Extended Experience with High Submuscular Placement of Urological Prosthetic Balloons and Reservoirs: Refined Technique for Optimal Outcomes.

INTRODUCTION: Since 2012, we have routinely placed urological prosthetic balloons and reservoirs in a high submuscular location between the transversalis fascia and rectus abdominis muscle during inflatable penile prosthesis and artificial urinary sphincter surgery. We review our experience of more than 600 high submuscular cases, describe refinements in our technique through time and compare outcomes to prior consecutive space of Retzius prosthetic cases. METHODS: We retrospectively reviewed patients who underwent inflatable penile prosthesis and/or artificial urinary sphincter placement between January 2009 and April 2016. Complications and need for surgical revision were recorded and compared between the 2 placement locations. RESULTS: During the study period 872 prosthetic cases were performed, including 619 high submuscular cases from 2012 to 2016 (inflatable penile prosthesis in 344, artificial urinary sphincter in 275). Of 399 first-time high submuscular implants 54 (14%) required revision, of which 8 (2%) were attributable to the urological balloon or reservoir due to "pain/bother" (4) or herniation (4). Of the 161 space of Retzius urological balloons and reservoirs placed from 2009 to 2011 a similar rate of herniation (3 cases, 1.9%) was noted, although higher rates of deep pelvic complications (3, 1.9%) were noted compared to high submuscular cases (2, 0.5%; p=0.14). Since implementing our refined high submuscular technique, no deep pelvic complications have occurred. CONCLUSIONS: Experience with high submuscular placement of urological balloons and reservoirs confirms that it is safe and well tolerated. With refinements in technique the complication rates are similar in frequency to those with space of Retzius but appear to be minor in nature with negligible risk of visceral or vascular injury.

Erectile function after anterior urethroplasty.

PURPOSE: We ascertained the impact of anterior urethroplasty on male sexual function. MATERIALS AND METHODS: A validated questionnaire was mailed to 200 men who underwent anterior urethroplasty to evaluate postoperative sexual function. Questions addressed the change in erect penile length and angle, patient satisfaction with erection, preoperative and postoperative coital frequency, and change in erection noted by the sexual partner. Results were stratified by the urethral reconstruction method, namely anastomosis, buccal mucosal graft, penile flap and all others, and compared with those in a similar group of men who underwent circumcision only. RESULTS: Of the 200 men who underwent urethroplasty 152 who were 17 to 83 years old (mean age 45.7) completed the questionnaire. Average followup was 36 months (range 3 to 149). Overall there was a similar incidence of sexual problems after urethroplasty and circumcision. Penile skin flap urethroplasty was associated with a slightly higher incidence of impaired sexual function than other procedures (p >0.05). Men with a longer stricture were most likely to report major changes in erectile function and penile length (p <0.05) but improvement was evident with time in 61.8%. CONCLUSIONS: Overall anterior urethral reconstruction appears no more likely to cause long-term postoperative sexual dysfunction than circumcision. Men with a long stricture may be at increased risk for transient erectile changes.

Bladder rupture after blunt trauma: guidelines for diagnostic imaging.

PURPOSE: The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome. METHODS: We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series. RESULTS: Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates. CONCLUSION: The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.

Urethral plate salvage with dorsal graft promotes successful penile flap onlay reconstruction of severe pendulous strictures.

PURPOSE: A modified 1-stage penile flap onlay reconstruction is presented for patients with a long stricture in whom the urethral plate is deficient or absent. MATERIALS AND METHODS: Of 37 patients who underwent transverse penile island flap onlay urethroplasty 3 men and 1 boy required simultaneous augmentation (2) or replacement (2) of an inadequate urethral plate. The 15-year-old boy had persistent severe chordee after multiple hypospadias procedures. A dorsal buccal mucosal graft was used in 3 cases and cadaveric dermal graft was used in 1. The goal of dorsal graft application in each case was to create a uniform urethral plate 1 cm. wide to promote successful 1-stage penile flap onlay reconstruction. RESULTS: No patient has required further instrumentation and all void without difficulty. In the 15-year-old boy chordee has completely resolved. CONCLUSIONS: Using dorsal grafts to salvage an inadequate urethral plate during 1-stage penile island flap onlay reconstruction obviates flap tubularization.

