Healthy Urethra Research Articles

Treatment algorithm for the comprehensive management of severe lichen sclerosus in boys based on the pathophysiology of the disease

It is estimated that approximately one out of 200 boys has the diagnosis of lichen sclerosus (LS), previously referred to as BXO (balanitis xerotica obliterans). Severe progressive disease is rare however, mismanagement of urethral tissues may contribute to progression of LS. The current literature regarding the management of severe lichen sclerosus was reviewed alongside our management of seven patients with ages ranging from six to ten years of age with severe lichen sclerosus who required surgical intervention. These patients were identified out of a busy pediatric practice that saw 5507 patients during the four-year span. Based on the pathophysiology of lichen sclerosus, urethral anatomy, and our management an algorithm was developed for medical and surgical management. All patients received initial medical treatment with topical steroids. Three patients underwent urethral mobilization and serial biopsy. One of these patients with severe disease required a second distal urethral mobilization. Three patients were treated with circumcision, and one is responding well to topical steroids after complex reconstruction. None developed postoperative urethral disease. Lichen sclerosus affects squamous epithelium but can extend to unaffected tissue if traumatized via the Koebner phenomenon. There are no randomized control trials for the management of the disease. Thus, appropriate early management with avoidance of urethral dilation or incision may prevent extension down the urethra that can lead to severe stricture disease. Several authors identified this as one of the worst forms of stricture diseases to manage. Based on the pathophysiology of the disease and our 4-year experience treating patients, we propose an algorithm for management of severe lichen sclerosus in boys. The diagnosis of lichen sclerosus in boys requires a high level of suspicion, and early biopsies should be obtained if suspected. If identified before circumcision or meatotomy, initial treatment should be medical. If the patient fails topical steroid therapy, circumcision and biopsy are the initial recommended surgical approach. Optimally, a biopsy with the first meatotomy establishes the diagnosis. If the disease persists, urethral mobilization may represent a curative treatment as it advances healthy urethra and allows complete removal of distal squamous epithelium instead of traumatic repeated dilations or incisions. This paper summarizes the available literature on the management of severe LS and provides a flow diagram based on the pathophysiology of the disease and our experience sever cases.

Searching for an explanation for the high complication rate after hypospadias surgery: A comparative histology study between the urethral plate in hypospadias patients and the healthy urethra

Searching for an explanation for the high complication rate after hypospadias surgery: A comparative histology study between the urethral plate in hypospadias patients and the healthy urethra

Preventing Urinary Fistulae After Artificial Urinary Sphincter Removal: Outcomes of a Standardized Protocol

ABSTRACT Introduction The artificial urinary sphincter (AUS) is the standard treatment for moderate to severe stress urinary incontinence in male patients. Despite their efficacy, the AUS is not without risk. Patients with an AUS are susceptible to complications such as mechanical failure, device infection, and urethral erosion. Erosion of the urethra can result in negative sequelae such as urethral stricture disease and urinary fistulae. Objective While there is no debate that patients presenting with urethral erosion require removal of the AUS, there is a lack of consensus on how to manage the patient in the perioperative period. We present our experience using a standardized surgical technique and perioperative protocol used at our institution to manage patients with an AUS presenting with urethral erosion. Methods Using an IRB-approved prosthetic database we completed a retrospective review of 97 patients who underwent AUS explantation between 2009 and 2020. Indications for removal, patient demographics, AUS component characteristics, and post-operative outcomes were analyzed. Patients undergoing AUS removal in the setting of urethral erosion were treated with a standardized protocol. Upon presentation, cystourethroscopy is performed to confirm erosion and to facilitate safe passage of a urethral catheter. With the urethral catheter in place, all AUS components are removed. After urethral cuff removal, urethrorraphy is performed. A 10-French surgical drain is placed through a separate stab incision and made to lie in the perineum and the wounds are closed in multiple layers. The urethral catheter is left in place for 4 weeks. After 4 weeks, physical examination and cystourethroscopy is performed to confirm repair of the urethra and the absence of fistula. Patients are seen monthly and are deemed eligible for reimplantation only after a minimum of 3 months have elapsed after explantation and the patient is deemed to have sufficient healthy urethra. Results No intraoperative complications occurred during AUS explantation. 117 patients underwent AUS removal during the study period. 94 (80.3%) patients had AUS removal due to urethral erosion. After median follow-up of 18.1 months (IQR 6.5 – 48.2) after AUS removal, there were a total 6 (4.0%) patients who developed a urethrocutaneous fistula with median time from AUS removal to fistula resolution of 6.5 months. Each patient with fistulae had presented with erosion of the urethra as indication for AUS removal. 67 (57.3%) patients underwent successful AUS reimplantation after removal with median time between explant and reimplant of 3.5 months (IQR3-4.8). Risk factors for urinary fistulae include urethral erosion, prior treatment with pelvic radiotherapy, and increasing age at time of AUS removal. Conclusions Urinary fistula can be prevented after urethral erosion with standardized surgical technique and peri-operative management in patients with an AUS. Disclosure No

