1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57
Dorsal Onlay Urethroplasty for Membranous Urethral Strictures: Urinary and Erectile Functional Outcomes Stephen Blakely, Tiffany Caza, Steve Landas and Dmitriy Nikolavsky* From the State University of New York Upstate Medical University, Departments of Urology and Pathology (TC, SL), Syracuse, New York
Purpose: We evaluated urinary and erectile functional outcomes after dorsal onlay urethroplasty for bulbomembranous urethral strictures. Our aim was to understand the functional implications of dissection of the posterior urethra. Materials and Methods: We report on men who underwent membranous urethral stricture repair by buccal mucosal graft dorsal onlay substitution urethroplasty. Continence and erectile function were assessed preoperatively and postoperatively. Tissue routinely excised from the intercrural space during dissection of the dorsal aspect of the membranous urethra was evaluated for scar, striated muscle and nerves. Results: A total of 16 consecutive men with a mean age of 48.3 years (range 26 to 72) who had strictures with a mean length of 56 mm (range 15 to 170) involving the membranous urethra were included in analysis. Of the 16 men 15 were continent preoperatively and remained continent postoperatively. Three of 10 men (30%) with a preoperative SHIM (Sexual Health Inventory for Men) score of 17 to 25 had a decrease after urethroplasty. All 16 men had an improved maximum urinary flow rate with a mean improvement of 22 ml per second. I-PSS (International Prostate Symptom Score) improved from a median of 23 to 4 postoperatively with a median bother score improvement of 5 to 0. Histopathological assessment identified striated muscle and nerves in 6 (46%) and 9 (69%) of 13 specimens. Overall nerves and muscle comprised an average of less than 15% of the specimen. Conclusions: The dorsal onlay technique with a buccal mucosal graft for membranous urethral stricture repair does not compromise continence or erectile function in most patients. Dissection at the level of the membranous urethra should be limited because striated muscle and cavernous nerves are present.
Abbreviations and Acronyms BMG ¼ buccal mucosal graft ED ¼ erectile dysfunction PVR ¼ post-void residual urine Qmax ¼ maximum urinary flow TURP ¼ transurethral prostate resection Accepted for publication November 11, 2015. No direct or indirect commercial incentive associated with publishing this article. The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number. * Correspondence: Department of Urology, State University of New York Upstate Medical University, 750 East Adams St., Syracuse, New York 13210 (telephone: 315-464-4473; FAX: 315464-6117; e-mail: [email protected]).
Key Words: urethral stricture, transplants, mouth mucosa, penile erection, urinary incontinence
MEMBRANOUS urethral strictures are commonly managed by dilation or self-calibration due to fear of causing urinary incontinence or impotence according to the literature.1e3 For most other strictures urethroplasty is the accepted gold standard solution. We hypothesized that careful dissection through the intracrural space,
limited resection of the intracrural tissue anterior and placement of a dorsal onlay buccal graft would not compromise continence or erectile function in men with bulbomembranous or membranous urethral strictures. While a small series of augmentation urethroplasty in this location has shown acceptable
0022-5347/16/1955-0001/0 THE JOURNAL OF UROLOGY® Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
Dochead: Adult Urology
http://dx.doi.org/10.1016/j.juro.2015.11.028 Vol. 195, 1-7, May 2016 Printed in U.S.A.
www.jurology.com
FLA 5.4.0 DTD JURO13111_proof 18 February 2016 2:34 pm EO: JU-15-1780
j
1
58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114
2
115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 ½F1 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171
DORSAL ONLAY URETHROPLASTY FOR MEMBRANOUS URETHRAL STRICTURES
patency rates,4 little is known about the functional outcomes after augmentation urethroplasty in the posterior urethra. To our knowledge we report the first study of sexual and continence outcomes of augmentation of the membranous urethra. Additionally we histopathologically evaluated tissue anterior to the membranous urethra to assess the anatomical implications of this technique.
