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ObjectiveTo determine whether ejaculatory dysfunction (EjD) and post-void dribbling (PVD) after urethroplasty are associated, providing evidence for a common etiology.MethodsWe reviewed a prospectively maintained database for first-time, anterior urethroplasties. One item from the Male Sexual Health Questionnaire (MSHQ) assessed EjD: "How would you rate the strength or force of your ejaculation". One item from the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS-PROM) assessed PVD: "How often have you had slight wetting of your pants after you had finished urinating?". The frequency of symptoms was compared after penile vs. bulbar repairs, and anastomotic versus augmentation bulbar repairs. Associations were assessed with chi-square.ResultsA total of 728 men were included. Overall, postoperative EjD and PVD were common; 67% and 66%, respectively. There was a significant association between EjD and PVD for the whole cohort (p

Objective To determine surgical site infection and urinary tract infection (UTI) rates in the setting of urethroplasty. Given significant variation in the utilization of antibiotics, there is an opportunity to improve antibiotic stewardship. This study aims to elucidate the rate of both UTI and surgical site infection after urethroplasty on a standardized perioperative antibiotic regimen, and to obtain patient and operative characteristics that may predict infection. Methods We prospectively treated 390 patients undergoing urethroplasty at 11 centers with a standardized perioperative antibiotic protocol. Patients had a urine culture or urine analysis within 3 weeks of surgery. After surgery, patients were discharged with an indwelling catheter, removed per usual surgeon practice. All were given nitrofurantoin from discharge until catheter removal. Logistic regression analyses were performed to determine the correlation between patient characteristics or operative categories with post-operative infection. Results The rates of postoperative UTI and wound infection within 30 days were 6.7% and 4.1%, respectively. On multivariate analysis of demographics, comorbidities, and stricture characteristics and repair, only preoperative UTI (P = .012), history of cardiovascular disease (P = .015), and performing a membranous urethroplasty (0.018) were significant predictors of a UTI within 30 days postoperatively. Location of repair nor graft use increased the risk of UTI. There were no factors predictive of postoperative wound infection. Conclusion A standardized antibiotic protocol was created to narrow and limit excess antibiotic use. This protocol, with clear definitions of UTI and wound infection, allowed determination of accurate infection rates in urethroplasties. Preoperative UTI, even when properly treated, increases the risk of postoperative UTI.

BACKGROUND: To evaluate erectile and sexual function after pelvic fracture urethral injury (PFUI) by performing a retrospective review of a large multi-center database. We hypothesized that most men will have erectile dysfunction (ED) and poor sexual function following PFUI, which will remain after posterior urethroplasty. METHODS: Using the Trauma and Urologic Reconstructive Networks of Surgeons (TURNS) database, we identified PFUI patients undergoing posterior urethroplasty. We excluded patients with incomplete demographic, surgical and/or questionnaire data. Sexual Health Inventory of Men (SHIM), Male Sexual Health Questionnaire (MSHQ), and subjective changes in penile curvature were collected before urethroplasty surgery and at follow-up. We performed descriptive statistics for erectile and ejaculatory function using STATA v12. RESULTS: We identified 92 men meeting inclusion criteria; median age was 41.7 years and BMI was 26.5. The mechanism of injury was blunt in all patients, and average distraction defect length was 2.3 cm (SD 1.0 cm). In the 38 patients who completed both pre and post-operative SHIM questionnaires, the mean SHIM score was 10.5 (SD 7.0), with 63% having severe ED (SHIM

To assess the efficacy, effect of radiotherapy, and complications of direct visual internal urethrotomy (DVIU) and intralesional mitomycin C (MMC) for recurrent bladder neck contracture/vesicourethral anastomotic stenosis (BNC/VUAS).Patients who underwent DVIU with intralesional MMC for recurrent BNC/VUAS between 2007 and 2019 at 2 institutions were included. Cold knife incisions were performed in a reproducible fashion followed by injection of 0.3-0.4 mg/mL MMC at each incision site. Those with evidence of complete urethral obliteration, stenosis of the entire posterior urethra, or3 months follow-up were excluded. Success was defined as the ability to pass a 17-French cystoscope postoperatively without the need for catheterization or additional procedures.Eighty-six patients were analyzed over a median follow-up of 21.1 months. Around 91% had at least 1 prior DVIU, 56% had at least 1 prior dilation, and 44% presented with an indwelling catheter or performed intermittent catheterization. Success was achieved in 65% after 1 procedure, an additional 18% after 2 procedures, and another 7% after 3 or more procedures (90% overall success rate). Nonradiated patients showed a higher overall success rate compared to radiated patients (94% vs 76%, P = 0.04). Of the 9 cystoscopic failures, 5 were asymptomatic and pursued observation. Only 2 (5%) patients with a history of catheterization required this postoperatively. Two patients underwent subsequent urinary diversion surgery. No long-term complications were seen.DVIU with low-dose MMC remains a safe and effective BNC/VUAS treatment. A patent bladder neck was achieved in90% of nonradiated patients and75% of radiated patients.

