Biomedical subjects

A F Morey

Publications and source records attributed to A F Morey.

At least 37 records · Page 2Linked to original sources

PubMed1999

Single shot intraoperative excretory urography for the immediate evaluation of renal trauma.

PURPOSE: We reviewed the quality and usefulness of single shot intraoperative excretory urography (IVP) for evaluating suspected upper urinary tract trauma at our trauma center. MATERIALS AND METHODS: Between 1990 and 1997 single shot intraoperative IVP for staging renal injuries was performed in 50 patients in whom clinical instability and/or major associated injuries mandated an intraoperative study. Contrast material (2 ml/kg) was injected intravenously and images were obtained after 10 minutes. The quality and usefulness of each study were scored by a single attending urologist on a scale of 1-worst to 5-best. RESULTS: Intraoperative study quality was generally good (average score 3.84). The information obtained was generally considered useful for determining urological treatment (average score 3.96). In 16 patients (32%) intraoperative IVP findings safely obviated renal exploration. No contrast medium reactions were noted and no complications developed that were attributable to intraoperative IVP. CONCLUSIONS: Intraoperative single shot, high dose IVP is safe, efficient and of high quality in the majority of cases when performed as recommended. This study often provides important information that facilitates rapid and accurate decision-making. Intraoperative IVP is a useful tool for guiding the exploration of penetrating renal injuries and confirming blunt renal injuries that may be safely observed.

Humans↗

PubMed1998

[Therapy of urethral stricture using free transplants].

Single stage urethroplasty with an onlay patch graft of penile skin or buccal mucosa is an effective treatment for patients with complex anterior urethral stricture disease. Using buccal mucosa, operative time is substantially reduced by using a two-team approach in which one team harvests the graft from the mouth while a perineal team simultaneously exposes and calibrates the stricture. Excellent results can be expected using grafts urethral substitution in men with refractory bulbar strictures. Focal areas of severe stenosis may be excised from the graft bed. For patients with long or dense stricture, grafts may easily be combined with other tissue transfer techniques.

Follow-Up Studies↗

PubMed1998

Workup and management of traumatic hematuria.

Hematuria is an important indicator of genitourinary tract injury after trauma. Correct initial evaluation of hematuria will affect diagnosis, management, and outcome of resultant injuries. This article presents recommendations for further evaluation when hematuria is found, depending on the mechanism of injury and clinical status of the patient. Once injuries have been adequately diagnosed and staged, appropriate management decisions can be made with urologic consultation.

Adult↗

PubMed1998

Battlefield urologic injuries: the Gulf War experience.

BACKGROUND: We sought to ascertain the incidence and type of urologic injuries requiring operations during the Gulf War. STUDY DESIGN: Of the 31 United States urologic surgeons deployed to the Persian Gulf theater of operations, 11 responded to a survey concerning the type and frequency of urologic trauma surgical procedures. RESULTS: The 11 urologic surgeons performed a total of 55 surgical procedures, 30 of which were for urologic injuries. Most injuries were due to fragmentation devices. Only 17% involved the kidney and none involved the ureter; 83% involved the pelvic organs and external genitalia. The majority of surgical procedures performed for these injuries were conservative (organ sparing). Anecdotal observations by the surgeons suggested that the use of the flak vest may have led to a shift away from abdominal injuries to injuries of the pelvis and genitalia. CONCLUSIONS: Urologic injuries in the Gulf War primarily involved the pelvis and genitalia and were frequently managed conservatively. The prevalence of fragmentation injuries and use of the flak vest may explain this observation.

Humans↗

PubMed1998

American Urological Association symptom index in the assessment of urethroplasty outcomes.

