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Gutierrez WR, Luo Y, Dahmoush L, Oleson JJ, Schlaepfer CH, Breyer BN, Elliott SP, Myers JB, Vanni AJ, Juhr D, Christel KN, Erickson BA. Deep Phenotyping the Anterior Urethral Stricture: Characterizing the Relationship Between Inflammation, Fibrosis, Patient History, and Disease Pathophysiology. J Urol 2024:101097JU0000000000003962. [PMID: 38593413 DOI: 10.1097/ju.0000000000003962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/28/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE Anterior urethral stricture disease (aUSD) is a complex, heterogeneous condition that is idiopathic in origin for most men. This gap in knowledge rarely affects the current management strategy for aUSD, as urethroplasty does not generally consider etiology. However, as we transition towards personalized, minimally invasive treatments for aUSD and begin to consider aUSD prevention strategies, disease pathophysiology will become increasingly important. The purpose of this study was to perform a deep phenotype of men undergoing anterior urethroplasty for aUSD. We hypothesized that unique biologic signatures and potential targets for intervention would emerge based on stricture presence/absence, stricture etiology, and the presence/absence of stricture inflammation. MATERIALS AND METHODS Men with aUSD undergoing urethroplasty were recruited from one of 5 participating centers. Enrollees provided urethral stricture tissue and blood/serum on the day of surgery and completed patient-reported outcome measure questionnaires both pre- and postoperatively. The initial study had 3 aims: (1) to determine pediatric and adult subacute and repeated perineal trauma (SRPT) exposures using a study-specific SRPT questionnaire, (2) to determine the degree of inflammation and fibrosis in aUSD and peri-aUSD (normal urethra) tissue, and (3) to determine levels of systemic inflammatory and fibrotic cytokines. Two controls groups provided serum (normal vasectomy patients) and urethral tissue (autopsy patients). Cohorts were based on the presence/absence of stricture, by presumed stricture etiology (idiopathic, traumatic/iatrogenic, lichen sclerosus [LS]), and by the presence/absence of stricture inflammation. RESULTS Of 138 enrolled men (120 tissue/serum; 18 stricture tissue only), 78 had idiopathic strictures, 33 had trauma-related strictures, and 27 had LS-related strictures. BMI, stricture length, and stricture location significantly differed between cohorts (P < .001 for each). The highest BMIs and the longest strictures were observed in the LS cohort. SRPT exposures did not significantly differ between etiology cohorts, with > 60% of each reporting low/mild risk. Stricture inflammation significantly differed between cohorts, with mild to severe inflammation present in 27% of trauma-related strictures, 54% of idiopathic strictures, and 48% of LS strictures (P = .036). Stricture fibrosis did not significantly differ between cohorts (P = .7). Three serum cytokines were significantly higher in patients with strictures compared to stricture-free controls: interleukin-9 (IL-9; P = .001), platelet-derived growth factor-BB (P = .004), and CCL5 (P = .01). No differences were observed in the levels of these cytokines based on stricture etiology. However, IL-9 levels were significantly higher in patients with inflamed strictures than in patients with strictures lacking inflammation (P = .019). Degree of stricture inflammation positively correlated with serum levels of IL-9 (Spearman's rho 0.224, P = .014). CONCLUSIONS The most common aUSD etiology is idiopathic. Though convention has implicated SRPT as causative for idiopathic strictures, here we found that patients with idiopathic strictures had low SRPT rates that were similar to rates in patients with a known stricture etiology. Stricture and stricture-adjacent inflammation in idiopathic stricture were similar to LS strictures, suggesting shared pathophysiologic mechanisms. IL-9, platelet-derived growth factor-BB, and CCL5, which were elevated in patients with strictures, have been implicated in fibrotic conditions elsewhere in the body. Further work will be required to determine if this shared biologic signature represents a potential mechanism for an aUSD predisposition.
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Affiliation(s)
- Wade R Gutierrez
- Department of Urology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Yi Luo
- Department of Urology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Laila Dahmoush
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Jacob J Oleson
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Charles H Schlaepfer
- Department of Urology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | | | | | - Jeremy B Myers
- Division of Urology, Department of Surgery, University of Utah
| | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Denise Juhr
- Department of Urology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Katherine N Christel
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Bradley A Erickson
- Department of Urology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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Li KD, Jones CP, Hakam N, Erickson BA, Vanni AJ, Chancellor MB, Breyer BN. Haemorrhagic cystitis: a review of management strategies and emerging treatments. BJU Int 2023; 132:631-637. [PMID: 37501638 DOI: 10.1111/bju.16140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Haemorrhagic cystitis (HC) is characterised by persistent haematuria and lower urinary tract symptoms following radiotherapy or chemotherapy. Its pathogenesis is poorly understood but thought to be related to acrolein toxicity following chemotherapy or fibrosis/vascular remodelling after radiotherapy. There is no standard of care for patients with HC, although existing strategies including fulguration, hyperbaric oxygen therapy, botulinum toxin A, and other intravesical therapies have demonstrated short-term efficacy in cohort studies. Novel agents including liposomal tacrolimus are promising targets for further research. This review summarises the incidence and pathogenesis of HC as well as current evidence supporting its different management strategies.
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Affiliation(s)
- Kevin D Li
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Charles P Jones
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Nizar Hakam
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | | | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Michael B Chancellor
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oaks, MI, USA
| | - Benjamin N Breyer
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
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Jamil ML, Hamsa A, Grove S, Cho EY, Alsikafi NF, Breyer BN, Broghammer JA, Buckley JC, Elliott SP, Erickson BA, Myers JB, Peterson AC, Rourke KF, Voelzke BB, Zhao LC, Vanni AJ. Outcomes of Urethroplasty for Synchronous Anterior Urethral Stricture Utilizing the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System. Urology 2023; 181:155-161. [PMID: 37673405 DOI: 10.1016/j.urology.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/20/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE To describe the characteristics, management, and functional outcomes of patients with synchronous urethral stricture disease (SUSD) utilizing a multi-institutional cohort. METHODS Data were collected and assessed from a prospectively maintained, multi-institutional database. Patients who underwent anterior urethroplasty for urethral stricture disease (USD) were included and stratified by the presence or absence of SUSD. USD location and etiology were classified according to the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System. Anterior urethroplasty techniques were recorded for both strictures. Functional failure was compared between groups. RESULTS One thousand nine hundred eighty-three patients were identified, of whom, 137/1983 (6.9%) had SUSD. The mean primary stricture length for patients with SUSD was 3.5 and 2.6 cm for the secondary stricture. Twelve anterior urethroplasty technique combinations were utilized in treating the 27 different combinations of SUSD. Functional failure was noted in 18/137 (13.1%) patients with SUSD vs 192/1846 (10.4%) patients with solitary USD, P = .3. SUSD was not associated with increased odds of functional failure. S classifications: S1b, P = .003, S2a, P = .001, S2b, P = .01 and S2c, P = .02 and E classifications: E3a, P = .004 and E6, P = .03, were associated with increased odds of functional failure. CONCLUSION Repair of SUSD in a single setting does not increase the risk of functional failure compared to patients with solitary USD. Increasing S classification, S1b through S2c and E classifications E3a and E6 were associated with increased functional failure. This reinforces the importance of the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System as a necessary tool in large-scale multi-institutional analysis when assessing highly heterogenous patient populations.
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Affiliation(s)
| | | | | | - Eric Y Cho
- University of California San Diego, San Diego, CA
| | | | | | | | | | | | | | | | | | - Keith F Rourke
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA.
