Bulbar Urethroplasty Research Articles

Opciones de tratamiento quirúrgico en la estenosis de uretra bulbar

ObjectiveTo review the outcome of bulbar urethroplasty using two stage surgical techniques. Material and methodsTwenty-two of the 35 patients studied corresponded to end-to-end urethroplasty (ATT) and 13 to dorsal onlay graft (DOG) in preputial skin or oral mucosa variants. Clinical outcome was considered a failure when postoperative surgery was needed or the uroflowmetry was less than 15ml/s. The following variables were studied: age, previous surgery, number of urethrotomies and stricture length. The curves and log-rank Curves using the log-rank were elaborated for follow-up and comparison, with the Cox regression model for risk factors. ResultsMean follow-up was 40.02 months. Of all the cases. 85.71% were successful. Of these, 86.36% were in the ATT group and 84.61% in the DOG group. There were no significant differences in the comparative LR test based in stricture length, previous surgery between both group and individualized for each management. The Cox regression model showed a risk of failure in the technique for the elderly patients (OR 2.2), it not achieving statistical significance in the remaining variables. ConclusionsThe success rate achieved with the ATT technique is verified a gold standard option in short strictures. The DOG is shown as a valid option in long strictures in bulbar urethral in medium follow-up, using a oral mucosa or preputial onlay graft. More long-term follow-up must be performed with a greater number of patients to better evaluate these results.

Current controversies in reconstructive surgery of the anterior urethra: a clinical overview

We performed an overview of the surgical techniques suggested for the treatment of anterior urethral strictures using MEDLINE. In applying the MEDLINE search, we used the ″MeSH″ (Medical Subject Heading) and "free text" protocols. The MeSH search was conducted by combining the following terms: "urethral stricture", "flap", "graft", "oral mucosa", "urethroplasty", "urethrotomy" and "failed hypospadias". Multiple "free text" searches were performed individually applying the following terms through all fields of the records: "reconstructive urethral surgery", "end-to-end anastomosis", "one-stage", "two stage". Descriptive statistics of the articles were provided. Meta-analyses were not employed. Seventy-eight articles were determined to be germane in this review. Six main topics were identified as controversial in anterior urethra surgery: the use of oral mucosa vs penile skin; the use of free grafts vs pedicled flaps in penile urethroplasty; the use of grafts vs anastomotic repair in bulbar urethral strictures; the use of dorsal vs ventral placement of the graft in bulbar urethroplasty; the use of definitive perineal urethrostomy vs one-stage repair in complex urethral strictures; the surgical options for patients with failed hypospadias repair. Different points of view are documented and presented in the literature by various authors from different countries. The aim of this clinical overview is to survey the main controversial issues in surgical reconstruction of the anterior urethra focusing on the use of flap or graft, substitute material, type of surgery and challenging situations, such as failed hypospadias or complex urethral stricture repair.

Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts

ObjectivesTo investigate the versatility of the ventral urethrotomy approach in bulbar reconstruction with buccal mucosa (BM) grafts placed on the dorsal, ventral or dorsal plus ventral urethral surface. Patients and methodsBetween 1999 and 2008, 216 patients with bulbar strictures underwent BM graft urethroplasty using the ventral-sagittal urethrotomy approach. Of these patients, 32 (14.8%; mean stricture 3.2cm, range 1.5–5) had a dorsal graft urethroplasty (DGU), 121 (56%; mean stricture 3.7, range 1.5–8) a ventral graft urethroplasty (VGU), and 63 (29.2%; mean stricture 3.4, range 1.5–10) a dorsal plus ventral graft urethroplasty (DVGU). The strictured urethra was opened by a ventral-sagittal urethrotomy and BM graft was inserted dorsally or ventrally or dorsal plus ventral to augment the urethral plate. ResultsThe median follow-up was 37months. The overall 5-year actuarial success rate was 91.4%. The 5-year actuarial success rates were 87.8%, 95.5% and 86.3% for the DGU, VGU and DVGU, respectively. There were no statistically significant differences among the three groups. Success rates decreased significantly only with a stricture length of >4cm. ConclusionsIn BM graft bulbar urethroplasties the ventral urethrotomy access is simple and versatile, allowing an intraoperative choice of dorsal, ventral or combined dorsal and ventral grafting, with comparable success rates.

