57 Urethral Rest Promotes Identification of Resectable Stricture Segments During Anterior Urethral Reconstruction

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57 Urethral Rest Promotes Identification of Resectable Stricture Segments During Anterior Urethral Reconstruction
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  RESULTS: 44,071 of 132,606 cases (33%) were missing atleast one component of cT stage, PSA or Gleason grade. Of those withmissing data 51% were missing cT stage only and 91% of those werecategorized as T2NOS. 22% were missing PSA only. 2% were missingGleason score only. The remainder (25%) was missing combinations of multiple variables. Men who were missing at least one variable weremore likely to be high risk on the other known variables (p  0.0001).When men who were only missing data based on T2NOS were com-pared to men with known T2a/b/c, they still differed on Gleason scoreand PSA (p  0.0001).CONCLUSIONS: D’Amico risk stratification is difficult withSEER cases due to missing data in 33%. Those with missing data arehigher risk patients; thus, to exclude them creates a biased sample.One may consider reporting grade, stage and PSA separately in order to avoid reporting bias. We are currently working on validating methodsof imputing missing data so as to avoid excluding these high riskpatients. Source of Funding:  National Institutes of Health 5K12-RR023247-03 56 NOCTURIA IS A MARKER OF INCREASED MORTALITY RISK:RESULTS FROM THE THIRD NATIONAL HEALTH ANDNUTRITION EXAMINATION SURVEY Varant Kupelian*, Watertown, MA; Mary Fitzgerald, Maywood, IL;Steven Kaplan, New York, NY; Jens Peter Norgaard, Copenhagen,Denmark; Gretchen Chiu, Raymond Rosen, Watertown, MA INTRODUCTION AND OBJECTIVES: Nocturia, a commonsymptom in both men and women, has been shown to be associatedwith chronic illnesses such as heart disease and hypertension. Usingdata from the Third National Health and Nutrition Examination Survey(NHANES III), the objective of this study is to investigate the associa-tion of nocturia with subsequent mortality risk.METHODS: NHANES III is a national probability survey of theU.S. conducted between 1988 and 1994. Nocturia was assessed by thequestion “how many times a night do you usually get up to urinate (passwater)?”. Mortality data was obtained by linkage of the NHANES III todeath certificate data found in the National Death Index with follow-upthrough December 31, 2000. Cox proportional hazards regressionmodels were used to assess the association between nocturia andmortality and to control for the effect of potential confounders and effectmodifiers. Analyses were conducted on a sample of 15,988 men andwomen age 20 and older.RESULTS: Overall prevalence of nocturia, defined as two or more episodes of urination per night, was 15.5% among men and20.9% among women, and increased rapidly with age. Multivariateanalyses show a statistically significant trend towards increased mor-tality risk with increased number of voiding episodes among both menand women. Analyses stratified by age groups (  50, 50-64, and 65 andolder), show associations of larger magnitudes in the younger agegroups with attenuated but statistically significant associations in theoldest age group. Adjustment for heart disease, diabetes, and obesitysuggests that the association between nocturia and mortality is onlypartially explained by those chronic conditions.CONCLUSIONS: Nocturia is a predictor of mortality, more so inrelatively younger men and women, rather than in the elderly. Comor-bid conditions that are already recognized as being related to nocturia,only partially explain the increased risk of mortality. This suggests thatother, unmeasured factors are contributory. Possible candidates in-clude effects of sleep disruption and of other unrecognized comorbidmedical conditions. Association of nocturia and mortality by gender and age. Unadjustedand adjusted hazard ratios (HR) and 95% confidence intervals(95%CI) comparing respondents with nocturia > 2to those with nocturia < 2 per night.      A   g   e Men Women      U   n   a     d     j   u   s    t   e     d     H     R     (     9    5     %     C     I     )     A     d     j   u   s    t   e     d     H     R     *     (     9    5     %     C     I     )     U   n   a     d     j   u   s    t   e     d     H     R     (     9    5     %     C     I     )     A     d     j   u   s    t   e     d     H     R     *     (     9    5     %     C     I     ) 20-49 4.09 (2.20, 7.63) 2.56 (1.32, 4.94) 2.70 (1.53, 4.76)  1.10 (0.66, 1.86) 50-64 2.05 (1.40, 3.02) 1.60 (1.06, 2.41) 2.25 (1.56, 3.25) 1.94 (1.27, 2.96)65-90 1.65 (1.36, 2.00) 1.35 (1.11, 1.63) 1.54 (1.31, 1.82) 1.19 (1.04, 1.37)Overall 4.75 (3.95, 5.72) 1.49 (1.25, 1.78) 3.58 (3.05, 4.20) 1.32 (1.14, 1.51) *Adjusted for age, BMI, marital