title: Total bladder and posterior urethral reconstruction: salvage technique for defunctionalized bladder with recalcitrant posterior urethral stenosis.
abstract: OBJECTIVE
  Recalcitrant posterior urethral stenosis is a challenging disease. When combined with a defunctionalized bladder, cutaneous urinary diversion is the most common surgical option. We present a novel technique of total lower urinary tract reconstruction, combining salvage cystectomy, ileal neobladder formation and urethral pull-through, as an orthotopic alternative in patients with a defunctionalized bladder and recalcitrant posterior urethral stenosis.
  
  
  METHODS
  We completed a retrospective review of 8 patients who underwent salvage cystectomy, orthotopic ileal neobladder formation and urethral pull-through. Artificial urinary sphincter placement was performed in a staged fashion. Six patients received prostate cancer treatment including radiation therapy, 1 had urethral disruption after robotic radical prostatectomy, and 1 experienced bladder rupture and urethral distraction injury during a motorcycle accident. Patient demographics, operative variables and postoperative outcomes were examined.
  
  
  RESULTS
  No high grade complications were observed after salvage cystectomy, orthotopic neobladder formation and urethral pull-through. After staged artificial urinary sphincter placement, a median of 2 revision surgeries (range 0 to 4) was required to establish social continence. All patients maintained functional urinary storage, urethral patency and social continence at a median followup of 58 months. No patient had complications related to orthotopic neobladder formation, including ureteroileal anastomotic stricture or pyelonephritis, and no patient required cutaneous diversion.
  
  
  CONCLUSIONS
  Total lower urinary tract reconstruction with cystectomy, ileal neobladder formation and urethral pull-through offers an orthotopic alternative for patients with recalcitrant posterior urethral stenosis and defunctionalized bladders. Although it requires staged placement of an artificial urinary sphincter, this approach can offer functional urinary storage, durable urethral patency and avoidance of cutaneous urinary diversion.
authors.affiliation: Center for Genitourinary Prosthetics and Reconstruction, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California. Electronic address: mbpatil@gmail.com.
authors.forename: Mukul B
authors.initials: MB
authors.lastname: Patil
authors.affiliation: Center for Genitourinary Prosthetics and Reconstruction, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
authors.forename: Donald
authors.initials: D
authors.lastname: Hannoun
authors.affiliation: Center for Genitourinary Prosthetics and Reconstruction, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
authors.forename: Polina
authors.initials: P
authors.lastname: Reyblat
authors.affiliation: Center for Genitourinary Prosthetics and Reconstruction, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
authors.forename: Stuart D
authors.initials: SD
authors.lastname: Boyd
mesh_terms: D000368:Aged; D015653:Cystectomy; D006801:Humans; D007082:Ileum / Q000637:transplantation*; D008875:Middle Aged; D012189:Retrospective Studies; D016879:Salvage Therapy; D014521:Urethra / Q000601:surgery*; D014525:Urethral Stricture / Q000150:complications / Q000601:surgery*; D001743:Urinary Bladder / Q000601:surgery*; D001745:Urinary Bladder Diseases / Q000150:complications / Q000601:surgery*; D016476:Urinary Reservoirs, Continent; D016741:Urinary Sphincter, Artificial; D013520:Urologic Surgical Procedures / Q000379:methods
keywords: artificial; cystitis; radiation; urethral stricture; urinary diversion; urinary sphincter