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Schlaepfer CH, Flynn KJ, Vanni AJ, Breyer BN, Erickson BA. AUTHOR REPLY. Urology 2023; 180:256. [PMID: 37652798 DOI: 10.1016/j.urology.2023.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Schlaepfer CH, Flynn KJ, Alsikafi NF, Breyer BN, Broghammer JA, Buckley JC, Elliott SP, Myers JB, Vanni AJ, Voelzke BB, Zhao LC, Erickson BA. Clinical Validation of an Adult-acquired Buried Penis Classification System Based on Standardized Evaluation of the Penis, Abdomen, and Scrotum. Urology 2023; 180:249-256. [PMID: 37507025 DOI: 10.1016/j.urology.2023.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/09/2023] [Accepted: 04/25/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVE To clinically validate a previously developed adult-acquired buried penis (AABP) classification system that is based on a standardized preoperative physical examination that subtypes patients by their penile skin/escutcheon complex (P), abdominal pannus (A), and scrotal skin (S). METHODS The Trauma and Urologic Reconstruction Network of Surgeons (TURNS) database was used to create an AABP cohort. Patients were retrospectively classified using the previously described PAS classification system. The frequency of subtypes, surgical methods utilized for AABP repair, and correlations between PAS classification and surgery subtypes were analyzed. RESULTS The final cohort consisted of 101 patients from 10 institutions. Interrater reliability between two reviewers was excellent (κ = 0.95). The most common subtypes were P2c (contributory escutcheon+insufficient penile skin; 27%) and P2a (contributory escutcheon+sufficient penile skin; 21%) for penile subtypes, A0 (no pannus; 41%) and A1 (noncontributory pannus; 39%) for abdominal subtypes, and S0 (normal scrotal skin with preserved scrotal sulcus; 71%) for scrotal subtypes. AABP repair procedures included escutcheonectomy (n = 59, 55%), scrotoplasty (n = 51, 48%), split-thickness skin grafting (n = 50, 47%), penile skin excision (n = 47, 44%) and panniculectomy (n = 7, 7%). P, A, and S subtypes were strongly associated with specific AABP surgical techniques. CONCLUSION The PAS classification schema adequately describes AABP heterogeneity, is reproducible among observers, and correlates well with AABP surgery types. Future work will focus on how PAS subtypes affect both surgical and patient-centered outcomes.
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Jamil ML, Perecman A, Sherman A, Sullivan T, Christ K, Hansma A, Burks E, Vanni AJ. Urinary microbiome differences between lichen sclerosus induced and non-lichen sclerosus induced urethral stricture disease. World J Urol 2023; 41:2495-2501. [PMID: 37421420 DOI: 10.1007/s00345-023-04490-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/09/2023] [Indexed: 07/10/2023] Open
Abstract
OBJECTIVE To describe differences in the urinary microbiome of patients with pathologically confirmed lichen sclerosus (LS) urethral stricture disease (USD) vs non-lichen sclerosus (non-LS) USD pre- and post-operatively. METHODS Patients were pre-operatively identified and prospectively followed, all underwent surgical repair and had tissue samples obtained to make a pathological diagnosis of LS. Pre- and post-operative urine samples were collected. Bacterial genomic DNA was extracted. Alpha and beta diversity measurements were calculated and compared. A zero-inflated negative binomial model was utilized to compare taxa abundances between disease status and surgery status. RESULTS Urine samples were obtained from both cohorts, 69 samples in total: 36 samples were obtained pre-operatively and 33 samples were obtained post-operatively. Ten patients provided both a pre-operative and post-operative urine sample. Twenty-six patients had pathological evidence of LS and 33 patients did not. There was a statistically significant difference in alpha diversity between the pre-operative urine samples of patients with non-LS USD and LS USD, (p = 0.01). There was no significant difference in alpha diversity within post-operative urine samples between patients with non-LS USD and LS USD, (p = 0.1). A significant difference was observed in Weighed UniFrac distances with respect to disease and operative status, (p = 0.001 and 0.002). CONCLUSIONS LS USD have significant alterations in diversity and differential abundance of urine microbiota compared to non-LS USD controls. These findings could be used to guide further investigations into the role of the urinary microbiome in LS USD pathogenesis, severity of presentation, and stricture recurrence.
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Affiliation(s)
- Marcus L Jamil
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Aaron Perecman
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Amanda Sherman
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Travis Sullivan
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Kimberly Christ
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Alexandra Hansma
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
- Tufts University, Medford, MA, USA
| | - Eric Burks
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
- Tufts University, Medford, MA, USA
- Boston Medical Center, Boston, Massachusetts, USA
| | - Alex J Vanni
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA.
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Campbell JG, Hayden JP, Vanni AJ. Biomarkers in Urethral Stricture Disease and Benign Lower Urinary Tract Disease. Urol Clin North Am 2023; 50:31-38. [DOI: 10.1016/j.ucl.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
PURPOSE OF REVIEW To provide an overview of female urethral stricture disease and updates on surgical outcomes. RECENT FINDINGS In a large retrospective case series, women reported significant improvements in urinary symptoms and quality of life following treatment of their urethral stricture. Both vaginal flap and buccal mucosal graft urethroplasty have higher short- and long-term success rates than urethral dilation. Female urethral stricture disease is rare and surgical reconstruction has the highest likelihood of long-term success. Due to the complexity of reconstruction, referral to a reconstructive trained urologist should be considered.
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Affiliation(s)
- Jack Campbell
- Urology Institute, Lahey Hospital & Medical Center, Burlington, MA, USA.,Department of Urology, Medical Center, University of Kansas, Kansas City, KS, USA
| | - Alex J Vanni
- Urology Institute, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Casey G Kowalik
- Department of Urology, Medical Center, University of Kansas, Kansas City, KS, USA. .,Department of Urology, University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66201, USA.
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Kreshover JE, Vanni AJ, Sternberg KM, Bhojani N, Kobashi KC. Urological Education in United States Medical Schools: Where Are We Now and How Can We Do Better? Urol Pract 2022; 9:581-586. [PMID: 37145808 DOI: 10.1097/upj.0000000000000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/26/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION While urological complaints increase in aging populations and conditions commonly require management by multiple physician specialty types, exposure to formal urological education in United States medical schools is limited and has been decreasing over time. We aim to update the current status of urological education in the United States curriculum and delve further into the subject matter being taught and the type and timing of this education. METHODS An 11-question survey was developed to describe the current status of urological education. The survey was distributed using Survey Monkey to the American Urological Association's medical student listserv in November 2021. Descriptive statistics were used to summarize survey findings. RESULTS Of 879 invitations sent, 173 responded (20%). Most (112/173, 65%) of respondents were in their fourth year. Only 4 (2%) reported that their school had a required clinical urology rotation. Kidney stones (98%) and urinary tract infections (100%) were the most frequent topics taught. The least exposure included infertility (20%), urological emergencies (19%), bladder drainage (17%), and erectile dysfunction (13%). Videos and case vignettes were the preferred learning modalities and the majority (84%) of respondents were familiar with the American Urological Association's medical student curriculum material. CONCLUSIONS The majority of United States medical schools do not have a required clinical urology rotation and some core urological topics are not taught at all. Future incorporation of urological educational material through video and case vignette learning may be the best opportunity to provide exposure to clinical topics that will commonly be encountered regardless of chosen medical discipline.
