Purpose: The treatment of urethral stenosis after a combination of prostatectomy and radiation therapy for prostate cancer is understudied. We evaluate the clinical and patient-related outcomes after dorsal onlay buccal mucosal graft urethroplasty (D-BMGU) in men who underwent prostatectomy and radiation therapy. Materials and Methods: A multi-institutional, retrospective review of men with vesicourethral anastomotic stenosis or bulbomembranous urethral stricture disease after radical prostatectomy and radiation therapy from 8 institutions between 2013 to 2021 was performed. The primary outcomes were stenosis recurrence and development of de novo stress urinary incontinence. Secondary outcomes were surgical complications, changes in voiding, and patient-reported satisfaction. Results: Forty-five men were treated with D-BMGU for stenosis following prostatectomy and radiation. There was a total of 7 recurrences. Median follow-up in patients without recurrence was 21 months (IQR 12-24). There were no incidents of de novo incontinence, 28 patients were incontinent pre- and postoperatively, and of the 6 patients managed with suprapubic catheter preoperatively, 4 were continent after repair. Following repair, men had significant improvement in postvoid residual, uroflow, International Prostate Symptom Score, and International Prostate Symptom Score quality-of-life domain. Overall satisfaction was +2 or better in 86.6% of men on the Global Response Assessment. Conclusions: D-BMGU is a safe, feasible, and effective technique in patients with urethral stenosis after a combination of prostatectomy and radiation therapy. Although our findings suggest this technique may result in lower rates of de novo urinary incontinence compared to conventional urethral transection and excision techniques, head-to-head comparisons are needed.

You have accessJournal of UrologyCME1 May 2022MP22-07 OUTCOMES OF DORSAL ONLAY BUCCAL MUCOSAL GRAFT URETHROPLASTY IN PATIENTS WITH POST-PROSTATECTOMY, POST-RADIATION ANASTOMOTIC CONTRACTURE Joshua Sterling, Alex Wang, Kelly Crane, Javier C. Angulo, Wagner Franca, Brian Flynn, Francisco Martins, Erick A. Ramirez, Paul Rusilko, Jay Simhan, Daniel Swerdloff, and Dmitriy Nikolavsky Joshua SterlingJoshua Sterling More articles by this author , Alex WangAlex Wang More articles by this author , Kelly CraneKelly Crane More articles by this author , Javier C. AnguloJavier C. Angulo More articles by this author , Wagner FrancaWagner Franca More articles by this author , Brian FlynnBrian Flynn More articles by this author , Francisco MartinsFrancisco Martins More articles by this author , Erick A. RamirezErick A. Ramirez More articles by this author , Paul RusilkoPaul Rusilko More articles by this author , Jay SimhanJay Simhan More articles by this author , Daniel SwerdloffDaniel Swerdloff More articles by this author , and Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002561.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Treatment of patients with vesicourethral anastomotic contracture (VUAS) /membranous stenosis (Sp) following a combination of prostatectomy and radiation treatment for prostate cancer (CaP) are understudied. We evaluate feasibility of dorsal onlay buccal mucosal graft urethroplasty (D-BMGU) and evaluate patency and continence outcomes in patients with a history of prior radical prostatectomy and radiation therapy. METHODS: Retrospective multi-institutional review of patients with post-prostatectomy, post-radiation VUAS/Sp from 8 institutions between 2013-2021 was performed. Patients with at least 8-months follow-up were assessed. Patient demographics, stenosis characteristics, peri-operative outcomes, and post-operative clinical and patient-reported outcomes were analyzed. The primary outcomes were recurrence and development of de-novo stress urinary incontinence (SUI). Secondary outcomes were surgical complications, changes in voiding and patient-reported satisfaction using a Global Response Assessment (GRA). RESULTS: Of 48 patients treated with D-BMGU for stenosis following prostatectomy and radiation, 38 met the inclusion criteria. Median age and