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Objective: To evaluate the outcomes of excision and primary anastomosis (EPA) for radiation-associated bulbomembranous stenoses using a multi-institutional analysis. The treatment of radiation-associated urethral stenosis is typically complex owing to the adverse impact of radiation on adjacent tissue.Methods: An IRB-approved multi-institutional retrospective review was performed on patients who underwent EPA for bulbomembranous urethral stenosis following prostate radiotherapy. Preoperative patient demographics, operative technique, and postoperative outcomes were abstracted from 1/2007-6/2018. Success was defined as voiding per urethra without the need for endoscopic treatment and a minimum follow-up of 12 months.Results: One hundred and thirty-seven patients from 10 centers met study criteria with a mean age of 69.3 years (50-86), stenosis length of 2.3 cm (1-5) and an 86.9% (119/137) success rate at a mean follow-up 32.3 months (12-118). Univariate Cox regression analysis identified increasing patient age (P = .02), stricture length (P <.0001) and combined modality radiotherapy (P = .004) as factors associated with stricture recurrence while body mass index (P = .79), diabetes (P = .93), smoking (P = .62), failed endoscopic treatment (P = .08) and gracilis muscle use (P = .25) were not. On multivariate analysis, increasing patient age (H.R.1.09, 95%CI 1.01-1.16; P = .02) and stenosis length (H.R.2.62, 95%CI 1.49-4.60; P = .001) remained associated with recurrence. Subsequent artificial urinary sphincter was performed in 30 men (21.9%), of which 25 required a transcorporal cuff and 5 developed cuff erosion.Conclusions: EPA for radiation-associated urethral stenosis effectively provides unobstructed instrumentation-free voiding. However, increasing stenosis length and age are independently associated with surgical failure. Patients should be counseled that further surgery for incontinence may be necessary. [ABSTRACT FROM AUTHOR]

Purpose: Ideal treatment of lichen sclerosus (LS)-induced penile urethral strictures (PUS) remains elusive. The objective of this study was to compare multi-institutional outcomes of single-stage urethroplasty (SSU) with oral mucosal graft, staged urethroplasty, and perineal urethrostomy (PU) for treatment of LS-induced PUS., Materials and Methods: Multi-institutional analysis was performed at 9 centers on men undergoing SSU, staged urethroplasty, or PU for LS-induced PUS. Meatal strictures (<2 cm), bulbar urethral involvement, and panurethral strictures (>10 cm) were excluded. The primary outcome was recurrence-free status on follow-up assessment. Secondary outcomes included 90-day complications (Clavien ≥ 2), erectile dysfunction, chordee, and urethrocutaneous fistula., Results: Two hundred thirty-one patients were included with a median stricture length of 5 cm and median follow-up of 53 months among those without stricture recurrence. 1-, 5-, and 10-year stricture-free estimates were 90%, 80%, and 75%, respectively. 55% (127/231) underwent SSU with oral mucosal graft, 19% (44) staged urethroplasty, and 26% (60) underwent PU. On log-rank, there was no identifiable difference in stricture recurrence between techniques ( P = .6) with 5-year stricture-free estimates of 82%, 76%, and 75%, respectively. On χ 2 , there was no significant difference in 90-day complications (7.1% vs 16% vs 8.3%; P = .2), erectile dysfunction (7.1% vs 4.5% vs 3.3%; P = .6), chordee (5.5% vs 6.8% vs 1.7%; P = .4), or urethrocutaneous fistula (2.4% vs 6.8% vs 0%; P = .09). On Cox regression, only obesity (BMI ≥ 35) was associated with stricture recurrence (HR, 2.31, 95% CI, 1.28-4.17; P = .006)., Conclusions: Favorable comparative outcomes confirm SSU as a highly feasible treatment for LS-induced PUS in properly selected patients, especially when considering fewer surgeries required and preservation of an orthotopic meatus.