OBJECTIVE To demonstrate our hypothesis that the presence of extravasation on postoperative urethrogram is inconsequential for disease recurrence in urethroplasty postoperative follow-up. MATERIALS AND METHODS We utilized the Trauma and Urologic Reconstructive Network of Surgeons database to assess 1691 patients who underwent urethroplasty and post-operative urethrogram. Anatomic and functional recurrence were defined as RESULTS Among 1101 patients with cystoscopy follow-up, 54 (4.9%) had extravasation on initial postoperative urethrogram. Among those 54, 74.1% developed an anatomic recurrence vs 13% without extravasation (P CONCLUSION Postoperative urethrogram has a high specificity but low sensitivity for anatomic and functional recurrence during short term follow-up. The positive predictive value of urinary extravasation is high: patients with extravasation incur a high risk of anatomic recurrence within 1 year and such patients may warrant increased monitoring.

PurposePostoperative 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 methodsWe 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 (

INTRODUCTION AND OBJECTIVE:There is a paucity of evidence documenting the lived experience of patients with adult acquired buried penis (AABP) and how this condition is affected by surgical treatme...

INTRODUCTION AND OBJECTIVE:Anterior urethral stricture disease (aUSD) is often a diagnosis of exclusion in men presenting with refractory lower urinary tract symptoms (LUTS). When the stricture is ...

INTRODUCTION AND OBJECTIVE:The LSE anterior urethral stricture classification system has previously been validated for its interrater reliability and ability to predict urethroplasty technique. Her...

INTRODUCTION AND OBJECTIVE:Identifying non-invasive biomarkers that distinguish Lichen Sclerosus (LS) induced from non-LS induced urethral strictures would have broad implications for the diagnosis...

INTRODUCTION AND OBJECTIVE:Lichen sclerosus (LS) is a chronic inflammatory condition that can affect both the penile skin and urethral epithelium in men. Over time, severe impairment of sexual and ...

INTRODUCTION AND OBJECTIVE:Prior work has established that post-operative urethroscopy may be an effective tool to predict re-operation within 1 year following urethroplasty. Here, we examine early...

Background Our objective is to better comprehend treatment considerations for urethral stricture disease (USD) in patients requiring long-term clean intermittent catheterization (CIC). Patient characteristics, surgical outcomes and complications are unknown in this population. Methods Six members of the Trauma and Urologic Reconstruction Network of Surgeons (TURNS) participated in a prospective (2009 to present) and retrospective (prior to 2009) database recording patient demographics, surgical approach and outcomes. We included all patients undergoing urethroplasty who perform CIC. Descriptive statistics were used to analyze results. Results A total of 37 patients with 39 strictures were included. Bladder dysfunction was characterized as detrusor failure in 35% and neurogenic etiology in 65%. Median stricture length was 3 cm (IQR: 1.5-5.5) with 28% repaired with dorsal onlay buccal mucosal graft, 26% excision and primary anastomosis, 8% dorsal inlay, 8% ventral and dorsal, 8% flap based 8% non-transecting and 15% other. Functional success was 90%: 4 patients required DVIU or dilation due to recurrence, with 2 of those ultimately requiring repeat urethroplasty. 86% of patients returned to CIC; no patients reported new pad use for urinary leakage after urethroplasty. During a median follow-up period of 3.1 years (IQR: 1.0-5.3), no patients underwent urinary diversion. Conclusions Urethroplasty is suitable, safe and effective for patients dependent on CIC suffering from USD. The effect of continual CIC on long-term outcomes remains uncertain.

