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Doležel J, Hrabec R, Uher M, Čapák I, Šebová N, Staník M. Substitution Urethroplasty with Buccal Mucosal Graft in the Management of Stricture of Vesicourethral Anastomosis or Membranous Urethra: Single-Institution Long-Term Experience with Perineal Approach and Endourethroplasty. Urology 2024:S0090-4295(24)00418-7. [PMID: 38830554 DOI: 10.1016/j.urology.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/11/2024] [Accepted: 05/20/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVE To present long-term experience with buccal mucosa posterior urethroplasty (BMPU) for refractory posterior urethral stenosis (PUS) or vesicourethral anastomosis stenosis (VUAS) either by perineal approach (PA) or by endourethroplasty (EUP). MATERIALS AND METHODS A single-center retrospective study of 38 consecutive patients operated on between 1999 and 2022. BMPU consisted of the transfer of onlay or tubular buccal mucosa grafts into dilated and/or incised strictures through an open or endourological approach. If VUAS or PUS recurred with short stenosis within the first 12 months after surgery, it was transected by a cold-knife direct vision internal urethrotomy (DVIU), referred to as an 'auxiliary' DVIU. The primary outcome was three-year stricture recurrence-free survival (SRFS). RESULTS BMPU by perineal approach and EUP were performed in 27 (71%) and 11 (29%) patients, respectively. The three-year SRFS was 65% for the whole cohort, with rates of 63% for the perineal approach and 73% for endourological approach. With permitted auxiliary DVIU, three-year SRFS for the whole cohort was 81%. De novo incontinence occurred in 2 out of 18 preoperatively continent patients. Limitations include the retrospective nature of the single-center study and a small, heterogenous cohort of patients. CONCLUSIONS We present two techniques of substitution urethroplasty with BMG in the management of PUS and VUAS with a low rate of recurrence or de novo incontinence. A novel endourological approach (EUP) is a promising minimally invasive alternative to the perineal approach.
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Affiliation(s)
- Jan Doležel
- Department of Urologic Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic; Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Hrabec
- Department of Urologic Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic; Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michal Uher
- Research Group Bioinformatics, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Ivo Čapák
- Department of Urologic Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic; Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Natália Šebová
- Department of Urologic Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic; Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michal Staník
- Department of Urologic Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic; Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
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Myers JB, Hernandez BS, McCormick B, Ramsay J, Kriesel JD, Hebert KJ, Fendereski K. Comparison of Urinary Diversion in Patients With Prostatic Fistula to Those with Localized Radiation Injury After Radiotherapy for the Treatment of Prostate Cancer. Urology 2024; 183:256-263. [PMID: 38040294 DOI: 10.1016/j.urology.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE To compare characteristics and outcomes in patients who had radiotherapy (RT) for prostate cancer (PCa) and underwent urinary diversion (UD) due to prostatic fistula (Fistula) vs localized radiation injury (Localized). METHODS This study was a retrospective single-institution study. Exclusion criteria included follow-up <3 months, large pelvic tumor, and surgery for cancer control. The Fistula group included fistulization outside of the urinary tract (rectal, soft tissue, thigh, pubic symphysis, and extensive necrosis surrounding the prostate). The group Localized had a multitude of problems; however, all were confined to the urinary tract. Patient characteristics, perioperative variables, and outcomes were compared between groups. RESULTS Sixty-nine patients were included and had UD from 2009-2022. Median age and time from RT to UD were 73 (interquartile range (IQR) 67.9, 78.1) and 7.3 (IQR 3.2, 12.5) years. There were 29 (42%) and 40 (58%) patients in the Fistula and Localized groups. The Fistula group had a higher rate of abdominal/perineal approach (62.1% vs 12.5%, P <.001), a lower rate of right colon pouch (17.2% vs 40%, P = .043), and a longer operative time (515.7 vs 414.2 minutes, P = .017). Clavien-Dindo complications ≥3 were higher in the Fistula group (44.8% vs 20%, P = .027), including a higher rate of re-operation for recurrent pelvic abscess (37.9% vs 5%, P <.001). Survival for the cohort was 85.5% and did not differ between groups. CONCLUSION Patients with prostate fistula after RT for PCa undergoing UD had longer, more complex operations, and higher rates of complications, notably post-operative pelvic abscesses, compared to men with localized RT injury. Long-term survival was comparable in both groups.