Hypospadias: a contemporary epidemiologic assessment.

OBJECTIVES: To determine whether the incidence of hypospadias is increasing and whether racial differences among patients are significant, we evaluated the current incidence of hypospadias and patient race in an equal-access healthcare system. METHODS: We undertook a retrospective review of discharge records between 1990 and 1998 from 15 military treatment facilities to determine the total number of male live births and the number of male live births with hypospadias reported by race (categorized as white, black, Asian, Native American, and unknown). RESULTS: Among 99,210 male live births, 709 cases of hypospadias were identified (0.7%). Of the total male live births, 68,444 were white, 18,984 were black, 1761 were Asian, 175 were Native American, and 9846 were unknown, with an incidence of hypospadias of 0.8%, 0.6%, 0.5%, 0.6%, and 0.6%, respectively. Racial differences were not statistically significant (P = 0.2). CONCLUSIONS: The 0.7% incidence of hypospadias detected is near the upper limit of what has been historically reported. No significant difference between races was found, but the incidence of hypospadias in minorities is higher than previously reported.

Treatment of grade 4 renal stab wounds with absorbable fibrin adhesive bandage in a porcine model.

PURPOSE: In a porcine model we evaluated the efficacy of the absorbable fibrin adhesive bandage and other novel fibrin products for treating major renal stab wounds. MATERIALS AND METHODS: In commercial swine we produced an almost lethal, grade 4 renal stab wound via a 3.5 cm. sagittal, centrally located, through-and-through laceration. Each pig then received treatment in random fashion, including conventional oversewing of capsular defects with absorbable gelatin sponge and horizontal mattress sutures in 6, external absorbable fibrin adhesive bandage that was pressure held for 60 seconds in 6, external and internal absorbable fibrin adhesive bandage that was applied externally, inserted into the renal defect and pressure held for 60 seconds in 6, liquid fibrin sealant that was placed in the laceration and held for 60 seconds in 8, fibrin foam that was applied in the same manner as liquid fibrin in 5 and closing of the peritoneum over the lacerated kidney without further treatment in 6. Blood loss and time to hemostasis were recorded. Animals were sacrificed at 6 weeks to evaluate the injured renal unit. RESULTS: Compared with conventional therapy the absorbable fibrin adhesive bandage applied externally alone or externally and internally resulted in significantly less bleeding and significantly less time to hemostasis (p <0.001). Liquid fibrin and fibrin foam did not reliably achieve hemostasis. Postoperatively computerized tomography and histological sectioning suggested that the absorbable fibrin adhesive bandage results in a stable, durable clot and healing is at least as successful as with conventional treatment. CONCLUSIONS: The absorbable fibrin adhesive bandage appears to be a safe, rapid means of renal salvage after injury.

Potential uses of absorbable fibrin adhesive bandage for genitourinary trauma.

Fibrin sealants have become increasingly popular in nearly all surgical specialties. The absorbable fibrin adhesive bandage (AFAB) is a novel, potentially revolutionary product made from dried fibrinogen and thrombin. The AFAB appears to have excellent efficacy in producing rapid hemostasis in a variety of experimental major renal trauma models. The AFAB also appears to enhance healing of the urinary collecting system. Further study is essential to explore new urologic applications of this exciting technology.

Radiographic evaluation of suspected bladder rupture following blunt trauma: critical review.

Indications for urgent radiographic evaluation of suspected bladder injuries are poorly defined. Review of the existing literature reveals that traumatic bladder rupture is strongly correlated with the combination of pelvic fracture and gross hematuria. Nearly all patients with hematuria or pelvic fracture alone do not have bladder rupture. Bladder rupture is commonly associated with suprapubic discomfort or inability to void in coherent, responsive patients. Intoxicated or unresponsive patients should warrant a higher index of suspicion for bladder injury among clinicians treating patients with pelvic trauma. Similarly, patients having neurologic or preexisting urologic co-morbidities may not manifest typical symptoms of bladder rupture. The above clinical indicators should be considered when clinicians determine the appropriateness of urgent cystography to detect bladder rupture.

