The Lived Experience of Patients with Adult Acquired Buried Penis.

PURPOSE: We describe the lived experience of adults with acquired buried penis (AABP) through thematic analysis of patient interviews. We examine the challenges that patients face and the impacts of surgery. MATERIALS AND METHODS: This mixed-methods study utilized validated instruments and semi-structured interviews to capture pre- and postsurgical outcomes. Semi-structured interviews were conducted with open-ended questions to elicit the impact of AABP on a patient's quality of life in several domains including urinary function, sexual function, interpersonal relationships and mental health. Recruitment was completed once we achieved thematic saturation. RESULTS: Twenty patients participated in the study; 11 underwent surgical treatment for AABP. Semi-structured interviewee responses were coded into 12 different themes and 39 subthemes. The most common themes were problems with urinary (19/20, 95%) and sexual function (19/20, 95%). Most participants (16/20, 80%) reported negative impacts of AABP on social life. Interviewees struggled with relationships (8/20, 40%) and mental health (11/20, 55%), often avoiding romantic relationships and reporting fear of rejection with concomitant depression and/or anxiety. The majority (70%, 14/20) experienced difficulties accessing care. Among patients who underwent surgery, the majority discussed improvement in urinary and sexual function (82% [9/11] and 73% [8/11], respectively). Though weight gain was a precipitating factor, weight loss did not result in symptom improvement. Rather, in 4/20 (20%), weight loss made their condition worse. CONCLUSIONS: Patients living with AABP experience profound negative impacts on quality of life including their urinary and sexual function, social life and mental health. Many patients face issues with access to care.

Minimizing Antibiotic Use in Urethral Reconstruction.

PURPOSE: There are no established guidelines regarding management of antibiotics for patients specifically undergoing urethral reconstruction. Our aim was to minimize antibiotic use by following a standardized protocol in the pre-, peri- and postoperative setting, and adhere to American Urological Association antibiotic guidelines. We hypothesized that prolonged suppressive antibiotics post-urethroplasty does not prevent urinary tract infection and/or wound infection rates. MATERIALS AND METHODS: We prospectively treated 900 patients undergoing urethroplasty or perineal urethrostomy at 11 centers over 2 years. The first-year cohort A received prolonged postoperative antibiotics. Year 2, cohort B, did not receive prolonged antibiotics. A standardized protocol following the American Urological Association guidelines for perioperative antibiotics was used. The 30-day postoperative infectious complications were determined. We used chi-square analysis to compare the cohorts, and multivariate logistic regression to identify risk factors. RESULTS: The mean age of participants in both cohorts was 49.7 years old and the average stricture length was 4.09 cm. Overall, the rate of postoperative urinary tract infection and wound infection within 30 days was 5.1% (6.7% in phase 1 vs 3.9% in phase 2, p=0.064) and 3.9% (4.1% in phase 1 vs 3.7% in phase 2, p=0.772), respectively. Multivariate logistic regression analysis of patient characteristics and operative factors did not reveal any factors predictive of postoperative infections. CONCLUSIONS: The use of a standardized protocol minimized antibiotic use and demonstrated no benefit to prolonged antibiotic use. There were no identifiable risk factors when considering surgical characteristics. Given the concern of antibiotic over-prescription, we do not recommend prolonged antibiotic use after urethral reconstruction.

Defining Success after Anterior Urethroplasty: An Argument for a Universal Definition and Surveillance Protocol.

PURPOSE: A successful urethroplasty has been defined in different ways across studies. This variety in the literature makes it difficult to compare success rates and techniques across studies. We aim to evaluate the success of anterior urethroplasty based on different definitions of success in a single cohort. MATERIALS AND METHODS: Data were collected from a multi-institutional, prospectively maintained database. We included men undergoing first-time, single-stage, anterior urethroplasty between 2006 and 2020. Exclusion criteria included lack of followup, hypospadias, extended meatotomy, perineal urethrostomy, posterior urethroplasty and staged repairs. We compared 5 different ways to define a "failed" urethroplasty: 1) stricture retreatment, 2) anatomical recurrence on cystoscopy, 3) peak flow rate <15 ml/second, 4) weak stream on questionnaire and 5) failure by any of these measures. Kaplan-Meier survival curves were generated for each of the definitions. We also compared outcomes by stricture length, location and etiology. RESULTS: A total of 712 men met inclusion criteria, including completion of all types of followup. The 1- and 5-year estimated probabilities of success were "retreatment," 94% and 75%; "cystoscopy," 88% and 71%; "uroflow," 84% and 58%; "questionnaire," 67% and 37%; and "any failure," 57% and 23%. This pattern was inconsistent across stricture length, location and etiology. CONCLUSIONS: The estimated probability of success after first-time, anterior urethroplasty is highly dependent on the way success is defined. The variability in definitions in the literature has limited our ability to compare urethroplasty outcomes across studies.