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Affiliation(s)
| | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, Vermont
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Fendereski K, McCormick BJ, Keihani S, Hagedorn JC, Voelzke B, Selph JP, Figler BD, Johnsen NV, da Silva RD, Broghammer JA, Gupta S, Miller B, Burks FN, Eswara JR, Osterberg EC, Carney KJ, Erickson BA, Gretzer MB, Chung PH, Harris CR, Murphy GP, Rusilko P, Anderson KT, Shridharani A, Benson CR, Alwaal A, Blaschko SD, Breyer BN, McKibben M, IanSchwartz, Simhan J, Vanni AJ, Moses RA, Myers JB. The Outcomes of Pelvic Fracture Urethral Injuries Stratified by Urethral Injury Severity: A Prospective Multi-institutional Genitourinary Trauma Study (MiGUTS). Urology 2022; 170:197-202. [PMID: 36152870 DOI: 10.1016/j.urology.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVES To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury. METHODS Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs. minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score. RESULTS There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (p< 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (p<0.001). CONCLUSIONS In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jairam R Eswara
- St. Elizabeth's Medical Center, Boston University School of Medicine.
| | | | | | | | | | - Paul H Chung
- Sidney Kimmel Medical College of Thomas Jefferson University.
| | | | | | | | | | | | | | | | | | | | | | - IanSchwartz
- Division of Urology Hennepin County Medical Center, University of Minnesota.
| | | | | | | | - Jeremy B Myers
- University of Utah, Department of Surgery (Primary Investigator).
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Moses RA, Broghammer JA, Breyer BN, Voelzke BB, Buckley JC, Erickson BA, Elliot S, Vanni AJ, Ramkumar N, Myers JB. Patient Risk Factors and Their Association with Patient Reported Urinary Quality of Life following Artificial Urinary Sphincter Placement: A Paired Pre-and Post-operative Analysis. Urology 2022; 169:226-232. [PMID: 35905775 DOI: 10.1016/j.urology.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 07/09/2022] [Accepted: 07/13/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the associations between patient risk factors and incontinence related patient-reported outcome measures (PROMs) pre-and-post artificial urinary sphincter (AUS) implantation. We hypothesize patient risk factors, including prior radiation and diabetes will have a negative association with post AUS PROMs. METHODS A review of prospectively collected pre-and-post-operative Incontinence Symptom Index [ISI] and Incontinence Impact Questionnaire-7 (IIQ-7)s from multiple institutions in the Trauma and Urologic Reconstruction Network of Surgeons was performed. Changes in pre-and-post AUS ISI and IIQ-7 scores were compared for the entire cohort then stratified by patients with prior AUS, obesity, diabetes, prior radiation, and mixed urinary incontinence. RESULTS A total of 145 patients, 67.2 (SD 10.9) years had complete pre-and-post AUS questionnaires (median follow up 186 days, IQR 136-362). Post AUS ISI and IIQ-7 scores improved significantly for the group at large. Prior radiation was associated with less improvement in total IIQ-7 scores, -25.5 (31.9) vs. -39 (33.0), p=0.03. Obesity was associated with a greater reduction in incontinence severity -13.6 (SD 9.1) vs. -9.2 (SD 8.9), P<0.01, urge -5.2(SD 4.2) vs. -2.5(SD 4.5), p <0.01, and total ISI score -29.7(SD19.7) vs. -21.2 (SD 19.9), p=0.02. Prior AUS, diabetes, and mixed incontinence were not associated with post AUS PROMs outcome. CONCLUSION Overall, patients reported a significant reduction in incontinence severity, bother, impact, and distress post AUS placement. Prior radiation was associated with less improvement in total IIQ-7 scores. In contrast, obesity demonstrated a greater reduction in ISI severity and urge scores compared to non-obese patients.
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Affiliation(s)
- Rachel A Moses
- Section of Urology, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
| | | | - Benjamin N Breyer
- Department of Urology, University of California San Francisco, San Francisco, CA, USA.
| | | | - Jill C Buckley
- Department of Urology, University of California San Diego, San Diego, CA, USA.
| | - Brad A Erickson
- Department of Urology, University of Iowa, Iowa City, IA, USA.
| | - Sean Elliot
- Department of Urology, University of Minnesota, Minneapolis, MN, USA.
| | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, Burlington, MA, USA.
| | - Niveditta Ramkumar
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
| | - Jeremy B Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA.
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Farrell MR, Campbell JG, Zhang L, Nowicki S, Vanni AJ. Transurethral reconstruction of fossa navicularis strictures with dorsal inlay buccal mucosa graft urethroplasty. World J Urol 2022; 40:1523-1528. [PMID: 35384486 DOI: 10.1007/s00345-022-03994-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/04/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To describe a single stage, glans-sparing urethroplasty technique for fossa navicularis strictures using a transurethral dorsal inlay buccal mucosa graft. METHODS We conducted a retrospective review of a prospectively maintained urethral stricture database to identify all fossa navicularis strictures reconstructed with a single stage, transurethral dorsal inlay buccal mucosa graft urethroplasty (5/2015-6/2020). Primary outcomes were anatomic success, defined as the ability to pass a 17 Fr flexible cystoscope, and functional success, defined as the lack of obstructive voiding symptoms and no need for further procedures. Secondary outcomes were postoperative complications and patient satisfaction. RESULTS Sixteen patients were included. Mean age was 63.1 years (43.9-75.6) and mean stricture length was 1.7 cm (1.4-2.0). Stricture etiology included internal trauma (62.5%), idiopathic (25.0%), and lichen sclerosus (12.5%). Prior endoscopic procedures were done in 75% of patients. Over a median follow-up of 28.8 months (IQR 17.6-38.0), anatomic success was 15/16 (93.8%) and functional success was 16/16 (100%). The single anatomic recurrence was at 4.2 months postoperatively. No additional procedures were required. Urinary tract infection occurred in 25% (4/16). There were no instances of de novo erectile dysfunction, chordee, or wound infection. All patients would recommend urethroplasty to others and all patients were either very satisfied (83.3%) or satisfied (16.7%) with the procedure. Penile sensitivity was unchanged in 83.3%, increased in 8.3% and decreased in 8.3%. CONCLUSION Transurethral dorsal inlay buccal mucosa graft urethroplasty is a viable option for reconstruction of fossa navicularis strictures that avoids splitting the glans and results in excellent cosmesis.
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Affiliation(s)
- M Ryan Farrell
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Jack G Campbell
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Lawrence Zhang
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Samuel Nowicki
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Alex J Vanni
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA.
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Farrell MR, Tighiouart H, Vanni AJ. Hypoalbuminemia Is Associated with Increased 30-Day Complications following Rectourethral Fistula Repair: A National Surgical Quality Improvement Program Study. Urol Pract 2022; 9:158-165. [PMID: 37145691 DOI: 10.1097/upj.0000000000000286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION We sought to assess patient risk factors for 30-day postoperative complications among men undergoing surgical management of rectourethral fistula (RUF). METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for all male patients who underwent RUF repair (2006-2018). Hypoalbuminemia was defined as preoperative serum albumin <3.5 gm/dL. Postoperative 30-day complications included wound infection, organ space surgical site infection, urinary tract infection, sepsis, venous thromboembolism, pneumonia, cerebrovascular accident, myocardial infarction, return to operating room and mortality. The association between pre-selected patient covariates and postoperative complications was investigated using logistic regression analysis. RESULTS A total of 250 patients were identified. Concurrent procedures during RUF repair were bowel diversion in 43/250 patients (17.2%), bowel resection (34/250, 13.6%), cystectomy (20/250, 8.0%) and urethroplasty (37/250, 14.8%). Overall, median age was 66.0 years (IQR 59.0-72.0), body mass index 26.6 kg/m2 (IQR 23.7-29.5) and 247/250 patients (98.8%) were functionally independent. Comorbidities included hypertension (140/250, 56.0%), smoking (55/250, 22.0%), diabetes (17/250, 6.8%), chronic obstructive pulmonary disease (11/250, 4.4%) and congestive heart failure (1/250, 0.4%). Hypoalbuminemia (<3.5 gm/dL) was present in 25/126 patients (19.8%). Overall, 51/250 patients (20.4%) experienced a complication within 30 days of surgery including wound infection (14/250, 5.6%), sepsis (13/250, 5.2%), organ space infection (11/250, 4.4%), urinary tract infection (8/250, 3.2%), venous thromboembolism (8/250, 3.2%) and mortality (5/250, 2.0%). After adjusting for covariates, hypoalbuminemia was associated with increased odds of a 30-day complication (OR 2.49, 95% CI 1.06-5.86, p=0.036). CONCLUSIONS Hypoalbuminemia was associated with increased odds of short-term complications after surgical management of RUF.