Objective To evaluate our 20-year experience of urethroplasty with ventral buccal mucosa graft (BMG) and gracilis muscle flap coverage for long segment urethral strictures unfit for standard repair due to a compromised graft bed and poor vascular supply. Methods We retrospectively reviewed the records of 1687 patients who underwent urethroplasty at our institution between 1999 and 2019. We identified 30 patients who underwent urethroplasty with a ventral BMG and gracilis muscle flap graft bed. Stricture recurrence was defined as the inability to pass a 17-French cystoscope. Results Mean stricture length was 7.6 centimeters (range 3.5-15). Strictures were located in the posterior urethra with or without involvement of the bulbar urethra in 60% of cases, the bulbomembranous urethra in 30%, the bulbar urethra in 6.7%, and the proximal pendulous urethra in 3.3%. Stricture etiology was radiation therapy in 60% of cases, prostatectomy in 23.3%, transurethral surgery in 13.3%, idiopathic in 13.3%, trauma in 10%, and hypospadias failure in 3.3%. Ten (33.3%) patients were previously treated with urethroplasty, 26 (86.7%) had prior endoscopic stricture management, and 3 (10%) previously underwent UroLume stent placement. Urethral reconstruction was successful in 23 cases (76.7%) at a mean follow-up of 32 months (range 4-92). Two of the patients in whom treatment failed underwent urinary diversion, 3 underwent suprapubic tube placement, 1 had endoscopic urethral dilation, and 1 had direct visual internal urethrotomy performed. Mean time to recurrence was 8 months (range 2-17). Postoperatively, 7 patients (23.3%) had incontinence requiring artificial urinary sphincter placement. Conclusion Ventral BMG urethroplasty with gracilis muscle flap coverage can be successfully performed for high risk, long segment urethral strictures, avoiding urinary diversion in most patients.

There is not a universally agreed upon treatment algorithm for radiation cystitis. The goal of this review will be to discuss numerous options available to the provider at various points in treatment and the literature supporting its use. There are various degrees of presentation, with milder forms that can be managed as outpatient and more serious forms requiring inpatient admission. There are a myriad of treatment options, including intravesical instillations, ablative procedures, systemic therapies, hyperbaric oxygen therapy, arterial embolization, and urinary diversion. If these measures are able to control the bleeding in the acute setting, the patient can then be considered for outpatient systemic therapy to decrease the risk of hematuria recurrence. Hyperbaric oxygen therapy has emerged as an outpatient treatment option with very promising results; however, further research needs to evaluate its long-term cost-effectiveness. Radiation cystitis is a devastating disease process that can occur months to years following radiotherapy and poses many therapeutic challenges. When conservative measures fail to control bladder hemorrhage, arterial embolization or urinary diversion may be ultimately necessary as life-saving measures, however, these are associated with considerable morbidity and mortality. Due to the devastating impact of radiation cystitis on patient quality of life, further research is imperative in order to add further innovative treatment strategies to our armamentarium.

Objective To evaluate the presenting complications of patients to reconstructive urologists after masculinizing gender affirming genital reconstructive surgery (GRS) performed elsewhere. Methods We identified patients who underwent revision surgery by one of the co-authors for sequelae of masculinizing GRS. We reviewed patient demographics, medical history, details of prior GRS, and complications from GRS. Specific attention was paid to the presence of the following: suprapubic tube dependence, vaginal remnant, urethrocutaneous fistula (UCF) within the fixed urethra (pars fixa), UCF in the phallic urethra, phallic urethral stricture, meatal stenosis, and anastomotic urethral stricture. Statistical analysis was performed using the Fisher's exact test to determine differences in presenting symptoms by GRS. Results Fifty-five patients who had reconstructive surgery for complications from masculinizing GRS from September 2004 to September 2017 were identified. The median age at surgical correction was 33 years. Fifteen (27%) patients had prior metoidioplasty and 40 (73%) had prior phalloplasty. The median time from date of GRS to presentation to a reconstructive urologist was 4 months. Urethral strictures (n = 47, 86%) were the most common indication for subsequent surgery, followed by urethrocutaneous fistulae (n = 31, 56%) and vaginal remnant (n = 26, 47%). The majority of patients presented with 2 or more simultaneous complications (n = 40, 73%). Conclusion There are several common presenting urologic complications after masculinizing GRS. Patients may present to reconstructive urologists early after GRS performed elsewhere. The long-term outcomes of GRS deserve further study.

