A 46-year-old man with human immunodeficiency virus presented with a condyloma that formed during 6 months and encased his penis, scrotum, and perineum. Visible condyloma growth began when this immunocompromised patient started highly active antiretroviral therapy, and it grew rapidly as his viral load plummeted. The patient underwent resection and reconstruction with skin grafting. Pathology findings revealed benign condyloma acuminatum. This rapid progression of condyloma growth is a cutaneous manifestation of immune reconstitution inflammatory syndrome.

Purpose

Adults with complications from previous hypospadias surgery experience various problems, including urethral stricture, persistent hypospadias and urethrocutaneous fistula. Innate deficiencies of the corpus spongiosum and multiple failed operations makes further management challenging.

Materials and methods

We reviewed our prospective urethroplasty database of men who presented with complications of previous hypospadias surgery. Patients were included in study if they had greater than 6 months of followup. Our surgical management was defined as an initial success if there were no urethral complications. The overall success rate included men with the same result after additional treatment.

Results

A total of 50 men had followup greater than 6 months (median 89) and were included in study. These 50 patients presented with urethral stricture (36), urethrocutaneous fistula (12), persistent hypospadias (7), hair in the urethra (6) and severe penile chordee (7). Patients underwent a total of 74 urethroplasties, including stage 1 urethroplasty in 19, a penile skin flap in 11, stage 2 urethroplasty in 11, urethrocutaneous fistula closure in 9, permanent perineal urethrostomy in 6, excision and primary anastomosis in 6, a 1-stage buccal mucosa onlay in 4, tubularized plate urethroplasty in 3, combined techniques in 3 and chordee correction in 1. In 25 men (50%) treatment was initially successfully. Of the 25 men in whom surgery failed 18 underwent additional procedures, including 13 who were ultimately treated successfully for an overall 76% success rate (38 of 50).

Conclusions

Managing problems from previous hypospadias surgery is difficult with a high initial failure rate. Additional procedures are commonly needed.

Purpose

We assessed the use of conservative management for American Association for the Surgery of Trauma grade V renal trauma in the National Trauma Databank.

Materials and methods

We used data of grade V renal trauma patients in the 2017-2019 National Trauma Databank. Conservative management was defined by the absence of surgical or procedural intervention except for ureteral stent or percutaneous drain placement. We initially analyzed patients who survived to final hospital discharge and reported the percent utilization of conservative management. We then repeated our analysis in the overall grade V population and in all those who did not die in the emergency department.

Results

Of 1,474 who survived to discharge, 557 (37.8%) patients were managed conservatively. In the adjusted analysis, penetrating trauma mechanism (OR 0.13, 95% CI 0.09-0.19, P < .001) and receiving transfusion (OR 0.22, 95% CI 0.17-0.29, P < .001) were associated with decreased odds of receiving conservative management. Overall, there were 1,919 patients with grade V injury, of whom 731 (38.1%) were managed conservatively. Mortality rate was 22.8% in those managed conservatively vs 23.8% in those who had intervention. After excluding 110 patients who died in the emergency department, there were 1,809 patients, of whom 625 (34.6%) were managed conservatively. Mortality rate was 22.6% in the operatively managed group and 10.9% in the conservatively managed group.

Conclusions

A substantial portion of grade V renal trauma cases were managed successfully without intervention in the National Trauma Databank. Further research is needed to identify radiological phenotypes suitable for nonoperative management and to overcome possible renal trauma grade misclassification.

Purpose

Male urethral stricture disease accounts for a significant number of hospital admissions and health care expenditures. Although much research has been completed on treatment for urethral strictures, fewer studies have addressed the treatment of strictures in men with recurrent stricture disease after failed prior urethroplasty. We examined outcome results for repeat urethroplasty.

Materials and methods

A prospectively collected, single surgeon urethroplasty database was queried from 1977 to 2011 for patients treated with repeat urethroplasty after failed prior urethral reconstruction. Stricture length and location, and repeat urethroplasty intervention and failure were evaluated with descriptive statistics, and univariate and multivariate logistic regression.

Results

Of 1,156 cases 168 patients underwent repeat urethroplasty after at least 1 failed prior urethroplasty. Of these patients 130 had a followup of 6 months or more and were included in analysis. Median patient age was 44 years (range 11 to 75). Median followup was 55 months (range 6 months to 20.75 years). Overall, 102 of 130 patients (78%) were successfully treated. For patients with failure median time to failure was 17 months (range 7 months to 16.8 years). Two or more failed prior urethroplasties and comorbidities associated with urethral stricture disease were associated with an increased risk of repeat urethroplasty failure.

