Open superior to stent in urethral stricture repair

May 15, 2008

Several challenging issues related to urologic trauma and reconstructive surgery include management of bladder neck stenosis after prostate cancer therapy, advanced urethral reconstruction for benign disease, and renal trauma.

Key Points

The 2008 AUA annual meeting will provide a forum for reviewing and evaluating several challenging issues related to urologic trauma and reconstructive surgery. These include management of bladder neck stenosis after prostate cancer therapy, advanced urethral reconstruction for benign disease, and renal trauma.

"Even after multiple prior procedures, recurrent bladder neck contracture can be stabilized by excising fibrotic tissue around the vesicourethral anastomosis and repeating it."

Management of rectourethral fistula has improved with the advent of procedures that make use of gracilis muscle flaps. Applied by perineal approach, gracilis muscle flaps have proven to be highly effective for preventing recurrence and promoting preservation of bowel and bladder function.

Less favorable results have emerged for urethral stents to treat bladder neck stenosis. Some patients do have functional improvement, but the improvement appears to wane over time. Subsequently, the endoscopic app-roach is associated with multiple addi-tional procedures and stenosis recurrence.

Stenting is attractive because of its minimal invasiveness compared with open surgery and will continue to have a following in the urology community.

"When stents fail, the creative application of various reconstructive procedures can be performed in a single stage to offer effective long-term salvage therapy," Dr. Morey said. "However, these complex procedures are extremely challenging and should be performed only by experienced surgeons in centers of excellence."

New light is also being shed on treatment of benign urethral conditions, many of which often require complex reconstruction procedures. Balanitis xerotica obliterans, or lichen sclerosus, offers a case in point. One report suggests that testosterone replacement therapy, when used as an adjunct to staged urethral reconstruction, improves short-term outcomes in patients with advanced changes in both the prepuce and glans.

Use of oral mucosa for urethral reconstruction has gained a following in the urology community in recent years. Oral mucosa is being used in a variety of novel urologic applications, such as augmentation during second-stage urethroplasty as an alternative to separate, formal revision of a first-stage procedure, post-stenting reconstructions, in conjunction with perineal urethrostomy, and combination dorsal and ventral grafts. Lingual mucosa appears to offer an equally promising substitute material for urethral reconstruction, but both buccal and lingual mucosa are being used with success.

Presentations at the AUA meeting will emphasize complete fibrosis excision and direct wide-caliber re-anastomosis as the cornerstones of successful posterior urethroplasty. Moreover, recent experience again has called into question the necessity of urethral rerouting for favorable outcomes.

Emerging evidence suggests that an aggressive surgical approach produces the best results in patients with significant stricture of the bulbar urethra. Repairs involving excision and primary anastomosis achieve results that are superior to those associated with repair procedures involving flaps or grafts. Furthermore, new evidence supports open surgical reconstruction as a primary approach to therapy in lieu of minimally invasive procedures, which may produce additional fibrotic changes, thus jeopardizing results of subsequent urethroplasty.

Advances in renal trauma

In contrast to the clinical situation surrounding bulbar stricture, the approach to blunt renal trauma has evolved over the past 3 decades from routine open exploratory surgery to virtual elimination of surgery, particularly nephrectomy. The trend toward conservative management has occurred against a backdrop of more high-grade injuries to the kidneys in recent years. The result has been kidney preservation for most patients.

For patients who have significant segmental-vessel bleeding due to renal trauma, angiographic embolization can preserve a significant degree of renal function, enough to prevent the need for dialysis should a patient lose function in the contralateral kidney. Urologists should recognize, however, that a significant proportion of patients will require ureteral stenting for urinary extravasation after angiographic embolization.

Fianlly, recent evidence has demonstrated that the size of a perirenal hematoma on an axial scan may be closely associated with the need for angiographic embolization.

"For urologists unaccustomed to dealing with challenging, high-grade renal injuries, assessment of perirenal hematoma size may provide guidance in a snapshot about the potential utility of an angiographic approach to achieving hemostasis," Dr. Morey suggested.