PURPOSE: In men undergoing urethroplasty we used the American Urological Association (AUA) symptom index to assess the magnitude of symptoms and determine the validity of this index as an outcome assessment tool. MATERIALS AND METHODS: The AUA symptom index was completed by individual interview of 50 men a mean of 41 years old who underwent urethral reconstruction. Symptom scores were then correlated with radiographic retrograde urethrograms and urinary flow rates to determine whether changes in the score were consistent with these other clinical indicators of success or failure. RESULTS: Mean preoperative AUA symptom index score in all evaluable patients was 26.9 (maximum 35), indicating severely bothersome voiding symptoms. In patients with radiographic evidence of successful urethral reconstruction the average postoperative score was 5.1 (p <0.0001). In those with recurrent stricture after urethroplasty scores were essentially unchanged but after successful repeat urethroplasty the mean symptom index score decreased to 3.4 (p <0.0001). A statistically significant inverse correlation (r = -0.712, p <0.0001) was found between AUA symptom index scores and maximum urinary flow rates. CONCLUSIONS: Patients with urethral strictures who are selected for formal urethroplasty have severe obstructive and irritative voiding symptoms. Results of the AUA symptom index correlate closely with conventional measures of urethroplasty outcome, such as radiographic retrograde urethrography and urinary flow studies. The AUA symptom index appears to have clinical validity as an adjunctive outcome assessment tool after urethroplasty.

Adolescent↗

PubMed1998

Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures.

PURPOSE: We review the applications and outcomes of penile circular fasciocutaneous flap urethroplasty in 66 patients at our institution. MATERIALS AND METHODS: We used a circular distal penile skin flap for urethral reconstruction in 66 men with complex urethral strictures. Average stricture length in this series was 9.08 cm. and mean followup was 41 months (range 1 to 7 years). RESULTS: The initial overall success rate was 79% (52 of 66 cases). Recurrent stenosis was noted in 7 of the 54 onlay (13%) and 7 of the 12 tubularized repairs (58%). Most recurrent strictures were successfully treated with a single subsequent procedure, including repeat urethroplasty in 5 cases and optical urethrotomy or dilation in 6. Two patients required perineal urethrostomy and 1 awaits further reconstruction. Including subsequent procedures, the overall long-term followup success rate was 95%. Neurovascular lower extremity complications developed in 4 patients after prolonged high lithotomy positioning. CONCLUSIONS: Circular fasciocutaneous flap urethroplasty is a highly effective 1-stage method of reconstructing complex urethral strictures. Onlay repairs appear to be more successful than those involving flap tubularization. Limiting the time that the patient spends in the high lithotomy position appears to prevent neurovascular extremity complications.

Follow-Up Studies↗

PubMed1998

Reconstruction of resistant strictures of the fossa navicularis and meatus.

PURPOSE: We evaluate the long-term efficacy of an integrated 1-stage approach for the reconstruction of resistant strictures of the fossa navicularis and meatus. MATERIALS AND METHODS: In 19 men with resistant glanular urethral strictures of varied origin reconstruction was tailored to the individual characteristics of the urethral stricture and glans. Urethral reconstruction was performed with a ventral transverse island fasciocutaneous penile flap in 16 cases, resection and primary end-to-end anastomosis in 2, and a buccal mucosal graft in 1. The glanuloplasty was completed as a glans cap in 15 patients and as glans wings in 4. In the latter group the glans was significantly scarred from the causative process and previous failed procedures. RESULTS: The patients were followed for a mean of 42.7 months. Transient urinary splaying and mild glans torsion were observed postoperatively but resolved within 8 weeks. Overall, a durable, functional and cosmetic result was achieved in 18 patients (94.7%), and only 1 had an anastomotic stricture that required reoperation. CONCLUSIONS: Although the management of resistant glanular urethral strictures can be difficult, the appropriate reconstructive techniques can permanently correct these strictures. We describe a logical 1-stage approach to reconstructing the fossa navicularis and meatus, allowing a functionally successful and cosmetically appealing long-term outcome.

Adult↗

PubMed1998

Obliterative vesicourethral strictures following radical prostatectomy for prostate cancer: reconstructive armamentarium.

PURPOSE: We report the reconstructive techniques used to correct obliterative vesicourethral strictures related to prostate cancer surgery. MATERIALS AND METHODS: Four men with anastomotic obliteration after radical prostatectomy underwent primary excision with end-to-end anastomosis, penile fasciocutaneous flap, free-graft urethroplasty with rectus muscle flap or anterior bladder tube with omental pedicle flap procedure. RESULTS: At mean followup of 33.8 months all patients had urethral patency but none was continent. CONCLUSIONS: Single stage reconstruction of the obliterated vesicourethral anastomosis after prostatectomy successfully restored urethral patency. No technique was applicable in all cases. Sphincteric function is likely to be compromised after the primary procedure, resulting in incontinence after successful urethral reconstruction. Subsequent artificial sphincter placement appears to be safe and helpful in restoring continence.