Urethroscopic Findings following Urethroplasty Predict the Need for Secondary Intervention in the Long Term: A Multi-Institutional Study from Trauma and Urologic Reconstructive Network of Surgeons.

PURPOSE: Postoperative surveillance urethroscopy has been shown to be an effective tool to predict reoperation within 1 year after urethroplasty. We aimed to evaluate early surveillance urethroscopy findings and long-term outcomes among urethroplasty patients in order to define the value of surveillance urethroscopy to predict failure. MATERIALS AND METHODS: We evaluated 304 patients with at least 4 years of followup after urethroplasty performed at 10 institutions across the United States and Canada. All patients were surveilled using a flexible 17Fr cystoscope and were categorized into 3 groups: 1) normal lumen, 2) large-caliber stricture (≥17Fr) defined as the ability of the cystoscope to easily pass the narrowing and 3) small-caliber stricture (<17Fr) that the cystoscope could not be passed. Failure was stricture recurrence requiring a secondary intervention. RESULTS: The median followup time was 64.4 months (range 55.3-80.6) and the time to initial surveillance urethroscopy was 3.7 months (range 3.1-4.8) following urethroplasty. Secondary interventions were performed in 29 of 194 (15%) with normal lumens, 11 of 60 (18.3%) with ≥17Fr strictures and 32 of 50 (64%) with <17Fr strictures (p <0.001). The 1-, 3- and 9-year cumulative probability of intervention was 0.01, 0.06 and 0.23 for normal, 0.05, 0.17 and 0.18 for ≥17Fr, and 0.32, 0.50 and 0.73 for <17Fr lumen groups, respectively. Patient-reported outcome measures performed poorly to differentiate the 3 groups. CONCLUSIONS: Early cystoscopic visualization of scar recurrence that narrows the lumen to <17Fr following urethroplasty is a significant long-term predictor for patients who will eventually undergo a secondary intervention.

A narcotic free pathway for postoperative pain following urethroplasty.

INTRODUCTION: In an effort to decrease physician contribution to the opioid crisis, we utilized a narcotic free pathway (NFP) after urethroplasty. Our objectives were to demonstrate feasibility of a NFP and identify patients at higher risk for requiring postoperative narcotics. MATERIALS AND METHODS: We implemented a NFP for patients undergoing urethroplasty. Pain was assessed using the Likert scale (1-10). Narcotic use was quantified using oral morphine equivalents (OMEs). RESULTS: Forty-six patients underwent urethroplasty following the NFP over a 7-month period. Fifteen patients were excluded, leaving 31 patients in the final analysis. Postintervention data was compared to 30 patients who underwent urethroplasty prior to implementation of the NFP. The groups had similar demographics except for a history of heroin abuse (0% preintervention, 12.9% postintervention, p = 0.04). Surgical characteristics were not statistically different aside from length of surgery (183.6 minutes preintervention, 145.5 minutes postintervention, p = 0.01). The mean [SD] perioperative OME use preintervention was 194.9 [151] mg, compared to 40.4 [111.9] mg postintervention (p < 0.001). Six patients postintervention were discharged with a narcotic prescription (mean 27.5 mg OME) compared to 26 patients preintervention (mean 76 mg OME) (p < 0.001). There was no difference in pain scores at any time interval. Patients with a history of chronic opioid use were more likely to require narcotics (OR 5.33, CI 1-28.44). CONCLUSIONS: The narcotic free pathway resulted in a dramatic reduction in narcotic prescriptions without a significant difference in postoperative pain scores. Opioid use can be minimized following urethral and perineal surgery.

Outcomes and Risk Factors of Revision and Replacement Artificial Urinary Sphincter Implantation in Radiated and Nonradiated Cases.

