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Purpose: The treatment of urethral stenosis after a combination of prostatectomy and radiation therapy for prostate cancer is understudied. We evaluate the clinical and patient-related outcomes after dorsal onlay buccal mucosal graft urethroplasty (D-BMGU) in men who underwent prostatectomy and radiation therapy., Materials and Methods: A multi-institutional, retrospective review of men with vesicourethral anastomotic stenosis or bulbomembranous urethral stricture disease after radical prostatectomy and radiation therapy from 8 institutions between 2013 to 2021 was performed. The primary outcomes were stenosis recurrence and development of de novo stress urinary incontinence. Secondary outcomes were surgical complications, changes in voiding, and patient-reported satisfaction., Results: Forty-five men were treated with D-BMGU for stenosis following prostatectomy and radiation. There was a total of 7 recurrences. Median follow-up in patients without recurrence was 21 months (IQR 12-24). There were no incidents of de novo incontinence, 28 patients were incontinent pre- and postoperatively, and of the 6 patients managed with suprapubic catheter preoperatively, 4 were continent after repair. Following repair, men had significant improvement in postvoid residual, uroflow, International Prostate Symptom Score, and International Prostate Symptom Score quality-of-life domain. Overall satisfaction was +2 or better in 86.6% of men on the Global Response Assessment., Conclusions: D-BMGU is a safe, feasible, and effective technique in patients with urethral stenosis after a combination of prostatectomy and radiation therapy. Although our findings suggest this technique may result in lower rates of de novo urinary incontinence compared to conventional urethral transection and excision techniques, head-to-head comparisons are needed.

Purpose: We evaluated the effect of partial bladder outlet obstruction on bladder weight, protein synthesis, mitotic markers and the mitogen activated protein kinase pathway in a mouse model., Materials and Methods: Mice were divided into 3 groups, including control, sham treated and partially obstructed. Bladders were harvested from the mice in the partially obstructed group 12, 24, 48, 72 and 168 hours after surgical partial outlet obstruction, respectively. Partially obstructed bladders were compared to bladders in the control and sham treated groups by weight, protein content, and expression of proliferating cellular nuclear antigen, cyclin D3, HsP 70, c-jun and phosphorylated c-jun. Bladders were examined histologically for changes occurring with partial obstruction., Results: We tested 3 groups of mice, including control, sham treated and partially obstructed mice, to understand the pathophysiology of the bladder response to partial obstruction. We found no statistical difference in body weight among the groups. Furthermore, there was a significant increase in bladder weight and protein content in partially obstructed mice compared to those in controls and sham operated mice. There was up-regulation of proliferating cellular nuclear antigen, cyclin D3, HsP70, c-jun and phosphorylated c-jun with partial obstruction. Fibrosis was prominent at 168 hours compared to that in controls., Conclusions: Bladder weight and protein content increase with partial bladder outlet obstruction in mice. Cell cycle proteins and elements of the mitogen activated protein kinase pathway are up-regulated during this process.

Purpose: We report the long-term success of a 1-stage perineal anastomotic repair in patients with pelvic fracture urethral distraction defects., Materials and Methods: A retrospective analysis of 120 patients undergoing perineal bulboprostatic anastomotic repair of pelvic fracture urethral distraction defect in a single stage using our progressive approach between May 1991 and May 2001 was performed. Patients with posterior urethral stricture due to other etiologies, or those who underwent substitution urethroplasty or abdominoperineal repair were excluded from this review. Preoperative evaluation of the urethral defect included simultaneous retrograde urethrogram and voiding cystourethrogram. Postoperative retrograde urethrogram was performed at 3 weeks, 3 months, 12 to 18 months and as indicated thereafter., Results: Mean patient age was 32 (range 6 to 82) years. The estimated preoperative radiographic length of the distraction defect was 3.1 cm (range 0.5 to 10). Mean followup was 64 (range 9 to 128) months, mean hospital stay was 1.8 days and duration of urethral stenting was 3.4 weeks. Perineal anastomotic repair was successful in 103 of 109 (95%) adults, in 8 of 11 (73%) prepubescent boys and in 25 of 29 (86%) undergoing secondary repairs. All treatment failures were at the anastomosis and occurred within the first postoperative year. Successful management of failed repairs was accomplished endoscopically in 3 of 7 and by repeat perineal anastomotic repair in 2 of 2, resulting in a final success rate of 97% in adults, 91% in prepubescent boys and 97% in secondary repairs., Conclusions: The overall success of our progressive 1-stage perineal anastomotic repair of pelvic fracture urethral distraction defect continues to be excellent with the majority of failures occurring in prepubescent boys and secondary repairs.

