Management of urethral stricture disease: developing options for surgical intervention.
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Balanitis↗
Biomedical subjects
George D Webster
Publications and source records attributed to George D Webster.
Evaluation and surgical management of intrinsic sphincter deficiency after radical prostatectomy.
Urinary incontinence following prostatectomy is usually due to intrinsic sphincter deficiency and is often referred to as post-prostatectomy incontinence (PPI). The male sling is an effective minimally invasive procedure for low volume PPI. Although the male sling procedure is becoming increasingly popular, the artificial urinary sphincter (AUS) remains the gold standard. Placement of the AUS cuff using the transcorporal technique salvages patients with urethral atrophy as well as prior AUS erosion or infection. As the surgical options for PPI expand, it is important to analyze the outcomes with contemporary surgical techniques and to develop an algorithm for procedure selection.
Journal Article↗
Anatomical correction of vaginal vault prolapse by uterosacral ligament fixation in women who also require a pubovaginal sling.
PURPOSE: We describe the anatomical and functional outcome in patients who underwent vaginal vault fixation to the proximal uterosacral ligaments for the treatment of vault prolapse and who also required a concomitant pubovaginal sling for associated stress urinary incontinence as well as the repair of other sector defects. MATERIALS AND METHODS: We retrospectively analyzed the records of 33 patients who underwent such repairs between November 1998 and December 2001. Endopelvic fascial defects were described using the pelvic organ prolapse quantitative system (POPQ). Outcome measures included anatomical and functional assessment of pelvic floor defects and urinary incontinence. RESULTS: Preoperatively all patients complained of a vaginal bulge and stress urinary incontinence, while 17 of the 33 had urge incontinence, and 24 and 9 had POPQ stage III or IV and stage II prolapse, respectively. Mean followup was 28 months (range 6 to 43). There was significant improvement in all POPQ measurements (p <0.05). Most notably vaginal cuff support improved by a mean of 7 cm. Stages IIAp (rectocele) and IIC (cuff) prolapse developed in 4 and 2 failed cases, respectively. Stress urinary incontinence was cured in all 33 patients and urge incontinence was cured in 14 of 17, while in 27 vaginal prolapse symptoms resolved and most had improved defecation dysfunction. No patients had urinary obstructive symptoms. There were no ureteral, bladder or rectal complications but 1 patient required blood transfusion. CONCLUSIONS: Suspension of the vaginal cuff to the proximal uterosacral ligaments with site specific repair of other associated endopelvic fascial defects provides excellent anatomical and functional correction of vault prolapse. Furthermore, a concomitant pubovaginal sling is a compatible repair for associated stress urinary incontinence. It did not compromise vaginal repair and prolapse repair did not jeopardize the outcome of the sling.
Adult↗
Preoperative urodynamic evaluation may predict voiding dysfunction in women undergoing pubovaginal sling.
PURPOSE: We determine which urodynamic parameters can best predict postoperative voiding dysfunction following pubovaginal sling surgery. MATERIALS AND METHODS: The records of 98 consecutive women who had undergone pubovaginal sling surgery with allograft fascia lata between July 1998 and July 2000 were reviewed. Urodynamic and followup data were sufficient for evaluation for 73 patients. Urodynamic and clinical parameters were correlated with urinary retention, time to return of efficient voiding and development of postoperative urgency symptoms. RESULTS: Average time to return of efficient voiding was 3.92 days (median 3). Of 21 women who voided without a detrusor contraction urinary retention developed in 4 (23%) versus 0 of 48 who voided with detrusor contraction (p = 0.007). Urinary retention was defined as the need to perform even occasional self-catheterization. All 4 women with urinary retention had a detrusor pressure of less than 12 cm. H(2)O (0 in 3, 4 in 1). None of the women with a detrusor pressure of greater than 12 cm. H(2)O had urinary retention (p = 0.047). The presence of Valsalva voiding in women without a detrusor contraction did not affect the incidence of urinary retention (11.1%) compared to those who did not demonstrate Valsalva voiding (5.1%) (p = 0.603). Peak flow rate, detrusor instability on preoperative urodynamics and post-void residual urine volume were not associated with postoperative urinary retention. Finally, post-void residual urine volume predicted delayed return to normal voiding (p = 0.001). There were no other urodynamic parameters that were significantly associated with urinary retention, delayed return to normal voiding or postoperative urgency symptoms including peak flow rate, capacity or compliance. CONCLUSIONS: Women who void without or with a weak detrusor contraction are most likely to have urinary retention postoperatively. Therefore, we conclude that preoperative urodynamic evaluation may be used to counsel women regarding the risk of urinary retention following the pubovaginal sling procedure.