stenosis length were 68.5 years, (IQR 63.25-72), and 2.75 cm (IQR 2-4 cm), respectively. Prior CaP treatment modalities included primary robotic prostatectomy and subsequent salvage or adjuvant radiotherapy in 89% (34/38) and primary radiation and salvage prostatectomy in 11% (4/38). The mean length of stay after D-BMGU was 1.5 days (IQR 1-2). At a median follow-up of 21 months (IQR 13-39), 5 patients (13%) had recurrence. Among 11 preoperatively-continent patients (31%) all retained continence. Of 20 patients with preoperative SUI (52%), all but one (95%) remained incontinent post-operatively. Continence was unknown for 7 patients and 3 had post operative incontinence. 47% (17/36) of the cohort subsequently received an artificial urinary sphincter. Patients experienced significant improvement in PVR (158 to 47 cc, p <0.001) and Uroflow (6.3 to 15.4 cc/s, p <0.001), and also reported high overall satisfaction, with 84% reporting a GRA of +2 or better. CONCLUSIONS: Dorsal onlay buccal mucosa graft urethroplasty is a safe and feasible technique in patients with post-radiation post prostatectomy anastomotic contracture. Although our findings suggest the DBMGU technique may confer lower rates of de-novo SUI compared to conventional urethral transection, head-to-head comparisons are needed to further characterize any continence benefit. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e374 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Sterling More articles by this author Alex Wang More articles by this author Kelly Crane More articles by this author Javier C. Angulo More articles by this author Wagner Franca More articles by this author Brian Flynn More articles by this author Francisco Martins More articles by this author Erick A. Ramirez More articles by this author Paul Rusilko More articles by this author Jay Simhan More articles by this author Daniel Swerdloff More articles by this author Dmitriy Nikolavsky More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) I (MP03)1 Sep 2021MP03-12 MULTI-INSTITUTIONAL FEASIBILITY OF DORSAL ONLAY URETHROPLASTY FOR MEMBRANOUS URETHRAL STRICTURE FOLLOWING ENDOSCOPIC PROSTATE PROCEDURES: OPERATIVE RESULTS AND MULTIVARIATE ANALYSIS Connor Policastro, Francisco Martins, Keith Rourke, Erick Ramírez, Jaime Gago, Jay Simhan, Eric Li, Paul Rusilko, Krishnan Venkatesan, Jonathan Warner, Dmitriy Nikolavsky, and Javier Angulo Connor PolicastroConnor Policastro More articles by this author , Francisco MartinsFrancisco Martins More articles by this author , Keith RourkeKeith Rourke More articles by this author , Erick RamírezErick Ramírez More articles by this author , Jaime GagoJaime Gago More articles by this author , Jay SimhanJay Simhan More articles by this author , Eric LiEric Li More articles by this author , Paul RusilkoPaul Rusilko More articles by this author , Krishnan VenkatesanKrishnan Venkatesan More articles by this author , Jonathan WarnerJonathan Warner More articles by this author , Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author , and Javier AnguloJavier Angulo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001964.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Reconstruction of membranous urethral stenosis in patients with previous transurethral resection of the prostate (TURP) or other endoscopic prostate ablative procedures is a surgical challenge that is poorly described. Here we evaluate multi-institutional results of Dorsal-Onlay Buccal Mucosal Graft Urethroplasty (DBMGU) for urethral stricture in these patients. METHODS: Multi-institutional review of DBMGU in patients with membranous or bulbomembranous urethral stenosis from 2002 to 2020 and a minimum of 6-months follow-up was conducted. The primary objective was evaluation of urethral patency and stenosis recurrence with identification of risk factors using stepwise logistic regression (p=0.1 entry and p=0.05 stay criteria) and assessment of de-novo stress urinary incontinence (SUI). Secondary objectives included an evaluation of changes in voiding, sexual function and patient satisfaction. RESULTS: 107 men with post-TURP urethral stenosis received