14 DORSAL VS VENTRAL ONLAY FOR SINGLE STAGE BULBAR URETHROPLASTY

INTRODUCTION AND OBJECTIVES: Buccal mucosa is widely accepted as a graft material for bulbar urethroplasty. However, the ideal location for the graft remains contentious. In an effort to determine whether outcomes differ based on whether the graft is placed ventrally or dorsally, we retrospectively reviewed our experience with buccal mucosal grafts for bulbar urethral strictures. METHODS: This was a retrospective, single-center study of all single-stage bulbar urethroplasties performed from 2001-2011 by two surgeons in which buccal mucosa was used as an onlay graft. Our primary objective was to assess whether outcomes differed based on a ventral or dorsal position. Failure was defined as the need for endoscopic or open revision of the reconstruction, or placement of a suprapubic catheter for urinary retention. RESULTS: A total of 105 patients were reviewed; 41 underwent dorsal onlay, and 63 underwent ventral onlay. Median age was 39. Stricture etiology included trauma (37), instrumentation (8), infection (5), radiation (4), hypospadias (3), BXO (1), and was unknown in 46. Prior urethroplasty had been performed in 14 (13.3%), one DVIU had been performed in 31 (29.5%), more than one DVIU in 40 (38.1%), and only 17 (16.2%) patients had not undergone a DVIU or a urethroplasty prior to the onlay. There was no significant difference between the ventral and dorsal onlay cohorts in terms of etiology, number of prior DVIUs, prior urethroplasty, or prior procedures. A greater number of patients in the dorsal onlay group underwent an augmented anastomosis than in the ventral onlay group (41.5% vs 14.3%, p 0.002). Mean follow-up was 17.9 months. There were 7 failures (17.1%) in the dorsal onlay group and 12 failures in the ventral onlay group (19.1%). Median time to failure was 8.5 months in the dorsal onlay group and 15 months in the ventral onlay group (p 0.13). Neither type of onlay nor presence of prior urethroplasty, prior DVIU, prior procedure, or augmented anastomosis was predictive of failure. CONCLUSIONS: In this retrospective review of substitution urethroplasties in a heterogenous group of patients, there is no evidence to suggest that dorsal or ventral onlay of buccal mucosa is inherently superior. Intra-operative decision-making is likely to be important, and prospective studies are necessary to further evaluate the long-term efficacy of each of these approaches.