MATERIALS AND METHODS Using an institutional review board approved urethroplasty database we retrospectively identified patients who underwent urethroplasty performed by a single surgeon (DN) for strictures involving the membranous urethra that were not caused by pelvic fracture. Membranous involvement, which was often predicted by history and imaging (fig. 1), was confirmed intraoperatively if the strictured segment entered the urogenital diaphragm. Clinical data were obtained from the medical record,
including patient age, stricture length and etiology, prior interventions and certain measured outcomes. The primary outcomes were erectile function and continence. Erectile function was measured using the SHIM questionnaire. Men were included on erectile function analysis if they had mild ED (SHIM 17 to 21) or no ED (SHIM 22 to 25) preoperatively. At every visit patients were questioned about continence, which was defined as complete absence of involuntary loss of urine and no pad use. Secondary outcomes were urinary function evaluations using a standardized question about continence, uroflowmetry, PVR measurement and I-PSS. Stricture recurrence was defined as the need for additional intervention. All patients completed the studies and questionnaires preoperatively, and 4, 8, 12 or 24 months postoperatively. Preoperative and postoperative values were compared with the Student t-test or the chisquare test.
Surgical Technique With the patient in the lithotomy position urethroscopy is performed using a flexible cystoscope or ureteroscope.
Figure 1. A, retrograde urethrogram demonstrates bulbomembranous urethral stricture in patient after numerous endoscopic procedures and finding of transurethral resection defect on intraoperative cystoscopy. Cowper gland and duct helped estimate location of membranous urethra and proximal bulbous urethra, respectively. B, computerized tomography shows open bladder neck and prostatic urethra in same patient. C to E, findings in patient after external beam radiation, including panurethral stricture with membranous involvement and open bladder neck. C, retrograde urethrogram. D, voiding cystourethrogram. E, computerized tomography.
Dochead: Adult Urology
FLA 5.4.0 DTD JURO13111_proof 18 February 2016 2:34 pm EO: JU-15-1780
172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228
DORSAL ONLAY URETHROPLASTY FOR MEMBRANOUS URETHRAL STRICTURES
229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285
½F2
When available, suprapubic access is used. A wire is placed across the strictured segment. A midline perineal incision is made. The bulbospongiosus muscle is spared by dissecting between the muscle and the bulbous urethra. Muscle retraction is facilitated by dividing the central perineal tendon. Left lateral urethral dissection is performed as described by Kulkarni et al.5 As the urethra is dissected from the left corpora cavernosa it is rotated to the patient right, exposing the space between diverging crura (fig. 2). The dorsal aspect of the urethra is incised longitudinally through the length of the stricture with extension about 1 cm proximal and distal into normal urethra. Tissue in the intercrural space, where the urethra makes a turn into the pelvis, is sharply
3
excised to allow for calibration of the membranous urethra to 24Fr. Only tissue that grossly represents scar is excised. No cautery is done around the urethra or the corpora cavernosa. Any bleeding is controlled by periods of direct pressure or suturing as needed. Resection is limited to the area between the 11 and 1 o’clock positions in relation to the lumen with the goal of creating a smooth shallow trough between the corpora cavernosa as a bed for future graft placement. This resection also improves visualization of the proximal apex of the urethrotomy for apical suture placement. In this study the resected intercrural tissue was analyzed as described. Flexible cystoscopy is then performed to rule out more proximal involvement.
Figure 2. A, lateral dissection of urethra and dorsal urethrotomy. Dotted line indicates area to be excised. B, intracrural tissue is excised anterior between 1 and 11-oclock positions. C, buccal mucosa is sutured to proximal apex of urethrotomy and quilted on corpora cavernosa. D, intraoperative image shows repair of bulbomembranous urethral stricture. Bulbar urethra with dorsal urethrotomy is rotated toward patient right (dashed arrow). Elliptical buccal mucosal graft 4 1.5 cm (solid arrow) is quilted to underlying corpora cavernosa. Atraumatic forceps is placed in bladder through proximal urethral lumen.