Aged↗

PubMed1997

Failed anterior urethroplasty: guidelines for reconstruction.

PURPOSE: We analyzed the methods and outcomes of repeat urethroplasty in men with recurrent stricture after the failure of previous anterior urethroplasty. MATERIALS AND METHODS: In 31 men with recurrent stricture after previous urethroplasty anterior urethral reconstruction was performed. Reconstructive methods varied according to stricture length and location. RESULTS: End-to-end urethroplasty performed in 11 of 13 men with short (average 1.8 cm.) bulbar strictures was successful in all. Patch graft urethroplasty was successfully done in 4 men with intermediate (average 4.4 cm.) strictures. Penile circular fasciocutaneous flap urethroplasty performed in 13 of 14 men with long or distal strictures (average 8 cm.) was successful in 10 (79%). Overall excellent results were obtained in 28 of the 31 cases (90%). CONCLUSIONS: Guidelines for urethral reconstruction after failed anterior urethroplasty are predicated on stricture length, location and severity. Circular fasciocutaneous flap urethroplasty is extremely versatile and effective for refractory long or distal strictures. End-to-end urethroplasty with stricture excision is highly reliable for less extensive bulbar strictures for which previous operative repair has failed. Grafts are best used selectively in the reoperative setting.

Clinical Protocols↗

PubMed1997

Skin graft reconstruction of chronic genital lymphedema.

OBJECTIVES: We present a simple, reliable method of scrotal and penile reconstruction yielding satisfactory cosmetic and functional results for patients with disabling chronic genital lymphedema. METHODS: Nine patients were treated with wide excision of the affected genital skin and subsequent coverage of exposed areas with split-thickness skin grafts in a single-stage procedure. RESULTS: All patients have had excellent cosmetic results without recurrence of genital lymphedema or compromise of sexual function postoperatively. CONCLUSIONS: Single-stage reconstruction for idiopathic genital lymphedema by radical skin excision and split-thickness skin grafting provides gratifying functional and cosmetic results.

Chronic Disease↗

PubMed1997

Reconstruction of posterior urethral disruption injuries: outcome analysis in 82 patients.

PURPOSE: We sought to identify the long-term success rate of perineal anastomotic reconstruction for posterior urethral disruption. MATERIALS AND METHODS: We reviewed the records of 82 patients with traumatic prostatomembranous urethral strictures who underwent perineal anastomotic urethroplasty by 1 surgeon. RESULTS: Excision of fibrosis with simple perineal anastomosis was performed in 52 patients (63%), while pubectomy was required in 30 (37%) to obtain a tension-free anastomosis. Median followup was longer than 1 year. Potency improved from 46% before reconstruction to 62% postoperatively. Nine patients (11%) required 1 endoscopic urethrotomy after urethroplasty to improve flow rate and this procedure was successful in 8 (88%). In 3 patients (3%) urethroplasty ultimately failed and they remained untreated because of insurmountable co-morbidity. Overall, long-term success was observed in 79 patients (97%). CONCLUSIONS: Excellent long-term results can be expected from anastomotic urethroplasty in patients with traumatic posterior urethral strictures. Subsequent urethrotomy, when required, has a high likelihood of success. A significant number of patients regain potency after urethral reconstruction. Persistent impotence probably reflects the severity of pelvic trauma.

Humans↗

PubMed1997

Single stage reconstruction of complex anterior urethral strictures: combined tissue transfer techniques.