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Affiliation(s)
- Jeremy B Myers
- University of Utah, Department of Surgery (Urology), Salt Lake City, UT
| | | | | | - Joemy Ramsay
- University of Utah, Department of Surgery (Urology), Salt Lake City, UT
| | - John D Kriesel
- University of Utah, Department of Internal Medicine (Infectious Disease), Salt Lake City, UT
| | - Kevin J Hebert
- University of Utah, Department of Surgery (Urology), Salt Lake City, UT
| | - Kiarad Fendereski
- University of Utah, Department of Surgery (Urology), Salt Lake City, UT.
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3
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Jung H, Chen ML, Wassersug R, Mukherjee S, Kumar S, Mankowski P, Genoway K, Kavanagh A. Urethroplasty Outcomes for Pars Fixa Urethral Strictures Following Gender-affirming Phalloplasty and Metoidioplasty: A Retrospective Study. Urology 2023; 182:89-94. [PMID: 37467808 DOI: 10.1016/j.urology.2023.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/03/2023] [Accepted: 07/05/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To evaluate outcomes of three urethroplasty techniques for pars fixa (PF) urethral strictures and provide a treatment algorithm based on stricture characteristics. The PF is an essential anatomic region of the neourethra created in gender-affirming phalloplasty and metoidioplasty. Urethral strictures in this region present a reparative challenge given its unique anatomy and vascularization. METHODS A total of 41 urethroplasties performed on 41 patients between March 2018 and June 2021 were reviewed at two surgical centers. A Heineke-Mikulicz (HM) repair was done for strictures under 20 mm when the proximal and distal urethral segments were mobile and supported a tension-free closure. Substitution urethroplasty with ventral onlay buccal mucosal graft was utilized for strictures under 40 mm not suitable for HM repair. Complex or long (≥40 mm) strictures were treated by two-stage Johansen urethroplasty. Success of each surgical approach was defined by a minimum of 12-month follow-up without the need for a repeat intervention. RESULTS Mean follow-up was 30.2 months (range: 12.4-52.0 months). Mean stricture length was 16.9 mm (range: 2-55 mm). Most strictures (46%) were located at the distal PF. HM urethroplasty had a success rate of 44% (n = 16). Substitution urethroplasty had a success rate of 92% (n = 13). Two-stage Johansen urethroplasty had a success rate of 75% (n = 12). CONCLUSION The success rates of PF urethral stricture repair ranged from 44% to 92% depending on the surgical approach, and the best reparative procedure depends on stricture length, severity, and local tissue mobility.
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Affiliation(s)
- Hoyoung Jung
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | | | - Richard Wassersug
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Smita Mukherjee
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Sahil Kumar
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Peter Mankowski
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada; Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Krista Genoway
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada; Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex Kavanagh
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada; Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada.
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Sterling J, Rahman SN, Varghese A, Angulo JC, Nikolavsky D. Complications after Prostate Cancer Treatment: Pathophysiology and Repair of Post-Radiation Urethral Stricture Disease. J Clin Med 2023; 12:3950. [PMID: 37373644 DOI: 10.3390/jcm12123950] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Radiation therapy (RT) in the management of pelvic cancers remains a clinical challenge to urologists given the sequelae of urethral stricture disease secondary to fibrosis and vascular insults. The objective of this review is to understand the physiology of radiation-induced stricture disease and to educate urologists in clinical practice regarding future prospective options clinicians have to deal with this condition. The management of post-radiation urethral stricture consists of conservative, endoscopic, and primary reconstructive options. Endoscopic approaches remain an option, but with limited long-term success. Despite concerns with graft take, reconstructive options such as urethroplasties in this population with buccal grafts have shown long-term success rates ranging from 70 to 100%. Robotic reconstruction is augmenting previous options with faster recovery times. Radiation-induced stricture disease is challenging with multiple interventions available, but with successful outcomes demonstrated in various cohorts including urethroplasties with buccal grafts and robotic reconstruction.