PURPOSE: Risk factors for complications after artificial urinary sphincter surgery include a history of pelvic radiation and prior artificial urinary sphincter complication. The survival of a second artificial urinary sphincter in the setting of prior device complication and radiation is not well described. We report the survival of redo artificial urinary sphincter surgery and identify risk factors for repeat complications. MATERIALS AND METHODS: A multi-institutional database was queried for redo artificial urinary sphincter surgeries. The primary outcome was median survival of a second and third artificial urinary sphincter in radiated and nonradiated cases. A Cox proportional hazards survival analysis was performed to identify additional patient and surgery risk factors. RESULTS: Median time to explantation of the initial artificial urinary sphincter in radiated (150) and nonradiated (174) cases was 26.4 and 35.6 months, respectively (p=0.043). For a second device median time to explantation was 30.1 and 38.7 months (p=0.034) and for a third device it was 28.5 and 30.6 months (p=0.020), respectively. The 5-year revision-free survival for patients undergoing a second artificial urinary sphincter surgery with no risk factors, history of radiation, history of urethroplasty, and history of radiation and urethroplasty were 83.1%, 72.6%, 63.9% and 46%, respectively. CONCLUSIONS: Patients without additional risk factors undergoing second and third artificial urinary sphincter surgeries experience revision-free rates similar to those of their initial artificial urinary sphincter devices. Patients who have been treated with pelvic radiation have earlier artificial urinary sphincter complications. When multiple risk factors exist, revision-free rates decrease significantly.

Multicenter analysis of posterior urethroplasty complexity and outcomes following pelvic fracture urethral injury.

PURPOSE: To analyze outcomes of posterior urethroplasty following pelvic fracture urethral injuries (PFUI) and to determine risk factors for surgical complexity and success. METHODS: Patients who underwent posterior urethroplasty following PFUI were identified in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) database. Demographics, injury patterns, management strategies, and prior interventions were evaluated. Risk factors for surgical failure and the impact of ancillary urethral lengthening maneuvers (corporal splitting, pubectomy and supracrural rerouting) were evaluated. RESULTS: Of the 436 posterior urethroplasties identified, 122 were following PFUI. 83 (68%) patients were acutely managed with suprapubic tubes, while 39 (32%) underwent early endoscopic realignment. 16 (13%) patients underwent pelvic artery embolization in the acute setting. 116 cases (95%) were completed via a perineal approach, while 6 (5%) were performed via an abdominoperineal approach. The need for one or more ancillary maneuvers to gain urethral length occurred in 4 (36%) patients. Of these, 44 (36%) received corporal splitting, 16 (13%) partial or complete pubectomy, and 2 (2%) supracrural rerouting. Younger patients, those with longer distraction defects, and those with a history of angioembolization were more likely to require ancillary maneuvers. 111 patients (91%) did not require repeat intervention during follow-up. Angioembolization (p = 0.03) and longer distraction defects (p = 0.01) were associated with failure. CONCLUSIONS: Posterior urethroplasty provides excellent success rates for patients following PFUI. Pelvic angioembolization and increased defect length are associated with increased surgical complexity and risk of failure. Surgeons should be prepared to implement ancillary maneuvers when indicated to achieve a tension-free anastomosis.

Renal Trauma Classification and Management: Validating the Revised Renal Injury Grading Scale.

PURPOSE: To better characterize traumatic renal injury a revision to the 1989 American Association for the Surgery of Trauma renal injury scale was proposed in which grade IV includes all collecting system and segmental vascular injuries and grade V includes main renal hilar injury. We sought to validate the 2009 grading scale, emphasizing reclassifications between the 1989 and 2009 versions, and subsequent management. MATERIALS AND METHODS: Patient demographics and renal injury characteristics, computerized tomography imaging, radiology reports and subsequent management were recorded in a prospective trauma database. Multivariable logistic regression models for intervention were compared using 1989 and 2009 grades to evaluate which grading scale better predicted management. RESULTS: Of 256 renal injury cases 56 (21.9%) were reclassified using the revised 2009 scale, including 50 (19.5%) which were upgraded, 6 (2.3%) which were downgraded and 200 (78.1%) which were unchanged. Of grade III or higher cases management was nonoperative in 112 (78.9%), angioembolization in 9 (6.3%), nephrectomy in 9 (6.3%) and renorrhaphy in 12 (8.5%). Management was significantly associated with original and revised grades (chi-square p=0.02 and <0.001, respectively). Further, the multivariable model using the 2009 grades significantly outperformed the 1989 model. Radiology reports rarely included renal injury scales. CONCLUSIONS: Using the revised renal injury grading scale led to more definitive classification of renal injury and a stronger association with renal trauma management. Applying the revised criteria may facilitate and improve the multidisciplinary care of renal trauma.