Objective To analyze contemporary urethroplasty trends and urethral stricture etiologies over a 7-year study period among urologists from a large multi-institutional surgical outcomes group. Methods Review of a multi-institutional, prospectively maintained urethroplasty database was performed on 2098 anterior urethroplasties done between 2010 and 2017 by 10 surgeons. Stricture characteristics, including etiology, length, and anatomic location were analyzed and compared to urethroplasty type over the study period using chi-squared analysis to assess for linear trends within the group and by surgeon. Results Average stricture lengths for bulbar (2.8 ± 1.8 cm), penile (3.6 ± 2.6 cm), and penile-bulbar strictures (8.7 ± 5.0) remained stable. The most common stricture etiology was idiopathic/unknown in all study years (63%). In the bulbar urethra, the group performed significantly (1) fewer excisional repairs (−31%) and more substitutional repairs (+78%); (2) of substitutional repairs, more grafts are being placed dorsally (+95%) vs ventrally (−75%) (3) of the bulbar excisional repairs, more are being performed without transection of the bulbar urethra (+430%); and in the penile urethra (4) the fasciocutaneous flap is in decline (−86%), while single-stage dorsal repairs are increasing (+280%). Conclusion Anterior urethroplasty techniques continue to evolve in the absence of robust clinical data or randomized controlled trials, with a general movement in this cohort toward an initial dorsal approach for most strictures. Inter- and intrasurgeon variability in the surgical management of similar strictures was noted, and the feasibility of any future randomized controlled trials, without apparent surgical equipoise, must be questioned.

PurposeWe report multi-institutional outcomes in patients who underwent urethroplasty with a rectal mucosa graft.Materials and methodsWe used the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) database to identify patients who underwent urethral reconstruction with transanal harvest of a rectal mucosa graft. We reviewed preoperative demographics, stricture etiology, previous management and patient outcomes.ResultsWe identified 13 patients from April 2013 to June 2017. Median age at surgery was 54 years. The stricture etiology was lichen sclerosus in 6 of 13 patients (46%), idiopathic in 2 (15%), hypospadias in 1 (7%), prior gender confirming surgery in 3 (23%) and rectourethral fistula after radiation for prostate cancer in 1 (7%). Prior procedures included failed urethroplasty with a buccal mucosa graft in 9 of 13 patients (69%), direct vision internal urethrotomy in 2 (15%) and none in 2 (15%). Median stricture length was 13 cm. Stricture location in the 9 cisgender patients was panurethral in 5 (56%), bulbopendulous in 2 (22%) and bulbar in 2 (22%). It was located at the junction of the fixed urethra extending into the neophallus in all 3 patients (100%) who underwent prior gender confirming surgery. Mean rectal mucosa graft length for urethroplasty was 10.6 cm (range 3 to 16). Repair types included dorsal or ventral onlay, or 2-stage repair. Stricture recurred at a median followup of 13.5 months in 2 of 13 patients (15%). Postoperative complications included glans dehiscence, urethrocutaneous fistula and compartment syndrome in 1 patient each (7%). No rectal or bowel related complications were reported.ConclusionsUrethral reconstruction with a transanal harvested rectal mucosa graft is a safe technique when a buccal mucosa graft is unavailable or not indicated.

We evaluated the pathophysiology of lichen sclerosus and nonlichen sclerosus urethral stricture disease by comparing protein expression related to inflammation, cell cycle disruption, oxidative stress, hormone receptor status and infection.Tissue samples were collected from the urethral strictures of 81 patients undergoing urethroplasty. Clinical and demographic data were obtained by chart review. After identifying areas pathognomonic for lichen sclerosus a tissue microarray was created with cores from each sample and immunohistochemistry was performed.Patients had similar baseline demographics and comorbidities. Of the 81 strictures 58 were and 23 were not due to lichen sclerosus. Lichen sclerosus strictures were significantly longer and showed higher levels of inflammation. The proportion of T cells which stained positive for CD8 was significantly higher in strictures due to lichen sclerosus (50% vs 13%, p = 0.004). CCL-4 was expressed significantly more in strictures due to lichen sclerosus (76% vs 42%, p = 0.01). Several other inflammatory markers were only found in strictures due to lichen sclerosus. Block-like p16, a surrogate for high risk human papillomavirus infection, and varicella zoster virus were found only in lichen sclerosus urethral stricture disease samples, although both were rare. Epstein-Barr virus RNA was found in significantly more lichen sclerosus samples (37% vs 10%, p = 0.024).To our knowledge this is the first study to evaluate protein expression in lichen sclerosus urethral stricture disease. These strictures demonstrate increased inflammation compared to nonlichen sclerosus urethral strictures. Markers of oxidative stress, cell cycle dysregulation and the androgen receptor do not appear to be uniquely associated with lichen sclerosus urethral stricture disease. Positive staining for several viruses in samples of lichen sclerosus urethral stricture disease suggests a possible infectious etiology.

