Editorial: The art of urethral reconstruction.
Explore the source record for details and available documents.
Constriction, Pathologic↗
Biomedical subjects
Allen F Morey
Publications and source records attributed to Allen F Morey.
Percutaneous transrenal application of fibrin sealant for refractory urinary leak after gunshot wound.
Explore the source record for details and available documents.
Aged↗
Single dose levofloxacin prophylaxis for prostate biopsy in patients at low risk.
PURPOSE: We determine if a single 500 mg. oral tablet of levofloxacin represents adequate prophylaxis for patients at low risk who undergo transrectal prostate biopsy. MATERIALS AND METHODS: From April 2000 to May 2001 we prospectively evaluated 400 consecutive men who underwent transrectal needle biopsy of the prostate after a single 500 mg. oral dose of levofloxacin. Under an institutional review board approved protocol the drug was issued under a standing order by a clinic nurse 30 to 60 minutes before the procedure. Patients were issued 2 additional daily doses of levofloxacin if they were deemed at increased risk for infectious complications, that is if they had a large prostate more than 75 cc, diabetes mellitus, recent steroid use, severe voiding dysfunction or immune compromise. No patient received a cleansing enema before the procedure. Complications, the number of biopsy cores, prostate size and cancer detection rates were assessed. RESULTS: Only 1 of the 377 patients at low risk in whom biopsy was completed experienced a symptomatic urinary tract infection (0.27%). None of the 23 men at high risk who received additional doses of levofloxacin experienced a complication. Thus, the overall infection rate was 1 of 400 cases (0.25%) in this series. A mean of 7 biopsy cores (range 2 to 16) was obtained per patient and mean prostate volume was 49.75 cc (range 12 to 150). Prostate cancer was present in 93 patients (23%). CONCLUSIONS: A single 500 mg. dose of levofloxacin before transrectal needle biopsy of the prostate is effective and safe in patients at low risk. The administration of prophylaxis by a clinic nurse under a standing order optimizes patient compliance and physician efficiency. In patients at higher risk for infection additional antibiotic administration appears to provide adequate prophylaxis.
Administration, Oral↗
Outpatient anterior urethroplasty: outcome analysis and patient selection criteria.
PURPOSE: We compared the outcomes of anterior urethroplasty for stricture disease performed on an outpatient and an inpatient basis. MATERIALS AND METHODS: We reviewed the records of 78, 1-stage anterior urethroplasties performed via excision with primary anastomosis, buccal mucosal graft or penile fasciocutaneous skin flap techniques from September 1997 to December 2000 by a single surgeon (A. F. M.). All patients had more than 1 year of followup (range 1 to 4.5). Of the graft procedures only those in the bulbar urethra were included in analysis. Outpatient procedures were defined as those in which the patient was discharged home within 24 hours. Clinical outcome was considered a failure when instrumentation was required postoperatively. RESULTS: Of the 78 anterior urethral repairs 54 (69%) were performed on an outpatient basis, including 50 (93%) in which the outcome was successful compared with 88% (21) of the 24 inpatient procedures. Excision with primary anastomosis had the highest outpatient rate (28 of 31 patients or 90%), followed by penile skin flaps (16 of 25 or 64%) and buccal mucosal grafts (10 of 22 or 45%). Patient characteristics were significantly associated with outpatient procedures, including younger mean age (36 versus 46 years), shorter mean stricture length (3.1 versus 6.6 cm.) and shorter mean operative time (3.2 versus 4.66 hours) (p <0.05). CONCLUSIONS: Anterior urethral reconstruction can often be completed safely and effectively on an outpatient basis.
Adolescent↗
Imaging of the male urethra for stricture disease.
Imaging of the urethra for suspected stricture disease should initially consist of conventional imaging with a dynamic RUG. It is easy to perform and detects clinically relevant strictures involving the anterior urethra and those with extension into the membranous urethra. Additional studies, including antegrade imaging, sonographic urethrography, and MRI are best used in conjunction with RUG as clinically indicated to better define the extent of disease and assist in guiding reconstruction. Post-operatively, VCUG is appropriate to evaluate complete healing and adequacy of repair. Sonourethrography is a simple technique that provides a dynamic, precise assessment of anterior urethral strictures. It is best employed as a staging study in men with known symptomatic strictures in whom the need for operative therapy is clear. For short bulbar strictures ultrasound is more accurate in measuring stricture length than conventional radiographic RUG and is therefore helpful in determining whether to excise or graft. For long or complex strictures assessment of the stricture's diameter may be helpful in determining flap width or in identifying the focal urethral segments to be excised. The simplicity, precision, and availability of sonography along with the absence of radiation exposure make sonourethrography a valuable staging tool for the reconstructive urologist. MRI is valuable for defining the distorted pelvic anatomy that is frequently associated with posterior urethral strictures resulting from trauma. By determining the location of the prostate and the length of the prostatomembranous defect, MRI may help determine whether a transperineal or transpubic approach for reconstruction is necessary.
Humans↗
Multi-institutional experience with buccal mucosa onlay urethroplasty for bulbar urethral reconstruction.
