Open urethroplasty has high success rates

May 15, 2010

A lower lithotomy position is an acceptable standard approach when performed with adjustable stirrups and pneumatic compression stockings.

Key Points

Notable presentations include studies related to lithotomy position, radiation-induced strictures, identifying and eliminating unnecessary imaging studies, use of buccal mucosal grafts for urethral repair, and the transobturator sling for male urinary incontinence.

Low "social" lithotomy has gained increasing support as a favored position for a variety of perineal surgical procedures. Data from a large prospective series will show that a lower lithotomy position is an acceptable standard approach when performed with adjustable stirrups and pneumatic compression stockings.

"High lithotomy positioning does not appear to be necessary to achieve adequate exposure for the deep perineum. The reduced risk inherent to the low lithotomy position is an important message for perineal surgeons to remember."

Radiation therapy-induced urethral strictures have become increasingly common and can be challenging for urologists to repair. Tissues are usually very fibrotic and often occur in older patients who have undergone multiple endoscopic procedures, said Dr. Morey.

Several presentations at the AUA meeting will inform on various aspects of managing radiation-induced strictures. Data will show that open urethroplasty for the bulbomembranous radiation-induced stricture is successful in about 80% of patients. Some patients may have transient, mild incontinence, but overall, an excisional procedure with primary anastomosis achieves good outcomes most of the time, said Dr. Morey.

Other data will show that metal stents used for radiation-induced strictures might not provide durable patency. Postoperative recurrence appears to be >50% for stents placed within radiated tissues, Dr. Morey said, thus suggesting that an open approach might be preferable.

Focus on decreased imaging

Imaging studies have come under closer scrutiny in the era of cost containment. Presentations at the AUA meeting will review several clinical circumstances in which imaging might be avoided.

For patients with renal injuries, repeat abdominal computed tomography scans are often performed 48 hours after initial evaluation. The strategy appears to offer little benefit and rarely changes clinical management.

"Routine repeat imaging for lower grade renal injuries can be safely omitted because it doesn't change management," Dr. Morey said.

Concern has also arisen regarding possible unnecessary radiation exposure with abdominal CT imaging of children with abdominal blunt trauma and microhematuria. Results of a new study will show that abdominal CT has a very low yield of clinically significant findings in children with any degree of microhematuria, as opposed to gross hematuria.

Similarly, postoperative imaging after anastomotic urethroplasty rarely produces clinically significant findings. Excision with primary anastomosis tends to be the mainstay of reconstructive procedures and is associated with little or no risk of extravasation after several weeks of catheter drainage. A routine postoperative cystourethrogram appears unnecessary.

"For the standard two-layer anastomotic urethroplasty procedure, we have abandoned routine postoperative imaging studies," said Dr. Morey.

More data on buccal mucosal grafting

Buccal mucosal grafting continues to evolve as a two-stage procedure. Focal urethrectomy with graft reconstruction in a staged procedure appears to be safe and effective for many patients with advanced or complex strictures and adverse tissue characteristics, he added. Data reported at the AUA meeting will show that a substantial portion of patients may not request the final stage of retubularization.

"Many patients are happy to be voiding well after the initial procedure to remove the diseased segment and replacement with a graft," Dr. Morey said. "Some patients might be quite satisfied with that alone and not so concerned about cosmetic changes."

As successful as they are, buccal mucosal grafts do not appear to be immune to developing fibrotic complications when used for urethral substitution. Pathologic changes secondary to lichen sclerosis may occur within the graft in a substantial proportion of patients, he noted.