Low Yield of Early Postoperative Imaging After Anastomotic Urethroplasty

Urethral Outcomes of the Labia Minora Ring Flap for Metoidioplasty and Phalloplasty

OBJECTIVE

To determine urethral outcomes of single-stage metoidioplasty and radial forearm free flap (RFFF) phalloplasty using the labia minora ring flap for urethral lengthening (UL).

METHODS

A retrospective review was performed of patients undergoing single-stage metoidioplasty and RFFF phalloplasty utilizing the labia minora ring flap technique. The ring flap consists of endodermal labia minora tissue ventral to the clitoris and surrounding the vaginal introitus. During metoidioplasty, the ring flap accounts for the entirety of UL. During RFFF phalloplasty, the ring flap becomes the pars fixa (PF) urethra. The primary outcomes measured were rates of fistula, stricture, and surgical revision.

RESULTS

Between November 2017 and August 2023, 311 patients underwent metoidioplasty or RFFF phalloplasty (mean follow-up 37 months). Of the 69 metoidioplasties, urethrocutaneous fistulas developed in 11 patients (16%); strictures occurred in 4 (6%). Of the 242 phalloplasty patients, there were 71 fistulas (29%), 56 of which resolved spontaneously. Strictures developed in 44 patients (18%). Twenty-five patients (10%) developed both a stricture and fistula. Surgical repair was required in 8/69 (12%) metoidioplasty patients and in 46/242 (19%) RFFF phalloplasty patients for an overall revision rate of 17%.

CONCLUSION

UL during metoidioplasty or RFFF phalloplasty can be accomplished in a single stage using the labia minora ring flap with comparable surgical revision rates to previously described techniques. This approach can also be applied to other phalloplasty techniques. Many fistulas of the PF urethra resolve spontaneously. Higher urethral revision rates were seen in phalloplasty compared to metoidioplasty.

Routine Imaging After Bulbar Urethral Reconstruction Does Not Impact Surgical Outcomes and May Not Be Necessary

OBJECTIVE

To assess whether omitting routine post-operative imaging adversely impacts clinical outcomes after bulbar urethroplasty. Contrast imaging is commonly performed prior to catheter removal after urethroplasty but the clinical need for this is unclear.

METHODS

This was a matched, case-control analysis comparing patients undergoing routine voiding cystourethrogram (VCUG) prior to catheter removal after bulbar urethroplasty to patients without imaging. Patients were matched with respect to age, stricture etiology, length, and urethroplasty technique. Follow-up consisted of clinical assessment 3 weeks post-operatively for VCUG/catheter removal, cystoscopy at 3-4 months with clinical assessment annually. Outcome measures were 90-day complications (Clavien ≥2) and stricture recurrence (failure to pass a 16-Fr flexible cystoscope on follow-up). Chi-square and Kaplan-Meier analysis were conducted where appropriate.

RESULTS

Hundred patients undergoing bulbar urethroplasty with VCUG prior to catheter removal were compared to 100 matched case controls without imaging. Groups did not differ with respect to failed endoscopic treatment (P = .82), prior urethroplasty (P = .09), comorbidities (P = .54), smoking (P = .42), or pre-operative bacteriuria (P = 1.00). The incidence of extravasation in the VCUG group was 2%. Overall 90-day complications were 9.5% and 15 patients developed recurrence with a median follow-up of 174 months. On chi-square analysis, 90-day complications did not differ between patients undergoing VCUG and those without (12% vs 7.0%; P = .34). On log-rank analysis, stricture recurrence did not differ between groups (P = .44).

CONCLUSION

Routine imaging with VCUG after bulbar urethroplasty does not influence the risk of post-operative complications or stricture recurrence. Surgeons should consider avoiding this potentially unnecessary examination in routine clinical practice.

Anastomotic Urethroplasty with Double Layer Continuous Running Suture Re-Anastomosis Versus Interrupted Suture Re-Anastomosis for Infective Bulbar Urethral Strictures: A Prospective Randomised Trial