Urinary and Sexual Function after Perineal Urethrostomy for Urethral Stricture Disease: An Analysis from the TURNS.

PURPOSE: Perineal urethrostomy is a viable option for many complex urethral strictures. However, to our knowledge no comparison with anterior urethroplasty regarding patient reported outcome measures has been published. We compared these groups using a large multi-institution database. MATERIALS AND METHODS: We performed a retrospective study of anterior urethroplasty in the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) database. The anterior urethroplasty cohort was defined by long strictures greater than 6 cm. We compared demographic, clinical, urinary and sexual characteristics using validated patient reported outcome measures between patients treated with long stricture anterior urethroplasty and those who underwent perineal urethrostomy. RESULTS: Of the 131 patients 92 treated with long stricture anterior urethroplasty and 39 treated with perineal urethrostomy met study inclusion criteria. The cumulative incidence of failure at 2 years was 30.2% (95% CI 18.3-47.3) for long stricture anterior urethroplasty and 14.5% (95% CI 4.8-39.1) for perineal urethrostomy (p = 0.09). Compared to baseline metrics, patients who underwent long stricture anterior urethroplasty and perineal urethrostomy had similar improvements in urinary function and stable sexual function after surgery. CONCLUSIONS: Patients reported improvement in urinary function after perineal urethrostomy with no deleterious effect on sexual function. These patient reported outcome measures were comparable to those of long stricture anterior urethroplasty. Perineal urethrostomy failure rates were similar to those of long stricture anterior urethroplasty.

Effect of Urethroplasty on Anxiety and Depression.

PURPOSE: To our knowledge anxiety and depression in patients with urethral stricture disease and the impact of urethroplasty on mental health has never been explored. We hypothesized that patients with urethral stricture disease would have higher than normal anxiety and depression levels, and urethroplasty would improve mental health. MATERIALS AND METHODS: We retrospectively reviewed the records of patients in a multi-institutional reconstructive urology database who underwent anterior urethroplasty. Preoperative and postoperative evaluation of anxiety and depression, and overall health was recorded using the validated EQ-5D™-3L Questionnaire. Sexual function was evaluated with the IIEF (International Index of Erectile Function) and the Men's Sexual Health Questionnaire. Stricture recurrence was defined as the need for a subsequent procedure. RESULTS: Median followup in the 298 patients who met study inclusion criteria was 4.2 months. Preoperative anxiety and depression was reported by 86 patients (29%). Those with anxiety and depression reported higher rates of marijuana use, a worse preoperative IIEF score (17.5 vs 19.6, p = 0.01) and a lower image of overall health (66 vs 79, p ≤0.001). Improvement or resolution of anxiety and depression was experienced by 56% of patients treated with urethroplasty while de novo postoperative anxiety and depression were reported by 10%. These men reported a decreased flow rate (16 vs 25 ml per second, p = 0.01). Clinical failure in 8 patients (2.7%) had no effect on the development, improvement or resolution of anxiety and depression. CONCLUSIONS: Of patients with preoperative anxiety and depression 56% reported improvement or resolution after urethroplasty. Although new onset anxiety and depression was rare, these patients had a significantly lower postoperative maximum flow rate, possibly representing a group with a perceived suboptimal surgical outcome. A urethral stricture disease specific questionnaire is needed to further elucidate the interplay of urethral stricture disease with anxiety and depression.

Prevalence of Post-Micturition Incontinence before and after Anterior Urethroplasty.