Fascia Lata↗
Urethral erosion after synthetic and nonsynthetic pubovaginal slings: differences in management and continence outcome.
PURPOSE: We present a series of urethral erosion following a pubovaginal sling procedure due to synthetic and nonsynthetic materials and discuss their management and continence outcome. MATERIALS AND METHODS: During a 3-year period 57 patients underwent urethrolysis for urethral obstruction after receiving a pubovaginal sling. Urethral erosion, defined as sling material entering the urethral lumen, was present in 9 patients and this cohort comprises the focus of our review. In 3 patients the eroded material was synthetic, that is ProteGen (Boston Scientific, Natick, Massachusetts) in 2 and polypropylene in 1. This condition was treated with removal of the whole sling, multilayer closure of the erosion and selective use of a Martius flap. In 6 patients the eroded material was nonsynthetic, that is allograft fascia in 5 and autograft fascia in 1. This condition was treated with sling incision and multilayer closure of the urethra. Preoperative assessment included a urogynecologic questionnaire, measurement of pad use, a voiding diary, cystourethroscopy and videourodynamics. Postoperatively similar parameters were used to assess continence outcomes and the need for subsequent procedures. RESULTS: Nine patients were followed 30 months after urethrolysis. All 9 women had some manifestation of voiding dysfunction following the pubovaginal sling procedure, including urinary retention in 4, urge incontinence in 3 and mixed incontinence in 2. Urinary retention resolved in 3 patients and urge incontinence resolved in 4. Stress urinary incontinence (SUI) persisted in 2 of the 3 patients in the synthetic group, while no patient in the nonsynthetic group had recurrent SUI. There were no recurrent urethral erosions or fistulas in either group. CONCLUSIONS: Urethral erosion after a pubovaginal sling procedure can occur irrespective of the sling material. However, recurrent SUI is not an invariable outcome of the management of urethral erosion following the pubovaginal sling procedure.
Fascia Lata↗
Perineal repair of pelvic fracture urethral distraction defects: experience in 120 patients during the last 10 years.
PURPOSE: We report the long-term success of a 1-stage perineal anastomotic repair in patients with pelvic fracture urethral distraction defects. MATERIALS AND METHODS: A retrospective analysis of 120 patients undergoing perineal bulboprostatic anastomotic repair of pelvic fracture urethral distraction defect in a single stage using our progressive approach between May 1991 and May 2001 was performed. Patients with posterior urethral stricture due to other etiologies, or those who underwent substitution urethroplasty or abdominoperineal repair were excluded from this review. Preoperative evaluation of the urethral defect included simultaneous retrograde urethrogram and voiding cystourethrogram. Postoperative retrograde urethrogram was performed at 3 weeks, 3 months, 12 to 18 months and as indicated thereafter. RESULTS: Mean patient age was 32 (range 6 to 82) years. The estimated preoperative radiographic length of the distraction defect was 3.1 cm (range 0.5 to 10). Mean followup was 64 (range 9 to 128) months, mean hospital stay was 1.8 days and duration of urethral stenting was 3.4 weeks. Perineal anastomotic repair was successful in 103 of 109 (95%) adults, in 8 of 11 (73%) prepubescent boys and in 25 of 29 (86%) undergoing secondary repairs. All treatment failures were at the anastomosis and occurred within the first postoperative year. Successful management of failed repairs was accomplished endoscopically in 3 of 7 and by repeat perineal anastomotic repair in 2 of 2, resulting in a final success rate of 97% in adults, 91% in prepubescent boys and 97% in secondary repairs. CONCLUSIONS: The overall success of our progressive 1-stage perineal anastomotic repair of pelvic fracture urethral distraction defect continues to be excellent with the majority of failures occurring in prepubescent boys and secondary repairs.
Adolescent↗
Reconstruction of posterior urethral disruption.
Posterior urethral disruption may be a devastating complication of pelvic trauma. The acute management of these injuries is reviewed as well as the controversy surrounding early versus delayed repair. The various approaches to delayed repair of pelvic fracture urethral distraction defects are presented and the technique of perineal repair is discussed in detail.
Endoscopy↗
Sacral neuromodulation in an older, urge-incontinent population.