Author(s): Chung, Paul H; Vanni, Alex J; Breyer, Benjamin N; Erickson, Bradley A; Myers, Jeremy B; Alsikafi, Nejd; Buckley, Jill; Elliott, Sean P; Zhao, Lee C; Voelzke, Bryan B; Trauma and Urologic Reconstructive Network of Surgeons (TURNS) | Abstract: ObjectiveTo compare the utility of generic health quality of life (QOL) and condition specific indicators as patient reported outcomes measures for urethral stricture surgery.Materials and methodsPatient data were obtained from the Trauma and Urologic Reconstructive Network of Surgeons collaborative database. Patients who underwent any successful urethroplasty and completed both pre- and postoperative generic and condition-specific questionnaires were included.ResultsA total of 201 patients met inclusion criteria. Urethral-stricture specific measures improved after surgery: mean LUTS score (13.1-4.0, pl0.05), Peeling curve (3.1-1.7, p l 0.05), and overall interference of urinary symptoms on life (3.0-1.6, p l 0.05). Mean overall health status visual analog scale (74.2-80.0, p l 0.05) and generic health QOL EQ-5D index scores (0.90-0.95, p l 0.05) also improved; however, individual EQ-5D measures assessing mobility, self-care, and activity level did not change. EQ-5D measures for pain/discomfort (1.48-1.23, p l 0.05) and anxiety/depression (1.33-1.21, p l 0.05) improved, but not to the same extent as stricture-specific measures. More patients reported improvement in condition-specific urethra/penis pain and bladder pain compared to improvement in generic EQ-5D pain/discomfort (p l 0.001).ConclusionGeneric health QOL indicators are less meaningful in the assessment of urethral stricture surgery and should be replaced with condition-specific outcomes measures. It is important to ensure that appropriate condition-specific outcomes measures are utilized as patient reported outcomes measures become more prevalent in medicine and potentially become utilized to evaluate surgeon outcomes and determine surgeon reimbursement.

Background: Robotic pelvic surgery is being increasingly utilized for reconstruction proximal to the genitourinary diaphragm. We describe a combined robotic, transabdominal, and open transperineal approach for complex anastomotic posterior urethroplasty. Materials and Methods: We performed a multi-institutional retrospective study of patients who underwent anastomotic posterior urethroplasty by a combined robotic, transabdominal, and open transperineal approach between January 2012 and December 2018. Patient demographics; preoperative, intraoperative, and postoperative clinical data; and complications were reviewed. Urethroplasty success, de novo stress urinary incontinence (SUI), and de novo erectile dysfunction (ED) were evaluated. Results: Twelve patients were identified with a mean follow-up of 596 (range 73-1618) days. Mean patient age was 65.9 (range 53.4-76.8). Reconstruction required corporal splitting, prostatectomy, and gracilis muscle flap use in one (8.3%), eight (66.7%), and four (33.3%) patients, respectively. Postoperative urinary leak, thromboembolic event, and wound abscess occurred in one (8.3%), one (8.3%), and two (16.7%) patients, respectively. Stenosis recurrence occurred in two patients (16.7%) at a mean 187.5 (20-355) postoperative days. De novo ED and de novo SUI were reported in two (16.7%) and four (33.3%) patients, respectively. Nine patients (75.0%) underwent placement of an artificial urinary sphincter at a mean interval of 359.2 (111-1456) days after the index procedure, with no subsequent erosion. Conclusions: Complex posterior urethroplasty by a combined robotic, transabdominal and open transperineal approach is associated with success and complications rates that are comparable to open techniques and may allow for adjunctive procedures such as prostatectomy. This technique allows for the reconstruction of posterior urethral stenoses that would otherwise have been managed conservatively or with urinary diversion.

Primary urethral cancer (PUC) is a rare but highly aggressive malignancy that causes malignant urethral obstruction. We conducted a literature review using PubMed to identify original research studies that assessed the diagnosis and management of primary urethral cancer. PUC affects men more than women, is more common in African Americans than Caucasians, and is associated with history of chronic inflammation and irritation of the urinary tract. Patients suspected of PUC should undergo a complete work-up including cystoscopy, magnetic resonance imaging, and biopsy. In men and women, surgical monotherapy ranging from organ-sparing to more radical reconstructive procedures has adequate survival rates for early stage PUC and has been shown to be similarly as effective as radiation monotherapy, while multimodal therapy has become the standard of treatment for advanced stage PUC. Salvage surgery or radiation therapy has been linked with increased survival rates. Nodal involvement at the time of diagnosis is a negative prognosticator and should be treated with multimodal therapy. Further prospective studies with greater sample sizes and standardized clinical trials would allow for greater consistency in evaluating the different treatment modalities for PUC.

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 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 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.