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Affiliation(s)
- Joshua Sterling
- Yale School of Medicine, 20 York Street, New Haven, CT 06511, USA
| | - Syed N Rahman
- Yale School of Medicine, 20 York Street, New Haven, CT 06511, USA
| | - Ajin Varghese
- New York College of Osteopathic Medicine, 8000 Old Westbury, Glen Head, NY 11545, USA
| | - Javier C Angulo
- Faculty of Biomedical Sciences, Universidad Europea, 28905 Madrid, Spain
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Kunkel G, Patel H, Kaldany A, Allu S, Elsamra S, Cancian M. Pelvic radiation-induced urinary strictures: etiology and management of a challenging disease. World J Urol 2023; 41:1459-1468. [PMID: 37014391 DOI: 10.1007/s00345-023-04378-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/16/2023] [Indexed: 04/05/2023] Open
Abstract
Radiation is a common treatment modality for pelvic malignancies. While it can be effective at cancer control, downstream effects can manifest months to years after treatment, leaving patients with significant morbidity. Within urology, a particularly difficult post-radiation consequence is urinary tract stricture, either of the urethra, bladder neck, or ureter. In this review, we will discuss the mechanism of radiation damage and treatment options for these potentially devastating urinary sequelae.
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Affiliation(s)
- Gregory Kunkel
- Department of Urology, UMass Chan: University of Massachusetts Medical School, Worcester, MA, USA.
| | - Hiren Patel
- Division of Urology, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alain Kaldany
- Division of Urology, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sai Allu
- Division of Urology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Sammy Elsamra
- Division of Urology, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Madeline Cancian
- Division of Urology, Brown University Warren Alpert Medical School, Providence, RI, USA
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Krughoff K, Shapiro J, Peterson AC. Pelvic Fracture Urethral Distraction Defect. Urol Clin North Am 2022; 49:383-391. [DOI: 10.1016/j.ucl.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Balzano FL, Abramowitz DJ, Sam AP, Pachorek M, Warner JN. Simplified posterior urethroplasty utilizing laparoscopic instrumentation. Transl Androl Urol 2022; 10:4384-4391. [PMID: 35070820 PMCID: PMC8749072 DOI: 10.21037/tau-21-498] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/12/2021] [Indexed: 11/06/2022] Open
Abstract
Background Posterior urethral stricture disease presents challenges for even the most skilled reconstructive urologists. Regardless of the surgical technique used, these are complex operations that occur in hard-to-access locations. We describe the use of a novel combination of laparoscopic instrumentation to simplify posterior urethral reconstruction. Methods We retrospectively identified patients undergoing a posterior urethral stricture repair utilizing a combination of the RD-180® suture device and the Securestrap®. These procedures were performed by a single surgeon at our institution. Patients with greater than or equal to 4 months of follow up were included in the analysis. Results From October 2016 to October 2020, 20 patients underwent posterior urethral stricture repair using these laparoscopic instruments. Median age was 70 years (28–90 years). Median follow up was 12 months (5–50 months). Mean stricture length was 3 cm (1.5–16 cm). Median operative time was 150 minutes (120–180 minutes). No peripheral neuropathies or positional injuries were noted. With failure defined as inability to pass a 16-Fr scope, success rate was 95% (19/20 patients). Conclusions The combination of the RD-180® and the Securestrap® has become essential to our posterior urethral stricture repair armamentarium. Further data and longer follow up is needed to confirm these reliable outcomes.