DBMGU. Mean age, stenosis length and BMI were 69±9.5 years, 3.5±1.8 cm and 27.7±5, respectively. Prior endoscopic procedures included: 47 (44%) monopolar TURP, 33 (30.8%) bipolar TURP, 16 (15%) Greenlight laser, 9 (8.4%) holmium laser enucleation and 2 (1.9%) transurethral bladder neck incision. Radiotherapy was performed in 10 (9.3%). At a mean of 59.3±45.1 months follow-up (range 6-148), stenosis recurred in 10 patients (9.35%). Univariate analysis revealed diabetes, smoking, monopolar TURP, associated radiation, prior dilatation, prior DVIU, stricture length and postoperative complications within 90 days were included in the regression model for recurrence. Multivariate analysis confirmed postoperative complications (OR 12.5; p=.009), associated radiation (OR 8.3; p=.016) and ≥2 dilatations before urethroplasty (OR 8.3; p=.032) as independent predictors of recurrence. Only 1 patient (0.9%) developed de-novo SUI following DBMGU. Patients had improvement in Qmax (6.2 to 16.8cc/s; p<.001), PVR (128 to 60cc; p<.001), SHIM (11.5 to 11.7; p=.028), IPSS (20 to 7.7; p<.001) and QoL (4.4 to 1.7; p<.001). 87 cases (81.3%) reported GRA of +2 or better. CONCLUSIONS: DBMGU is effective in treating post-TURP bulbomembranous stenosis. This non-transecting approach confers a very low risk of de-novo SUI, preserves erectile function and improves voiding function. Further work is needed to compare this technique with other approaches in this challenging setting. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e25-e26 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Connor Policastro More articles by this author Francisco Martins More articles by this author Keith Rourke More articles by this author Erick Ramírez More articles by this author Jaime Gago More articles by this author Jay Simhan More articles by this author Eric Li More articles by this author Paul Rusilko More articles by this author Krishnan Venkatesan More articles by this author Jonathan Warner More articles by this author Dmitriy Nikolavsky More articles by this author Javier Angulo More articles by this author Expand All Advertisement Loading ...

(1) Background: To critically evaluate dorsal onlay buccal mucosal graft urethroplasty (DOBMGU) for posterior urethral stenosis repair following transurethral resection and other endoscopic prostate procedures. (2) Methods: A retrospective multi-institutional review of patients with membranous or bulbomembranous urethral stenosis for whom treatment with DOBMGU was conducted after receipt of prostate endoscopic procedures. Baseline data, peri-operative care, post-operative care and patient-reported outcomes were analyzed. The primary outcomes were procedural failure and development of de novo stress urinary incontinence (SUI). The secondary outcomes were changes in voiding, sexual function and patient satisfaction. (3) Results: A total of 107 men with a mean age of 69 ± 9.5 years and stenosis length of 3.5 ± 1.8 cm were included. Prior endoscopic procedures among participants were 47 patients (44%) with monopolar TURP, 33 (30.8%) with bipolar TURP, 16 (15%) with Greenlight laser, 9 (8.4%) with Holmium laser enucleation and 2 (1.9%) with bladder neck incision. At a mean follow-up time of 59.3 ± 45.1 months, stenosis recurred in 10 patients (9.35%). Multivariate analysis confirmed that postoperative complications (OR 12.5; p = 0.009), history of radiation (OR 8.3; p = 0.016) and ≥2 dilatations before urethroplasty (OR 8.3; p = 0.032) were independent predictors of recurrence. Only one patient (0.9%) developed de novo SUI. Patients experienced significant improvement in PVR (128 to 60 cc; p = 0.001), Uroflow (6.2 to 16.8 cc/s; p = 0.001), SHIM (11.5 to 11.7; p = 0.028), IPSS (20 to 7.7; p < 0.001) and QoL (4.4 to 1.7; p < 0.001), and 87 cases (81.3%) reported a GRA of + 2 or better. (4) Conclusions: DOBMGU is an effective and safe option for patients with posterior urethral stenosis following TURP and other prostate endoscopic procedures. This non-transecting approach minimizes external urinary sphincter manipulation, thus limiting postoperative risk of SUI or erectile dysfunction.