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Affiliation(s)
- M Ryan Farrell
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, and Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Alex J Vanni
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Farrell MR, Zhang LT, Vanni AJ. Urethral duplication in an adult male: anatomic variants and operative approach to reconstruction. Can J Urol 2022; 29:11027-11031. [PMID: 35150227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Duplicated anterior urethras are a rare congenital anomaly that is exceedingly uncommon among adult patients, as surgical correction is often completed during childhood. We present the case of a 33-year-old man with uncorrected duplicated anterior urethras and urinary retention due to severe urethral stricture disease involving both of his uncorrected duplicated anterior urethras. This report highlights an operative management strategy for reconstruction to create a single, unobstructed urethra that terminates in an orthotopic meatus. Further, we provide an overview of the anatomic variants of urethral duplication.
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Affiliation(s)
- M Ryan Farrell
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Lawrence T Zhang
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Alex J Vanni
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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Kohli H, Childs B, Sullivan TB, Shevtsov A, Burks E, Kalantzakos T, Rieger-Christ K, Vanni AJ. Differential expression of miRNAs involved in biological processes responsible for inflammation and immune response in lichen sclerosus urethral stricture disease. PLoS One 2021; 16:e0261505. [PMID: 34910765 PMCID: PMC8673646 DOI: 10.1371/journal.pone.0261505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/05/2021] [Indexed: 11/27/2022] Open
Abstract
Purpose To better understand the pathophysiology of lichen sclerosus (LS) urethral stricture disease (USD), we aimed to investigate expression profiles of microRNAs (miRNAs) in tissue samples from men undergoing urethroplasty. Methods Urethral stricture tissue was collected from 2005–2020. Histologic features diagnostic of LS were the basis of pathologic evaluation. Foci of areas diagnostic for LS or non-LS strictures were chosen for RNA evaluation. In an initial screening analysis, 13 LS urethral strictures and 13 non-LS strictures were profiled via miRNA RT-qPCR arrays for 752 unique miRNA. A validation analysis of 23 additional samples (9 LS and 14 non-LS) was performed for 15 miRNAs. Statistical analyses were performed using SPSS v25. Gene Ontology (GO) analysis was performed using DIANA-mirPath v. 3.0. Results In the screening analysis 143 miRNAs were detected for all samples. 27 were differentially expressed between the groups (false discovery p-value <0.01). 15 of these miRNAs individually demonstrated an area under the curve (AUC)>0.90 for distinguishing between between LS and non-LS strictures. 11-fold upregulation of MiR-155-5p specifically was found in LS vs. non-LS strictures (p<0.001, AUC = 1.0). In the validation analysis, 13 of the 15 miRNAs tested were confirmed to have differential expression (false discovery p-value <0.10). Conclusions To our knowledge this is the first study evaluating miRNA expression profiles in LS and non-LS USD. We identified several miRNAs that are differentially expressed in USD caused by LS vs other etiologies, which could potentially serve as biomarkers of LS USD. The top eight differentially expressed miRNAs have been linked to immune response processes as well as involvement in wound healing, primarily angiogenesis and fibrosis.
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Affiliation(s)
- Harjivan Kohli
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
| | - Brandon Childs
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
| | - Travis B. Sullivan
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
| | - Artem Shevtsov
- Department of Pathology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Eric Burks
- Department of Pathology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Thomas Kalantzakos
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
| | - Kimberly Rieger-Christ
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
| | - Alex J. Vanni
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
- * E-mail:
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Ryan Farrell M, Nowicki S, Vanni AJ. V10-06 TRANSURETHRAL RECONSTRUCTION OF FOSSA NAVICULARIS STRICTURES WITH DORSAL INLAY BUCCAL MUCOSA GRAFT URETHROPLASTY. J Urol 2021. [DOI: 10.1097/ju.0000000000002061.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Vanni AJ. In Remembrance of Leonard N. Zinman, MD, FACS, FRCS (Hon). Urology 2021. [PMID: 34284009 DOI: 10.1016/j.urology.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Alex J Vanni
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, Institute of Urology, Burlington, MA.
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Farrell MR, Xu JT, Vanni AJ. Current Perspectives on the Diagnosis and Management of Primary Urethral Cancer: A Systematic Review. Res Rep Urol 2021; 13:325-334. [PMID: 34104638 PMCID: PMC8180270 DOI: 10.2147/rru.s264720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 04/28/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- M Ryan Farrell
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Jonathan T Xu
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Alex J Vanni
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
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Kim S, Cheng KC, Patell S, Alsikafi NF, Breyer BN, Broghammer JA, Elliott SP, Erickson BA, Myers JB, Smith TG, Vanni AJ, Voelzke BB, Zhao LC, Buckley JC. AUTHOR REPLY. Urology 2021; 152:147. [PMID: 34112339 DOI: 10.1016/j.urology.2020.10.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/06/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Sunchin Kim
- University of California San Diego, San Diego, CA
| | | | | | | | | | | | | | | | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA
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20
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Cavallo JA, Vanni AJ, Dy GW, Stair S, Shakir NA, Canes D, Zhao LC. Clinical Outcomes of a Combined Robotic, Transabdominal, and Open Transperineal Approach for Anastomotic Posterior Urethroplasty. J Endourol 2021; 35:1372-1377. [PMID: 33820448 DOI: 10.1089/end.2020.0973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Jaime A Cavallo
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut, USA.,Veterans Affairs Connecticut Healthcare System, West Haven and Newington, Connecticut, USA
| | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Geolani W Dy
- Department of Urology, Oregon Health & Science University, Portland, Oregon, USA
| | - Sabrina Stair
- Department of Urology, New York University Langone Health, New York, New York, USA
| | - Nabeel A Shakir
- Department of Urology, New York University Langone Health, New York, New York, USA
| | - David Canes
- Department of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York, New York, USA
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Cohen AJ, Cheng PJ, Song S, Patino G, Myers JB, Roy SS, Elliott SP, Pariser J, Drobish J, Erickson BA, Fuller TW, Buckley JC, Vanni AJ, Baradaran N, Breyer BN. Multicenter urethroplasty outcomes for urethral stricture disease for patients with neurogenic bladder or bladder dysfunction requiring clean intermittent catheterization. Transl Androl Urol 2021; 10:2035-2042. [PMID: 34159084 PMCID: PMC8185657 DOI: 10.21037/tau-20-988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
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.
