Conservative Management of Lichen Sclerosus Male Urethral Strictures: A Multi-Institutional Experience.

OBJECTIVE: To assess the outcomes and safety of conservative management of lichen sclerosus urethral stricture disease (LS-USD). METHODS: This multi-institutional study included patients with LS-USD managed with endoscopic procedures or clean intermittent catheterization (CIC) regimens between 2005 and 2019. Those with an obliterative stricture, a history of prior urethral reconstruction, or <3 months follow-up was excluded. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, and uroflowmetry values. Secondary outcome measures included patient-reported outcome measure questionnaires on urinary and sexual function. Failure was defined as progression to reconstructive surgery or permanent indwelling catheterization. RESULTS: 112 men were analyzed with a median follow-up of 30.0 months (IQR 12.0-55.5). Median age was 52.5 years (IQR 42.6-61.0) and median body mass index was 34.5 kg/m2 (IQR 29.9-40.7). Median stricture length was 12.0 cm (IQR 2.8-20.0). 89% of patients underwent urethral balloon dilation, with a median of 2 (IQR 1-3) per patient. CIC was performed in 46% of patients, with 31% of this subgroup using intraurethral steroids. 84% of patients avoided invasive surgery or permanent indwelling catheterization, with an improvement in urethral stricture patient-reported outcome measure scores (P = .0013). Those who failed were more likely to have a history of UTI (P = .04), urosepsis (P = .03), AUR (P <.001), and more likely to perform CIC (P = .01). CONCLUSIONS: Over medium-term follow-up, most patients with LS-USD were safely managed with conservative techniques. Caution is warranted in those who develop UTIs, urosepsis, and AUR and the potential long-term consequences of repetitive conservative interventions must be considered.

Rectal Mucosa Graft Take in Staged Urethroplasty.

When an oral mucosa graft is not a viable option for urethroplasty, colonic mucosa grafts have served as a promising alternative since described by Igor A. Thyrmos in 1902.1 In previous studies, colonic mucosa graft retrieval required sigmoid resection2-3 which limited adoption of this technique. We previously described the success of a minimally-invasive transanal endoscopic microsurgical technique of rectal mucosa graft harvest for urethroplasty.4 Here, we pictorially demonstrate the take of a transanal endoscopically harvested rectal musosa graft used in a 2-stage anterior urethroplasty (to our knowledge, the first such 2-stage procedure) with 6 months of follow-up.

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.

Management of Proximal Primary Urethral Cancer: Should Multidisciplinary Therapy Be the Gold Standard?

Primary urethral cancer (PUC) is a rare, but devastating genitourinary tumor that affects men and women. Although most PUC are localized, proximal PUC frequently presents with locally advanced disease, with 30% to 40% having lymph node metastasis. Single modality surgical or radiation therapy has dismal results. Multimodal therapy with cisplatin-based chemotherapy and consolidation surgery has greatly improved the local recurrence and overall survival rates for this aggressive disease. In locally advanced squamous cell carcinoma of the urethra, radiotherapy combined with radiosensitizing chemotherapy is an option for genital preservation. Prospective, multi-institutional studies are required to further define the optimal multidisciplinary treatment strategy for this destructive disease.

Short- and Long-term Complications and Outcomes of Radiation and Surgically Induced Rectourethral Fistula Repair With Buccal Mucosa Graft and Muscle Interposition Flap.

OBJECTIVE: To analyze and report 30-day, 90-day, and long-term complications and surgical outcomes over a 17-year period for anterior transperineal repair of rectourethral fistulas (RUFs) resulting from pelvic radiation and surgery. MATERIALS AND METHODS: We performed a retrospective review of patients undergoing RUF repair between January 1, 1998 and February 28, 2015, at a single institution. All RUF were repaired using an anterior transperineal approach with an interposition muscle flap and selective use of a buccal mucosa graft onlay. RESULTS: Ninety-eight patients underwent repair with an anterior transperineal approach and muscle interposition flap (49 non-radiation induced and 49 radiation or ablation induced). Thirty- and 90-day complication rates were 29% and 2%, respectively, for non-radiated RUF, and 29% and 24%, respectively, for radiated RUF. Urethral diverticula, urinary incontinence, urethral stricture, and bowel problems were delayed complications requiring surgery. At a median follow-up of 14.5 months (range 3-144), 98% (48 of 49) of non-radiated RUF were closed with 1 procedure, whereas 86% (42 of 49) of radiated RUF were closed with 1 procedure. Gastrointestinal tract continuity was restored in 94% (45 of 48) of non-radiated RUF and in 65% (30 of 46) of radiated RUF. CONCLUSION: Successful RUF closure is possible in 98% of non-radiated and in 86% of radiated or ablated patients with 1 procedure. Most radiation-induced RUF, regardless of size, can be successfully repaired with minimal short-term complications. Delayed complications may arise and require surgery, and thus continued surveillance is recommended.

