The urachal flap: a previously unreported tissue flap in vesicovaginal fistula repair.

OBJECTIVES: Tissue interposition is an important part of vesicovaginal fistula (VVF) repair that has been shown to improve success rates. The most common interpositional flap used during a transabdominal VVF repair is the omental flap; however, in some cases, it cannot be used. The urachus is a well-vascularized tissue that is easily mobilized for interposition. We describe our experience using a urachal flap in VVF repair. METHODS: Patients undergoing VVF repair at our center were identified, and a retrospective chart review was performed. Patients who underwent a transabdominal repair with interposition of a urachal flap were included. RESULTS: Thirteen patients were identified between 2005 and 2009. All were evaluated with a history, physical, upper and lower tract imaging, and cystoscopy. Median patient age was 49 years (range, 31-88 years). Fistula etiology was hysterectomy in 11 and prolapse repair in 2. Five patients presented with recurrent fistulas having failed previous repair. Of 13 patients, 12 had successful repairs with our described technique, including 4 patients who failed previous repairs. There was no recurrence of fistula after median follow-up of 6 months (range, 2 weeks to 4 years). Two patients had preoperative and postoperative complaints of stress urinary incontinence that was mild and did not require surgery. CONCLUSIONS: Vesicovaginal fistulas can be a difficult challenge for the reconstructive surgeon. The urachal flap is a well-vascularized tissue flap that can be easily mobilized and interposed for VVF repair. Of 13 patients in this series, 12 were successfully repaired using this technique. We feel that further evaluation and usage of this tissue flap are indicated.

Outcome of penile revascularization for arteriogenic erectile dysfunction after pelvic fracture urethral injuries.

OBJECTIVE: To review our experience with penile revascularization for patients with bilateral occlusion of the deep internal pudendal arteries after pelvic fracture urethral injury (PFUI). MATERIALS AND METHODS: We identified 17 patients who had undergone penile revascularization with end-to-side anastomosis of the deep inferior epigastric artery to the dorsal penile artery from July 1991 to December 2010. Success was defined as achieving erections sufficient for intercourse with or without pharmacologic assistance. RESULTS: All patients had had a PFUI causing arterial insufficiency and erectile dysfunction not responsive to pharmacologic intervention. Of the 17 patients, 4 (24%) underwent revascularization before and 13 (76%) after PFUI repair. The mean age at revascularization was 32.7 years (range 17-54). At an average follow-up of 3.1 years, the surgery was successful in 14 of the 17 patients (82%). In patients with erectile dysfunction as an indication for surgery, successful erections were achieved in 11 of 13. For those who underwent revascularization to prevent ischemic stenosis of the urethral repair, 3 of 4 achieved successful erections, and all subsequent urethral surgeries were successful. The penile duplex ultrasound parameters showed clinically and statistically significant improvements after revascularization. No operative complications developed. The average hospital length of stay was 4.7 days. Four patients experienced early postoperative complications, including an abdominal wall hematoma requiring evacuation in one, penile edema in two, and a superficial surgical site infection in one. No late complications occurred. CONCLUSION: Penile arterial revascularization in select patients can allow for successful treatment of PFUIs and the refractory erectile dysfunction caused by them.

Assessment and initial management of urologic trauma.

This article discusses the appropriate assessment, initial management, timely referral to a urologist for abdominal, bladder, urogenital, and renal/renal collecting system injury. Appropriate laboratory and physical examinations, as well as radiologic imaging, are paramount to obtaining accurate diagnosis and to providing appropriate treatment.

Correlation of CT scan versus plain radiography for measuring urinary stone dimensions.

OBJECTIVES: To correlate the measured dimensions of urinary stones from spiral non-contrast computerized tomography (CT) with that of plain radiography (KUB). METHODS: The transverse diameter as reported on CT was compared to the measured transverse diameter on KUB for 61 stones. The transverse and craniocaudal dimensions on CT were then re-measured for 30 urinary stones and again compared to the re-measured values for KUB. The craniocaudal dimension on CT was determined by measuring the stone on reconstructed coronal CT images. Measurements between imaging modalities were blinded and performed consecutively by a dedicated investigator. RESULTS: The mean transverse size of the stones on the initial CT report was 6.0 mm +/- 2.8 mm versus 5.6 mm +/- 2.3 mm on KUB (paired t-test, p = 0.05, 95% CI difference between the means -1.3 to 0.5). The stones were categorized in transverse size ranges of 1.0 mm to 5.0 mm, > 5.0 mm to 10.0 mm, and > 10.0 mm. A total of 14 stones failed to be put into the same size categories by the two methods. The largest difference in measurements was 5 mm. In the second analysis, where the CT dimensions were re-measured, the mean transverse dimension on CT was 4.5 mm +/- 2.1 mm versus 4.7 mm +/- 2.0 mm on plain radiography (paired t-test, p = 0.06, 95% CI difference between the means -0.02 to 0.6). Mean craniocaudal dimension of the stones on CT was 7.4 mm +/- 3.2 mm versus 6.0 mm +/- 2.7 mm on plain radiography (paired t-test, p = 0.0001, 95% CI between the means -2.0 to -0.9). When the stones were categorized in transverse size ranges of 1.0 mm to 5.0 mm, >5.0mm to 10.0mm, and >10.0mm, CT and KUB agreed for 30/30 stones. CONCLUSIONS: In this study, the initially reported CT transverse values were found to be significantly different from measured KUB values; moreover, large differences of up to 5 mm were found between the measurements. With fastidious measurement of stone dimensions on both CT and KUB, we found that the transverse dimension of stones measured by the two imaging modalities were similar. The craniocaudal measurements of the stones were found to be significantly different on CT versus KUB, with CT measurement being 1.4 mm larger on average.

Intact specimen extraction in laparoscopic nephrectomy procedures: Pfannenstiel versus expanded port site incisions.

OBJECTIVES: Laparoscopic nephrectomy is considered the standard of care for most Stage T1 and T2 renal tumors. Most centers perform intact extraction rather than morcellation. The extraction incision location varies, with no consensus on the best site. We compared the operative and perioperative parameters after transperitoneal laparoscopic nephrectomy procedures with intact specimen extraction through a Pfannenstiel (PFN) or expanded port site (EPS) incision. METHODS: The consecutive charts of 150 patients (March 2001 to October 2003) undergoing laparoscopic radical nephrectomy (LRN), laparoscopic nephroureterectomy, or laparoscopic donor nephrectomy with intact specimen extraction were reviewed. The specimens were extracted by way of a PFN or an EPS incision. Two analyses were completed. The first included only LRN, and the second included LRN, laparoscopic nephroureterectomy, and laparoscopic donor nephrectomy. RESULTS: In the LRN-only analysis, the PFN group had a shorter hospital stay (2.84 versus 3.37 days, P <0.05). This group also used significantly less morphine (23.7 versus 47.3 mg, P <0.006). The PFN group in the second analysis also used less morphine (26.3 versus 51.1 mg, P <0.002). Four extraction site complications were found; 1 patient in the PFN group developed cellulitis, and 3 patients in the EPS group developed an incisional hernia. CONCLUSIONS: This evidence suggests reduced morbidity with intact specimen extraction through a PFN incision compared with an EPS incision during laparoscopic nephrectomy procedures. Our practice has been modified on the basis of these data, and all specimens are now removed through a PFN incision when suitable. Urologists should consider PFN incisions for specimen extraction with laparoscopic nephrectomy procedures.