status, education, smoking, CVD, diabetes, hyper-tension,medicationsuse(diuretics,antihypertensive,lipidlowering,antidepressants) Source of Funding:  Analyses for the current manuscript weresupported through an unrestricted educational grant to NewEngland Research Institutes, Inc. from Ferring Pharmaceuticals. Trauma/Reconstruction: Trauma & ReconstructiveSurgery IIPodium 4 Saturday, May 29, 2010 3:30 PM-5:30 PM 57 URETHRAL REST PROMOTES IDENTIFICATION OFRESECTABLE STRICTURE SEGMENTS DURING ANTERIORURETHRAL RECONSTRUCTION Ryan Terlecki*, Matthew Steele, Celeste Valadez, Allen Morey,Dallas, TX  INTRODUCTION AND OBJECTIVES: Patients referred for de-finitive management of urethral stricture disease often present withindwelling urethral catheters or while active on a regimen of regular self-catheterization. Often, heroic urethral endoscopic manipulationsare undertaken by referring urologists immediately prior to consultationfor urethroplasty. We present our experience with implementation of aperiod of “urethral rest” prior to urethroplasty to allow ample time for recovery and delineation of involved tissues by the time of surgery.METHODS: As part of an institutional-review board approvedprotocol, we reviewed our database for all urethroplasties performed bya single surgeon (AFM). Data was gathered concerning patient history,demographics, operative details and clinical outcomes.RESULTS: From 2007-2009, of the 210 patients who under-went urethral reconstruction at our center, those undergoing meato-plasty or posterior urethroplasty were excluded, thus leaving 135 an-terior urethroplasty patients for analysis. Of these, 28 (21%) wereplaced on a period of urethral rest prior to reconstructive surgery, 15 of whom had suprapubic catheter placement. Median duration of urethralrest prior to reconstruction was 3 months, and all had at least 2 months.Urethral rest promoted identification of severely fibrotic stricture seg-ments which enabled focal or complete excision in 75% (excision andprimary anastomosis –12/28, 43%; augmented anastomotic–9/28,32%); straightforward graft or flap ventral onlay was performed in theremainder (7, 25%). Median stricture length was 3 cm (1.5-16.5) andmedian follow-up was 486 days. Recurrence was seen in 4/28 (14%; 1EPA, 3 AA). Recurrent strictures were less likely to have been man-aged with a suprapubic catheter preoperatively (40% vs. 57%).CONCLUSIONS: A two month period of urethral rest appears tobe a valuable first step toward completion of a successful urethroplastyby promoting delineation of urethral tissues. Strictures which have beenrecently manipulated, artificially appearing patent, often declare them-selves to be obliterative, thus requiring focal or complete excision e24 THE JOURNAL OF UROLOGY   Vol. 183, No. 4, Supplement, Saturday, May 29, 2010  rather than a straightforward onlay procedure. Referring urologistsshould refrain from urethral instrumentation prior to referral in order toavoid delay of reconstructive surgery. Source of Funding:  None 58 OUTCOME OF DORSAL BUCCAL GRAFT AUGMENTEDANASTOMOSIS FOR URETHRAL STRICTURES Britton E. Tisdale*, Erik T. Grossgold, Christopher Bayne, LisaParillo, Norfolk, VA; Jeremy B. Tonkin, Portsmouth, VA; Kurt A.McCammon, Gerald H. Jordan, Norfolk, VA INTRODUCTION AND OBJECTIVES: The use of buccal graftonlay has been shown to be an excellent option for long bulbar urethralstrictures. A narrow lumen may preclude the use of an onlay alone, andin these instances an augmented anastomosis is needed. We thereforeperformed this study to evaluate the outcomes and complications of dorsal buccal graft augmented anastomosis urethroplasty (BGAA) for anterior urethral strictures.METHODS: 76 patients underwent BGAA between 2000-2009.Their charts were retrospectively reviewed. Failure was defined asrecurrent stricture requiring intervention. Three weeks post surgerypatients underwent voiding urethrography. Flexible cysto-urethroscopyis performed 6 months after surgery. Patients are then followed yearly.RESULTS: Mean age was 44 years. Follow-up averaged 49months (range 3.6 to 108). Stricture etiology was idiopathic in 39/76(51%), perineal trauma in 13/76 (17%), instrumentation in 9/76 (12%),non-specified trauma in 7/76 (9%), post hypospadias surgery in 4/76(5%), post infectious in 3/76 (4%), radiation for local urethral cancer in1/76. Mean stricture length was 6cm (range 2-15cm). 