V10-08 DISTAL URETHRECTOMY AND ADVANCEMENT URETHROPLASTY FOR URETHRAL MEATUS STRICTURE IN FEMALE PATIENTS

You have accessJournal of UrologyLower Tract Reconstruction (V10)1 Sep 2021V10-08 DISTAL URETHRECTOMY AND ADVANCEMENT URETHROPLASTY FOR URETHRAL MEATUS STRICTURE IN FEMALE PATIENTS Camille Haudebert, Juliette Hascoet, Lucas Freton, Andrea Manunta, Nirit Rosenblum, Benjamin Brucker, and Benoit Peyronnet Camille HaudebertCamille Haudebert More articles by this author , Juliette HascoetJuliette Hascoet More articles by this author , Lucas FretonLucas Freton More articles by this author , Andrea ManuntaAndrea Manunta More articles by this author , Nirit RosenblumNirit Rosenblum More articles by this author , Benjamin BruckerBenjamin Brucker More articles by this author , and Benoit PeyronnetBenoit Peyronnet More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002061.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Female urethral stricture is a rare condition. Distal stricture have usually been managed using meatoplasty. Advancement urethroplasty might be an interesting surgical alternative to meatoplasty. METHODS: We present the case of a 79 year-old female. She reported voiding symptoms for several years: slow stream, hesitancy and straining to void. On physical examination a narrowing of the urethral meatus is noted. The cystoscopy was not possible during the visit because of the stricture, the stricture could only be catheterized with a 12 Fr urethral dilator. We offered to do a distal urethrectomy and advancement urethroplasty. RESULTS: The stricture is easily identified on physical examination. Two holding stiches are place within the urethral lumen. An incision is made just above the dorsal aspect of the urethral meatus. The dorsal urethra is then opened longitudinally until healthy tissue is found above the stricture. Here the stricture is about one centimeter long. To confirm that the incision has reached healthy urethral tissue, an urethro-cystoscopy is performed. Before further pursuing the incision, the healthy urethra is sutured to the vaginal aspect of the incision at 12 o’clock to start the advancement urethroplasty using 5/0 pds. The incision is then carried out to the ventral circumference of the urethral meatus. The distal urethrectomy is completed, making sure to remove all the thickened fibrotic tissue. Additional stitches are placed all around the new urethral meatus to complete the advancement urethroplasty. An indwelling 16F urethral catheter is placed at the end of the procedure. The operative time was 30 minutes with minimal blood loss. There was no postoperative complications. The patient was discharged on postoperative day 2 and the urethral catheter on day 8. The patient resumed spontaneous voiding and was completely relieved of her voiding symptoms. She did not experience stress urinary incontinence postoperatively. CONCLUSIONS: Distal urethrectomy with advancement urethroplasty is safe and feasible in female patients with relatively short (up to 1 cm long) stricture of the distal urethra. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e757-e757 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Camille Haudebert More articles by this author Juliette Hascoet More articles by this author Lucas Freton More articles by this author Andrea Manunta More articles by this author Nirit Rosenblum More articles by this author Benjamin Brucker More articles by this author Benoit Peyronnet More articles by this author Expand All Advertisement Loading ...