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Affiliation(s)
- Andrew J Cohen
- James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Philip J Cheng
- Department of Urology, University of Utah, Salt Lake City, UT, USA
| | - Sikai Song
- Department of Urology, Zuckerberg San Francisco General Hospital, University of California-San Francisco, San Francisco, CA, USA
| | - German Patino
- Department of Urology, Zuckerberg San Francisco General Hospital, University of California-San Francisco, San Francisco, CA, USA.,Hospital San Ignacio, Bogota, Colombia
| | - Jeremy B Myers
- Department of Urology, University of Utah, Salt Lake City, UT, USA
| | - Samit S Roy
- University of Minnesota, Minneapolis, MN, USA
| | | | | | | | | | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA, USA
| | | | - Benjamin N Breyer
- Department of Urology, Zuckerberg San Francisco General Hospital, University of California-San Francisco, San Francisco, CA, USA
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22
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Mazzone A, Anderson R, Voelzke BB, Vanni AJ, Elliott SP, Breyer BN, Erickson BA, Buckley J, Myers J. Sexual function following pelvic fracture urethral injury and posterior urethroplasty. Transl Androl Urol 2021; 10:2043-2050. [PMID: 34159085 PMCID: PMC8185675 DOI: 10.21037/tau-20-1287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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 <12). The median follow-up was 5.6 months and the mean post-operative SHIM was 9.3 (SD 6.5), with 68% having severe ED. The mean change in SHIM score was −1.18 (SD 6.29) with 6 (16%) patients reporting de novo ED (≥5 point decrease in score). Of the men with pre-operative MSHQ data, 46/74 (62.1%) had difficulty with ejaculation, 25/35 (71%) had change in penile length, and 6/33 (18%) reported penile curvature. In men with post-operative MSHQ, 19/44 (43%) expressed difficulty with ejaculation, 23/32 (72%) had change in penile length, and 9/33 (27%) reported penile curvature. Conclusions There is a high rate of severe ED, both following PFUI and remaining after posterior urethroplasty. Additionally, rates of ejaculatory difficulty and patient perceived changes in penile length and curvature underscore the complex nature of the impact of these injuries on sexual function beyond simple erectile function.
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Affiliation(s)
| | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center Burlington, Burlington, MA, USA
| | | | | | | | - Jill Buckley
- University of California San Diego, San Diego, CA, USA
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Voelzke BB, Leddy LS, Myers JB, Breyer BN, Alsikafi NF, Broghammer JA, Elliott SP, Vanni AJ, Erickson BA, Buckley JC, Zhao LC, Wright T, Rourke KF. Multi-institutional Outcomes and Associations After Excision and Primary Anastomosis for Radiotherapy-associated Bulbomembranous Urethral Stenoses Following Prostate Cancer Treatment. Urology 2021; 152:117-122. [PMID: 33556448 DOI: 10.1016/j.urology.2020.11.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/28/2020] [Accepted: 11/30/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- B B Voelzke
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - L S Leddy
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - J B Myers
- Division of Urology, University of Utah, Salt Lake City, UT
| | - B N Breyer
- Department of Urology, University of California-San Francisco Medical Center, San Francisco, CA
| | | | - J A Broghammer
- Department of Urology, University of Kansas Medical Center, Kansas City, KS
| | - S P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - A J Vanni
- Department of Urology, Lahey Clinic, Burlington, MA
| | - B A Erickson
- Department of Urology, University of Iowa, Iowa City, IA
| | - J C Buckley
- Department of Urology, University of California-San Diego, San Diego, CA
| | - L C Zhao
- Department of Urology, New York University Langone Health, New York City, NY
| | - T Wright
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| | - K F Rourke
- Division of Urology, University of Alberta, Edmonton, AB, Canada.
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Rozanski AT, Zhang LT, Muise AC, Copacino SA, Holst DD, Zinman LN, Buckley JC, Vanni AJ. Conservative Management of Lichen Sclerosus Male Urethral Strictures: A Multi-Institutional Experience. Urology 2021; 152:123-128. [PMID: 33482126 DOI: 10.1016/j.urology.2021.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 10/22/2022]
Abstract
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 <3 months follow-up was excluded. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, and uroflowmetry values. Secondary outcome measures included patient-reported outcome measure questionnaires on urinary and sexual function. Failure was defined as progression to reconstructive surgery or permanent indwelling catheterization. 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 <.001), and more likely to perform CIC (P = .01). 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.
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Affiliation(s)
| | | | - Alexandra C Muise
- University of California San Diego School of Medicine, San Diego, CA
| | | | - Daniel D Holst
- University of California San Diego School of Medicine, San Diego, CA
| | | | - Jill C Buckley
- University of California San Diego School of Medicine, San Diego, CA
| | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA
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25
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Kim S, Cheng KC, Patell S, Alsikafi NF, Breyer BN, Broghammer JA, Elliott SP, Erickson BA, Myers JB, Smith TG, Vanni AJ, Voelzke BB, Zhao LC, Buckley JC. Antibiotic Stewardship and Postoperative Infections in Urethroplasties. Urology 2020; 152:142-147. [PMID: 33373707 DOI: 10.1016/j.urology.2020.10.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Sunchin Kim
- University of California San Diego, San Diego, CA
| | | | | | | | | | | | | | | | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA
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Rozanski AT, Zhang LT, Holst DD, Copacino SA, Vanni AJ, Buckley JC. The Effect of Radiation Therapy on the Efficacy of Internal Urethrotomy With Intralesional Mitomycin C for Recurrent Vesicourethral Anastomotic Stenoses and Bladder Neck Contractures: A Multi-Institutional Experience. Urology 2020; 147:294-298. [PMID: 33035561 DOI: 10.1016/j.urology.2020.09.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/20/2020] [Accepted: 09/24/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE 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). METHODS 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, or <3 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. RESULTS 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. CONCLUSION DVIU with low-dose MMC remains a safe and effective BNC/VUAS treatment. A patent bladder neck was achieved in >90% of nonradiated patients and >75% of radiated patients.
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Affiliation(s)
| | | | - Daniel D Holst
- University of California San Diego School of Medicine, San Diego, CA
| | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA
| | - Jill C Buckley
- University of California San Diego School of Medicine, San Diego, CA
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Moynihan MJ, Voelzke B, Myers J, Breyer BN, Erickson B, Elliott SP, Alsikafi N, Buckley J, Zhao L, Smith T, Vanni AJ. Endoscopic treatments prior to urethroplasty: trends in management of urethral stricture disease. BMC Urol 2020; 20:68. [PMID: 32534592 PMCID: PMC7293125 DOI: 10.1186/s12894-020-00638-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 06/04/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Matthew J Moynihan
- Department of Urology, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA, 01805, USA.