Dochead: Adult Urology
FLA 5.4.0 DTD JURO13111_proof 18 February 2016 2:34 pm EO: JU-15-1780
286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342
4
343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 ½T1 388 389 390 391 392 393 394 395 396 397 398 399
DORSAL ONLAY URETHROPLASTY FOR MEMBRANOUS URETHRAL STRICTURES
The BMG is harvested in standard fashion and tailored to the size of the urethrotomy and urethral plate. The BMG is spread and quilted to the tunica albuginea of the corpora cavernosa and to the newly created intracrural trough. The proximal apex of the graft is sutured to the proximal apex of the urethrotomy with preplaced absorbable sutures and the distal apexes are similarly approximated. In panurethral stricture repair the distal apex is the urethral meatus, which is repaired as described by Kulkarni et al.6 The right lateral margin of the BMG is sutured to the right lateral edge of the urethrotomy. A 14Fr Foley catheter is positioned. The urethra is returned to its native position. The remaining free edge of the urethrotomy is sutured to the BMG and the tunica albuginea of the left corpora cavernosa. The bulbospongiosus muscle is repositioned over the bulbar urethra and the perineum is closed in layers. The Foley catheter was removed at followup 3 weeks postoperatively after retrograde urethrogram revealed no contrast extravasation.
Histopathological Evaluation Intercrural tissue specimens underwent gross examination by a surgical pathologist on the date of collection. Specimens were fixed overnight and embedded in paraffin wax. Sections (4 to 5 mm) were prepared and stained with hematoxylin and eosin. Tissue sections were evaluated independently by a uropathologist. The presence or absence of skeletal muscle and nerve tissue was recorded. The percent of skeletal muscle was estimated by the volume of skeletal muscle compared to the volume of the specimen. The makeup of the remaining tissue was characterized by histological component and degree of fibrosis using a collagen organization grading scale of 1 to 4, including 1ddisorganized collagen fibers, 2dslightly organized collagen representing immature connective tissue, 3dmoderately organized collagen and 4dwell organized collagen (formed scar). Fibrotic specimens were graded 4 for collagen organization.
RESULTS Clinical Outcomes Included in study were 16 men who underwent BMG dorsal onlay augmentation urethroplasty for stricture involving the membranous and bulbomembranous urethra. The table lists patient factors. Median followup was 8 months (range 4 to 27). In our study 6 men, including all 3 treated with prior radiation, had moderate to severe ED preoperatively. All 10 men with a preoperative SHIM score of 17 to 25 completed a preoperative and postoperative SHIM questionnaire. Seven men had no decrease in the SHIM score. Two patients with a decrease in the SHIM score had mild erectile dysfunction preoperatively (SHIM 21 and 19, respectively) and that classification was maintained postoperatively (each SHIM 18). At last followup 1 patient returned to baseline (SHIM 19) at 8 months Dochead: Adult Urology
Clinical and outcome characteristics in 16 patients Mean age (range) Mean mm stricture length (range) No. stricture etiology: TURP* External beam radiation Brachytherapy Traumatic catheter Other iatrogenic cause† Perineal trauma Unknown No. prior intervention (%) Dilation Internal urethrotomy Prior urethroplasty‡ No. preop suprapubic tube (%) No. preop SHIM (%): 22e25 17e21 12e16 8e11 1e7 No. preop continence (%)§ Median mos followup (range) No. stricture recurrence Median preop/postop score: SHIM I-PSS I-PSS bother Mean preop/postop max urinary flow (cc/sec) Mean preop/postop PVR (cc)
48.3 (26e72) 56 (15e170) 5 2 1 3 2 2 1 14 11 6 3 4 7 3 1 1 4 15 8 1
(87) (69) (37) (19) (25) (44) (19) (6) (6) (25) (94) (4e27)
20.5/21k 22/4{ 5/0{ 4.5/25.3{ 314/37**
* No TURP history but transurethral resection defect on cystoscopy in 2 patients. † Prior hypospadias repair and traumatic childhood cystoscopy in 1 patient each. ‡ Excision and primary anastomosis, and ventral onlay failed at 4 months in 1 patient each at our institution and unknown reconstruction was done in child hood for urethral injury in 1. § No patient had new onset incontinence postoperatively. k p ¼ 0.66. { p