5 REDO URETHROPLASTY AFTER FAILURE OF END-TO-END ANASTOMOTIC BULBAR URETHROPLASTY

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery I1 Apr 20125 REDO URETHROPLASTY AFTER FAILURE OF END-TO-END ANASTOMOTIC BULBAR URETHROPLASTY Andre Cavalcanti and Mauricio Rubinstein Andre CavalcantiAndre Cavalcanti Rio de Janeiro, Brazil More articles by this author and Mauricio RubinsteinMauricio Rubinstein Rio de Janeiro, Brazil More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.047AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES End-to-end anastomotic urethroplasty (EEA) for bulbar urethral stricture is associated with excellent long-term success rate: superior to 90% in the majority series. The management of the failures after this type of surgery is an uncommon subject on the literature . The aim of this study is to describe our experience with the surgical management of failures after EEA for bulbar urethral strictures. METHODS The charts of 33 patients submitted to a redo urethroplasty after failure of EEA for bulbar strictures were analysed. All surgeries were performed by the same surgeon between january 2006 and march 2011. The mean follow-up was 30.8 months (range from 6 to 63 months). The mean age was 45.9 years (range from 21 to 83 years). Successful urethral reconstruction was defined as normal voiding (max. flow rate > 15 ml/s) without the need for any postoperative procedure. All patients with max. flow rate < 15 ml/s were submitted to a urethrogram or cystoscopy to evaluate the urethral caliber. The stricture length range from 1 cm to 4 cm (mean of 2,8 cm). RESULTS 29 (87.9%) patients were treated with a single stage procedure and 4 (12.1%) with a staged procedure with buccal mucosa graft (BMG). In 6 (18.2%) patients a new EEA was performed and 23 (69,7%) were treated with a single staged substitution urethroplasty witha a BMG in diferent techniques: ventral onlay (4), dorsal onlay (9), dorsal augmented urethroplasty (7) and double graft (3). The success rate was 81,8% (27 pts) , with 6 failures. Permanent erectile dysfunction were observed in 5 patients (15.2%) and ejaculatory symptoms in 7 patients (21.2%). CONCLUSIONS Good success rate can be expected after a redo urethroplasty on bulbar urethra. The use of a diversity of techniques is necessary to find the best procedure for each patient, regarding the stricture characteristics: lenght, position and spongiosum quality. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e2 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andre Cavalcanti Rio de Janeiro, Brazil More articles by this author Mauricio Rubinstein Rio de Janeiro, Brazil More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Repeat Transurethral Manipulation of Bulbar Urethral Strictures is Associated With Increased Stricture Complexity and Prolonged Disease Duration

We examined the association of previous transurethral manipulation with stricture complexity and disease duration among men referred for bulbar urethral reconstruction. We retrospectively reviewed the records of 340 consecutive urethroplasties performed by a single surgeon between July 2007 and October 2010. Only men treated with initial open surgery for bulbar strictures were included in analysis, thus excluding those with hypospadias, lichen sclerosus, pelvic radiation, prior urethroplasty, incomplete data, or pure penile or posterior urethral stenosis. Cases were divided into 2 groups based on the history of transurethral treatment for urethral stricture before urethroplasty, including group 1-0 or 1 and group 2-2 or greater treatments. Of 101 patients with bulbar urethral stricture and all data available 50 and 51 underwent 0 to 1 and 2 or greater previous transurethral treatments, respectively. Repeat transurethral manipulation was strongly associated with longer strictures and the need for complex reconstruction. Repeat transurethral manipulation of bulbar urethral strictures was also associated with an eightfold increase in disease duration between stricture diagnosis and curative urethroplasty. Repeat transurethral manipulation of bulbar strictures is associated with increased stricture complexity and a marked delay to curative urethroplasty.

Editorial Comment

The findings reported in the literature are disparate in regard to the morbidity associated with closure vs nonclosure of the buccal mucosal harvest site when buccal mucosa is used in urethroplasty. The types of problems that have been reported with buccal mucosal harvest are pain, salivary changes, difficulty with full opening of the mouth and peri-oral numbness. In the literature, these complications have been categorized into either short or long-term problems. Effect of Wound Closure on Buccal Mucosal Graft Harvest Site Morbidity: Results of a Randomized Prospective TrialUrologyVol. 79Issue 2PreviewTo determine the effect of closure versus nonclosure of the buccal mucosal graft harvest site in men undergoing bulbar urethroplasty in a randomized prospective study. The optimal postoperative management of the buccal mucosal graft donor site remains unknown. Full-Text PDF ReplyUrologyVol. 79Issue 2PreviewAlthough the randomized clinical trial represents the ideal method of definitively answering a clinical question, there is a relative paucity of these studies in the urological literature. The use of randomized trials in surgery has been debated, with opposing views focusing on the common limiting factors of time, cost, effort, and planning associated with performing a well-done prospective trial.1 It has also been argued that the subspecialty of reconstructive urology itself may not be amenable to randomized clinical trials because of variability in disease presentation, complex comorbid patient concerns, and the wide range of surgical techniques intrinsic to the “art” of reconstructive surgery. Full-Text PDF

