Long-term outcomes for 2-stage urethroplasty: an analysis of risk factors for urethral stricture recurrence.

PURPOSE: To report long-term results and patient reported outcomes of staged anterior urethroplasties, and isolate risk factors for recurrence. METHODS:  We reviewed urethroplasty database for all patients who underwent staged urethroplasty from 2000 to 2017. Follow-up included a cystoscopy 4 months after their 2nd stage to assess early success, and then annual follow-up thereafter with post-void residual and symptom assessment. Stricture characteristics, etiology and graft type were analyzed with regards to success. RESULTS:  Forty-nine patients were eligible for inclusion. The median stricture length was 7 cm (3-17 cm). The early success rate demonstrated by cystoscopy at 4 months was 100%. Long-term success was 96.4% in buccal graft (BMG) only patients; however, long-term success fell considerably to 53% in patients requiring any use split thickness skin graft (STSG) in the first stage. Median follow up time was 57 months (6-240 months). On analysis, age, increased stricture length and especially the use of STSG all appeared to be associated with late recurrence. The recurrence group had longer stricture length and were more likely to be panurethral. All recurrences occurred after the initial 4-month cystoscopy with a median time to recurrence of 78 months. CONCLUSION: Staged repairs that are amenable to BMG-only repairs have high long-term success rates. Increasing stricture length and the addition of split-thickness skin graft were associated with lower success rate in staged urethral reconstruction. Patients requiring staged repairs often experience recurrence in a very delayed fashion reinforcing the need for close, long-term follow up.

Analysis of Factors Associated with Patient or Caregiver Regret following Surgery for Fecal Incontinence.

PURPOSE: Malone antegrade continence enema has been a successful and widely used procedure for achieving fecal continence in children. We present data on the previously uninvestigated issue of patient and caregiver regret following surgery for intractable constipation and fecal incontinence. MATERIALS AND METHODS: We reviewed all patients undergoing antegrade continence enema or cecostomy creation at a single institution between 2006 and 2016. Patients and caregivers were assessed for decisional regret using the Decisional Regret Scale. Results were correlated with demographics, surgical outcomes and complications. RESULTS: A total of 81 responses (49 caregivers and 32 patients) were obtained. Mean followup was 49 months. Decisional regret was noted in 43 subjects (53%), including mild regret in 38 (47%) and moderate to severe regret in 5 (6%). No statistical difference in regret was noted based on gender, complications or performance of concomitant procedures. On regression analysis incontinence was strongly associated with decisional regret (OR 4.4, 95% CI 1.1-18.1, p <0.001) and regret increased as age at surgery increased, particularly when patients were operated on at age 13 to 15 years (OR 2.6, 95% CI 1.0-6.4 for age 13 years; OR 2.9, 95% CI 1.1-7.8 for age 14 years; OR 3.1, 95% CI 1.1-8.8 for age 15 years). CONCLUSIONS: This is the first known study describing decisional regret following surgery for fecal incontinence. Surgical factors aimed at achieving continence may be effective in decreasing postoperative regret. The finding of increased regret in teenage patients compared to younger children should be shared with families since it may impact the age at which surgery is pursued.

Primary Yolk Sac Tumor of the Prostate: A Case Report and Review of the Literature.

Endodermal sinus (yolk sac) tumors (ESTs) are rare neoplasms that most commonly arise in the ovaries or testis. Only six cases of prostatic ESTs have been reported in the literature. We report a case of prostatic EST, the first case in which the patient had a history of previous testis cancer. Treatment included cisplatin-based chemotherapy and radical prostatectomy. Previous cases of primary ESTs and use of cisplatin-based therapy as well as metastatic tumors to the prostate are discussed.

Cancer chemotherapeutic agents as human teratogens.

BACKGROUND: Cancer is the second leading cause of death among women of reproductive age. Although the coincidence of pregnancy and cancer is rare and treatment may sometimes be safely delayed, the use of chemotherapeutic agents in pregnancy is sometimes unavoidable or inadvertent. METHODS: We review the literature for the use of antineoplastic agents in single-agent and combination therapy from 1951 through June 2012. We also summarize the evidence relating to teratogenicity of disorder-specific combination chemotherapy treatments for those malignancies frequently encountered in women of childbearing age. Major endpoints were called "adverse pregnancy outcomes" (APOs), to include structural anomalies (congenital malformations), functional defects, blood or electrolyte abnormalities, stillbirths, spontaneous abortions (miscarriages), and fetal, neonatal, or maternal deaths. RESULTS: The registry totals 863 cases. Rates of APOs (and congenital malformations) after any exposure were 33% (16%), 27% (8%), and 25% (6%), for first, second, and third trimesters. Among the groups of cancer drugs, antimetabolites and alkylating agents have the highest rates of APOs. Mitotic inhibitors and antibiotics seem more benign. Mixed results were observed from single-agent exposure, often because of small numbers of exposures. As a whole, the alkylating agents and antimetabolites are more harmful when given as a single agent rather than as part of a regimen. First-trimester exposure poses a more permanent risk to the fetus. CONCLUSIONS: Systematic ascertainment of women early in pregnancy, preferably in a population base, is needed for assessment of true risks. Long-term follow-up is needed to rule out neurobehavioral effects.

Urinary and Sexual Outcomes Following Bulbar Urethroplasty-An Analysis of 2 Common Approaches.

OBJECTIVE: To report success and patient reported urinary and sexual outcomes of patients who underwent anastomotic urethroplasty and dorsal buccal onlay urethroplasty. MATERIALS AND METHODS: Patients who underwent primary transecting anastomotic or dorsal buccal onlay urethroplasty for bulbar strictures at our institution between 1998 and 2015 were analyzed. Patients who had a prior urethroplasty, involvement of a different portion of the urethra, or a diagnosis of lichen sclerosis (LS) or hypospadias were excluded. Outcomes were assessed by cystoscopy at 4 months, validated questionnaires assessing urinary, erectile, and ejaculatory function at the time of their most recent assessment. RESULTS: A total of 40 and 139 patients were included in the dorsal buccal and anastomotic groups, respectively. Wide patency at 4-month cystoscopy was 97.5% and 100% (P= .06) and the long-term success was 95% and 99.3% (P= .06) with a mean follow-up of 51.4 and 63.3 months. Patient reported outcomes were similar with 2 exceptions: postvoid dribbling was reported more often in the onlay group (28.1% vs 8.3%, P< .0001), and tethering with erections in the anastomotic group (23.4% vs 3.1%, P= .008). Ninety-eight percent of patients in the anastomotic group and 91% in the dorsal buccal onlay group would choose their surgery again (P= .07). CONCLUSION: Both anastomotic urethroplasty and dorsal onlay graft are associated with high success with comparable satisfaction. Patient reported outcome measures were similar regardless of approach, despite inherent differences in stricture length. Our data indicates that anastomotic urethroplasty should not be avoided due to concerns of sexual side effects.

Penile Fracture Following a Fall in a 7-Year-Old Male.

We report a rare case of isolated penile fracture in a prepubescent male caused by an accidental fall. The patient presented with swelling and ecchymosis on the base of the penis and along the penile shaft. A flexible cystoscopy was performed, which did not reveal any concomitant urethral injury. The penis was degloved and the corporal tear was closed with absorbable suture. Due to the location of the injury, ventral mobilization of the urethra was required. The pathophysiology of penile fracture as well as the diagnosis and management of this rare injury are discussed in this report.