Dorsal Onlay Urethroplasty for Membranous Urethral Strictures: Urinary and Erectile Functional Outcomes Stephen Blakely, Tiffany Caza, Steve Landas and Dmitriy Nikolavsky* From the State University of New York Upstate Medical University, Departments of Urology and Pathology (TC, SL), Syracuse, New York
Purpose: We evaluated urinary and erectile functional outcomes after dorsal onlay urethroplasty for bulbomembranous urethral strictures. Our aim was to understand the functional implications of dissection of the posterior urethra. Materials and Methods: We report on men who underwent membranous urethral stricture repair by buccal mucosal graft dorsal onlay substitution urethroplasty. Continence and erectile function were assessed preoperatively and postoperatively. Tissue routinely excised from the intercrural space during dissection of the dorsal aspect of the membranous urethra was evaluated for scar, striated muscle and nerves. Results: A total of 16 consecutive men with a mean age of 48.3 years (range 26 to 72) who had strictures with a mean length of 56 mm (range 15 to 170) involving the membranous urethra were included in analysis. Of the 16 men 15 were continent preoperatively and remained continent postoperatively. Three of 10 men (30%) with a preoperative SHIM (Sexual Health Inventory for Men) score of 17 to 25 had a decrease after urethroplasty. All 16 men had an improved maximum urinary flow rate with a mean improvement of 22 ml per second. I-PSS (International Prostate Symptom Score) improved from a median of 23 to 4 postoperatively with a median bother score improvement of 5 to 0. Histopathological assessment identified striated muscle and nerves in 6 (46%) and 9 (69%) of 13 specimens. Overall nerves and muscle comprised an average of less than 15% of the specimen. Conclusions: The dorsal onlay technique with a buccal mucosal graft for membranous urethral stricture repair does not compromise continence or erectile function in most patients. Dissection at the level of the membranous urethra should be limited because striated muscle and cavernous nerves are present.
Abbreviations and Acronyms BMG ¼ buccal mucosal graft ED ¼ erectile dysfunction PVR ¼ post-void residual urine Qmax ¼ maximum urinary flow TURP ¼ transurethral prostate resection Accepted for publication November 11, 2015. No direct or indirect commercial incentive associated with publishing this article. The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number. * Correspondence: Department of Urology, State University of New York Upstate Medical University, 750 East Adams St., Syracuse, New York 13210 (telephone: 315-464-4473; FAX: 315464-6117; e-mail: [email protected]).
Key Words: urethral stricture, transplants, mouth mucosa, penile erection, urinary incontinence
MEMBRANOUS urethral strictures are commonly managed by dilation or self-calibration due to fear of causing urinary incontinence or impotence according to the literature.1e3 For most other strictures urethroplasty is the accepted gold standard solution. We hypothesized that careful dissection through the intracrural space,
limited resection of the intracrural tissue anterior and placement of a dorsal onlay buccal graft would not compromise continence or erectile function in men with bulbomembranous or membranous urethral strictures. While a small series of augmentation urethroplasty in this location has shown acceptable
0022-5347/16/1955-0001/0 THE JOURNAL OF UROLOGY® Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
Dochead: Adult Urology
http://dx.doi.org/10.1016/j.juro.2015.11.028 Vol. 195, 1-7, May 2016 Printed in U.S.A.
www.jurology.com
FLA 5.4.0 DTD JURO13111_proof 18 February 2016 2:34 pm EO: JU-15-1780
j
1
58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114
2
115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 ½F1 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171
DORSAL ONLAY URETHROPLASTY FOR MEMBRANOUS URETHRAL STRICTURES
patency rates,4 little is known about the functional outcomes after augmentation urethroplasty in the posterior urethra. To our knowledge we report the first study of sexual and continence outcomes of augmentation of the membranous urethra. Additionally we histopathologically evaluated tissue anterior to the membranous urethra to assess the anatomical implications of this technique.