614 Non-transecting anastomotic bulbar urethroplasty

614 Non-transecting anastomotic bulbar urethroplasty

V8 Presentation of a potential appropriate method for bulbar urethroplasty with tissue-engineered oral mucosa graft (MukoCell®)

V8 Presentation of a potential appropriate method for bulbar urethroplasty with tissue-engineered oral mucosa graft (MukoCell®)

The Role of Dilation and Internal Urethrotomy as a Risk Factor of Failure in Patients Who Undergoing One-Stage Bulbar Oral Graft Urethroplasty

Purpose: To test the hypothesis if dilation or direct visual internal urethrotomy (DVIU) are predictive of urethroplasty failure. Retrospective study, from 1999 to 2010, including184 patients (median age 37 years) who underwent ventral onlay oral graft urethroplasty for bulbar strictures. Exclusion criteria were traumatic strictures, lichen sclerosus, failed hypospadias repair, failed urethroplasty, panurethral strictures, and incomplete medical charts. Pre-operative evaluation included clinical history, physical examination, urine culture, residual urine measurement, uroflowmetry, urethrography, ultrasound and urethroscopy. Surgery was considered a failure when any post-operative instrumentation was needed. Median follow-up was 48 months. Out of 184 patients, 38 (20.7%) had not undergone previous treatment, 7 (3.8%) had undergone dilation, 81 (44%) DVIU and 58 (31.5%) DVIU associated with dilation. Out of 184 patients, 157 (85.3%) were successful and 27 (14.7%) failures. Out of 38 patients who had not undergone previous treatment, 33 (86.8%) were successful; out of 7 patients who had undergone dilation, 6 (85.7%) were successful; out of 81 patients who had undergone DVIU, 72 (88.9%) were successful; out of 58 patients who had undergone DVIU and dilation, 46 (79.3%) were successful. According to the number of previous DVIU, ventral graft urethroplasty for bulbar strictures showed high failure rate in patients who had undergone more than four DVIU associated or not with dilation.

Reply

We agree with the reviewer's criticisms and believe that our results need to be interpreted with caution for those reasons. Although our urethroplasty success rates were lower and complication rates higher in the class II and III obese patients (compared with the nonobese controls), it was never our intention to suggest that conservative management of bulbar strictures is more appropriate for the obese patient population. In fact, as our data showed, in most obese men undergoing bulbar urethroplasty endoscopic management had previously failed. Given that the outcomes of urethroplasty are known to be poorer in patients with a history of multiple previous endoscopic treatments, 1 Breyer B.N. McAninch J.W. Whitson J.M. et al. Multivariate analysis of risk factors for long-term urethroplasty outcome. J Urol. 2010; 183: 613-617 Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar it is possible that our oral mucosa bulbar urethroplasty results could have been better in obese patients had they not undergone multiple previous instrumentations. Our goal in presenting these data was to emphasize the need for realistic expectations when it comes to managing bulbar urethral stricture disease in the very obese patient. Editorial CommentUrologyVol. 78Issue 6PreviewAs has been stated in previous reports, “obesity is a global epidemic with an increasing incidence in Western countries.” The authors must thus be commended for addressing an important question: how does obesity affect the success of urethral reconstructive surgery in patients with bulbar urethral stricture disease? The available urologic data on this subject are scant and give us no clear answers. One report by Breyer et al1 suggested that obesity might adversely affect the success of urethroplasty, but in a nonlinear fashion. Full-Text PDF

Effect of Wound Closure on Buccal Mucosal Graft Harvest Site Morbidity: Results of a Randomized Prospective Trial