Objective: To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury., Methods: Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score., Results: There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (P < 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (P < 0.001)., Conclusion: In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: A successful urethroplasty has been defined in different ways across studies. This variety in the literature makes it difficult to compare success rates and techniques across studies. We aim to evaluate the success of anterior urethroplasty based on different definitions of success in a single cohort., Materials and Methods: Data were collected from a multi-institutional, prospectively maintained database. We included men undergoing first-time, single-stage, anterior urethroplasty between 2006 and 2020. Exclusion criteria included lack of followup, hypospadias, extended meatotomy, perineal urethrostomy, posterior urethroplasty and staged repairs. We compared 5 different ways to define a "failed" urethroplasty: 1) stricture retreatment, 2) anatomical recurrence on cystoscopy, 3) peak flow rate <15 ml/second, 4) weak stream on questionnaire and 5) failure by any of these measures. Kaplan-Meier survival curves were generated for each of the definitions. We also compared outcomes by stricture length, location and etiology., Results: A total of 712 men met inclusion criteria, including completion of all types of followup. The 1- and 5-year estimated probabilities of success were "retreatment," 94% and 75%; "cystoscopy," 88% and 71%; "uroflow," 84% and 58%; "questionnaire," 67% and 37%; and "any failure," 57% and 23%. This pattern was inconsistent across stricture length, location and etiology., Conclusions: The estimated probability of success after first-time, anterior urethroplasty is highly dependent on the way success is defined. The variability in definitions in the literature has limited our ability to compare urethroplasty outcomes across studies.

Objective: To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates., Methods: We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure <90 mmHg), and Glasgow Coma Scale (GCS)., Results: A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P <.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55)., Conclusion: Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To determine whether ejaculatory dysfunction (EjD) and post-void dribbling (PVD) after urethroplasty are associated, providing evidence for a common etiology., Methods: We reviewed a prospectively maintained database for first-time, anterior urethroplasties. One item from the Male Sexual Health Questionnaire (MSHQ) assessed EjD: "How would you rate the strength or force of your ejaculation". One item from the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS-PROM) assessed PVD: "How often have you had slight wetting of your pants after you had finished urinating?". The frequency of symptoms was compared after penile vs. bulbar repairs, and anastomotic versus augmentation bulbar repairs. Associations were assessed with chi-square., Results: A total of 728 men were included. Overall, postoperative EjD and PVD were common; 67% and 66%, respectively. There was a significant association between EjD and PVD for the whole cohort (p<0.0001); this association remained significant after penile repairs (p=0.01), bulbar repairs (p<0.0007), and bulbar anastomotic repairs (p=0.002), but not after bulbar augmentation repairs (p=0.052). EjD and PVD occurred at similar rates after penile and bulbar urethroplasty. The rate of EjD was similar after bulbar augmentation and bulbar anastomotic urethroplasties, but PVD was more common after bulbar augmentation (70% vs. 52%) (p = 0.0001)., Conclusion: EjD and PVD after anterior urethroplasty are significantly associated with one another, supporting the theory of a common etiology. High rates after penile repairs argue against a bulbospongiosus muscle damage etiology, and high rates after anastomotic repairs argue against graft sacculation. More work is needed to better understand and prevent symptoms., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To find clinical or radiographic factors that are associated with angioembolization failure after high-grade renal trauma., Material and Methods: Patients were selected from the Multi-institutional Genito-Urinary Trauma Study. Included were patients who initially received renal angioembolization after high-grade renal trauma (AAST grades III-V). This cohort was dichotomized into successful or failed angioembolization. Angioembolization was considered a failure if angioembolization was followed by repeat angiography and/or an exploratory laparotomy., Results: A total of 67 patients underwent management initially with angioembolization, with failure in 18 (27%) patients. Those with failed angioembolization had a larger proportion ofgrade IV (72% vs 53%) and grade V (22% vs 12%) renal injuries. A total of 53 patients underwent renal angioembolization and had initial radiographic data for review, with failure in 13 cases. The failed renal angioembolization group had larger perirenal hematoma sizes on the initial trauma scan., Conclusion: Angioembolization after high-grade renal trauma failed in 27% of patients. Failed angioembolization was associated with higher injury grade and a larger perirenal hematoma. Likely these characteristics are associated with high-grade renal trauma that may be less amenable to successful treatment after a single renal