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) I (MP03)1 Sep 2021MP03-17 ORAL MUCOSA GRAFTING (OMG) OR EXCISION AND PRIMARY ANASTOMOSIS (EPA) FOR THE TREATMENT OF RADIATION-ASSOCIATED URETHRAL STRICTURES: COMPARATIVE ANALYSIS Matthias D. Hofer, Dmitriy Nikolavsky, Connor Policastro, Brian J Flynn, Kirk Redger, Allen F. Morey, Sarah Sanders, Avery Wolfe, Aziz Shaaban, Jay Simhan, Curran Uppaluri, Erick Ramirez, Javier Angulo, Krishnan Venkatesan, Akio Horiguchi, Cooper Benson, Ayman Elmasri, Diana Bowen, Chris M. Gonzalez, Ryan Dornbier, and Francisco E. Martins Matthias D. HoferMatthias D. Hofer More articles by this author , Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author , Connor PolicastroConnor Policastro More articles by this author , Brian J FlynnBrian J Flynn More articles by this author , Kirk RedgerKirk Redger More articles by this author , Allen F. MoreyAllen F. Morey More articles by this author , Sarah SandersSarah Sanders More articles by this author , Avery WolfeAvery Wolfe More articles by this author , Aziz ShaabanAziz Shaaban More articles by this author , Jay SimhanJay Simhan More articles by this author , Curran UppaluriCurran Uppaluri More articles by this author , Erick RamirezErick Ramirez More articles by this author , Javier AnguloJavier Angulo More articles by this author , Krishnan VenkatesanKrishnan Venkatesan More articles by this author , Akio HoriguchiAkio Horiguchi More articles by this author , Cooper BensonCooper Benson More articles by this author , Ayman ElmasriAyman Elmasri More articles by this author , Diana BowenDiana Bowen More articles by this author , Chris M. GonzalezChris M. Gonzalez More articles by this author , Ryan DornbierRyan Dornbier More articles by this author , and Francisco E. MartinsFrancisco E. Martins More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001964.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radiation-associated strictures occurring after radiotherapy for prostate cancer usually affect the bulbomembranous urethra. These strictures are more challenging to repair and have an increased rate of recurrence. While EPA has traditionally been the preferred surgical repair, the use of OMG for these strictures has been emerging. We analyze both techniques and aim to identify those patients that are better suited for either technique. METHODS: In a multicentric international study we collected 181 patients with radiation-associated strictures of which 75 underwent OMG dorsal onlay and 106 EPA urethroplasties between 2004 and 2020. Mean follow-up was 46.64 months. RESULTS: Three patients were lost to follow-up. 94/178 (52.5%) had been treated with external beam radiation, 57 (31.9%) with brachytherapy, and 27 (15.1%) with a combination of both. Mean stricture length was 2.82 cm. Mean surgical time was 167.5 minutes and mean blood loss 174.5 ml. Overall, 141/175 (80.6%) of patients experienced a durable urethral patency. There was no difference in patient characteristics such as co-morbidities, specifically hypertension, diabetes, or lung disease between OMG and EPA cohorts, and there also no difference in frequency of prior endoscopic interventions or operative parameters such as blood loss or surgical time. Patients treated with OMG patients had significantly longer strictures than those in EPA patients (3.72 vs. 2.14 cm (p<0.001). Notably, there was no difference in post-op parameters such as post-void dribbling, penile pain, or erectile dysfunction. Patients treated with OMG urethroplasty had a significantly lower risk of recurrence (8/69 (11.6%) vs. 26/106 (24.5%) p=0.035) albeit this cohort also had a significantly shorter follow-up (39.1 months vs 51.8; p=0.014). Patients undergoing EPA had a significantly higher risk of recurrence if they had diabetes (p=0.031) or an increased body mass index (BMI, p=0.048) with increased stricture length being associated with recurrence with borderline significance (p=0.053). We found no specific risk factors for recurrence among OMG patients. Dose of radiation did not impact success of either technique. CONCLUSIONS: Both OMG and EPA urethroplasties are very successful in treating radiation-associated urethral strictures. OMG grafting appears to be better suited for patients with longer strictures and those with diabetes and higher BMI, both of which may be associated with decreased urethral perfusion facilitating stricture recurrence after EPA. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e27-e28 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthias D. Hofer More articles by this author Dmitriy Nikolavsky More articles by this author Connor Policastro More articles by this author Brian J Flynn More articles by this author Kirk Redger More articles by this author Allen F. Morey More articles by this author Sarah Sanders More articles by this author Avery Wolfe More articles by this author Aziz Shaaban More articles by this author Jay Simhan More articles by this author Curran Uppaluri More articles by this author Erick Ramirez More articles by this author Javier Angulo More articles by this author Krishnan Venkatesan More articles by this author Akio Horiguchi More articles by this author Cooper Benson More articles by this author Ayman Elmasri More articles by this author Diana Bowen More articles by this author Chris M. Gonzalez More articles by this author Ryan Dornbier More articles by this author Francisco E. Martins More articles by this author Expand All Advertisement Loading ...