To determine the effect of closure versus nonclosure of the buccal mucosal graft harvest site in men undergoing bulbar urethroplasty in a randomized prospective study. The optimal postoperative management of the buccal mucosal graft donor site remains unknown. A total of 50 consecutive patients were randomized to either donor site closure or leaving the donor site open. Postoperatively, questionnaires assessing pain, diet, salivation, perioral sensation, and mouth opening were completed daily for the first week and then monthly for 6 months. The primary endpoint was postoperative oral pain. The secondary endpoints were the interval to a regular diet, perioral numbness, changes in salivation, and interval to full mouth opening. Of the 50 patients, 24 and 26 were randomized to the open and closed groups, respectively. The early postoperative pain scores demonstrated a trend favoring the nonclosure group until day 3 (4.1 vs 2.2; P=.07). At 6 months, no difference was found in the pain scores between the 2 groups (0.2 vs 0.3; P=.63). The return to a regular diet also favored the nonclosure group (70.8% vs 19.2% on day 1; P=.01) as did the return to full mouth opening (79.1% vs 15.3% on day 1; P=.001). Nonclosure resulted in less early perioral numbness (62.5% vs 92.3% on day 1; P=.008) and reduced the occurrence of bothersome numbness at 6 months (4.2% vs 23.2%; P=.05). The results of the present randomized prospective trial suggest that leaving the buccal mucosa graft harvest site open leads to lower reported early pain scores, an earlier return to a full diet, an earlier return to full mouth opening, and a decrease in bothersome perioral numbness at 6 months postoperatively.

Outcomes of Grafted Bulbar Urethroplasty in Men with Class II or III Obesity

To evaluate the outcomes of grafted bulbar urethroplasty in class II or III obese patients. Retrospective chart review was performed for men with World Health Organization class II/III obesity undergoing grafted urethroplasty for management of bulbar strictures from 2003-2010. Extracted data included age, body mass index (BMI), stricture etiology, stricture length/location, number/type of previous therapies, definitive therapy, follow-up, outcome, and complications. Outcomes were compared with a cohort of 20 age-matched nonobese men with bulbar strictures managed with grafted urethroplasty. Fifteen class II/III obese men were included in the study. Obese patient age (43.8 years, range 27-60) and BMI (44.0 kg/m(2), range 35-57) were averaged. Each patient reported a mean of 3.8 previous dilations or urethrotomies (range 0-9). All men were treated with grafted bulbar urethroplasty (11 ventral, 4 dorsal) with oral mucosa (13 buccal, 2 lingual). After a mean follow-up of 29.4 months (range 7-62), the urethral patency rate was 66.7% (10/15). Complications included prolonged urethral leak in 5/15 (33%) and wound infection in 5/15 (33%) patients. Urethral patency rates and complications were significantly higher in class II/III obese patients when compared with the nonobese cohort. Obese men demonstrated poorer outcomes after grafted bulbar urethroplasty when compared with published success rates in the general population as well as an aged-matched, nonobese cohort from our institution. Prior failed endoscopic procedures and other medical comorbidities may have also contributed to the observed results in this patient population.

Non‐transecting anastomotic bulbar urethroplasty: a preliminary report

To report our early experience with a novel approach to the excision and end-to-end anastomotic repair of bulbar urethral strictures. A total of 22 patients underwent excision and end-to-end anastomosis of a proximal bulbar urethral stricture using a technique in which the corpus spongiosum is not transected, so as to maintain its blood supply intact. The range of follow-up was 6-21 months and for 16 patients the follow up was ≥1 year. At 1 year of follow-up there was no evidence of a recurrent stricture on symptomatic assessment or uroflowmetry in the 16 patients. On urethrography one patient has a urethral calibre 80% of normal. In the other 15 the calibre is normal or greater than normal. The non-transecting anastomotic bulbar urethroplasty technique used appears to give results that are as good as those of traditional anastomotic urethroplasty with less surgical trauma.

