Abstracts from the New England Section of the AUA 2021

NE-AUA 2021 Abstracts Scientific Session III: BPH/RECON The Climate of Medical Malpractice in Reconstructive Urology Suprita Krishna, MD 1 , M. Ryan Farrell, MD, MPH 2 , Divya Parikh, MPH 3 , Alex J. Vanni, MD 2 1 Beth Israel Deaconess Medical Center, Boston, MA, USA; 2 Lahey Hospital and Medical Center, Burlington, MA, USA; 3 Medical Professional Liability Association, Rockville, MD, USA Introduction: Urologic medical malpractice continues to evolve and has the potential to influence physician decision making through efforts to mitigate risk with defensive practice. To date, little is known about the medical malpractice climate in reconstructive urology. We provide data on reconstructive urology malpractice claims and associated costs. Materials &Methods: National, provider level medical professional liability claims data were obtained from theMedical Professional LiabilityAssociation Data Sharing Project from 2014-2018. We utilized ICD 9/10 codes to query claims for reconstructive urology conditions and associated procedures including ureteropelvic junction obstruction (UPJO)/ureteral stricture, urethral stricture, bladder neck contracture, rectourethral fistula, Peyronie’s disease, buried penis repair/penile skin graft procedures, erectile dysfunction, and male incontinence. Defense expenses were reported as allocated loss adjustment expenses (ALAE) for closed claims. Results: Over the 5-year study period, urology ranked 13 of 29 specialties with 926 closed claims. The majority of claims did not result in an indemnity payment (paid:closed ratio 30%). Total indemnity paymentswere $101,594,296. The average indemnity payment was $365,447 and average ALAE was $49,490. With respect to presenting reconstructive urology conditions, there were a total of 66 closed claims with a paid:closed ratio of 24%. Total indemnity payments were $3,494,450, average indemnity payment was $218,403, and average ALAE was $45,685. The most common reconstructive urology conditions that resulted in claims weremale incontinence (n=25, 38%) and erectile dysfunction (n=19, 29%) followed by UPJO/ureteral stricture (n=7, 11%), urethral stricture (n=6, 9%), bladder neck contracture (n=4, 6%), Peyronie’s disease (n=3, 5%), buried penis (n=2, 3%), and rectourethral fistula (n=0). The most common specified procedures associated with these presenting conditions were procedures on the urethra (n=12) and incontinence procedures (n=7). The severity of patient injury was most commonly mild (emotional, insignificant, or minor temporary injury; n=32, 48%) or moderate (major temporary or minor permanent injury; n=24, 36%). Conclusions: The incidence of medical malpractice claims in reconstructive urology is low and themajority of claims do not result in indemnity payments. Male incontinence and erectile dysfunctionwere themost common presenting conditions associated with claims. These findings can be applied to improve risk mitigation strategies and patient care. 31 17 Transurethral Reconstruction of Fossa Navicularis Strictures with Dorsal Inlay Buccal Mucosa Graft Urethroplasty M. Ryan Farrell, MD, MPH 1 , Samuel Nowicki, BS 2 , Alex J. Vanni, MD 1 1 Lahey Hospital and Medical Center, Burlington, MA, USA; 2 Tufts University School of Medicine, Boston, MA, USA Introduction: Fossa navicularis strictures are a challenging clinical entity. Successful reconstruction not only involves the creation of a widely patent urethra, but also requires attention to cosmesis. We describe a novel technique of single stage urethroplasty for fossa navicularis strictures using a transurethral dorsal inlay buccal mucosa graft and review the outcomes for this approach to reconstruction that avoids splitting the glans. Materials &Methods: We conducted a retrospective reviewof a prospectively maintained urethral stricture database to identify all fossa navicularis strictures that were reconstructed with a single stage, transurethral dorsal inlay buccal mucosa graft urethroplasty between 5/2015 and 6/2020 at our institution. The surgical technique involved creation of transurethral dorsal urethrotomies down to healthy corpus spongiosum to allow for excision of a triangular wedge of fibrotic urethra. The fossa navicularis was calibrated to ensure the lumen was at least 20 Fr. A buccal mucosa graft was then tailored to the triangular defect and secured in place with 5-0 monocryl suture. Patients were discharged the same day with a 14 Fr Foley catheter that remained in place for 1 week. Primary outcomes were anatomic success, defined as the ability to pass a 17 Fr flexible cystoscope, and functional success, defined as the lack of obstructive voiding symptoms and no need for further procedures. Secondary outcomes were postoperative complications and patient satisfaction. Results: Of the 43 patients that underwent reconstruction of fossa navicularis strictures during this time period, transurethral dorsal inlay buccal mucosa graft urethroplasty was performed in 16 men. Mean age was 63.1 years (43.9- 75.6) andmean stricture lengthwas 1.7 cm (1.4-2.0). Stricture etiology included internal trauma (62.5%), idiopathic (25.0%), and lichen sclerosus (12.5%). Prior endoscopic procedures were done in 75% of patients. Over a median follow- up of 19.3 months (IQR 7.6-24.1), anatomic success was 93.8% (15/16) and functional success was 100% (16/16). The single anatomic recurrence was at 4.2 months postoperatively. No additional procedures were required. Urinary tract infection occurred in 25% (4/16). There were no instances of de novo erectile dysfunction, chordee, wound infection, or hematoma. All patients would recommend urethroplasty to others and all patients were either very satisfied (83.3%) or satisfied (16.7%) with the procedure. Penile sensitivity was unchanged in 83.3%, increased in 8.3% and decreased in 8.3%. Conclusions: Transurethral dorsal inlay buccal mucosa graft urethroplasty is a viable option for reconstruction of fossa navicularis strictures that avoids splitting the glans and results in excellent cosmesis. 32