Q-flap reconstruction of panurethral strictures.

OBJECTIVE: To review our experience with an extended Q-shaped penile skin flap for the reconstruction of panurethral strictures. PATIENTS AND METHODS: Between 1991 and 1999, 15 men with extensive strictures underwent a single-stage urethral reconstruction with a distal circumferential penile skin flap incorporating a ventral midline extension (Q-flap). None had undergone previous urethroplasty nor had any been circumcised. RESULTS: The Q-flap provided a pedicled strip of penile skin with a mean (range) length of 17 (15-24) cm; no additional graft materials were necessary. Excellent results were obtained in 10 patients; in the remainder, complications included recurrent stricture (in two) and (in one patient each) a cerebral vascular accident, urethrocutaneous fistula, meatal stenosis, femoral neuropathy and prolonged catheterization for focal extravasation. CONCLUSION: The Q-flap provides an abundant hairless penile skin flap that enables single-stage panurethral reconstruction while eliminating the additional time and morbidity of harvesting further grafts.

Fibrin sealant treatment of splenic injury during open and laparoscopic left radical nephrectomy.

PURPOSE: We describe the use of fibrin sealant for rapid and definitive hemostasis of splenic injuries incurred during open and laparoscopic left nephrectomy. MATERIALS AND METHODS: In 2 patients undergoing left nephrectomy for a suspicious renal mass splenic laceration occurred during mobilization of the colonic splenic flexure at open nephrectomy and laparoscopic upper pole dissection, respectively. Fibrin sealant was applied topically in each case. RESULTS: In each patient fibrin sealant achieved immediate hemostasis and each recovered without further splenic bleeding. CONCLUSIONS: The topical application of fibrin sealant safely, rapidly and reliably achieves definitive hemostasis of splenic injuries. It is simple to use in the open and laparoscopic approaches.

Does the absorbable fibrin adhesive bandage facilitate partial nephrectomy?

PURPOSE: To evaluate the ability of the absorbable fibrin adhesive bandage (AFAB), a prototype product comprising lyophilized fibrinogen and thrombin on a VicrylTM mesh backing, to seal the collecting system and control bleeding after partial nephrectomy. MATERIALS AND METHODS: Growing female pigs (n = 18) underwent left nephrectomy and a 40% (by length) right lower pole partial nephrectomy. One of three treatments was immediately applied: Conventional-closure of the collecting system, ligation of visible segmental vessels, application of SurgicelTM with bolstering sutures to the renal capsule; AFAB-application of up to two 4 x 4-inch AFABs held under pressure for 60 seconds; Placebo-application of a hemostatically inert VicrylTM bandage, visually identical to the AFAB. Blood loss and ischemic and total operative times were recorded, and abdominal computerized tomography (CT) was performed on postoperative day 6. Animals were sacrificed at 6 weeks to evaluate the remaining renal mass histologically. RESULTS: Compared with conventional therapy, use of the AFAB resulted in significantly less bleeding (13 versus 68 ml., p <0.001) and lower operative (7.2 versus 16.3 minutes, p <0.001) and ischemic times (3.4 versus 7.8 minutes, p <0.001). Estimated blood loss in the placebo bandage group was dramatically higher (357 ml., p <0.001). Postoperative CT and histological sectioning suggested that the AFAB produces a stable, durable clot and that healing is at least as successful as with conventional treatment. CONCLUSION: Use of the AFAB facilitated performance of partial nephrectomy by reducing blood loss and ischemic and total operative times. The AFAB appears equivalent to conventional surgery in its ability to seal the collecting system.

Complications related to the high lithotomy position during urethral reconstruction.