Introduction: The objective of this study was to compare a double-layer running suture re-anastomosis urethral stricture repair with early catheter removal to the conventional interrupted suture re-anastomosis after excision of a bulbar urethral stricture. Methods: A consecutive series of patients with bulbar urethral stricture were enrolled in the study. The patients were randomized into two groups according to an odd/even serial number distribution. Patients’ medical records were analyzed for demographics, stricture characteristics, and lower urinary tract obstructive symptoms. The outcomes were based on the presence/absence of obstructive voiding symptoms, and retrograde urethrography (RGU) performed on the first post-operative day in Group 1 and in both groups (Groups 1 and 2) at six weeks after surgery. Flexible urethroscopy was only performed on specific cases where RGU was unclear both pre- and post-operatively or when clinical recurrence was suspected. The minimum follow-up (FU) was 18 months. Success was defined as no need for subsequent dilatation, direct vision internal urethrotomy (DVIU), or urethroplasty. Results: A total of thirty-six patients with a mean age of 45 years (range 20 to 69 years) with bulbar urethral stricture were included in this study. Group 1 and Group 2 included 19 and 17 patients, respectively. Two patients were lost during randomization and subsequently to FU. The average stricture lengths were comparable between the two groups according to the retrograde urethrogram: 1.20 cm (range 0.6 to 2) in Group 1 and 1.27 cm (range 0.5 to 2.4) in Group 2, respectively (p = 0.631). The success rate for Group 1 was 90% after a mean follow-up of thirty-six months (range 20 to 40), which was clinically significant compared to the 71% in Group 2 after a mean FU of thirty-three months (range 19 to 40; p = 0.0218; 95% CI: 0.462–41.5766). Conclusions: Anastomotic urethroplasty (AR) performed with a double layer re-anastomosis had a cure rate comparable to the conventional anastomosis with interrupted sutures after a follow-up of eighteen months and longer. The urethral catheter can be safely removed within twenty-four hours after the excision of stricture and double-layer re-anastomosis.

Urethrogram: Does Postoperative Contrast Extravasation Portend Stricture Recurrence?

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 <17 Fr stricture documented at 12-month cystoscopy and need for a secondary procedure during 1 year of follow-up, respectively. Our primary outcomes were the sensitivity and positive predictive value of post-operative urethrogram for predicting anatomic and functional recurrence of urethral stricture disease.

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 <.001). Similarly, functional recurrence was 9.3% with extravasation vs 3.2 % without extravasation (P = .04). Patients with extravasation more often reported a postoperative urinary tract infection (12.9% vs 2.7%; P <.01) or wound infection (7.4% vs 2.6%; P = .04). Sensitivity of postoperative urethrogram in predicting any recurrence was 27.3%, specificity 98.7%, positive predictive value 77.8%, and negative predictive value 89.3%. Fourty-five of 54 patients with extravasation had a recurrence of some kind, equating to a 22.2% urethroplasty success rate at 1 year.

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.

A Comprehensive Review Emphasizing Anatomy, Etiology, Diagnosis, and Treatment of Male Urethral Stricture Disease

To date, urethral stricture disease in men, though relatively common, represents an often poorly managed condition. Therefore, this article is dedicated to encompassing the currently existing data upon anatomy, etiology, symptoms, diagnosis, and treatment of the disease, based on more than 40 years of experience at a tertiary referral center and a PubMed literature review enclosing publications until September 2018.

Pericatheter urethrogram after anastomotic urethroplasty: Is it a must?

Objective:

To share our initial experience of patient undergoing anastomotic Urethroplasty and trial without catheter, without post Urethroplasty pericatheter urethrogram.

Methods:

Prospectively maintained records of all patients undergoing standard transecting anastomotic Urethroplasty by single surgeon (one of the authors) at The Kidney Centre PGTI Karachi, Pakistan and Lifecare Hospital Abu Dhabi UAE from September 2006 to December 2017 were reviewed. In all except two cases, supra pubic catheter was removed at 2^nd weeks and per urethral catheter by 4 to 5 weeks following which patients were assessed for TWOC without pericatheter urethrogram. Patients were further advised to follow up with Uroflowmetry (UFM) at one week, one month, three and 12 months. In our series, Qmax less than 15 ml/s on UFM were considered to have recurrence and these patients were subjected to ascending urethrogram after six weeks of procedure.

Results:

There were 18 patients who underwent anastomotic Urethroplasty in bulbar urethra. The mean age of study patients was 37.2+11.2 years with p-value of 0.84. The recurrence rate of urethral stricture was 16.6 % (3/18 patient) with Qmax of 4.6 and 7.2ml/sec with mean follow-up period of 13.82+13.4 months (range 3-53 months) 02 patients developed infection. No patient developed incontinence or impotence.

Conclusion:

We found pericatheter urethrogram is not mandatory as a routine for all tension free anastomotic Urethroplasty before per urethral catheter removal. However, it may have a role in difficult cases with tension anastomoses or re-do procedure. This will avoid risk of infection, radiation exposure and extra cost.

A Critical Evaluation of the Utility of Imaging After Urethroplasty for Bulbar Urethral Stricture Disease

OBJECTIVE

To determine the incidence of extravasation on initial postoperative pericatheter retrograde urethrogram (pcRUG) after bulbar urethroplasty and the relationship to repair type.

MATERIALS AND METHODS

We performed a retrospective review to collect stricture-related and postoperative information with emphasis on pcRUGs. All men had a pcRUG at the initial follow-up appointment. The Foley catheter was removed if no extravasation was seen and left in place for an extra week, with a repeat pcRUG if extravasation was noted.

