Reconstructive Urology: Helping to Restore Quality of Life
As one of the country’s leading experts in adult reconstructive urology, Steven B. Brandes, MD, cares for patients with the most complex conditions and disorders of the genitourinary system. Dr. Brandes joined NewYork-Presbyterian/Columbia University Medical Center in February 2016 as Director of the new Division of Reconstructive Urologic Surgery in the Department of Urology. This comprehensive program, in collaboration with Gynecologic Oncology, Colorectal Surgery, and Plastic Surgery, addresses the myriad issues related to surgically restoring lower urinary tract and genital form and function. The program’s faculty provide unique expertise in improving quality of life and restoring urination and kidney and sexual function for patients who suffer from the complications of radiation therapy, iatrogenic injuries from cancer surgery, traumatic injuries (such as pelvic fracture), or who have congenital anomalies of the kidney or urinary tract.
“We welcome complex patients. There’s no case too complicated or too large. And by the same token, there’s also no case too simple. We see patients with all stages of conditions.” — Dr. Steven B. Brandes
“Our multidisciplinary reconstructive urology program is very unique. There is only a handful of other such programs in the entire country, and we are one of only two in the Tri-state area,” says Dr. Brandes. “We see patients with highly complex problems. Most patients are referred by urologists or colorectal surgeons due to complications or sequela of a previous surgery or treatment. This is a very limited and select population of highly challenging patients, many who have failed prior attempts at surgical repair.”
Patients will also often self-refer because they are frustrated with their poor quality of life. Because of the highly specialized team approach to surgical reconstruction, patients are often referred to Columbia Reconstructive Urology from states across the eastern seaboard, from Florida to New England. “We are not just a regional, but an east coast referral center for complex GU reconstruction,” adds Dr. Brandes.
Prior to joining Columbia, Dr. Brandes was Director of the Section of Reconstructive Urology at Barnes-Jewish Hospital in St. Louis and Professor of Urologic Surgery at Washington University School of Medicine. He also served as the Director of both Washington University’s Urology Residency Program and its Reconstructive Urology Fellowship. Earlier in his career, Dr. Brandes was Chief of Urology at the St. Louis Veteran Affairs Medical Center.
A strong advocate for multidisciplinary approaches to urologic care, Dr. Brandes adheres to a holistic care methodology that seeks to maintain not only the best possible urinary and kidney function, but also addresses issues of fertility, sexuality, and independent living. He and his team have extensive experience in urethral stricture surgery (urethroplasty), neo-bladder and bladder neck reconstruction, management of the neurogenic bowel and bladder, long-term surgical management of catheterizable pouch and stoma problems, male incontinence and erectile dysfunction, the hypospadias ‘cripple,’ as well as functional and cosmetic issues of the vagina and penis, and the ability to have children. They also have extensive experience with prosthetic surgery for urinary incontinence and erectile dysfunction. A complete reconstructive urology team has been assembled with three urologists, a urology fellow, and a nurse practitioner: Peter J. Stahl, MD, erectile dysfunction and infertility; Doreen E. Chung, MD, pelvic floor reconstruction; Shumyle Alam, MD, pediatric reconstruction; Robert A. Goldfarb, MD, clinical fellow; and Laura Ruffo, NP, advanced practice nurse practitioner.
“We don’t do our reconstructive surgeries in a vacuum,” says Dr. Brandes. “So many of our patients have to be treated in tandem with colleagues in other specialties. We involve plastic surgery to help us with the muscle flaps for flap reconstruction. We also involve colorectal surgery because there is frequently communication between the bowels and the bladder or the upper urinary tract. Furthermore, we work with our GYN colleagues as well for patients with cervical cancer who undergo high dose radiation and develop stenoses, fistulas, or contractures of the ureters or bladder. We also recently added a stress support program for our patients with psychologists to help patients cope with the stress and anxiety of their poor quality of life before we get to fix them.”
The Columbia Urology clinical reconstruction program primarily focuses on urologic cancer survivorship. “Reconstructive urology involves managing complications of post-oncologic radiation therapy and surgery; one to five percent of patients have severe complications,” says Dr. Brandes. “Our goal is to replicate normal function or return patients back to normal functioning, whether for urination, sexual function, or to achieve normal looking and functioning genitalia.”