Conclusions

Repeat urethroplasty is a successful treatment option. Patients in whom treatment failed had longer strictures and more complex repairs.

Background

Female urethral stricture disease is under-recognized and is often treated with dilation despite poor definitive outcomes. Our objective was to describe a multi-institutional experience treating female urethral stricture disease with female dorsal onlay buccal mucosa graft (FD-BMG) urethroplasty outcomes.

Methods

We retrospectively identified 39 consecutive FD-BMG urethroplasty operations performed by 6 reconstructive surgeons from 12/2007 to 1/2016. Surgical technique included dorsally-placed buccal mucosal grafts in all cases. Stricture recurrence was defined by cystoscopy.

Results

Mean age was 50 (range, 29-81) years. Stricture etiology was unknown (49%), iatrogenic (36%), or trauma/straddle injury (15%). A majority of women (87%) women had undergone a prior stricture-related urethral procedure(s) before the surgeons' index urethroplasty. Mean stricture length was 2.1 cm and mean caliber was 11 Fr. Mean postoperative follow-up was 33 (range, 7-106) months. Postoperative complications within 30 days were seen in 7 individuals (18%) and were all Clavien-Dindo grade II. Stricture recurrence was seen in 9 (23%) patients, with mean time to recurrence 14 months. No patients experienced de novo incontinence.

Conclusions

FD-BMG urethroplasty is a safe and effective management option for female urethral strictures. Referral to a reconstructive center is encouraged to avoid repeated unnecessary endoscopic procedures that have poor definitive success.

Background

Female urethral stricture disease is under-recognized and is often treated with dilation despite poor definitive outcomes. Our objective was to describe a multi-institutional experience treating female urethral stricture disease with female dorsal onlay buccal mucosa graft (FD-BMG) urethroplasty outcomes.

Methods

We retrospectively identified 39 consecutive FD-BMG urethroplasty operations performed by 6 reconstructive surgeons from 12/2007 to 1/2016. Surgical technique included dorsally-placed buccal mucosal grafts in all cases. Stricture recurrence was defined by cystoscopy.

Results

Mean age was 50 (range, 29-81) years. Stricture etiology was unknown (49%), iatrogenic (36%), or trauma/straddle injury (15%). A majority of women (87%) women had undergone a prior stricture-related urethral procedure(s) before the surgeons' index urethroplasty. Mean stricture length was 2.1 cm and mean caliber was 11 Fr. Mean postoperative follow-up was 33 (range, 7-106) months. Postoperative complications within 30 days were seen in 7 individuals (18%) and were all Clavien-Dindo grade II. Stricture recurrence was seen in 9 (23%) patients, with mean time to recurrence 14 months. No patients experienced de novo incontinence.

Conclusions

FD-BMG urethroplasty is a safe and effective management option for female urethral strictures. Referral to a reconstructive center is encouraged to avoid repeated unnecessary endoscopic procedures that have poor definitive success.

OBJECTIVE:To understand the prevalence of chronic perineal pain, activity limitations, and patient satisfaction after urethroplasty. METHODS:From 2014 to 2016, we prospectively enrolled men undergoing urethroplasty for bulbar urethral strictures. Patients, before and after surgery, completed questions from the Core Lower Urinary Tract Symptom Score assessing pain frequency in the bladder and penis or urethra, as well as nonvalidated questions assessing perineal pain. Overall satisfaction with their current urinary condition and pain-related activity limitations at home, work, or during exercise were also measured. Patients with <3 months of follow-up were excluded. Pre-and postoperative scores were compared using the Wilcoxon signed-rank test. RESULTS:Thirty-five men were included in the study. Mean age and body mass index were 44.6 years and 30.9 kg/m2, respectively. Urethroplasties were anastomotic in 24 (69%) and were single-stage buccal graft substitution in 11 (31%). Median follow-up after surgery was 483 days (range: 90-810 days). A total of 10 patients (29%) reported worsening perineal pain intensity after surgery, whereas 8 (23%) reported improvement and 17 (48%) reported no change. Overall, pain frequency in the bladder, penis or urethra, and perineum improved. Home and exercise pain-related activity restrictions improved significantly after surgery. Satisfaction with current urinary condition also improved with 91% reporting feeling "delighted," "pleased," or "mostly satisfied" with their current condition. CONCLUSION:Patients are highly satisfied with their urinary condition after urethroplasty. Pain frequency in the bladder and the urethra significantly improves after urethroplasty; however, perineal pain intensity can worsen and become chronic after surgery in some patients.