RESULTS

We limited our analysis to men who underwent bulbar urethroplasty from January 1996 to December 2012 (by two surgeons: GDW, ACP). We identified 437 patients and 407 (93%) had follow up data. The mean stricture length was 1.97 cm ± 1.2 cm. In those patients who underwent excision and primary anastomosis (EPA) (n = 232, 57%), we performed the1st pcRUG 1 week earlier compared to those who underwent augmented anastomotic repair (n = 150, 37%) or onlay repair (n = 25, 6%). There was no difference in extravasation rates among all repair types at first pcRUG. The overall rate of extravasation on the first postoperative pcRUG significantly decreased in all patients (0.98% vs 5%, P = .0008) and in those who underwent EPA (5.6% vs 0.4%, P = .0016) when the Foley catheter remained for an extra week.

CONCLUSION

Men who undergo bulbar urethroplasty have a low extravasation rate (2.2%) 3 weeks postoperatively and those who underwent EPA benefited from an additional week of catheterization.

Posterior Urethral Strictures

Pelvic fracture urethral injuries are typically partial and more often complete disruptions of the most proximal bulbar and distal membranous urethra. Emergency management includes suprapubic tube placement. Subsequent primary realignment to place a urethral catheter remains a controversial topic, but what is not controversial is that when there is the development of a stricture (which is usually obliterative with a distraction defect) after suprapubic tube placement or urethral catheter removal, the standard of care is delayed urethral reconstruction with excision and primary anastomosis. This paper reviews the management of patients who suffer pelvic fracture urethral injuries and the techniques of preoperative urethral imaging and subsequent posterior urethroplasty.

Is postoperative imaging mandatory after meningioma removal? Results of a prospective study

Background

Routine postoperative imaging (PI) following surgery for intracranial meningiomas is common practice in most neurosurgical departments. The purpose of this study was to determine the role of routine PI and its impact on clinical decision making after resection of meningioma.

Methods

Patient and tumor characteristics, details of radiographic scans, symptoms and alteration of treatment courses were prospectively collected for patients undergoing removal of a supratentorial meningioma of the convexity, falx, tentorium, or lateral sphenoid wing at the authors’ institution between January 1st, 2010 and March 31st, 2012. Patients with infratentorial manifestations or meningiomas of the skull base known to be surgically difficult (e.g. olfactory groove, petroclival, medial sphenoid wing) were not included. Maximum tumor diameter was divided into groups of < 3cm (small), 3 to 6 cm (medium), and > 6 cm (large).

Results

206 patients with meningiomas were operated between January 2010 and March 2012. Of these, 113 patients met the inclusion criteria and were analyzed in this study. 83 patients (73.5%) did not present new neurological deficits, whereas 30 patients (26.5%) became clinically symptomatic. Symptomatic patients had a change in treatment after PI in 21 cases (70%), while PI was without consequence in 9 patients (30%). PI did not result in a change of treatment in all asymptomatic patients (p<0.001) irrespective of tumor size (p<0.001) or localization (p<0.001).

Conclusions

PI is mandatory for clinically symptomatic patients but it is safe to waive it in clinically asymptomatic patients, even if the meningioma was large in size.

Tips for successful open surgical reconstruction of posterior urethral disruption injuries

This article provides an overview of the open surgical management of posterior urethral disruption injuries. The discussion includes the evaluation of the patient before surgery with a focus on urethral imaging and details of posterior urethroplasty surgical technique.

Cost-effectiveness of risk stratified followup after urethral reconstruction: a decision analysis

PURPOSE

We propose a novel risk stratified followup protocol for use after urethroplasty and explore potential cost savings.

MATERIALS AND METHODS

Decision analysis was performed comparing a symptom based, risk stratified protocol for patients undergoing excision and primary anastomosis urethroplasty vs a standard regimen of close followup for urethroplasty. Model assumptions included that excision and primary anastomosis has a 94% success rate, 11% of patients with successful urethroplasty had persistent lower urinary tract symptoms requiring cystoscopic evaluation, patients in whom treatment failed undergo urethrotomy and patients with recurrence on symptom based surveillance have a delayed diagnosis requiring suprapubic tube drainage. The Nationwide Inpatient Sample from 2010 was queried to identify the number of urethroplasties performed per year in the United States. Costs were obtained based on Medicare reimbursement rates.

RESULTS

The 5-year cost of a symptom based, risk stratified followup protocol is $430 per patient vs $2,827 per patient using standard close followup practice. An estimated 7,761 urethroplasties were performed in the United States in 2010. Assuming that 60% were excision and primary anastomosis, and with more than 5 years of followup, the risk stratified protocol was projected to yield an estimated savings of $11,165,130. Sensitivity analysis showed that the symptom based, risk stratified followup protocol was far more cost-effective than standard close followup in all settings. Less than 1% of patients would be expected to have an asymptomatic recurrence using the risk stratified followup protocol.

CONCLUSIONS

A risk stratified, symptom based approach to urethroplasty followup would produce a significant reduction in health care costs while decreasing unnecessary followup visits, invasive testing and radiation exposure.