Long-term Follow Up of Ileal Ureteral Replacement for Complex Ureteral Strictures: Single Institution Study.

OBJECTIVE: To report our 16-year experience with ileal ureter interposition for complex ureteral stricture. Ureteral reconstruction continues to evolve to include less invasive techniques to successfully manage ureteral stricture. However, long, complex, obliterative and especially radiated ureteral strictures are not amenable to less invasive techniques and may require Ileal ureter interposition. MATERIALS AND METHODS: Retrospective review of a single institution's ureteral reconstruction database was performed. Demographics, operative details, success rate, complication rate, and length of follow-up were noted. Unilateral replacements utilized ileal ureteral interposition. Success rate was defined as no need for further open intervention. RESULTS: Between 2003 and 2019, 188 ureteral reconstructions were performed, of which 46 required ileal ureter interposition. Of these 46 patients, 10 required bilateral reconstruction. Average age was 53 years, 26 (57%) were female. The average stricture length was 9.1 cm (2-20 cm). Stricture etiology included iatrogenic causes (n = 24, 52%), radiation causes (n = 12; 26%), vascular disease (n = 3; 7%), and idiopathic retroperitoneal fibrosis (n = 3; 7%). Forty-three surgeries were performed by open abdominal approach; 3 were performed robotically. The average length of operation was 412 minutes, blood loss 417 mL and LOS was 10 days. At mean follow up of 4.4 years (1-16 years), overall success rate was 83%, with 17% (n = 8) patients requiring subsequent major surgery (5 successful ureteral revision, 3 nephrectomy) and 11 (24%) patients experiencing a major complication. CONCLUSION: In our long-term follow up of over 4 years, ileal ureteral interposition remains a successful option for complex ureteral strictures in properly selected patients.

Monitoring and malignancy concerns in patients with congenital bladder anomalies.

PURPOSE OF REVIEW: There are concerns that patients with congenital bladder anomalies (CBA) may be at higher risk for developing bladder malignancy later in life. To date there is no consensus on how to monitor these patients to prevent this devastating malignancy. We will review the current understanding of bladder malignancy in patients with CBA and the status of surveillance tests. RECENT FINDINGS: Initial reports observed that augmentation cystoplasty in CBA may be an independent risk factor for bladder malignancy. Since that time, studies have identified that the augmented bladder may not be the culprit, but the congenital bladder itself may be at risk. Further, reports determined cystoscopy and cytology are not cost-effective at detecting these malignancies. Bladder cancer in these patients at presentation is typically aggressive and presents at a younger age, high stage with high mortality. SUMMARY: Surveillance cystoscopy and cytology of the adult congenital bladder should be discontinued as the evidence shows they are not effective, given the low incidence, high cost, and inability to alter the course of disease. Symptomatic patients should prompt a detailed evaluation for bladder cancer using standard testing.

Management of the devastated posterior urethra and bladder neck: refractory incontinence and stenosis.

Stricture of the proximal urethra following treatment for prostate cancer occurs in an estimated 1-8% of patients. Following prostatectomy, urethral reconstruction is feasible in many patients. However, in those patients with prior radiation therapy (RT), failed reconstruction, refractory incontinence or multiple comorbidities, reconstruction may not be feasible. The purpose of this article is to review the evaluation and management options for patients who are not candidates for reconstruction of the posterior urethra and require urinary diversion. Patient evaluation should result in the decision whether reconstruction is feasible. In our experience, risk factors for failed reconstruction include prior radiation and multiple failed endoscopic treatments. Pre-operative cystoscopy is an essential part of the evaluations to identify tissue necrosis, dystrophic calcification, or tumor in the urethra, prostate and/or bladder. If urethral reconstruction is not feasible it is imperative to discuss options for urine diversion with the patient. Treatment options include simple catheter diversion, urethral ligation, and both bladder preserving and non-preserving diversion. Surgical management should address both the bladder and the bladder outlet. This can be accomplished from a perineal, abdominal or abdomino-perineal approach. The devastated bladder outlet is a challenging problem to treat. Typically, patients undergo multiple procedures in an attempt to restore urethral continuity and continence. For the small subset who fails reconstruction, urinary diversion provides a definitive, "end-stage" treatment resulting in improved quality of life.

Evaluation and treatment of adult concealed penis.

Concealed penis is a rare congenital disorder most commonly seen in children and the condition and surgical management have been well described. In contrast, there is a paucity of information with regards to adult concealed penis. Adult concealed penis may be due to trapping from skin contraction related to lichen sclerosis, cicatricial scars following surgical procedures, or prepubic adipose tissue causing poor phallic exposure. One of the greatest risk factors for concealed penis is obesity, and as this becomes a national pandemic, the incidence of adult concealed penis may increase. Therefore, a greater number of urologists may be faced with treating this difficult condition. This article reviews the etiology of adult concealed penis and describes the patient evaluation and various surgical approaches.