PURPOSE: We identified risk factors for complications of the lower extremities related to high lithotomy positioning during specific urethral reconstruction procedures in male patients. MATERIALS AND METHODS: Records from 185 open urethroplasties were evaluated for position related complications of the lower extremities (the compartmental syndrome, rhabdomyolysis, neurapraxia). Morphometric data (patient height, weight) and surgical details (duration of surgery and lithotomy positioning, types of repair and stirrups, stricture length and location) were assessed. RESULTS: In the 185 patients 18 position related complications (10%) were identified, 4 of which were severe. Univariate analysis showed length of stricture, and duration of surgery and lithotomy positioning to be statistically significant risk factors (p <0.05). Height, weight, body mass index and type of stirrups did not increase risk. Anterior end-to-end anastomosis and straightforward buccal mucosa patch grafts entailed negligible risk. Longer procedures (prostatomembranous and penile skin flap repairs) had higher complication rates (12% and 22%, respectively). Beginning penile skin flap procedures with patients in the supine position during flap harvesting followed by repositioning into high lithotomy for perineal flap transfer virtually eliminated the risk of severe complications. CONCLUSIONS: The risk of position related complications during urethral reconstruction is directly proportional to the duration of high lithotomy positioning. Procedures of less than 5 hours in duration had minimal risk. For complex flap procedures, we perform penile flap dissection with the patient supine and reposition for perineal flap transfer.

Bladder entrapment after external fixation of traumatic pubic diastasis: importance of follow-up computed tomography in establishing prompt diagnosis.

A 30-year-old male was an unrestrained driver in a high-speed motor vehicle crash. On presentation, the patient was profoundly hypotensive with multiple injuries, including a 20-cm-deep perineal laceration with avulsion of the rectum, a diffusely tender abdomen, an unstable open-book pelvic fracture, and multiple rib fractures. Blood noted at the urethral meatus prompted a retrograde urethrogram and cystogram, which were within normal limits. A Foley catheter was placed with the return of clear urine. Closed reduction and external fixation of the pelvic fracture were performed emergently without difficulty. Postoperative computed tomography of the abdomen and pelvis revealed a retrovesical pelvic hematoma and entrapment of the bladder in the reduced pubic symphysis diastasis. Lower abdominal exploration revealed an intact bladder without evidence of gross bladder wall injury. On release of the external fixator, the bladder was easily reduced into the normal retropubic location. Definitive internal fixation of the pubic diastasis was performed. No urologic sequelae were noted postoperatively.

Sonographic staging of anterior urethral strictures.

PURPOSE: Although radiographic retrograde urethrography has traditionally been the gold standard for imaging the anterior urethra, sonourethrography has proved to be precise and effective for evaluating urethral strictures. We review the evolution of sonourethrography and demonstrate its practical contemporary applications. MATERIALS AND METHODS: We performed literature reviews on MEDLINE and chart reviews of our patient records from 1988 to 1998. RESULTS: Sonourethrography measures stricture length in the bulbar urethra more accurately than conventional retrograde urethrography. Spongiofibrosis is manifested sonographically by a lack of urethral distensibility during retrograde instillation of saline solution. Posterior shadowing is noted in severe posttraumatic cases. Sonographic staging before treatment of complex or reoperative anterior strictures elucidates complicating features, such as calculi, urethral hair, false passage and stent encrustation. CONCLUSIONS: Sonographic staging of anterior urethral strictures offers clinically important information that may be useful in guiding reconstructive therapy.

Modified anatrophic nephrolithotomy for management of staghorn calculi: is renal function preserved?

PURPOSE: We report the results of modified anatrophic nephrolithotomy in select patients with complex staghorn calculi. MATERIALS AND METHODS: From 1987 to 1997 modified anatrophic nephrolithotomy, including 1 bilateral procedure, was performed in 15 patients at San Francisco General Hospital. Preoperative imaging included excretory urography, sonography and computerized tomography. Preoperative and postoperative quantitative renal function was assessed with 99mtechnetium dimercapto-succinic acid renal scintigraphy and serum creatinine measurements. RESULTS: Mean patient age was 42 years and 11 of the 15 patients were male. Bilateral nephrolithotomy was performed in 1 patient on separate occasions. Average surgical time was 3.7 hours with blood loss of 325 ml. Length of hospital stay averaged 4 days. Residual stones were present after 3 procedures, and 1 of these patients required a secondary procedure. There were no other short-term complications. Renal function was not significantly altered. CONCLUSIONS: Modified anatrophic nephrolithotomy for staghorn renal stones rendered most patients stone-free with concomitant preservation of renal function. Because of its safety, efficacy and simplicity we believe that continued use of this procedure is warranted in select patients with complex renal stone disease.