angioembolization., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: To determine if the number of endoscopic treatments of urethral stricture disease (USD) prior to urethroplasty has changed in the context of new AUA guidelines on management of USD. In addition to an increase in practicing reconstructive urologists and published reconstructive literature, the AUA guidelines regarding the management of male USD were presented in May 2016, advocating consideration of urethroplasty in patients with 1 prior failed endoscopic treatment., Methods: A retrospective review of a prospectively maintained, multi-institutional urethral stricture database of high volume, geographically diverse institutions was performed from 2006 to 2017. We performed a review of relevant literature and evaluated pre-urethroplasty endoscopic treatment patterns prior to and after the AUA male stricture guideline., Results: 2964 urethroplasties were reviewed in 10 institutions. There was both a decrease in the number of endoscopic treatments prior to urethroplasty in the pre-May 2016 compared to post-May 2016 cohorts both for overall urethroplasties (2.3 vs 1.6, P = 0.0012) and a gradual decrease in the number of pre-urethroplasty endoscopic treatments over the entire study period., Conclusion: There was a decrease in the number of endoscopic treatments of USD prior to urethroplasty in the observed period of interest. Declining endoscopic USD management is not likely to be a reflection of a solely unique influence of the guidelines as endoscopic treatment decreased over the entire study period. Further research is needed to determine if there will be a continued trend in the declining use of endoscopic treatment and elucidate the barriers to earlier urethroplasty in patients with USD.

Objective: To evaluate the presenting complications of patients to reconstructive urologists after masculinizing gender affirming genital reconstructive surgery (GRS) performed elsewhere., Methods: We identified patients who underwent revision surgery by one of the co-authors for sequelae of masculinizing GRS. We reviewed patient demographics, medical history, details of prior GRS, and complications from GRS. Specific attention was paid to the presence of the following: suprapubic tube dependence, vaginal remnant, urethrocutaneous fistula (UCF) within the fixed urethra (pars fixa), UCF in the phallic urethra, phallic urethral stricture, meatal stenosis, and anastomotic urethral stricture. Statistical analysis was performed using the Fisher's exact test to determine differences in presenting symptoms by GRS., Results: Fifty-five patients who had reconstructive surgery for complications from masculinizing GRS from September 2004 to September 2017 were identified. The median age at surgical correction was 33 years. Fifteen (27%) patients had prior metoidioplasty and 40 (73%) had prior phalloplasty. The median time from date of GRS to presentation to a reconstructive urologist was 4 months. Urethral strictures (n = 47, 86%) were the most common indication for subsequent surgery, followed by urethrocutaneous fistulae (n = 31, 56%) and vaginal remnant (n = 26, 47%). The majority of patients presented with 2 or more simultaneous complications (n = 40, 73%)., Conclusion: There are several common presenting urologic complications after masculinizing GRS. Patients may present to reconstructive urologists early after GRS performed elsewhere. The long-term outcomes of GRS deserve further study., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this multi-institutional study was to compare outcomes of transecting and nontransecting anastomotic bulbar urethroplasty., Materials and Methods: We performed a retrospective, multi-institutional review of the records of 352 patients who underwent transecting or nontransecting anastomotic bulbar urethroplasty performed by 1 of 4 reconstructive urologists from September 2003 to March 2017. Study outcomes were urethroplasty success, defined as urethral patency greater than 16Fr on cystoscopy; de novo sexual dysfunction assessed at 6 months, defined as a 5-point or greater change in the SHIM (Sexual Health Inventory for Men) or a patient reported adverse change; and 90-day complications, defined as Clavien 2 or greater. When appropriate, comparisons were made between the transecting and nontransecting cohorts using the Mantel-Cox test, the t-test or the chi-square test., Results: Of the 352 patients with a mean stricture length of 1.7 cm (range 0.5 to 5) 258 and 94 underwent transecting and nontransecting anastomotic bulbar urethroplasty, respectively. The overall success rate was 94.9% at a mean followup of 64.2 months (range 6 to 170). Of the patients 7.1% experienced a 90-day complication and 11.6% reported sexual dysfunction. When comparing transecting and nontransecting techniques, there was no difference in success (93.8% vs 97.9%, Mantel-Cox test p = 0.18) or postoperative complications (8.1% vs 4.3%, p = 0.25). Patients treated with transecting anastomotic urethroplasty were more likely to report an adverse change in sexual function (14.3% vs 4.3%, p = 0.008). On multivariate analysis only transecting urethroplasty was associated with sexual dysfunction (p = 0.01) while age (p = 0.29), stricture length (p = 0.42), etiology (p = 0.99) and surgeon (p = 0.88) were not., Conclusions: Anastomotic urethroplasty is a highly effective surgery with relatively minimal associated morbidity. Nontransecting anastomotic urethroplasty compares quite favorably to the transecting technique and likely reduces the risk of associated sexual dysfunction.

