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Trauma/Reconstruction/Diversion Urological Survey Trauma, and Genital and Urethral Reconstruction Re: Predictors of Erectile Dysfunction Post Pelvic Fracture Urethral Injuries: A Multivariate Analysis M. H. Koraitim Department of Urology, Faculty of Medicine, University of Alexandria, Alexandria, Egypt Urology 2013; 81: 1081e1085.

Abstract available at http://jurology.com/ Editorial Comment: It is not uncommon for young men sustaining pelvic fracture urethral injuries (PFUIs) to suffer from erectile dysfunction (ED). I know I have placed penile implants in a few dozen of these patients through the years. In this report of a 25-year experience from Alexandria, Egypt ED was noted in 40 of 90 patients (44%) with PFUI, and associations with pelvic fracture patterns were evaluated. ED was strongly linked to the presence of pubic diastasis, lateral prostatic displacement and urethral gap length greater than 3 cm. Although this is a detailed analysis from a center of excellence, the maneuvers performed intraoperatively as part of the reconstruction were not evaluated. In particular I believe aggressive incision between the corpora (performed in the hope of decreasing tension) may cause unnecessary bleeding and place the attenuated corporeal circulation at risk. I almost never split the corpora during anastomotic urethroplastydonly in a limited manner to expose the pubis and only as much as necessary to improve proximal exposure of the membranous urethra. Allen F. Morey, MD

Re: Expanded Use of a Dorsal Onlay Augmented Anastomotic Urethroplasty with Buccal Mucosa for Long Segment Bulbar Urethral Strictures: Analysis of Outcomes and Complications N. Y. Hoy, A. Kinnaird and K. F. Rourke Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada Urology 2013; 81: 1357e1361.

Abstract available at http://jurology.com/ Editorial Comment: The authors present an 8-year series of 163 patients undergoing augmented anastomostic urethroplasty with dorsal buccal mucosa graft. A staggering 60% of these men had idiopathic strictures, thus again indicating that there is much we do not know about the origin of urethral strictures. The authors kept patients in the hospital for 48 hours and removed the catheter at 3 weeks without additional imaging (we keep them 24 hours and perform voiding cystourethrography at 3 weeks). Cystoscopy was performed at 6 months. Those with strictures longer than 5 cm had a higher recurrence rate but overall an impressive 97% success rate is noted. The augmented anastomotic approach has a number of theoretical benefits compared to straightforward grafting, such as use of a smaller graft and elimination of the most occlusive stricture

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segment. The authors note that there did not appear to be any increased risk of complications associated with urethral transection. It is interesting that the authors harvested buccal mucosa grafts initially, before placing the patient in the lithotomy position. We abandoned this practice after having several cases where the stricture could be reconstructed primarily without using the graft. The median stricture length in this series was 4.5 cm (range 2 to 12). For those in the 2 to 4 cm range we prefer to attempt anastomotic urethroplasty without grafting when possibledwhich is usually achievable in the proximal bulb. If additional tissue is required, we may then use a small penile skin mini patch. Patients are always relieved to learn that buccal mucosa harvesting has not been necessary. Allen F. Morey, MD

Re: Conservative Management of Urorectal Fistulae K. Venkatesan, E. Zacharakis, D. E. Andrich and A. R. Mundy Institute of Urology, Department of Urology, University College Hospital, London, United Kingdom Urology 2013; 81: 1352e1356.

Abstract available at http://jurology.com/ Editorial Comment: Surgical treatment of urorectal fistulas is one of the most formidable undertakings in all of reconstructive urology. These patients will teach you valuable and painful lessons, and after tackling dozens of these cases at our referral center I am still learning. Ancillary problems we have faced include bladder neck contracture, ureteral stricture, delayed healing, incontinence, bowel complications, recurrent fistula and hypertonic bladder. However, despite these problems, we have not found any patients amenable to the notion of nonoperative care, primarily because most are disabled by pelvic pain. I believe that the pain in these patients stems from sustained exposure of deep pelvic structures to the chronic inflammatory influences of coliform bacteria. One thing that is reliable about this group of patients is that the pain disappears following surgery. This study records the clinical course of 3 men treated nonoperatively from a series of 43 patients with urorectal fistulas at the Institute of Urology in London. The authors do not advocate the nonoperative approach, but they do lay out the option as one that could be mentioned for those who are not completely disabled by pelvic pain or other sequelae. Allen F. Morey, MD

Re: Elective versus Routine Postoperative Clinic Appointments after Circumcisions Performed under Local Anesthesia M. J. Wardenburg, R. W. Dobbs, G. Barnes, U. Al-Qassab, C. W. Ritenour and M. M. Issa Department of Urology, Veterans Affairs Medical Center, Atlanta, Georgia Urology 2013; 81: 1135e1140.

Abstract available at http://jurology.com/ Editorial Comment: What is the appropriate postoperative followup protocol for circumcision? This clever study from the Veterans Affairs Medical Center in Atlanta compares 2 groups of patientsdthose having routine appointments and those having elective appointments postoperatively. In the routine followup group 84% of postoperative visits were subsequently categorized as unnecessary. In the elective group 71% of patients had an uneventful recovery and elected not

Re: predictors of erectile dysfunction post pelvic fracture urethral injuries: a multivariate analysis.

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