PURPOSE: In this study we aimed to define the prevalence of preoperative and postoperative post-micturition incontinence or post-void dribbling after anterior urethroplasty for urethral stricture disease. We also sought to determine risk factors for its presence. MATERIALS AND METHODS: We retrospectively reviewed a prospectively maintained, multi-institutional urethral stricture database to evaluate post-micturition incontinence using a single question from a validated questionnaire, "How often have you had a slight wetting of your pants a few minutes after you had finished urinating and had dressed yourself?" Possible answers were never-0 to all the time-3. The presence of post-micturition incontinence was defined as any answer greater than 0. Comparisons were made to stricture type and location, repair type and patient medical comorbidities. RESULTS: Preoperative and postoperative post-micturition incontinence questionnaires were completed by 614 and 331 patients, respectively. Patients without complete data available were excluded from study. Preoperative post-micturition incontinence was present in 73% of patients, of whom 44% stated that this symptom was present most of the time. Overall postoperative post-micturition incontinence was present in 40% of patients and again it was not predicted by stricture location or urethroplasty type. Of the 331 patients with followup questionnaires 60% reported improvement, 32% reported no change and 8% reported worsening symptoms. The overall rate of de novo post-micturition incontinence was low at 6.3%. CONCLUSIONS: The prevalence of preoperative post-micturition incontinence is high and likely under reported. In most patients post-micturition incontinence improves after urethroplasty and the prevalence of de novo post-micturition incontinence is low. The presence of post-micturition incontinence was not predicted by stricture length or location, or urethroplasty repair type.

Urethral lichen sclerosus under the microscope: a survey of academic pathologists.

INTRODUCTION: Given the poor understanding of the pathophysiology of genital lichen sclerosus (GLS) and a lack of accepted definitive diagnostic criteria, we proposed to survey pathologists regarding their understanding of GLS. We hypothesized that significant disagreement about GLS will exist. MATERIALS AND METHODS: All urologists participating in the Trauma and Urologic Reconstruction Network of Surgeons identified genitourinary (GUP) and dermatopathologists (DP) at their respective institutions who were then invited to participate in an online survey regarding their experience with diagnosing GLS, GLS pathophysiology and its relationship to urethral stricture disease. RESULTS: There were 23 (12 DP, 11 GUP) pathologists that completed the survey. The most agreed upon criteria for diagnosis were dermal collagen homogenization (85.7%), loss of the normal rete pattern (33.3%) and atrophic epidermis (28.5%). No pathologists believed GLS had an infectious etiology (19% maybe, 42% unknown) and 19% believed GLS to be an autoimmune disorder (42% maybe, 38% unknown); 19% believed LS to be premalignant, but 52% believed it was associated with cancer; 80% believed that LS could involve the urethra (DP (92%) versus GUP (67%); p = 0.272). Of those diagnosing urethral GLS, 80% of DUP believed that GLS must first involve the glans/prepuce before involving the urethra, while all GUP believed that urethral disease could exist in isolation (p = 0.007). CONCLUSIONS: There was significant disagreement in this specialized cohort of pathologists when diagnosing GLS. A logical first step appears to be improving agreement on how to best describe and classify the disease. This may lead to improve treatments.

Understanding the Relationship between Chronic Systemic Disease and Lichen Sclerosus Urethral Strictures.

PURPOSE: Lichen sclerosus is a chronic, inflammatory skin condition of the genitalia of unknown origin that accounts for nearly 10% of urethral stricture disease. In this study we determine systemic comorbidities associated with lichen sclerosus in men. MATERIALS AND METHODS: We analyzed data from 1,151 men who were enrolled in a multi-institutional prospective urethroplasty outcomes database. Individuals were grouped by stricture etiology, and baseline demographics, medical histories and patient reported outcome measures were retrospectively compared across groups. RESULTS: Of the 1,151 men in the database 81 (7.0%) were noted to have lichen sclerosus related urethral stricture disease. Average patient age was 46.06 ± 16.52 years, with those with lichen sclerosus being significantly older than those without lichen sclerosus (51.26 ± 13.84 vs 45.68 ± 16.64, p = 0.0011). Men with lichen sclerosus were more likely to have hypertension, hyperlipidemia and diabetes, and to use tobacco products. Controlling for age, men with lichen sclerosus related urethral stricture disease had a higher body mass index (aOR 1.089, 95% CI 1.050-1.130), and were more likely to have hypertension (aOR 2.028, 1.21-3.41) and be active tobacco users (aOR 2.0, 1.36-3.40). Mean preoperative patient reported outcome measures scores for urinary and sexual function were similar. Controlling for stricture length and location, the adjusted odds of surgical failure were higher for lichen sclerosus related urethral stricture disease (aOR 1.9, 95% CI 0.9-4.2). CONCLUSIONS: Lichen sclerosus related urethral stricture disease is associated with chronic systemic diseases. This association may implicate a systemic inflammatory and/or autoimmune pathophysiology. A 2-hit mechanism implicating local and systemic factors for lichen sclerosus related urethral stricture disease development and progression is hypothesized.

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.

Delayed gangrenous penile necrosis following prolonged utilization of penile constriction ring.