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Liu W, Shakir N, Zhao LC. AUTHOR REPLY. Urology 2022; 159:221. [PMID: 35027180 DOI: 10.1016/j.urology.2021.07.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/19/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Wen Liu
- Department of Urology, Grossman School of Medicine at New York University Langone Health, New York, NY
| | - Nabeel Shakir
- Department of Urology, Grossman School of Medicine at New York University Langone Health, New York, NY
| | - Lee Cheng Zhao
- Department of Urology, Grossman School of Medicine at New York University Langone Health, New York, NY
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9
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Bearrick E, Viers B. EDITORIAL COMMENT. Urology 2022; 159:220-221. [PMID: 35027179 DOI: 10.1016/j.urology.2021.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/19/2021] [Indexed: 10/19/2022]
Affiliation(s)
| | - Boyd Viers
- Department of Urology, Mayo Clinic, Rochester, MN
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10
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Martins FE, Holm HV, Lumen N. Devastated Bladder Outlet in Pelvic Cancer Survivors: Issues on Surgical Reconstruction and Quality of Life. J Clin Med 2021; 10:4920. [PMID: 34768438 PMCID: PMC8584541 DOI: 10.3390/jcm10214920] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022] Open
Abstract
Bladder outlet obstruction following treatment of pelvic cancer, predominantly prostate cancer, occurs in 1-8% of patients. The high incidence of prostate cancer combined with the long-life expectancy after treatment has increased concerns with cancer survivorship care. However, despite increased oncological cure rates, these adverse events do occur, compromising patients' quality of life. Non-traumatic obstruction of the posterior urethra and bladder neck include membranous and prostatic urethral stenosis and bladder neck stenosis (also known as contracture). The devastated bladder outlet can result from benign conditions, such as neurogenic dysfunction, trauma, iatrogenic causes, or more frequently from complications of oncologic treatment, such as prostate, bladder and rectum. Most posterior urethral stenoses may respond to endoluminal treatments such as dilatation, direct vision internal urethrotomy, and occasionally urethral stents. Although surgical reconstruction offers the best chance of durable success, these reconstructive options are fraught with severe complications and, therefore, are far from being ideal. In patients with prior RT, failed reconstruction, densely fibrotic and/or necrotic and calcified posterior urethra, refractory incontinence or severe comorbidities, reconstruction may not be either feasible or recommended. In these cases, urinary diversion with or without cystectomy is usually required. This review aims to discuss the diagnostic evaluation and treatment options for patients with bladder outlet obstruction with a special emphasis on patients unsuitable for reconstruction of the posterior urethra and requiring urinary diversion.
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Affiliation(s)
- Francisco E. Martins
- Department of Urology, School of Medicine, University of Lisbon, Hospital Santa Maria/CHULN, 1649-035 Lisbon, Portugal
| | | | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, 9000 Ghent, Belgium;
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Multi-Institutional Study of Dorsal Onlay Urethroplasty of the Membranous Urethra after Endoscopic Prostate Procedures: Operative Results, Continence, Erectile Function and Patient Reported Outcomes. J Clin Med 2021; 10:jcm10173969. [PMID: 34501417 PMCID: PMC8432256 DOI: 10.3390/jcm10173969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
(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.
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Warner JN, Gallegos MA. Letter to the Editor RE: Multi-Institutional Outcomes and Associations after Excision and Primary Anastomosis for Radiotherapy-Associated Bulbomembranous Urethral Stenoses Following Prostate Cancer Treatment. Urology 2021; 153:359-360. [PMID: 33945816 DOI: 10.1016/j.urology.2021.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Jonathan N Warner
- Department of Surgery, Division of Urology, City of Hope Duarte, CA.
| | - Maxx A Gallegos
- Department of Surgery, Division of Urology, University of New Mexico, Albuquerque, NM
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Waterloos M, Martins F, Verla W, Kluth LA, Lumen N. Current Management of Membranous Urethral Strictures Due to Radiation. Front Surg 2021; 8:635060. [PMID: 33748181 PMCID: PMC7969877 DOI: 10.3389/fsurg.2021.635060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/01/2021] [Indexed: 11/13/2022] Open
Abstract
Radiotherapy is a frequently used treatment for prostate cancer. It does not only causes the intended damage to cancer cells, but also affects healthy surrounding tissue. As a result radiation-induced urethral strictures occur in 2.2% of prostate cancer patients. Management of urethral strictures is challenging due to the presence of poor vascularized tissue for reconstruction and the proximity of the sphincter, which can impair the functional outcome. This review provides a literature overview of risk factors, diagnostics and management of radiation-induced urethral strictures.