Congenital penile curvature: update and management.

Congenital penile curvature results from disproportionate development of the tunica albuginea of the corporal bodies and is not associated with urethral malformation. Patients usually present after reaching puberty as the curvature becomes more apparent with erections, and severe curvature can make intercourse difficult or impossible, at which point surgical repair is recommended. Excellent outcomes can be expected with surgical intervention. The three most commonly used repair techniques are the original Nesbit procedure, modified Nesbit procedure, and plication. Nesbit and modified Nesbit techniques require that an incision is made in the tunica albuginea while plication techniques utilize plicating sutures without an incision. While Nesbit and modified Nesbit techniques are more complex operations, these generally result in less recurrences and more satisfactory outcomes as opposed to the quicker and simpler plication technique.

Annual endoscopy and urine cytology for the surveillance of bladder tumors after enterocystoplasty for congenital bladder anomalies.

PURPOSE: It is currently recommended that patients with congenital bladder anomalies managed by enterocystoplasty undergo annual surveillance with urine cytology and endoscopy. We reviewed our experience with this protocol and suggest modifications based on this experience. MATERIALS AND METHODS: A total of 65 patients 10 years or more after enterocystoplasty were placed on an annual surveillance protocol consisting of interval medical history, renal-bladder ultrasound, serum B12, electrolytes, creatinine, urinalysis, urine cytology and endoscopy. RESULTS: Of the 65 patients 50 (77%) with enterocystoplasty (ileal in 40 and colonic in 10) remain on the protocol. Median age at the initiation of surveillance was 28 years (range 24 to 40) with a median time from augmentation of 15 years (range 12 to 29). During the first 5 years of surveillance 26 of 250 cytology results (10.5%) were suspicious for cancer. Further evaluation revealed no evidence of malignancy. Specificity for cytology was 90% with unknown sensitivity. Of 250 surveillance endoscopic evaluations 4 lesions (1.6%) were identified and biopsied/removed. Pathological evaluation revealed 1 adenomatous polyp, 1 squamous metaplasia and 2 nephrogenic adenomas. Due to the low event rate and high cost routine cytology and endoscopy were discontinued after each patient completed 5 years of followup and annual evaluations were maintained. No tumors developed during the median surveillance interval of 15 years (range 12 to 20). Currently median patient age is 42 years (range 36 to 59) and median time since augmentation is 27 years (range 23 to 40). CONCLUSIONS: Due to the low incidence of malignancy, lack of proven benefit and enhanced cost containment we recommend that annual surveillance endoscopy and cytology be discontinued.

Effects of dibutyl phthalate in male rabbits following in utero, adolescent, or postpubertal exposure.

We evaluated sequelae in male rabbits following exposure to dibutyl phthalate (DBP) at a dose level known to adversely affect testicular function in rodents without causing systemic toxicity. Because rabbits have a relatively long phase of reproductive development simulating better than rodents the reproductive development of humans, and because the use of rabbits facilitates multiple evaluations of mating ability and seminal quality, we used this animal model. Rabbits were exposed to 0 or 400 mg DBP/kg/day in utero (gestation days [GD] 15-29) or during adolescence (postnatal weeks [PNW] 4-12), and male offspring were examined at 6, 12, and 25 weeks of age. Another group was exposed after puberty (for 12 weeks) and examined at the conclusion of exposure. The most pronounced reproductive effects were in male rabbits exposed in utero. Male offspring in this group exhibited reduction in numbers of ejaculated sperm (down 43%; p < 0.01), in weights of testes (at 12 weeks, down 23%; p < 0.05) and in accessory sex glands (at 12 and 25 weeks, down 36%; p < 0.01 and down 27%; p < 0.05, respectively). Serum testosterone levels were down (at 6 weeks, 32%; p < 0.05); a slight increase in histological alterations of the testis (p < 0.05) and a doubling in the percentage (from 16 to 30%, p < 0.01) of abnormal sperm; and 1/17 males manifesting hypospadias, hypoplastic prostate, and cryptorchid testes with carcinoma in situ-like cells. In the DBP group exposed during adolescence, basal serum testosterone levels were reduced at 6 weeks (p < 0.01) while at 12 weeks, testosterone production in vivo failed to respond normally to a GnRH challenge (p < 0.01). In addition, weight of accessory sex glands was reduced at 12 weeks but not at 25 weeks after a recovery period; there was a slight increase in the percentage of abnormal sperm in the ejaculate; and 1/11 males was unilaterally cryptorchid. In both of these DBP-treated groups, daily sperm production, epididymal sperm counts, mating ability, and weights of body and nonreproductive organs were unaffected. Thus, DBP induces lesions in the reproductive system of the rabbit, with the intrauterine period being the most sensitive stage of life.