PURPOSE: Buccal mucosa has been advocated as an ideal graft material for urethral reconstruction. We report our multicenter experience with buccal mucosa ventral onlay urethroplasty for complex bulbar urethral reconstruction in adults. MATERIALS AND METHODS: A retrospective analysis of patients who had undergone buccal onlay urethroplasty at 4 military medical treatment facilities participating in the Uniformed Services Urology Research Group was performed. The database generated included demographic data, genitourinary history, preoperative symptoms (American Urological Association symptom score), preoperative urinary flow rate, stricture length and operative statistics. Postoperative followup data included symptom score, flow rate, retrograde urethrogram results, and complications. RESULTS: A total of 53 patients (average age 32 years, range 17 to 64) underwent buccal mucosa graft urethroplasty between January, 1996 and March, 1998 for refractory strictures. Sixteen patients had undergone an average of 2.2 prior endoscopic procedures (range 1 to 7). Average stricture length was 3.6 plus or minus standard deviation 1.8 cm. (range 2 to 7.5) as measured on preoperative retrograde urethrogram. Followup averaged 25 months (range 11 to 40 months). Average symptom scores decreased from 21.2 (range 14 to 33) preoperatively to 5.4 (range 3 to 8) postoperatively (p <0.001). Average peak urinary flow rates increased from 7.9 preoperatively to 30.1 ml. per second postoperatively (p <0.001). Postoperative retrograde urethrograms were available for 34 patients and were normal in 24. The overall complication rate was 5.4%. Three patients required endoscopic incisions. One patient has a recurrent narrowing and treatment is considered a failure. There were 4 sacculations (7.5%) and 6 narrowings, 3 of which required further treatment. Of the patients 50 required no additional procedures (94.3%). CONCLUSIONS: Buccal mucosa grafts used as a ventral onlay for bulbar urethral reconstruction yield reproducibly excellent results with minimal morbidity and low complication rates. Longer followup will be required to confirm the durability of our results.
Adolescent↗
End-to-end reconstruction of synchronous urethral strictures.
Explore the source record for details and available documents.
Humans↗
Fibrin sealant for the reconstruction of fournier's gangrene sequelae.
PURPOSE: We describe the use of fibrin tissue adhesive as an adjunct for reconstructing genital skin loss due to Fournier's gangrene. MATERIALS AND METHODS: We treated 2 patients with Fournier's gangrene with repeat surgical débridement and antibiotics. Delayed primary closure was enhanced by using liquid fibrin sealant. In 1 case the sealant was used to obliterate a large testicular thigh pouch that had become infected. In the other case it was used to anchor the under surface of a thigh flap for scrotal reconstruction. RESULTS: In each patient the fibrin tissue adhesive prevented further complications of Fournier's disease. CONCLUSIONS: Fibrin sealant is an effective adjunct for managing extensive genital skin loss caused by Fournier's gangrene.
Aged↗
Mechanical and antibiotic bowel preparation for urinary diversion surgery.
PURPOSE: We reviewed the existing scientific literature regarding the efficacy of preoperative mechanical and antibiotic bowel preparation for urinary diversion surgery. MATERIALS AND METHODS: We performed MEDLINE searches of the literature from 1966 through 2000 and obtained additional references through a review of the bibliographies of select articles. RESULTS: For urinary diversion surgery information regarding appropriate mechanical and antibiotic bowel preparation is scant. The colorectal surgery literature indicates that oral sodium phosphate appears to be better tolerated than polyethylene glycol and is as effective, although the latter is preferred in patients with compromised renal, cardiac or liver function. A combination of oral and parenteral antibiotics should be used for all urinary reconstructive surgeries involving gastrointestinal tract segments. A parenteral second generation cephalosporin antibiotic should be given within 1 hour of skin incision and repeated at an interval of twice the antibiotic serum half-life or when blood loss exceeds 1 l. CONCLUSIONS: For urinary diversion surgery contemporary methods of mechanical and antibiotic bowel preparation appear to be safe, effective and better tolerated than traditional bowel preparation methods.
Administration, Oral↗
Drain-free simple retropubic prostatectomy with fibrin sealant.
PURPOSE: We present our preliminary experience with liquid fibrin sealant during simple retropubic prostatectomy. MATERIALS AND METHODS: We reviewed 18 consecutive simple retropubic prostatectomies performed for symptomatic advanced benign prostatic hyperplasia at our institution between 1997 and 2001. Adenoma enucleation was performed via transverse anterior prostatic capsulotomy. In the first 13 cases (group 1) a Jackson-Pratt suction drain was placed in the pelvis after prostatic capsular closure. In the remaining 5 cases (group 2) 2 ml. liquid fibrin sealant were administered over the closed prostatic capsule instead of a pelvic drain. RESULTS: The 2 groups were matched for age and prostate size. Average time to drain removal in control group was 3.92 days, while the fibrin sealant group had no clinically apparent adverse sequelae despite the lack of pelvic drainage. Average hospitalization in group 1 was 4.38 days, while all group 2 patients were discharged home after 2 days (p = 0.001). In addition, a trend toward earlier resumption of a full diet was noted in the sealant group (2.61 versus 1 day, p = 0.075). CONCLUSIONS: Liquid fibrin sealant appears to expedite recovery and shorten hospitalization when used as an adjunct during simple prostatectomy.
Aged↗
Current applications of fibrin sealant in urologic surgery.
Biosurgical preparations designed to promote surgical hemostasis and tissue adhesion are being increasingly employed across all surgical disciplines. Fibrin sealant is the most widely studied and utilized biosurgical adjunct in urology. Complex reconstructive, oncologic, and laparoscopic genitourinary procedures are those most appropriate for sealant use. This article details the diverse urologic applications of fibrin sealant in the management of genitourinary injuries, surgery, and complications.
Female↗