Purpose: There is a lack of national data describing the demographics and nature of pediatric renal trauma. We used the National Trauma Data Bank to analyze mechanisms and grades of injury, demographics and treatment characteristics of pediatric renal trauma cases., Materials and Methods: Renal injuries were identified by Abbreviated Injury Scale codes and converted to American Association for the Surgery of Trauma renal injury grades. Patients were stratified by age (0 to 1, 2 to 4, 5 to 14 and 15 to 18 years) for more specific analyses of mechanisms and grades of injury. Data reviewed included mechanisms and grades of renal injury, demographics, and setting and type of treatment., Results: A total of 2,213 pediatric renal injuries were converted to American Association for the Surgery of Trauma grade. Mean ± SD age at injury was 13.7 ± 4.4 years, with 2,089 patients (94%) being 5 to 18 years old. Of the injuries 79% were grade I, II or III. Penetrating injury accounted for less than 10% of all pediatric renal injuries. A majority of patients (57%) were admitted to university hospitals with a dedicated trauma service (73%) and only 12% of patients were admitted to a pediatric hospital. A total of 122 nephrectomies (5.5%) were performed., Conclusions: Most renal trauma in children is low grade, is blunt in nature and occurs after age 5 years. The majority of these cases are managed at adult hospitals. Although most patients are treated conservatively, the rate of nephrectomy is 3 times higher at adult hospitals than at pediatric centers., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The National Highway Traffic Safety Administration's New Car Assessment Program (NCAP) implemented side-impact crash testing on all new vehicles since 1998 to assess the likelihood of major thoracoabdominal injuries during a side-impact crash. Higher crash test rating is intended to indicate a safer car, but the real-world applicability of these ratings is unknown. Our objective was to determine the relationship between a vehicle's NCAP side-impact crash test rating and the risk of major thoracoabdominal injury among the vehicle's occupants in real-world side-impact motor vehicle crashes., Methods: The National Automotive Sampling System Crashworthiness Data System contains detailed crash and injury data in a sample of major crashes in the United States. For model years 1998 to 2010 and crash years 1999 to 2010, 68,124 occupants were identified in the Crashworthiness Data System database. Because 47% of cases were missing crash severity (ΔV), multiple imputation was used to estimate the missing values. The primary predictor of interest was the occupant vehicle's NCAP side-impact crash test rating, and the outcome of interest was the presence of major (Abbreviated Injury Scale [AIS] score ≥ 3) thoracoabdominal injury., Results: In multivariate analysis, increasing NCAP crash test rating was associated with lower likelihood of major thoracoabdominal injury at high (odds ratio [OR], 0.8; 95% confidence interval [CI], 0.7-0.9; p < 0.01) and medium (OR, 0.9; 95% CI, 0.8-1.0; p < 0.05) crash severity (ΔV), but not at low ΔV (OR, 0.95; 95% CI, 0.8-1.2; p = 0.55). In our model, older age and absence of seat belt use were associated with greater likelihood of major thoracoabdominal injury at low and medium ΔV (p < 0.001), but not at high ΔV (p ≥ 0.09)., Conclusion: Among adults in model year 1998 to 2010 vehicles involved in medium and high severity motor vehicle crashes, a higher NCAP side-impact crash test rating is associated with a lower likelihood of major thoracoabdominal trauma., Level of Evidence: Epidemiologic study, level III.