| | | | | | - Benjamin N Breyer
- University of California - San Francisco, San Francisco, California, USA
| | | | | | | | - Jill Buckley
- University of California - San Diego, San Diego, California, USA
| | - Lee Zhao
- New York University, Langone Medical Center, New York City, New York, USA
| | | | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA, 01805, USA
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Rozanski AT, Vanni AJ. Ventral Buccal Mucosa Graft Urethroplasty with Gracilis Muscle Flap for High Risk, Long Segment Urethral Strictures: A 20-Year Experience. Urology 2020; 140:178-180. [DOI: 10.1016/j.urology.2020.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 11/16/2022]
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Affiliation(s)
- Alex J Vanni
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, Burlington, MA
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Levy AC, Moynihan M, Bennett JA, Sullivan T, Stensland K, Browne BM, Fredrick A, Cavallo JA, Pagura E, Tua-Caraccia R, Rieger-Christ KM, Vanni AJ. Protein Expression Profiles among Lichen Sclerosus Urethral Strictures-Can Urethroplasty Success be Predicted? J Urol 2019; 203:773-778. [PMID: 31621469 DOI: 10.1097/ju.0000000000000610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE 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. MATERIALS AND METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Alison C Levy
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | | | | | - Travis Sullivan
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | | | | | - Ariel Fredrick
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Jaime A Cavallo
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | | | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, Massachusetts
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31
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Dy GW, Granieri MA, Fu BC, Vanni AJ, Voelzke B, Rourke KF, Elliott SP, Nikolavsky D, Zhao LC. Presenting Complications to a Reconstructive Urologist After Masculinizing Genital Reconstructive Surgery. Urology 2019; 132:202-206. [DOI: 10.1016/j.urology.2019.04.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/23/2019] [Accepted: 04/27/2019] [Indexed: 11/29/2022]
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Johnsen NV, Moses RA, Elliott SP, Vanni AJ, Baradaran N, Greear G, Smith TG, Granieri MA, Alsikafi NF, Erickson BA, Myers JB, Breyer BN, Buckley JC, Zhao LC, Voelzke BB. Multicenter analysis of posterior urethroplasty complexity and outcomes following pelvic fracture urethral injury. World J Urol 2019; 38:1073-1079. [PMID: 31144093 DOI: 10.1007/s00345-019-02824-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 05/25/2019] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Niels Vass Johnsen
- Departments of Urology, University of Washington, Seattle, WA, USA. .,Harborview Medical Center, Box 359868, 325 Ninth Ave, Seattle, WA, 98104, USA.
| | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Nima Baradaran
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | | | | | | | | | - Bryan B Voelzke
- Departments of Urology, University of Washington, Seattle, WA, USA
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Biebel M, Rodriguez D, Pan S, Vanni AJ, Munarriz R. Case – Penile fracture in a patient with Ehlers-Danlos syndrome. Can Urol Assoc J 2019; 14:E39-E41. [DOI: 10.5489/cuaj.5982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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34
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Cotter KJ, Hahn AE, Voelzke BB, Myers JB, Smith TG, Elliott SP, Alsikafi NF, Breyer BN, Vanni AJ, Buckley JC, Zhao LC, Broghammer JA, Erickson BA. Trends in Urethral Stricture Disease Etiology and Urethroplasty Technique From a Multi-institutional Surgical Outcomes Research Group. Urology 2019; 130:167-174. [PMID: 30880075 DOI: 10.1016/j.urology.2019.01.046] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 12/31/2018] [Accepted: 01/03/2019] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
| | - Amy E Hahn
- Department of Urology, University of Iowa, Iowa City, IA
| | | | | | | | | | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA
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35
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Hampson LA, Myers JB, Vanni AJ, Virasoro R, Smith TG, Capiel L, Chandrapal J, Voelzke BB. Dorsal buccal graft urethroplasty in female urethral stricture disease: a multi-center experience. Transl Androl Urol 2019; 8:S6-S12. [PMID: 31143666 DOI: 10.21037/tau.2019.03.02] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Lindsay A Hampson
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA.,Department of Urology, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Jeremy B Myers
- Division of Urology, University of Utah Health, Salt Lake City, UT, USA
| | - Alex J Vanni
- Center for Reconstructive & Urologic Surgery, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Ramón Virasoro
- Department of Urology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Thomas G Smith
- Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Leandro Capiel
- Centro de Educación Medica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | | | - Bryan B Voelzke
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA
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Pagura EJ, Cavallo JA, Zinman LN, Vanni AJ. Rectal Mucosa Graft Take in Staged Urethroplasty. Urology 2019; 127:e1-e2. [PMID: 30822477 DOI: 10.1016/j.urology.2019.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 10/27/2022]
Abstract
When an oral mucosa graft is not a viable option for urethroplasty, colonic mucosa grafts have served as a promising alternative since described by Igor A. Thyrmos in 1902.1 In previous studies, colonic mucosa graft retrieval required sigmoid resection2-3 which limited adoption of this technique. We previously described the success of a minimally-invasive transanal endoscopic microsurgical technique of rectal mucosa graft harvest for urethroplasty.4 Here, we pictorially demonstrate the take of a transanal endoscopically harvested rectal musosa graft used in a 2-stage anterior urethroplasty (to our knowledge, the first such 2-stage procedure) with 6 months of follow-up.
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Affiliation(s)
| | - Jaime A Cavallo
- Institute for Urology, Lahey Hospital and Medical Center, Burlington, MA
| | - Leonard N Zinman
- Institute for Urology, Lahey Hospital and Medical Center, Burlington, MA
| | - Alex J Vanni
- Institute for Urology, Lahey Hospital and Medical Center, Burlington, MA.
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Baradaran N, Fergus KB, Moses RA, Patel DP, Gaither TW, Voelzke BB, Smith TG, Erickson BA, Elliott SP, Alsikafi NF, Vanni AJ, Buckley J, Zhao LC, Myers JB, Breyer BN. Clinical significance of cystoscopic urethral stricture recurrence after anterior urethroplasty: a multi-institution analysis from Trauma and Urologic Reconstructive Network of Surgeons (TURNS). World J Urol 2019; 37:2763-2768. [PMID: 30712091 DOI: 10.1007/s00345-019-02653-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 01/24/2019] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To assess the functional Queryoutcome of patients with cystoscopic recurrence of stricture post-urethroplasty and to evaluate the role of cystoscopy as initial screening tool to predict future failure. METHODS Cases with cystoscopy data after anterior urethroplasty in a multi-institutional database were retrospectively studied. Based on cystoscopic evaluation, performed within 3-months post-urethroplasty, patients were categorized as small-caliber (SC) stricture recurrence: stricture unable to be passed by standard cystoscope, large-caliber (LC) stricture accommodating a cystoscope, and no recurrence. We assessed the cumulative probability of intervention and the quality of life scores in association with cystoscopic recurrence 1-year post-urethroplasty. Patients with history of hypospadias, perineal urethrostomy, urethral fistula, and meatal pathology were excluded. RESULTS From a total of 2630 men in our cohort, 1054 patients met the inclusion criteria: normal (n = 740), LC recurrence (n = 178), and SC recurrence (n = 136) based on the first cystoscopic evaluation performed at median 111 days postoperatively. Median follow-up was 350 days (IQR 121-617) after urethroplasty. Cystoscopic recurrence was significantly associated with secondary interventions (2.7%, 6.2%, 33.8% in normal, LC, and SC groups, respectively). Quality of life variables were not statistically significantly different among the three study groups. CONCLUSIONS Many patients with cystoscopic recurrence do not need an intervention after initial urethroplasty. Despite good negative predictive value, cystoscopy alone may be a poor screening test for stricture recurrence defined by patient symptoms and need for secondary interventions.
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Affiliation(s)
- Nima Baradaran
- Department of Urology, Ohio State University, Columbus, OH, USA
| | - Kirkpatrick B Fergus
- Department of Urology, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, 1001 Potrero Suite 3A, San Francisco, CA, 94110, USA
| | - Rachel A Moses
- Division of Urology, University of Utah, Salt Lake City, UT, USA
| | - Darshan P Patel
- Division of Urology, University of Utah, Salt Lake City, UT, USA
| | - Thomas W Gaither
- Department of Urology, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, 1001 Potrero Suite 3A, San Francisco, CA, 94110, USA
| | - Bryan B Voelzke
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Thomas G Smith
- Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | | | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | | | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Jill Buckley
- Department of Urology, University of California San Diego, San Diego, CA, USA
| | - Lee C Zhao
- New York University School of Medicine, New York, NY, USA
| | - Jeremy B Myers
- Division of Urology, University of Utah, Salt Lake City, UT, USA
| | - Benjamin N Breyer
- Department of Urology, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, 1001 Potrero Suite 3A, San Francisco, CA, 94110, USA.