Penile strangulation secondary to utilization of a constrictive ring is a rare urologic emergency that requires urgent decompression to prevent prolonged vascular obstruction resulting in necrosis and gangrene. Current literature is mainly comprised of case presentations that focus on management in the acute setting via removal of the ring. Herein, we describe surgical management of a patient who presents in delayed fashion after self-removal of the constrictive ring. We discuss our penectomy-sparing technique of debridement and split thickness skin graft.

Acquired rectourethral fistulas in adults: a systematic review of surgical repair techniques and outcomes.

BACKGROUND: Rectourethral fistulas are uncommon. Retrospective studies and case reports have highlighted various approaches for surgical repair. Because clinical presentations and technical expertise vary widely, no single procedure has been universally adopted. OBJECTIVE: We sought to qualitatively analyze studies describing surgical techniques and outcomes in adult acquired rectourethral fistulas to outline universal approaches for evaluation and management. DATA SOURCES: MEDLINE (PubMed, Ovid) and the Cochrane Library were searched by using the terms rectourethral fistulas, recto-urethral fistulas, urethrorectal fistulas, and prostatourethral-rectal fistulas. STUDY SELECTION: All studies were retrospective, in English, and reported at least 4 cases. Any series with >50% congenital cases or <50% adults (19+ years) was excluded. Of the 569 records identified, 26 articles were included. INTERVENTION: The intervention was surgical repair of rectourethral fistula. MAIN OUTCOME MEASURES: The main outcome measures were successful fistula closure, fistula recurrence or persistence, and permanent fecal and/or urinary diversion. RESULTS: Four hundred sixteen patients were identified, including 169 (40%) who had previous pelvic irradiation and/or ablation. Most patients (90%) underwent 1 of 4 categories of repair: transanal (5.9%), transabdominal (12.5%), transsphincteric (15.7%), and transperineal (65.9%). Tissue interposition flaps, predominantly gracilis muscle, were used in 72% of repairs. The fistula was successfully closed in 87.5%. Overall permanent fecal and/or urinary diversion rates were 10.6% and 8.3%. Most high-volume centers (≥25 patients) performed transperineal repairs with tissue flaps in 100% of cases. LIMITATIONS: This review was limited by the heterogeneity of repairs and bias toward preferred surgical approaches in single-center studies. CONCLUSIONS: Regardless of complexity, rectourethral fistulas have an initial closure rate approaching 90% when the transperineal approach is used. Permanent fecal and/or urinary diversion should be a last resort in patients with devastated, nonfunctional fecal and urinary systems.

Urologic disease in a resource-poor country.

BACKGROUND: Understanding the role that urologic disease plays within central Haiti could lead to the development of sustainable and regionally appropriate urologic care. We aim to document the prevalence of urologic surgical disease presenting for treatment in central Haiti. METHODS: The present study is based on a retrospective review of surgical case logs at five Partners in Health and Zanmi Lasante hospitals in central Haiti. Data were collected from June 30, 2009, through July 29, 2010, and included patient demographics, disease processes, interventions required, surgeon name, and surgeon training (urologic trained versus non-urologic trained). RESULTS: Urologic surgical disease comprised 498/5,539 (9.0 %) of all surgical cases in central Haiti from July 2009-July 2010. A total of 492 diagnoses and 498 urologic procedures on 469 patients were recorded. Most common diagnoses included hydrocele (33.3 %), phimosis (23.0 %), benign prostatic hyperplasia (10.8 %), and cryptorchidism (7.3 %). Hydrocelectomy was the most commonly performed procedure (160/498, 32.1 %), followed by circumcision (117/498, 23.4 %) and open prostatectomy (38/498, 7.6 %). Surgeon training (urologic versus non-urologic) was determined for 360/498 (72.3 %) of surgical cases. Urologic trained surgeons performed 55/360 (15.3 %) of all surgical procedures. Among patients who underwent prostatectomy, urology surgeons performed 14/31 (45.2 %) of open prostatectomies, and non-urology surgeons performed 17/31 (54.8 %). Urologists performed all transurethral resections of the prostate (9 vs. 0; p = 0.0051). CONCLUSIONS: Urologic surgical diseases comprise a substantial source of morbidity for patients in central Haiti. Understanding the scale and scope of urologic disease is important in developing health systems to adequately address the regional burden of surgical disease in limited-resource settings.