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Affiliation(s)
- Marjan Waterloos
- Department of Urology, AZ Maria Middelares Ghent, Ghent, Belgium
- Department of Urology, University Hospital Ghent, Ghent, Belgium
| | - Francisco Martins
- Department of Urology, University of Lisbon School of Medicine, Lisbon, Portugal
| | - Wesley Verla
- Department of Urology, University Hospital Ghent, Ghent, Belgium
| | - Luis Alex Kluth
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Nicolaas Lumen
- Department of Urology, University Hospital Ghent, Ghent, Belgium
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Esquinas C, Ruiz S, de Sancha E, Vazquez M, Dorado JF, Virseda M, Arance I, Angulo JC. Outcomes of a Series of Patients with Post-Prostatectomy Incontinence Treated with an Adjustable Transobturator Male System or Artificial Urinary Sphincter. Adv Ther 2021; 38:678-690. [PMID: 33230712 PMCID: PMC7854436 DOI: 10.1007/s12325-020-01563-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/04/2020] [Indexed: 12/26/2022]
Abstract
Introduction A prospective evaluation of outcomes in a series of patients with post-prostatectomy incontinence (PPI) treated with two different devices is presented. Methods Consecutive patients with PPI underwent interventions with an adjustable transobturator male system (ATOMS) or artificial urinary sphincter (AUS). Decisions were based on patient preference after physician counselling. Patient characteristics and operative and postoperative parameters including dryness, satisfaction, complications, revision and device durability were evaluated. Results One hundred twenty-nine patients were included: 102 (79.1%) received ATOMS and 27 (20.9%) AUS. Mean follow-up was 34.9 ± 15.9 months. No difference was observed between patient age (p = 0.56), ASA score (p = 0.13), Charlson index (p = 0.57) and radiation (p = 0.3). BMI was higher for AUS (27.1 vs. 29.7; p = 0.003) and also baseline incontinence severity (7.9% mild, 44.1% moderate and 48% severe for ATOMS vs. 11.1% moderate and 88.9% severe for AUS; p = 0.0007). Differential pad test was higher for AUS (− 470 vs. − 1000 ml; p < 0.0001) and so was ICIQ-SF (15.62 vs. 18.3; p < 0.001), but total dryness (76.5 vs. 66.7%; p = 0.33), social continence (90.2 vs. 85.2%; p = 0.49) and satisfaction (92.2 vs. 88.9%; p = 0.69) were equivalent. The postoperative complication rate was similar (22.6 vs. 29.6%; p = 0.4). The surgical revision rate was higher for AUS (6.9 vs. 22.2%; p = 0.029) and also the explant rate but did not reach statistical significance (4.9 vs. 14.8%; p = 0.09). Time to explant was shorter for AUS (log-rank p = 0.021). Regression analysis revealed radiation (p = 0.003) and incontinence severity (p = 0.029) predict total dryness, while complications (p < 0.005) and type of device (p = 0.039) independently predict surgical revision. Conclusions Both ATOMS and AUS are effective devices. Pad test change for AUS exceeds that of ATOMS. The revision rate is higher for AUS, and durability is superior for ATOMS. The satisfaction rate is equivalent. Larger series and longer follow-up are needed to compare both devices more appropriately. According to our experience, the AUS is not the only gold standard for PPI. Electronic supplementary material The online version of this article (10.1007/s12325-020-01563-z) contains supplementary material, which is available to authorized users.
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