Surgical Management of Urologic Trauma and Iatrogenic Injuries.

Genitourinary trauma usually occurs in the setting of multisystem trauma, accounting for approximately 10% of all emergency department admissions. Timely evaluation and management of the trauma patient have the potential to minimize urologic morbidity and mortality. New imaging modalities and a growing emphasis on nonoperative expectant management of both upper and lower urinary tract injuries have changed the field of urologic trauma. Concomitant injury to both the upper and the lower urinary tract is rare, but careful evaluation is critical to identify these devastating injuries.

Urethral Reconstruction with Rectal Mucosa Graft Onlay: A Novel, Minimally Invasive Technique.

PURPOSE: Alternative grafts are needed for patients who are not suitable candidates for oral mucosa graft harvest or who have a paucity of oral mucosa graft available for reconstruction. Circumferential colonic mucosal grafts have demonstrated feasibility for urethral reconstruction, although sigmoid resection has been required for graft retrieval. We report the feasibility and short-term outcomes of urethral reconstruction using a rectal mucosa graft harvested by a novel, minimally invasive, transanal endoscopic microsurgical technique. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent transanal endoscopic microsurgical rectal mucosa graft harvest and onlay urethroplasty since the technique was first implemented in 2013. Graft failure was defined as inability to pass a 16Fr cystoscope in the grafted urethra. RESULTS: All 4 strictures were bulbopendulous with a median length of 13.5 cm (range 10 to 21). Median followup was 18 months (range 12 to 28). Stricture etiology was lichen sclerosus in 3 patients and failed hypospadias interventions in 1. Three patients had undergone at least 1 prior urethroplasty. In 1 patient stricture recurred in the graft 10 months following reconstruction. There were no colorectal complications. CONCLUSIONS: To our knowledge this is the first study demonstrating urethral reconstruction using a rectal mucosa graft harvested by the transanal endoscopic microsurgical technique. Initial data revealed that this technique is feasible and safe, and minimizes graft harvest morbidity. Transanal endoscopic microsurgical harvest of a rectal mucosa graft may provide an alternative graft material for patients with long segment urethral strictures who are not candidates for oral mucosa graft harvest. Further experience and longer followup are needed to validate these findings.

Management of Radiation Anterior Prostato-symphyseal Fistulas With Interposition Rectus Abdominis Muscle Flap.

OBJECTIVE: To describe a novel, organ-sparing approach for reconstruction of radiation-induced anterior prostato-symphyseal fistulas (PSFs) at our institution over a consecutive 10-year period. MATERIALS AND METHODS: We performed a retrospective review of patients undergoing surgical reconstruction for anterior PSF between January 1, 2006 and October 31, 2015. Patient demographics as well as preoperative, operative, and postoperative data were reviewed, including etiology of fistula, surgical management, and outcomes. RESULTS: A total of 4 patients with anterior PSF underwent organ-sparing reconstruction. All fistulas were the result of previous pelvic radiation. All 4 patients presented with pubic osteomyelitis. Patients underwent pubic symphysis debridement, fistula closure, and placement of an interposition rectus abdominis muscle flap. At a median follow-up of 27 months, 100% of the patients undergoing repair with interposition rectus flap were closed with 1 procedure. CONCLUSION: Radiation-induced PSF can be successfully reconstructed with pubic symphysis debridement and fistula closure using an adjunct rectus abdominis interposition flap, avoiding prostatectomy and urinary diversion.