To evaluate the outcomes of excision and primary anastomosis (EPA) for radiation-associated bulbomembranous stenoses using a multi-institutional analysis. The treatment of radiation-associated urethral stenosis is typically complex owing to the adverse impact of radiation on adjacent tissue.An IRB-approved multi-institutional retrospective review was performed on patients who underwent EPA for bulbomembranous urethral stenosis following prostate radiotherapy. Preoperative patient demographics, operative technique, and postoperative outcomes were abstracted from 1/2007-6/2018. Success was defined as voiding per urethra without the need for endoscopic treatment and a minimum follow-up of 12 months.One hundred and thirty-seven patients from 10 centers met study criteria with a mean age of 69.3 years (50-86), stenosis length of 2.3 cm (1-5) and an 86.9% (119/137) success rate at a mean follow-up 32.3 months (12-118). Univariate Cox regression analysis identified increasing patient age (P = .02), stricture length (P.0001) and combined modality radiotherapy (P = .004) as factors associated with stricture recurrence while body mass index (P = .79), diabetes (P = .93), smoking (P = .62), failed endoscopic treatment (P = .08) and gracilis muscle use (P = .25) were not. On multivariate analysis, increasing patient age (H.R.1.09, 95%CI 1.01-1.16; P = .02) and stenosis length (H.R.2.62, 95%CI 1.49-4.60; P = .001) remained associated with recurrence. Subsequent artificial urinary sphincter was performed in 30 men (21.9%), of which 25 required a transcorporal cuff and 5 developed cuff erosion.EPA for radiation-associated urethral stenosis effectively provides unobstructed instrumentation-free voiding. However, increasing stenosis length and age are independently associated with surgical failure. Patients should be counseled that further surgery for incontinence may be necessary.

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.

Background To determine if the number of endoscopic treatments of urethral stricture disease (USD) prior to urethroplasty has changed in the context of new AUA guidelines on management of USD. In addition to an increase in practicing reconstructive urologists and published reconstructive literature, the AUA guidelines regarding the management of male USD were presented in May 2016, advocating consideration of urethroplasty in patients with 1 prior failed endoscopic treatment. Methods A retrospective review of a prospectively maintained, multi-institutional urethral stricture database of high volume, geographically diverse institutions was performed from 2006 to 2017. We performed a review of relevant literature and evaluated pre-urethroplasty endoscopic treatment patterns prior to and after the AUA male stricture guideline. Results 2964 urethroplasties were reviewed in 10 institutions. There was both a decrease in the number of endoscopic treatments prior to urethroplasty in the pre-May 2016 compared to post-May 2016 cohorts both for overall urethroplasties (2.3 vs 1.6, P = 0.0012) and a gradual decrease in the number of pre-urethroplasty endoscopic treatments over the entire study period. Conclusion There was a decrease in the number of endoscopic treatments of USD prior to urethroplasty in the observed period of interest. Declining endoscopic USD management is not likely to be a reflection of a solely unique influence of the guidelines as endoscopic treatment decreased over the entire study period. Further research is needed to determine if there will be a continued trend in the declining use of endoscopic treatment and elucidate the barriers to earlier urethroplasty in patients with USD.

INTRODUCTION AND OBJECTIVE:The Urethral Stricture Symptom and Impact Measure (USSIM) is a condition-specific outcome measure for men with urethral stricture. Concept elicitation, cognitive, and pri...

INTRODUCTION AND OBJECTIVE:Oral mucosa graft urethroplasty was first described by the Ukrainian surgeon Kirill Sapezhko in 1894. His protege, I.A. Thyrmos, pioneered substitution urethroplasty with...

INTRODUCTION AND OBJECTIVE:Treatment considerations are unique for urethral stricture disease (USD) in patients requiring long-term clean intermittent catheterization (CIC). Patient characteristics...

INTRODUCTION AND OBJECTIVE:Post-void dribbling (PVD) and ejaculatory dysfunction (EjD) are common after urethroplasty (UP). Although the etiology remains unknown, they are thought to share a simila...