Purpose: We present a series of urethral erosion following a pubovaginal sling procedure due to synthetic and nonsynthetic materials and discuss their management and continence outcome., Materials and Methods: During a 3-year period 57 patients underwent urethrolysis for urethral obstruction after receiving a pubovaginal sling. Urethral erosion, defined as sling material entering the urethral lumen, was present in 9 patients and this cohort comprises the focus of our review. In 3 patients the eroded material was synthetic, that is ProteGen (Boston Scientific, Natick, Massachusetts) in 2 and polypropylene in 1. This condition was treated with removal of the whole sling, multilayer closure of the erosion and selective use of a Martius flap. In 6 patients the eroded material was nonsynthetic, that is allograft fascia in 5 and autograft fascia in 1. This condition was treated with sling incision and multilayer closure of the urethra. Preoperative assessment included a urogynecologic questionnaire, measurement of pad use, a voiding diary, cystourethroscopy and videourodynamics. Postoperatively similar parameters were used to assess continence outcomes and the need for subsequent procedures., Results: Nine patients were followed 30 months after urethrolysis. All 9 women had some manifestation of voiding dysfunction following the pubovaginal sling procedure, including urinary retention in 4, urge incontinence in 3 and mixed incontinence in 2. Urinary retention resolved in 3 patients and urge incontinence resolved in 4. Stress urinary incontinence (SUI) persisted in 2 of the 3 patients in the synthetic group, while no patient in the nonsynthetic group had recurrent SUI. There were no recurrent urethral erosions or fistulas in either group., Conclusions: Urethral erosion after a pubovaginal sling procedure can occur irrespective of the sling material. However, recurrent SUI is not an invariable outcome of the management of urethral erosion following the pubovaginal sling procedure.

Purpose: We determine which urodynamic parameters can best predict postoperative voiding dysfunction following pubovaginal sling surgery., Materials and Methods: The records of 98 consecutive women who had undergone pubovaginal sling surgery with allograft fascia lata between July 1998 and July 2000 were reviewed. Urodynamic and followup data were sufficient for evaluation for 73 patients. Urodynamic and clinical parameters were correlated with urinary retention, time to return of efficient voiding and development of postoperative urgency symptoms., Results: Average time to return of efficient voiding was 3.92 days (median 3). Of 21 women who voided without a detrusor contraction urinary retention developed in 4 (23%) versus 0 of 48 who voided with detrusor contraction (p = 0.007). Urinary retention was defined as the need to perform even occasional self-catheterization. All 4 women with urinary retention had a detrusor pressure of less than 12 cm. H(2)O (0 in 3, 4 in 1). None of the women with a detrusor pressure of greater than 12 cm. H(2)O had urinary retention (p = 0.047). The presence of Valsalva voiding in women without a detrusor contraction did not affect the incidence of urinary retention (11.1%) compared to those who did not demonstrate Valsalva voiding (5.1%) (p = 0.603). Peak flow rate, detrusor instability on preoperative urodynamics and post-void residual urine volume were not associated with postoperative urinary retention. Finally, post-void residual urine volume predicted delayed return to normal voiding (p = 0.001). There were no other urodynamic parameters that were significantly associated with urinary retention, delayed return to normal voiding or postoperative urgency symptoms including peak flow rate, capacity or compliance., Conclusions: Women who void without or with a weak detrusor contraction are most likely to have urinary retention postoperatively. Therefore, we conclude that preoperative urodynamic evaluation may be used to counsel women regarding the risk of urinary retention following the pubovaginal sling procedure.