Penile adhesions may cause pain, bleeding, disfigurement and distress. In the setting of lichen sclerosus (LS), they often recur but current treatment options are limited. We present a novel surgical technique for treatment of recurrent penile adhesions using sub-coronal buccal mucosal graft (BMG) resurfacing. A retrospective, international multi-institutional study was conducted to include patients with refractory penile adhesions who were treated with this technique. Patients with > 12-month follow-up were included in analysis. The procedure involved circumferential excision of the diseased skin and replacement with a BMG. The primary outcomes were recurrence and surgical complications. Secondary outcomes were patient-reported outcome measures (PROMs) including Sexual Health Inventory for Men (SHIM) questionnaire and Global Response Assessment (GRA) questionnaire measuring functional and esthetic outcomes. Twenty-five men underwent the procedure across six institutions between 3/2014 and 11/2019. Twenty-one men met inclusion criteria. Mean operative time and hospital stay for sub-coronal resurfacing were 40 min (25–50) and 0.76 days (1–2), respectively. At the mean follow-up of 18 months (12–61), no patients developed recurrence. All patients who presented with pain and postcoital bleeding saw improvement on follow-up (18/18). There was a significant improvement in SHIM scores after the operation (14.4 pre-op, 17.0 post-op; p = 0.003). Overall improvement of symptoms was reported by all patients: 57% GRA + 3; 29% GRA + 2; 14% GRA + 1. Baseline penile sensation was preserved in 17/21 (81%) patients. Recurrent penile adhesions in the setting of LS are notoriously difficult to treat. A sub-coronal BMG resurfacing is feasible. This initial patient cohort demonstrated no recurrence and overall high satisfaction.

OBJECTIVE To evaluate the outcomes and factors affecting success of urethroplasty in patients with stricture recurrence after Urolume urethral stent. MATERIAL AND METHODS This is a retrospective international multicenter study on patients treated with urethral reconstruction after Urolume stent. Stricture and stent length, time between urethral stent insertion and urethroplasty, age, mode of stent retrieval, type of urethroplasty, complications and baseline, and posturethroplasty voiding parameters were analyzed. Successful outcome was defined as standard voiding, without need of any postoperative adjunctive procedure. RESULTS Sixty-three patients were included. Stent was removed at urethroplasty in 61 patients. Reconstruction technique was excision and primary anastomosis in 14 (22.2%), dorsal onlay buccal mucosa graft (BMG) in 9 (14.3%), ventral onlay BMG in 6 (9.5%), dorsolateral onlay BMG in 9 (14.3%), ventral onlay plus dorsal inlay BMG in 3 (4.8%), augmented anastomosis in 5 (7.9%), pedicled flap urethroplasty in 6 (9.5%), 2-stage procedure in 4 (6.4%), and perineal urethrostomy in 7(11.1%). Success rate was 81% at a mean 59.7 +/- 63.4 months. Dilatation or internal urethrotomy was performed in 10 (15.9%) and redo-urethroplasty in 5 (7.9%). Total International Prostate Symptom Score, quality of life, urine maximum flow, and postvoid residual significantly improved (P <.0001). Complications occurred in 8 (12.7%), all Clavien-Dindo <= 2. Disease-free survival rate after reconstruction was 88.1%, 79.5%, and 76.7% at 1, 3, and 5 years, respectively. Explant of individual strands followed by onlay BMG is the most common approach and was significantly advantageous over the other techniques (P = .018). CONCLUSION Urethroplasty in patients with Urolume urethral stents is a viable option of reconstruction with a high success rate and very acceptable complication rate. Numerous techniques are viable; however, urethral preservation, tine-by-tine stent extraction, and use of BMG augmentation produced significantly better outcomes. (C) 2018 Elsevier Inc.