Background There exists significant controversy regarding the use of suprapubic tubes (SPT) in pelvic fracture urethral injury (PFUI) patients undergoing internal fixation (IF) as to the potential risk of infection. Using the National Trauma Data Bank, we sought to examine if placement of SPT in patients with traumatic urethral injuries undergoing IF of pelvic fractures increases the risks of infectious complications during the index hospitalization. Patients and methods Using International Classification of Disease, version 9 and Abbreviated Injury Scale codes, patients with PFUI were identified in the National Trauma Data Bank between 2002 and 2014. International Classification of Disease, version 9 codes were used to identify patients who underwent IF of pelvic fractures, as well as those who underwent SPT placement. Covariates analyzed included age, Injury Severity Score (ISS), diabetes, hypertension, coronary artery disease, obesity, smoking status, associated colorectal injuries, and pelvic angioembolization. Demographics, management and infectious complications were compared between IF patients who did or did not undergo SPT placement using χ and t tests. Poisson regression analysis was performed to identify independent predictors of infectious complications. Results Six hundred ninety-six PFUI patients were identified. Two hundred four (29.3%) patients underwent IF during the index hospitalization, of which 35 underwent concomitant SPT placement during that same admission. There was no difference in likelihood of undergoing IF in patients with or without SPT (p = 0.36). Multivariate analysis revealed that only ISS (Relative risk [RR], 4.00; 95% confidence interval, 1.25-12.77) and smoking status (RR, 2.45; 95% confidence interval, 1.11-5.43) were significant predictors of infectious complications, while SPT placement was not. Conclusion Among patients with PFUI undergoing IF, SPT placement does not appear to increase the risk for acute infectious complications during the index hospitalization, while higher ISS and smoking are significantly associated. Further longitudinal studies are required to provide definitive recommendations regarding the long-term safety of SPT placement in this patient population. Level of evidence Prognostic, level IV.

Objective To develop and validate a clinical classification system for urethral stricture disease (USD) based on the retrograde urethrogram (RUG), physical exam, and stricture-specific patient history. Materials and methods Three elements were chosen to be included in the classification system: 1) Length of urethral stricture (L); 2) Stricture segment/location (S); 3) Stricture Etiology (E) (LSE classification system). Each element was divided into clinically relevant sub-categories. A three-step development and validation process then ensued, culminating in an in-person Trauma and Urologic Reconstruction Network of Surgeons (TURNS) meeting, at which the final classification system was unanimously agreed upon by attendees based on interrater reliability data obtained from the classifying of 22 clinical vignettes. A final validation step involved retrospectively classifying cases in the TURNS database to determine if classification influenced surgical technique and was associated with presumed stricture etiology. Results The final LSE classification system was found to have an interrater reliability of 0.79 (individual components 0.76, 0.70 and 0.93 respectfully). Retrospective classification of the 2162 TURNS strictures revealed the segment (S) to be strongly associated with urethroplasty type (p = 0.0005) and stricture etiology (E) (p = 0.0005). Conclusion We developed and validated a novel, easy to use, urethral stricture classification system. The system's ability to aid in directing treatments, predict treatment outcomes, and facilitate collaborative research efforts will require further study.

Objective To determine if age is an independent predictor of surgical success in patients undergoing urethroplasty. Urethroplasty performed by excision and primary anastomosis depends on vascular collateralization. Successful augmented urethroplasty depends on graft neovascularization. Older patients have more comorbid conditions including peripheral vascular disease associated with reduced penile blood flow. Methods This is a retrospective review of urethroplasties from 11 institutions. Primary outcome was functional success at 1 year from surgery, defined as freedom from post-urethroplasty procedures. Secondary outcome was freedom from cystoscopic evidence of stricture recurrence at 3 months. Study outcomes were compared between 2 age cohorts ( Results Of 322 urethroplasties, 258 were performed in patients Conclusion Urethroplasty success may be affected by comorbidities but not age. Age alone should not be used as an absolute exclusion criterion for men needing urethral reconstruction.

We evaluated the short and long-term surgical outcomes of urinary diversion done for urinary adverse events arising from prostate radiation therapy. We hypothesized that patient characteristics are associated with complications after urinary diversion.We performed a retrospective cohort study of 100 men who underwent urinary diversion (urinary conduit or continent catheterizable pouch) due to urinary adverse events after prostate radiotherapy from 2007 to 2016 from 9 academic centers in the United States. Outcome measurements included predictors of short and long-term complications, and readmission after urinary diversion of patients who had prostate cancer treated with radiotherapy. The data were summarized using descriptive statistics and univariate associations with complications were identified with logistic regression controlling for center.Mean patient age was 71 years and median time from radiotherapy to urinary diversion was 8 years. Overall 81 (81%) patients had combined modality therapy (radical prostatectomy plus radiotherapy or various combinations of radiotherapy). Grade 3a or greater Clavien-Dindo complications occurred in 31 (35%) men, including 4 deaths (4.5%). Normal weight men had more short-term complications compared to overweight (OR 4.9, 95% CI 1.3-23.1, p=0.02) and obese men (OR 6.3, 95% CI 1.6-31.1, p=0.009). Hospital readmission within 6 weeks of surgery occurred for 35 (38%) men. Surgery was needed to treat long-term complications after urinary diversion in 19 (22%) patients with a median followup of 16.3 months.Urinary diversion after prostate radiotherapy has a considerable short and long-term surgical complication rate. Urinary diversion most often cannot be avoided in these patients but appreciation of the risks allows for informed shared decision making between surgeons and patients.