Erectile Dysfunction After Anterior Urethroplasty: A Prospective Analysis of Incidence and Probability of Recovery—Single-center Experience

To evaluate the incidence and probability of recovery of erectile dysfunction after different types of one-stage urethroplasties for anterior urethral stricture disease. Seventy-eight men undergoing single-stage anterior urethroplasty from January 1, 2008 to March 31, 2010 were followed prospectively. Patients were divided into 3 groups: group 1 (n=25)-penile substitution urethroplasty; group 2 (n=32)--primary excision anastomotic bulbar urethroplasty; and group 3 (n=21)--bulbar substitution urethroplasty. Patients willing to participate completed the International Index of Erectile Function (IIEF) preoperatively and then on subsequent follow-up visits at 3, 6, 9, 12, and 15 months after urethroplasty. Pre- and post-urethroplasty erectile functions were compared. Our mean follow-up period was 15.50+2.389 months. The mean age (years) was similar among groups. The mean stricture length (cm) was 4.78±0.747, 2.95±0.658, and 6.13±0.981 in-groups 1, 2, and 3, respectively (P=.001). Mean preoperative IIEF score was 24.60±2.365 (similar among groups). Erectile dysfunction (ED) was found in 15 (20%) patients: 4/25 (16%), 9/32 (28%), and 2/21 (10%) in groups 1, 2, and 3, respectively. Mean postoperative decline (3 months) in IIEF score was 22.54±4.823. Overall, the decline was not significant among groups (P=.502.) Recovery of erectile function was seen in 75/78 (96%) men at a mean follow-up time of 5.63±2.59 months. Anterior urethroplasty has a probability of causing ED in as much as 20% of patients. The type of urethroplasty has no significant effect on ED. Recovery of erectile function occurs within 6 months of urethroplasty.

Italian Validation of the English Prom-Uss-Q Questionnaire in Patients Undergoing Anterior Urethroplasty

The aim of this study was to translate and validate in Italian the condition-specific patient-reported outcome measure for urethral stricture surgery (PROM-USS-Q) and evaluate its psychometric properties to determine whether it was suitable for routine use. We translated the English version; 52 men scheduled for bulbar urethroplasty at our high volume center agreed to self-complete PROM-USS-Q pre-operatively, and between four and six months post-operatively. We undertook an in-depth psychometric assessment of the questionnaire constructs. There was excellent correlation between change in voiding symptom score and change in Qmax (ρ=0.746) with parallel improvements in EQ-5D visual analogue and time trade-off scores demonstrating criterion validity. Test-retest reliability and internal consistency statistics were similarly robust: intra-class correlation coefficients ranged from 0.81 to 0.90 for the individual voiding questions. Cronbach's alpha was 0.79 for the overall score and ranged between 0.74 and 0.81. These indices exceeded our predefined reliability thresholds for inclusion. Statistically highly significant improvements in construct scores occurred following urethroplasty, demonstrating responsiveness to change. The PROM-USS-Q is a practical and robust instrument for assessing voiding symptoms and health-related quality of life following urethral stricture surgery.

Two-Sided Bulbar Urethroplasty Using Dorsal Plus Ventral Oral Graft: Urinary and Sexual Outcomes of a New Technique

Repair of bulbar strictures using anastomotic techniques may cause sexual complications, while 1-side graft urethroplasties may not be sufficient to provide an adequate lumen in narrow strictures. We evaluated the urinary and sexual results of a 2-sided dorsal plus ventral graft urethroplasty by preserving the narrow urethral plate in tight strictures. Between 2002 and 2010, 105 men with bulbar strictures underwent dorsal plus ventral graft urethroplasty. The results are reported in a homogeneous group of 73 of 105 cases in which buccal mucosa was used as a graft with findings after 1 year or more of followup. The urethra was opened ventrally, and the exposed dorsal urethra was incised in the midline to create a raw area over the tunica albuginea where the first graft was placed dorsal-inlay. Thereafter the urethra was augmented by the ventral-onlay second graft and the spongiosum was closed over itself. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Postoperative sexual dysfunction was investigated using a validated questionnaire. Mean followup was 48.9 months and mean stricture length was 3.3 cm. Of these 73 cases 64 (88%) were successful and 9 (12%) were treatment failures with re-stricture. Furthermore, of 49 of 73 cases who were preoperatively sexually active, none reported postoperative erectile impairment and all were satisfied with their sexual life. In cases of tight bulbar stricture the dorsal plus ventral buccal mucosa graft provides adequate urethral augmentation by preserving the urethral plate and avoiding postoperative sexual complications.