70/76 (92%) hadprevious urethral procedures, including dilation 54/76 (71%), urethrot-omy 46/76 (61%),   /   2 prior procedures 52/76 (68%), and urethro-plasty 20/76 (26%) before referral to our center. Two buccal grafts wereused on 20/76 (26%) of patients, one graft was used on 56/76 (74%).72/76 (95%) of repairs were successful and 4/76 (5%) failed. Threepatients underwent urethrotomy and are free from recurrence. Onepatient underwent dilation and is free from recurrence. One other patient has a wide calibre recurrence that is currently being monitored.Significant peri-operative complications included one pulmonary embo-lus (this patient was found to have a coagulopathy), one superficialvenous thrombosis and two post-operative fevers presumed to befebrile urinary tract infections.CONCLUSIONS: Dorsal buccal graft augmented anastomosisfor anterior urethral strictures has excellent results with a 95% successrate. Continued surveillance of these patients is needed to confirmpersistent durability. Source of Funding:  None 59 MANAGEMENT OF COMPLEX ANTERIOR URETHRALSTRICTURES WITH MULTI-STAGE BUCCAL GRAFTURETHROPLASTY. Spencer Kozinn*, Niall Harty, Alex Vanni, Leonard Zinman, Jill Buckley, Burlington, MA INTRODUCTION AND OBJECTIVES: We aim to describe in-dications and outcomes of salvage urethral reconstruction utilizing thecombination of urethrectomy with buccal graft replacement.METHODS: We retrospectively identified 50 consecutive pa-tients undergoing a multi-stage urethral reconstruction between 2003and 2008 at our institution. Demographics, etiology of stricture, need for first stage revision, pre- and post-operative urine flow rates, and out-comes of reconstruction, were analyzed.RESULTS: SEE TABLE 1. 29 (58%) patients went on to ure-thral tubularization, 3 (6%) patients are pending closure, and 18 (36%)patients have undergone first stage only with no current plan for completion. Etiology of the majority of strictures included hypospadius(n  22, 44%) and lichen sclerosus (n  18, 36%). 20% of the patientshad panurethral disease, with the rest involving varying lengths of theanterior urethra. Mean follow up was 19 months (range 1-53). 10patients required revision of their first stage, with 3 patients requiring atleast 2 repairs. Urine flow rates increased on average from 7.0 mL/secpre-operatively to 20.7 mL/sec postoperatively. In total, 5 (10%) pa-tients failed reconstruction, requiring scheduled balloon dilations tomaintain urethral patency.CONCLUSIONS: Urethrectomy with salvage reconstruction ina staged fashion is the optimal option for complex anterior urethralstricture resolution. Younger men with a hyposapdiac etiology trendtowards urethral closure when compared to men with lichen sclerosusas a stricture source. Although successful closure can be achieved,patients should be counseled that the first stage or subsequent closuremay require additional revision. Table 1Urethral Closure(n  29)1st Stage Only(n  21) Age (range) 41.7 (14-75) 47.5 (21-80)Stricture Etiology Hypospadius  17 (59%) 5 (24%) Lichen Sclerosus (LC)  5 (17%) 7 (33%) Hypospadius/LC   4 (1%) 1 (5%) Other   3 (10%) 8 (38%)Stricture Location Bulbo-pendulous  5 (17%) 8 (38%) Mid-pendulous  9 (31%) 4 (19%) Distal pendulous/Fossa navicularis  11 (38%) 3 (14%) Panurethral   4 (14%) 6 (29%) Source of Funding:  None 60 NOVEL TWO-STAGE PENILE URETHROPLASTY UTILIZINGVENTRAL URETHROTOMY AND DORSAL BUCCAL MUCOSAINLAY WITH LATERALIZATION AND PRESERVATION OF THEURETHRAL PLATE Chris McClung*, Jim Hotaling, Bryan Voelzke, Hunter Wessells,Seattle, WA INTRODUCTION AND OBJECTIVES: Staged urethral recon-struction is ideal in the setting of patients after failed urethral recon-struction, lichen sclerosis, and poor penile vascularity. However, avail-ability of sufficient buccal mucosa limits the repair of long defects whencomplete excision of the urethra is required. A one-stage, pendulousurethral reconstruction technique in which the urethra is first openedventrally followed by dorsal urethrotomy with inlay of dorsal buccalmucosa exists in the literature. Our primary aim was to determine thetechnical and anatomic feasibility of this technique in staged urethralreconstruction.METHODS: 9 patients underwent first stage penile urethro-plasty; 4 of these have gone on to second-stage repair. During the firststage repair, the urethra is circumferentially mobilized and split ven-trally to expose the lumen. Buccal mucosa is harvested, defatted, andfenestrated with an 18-gauge needle. The dorsum is incised, so that thesplit plate is lateralized and the buccal mucosa is inlayed between theedges of the incised urethral plate. The second stage repair involvestubularization of the neo-urethral plate over a Foley catheter. Dartosmuscle is used as an interposition flap when possible.RESULTS: The etiology of the urethral strictures was lichensclerosis in 6, hypospadius in 1, and blunt penile trauma in 1. Thelength of the pendulous strictures ranged from 6-13 cm (median length9cm). All 9 cases had good graft take with viability of the lateral urethralplates after the first stage. 4 subjects underwent a second stageprocedure. Of these 4, 3 had a follow up cystoscopy at 4 months to 2years (median follow-up 6.3 months) after completing the second stagerepair. All repaired segments were patent. Vol. 183, No. 4, Supplement, Saturday, May 29, 2010 THE JOURNAL OF UROLOGY   e25
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