The current management for complex urethral strictures commonly uses open reconstruction with buccal mucosa urethroplasty. However, there are multiple situations whereby buccal mucosa is inadequate (eg, pan-urethral stricture or prior buccal harvest) or inappropriate for utilization (eg, heavy tobacco use or oral radiation). Multiple options exist for use as alternatives or adjuncts to buccal mucosa in complex urethral strictures. This article reviews the current state of alternate techniques for urethral stricture treatment besides buccal mucosa, including injectable antifibrotic agents, augmentation urethroplasty with skin flaps, lingual mucosa, colonic mucosa, and new developments in tissue engineering for urethral graft material.

INTRODUCTION AND OBJECTIVE:Measurement of objective measures following urethroplasty (e.g., urethral patency, uroflowmetry) is vital, but patient-reported input via condition-specific outcome measu...

INTRODUCTION AND OBJECTIVE:The purpose of the study was to develop and then validate a retrograde urethrogram (RUG), patient history, and physical exam-based classification system for urethral stri...

INTRODUCTION AND OBJECTIVE:A urethral stricture classification system based on stricture length (L), segment (S) and etiology (E) has been previously validated to have sufficient inter-rater reliab...

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.

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.

Urethroplasty of lichen sclerosus strictures has a significantly higher failure rate than strictures due to other causes. We sought to determine predictors of urethroplasty failure in men with lichen sclerosus urethral stricture disease by evaluating protein expression profiles.Urethral tissue was excised from patients with lichen sclerosus who were undergoing urethroplasty of urethral stricture disease at a single institution. A tissue microarray was created with cores from each sample. Immunohistochemistry was performed to compare protein expression related to inflammation, cell cycle disruption, oxidative stress, hormone receptor status and infection. Stricture recurrence was defined by the need for a subsequent unanticipated procedure for urethral stricture disease.We evaluated 50 men with lichen sclerosus urethral stricture disease, including 31 with successful reconstruction and 19 with recurrent stricture. Recurrent strictures expressed lower levels of several inflammatory markers and had a lower Ki-67 mitotic index and significantly higher vascular endothelial growth factor levels than nonrecurrent strictures.To our knowledge this is the first study to use tissue protein expression to identify risk factors for urethroplasty failure among men with lichen sclerosus urethral stricture disease. Our findings suggest that recurrent lichen sclerosus strictures demonstrate a suppressed inflammatory response, a decreased cell turnover rate, and poor oxygenation and nutrient delivery. Prospective studies are needed to clarify the role of these pathways in the pathophysiology of lichen sclerosus urethral stricture disease, determine whether preoperative biopsy can predict urethroplasty success, help counsel patients and develop future treatments.

Background: Female urethral stricture disease is under-recognized and is often treated with dilation despite poor definitive outcomes. Our objective was to describe a multi-institutional experience treating female urethral stricture disease with female dorsal onlay buccal mucosa graft (FD-BMG) urethroplasty outcomes. Methods: We retrospectively identified 39 consecutive FD-BMG urethroplasty operations performed by 6 reconstructive surgeons from 12/2007 to 1/2016. Surgical technique included dorsally-placed buccal mucosal grafts in all cases. Stricture recurrence was defined by cystoscopy. Results: Mean age was 50 (range, 29–81) years. Stricture etiology was unknown (49%), iatrogenic (36%), or trauma/straddle injury (15%). A majority of women (87%) women had undergone a prior stricture-related urethral procedure(s) before the surgeons’ index urethroplasty. Mean stricture length was 2.1 cm and mean caliber was 11 Fr. Mean postoperative follow-up was 33 (range, 7–106) months. Postoperative complications within 30 days were seen in 7 individuals (18%) and were all Clavien-Dindo grade II. Stricture recurrence was seen in 9 (23%) patients, with mean time to recurrence 14 months. No patients experienced de novo incontinence. Conclusions: FD-BMG urethroplasty is a safe and effective management option for female urethral strictures. Referral to a reconstructive center is encouraged to avoid repeated unnecessary endoscopic procedures that have poor definitive success.

PurposePerineal 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 methodsWe 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.ResultsOf 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.ConclusionsPatients 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.

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