Outcomes for Management of Lichen Sclerosus Urethral Strictures by 3 Different Techniques.

OBJECTIVE: To evaluate the intermediate-term outcomes from a large, single institution series of patients with lichen sclerosus (LS) who underwent surgical management of their urethral strictures. MATERIALS AND METHODS: We retrospectively reviewed 79 patients who underwent surgical management of their LS urethral strictures from 2003 to 2014, comparing outcomes of patients undergoing a single-stage buccal mucosa graft (BMG) urethroplasty, 2-stage BMG urethroplasty, or perineal urethrostomy (PU). Demographic and surgical outcomes data were collected for all patients. RESULTS: Of the 79 patients, the mean follow-up was 32.4 months, mean age was 50.1 years, and the mean body mass index was 35.7, with morbid obesity (body mass index > 35) in 48% of the cohort. The mean stricture length was 9.6 cm (1.5-21 cm), with 62% of patients having a bulbopendulous stricture. Of the 37 patients who were planned for a 2-stage BMG urethroplasty, 9 (24%) patients had stricture recurrence or recurrent LS in the first-stage BMG. Single-stage BMG urethroplasty was performed in 20 patients with a mean stricture length of 9.47 cm (4-21 cm) and a success rate of 75%. Fourteen patients from the cohort received a PU as the primary treatment, with a success rate of 93%. CONCLUSION: Management of LS strictures continues to pose challenges to the reconstructive surgeon due to the high rate of stricture recurrence and often progression. Patients undergoing single-stage or 2-stage reconstruction often require revision and must be carefully observed for recurrent urethral stricture. PU offers the highest degree of success and should be considered for all patients.

Durable Results of Mitomycin C Injection with Internal Urethrotomy for Refractory Bladder Neck Contractures: Multi-institutional Experience.

INTRODUCTION: We evaluated our intermediate term experience with radial urethrotomy and intralesional mitomycin C injection in patients with recurrent bladder neck contractures. Recurrent bladder neck contractures in which previous endoscopic treatment failed pose a difficult management dilemma. METHODS: Prospectively collected data were reviewed in a retrospective manner of patients presenting with recurrent bladder neck contractures from January 2007 to June 2014. All patients had at least 1 prior failed incision of a bladder neck contracture and many had additional dilations or catheter dependence. Radial cold knife incisions of the bladder neck were performed followed by injection of 0.3 to 0.4 mg/ml mitomycin C at each incision site. All surgeons performed the incision technique and injection in a reproducible fashion. RESULTS: A total of 40 patients underwent urethrotomy with mitomycin C injection. At a median followup of 20.5 months 30 patients (75.0%) had a stable bladder neck after 1 procedure. An additional 5 patients required 2 procedures to obtain a stable patent bladder neck (87.5%). Of the 40 patients 14 (35.0%) presented in retention on catheter drainage and all had a stable, patent bladder neck. No recurrence was detected in the original 18 patients in the pilot study with patent bladder necks. Rigorous followup revealed no long-term complications. CONCLUSIONS: Urethrotomy with mitomycin C injection for the management of recurrent bladder neck contractures is safe and efficacious. The addition of an antifibrotic agent in conjunction with internal urethrotomy offers a definitive solution to a problem that would otherwise be managed with repeat urethral incision/dilation, catheter dependence or open bladder neck reconstruction.

Urethroplasty for high risk, long segment urethral strictures with ventral buccal mucosa graft and gracilis muscle flap.