The cancer survivorship program addresses not only issues of urinary and fecal control, but also erectile dysfunction and vaginal reconstruction. “These are issues that should be discussed even before patients undergo treatment and addressed afterward in a coordinated plan,” he says. “The end point is not just being alive, but quality of life. Being alive post-treatment or post-surgery with no quality of life is not a win. Quality of life is just as important, if not more important, than just quantity.”
Transition Urology: Facilitating Care from Childhood to Adulthood
Dr. Brandes also has a particular interest in transition urology and urologic congenitalism. “Patients who are born with congenital anomalies of the genitourinary system and kidney typically undergo complex reconstructive surgeries as children. However, these patients are truly never ‘fixed’ and continue to have lifelong maintenance issues and the need for further reconstructive surgeries,” says Dr. Brandes. “They may be well cared for as children at a children’s hospital, but once they reach adulthood, the resources and access to medical care for their complex urologic issues are marginal to non-existent. There really is no safety net for them in the adult world. They often get lost in the fray and end up with major complications.”
Through multidisciplinary care clinics, which include pediatric specialists within urology, Dr. Brandes and his colleagues are providing ongoing care for this vulnerable and underserved population. “I work closely with Shumyle Alam, who is a specialist in pediatric pelvic and urogenital reconstruction at Columbia, to provide continuity of care and ease the transition to adult care,” adds Dr. Brandes. “Having a fulfilling and meaningful life as an adult is much more complicated than just achieving fecal and urinary continence. It also includes the ability to achieve independence, socialization, and the potential for a sexual relationship, procreation, and a family.”
Pursuing Research and Education
Dr. Brandes, who is the current President of the Society of Genitourinary Reconstructive Surgeons, is the author of more than 100 peer-reviewed publications and book chapters, and has edited two textbooks on urologic reconstructive surgery. At Columbia, he is establishing a basic science laboratory in collaboration with the Cancer Research Center focused on his long-standing interest in regenerative medicine, tissue engineering, and the use of scaffolds for reconstruction of genital organs. He is also continuing clinical research in improving techniques in reconstructive surgery of the genitals and lower urinary tract, urethral stricture surgery, urinary fistula repairs, radiation fistulas, and traumatic urologic injuries
Reflecting on future advances in reconstructive urology, Dr. Brandes looks forward to the transplantation of artificial bladders and other organs. “The problem is that urine contains solutes, electrolytes, and chemicals,” he says. “When they come in contact with metal or plastic they cause calcification in the lining of the bladder or ureter that leads to obstruction or infection. So attempts at an artificial bladder or ureter have all failed. I would say it could be at least 10 years before we see anything commercially available.”
In the education realm, Dr. Brandes has been instrumental in the establishment of clinical fellowship in reconstructive urology surgery at Columbia for urologists from across the country who seek additional training and subspecialization. Columbia Urology’s first fellow was from the University of Minnesota, and their second fellow starting this summer is from the University of Texas-Houston.
Dr. Brandes was drawn to reconstructive urology because, he says, “This specialty is a crossroads between medicine and surgery, and you can incorporate as much or as little of both into your practice. I wanted to develop long-lasting relationships with my patients. That is very rewarding to me.”
Grossgold ET, Eswara JR, Siegel CL, Vetter J, Brandes SB. Routine urethro-graphy after buccal graft bulbar urethroplasty: The impact of initial urethral leak on surgical success. Urology. 2017 Feb 15. [Epub ahead of print]
Raup VT, Eswara JR, Geminiani J, Madison K, Heningburg AM, Brandes SB. Gracilis muscle interposition flap repair of urinary fistulae: Pelvic radiation is associated with persistent urinary incontinence and decreased quality of life. World Journal of Urology. 2016 Jan;34(1):131-36.
Weese JR, Raup VT, Eswara JR, Marshall SD, Chang AJ, Vetter J, Brandes SB. Anterior urethral stricture disease negatively impacts the quality of life of family members. Advances in Urology. 2016;2016:3582862.
Eswara JR, Raup VT, Potretzke AM, Hunt SR, Brandes SB. Outcomes of iatrogenic genitourinary injuries during colorectal surgery. Urology. 2015 Dec;86(6):1228-33.
Eswara JR, Chan R, Vetter JM, Lai HH, Boone TB, Brandes SB. Revision techniques after artificial urinary sphincter failure in men: Results from a multicenter study. Urology. 2015 Jul;86(1):176-80.