MATERIALS AND METHODS Using an institutional review board approved urethroplasty database we retrospectively identified patients who underwent urethroplasty performed by a single surgeon (DN) for strictures involving the membranous urethra that were not caused by pelvic fracture. Membranous involvement, which was often predicted by history and imaging (fig. 1), was confirmed intraoperatively if the strictured segment entered the urogenital diaphragm. Clinical data were obtained from the medical record,
including patient age, stricture length and etiology, prior interventions and certain measured outcomes. The primary outcomes were erectile function and continence. Erectile function was measured using the SHIM questionnaire. Men were included on erectile function analysis if they had mild ED (SHIM 17 to 21) or no ED (SHIM 22 to 25) preoperatively. At every visit patients were questioned about continence, which was defined as complete absence of involuntary loss of urine and no pad use. Secondary outcomes were urinary function evaluations using a standardized question about continence, uroflowmetry, PVR measurement and I-PSS. Stricture recurrence was defined as the need for additional intervention. All patients completed the studies and questionnaires preoperatively, and 4, 8, 12 or 24 months postoperatively. Preoperative and postoperative values were compared with the Student t-test or the chisquare test.
Surgical Technique With the patient in the lithotomy position urethroscopy is performed using a flexible cystoscope or ureteroscope.
Figure 1. A, retrograde urethrogram demonstrates bulbomembranous urethral stricture in patient after numerous endoscopic procedures and finding of transurethral resection defect on intraoperative cystoscopy. Cowper gland and duct helped estimate location of membranous urethra and proximal bulbous urethra, respectively. B, computerized tomography shows open bladder neck and prostatic urethra in same patient. C to E, findings in patient after external beam radiation, including panurethral stricture with membranous involvement and open bladder neck. C, retrograde urethrogram. D, voiding cystourethrogram. E, computerized tomography.
Dochead: Adult Urology
FLA 5.4.0 DTD JURO13111_proof 18 February 2016 2:34 pm EO: JU-15-1780
172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228
DORSAL ONLAY URETHROPLASTY FOR MEMBRANOUS URETHRAL STRICTURES
229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285
½F2
When available, suprapubic access is used. A wire is placed across the strictured segment. A midline perineal incision is made. The bulbospongiosus muscle is spared by dissecting between the muscle and the bulbous urethra. Muscle retraction is facilitated by dividing the central perineal tendon. Left lateral urethral dissection is performed as described by Kulkarni et al.5 As the urethra is dissected from the left corpora cavernosa it is rotated to the patient right, exposing the space between diverging crura (fig. 2). The dorsal aspect of the urethra is incised longitudinally through the length of the stricture with extension about 1 cm proximal and distal into normal urethra. Tissue in the intercrural space, where the urethra makes a turn into the pelvis, is sharply
3
excised to allow for calibration of the membranous urethra to 24Fr. Only tissue that grossly represents scar is excised. No cautery is done around the urethra or the corpora cavernosa. Any bleeding is controlled by periods of direct pressure or suturing as needed. Resection is limited to the area between the 11 and 1 o’clock positions in relation to the lumen with the goal of creating a smooth shallow trough between the corpora cavernosa as a bed for future graft placement. This resection also improves visualization of the proximal apex of the urethrotomy for apical suture placement. In this study the resected intercrural tissue was analyzed as described. Flexible cystoscopy is then performed to rule out more proximal involvement.
Figure 2. A, lateral dissection of urethra and dorsal urethrotomy. Dotted line indicates area to be excised. B, intracrural tissue is excised anterior between 1 and 11-oclock positions. C, buccal mucosa is sutured to proximal apex of urethrotomy and quilted on corpora cavernosa. D, intraoperative image shows repair of bulbomembranous urethral stricture. Bulbar urethra with dorsal urethrotomy is rotated toward patient right (dashed arrow). Elliptical buccal mucosal graft 4 1.5 cm (solid arrow) is quilted to underlying corpora cavernosa. Atraumatic forceps is placed in bladder through proximal urethral lumen.