PURPOSE: Long segment urethral strictures with a compromised graft bed and poor vascular supply are unfit for standard repair and at high risk for recurrence. We assessed the success of urethral reconstruction in these patients with a ventral buccal mucosa graft and gracilis muscle flap. MATERIALS AND METHODS: We retrospectively reviewed the records of 1,039 patients who underwent urethroplasty at Lahey Hospital and Medical Center between 1999 and 2014. We identified 20 patients who underwent urethroplasty with a ventral buccal mucosa graft and a gracilis muscle flap graft bed. Stricture recurrence was defined as the inability to pass a 16Fr cystoscope. RESULTS: Mean stricture length was 8.2 cm (range 3.5 to 15). Strictures were located in the posterior urethra with or without involvement of the bulbar urethra in 50% of cases, and in the bulbomembranous urethra in 35%, the bulbar urethra in 10% and the proximal pendulous urethra in 5%. Stricture etiology was radiation therapy in 45% of cases, followed by an idiopathic cause in 20%, trauma in 15%, prostatectomy in 10%, and hypospadias failure and transurethral surgery in 5% each. Nine patients (45%) were previously treated with urethroplasty and 3 (15%) previously underwent UroLume® stent placement. Urethral reconstruction was successful in 16 cases (80%) at a mean followup of 40 months. One of the patients in whom treatment failed had an ileal loop, 2 had a suprapubic tube and urethral dilatation had been done in 1. Mean time to recurrence was 10 months (range 2 to 17). Postoperatively 5 patients (25%) had incontinence requiring an artificial urinary sphincter. CONCLUSIONS: Urethroplasty for high risk, long segment urethral strictures can be successfully performed with a ventral buccal mucosa graft and a gracilis muscle flap, avoiding urinary diversion in most patients.

Removal of endoprosthesis with urethral preservation and simultaneous urethral reconstruction.

PURPOSE: We describe our experience with, and technique and outcomes of complex UroLume® stent extraction with simultaneous urethral preservation and reconstruction. MATERIALS AND METHODS: A retrospective review of our institutional review board approved database identified 12 patients who underwent successful UroLume stent extraction with urethral preservation using a standard atraumatic approach between 2000 and 2011. Patient demographics, indication for stent removal, number of stents removed, and stricture length, location and etiology are described. Urethral reconstruction type and outcomes were analyzed. RESULTS: Urethral preservation was possible in all cases. No patient required en bloc urethral resection. A total of 16 stents (12 anterior and 4 posterior urethra) were successfully removed by standard vertical urethrotomy with wire extraction. Average patient age was 52.8 years and mean stricture length was 6.7 cm. Obstruction or recurrent stricture in 83% of cases, pain in 42% and urinary tract infection in 33% were the main indications for extraction. Eight patients underwent dorsal onlay urethroplasty, 3 ventral onlay urethroplasty (with a gracilis muscle flap in 2) and 1 perineal urethrostomy. Ten of the 12 patients (83%) were stricture-free at a median followup of 4 years. One patient treated with 12 cm ventral fasciocutaneous flap reconstruction required repeat urethroplasty. Treatment failed in a morbidly obese patient with a history of external beam and brachytherapy radiation for prostate cancer, requiring suprapubic tube diversion. CONCLUSIONS: Removal of the dysfunctional UroLume stent using an atraumatic technique allows for urethral preservation and simultaneous urethral reconstruction. En bloc urethral resection and tissue loss are not necessary for stent extraction and successful urethral reconstruction.

Radial urethrotomy and intralesional mitomycin C for the management of recurrent bladder neck contractures.

PURPOSE: We evaluated urethrotomy combined with intralesional injection of the antiproliferative agent mitomycin C for the treatment of severe, recurrent bladder neck contractures after traditional endoscopic management failed. We report our experience with radial urethrotomy and intralesional mitomycin C in patients with recurrent bladder neck contractures. MATERIALS AND METHODS: A retrospective review was performed of patients evaluated for severe, recurrent bladder neck contractures between January 2007 and April 2010. All patients had at least 1 prior failed incision of a bladder neck contracture. Tri or quadrant cold knife incisions of the bladder neck were performed followed by injection of 0.3 to 0.4 mg/ml mitomycin C at each incision site. RESULTS: A total of 18 patients were treated with bladder neck incision and mitomycin C injection. Preoperatively 4 (22%) patients presented with indwelling Foley catheters while 7 (39%) required a dilation schedule. At a median followup of 12 months (range 4 to 26) 13 patients (72%) had a patent bladder neck after 1 procedure, as did 3 (17%) after 2 procedures and 1 after 4 procedures. All of the patients presenting with a prior indwelling urethral catheter or requiring a dilation schedule had a stable, patent bladder neck. CONCLUSIONS: Management of recurrent bladder neck contractures with radial urethrotomy combined with intralesional mitomycin C resulted in bladder neck patency in 72% of the patients after 1 procedure and in 89% after 2 procedures. Although early results are promising, longer followup and randomized, prospective studies are required to validate these findings.

