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Urethral Reconstruction - SIU 2006 Cape Town South Africa: Society Of Genitourinary Reconstructive Surgeons

March 28, 2017

UroToday- The Society of Genitourinary Reconstructive Surgeons met with a theme entitled New Techniques in Reconstructive Urologic Surgery. The session was chaired by Allen Morey from San Antonio and Kenneth Angermeier from Cleveland.

Part one of the meeting was devoted to urethral reconstruction and ran two hours in length.

Dr. Angermeier first lectured on the use of buccal mucosa in urethral reconstruction with special attention to current issues and advanced techniques. Ken touched upon all of the hotly debated questions including donor site, site of graft placement, and whether to leave the donor site open or closed after harvest. Recommendations included using the cheek as the donor site whenever possible while discussions included the increasing use of lingual mucosa if needed. He was also able to validate that leaving the donor site open rather than closing it did not lead to increased morbidity and may actually decrease post-operative symptoms of pain and tightness. He also described the use the tunica vaginalis flap to aid in urethral coverage after the closure of the second stage of a 2 stage urethral reconstruction.

Guido Barbagli from Arezzo Italy then lectured on the disease of Lichen Sclerosis of the male genitalia (or Balanitis Xerotica Obliterans). Lichen sclerosis is a complex immunological disorder of the genitalia which is progressive. It has also been associated with penile cancer with the incidence of neoplastic changes being between 2.3% to 8.4%. The histology of the disease was discussed with the pathologic finding of hyperkeratosis and vacuolar degeneration of the basal layer being characteristic. Surgical treatment varies widely but principles included the strict avoidance of the use of genital skin in the reconstruction and the absolute necessity of the need to assess the more proximal urethra which at first glance may seem uninvolved. Reconstruction centered on two-stage reconstructions with buccal mucosa and one report from Pune India of a one stage buccal mucosa reconstruction that utilized the Snodgrass technique where the urethral plate is split, a dorsal buccal graft placed, and the urethra subsequently tubularized.

Allen Morey from San Antonio discussed new perspectives in the reconstruction of traumatic urethral strictures. His discussion centered on answering the question of what the limits of an anastomotic or end-to-end urethroplasty truly are. Due to the known attrition over time of all substitution urethroplasties (even buccal mucosa grafts) Allen discussed results seen with anastomotic urethroplasties of bulbar strictures even 5 cm long. Factors that allow this extended anastomotic urethroplasty include and adequate penile length and adequate perineal length. Strictures that are located in the proximal ½ of the perineum are likely to be amenable to this aggressive mobilization and anastomosis.

Dr. Angermeier then discussed his experience with the management of radiotherapy-induced rectourethral fistulas. Kenneth discussed the increasing incidence of this condition with the use of combined radiation modalities such as brachytherapy plus external beam radiotherapy and with the advent of high dose rate brachytherapy. He discussed his techniques for repair that centered on the interposition of tissue (whether it is omentum or buccal mucosa with a gracilis flap). Ken believes flap type repairs, such as the York-Mason, have a low chance of success. In his series of 22 patients, 10 had undergone combined radiation therapy modalities. Time to presentation averaged 2 years and both fecal and urinary diversion with a suprapubic tube was essential and should be performed 3-6 months prior to any attempt at repair.

Finally, Andre Cavalcanti from Brazil discussed the presentation and subsequent management of gun shot wounds to the posterior urethra and prostate. In his large series of 13 patients, damage control and suprapubic diversion with delayed reconstruction was the preferred method of treatment in 11 patients while 2 underwent open primary alignment. Principles for definitive reconstruction, which was performed at a mean of 7 months post-injury, include urethral mobilization and tension-free anastomosis of what ultimately was a 1-3 cm urethral stricture or defect. Urethral catheters were kept for 3-4 weeks and the success rate was 82% with a mean follow-up of 2.3 years.

-- Allen Morey from San Antonio
-- Kenneth Angermeier from Cleveland
-- Guido Barbagli from Arezzo Italy
-- Andre Cavalcanti from Brazil
SIU 2006, Cape Town, South Africa, GURS Meeting, Sunday, November 12

Reviewed by Contributing Editor Michael J. Metro, MD

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