PURPOSE: Reconstruction of most urethral strictures is possible with anastomotic, graft or skin flap procedures alone. We describe the combination of tissue transfer techniques to preserve the urethral plate and reconstruct long and complex urethral strictures in 1 stage. MATERIALS AND METHODS: We reviewed the results in 25 patients who underwent anterior urethroplasty requiring more than 1 tissue transfer technique to achieve urethral reconstruction in 1 stage. RESULTS: Outcome was excellent in 22 patients (88%). Seven patients with pan-urethral strictures (mean length 19 cm.) required a fasciocutaneous flap combined with a buccal mucosa, bladder epithelium or skin graft. A total of 13 patients with focally dense strictures underwent excision of the most severe portion of the stricture with dorsal reapproximation, thereby improving the quality of the urethral plate and allowing simultaneous flap or graft onlay reconstruction. Five patients with multiple separate strictures required a distal onlay fasciocutaneous flap with excision and end-to-end anastomosis of a separate, more proximal stricture. CONCLUSIONS: A thorough knowledge of the vascular supply of the urethra allowed creative application of different tissue transfer techniques, enabling 1-stage reconstruction of complex urethral strictures. An excellent outcome was achieved by preserving or revising the urethral plate and avoiding the problems associated with hair-bearing flaps and 2-stage procedures.

Adult↗

PubMed1997

Reconstruction of traumatic posterior urethral strictures.

Reconstruction of posterior urethral disruption injuries is an extremely challenging surgical exercise even in the best of hands. A perineal anastomotic technique is successful in the vast majority of cases. Adequate excision of fibrotic tissue is of paramount importance in ensuring successful outcomes. A wide-caliber, spatulated tension-free bulboprostatic anastomosis is the goal of surgical reconstruction. Excellent long-term results can be expected from anastomotic urethroplasty in patients with traumatic posterior urethral strictures. Nearly all patients can void normally and retain continence postoperatively. Subsequent urethrotomy, when required, carries a high likelihood of success. A significant number of patients regain potency after urethral reconstruction. Persistent impotence probably reflects the severity of pelvic trauma.

Humans↗

PubMed1997

Role of preoperative sonourethrography in bulbar urethral reconstruction.

PURPOSE: The accuracy of sonourethrography for the evaluation of bulbar urethral strictures has been well documented. Thus, we sought to define the role of preoperative sonourethrography in establishing objective criteria for procedure selection during bulbar urethral reconstruction. MATERIALS AND METHODS: Sonourethrography was performed preoperatively, just before incision, in 67 men selected for bulbar urethroplasty. All patients had strictures 25 mm. or less in length on preoperative radiographic retrograde urethrography, thus potentially amenable to resection and end-to-end anastomosis. Ultrasonic measurements were prospectively recorded, compared with those on preoperative retrograde urethrography, and used to guide the selection of urethroplasty technique. RESULTS: Overall, a significant trend for retrograde urethrography to underestimate stricture length was demonstrated (r = 0.678, p < 0.0001). Indeed, sonographic measurements were frequently twice those of retrograde urethrography, occasionally more. All 26 patients with short strictures on retrograde urethrography (10 mm. or less) were successfully treated by resection and end-to-end anastomosis, and sonographic assessment did not alter management. However, ultrasonic measurement changed the reconstructive procedure selected in 15 of 41 patients (37%, 3 penile flaps, 12 graft procedures) with bulbar strictures of intermediate length on retrograde urethrography (11 to 25 mm.). CONCLUSIONS: Sonourethrography has a major influence on selection of therapy in patients with bulbar strictures of intermediate length. By prospectively identifying strictures too long for resection and end-to-end anastomosis, sonourethrography enables quantitative criteria for selection of patients who may be more appropriately treated by flap or graft procedures. We advocate excisional therapy for strictures appearing sonographically to be 25 mm. or less, and substitution urethroplasty for longer strictures.

Algorithms↗

PubMed1996

Ultrasound evaluation of the male urethra for assessment of urethral stricture.

Radiographic retrograde urethrography has traditionally been the preferred technique used by urologists to image the anterior urethra. Since originally described by McAninch in 1988, ultrasonic imaging of the urethra has evolved into a powerful and clinically useful tool for the accurate delineation of urethral pathology. Although posterior urethral and peri-urethral fibrosis cannot be assessed reliably using this technique, sono-urethrography has proven to be more accurate than conventional radiographic urethrography in measuring stricture length throughout the anterior urethra. Herein we describe the evolution of sono-urethrography, explain its many advantages over traditional imaging techniques, and show clinical examples of its importance in guiding the successful reconstruction of urethral strictures, particularly in the bulbar area.