Background: The traditional American Association for the Surgery of Trauma (AAST) grading of renal injury does not adequately identify the subset of patients who are most likely to require intervention for bleeding. Recently, several high-risk criteria (HRC) for bleeding after renal injury were identified, and we sought to externally validate these criteria among patients with grade 4 renal injury., Study Design: All patients presenting to a level I trauma center with blunt grade 4 renal injuries from 2003 to 2010 were reviewed, and stage was determined by the 1989 AAST staging criteria. Dependent variables included the presence of a hilar injury or any of the HRC (perirenal hematoma size, intravascular contrast extravasation, and medial or complex laceration). The primary outcome was the need for intervention (renorrhaphy, nephrectomy, or angiography) for hemodynamic instability., Results: A total of 84 patients with grade 4 renal lacerations were identified. Two or more HRC were present in 18 patients (21%), and intervention for hemodynamic instability was performed in 14 patients (17%). Compared with patients with 0 or 1 HRC, those with ≥ 2 HRC were approximately 25 times more likely to require intervention for hemodynamic instability (odds ratio [OR]24.9, 95% CI 5.5 to 112.9, p < 0.001). Patients with no HRC were unlikely to require intervention for hemodynamic instability., Conclusions: Among patients with blunt grade 4 renal injury, the presence of ≥ 2 HRC effectively predicts the need for intervention for hemodynamic instability and can be used to identify patients who require intensive monitoring. The AAST grading system for renal injury should be modified to better reflect injury severity., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

This article reviews the history, indications, technique, complications, and outcomes of primary urethral realignment of pelvic fracture urethral injuries. In clinically stable patients, an attempt at endoscopic urethral realignment is appropriate and may result in long-term urethral patency. However, long term follow up is necessary due to elevated rates of delayed stricture formation requiring endoscopic or surgical repair., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To identify the incidence of, risk factors for, and subsequent complications of perinephric hematomas after percutaneous nephrolithotomy., Materials and Methods: We retrospectively analyzed patients who had undergone CT within 5 days of surgery for evidence of perinephric hematomas. Hematoma severity was graded on a 4-point system in which 0 = no blood, 1 = subcapsular blood, 2 = perinephric blood that does not or minimally displaces the kidney, 3 = blood that displaces the kidney > 2 cm, and 4 = blood that extends into the retroperitoneum. Univariate analysis was performed to identify significant preoperative, intraoperative, or postoperative risk factors., Results: A total of 202 patients underwent percutaneous nephrolithotomy and were imaged with CT within 5 days of surgery. Of these, 140 (69%) were grade 0, 55 (27.2%) had localized bleeding (grades 1 or 2), and 7 (3.5%) had extensive bleeding (grades 3 or 4). Complications developed postoperatively in 13 of the patients in groups 1 to 4, including persistent fever longer than 12 hours after surgery in 8 patients, ileus in 2 patients, transfusion of packed red blood cells in 2 patients, and hydrothorax necessitating a chest tube in 1 patient. No patient had surgical or percutaneous intervention. At 3-month follow-up, no patients had symptoms or needed further imaging. Placement of a ureteral stent at the conclusion of the procedure occurred in a significantly higher number of patients in groups 1 to 4 (P = 0.009). The remaining factors were not significantly different. Subset analysis revealed a significantly greater hemoglobin decline in patients with extensive hematomas, groups 3 and 4, compared with groups 0 to 2 (P = 0.001)., Conclusions: Perinephric hematomas occur in nearly one-third of patients undergoing percutaneous nephrolithotomies but are extensive only 11% of the time. Hematomas are not associated with an increased incidence of clinically relevant complications. There does not appear to be any indication for serial imaging during hospitalization or at 3-month follow-up.