Radiographic staging of renal injuries.

Radiographic staging of renal injuries is the orderly process of establishing an immediate diagnosis so as to expedite effective treatment. Adult patients with gross hematuria or microhematuria associated with shock should undergo urgent imaging. Computerized tomography (CT scan) is the study of choice for evaluation of stable adult and pediatric patients with suspected renal trauma. Those in need of immediate surgical intervention are best evaluated by one-shot intravenous pyelogram (IVP) to determine the extent of the injured kidney and to document the normal function of the contralateral unit. Successful management of renal trauma is guided to a major degree by appropriate renal imaging.

Anterior urethral injury.

Anterior urethral injuries, although rare, may be associated with substantial long-term morbidity. Urethral injuries that occur due to penetrating trauma or penile fracture are best treated by meticulous two-layer primary repair. Those that occur due to rapid deceleration injury are usually best treated by suprapubic diversion and delayed reconstruction because of associated injuries and concomitant contusion of the supporting spongiosum.

Reconstructive surgery for trauma of the lower urinary tract.

Blunt external trauma is the most common cause of injuries of the lower urinary tract. Minor injuries often heal uneventfully with catheter drainage. Penetrating traumas are best treated with primary repair. Delayed reconstruction of urethral disruption injuries is safe and effective in the majority of cases, but immediate realignment is an attractive, minimally invasive alternative. Pelvic MR imaging and urethral ultrasound are important ancillary staging studies for evaluating patients who require complex urethral reconstruction.

Single shot intraoperative excretory urography for the immediate evaluation of renal trauma.

PURPOSE: We reviewed the quality and usefulness of single shot intraoperative excretory urography (IVP) for evaluating suspected upper urinary tract trauma at our trauma center. MATERIALS AND METHODS: Between 1990 and 1997 single shot intraoperative IVP for staging renal injuries was performed in 50 patients in whom clinical instability and/or major associated injuries mandated an intraoperative study. Contrast material (2 ml/kg) was injected intravenously and images were obtained after 10 minutes. The quality and usefulness of each study were scored by a single attending urologist on a scale of 1-worst to 5-best. RESULTS: Intraoperative study quality was generally good (average score 3.84). The information obtained was generally considered useful for determining urological treatment (average score 3.96). In 16 patients (32%) intraoperative IVP findings safely obviated renal exploration. No contrast medium reactions were noted and no complications developed that were attributable to intraoperative IVP. CONCLUSIONS: Intraoperative single shot, high dose IVP is safe, efficient and of high quality in the majority of cases when performed as recommended. This study often provides important information that facilitates rapid and accurate decision-making. Intraoperative IVP is a useful tool for guiding the exploration of penetrating renal injuries and confirming blunt renal injuries that may be safely observed.

Yield and efficacy of biopty gun testis needle biopsy.

OBJECTIVES: To assess whether a preliminary skin incision enhances diagnostic yield of percutaneous testis biopsy and to further evaluate the clinical efficacy of this procedure. METHODS: A total of 45 men (67 testes) underwent testicular biopsy with two passes of a Biopty gun spring-loaded needle. Twenty-seven biopsies were performed without a preliminary skin incision (group 1), and 40 were performed after a small scrotal incision (group 2). In 56 testes, needle biopsy histopathologic diagnosis was compared with that of open biopsy or orchiectomy specimens from the same patient. Needle and surgical specimens were fixed in Bouin's solution and sent separately for independent, blinded, histologic interpretation. RESULTS: Complications of the procedure were negligible. In all 67 needle biopsies, specimen quality was adequate for histopathologic interpretation. The mean number of seminiferous tubules obtained from needle biopsy was 28% higher among patients having a preliminary skin incision (25.9) compared with those without (18.7, P = 0.023). Correlation between needle and open histopathologic diagnosis was excellent (55 of 56, 98%). CONCLUSIONS: A preliminary skin incision made before needle biopsy increases the diagnostic yield of percutaneous testis biopsy. Percutaneous testis biopsy using the Biopty gun needle provides equal diagnostic information when compared with open testis biopsy or orchiectomy specimens. The concomitant reduction in morbidity and cost make this an attractive diagnostic procedure.