Humans↗

PubMed1996

When and how to use buccal mucosal grafts in adult bulbar urethroplasty.

OBJECTIVES: To evaluate the efficacy of buccal mucosa in the repair of adult urethral stricture disease, we report our experience with its use as a nontubularized onlay graft during bulbar urethral reconstruction. METHODS: From June 1993 to January 1996, 75 men underwent anterior urethral reconstruction for stricture disease. Single-stage urethroplasty with an onlay patch graft of buccal mucosa was performed in 13 patients with complex, refractory strictures of the bulbar urethra. In all cases, a two-team approach was used in which one team harvested the graft from the mouth while the perineal team simultaneously exposed and calibrated the stricture. RESULTS: The length of buccal mucosa ranged from 3.5 to 17 cm (average length 6.2). In 8 patients, other reconstructive techniques were used concomitantly, including fasciocutaneous penile flap or stricture excision and primary anastomosis, depending on the length and severity of the scarred area. Median follow-up time was 18 months. Excellent results were obtained in all 13 patients, and none has required urethral dilation or instrumentation subsequently. Operative time was significantly less than with other forms of substitution urethroplasty. CONCLUSIONS: Excellent results can be expected when buccal mucosa is used for urethral substitution in men with refractory bulbar strictures. For patients with long or dense strictures, buccal mucosal grafts may easily be combined with other reconstructive techniques. In patients with less complex stricture disease, the reduced operative time of this two-team approach may be beneficial.

Adult↗

PubMed1996

Technique of harvesting buccal mucosa for urethral reconstruction.

PURPOSE: Buccal mucosa has been used increasingly by urologists for urethral substitution in complex hypospadias repair. We have found buccal mucosa to be useful in reconstruction of bulbar urethral strictures, and describe a simple and reliable technique for harvest. MATERIALS AND METHODS: In 11 patients with refractory bulbar urethral strictures a nontubularized onlay patch of buccal mucosa was used for urethral reconstruction. All procedures were done with a 2-team approach in which 1 team (usually an oral surgeon and urologist) harvested the graft from the mouth, while the perineal team simultaneously exposed and calibrated the stricture. RESULTS: The length of buccal mucosa used ranged from 3.5 to 17 cm. (average 6.4). All patients achieved excellent results. No oral complications were noted, even in patients in whom multiple buccal mucosal grafts were obtained. CONCLUSIONS: With the technique reported, buccal mucosa is a reliable, easily obtained tissue for patch graft urethroplasty. Our 2-team approach decreased operative time considerably.

Humans↗

PubMed1996

Efficacy of radiographic imaging in pediatric blunt renal trauma.

PURPOSE: We sought to determine whether radiographic imaging can effectively detect significant renal injuries in children with blunt trauma who do not have significant hematuria. MATERIALS AND METHODS: We reviewed the records of 180 children who presented to our hospital for suspected renal trauma between 1977 and 1995. Results of excretory urography or abdominal computerized tomography were correlated with urinalysis findings and clinical outcome. RESULTS: Of 147 patients with microscopic hematuria after blunt trauma 77 underwent imaging. Only 1 patient had a significant renal injury (grade 2 or greater) and 76 had normal findings or renal contusions only, including 11 with microscopic hematuria and shock. Of the 74 patients who did not undergo imaging a clinical diagnosis of renal contusion was made and followup was available for 57 (77%). All patients healed without adverse sequelae. Of 33 patients with gross hematuria significant renal injuries were found in 9, including 3 who required immediate surgical repair of a major renal laceration or vascular injury. Combining our results with those of other reported series revealed significant renal injuries in only 11 of 548 children (2%) with less than 50 red blood cells per high power field on presenting urinalysis after blunt abdominal trauma. These patients were likely to have multiple associated injuries. CONCLUSIONS: Significant renal injuries are unlikely in pediatric patients with blunt renal trauma but no gross or substantial microscopic hematuria. Shock does not appear to be a clinically useful indicator.

Algorithms↗