601 ERECTILE DYSFUNCTION FOLLOWING ANTERIOR URETHROPLASTY: A PROSPECTIVE ANALYSIS OF INCIDENCE AND PROBABILITY OF RECOVERY–SINGLE CENTRE EXPERIENCE

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease1 Apr 2011601 ERECTILE DYSFUNCTION FOLLOWING ANTERIOR URETHROPLASTY: A PROSPECTIVE ANALYSIS OF INCIDENCE AND PROBABILITY OF RECOVERY–SINGLE CENTRE EXPERIENCE Prem Dogra, Ashish Saini, and Amlesh Seth Prem DograPrem Dogra Newdelhi, India More articles by this author , Ashish SainiAshish Saini Newdelhi, India More articles by this author , and Amlesh SethAmlesh Seth Newdelhi, India More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1433AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To evaluate the incidence and probability of recovery of erectile dysfunction following different types of one stage urethroplasties for anterior urethral stricture disease. METHODS 78 men undergoing single stage anterior urethroplasty from 1/1/2008 to 31/03/2010 were followed prospectively. Patients were divided into three groups. Group 1 (n=25): penile substitution urethroplasty, Group 2 (n=32): primary excision anastomotic bulbar urethroplasty and Group 3 (n=21): bulbar substitution urethroplasty. Patients willing to participate completed the International Index of Erectile Function (IIEF) preoperatively and then on subsequent follow up visits at 3,6,9,12,15 months following urethroplasty. Pre and post urethroplasty erectile functions were compared. RESULTS Our mean follow up period is 15.50+2.389 months. The mean age (yrs) was similar in between groups. The mean stricture length (cm) was 4.78 ± .747, 2.95 ± .658 and 6.13 ± 0.981 in-group 1, 2 and 3 respectively (p=.001). Mean preoperative IIEF score was 24.60 ± 2.365(similar in between groups). ED was found in 15(20%) patients: 4/25(16%), 9/32(28%) and 2/21(10%) in Group 1, 2 and 3 respectively. Mean postoperative decline (3months) in IIEF score was 22.54 ± 4.823. Overall, the decline was not significant in between groups (p=.502). Recovery of erectile function was seen in 75/78 (96%) men at a mean follow up time of 5.63 ± 2.59 months. CONCLUSIONS Anterior urethroplasty has a probability of causing ED in up to 20% of patients. Type of urethroplasty has no significant effect on ED. Recovery of erectile function occurs within 6 months of urethroplasty. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e242 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Prem Dogra Newdelhi, India More articles by this author Ashish Saini Newdelhi, India More articles by this author Amlesh Seth Newdelhi, India More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

199 REPEATED ENDOSCOPIC TREATMENT OF BULBAR URETHRAL STRICTURES IS ASSOCIATED WITH INCREASED STRICTURE COMPLEXITY AND DURATION OF SYMPTOMS