Dochead: Adult Urology
FLA 5.4.0 DTD JURO13111_proof 18 February 2016 2:34 pm EO: JU-15-1780
286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342
4
343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 ½T1 388 389 390 391 392 393 394 395 396 397 398 399
DORSAL ONLAY URETHROPLASTY FOR MEMBRANOUS URETHRAL STRICTURES
The BMG is harvested in standard fashion and tailored to the size of the urethrotomy and urethral plate. The BMG is spread and quilted to the tunica albuginea of the corpora cavernosa and to the newly created intracrural trough. The proximal apex of the graft is sutured to the proximal apex of the urethrotomy with preplaced absorbable sutures and the distal apexes are similarly approximated. In panurethral stricture repair the distal apex is the urethral meatus, which is repaired as described by Kulkarni et al.6 The right lateral margin of the BMG is sutured to the right lateral edge of the urethrotomy. A 14Fr Foley catheter is positioned. The urethra is returned to its native position. The remaining free edge of the urethrotomy is sutured to the BMG and the tunica albuginea of the left corpora cavernosa. The bulbospongiosus muscle is repositioned over the bulbar urethra and the perineum is closed in layers. The Foley catheter was removed at followup 3 weeks postoperatively after retrograde urethrogram revealed no contrast extravasation.
Histopathological Evaluation Intercrural tissue specimens underwent gross examination by a surgical pathologist on the date of collection. Specimens were fixed overnight and embedded in paraffin wax. Sections (4 to 5 mm) were prepared and stained with hematoxylin and eosin. Tissue sections were evaluated independently by a uropathologist. The presence or absence of skeletal muscle and nerve tissue was recorded. The percent of skeletal muscle was estimated by the volume of skeletal muscle compared to the volume of the specimen. The makeup of the remaining tissue was characterized by histological component and degree of fibrosis using a collagen organization grading scale of 1 to 4, including 1ddisorganized collagen fibers, 2dslightly organized collagen representing immature connective tissue, 3dmoderately organized collagen and 4dwell organized collagen (formed scar). Fibrotic specimens were graded 4 for collagen organization.
RESULTS Clinical Outcomes Included in study were 16 men who underwent BMG dorsal onlay augmentation urethroplasty for stricture involving the membranous and bulbomembranous urethra. The table lists patient factors. Median followup was 8 months (range 4 to 27). In our study 6 men, including all 3 treated with prior radiation, had moderate to severe ED preoperatively. All 10 men with a preoperative SHIM score of 17 to 25 completed a preoperative and postoperative SHIM questionnaire. Seven men had no decrease in the SHIM score. Two patients with a decrease in the SHIM score had mild erectile dysfunction preoperatively (SHIM 21 and 19, respectively) and that classification was maintained postoperatively (each SHIM 18). At last followup 1 patient returned to baseline (SHIM 19) at 8 months Dochead: Adult Urology
Clinical and outcome characteristics in 16 patients Mean age (range) Mean mm stricture length (range) No. stricture etiology: TURP* External beam radiation Brachytherapy Traumatic catheter Other iatrogenic cause† Perineal trauma Unknown No. prior intervention (%) Dilation Internal urethrotomy Prior urethroplasty‡ No. preop suprapubic tube (%) No. preop SHIM (%): 22e25 17e21 12e16 8e11 1e7 No. preop continence (%)§ Median mos followup (range) No. stricture recurrence Median preop/postop score: SHIM I-PSS I-PSS bother Mean preop/postop max urinary flow (cc/sec) Mean preop/postop PVR (cc)
48.3 (26e72) 56 (15e170) 5 2 1 3 2 2 1 14 11 6 3 4 7 3 1 1 4 15 8 1
(87) (69) (37) (19) (25) (44) (19) (6) (6) (25) (94) (4e27)
20.5/21k 22/4{ 5/0{ 4.5/25.3{ 314/37**
* No TURP history but transurethral resection defect on cystoscopy in 2 patients. † Prior hypospadias repair and traumatic childhood cystoscopy in 1 patient each. ‡ Excision and primary anastomosis, and ventral onlay failed at 4 months in 1 patient each at our institution and unknown reconstruction was done in child hood for urethral injury in 1. § No patient had new onset incontinence postoperatively. k p ¼ 0.66. { p