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Chung PH, Vanni AJ, Breyer BN, Erickson BA, Myers JB, Alsikafi N, Buckley J, Elliott SP, Zhao LC, Voelzke BB. Evaluation of Generic Versus Condition-Specific Quality of Life Indicators for Successful Urethral Stricture Surgery. Urology 2018; 126:222-226. [PMID: 30580004 DOI: 10.1016/j.urology.2018.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/09/2018] [Accepted: 12/11/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To 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 METHODS Patient 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. RESULTS A total of 201 patients met inclusion criteria. Urethral-stricture specific measures improved after surgery: mean LUTS score (13.1-4.0, p<0.05), Peeling curve (3.1-1.7, p < 0.05), and overall interference of urinary symptoms on life (3.0-1.6, p < 0.05). Mean overall health status visual analog scale (74.2-80.0, p < 0.05) and generic health QOL EQ-5D index scores (0.90-0.95, p < 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 < 0.05) and anxiety/depression (1.33-1.21, p < 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 < 0.001). CONCLUSION Generic 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.
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Affiliation(s)
- Paul H Chung
- Department of Urology, Thomas Jefferson University, Philadelphia, PA.
| | - Alex J Vanni
- Department of Urology, Lahey Clinic, Burlington, MA
| | | | | | - Jeremy B Myers
- Division of Urology, University of Utah, Salt Lake City, UT
| | | | - Jill Buckley
- Department of Urology, University of California San Diego, San Diego, CA
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York City, NY
| | - Bryan B Voelzke
- Department of Urology, University of Washington Medical Center, Seattle, WA
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Broadwin M, Vanni AJ. Outcomes of a urethroplasty algorithm for fossa navicularis strictures. Can J Urol 2018; 25:9591-9595. [PMID: 30553284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION There is no standardized treatment algorithm for isolated fossa navicularis strictures and treatment modality often falls to surgeon preference. We evaluated the outcomes of a standardized algorithm for fossa navicularis strictures based on stricture etiology, lumen size, and glans size to minimize the number of patients requiring a two-stage urethral reconstruction. MATERIALS AND METHODS We retrospectively reviewed a prospectively maintained urethral reconstruction database by a single surgeon from 2011-2018. A treatment algorithm was applied and patients underwent one of three treatment modalities: a two-stage buccal mucosa graft (BMG), a single-stage dorsal inlay BMG, or a single-stage dorsal inlay BMG and ventral fasciocutaneous flap repair. Stricture recurrence was measured by inability to pass 17 Fr flexible cystoscope. Patient sexual function and satisfaction were evaluated by the International Index of Erectile Function (IIEF) and a patient perception questionnaire. RESULTS Forty-two patients met inclusion criteria with a mean follow up of 12.3 months. Urethroplasty success rate was 92%. There was no change in IIEF scores pre and postoperatively between single stage BMG, two-stage BMG, and combined BMG and flap repairs (+ 0.4; p = 0.88, 0.0; p = 1.00, and -0.3; p = 0.74). Ninety-four percent of patients reported being very satisfied or satisfied with their reconstruction. CONCLUSION An algorithmic approach to the treatment of fossa navicularis strictures is an appropriate method for reconstructive intervention with a high rate of success and patient satisfaction with no significant impact on erectile function.
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Affiliation(s)
- Mark Broadwin
- Tufts University School of Medicine, Boston, Massachusetts, USA
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Cotter KJ, Flynn KJ, Hahn AE, Voelzke BB, Myers JB, Smith TG, Elliott SP, Alsikafi NF, Breyer BN, Vanni AJ, Buckley JC, Zhao LC, Erickson BA. Prevalence of Post-Micturition Incontinence before and after Anterior Urethroplasty. J Urol 2018; 200:843-847. [DOI: 10.1016/j.juro.2018.03.134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2018] [Indexed: 10/17/2022]
Affiliation(s)
| | - Kevin J. Flynn
- Department of Urology, University of Iowa, Iowa City, Iowa
| | - Amy E. Hahn
- Department of Urology, University of Iowa, Iowa City, Iowa
| | | | | | | | | | | | | | - Alex J. Vanni
- Lahey Hospital and Medical Center, Burlington, Massachusetts
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Erickson BA, Tesdahl BA, Voznesensky MA, Breyer BN, Voelzke BB, Alsikafi NF, Vanni AJ, Broghammer JA, Buckley JC, Myers JB, Brant WO, Zhao LC, Smith Iii TG, Swick BL, Dahmoush L. Urethral lichen sclerosus under the microscope: a survey of academic pathologists. Can J Urol 2018; 25:9328-9333. [PMID: 29900821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Bradley A Erickson
- Department of Urology, University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
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Kirshenbaum EJ, Zhao LC, Myers JB, Elliott SP, Vanni AJ, Baradaran N, Erickson BA, Buckley JC, Voelzke BB, Granieri MA, Summers SJ, Breyer BN, Dash A, Weinberg A, Alsikafi NF. Patency and Incontinence Rates After Robotic Bladder Neck Reconstruction for Vesicourethral Anastomotic Stenosis and Recalcitrant Bladder Neck Contractures: The Trauma and Urologic Reconstructive Network of Surgeons Experience. Urology 2018; 118:227-233. [PMID: 29777787 DOI: 10.1016/j.urology.2018.05.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/01/2018] [Accepted: 05/03/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To review a robotic approach to recalcitrant bladder neck obstruction and to assess success and incontinence rates. MATERIALS AND METHODS Patients with a recalcitrant bladder neck contracture or vesicourethral anastomotic stenosis who underwent robotic bladder neck reconstruction (RBNR) were identified. We reviewed patient demographics, medical history, etiology, previous endoscopic management, cystoscopic and symptomatic outcomes, urinary continence, and complications. Stricture success was anatomic and functional based upon atraumatic passage of a 17 Fr flexible cystoscope or uroflowmetry rate >15 ml/s. Incontinence was defined as the use of >1 pad per day or procedures for incontinence. RESULTS Between 2015 and 2017, 12 patients were identified who met study criteria and underwent RBNR. Etiology of obstruction was endoscopic prostate procedure in 7 and radical prostatectomy in 5. The mean operative time was 216 minutes (range 120-390 minutes), with a mean estimated blood loss of 85 cc (range 5-200 cc). Median length of stay was 1 day (range 1-5 days). Three of 12 patients had recurrence of obstruction for a 75% success rate. Additionally, 82% of patients without preoperative incontinence were continent with a median follow-up of 13.5 months (range 5-30 months). There was 1 Clavien IIIb complication of osteitis pubis and pubovesical fistula that required vesicopubic fistula repair with pubic bone debridement. CONCLUSION RBNR is a viable surgical option with high patency rates and favorable continence outcomes. This is in contrast to perineal reconstruction, which has high incontinence rates. If future incontinence procedures are needed, outcomes may be improved given lack of previous perineal dissection.