Management of surgical and radiation induced rectourethral fistulas with an interposition muscle flap and selective buccal mucosal onlay graft.

PURPOSE: Rectourethral fistulas are a rare but devastating complication of pelvic surgery and radiation. We review, analyze and describe the management and outcomes of nonradiated and radiation/ablation induced rectourethral fistulas during a consecutive 12-year period. MATERIALS AND METHODS: We performed a retrospective review of patients undergoing rectourethral fistula repair between January 1, 1998 and December 31, 2009. Patient demographics as well as preoperative, operative and postoperative data were obtained. All rectourethral fistulas were repaired using an anterior transperineal approach with a muscle interposition flap and selective use of a buccal mucosal graft urethral patch onlay. RESULTS: A total of 74 patients with rectourethral fistulas underwent repair with an anterior perineal approach and muscle interposition flap (68 gracilis muscle interposition flaps, 6 other muscle interposition flaps). We compared 35 nonradiated and 39 radiated/ablation induced rectourethral fistulas. Concurrent urethral strictures were present in 11% of nonradiated and 28% of radiated/ablation rectourethral fistulas. At a mean followup of 20 months 100% of nonradiated rectourethral fistulas were closed with 1 procedure while 84% of radiated/ablation rectourethral fistulas were closed in a single stage. Of the patients with nonradiated rectourethral fistulas 97% had the bowel undiverted. Of those undiverted cases 100% were without bowel complication. Of the patients with radiated/ablation rectourethral fistulas 31% required permanent fecal diversion. CONCLUSIONS: Successful rectourethral fistula closure can be achieved for nonradiated (100%) and radiation/ablation (84%) rectourethral fistulas using a standard anterior perineal approach with an interposition muscle flap and selective use of buccal mucosal graft, providing a standard for rectourethral fistula repair. Even the most complex radiation/ablation rectourethral fistula can be repaired avoiding permanent urinary and fecal diversion.

The use of bowel for ureteral replacement for complex ureteral reconstruction: long-term results.

PURPOSE: Ileal and intestinal ureteral replacement remains a useful procedure for complex ureteral reconstruction. We examined the long-term safety and efficacy of this procedure, especially in regard to maintaining preoperative renal function and the avoidance of major complications. MATERIALS AND METHODS: A total of 56 patients underwent intestinal ureteral substitution at our institution between 1979 and 2003, including 52 with an ileal ureteral replacement, 2 with colonic replacement alone and 2 with bilateral ureteral replacement, necessitating ileum and colon for 1 ureter each. The factors reviewed were indications for surgery, type of ureteral replacement, and the presence and type of complications. Followup data included excretory urogram or equivalent imaging results, and measurement of serum chloride, bicarbonate and creatinine before and after the procedure. RESULTS: Overall the complication rate remained low. Mean followup was 6.04 years (median 3.2). Most postoperative complications, which occurred in 10 patients (17.9%), were minor in nature, including pyelonephritis, fever of unknown origin, neuroma, hernia, recurrent urolithiasis and deep venous thrombosis. Major complications occurred in 6 patients (10.5%), including anastomotic stricture, ileal graft obstruction, wound dehiscence and chronic renal failure. Overall patients did not experience worsening renal function after the procedure with equivalent median creatinine before and after the procedure (1.0 mg/dl). CONCLUSIONS: During long-term followup major complications are rare and renal function remains preserved. Ileal and intestinal ureteral substitution remains a safe and efficacious procedure in patients with complex and difficult ureteral issues not amenable to more conservative measures.

Surgical repair of vesicovaginal fistulas.

Despite the many controversies surrounding the proper surgical repair of vesicovaginal fistulas, the current methods available allow surgeons to select the procedure best suited for each specific problem. Because each fistula is unique, surgeons will often be required to individually vary their approach and technique. Regardless of whether a transabdominal or transvaginal approach is selected, the concepts of using healthy tissue in tension-free closures and reinforcing the closures in high-risk situations will ensure success nearly all of the time. A urinary diversion should be considered in the rare situation where the fistula has failed even the most technically sound repair.