OBJECTIVE: The success of sacral neuromodulation in the treatment of urge incontinence has been reported in young populations. Herein we report the success in an older, urge-incontinent population. STUDY DESIGN: A cohort of 25 patients older than 55 years who had failed conventional therapy for the treatment of urge incontinence underwent percutaneous S3 sacral nerve test stimulation. Patients were considered candidates for permanent implantation if they were cured or had a greater than 50% improvement in incontinent episodes. Responders were implanted and completed a questionnaire, bladder diary, and disease-specific quality-of-life questionnaire. RESULTS: Twelve of the 25 patients (48%) responded to the test stimulation. The average follow-up after permanent implantation was 7.8 months. All patients obtained a >50% reduction in their incontinent episodes; 2 patients achieved total dryness. CONCLUSION: Our small cohort suggests that older urge-incontinent patients have improvement with sacral neuromodulation but cure rates may be lower than with a younger population.
Aged↗
Surgical management of the apical vaginal defect.
PURPOSE OF REVIEW: To review the etiology, presentation, imaging techniques and current surgical management of the apical vaginal defect. RECENT FINDINGS: Urologists are increasingly managing urinary incontinence and prolapse of the anterior and posterior compartment but most refer the management of the apical defect to gynecologists. A variety of abdominal and vaginal repairs are commonly utilized to repair the apical defect, often based on the surgeon's preference. Of the abdominal repairs, abdominal sacral colpopexy with mesh remains the gold standard. Laparoscopic techniques, although feasible, have not gained widespread acceptance. Of the vaginal restorative procedures there are proponents for uterosacral ligament vault suspension, iliococcygeus and sacrospinous ligament fixation. The uterosacral ligament vault suspension is the most anatomic of the repairs and hence least likely to create a predisposition to future anterior or posterior vaginal wall defects or compromise vaginal function. In rare instances where restorative procedures are discouraged and sexual function is no longer desired, obliterative procedures, which are better tolerated, may be more appropriate. SUMMARY: The best approach for restoration of vaginal apical support remains controversial with abdominal and vaginal routes commonly utilized. A single approach or procedure based on the surgeon's preference is not always optimal. Procedure selection should be individualized based on the patient's age, comorbidities, prior surgical history and level of physical and sexual activity. The transvaginal uterosacral ligament vaginal vault suspension is increasingly our procedure of choice for management of the apical defect due to its versatility, reduced postoperative morbidity and excellent short-term results.
Female↗
Transcorporal artificial urinary sphincter cuff placement in cases requiring revision for erosion and urethral atrophy.
PURPOSE: A distal cuff location is often required in patients undergoing artificial urinary sphincter reimplantation after previous erosion or in those requiring revision because of urethral atrophy at the original cuff site. Dissecting the urethra at a more distal site increases the risk of urethral injury and erosion, and often the urethral circumference is so small that a 4 cm. cuff is too large. We present a novel technique for distal cuff placement using transcorporal dissection that leaves corporal tunica albuginea on the dorsal surface of the urethra, allowing for its safer mobilization and adding to its bulk. MATERIALS AND METHODS: We reviewed the charts of 31 men who underwent this technique and contacted 26 by telephone. The indications for distal transcorporal cuff placement varied. In 7 men with inadequate urethral coaptation with a 4 cm. proximal cuff at initial implantation a primary transcorporal tandem cuff was implanted distal. In 8 men persistent or recurrent incontinence despite a 4 cm. proximal cuff led to secondary distal reimplantation. Previous artificial urinary sphincter erosion and/or infection in 10 cases, previous urethral surgery at the optimal cuff site in 5 and radiation changes at the optimal cuff site in 1 led to selection of the more distal site and technique. Of the transcorporally placed cuffs 18 were 4 cm. and 13 were 4.5 cm. Preoperatively 5.2 pads were used daily. Of the 31 patients 27 were impotent preoperatively, 1 had normal erections, 1 had partial erections with the MUSE drug delivery system (Vivus, Inc., Menlo Park, California) and 2 had a previously placed penile prosthesis. RESULTS: At a mean followup of 17 months 26 of the 31 patients (84%) had occasional or no stress incontinence requiring 0 to 1 pad daily, 2 with pure urge incontinence used 1 to 2 pads daily and 3 had mixed incontinence requiring 0 to 3 pads daily. Of the 26 men surveyed 25 were very satisfied with the postoperative level of incontinence. Postoperatively erectile function deteriorated in 1 patient and was unchanged in the remainder. There was no erosion or infection of the transcorporally placed cuffs, although 3 were replaced for malfunction. CONCLUSIONS: This technique offers significant advantages in cases of revision. The technique protects the urethra from intraoperative dissection injury and decreases the risk of erosion because the urethra is buttressed at its vulnerable location. In addition, bulk is added to the urethra, allowing for better cuff sizing, which is usually a problem at this location where the urethra is small, thereby, improving continence in revised cases. Our success has recently led us to abandon tandem cuff placement altogether. There is a potential for deteriorating erectile function in potent men who undergo implantation in this fashion.
Atrophy↗