Multi-institutional experience with buccal mucosa onlay urethroplasty for bulbar urethral reconstruction.

PURPOSE: Buccal mucosa has been advocated as an ideal graft material for urethral reconstruction. We report our multicenter experience with buccal mucosa ventral onlay urethroplasty for complex bulbar urethral reconstruction in adults. MATERIALS AND METHODS: A retrospective analysis of patients who had undergone buccal onlay urethroplasty at 4 military medical treatment facilities participating in the Uniformed Services Urology Research Group was performed. The database generated included demographic data, genitourinary history, preoperative symptoms (American Urological Association symptom score), preoperative urinary flow rate, stricture length and operative statistics. Postoperative followup data included symptom score, flow rate, retrograde urethrogram results, and complications. RESULTS: A total of 53 patients (average age 32 years, range 17 to 64) underwent buccal mucosa graft urethroplasty between January, 1996 and March, 1998 for refractory strictures. Sixteen patients had undergone an average of 2.2 prior endoscopic procedures (range 1 to 7). Average stricture length was 3.6 plus or minus standard deviation 1.8 cm. (range 2 to 7.5) as measured on preoperative retrograde urethrogram. Followup averaged 25 months (range 11 to 40 months). Average symptom scores decreased from 21.2 (range 14 to 33) preoperatively to 5.4 (range 3 to 8) postoperatively (p <0.001). Average peak urinary flow rates increased from 7.9 preoperatively to 30.1 ml. per second postoperatively (p <0.001). Postoperative retrograde urethrograms were available for 34 patients and were normal in 24. The overall complication rate was 5.4%. Three patients required endoscopic incisions. One patient has a recurrent narrowing and treatment is considered a failure. There were 4 sacculations (7.5%) and 6 narrowings, 3 of which required further treatment. Of the patients 50 required no additional procedures (94.3%). CONCLUSIONS: Buccal mucosa grafts used as a ventral onlay for bulbar urethral reconstruction yield reproducibly excellent results with minimal morbidity and low complication rates. Longer followup will be required to confirm the durability of our results.

Lower genitourinary injury and pelvic fractures in pediatric patients.

OBJECTIVES: To report the largest series of pelvic fracture and lower genitourinary tract injury in the pediatric population to further define its incidence. The association between pelvic fractures and lower genitourinary tract injury has been well recognized in the adult population. The incidence of bladder or urethral injury is approximately 10% to 15%. Previous limited pediatric reviews placed its incidence at slightly lower levels. METHODS: A retrospective review of 8021 trauma patients presenting between July 1992 and March 1999 to a pediatric trauma center included 212 consecutive patients with pelvic fractures. These records were reviewed to determine the incidence of genitourinary injury in children with pelvic fractures. Thirty-six patients were identified with a genitourinary injury, and their records were analyzed.Results. Thirty-six patients (17%) were identified to have sustained a genitourinary injury out of the study cohort of 212 patients with pelvic fractures when patients with isolated hematuria were included. Hematuria was noted in 30 patients (14.2%). Fourteen (6.6%) had gross hematuria. Only 2 (0.9%) of the 212 patients had a significant lower urinary tract injury (one extraperitoneal bladder rupture and one posterior urethral disruption); both had gross hematuria. Genital injuries were seen in 4 other patients (1.9%). Lower genitourinary injury occurred in a total of 6 (2.8%) of the 212 patients with pelvic fractures. CONCLUSIONS: The incidence of significant lower genitourinary injury in pediatric patients with pelvic fractures is lower than that reported in previous adult and pediatric reviews. Significant lower genitourinary injuries were not found in stable patients without gross hematuria or multiple associated injuries and with a normal genitourinary examination.