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery1 Apr 2011199 REPEATED ENDOSCOPIC TREATMENT OF BULBAR URETHRAL STRICTURES IS ASSOCIATED WITH INCREASED STRICTURE COMPLEXITY AND DURATION OF SYMPTOMS Steven Hudak, Celeste Valadez, Timothy Atkinson, and Allen Morey Steven HudakSteven Hudak Dallas, TX More articles by this author , Celeste ValadezCeleste Valadez Dallas, TX More articles by this author , Timothy AtkinsonTimothy Atkinson Dallas, TX More articles by this author , and Allen MoreyAllen Morey Dallas, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.270AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Men presenting for urethroplasty often have a longstanding history of failed visual urethrotomy and/or urethral dilation procedures. Previous studies have suggested that prior endoscopic treatment for urethral strictures is associated with an increased urethroplasty failure rate. We sought to further explore the impact of previous endoscopic treatment on the clinical course of men with bulbar urethral strictures, including stricture complexity and duration of symptoms. METHODS A retrospective review of 340 consecutive urethroplasties performed by a single surgeon between July 2007 and October 2010 was performed. Patients were divided into two groups based on endoscopic treatment history for urethral stricture disease at the time of urethroplasty (group 1: 0–1 treatment; group 2: ≥2 treatments). Only those with bulbar strictures were included, thus excluding those with pure penile and membranous strictures, as well as patients with a history of prior urethroplasty, hypospadias, lichen sclerosis, and pelvic radiation. RESULTS During the 39 month study period, 140 men with bulbar urethral strictures met the study criteria: 50 had 0–1 previous endoscopic treatments (group 1), 51 had ≥2 previous endoscopic treatments (group 2), and 39 were excluded due to incomplete records. As shown in the table, repeated endoscopic treatment was strongly associated with longer strictures, more commonly extending into the penile urethra and less often amenable to anastomotic reconstruction. Repeated endoscopic treatment of bulbar urethral strictures was also associated with an 8-fold increase in the symptomatic interval between stricture diagnosis and urethroplasty. Influence of Prior Treatment on Bulbar Urethroplasty Outcome Group 1, n=50 Group2,n=51 p Symptomatic Interval 23months 187 months <0.001 Stricture length 2.29 cm 3.68 cm <0.001 Extension into penile urethra 2(4%) 12(24%) 0.005 Need for flap/graft 6(12%) 21(41%) <0.001 Synchronous strictures 2(4%) 5(10%) 0.436 Recurrence 1(2%) 6(12%) 0.110 CONCLUSIONS Repeated endoscopic treatment of bulbar strictures is associated with increased stricture complexity and a markedly prolonged duration of symptoms. These data suggest that repeated endoscopic intervention is counterproductive and should be discouraged in treatment of bulbar strictures. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e82-e83 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Steven Hudak Dallas, TX More articles by this author Celeste Valadez Dallas, TX More articles by this author Timothy Atkinson Dallas, TX More articles by this author Allen Morey Dallas, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Grafts are Unnecessary for Proximal Bulbar Reconstruction

We compared our experience with the reconstruction of proximal vs distal bulbar stricture to assess the role of excision and primary anastomosis vs graft procedures at each site. We reviewed all urethroplasties done by a single surgeon during a 2-year period. Data analyzed included patient history and demographics, operative details, stricture length and site, and clinical outcome. The proximal bulbar urethra was defined as the segment within 5 cm of the membranous urethra and the distal bulb was defined as the adjoining segment extending to the penoscrotal junction. Cases involving the pendulous or posterior urethra were excluded from study. Of 210 urethroplasties from 2007 to 2009, 112 were done for bulbar strictures, including 72 (64%) for proximal bulbar strictures. All 72 cases were treated with excision and primary anastomosis. Median stricture length was 2 cm (range 1 to 5), although 31 of 72 strictures (43%) were of intermediate length (2.5 to 5 cm). Recurrence developed in 1 case (1.4%). Distal bulbar strictures in 40 of the 112 cases (36%) were treated predominantly with substitution urethroplasty in 36 (90%), and with excision and primary anastomosis in 4 (10%). Median stricture length was 3.75 cm (range 1.5 to 20). We noted intermediate length stricture in 18 of 40 cases (45%) and recurrence in 11 (28%). Of intermediate length strictures recurrence was much rarer after excision and primary anastomosis than after graft procedures (1 of 33 or 3.0% vs 6 of 16 or 38%, p<0.05). Location is critical when selecting an appropriate technique for bulbar urethral reconstruction. Excision and primary anastomosis are superior to grafts in the proximal bulb. Grafts are often unnecessary for reconstructing proximal bulbar strictures 5 cm or less.