Purpose: We describe the anatomical and functional outcome in patients who underwent vaginal vault fixation to the proximal uterosacral ligaments for the treatment of vault prolapse and who also required a concomitant pubovaginal sling for associated stress urinary incontinence as well as the repair of other sector defects., Materials and Methods: We retrospectively analyzed the records of 33 patients who underwent such repairs between November 1998 and December 2001. Endopelvic fascial defects were described using the pelvic organ prolapse quantitative system (POPQ). Outcome measures included anatomical and functional assessment of pelvic floor defects and urinary incontinence., Results: Preoperatively all patients complained of a vaginal bulge and stress urinary incontinence, while 17 of the 33 had urge incontinence, and 24 and 9 had POPQ stage III or IV and stage II prolapse, respectively. Mean followup was 28 months (range 6 to 43). There was significant improvement in all POPQ measurements (p <0.05). Most notably vaginal cuff support improved by a mean of 7 cm. Stages IIAp (rectocele) and IIC (cuff) prolapse developed in 4 and 2 failed cases, respectively. Stress urinary incontinence was cured in all 33 patients and urge incontinence was cured in 14 of 17, while in 27 vaginal prolapse symptoms resolved and most had improved defecation dysfunction. No patients had urinary obstructive symptoms. There were no ureteral, bladder or rectal complications but 1 patient required blood transfusion., Conclusions: Suspension of the vaginal cuff to the proximal uterosacral ligaments with site specific repair of other associated endopelvic fascial defects provides excellent anatomical and functional correction of vault prolapse. Furthermore, a concomitant pubovaginal sling is a compatible repair for associated stress urinary incontinence. It did not compromise vaginal repair and prolapse repair did not jeopardize the outcome of the sling.

Purpose: Allografts have been substituted for autografts as a pubovaginal sling to decrease postoperative morbidity, although to our knowledge their long-term durability is unknown. Since 1997, we have offered allograft fascia lata as an alternative to autograft fascia in women undergoing the pubovaginal sling procedure. We describe our continued experience with those with a minimum 2-year followup., Materials and Methods: We retrospectively reviewed the records of 134 consecutive women with all types of stress urinary incontinence but without neurovesical voiding dysfunction or a significant degree of pelvic prolapse who underwent pubovaginal sling (allografts in 63 and autografts in 71) performed by a single surgeon. Rectus abdominis or fascia lata autograft and freeze-dried, gamma irradiated allograft slings were placed using identical techniques and a 2 x 12 cm. piece of fascia. Outcome analysis included a chart review, third party telephone interview and selective videourodynamics. Surgical outcome was categorized by daily pad use as cured-0, improved-1 or failed-greater than 1 pad., Results: Of 140 women who received a pubovaginal sling 134 were still evaluable. Preoperative parameters were similar in each group. Mean followup plus or minus standard deviation was less in the allograft group (29 +/- 3 versus 44 +/- 7 months, p < 0.05). There was no statistical difference in the overall stress and urge incontinence cure rate in the allograft and autograft groups (45 of 63 cases and 55 of 71, p = 0.42), nor was there a difference in the total number with recurrent stress urinary incontinence (8 and 7, respectively, p = 0.58). In 24% and 16% of cases postoperative incontinence was due to urge incontinence in the allograft and autograft groups, respectively. Using allografts instead of autografts resulted in a significantly decreased postoperative pain and disability (p < 0.05)., Conclusions: Using allograft fascia lata as an alternative to autologous fascia for a pubovaginal sling significantly decreases postoperative pain and disability without compromising efficacy at 2 years. Therefore, we believe that allograft fascia should remain a suitable alternative to autografts for pubovaginal slings.