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Affiliation(s)
| | - Lee C Zhao
- Department of Urology, New York University, New York, NY
| | - Jeremy B Myers
- Division of Urology, University of Utah, Salt Lake City, UT
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, Burlington, MA
| | - Nima Baradaran
- Department of Urology, University of California San Francisco, San Francisco, CA
| | | | - Jill C Buckley
- Department of Urology, UC San Diego Health System, San Diego, CA
| | - Bryan B Voelzke
- Department of Urology, University of Washington, Seattle, WA
| | | | | | - Benjamin N Breyer
- Department of Urology, University of California San Francisco, San Francisco, CA
| | - Atreya Dash
- Department of Urology, University of Washington, Seattle, WA
| | - Aaron Weinberg
- Department of Urology, New York University, New York, NY
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Sukumar S, Elliott SP, Myers JB, Voelzke BB, Smith TG, Carolan AMC, Maidaa M, Vanni AJ, Breyer BN, Erickson BA. Multi-Institutional Outcomes of Endoscopic Management of Stricture Recurrence after Bulbar Urethroplasty. J Urol 2018; 200:837-842. [PMID: 29730205 DOI: 10.1016/j.juro.2018.04.081] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Approximately 10% to 20% of patients will have a recurrence after urethroplasty. Initial management of these recurrences is often by urethral dilation or direct vision internal urethrotomy. In the current study we describe the outcomes of endoscopic management of stricture recurrence after bulbar urethroplasty. MATERIALS AND METHODS We retrospectively reviewed bulbar urethroplasty data from 5 surgeons in the TURNS (Trauma and Urologic Reconstruction Network of Surgeons). Men who underwent urethral dilation or direct vision internal urethrotomy for urethroplasty recurrence were identified. Recurrence was defined as the inability to pass a 17Fr cystoscope through the area of reconstruction. The primary outcome was the success rate of recurrence management. Comparisons were made between urethral dilation and direct vision internal urethrotomy, and then between endoscopic management of recurrences after excision and primary anastomosis urethroplasty vs substitutional repairs using time to event statistics. RESULTS In 53 men recurrence was initially managed endoscopically. Median time to urethral stricture recurrence after urethroplasty was 5 months. At a median followup of 5 months the overall success rate was 42%. Success after urethral dilation was significantly less than after direct vision internal urethrotomy (1 of 10 patients or 10% vs 21 of 43 or 49%, p <0.001) with a failure HR of 3.15 (p = 0.03). Direct vision internal urethrotomy was more effective after substitutional failure than after excision and primary anastomosis urethroplasty (53% vs 13%, p = 0.005). CONCLUSIONS Direct vision internal urethrotomy was more successful than urethral dilation in the management of stricture recurrence after bulbar urethroplasty. Direct vision internal urethrotomy was more successful in patients with recurrence after substitution urethroplasty compared to after excision and primary anastomosis urethroplasty. Perhaps this indicates a different mechanism of recurrence for excision and primary anastomosis urethroplasty (ischemic) vs substitution urethroplasty (nonischemic).
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Affiliation(s)
- Shyam Sukumar
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
| | - Jeremy B Myers
- Department of Urology, University of Utah, Salt Lake City, Utah
| | - Bryan B Voelzke
- Department of Urology, University of Washington Medical Center, Seattle, Washington
| | - Thomas G Smith
- Department of Urology, Baylor College of Medicine, Houston, Texas
| | | | - Michael Maidaa
- Department of Urology, University of Iowa, Iowa City, Iowa
| | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Benjamin N Breyer
- Department of Urology, University of California-San Francisco, San Francisco, California
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Cotter KJ, Flynn KJ, Hahn AE, Voelzke BB, Myers JB, Smith TG, Elliott SP, Alsikafi NF, Breyer BN, Vanni AJ, Buckley JC, Zhao LC, Erickson BA. PD30-07 PREVALENCE OF POST-VOID DRIBBLING BEFORE AND AFTER ANTERIOR URETHROPLASTY. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.1526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
PURPOSE OF REVIEW This article discusses the incidence, evaluation, and treatment of bladder outlet obstruction from urethral stricture, vesicourethral anastomotic stricture, and bladder neck contracture following primary and salvage treatment of prostate cancer. RECENT FINDINGS Rates of stenosis after prostate cancer treatment appear similar across all primary treatment modalities including radical prostatectomy, radiation therapy, cryoablation, and high-intensity focused ultrasound in contemporary series. Urethral dilation and urethrotomy continue to report moderate patency rates. Urethroplasty achieves high patency rates even for long strictures, but more extensive reconstruction increases the risk of postoperative urinary incontinence. Recent AUA guidelines on urethral strictures provide new recommendations for management of these patients. All treatment options for prostate cancer carry a risk for bladder outlet obstruction, and intervention is often necessary to relieve long-lasting morbidity. Careful preoperative evaluation should be completed to assess location and extent of the stricture in order to choose optimal therapy. Endoscopic treatments, open reconstruction, and urinary diversion all play a role in relief of stenosis depending on stricture length, location, characteristics, and patient comorbidities.
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Affiliation(s)
- Brendan Michael Browne
- Department of Urology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA.
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Schober JP, Stensland KD, Breyer BN, Erickson BA, Myers JB, Voelzke BB, Elliott SP, Buckley JC, Vanni AJ. Effect of Urethroplasty on Anxiety and Depression. J Urol 2018; 199:1552-1556. [PMID: 29408454 DOI: 10.1016/j.juro.2018.01.074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2017] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Jared P Schober
- Department of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Kristian D Stensland
- Department of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Benjamin N Breyer
- Departments of Urology and Epidemiology and Biostatistics, University of California-San Francisco, San Diego, California
| | | | - Jeremy B Myers
- Division of Urology, University of Utah, Salt Lake City, Utah
| | - Bryan B Voelzke
- Department of Urology, University of Washington, Seattle, Washington
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
| | - Jill C Buckley
- Department of Urology, University of California-San Diego, San Diego, California
| | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts.
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Levy M, Gor RA, Vanni AJ, Stensland K, Erickson BA, Myers JB, Voelzke BB, Smith TG, Breyer BN, McClung C, Alsikafi NF, Fan Y, Elliott SP. The Impact of Age on Urethroplasty Success. Urology 2017; 107:232-238. [PMID: 28579068 DOI: 10.1016/j.urology.2017.03.066] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/18/2017] [Accepted: 03/21/2017] [Indexed: 12/14/2022]
Abstract
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 (<60 years old and ≥60 years old). Multivariable logistic regression analysis evaluated the influence of patient factors on our primary and secondary outcomes, using age as a continuous variable. RESULTS Of 322 urethroplasties, 258 were performed in patients <60 years and 64 in patients ≥60 years. Median follow-up was 1.8 years. The following were not significantly different between groups: stricture length or location, smoking status, number of previous urethrotomies or dilations, and urethroplasty type. The following were more common in patients ≥60 years: diabetes, hypertension, hyperlipidemia, coronary artery and peripheral vascular disease, chronic obstructive pulmonary disease, and cancer. There was no difference in need for repeat procedures or anatomic recurrence between age groups or with increasing age. Stricture length was the only statistically significant clinical factor. 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.
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Affiliation(s)
- Mya Levy
- University of Minnesota, Minneapolis, MN
| | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA
| | | | | | | | | | | | | | | | | | - Yunhua Fan
- University of Minnesota, Minneapolis, MN
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Chung PH, Vanni AJ, Breyer BN, Erickson BA, Myers JB, Voelzke BB. MP36-14 EVALUATION OF GENERIC VERSUS CONDITION-SPECIFIC QUALITY OF LIFE INDICATORS FOR SUCCESSFUL URETHRAL STRICTURE SURGERY. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.1125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kaufman DA, Zinman LN, Buckley JC, Marcello P, Browne BM, Vanni AJ. Short- and Long-term Complications and Outcomes of Radiation and Surgically Induced Rectourethral Fistula Repair With Buccal Mucosa Graft and Muscle Interposition Flap. Urology 2016; 98:170-175. [DOI: 10.1016/j.urology.2016.06.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/20/2016] [Accepted: 06/23/2016] [Indexed: 11/30/2022]
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