive urological centre as principal assistant to the trainer in the care of outpatients and inpatients, and in the performance of the various surgical procedures. Using a prospectively constructed logbook it was possible to compare the developing surgical experience of the Fellow in terms of both the frequency and complexity of the cases undertaken and the surgical outcomes, compared with similar data for the trainer. RESULTS: Over the 3-year period the Fellow progressively took on more cases and of increasing complexity, and the trainer progressively adopted the role of assistant, except for particularly complex cases. Throughout this period the complication rate of the trainer and the Fellow remained the same. CONCLUSIONS: Even at the end of 3 years the Fellow was still limited in what she could deal with as an independent practitioner. Fellowship training should be goal directed in content and duration, and based around hands-on experience.

Pelvic fracture-related injuries of the bladder neck and prostate: their nature, cause and management.

OBJECTIVE: To report our experience of bladder neck injuries, which are a well recognized but rare consequence of pelvic fracture-related trauma to the lower urinary tract, as we have been unable to find any reference in the English literature to their specific nature, cause and management in adults. PATIENTS AND METHODS: In the last 10 years we have treated 15 men with bladder neck injuries after pelvic fracture. Two were treated at our centre by delayed primary repair. Thirteen were initially treated elsewhere and presented to us 3 months to 5 years after their injury with intractable incontinence and various other symptoms most notably recurrent urinary infection and gross haematuria. Twelve of the injuries were at or close to the anterior midline and associated with lateral compression fractures or 'open-book' injuries. Five of them were confined to the bladder neck and prostatic urethra; the other seven extended into the subprostatic urethra. Four of these were associated with a coincidental typical rupture of the posterior urethra. All had an associated cavity involving the anterior disruption of the pelvic ring. Two of the injuries, following particularly severe trauma, were a simultaneous complete transection of the bladder neck and of the bulbo-membranous urethra with a sequestered prostate between. We have seen this in children before but not in adults. Another injury, also after particularly severe trauma, was an avulsion of the anterior aspect of the prostate. We have not seen this described before. Fourteen patients underwent lower urinary tract reconstruction and one underwent a Mitrofanoff procedure. All of the 14 had a layered reconstruction of the prostate and bladder neck and in 13, this was supplemented with an omental wrap. RESULTS: In all patients with an anterior midline rupture, the primary injury appeared to be to the prostate and prostatic urethra with secondary involvement of the bladder neck and the subprostatic urethra. The Mitrofanoff procedure was successful. Of the 14 patients with a layered reconstruction one, without an omental wrap, broke down but was successfully repaired on a subsequent occasion. The four patients who also had a ruptured urethra had a simultaneous bulbo-prostatic anastomotic urethroplasty, two of which required further attention. Eight of the 14 reconstructed patients underwent implantation of an artificial urinary sphincter (AUS) for sphincter weakness incontinence, in seven of whom this was successful. Two of these had previously undergone implantation of an AUS with an unsatisfactory outcome and were made continent by bladder neck reconstruction. The other six patients had acceptable urinary incontinence by reconstruction of the bladder neck and urethra alone. CONCLUSIONS: The primary injury is to the prostate and prostatic urethra. The bladder neck and subprostatic urethra are involved secondarily by extension. These injuries have a particular cause and a particular location with a predictable outcome. They need to be identified and treated promptly as they do not heal spontaneously and otherwise cause considerable morbidity. We also describe two particular types of bladder neck injury that we have not seen described before in adults.

What is the best technique for urethroplasty?

CONTEXT: There is no clear evidence that determines which type of urethroplasty to perform under which particular circumstance. OBJECTIVE: To review the options for urethroplasty at different sites in the urethra and for different types of stricture indicating which procedure should be used in which circumstances according to the best available evidence. EVIDENCE ACQUISITION: Recent publications have been reviewed and supplemented with the authors' personal experience. EVIDENCE SYNTHESIS: Currently, in the developed world, the most common types of stricture are relatively short and are situated in the bulbar urethra. There is good evidence that these are best treated by excision and end-to-end anastomosis if they are short enough or by patch urethroplasty using a buccal mucosal graft if they are longer. Distal penile urethral strictures are the next most common type of stricture, but the evidence base is weaker, although there is agreement that penile strictures due to lichen sclerosus often require a staged approach to reconstruction, again using buccal mucosal grafts. Urethroplasty for pelvic fracture urethral injury is an altogether different type of technique for an altogether different type of pathology. There is good evidence that this is best treated by bulbo-prostatic anastomotic urethroplasty. Other types of strictures and salvage surgery have no good evidence base and are specialised areas where experience and judgement are necessary. CONCLUSIONS: The evidence base for urethral surgery has been developed for the more common types of urethral strictures in the last 20 yr, but it is still as much an art as it is a science.