Does a standardized operative approach in cloacal reconstruction allow for preservation of a patent urethra?

BackgroundCloacal malformations are recognized as a particularly challenging congenital condition to manage and they present with a wide spectrum of anatomical configurations making surgical repair very complicated. Urethral necrosis or urethral loss is a known and devastating complication of cloacal repair. The surgical repair of these malformations has evolved over time and historically only common channel (CC) length was measured. More recently, it has been advocated that the urethral length and the CC are both important in determining surgical repair. The purpose of our study is to evaluate if this surgical approach allows for preservation of a patent urethra. MethodsA prospective database of all cloaca patients maintained with IRB approval (IRB# STUDY00000721) was retrospectively reviewed. We included any girl with cloacal malformation who underwent primary repair at our institution between May 2014 and December 2019. Standardized preop evaluation with endoscopy and 3-dimentional imaging to assess urethral length and CC length. These measurements were used to determine operative approach. Girls with CC < 1 cm undergo posterior sagittal anorectoplasty and introitoplasty (PSARP + I), those with CC measuring 1–3 cm and urethra > 1.5 cm undergo total urogenital mobilization (TUM) and those with CC > 3 cm or urethra < 1.5 cm undergo urogenital separation (UGS). Postoperative urethral patency was determined at the time of cystoscopy and exam under anesthesia (EUA) 4–6 weeks postoperatively by visualizing a viable and healthy urethra that is catheterizable. ResultsA total of 59 patients met inclusion criteria with a median age of 11.6 months. Four girls underwent PSARP + I, 19 girls had a TUM and 36 girls underwent a UGS. All of the girls who had PSARP +I (n = 4) or TUM (n = 19) had a viable and patent urethra that was catheterizable at the cystoscopy and EUA 4–6 weeks postoperatively. Of the 36 girls who had UGS, all but 2 (5.6%) had a viable and patent urethra that catheterized without problems. Overall, 97% of girls in this cohort had a patent urethra after cloacal repair using this surgical protocol. ConclusionsThe use of a standard protocol that considers urethral and common channel length for cloacal repairs results in a viable and patent urethra in 97% of patients. Level of evidenceLevel II.

Value of the Perineal Ultrasound in the Diagnosis of Anterior Urethral Stricture in Male Patient

Objectives: Determine the role of perineal ultrasound in the diagnosis of anterior urethral strictures andassessment of peristenotic fibrosis.Material and Method: Thirty healthy adult male and thirty patients with suspected urethral stricture havehad urethral ultrasound after distension of urethra with a normal saline. The thirty patents also underwentretrograde urethrogram (RUG).Results: Average diameters healthy urethra were 11.6 +/- 3.1 mm at penile level, 11.2 +/- 2.7 mm at thebulbar level, and 9.7 +/- 2.88 mm at the bulbomembranous level. The periurethral tissue thickness averaged2.7 +/- 0.5 mm at penile level, from 3.5 +/- 0.65 mm to bulbar level and 3.8±0.6 mm at the bulbomembranouslevel. Ultrasound made the diagnosis of 31 stenosis or 96.87%. On ultrasound, the length of the stenosiswas significantly longer than that seen on retrograde urethrogram with a significant difference between thetwo techniques (P = 0.045). There is also a significant difference in diameter of urethral strictures betweenthe two techniques. The thickness of the periurethral tissue at the level urethral stenosis was more thanthat measured in a healthy zone in all cases, whatever the urethral portion concerned. There was not nocorrelation between periurethral tissue thickness and degree of stenosis.Conclusion: Urethral ultrasound is a method that allows us to make the diagnosis of urethral stricture andto assess periurethral fibrosis. It could validly replace retrograde urethrogram in diagnosing anterior urethralstricture.

Intrasphincteric anastomotic urethroplasty allows preservation of continence in men with bulbomembranous urethral strictures following benign prostatic hyperplasia surgery.

Injury to the external sphincter during urethroplasty at or near the membranous urethra can result in incontinence in men whose internal sphincter mechanism has been compromised by previous benign prostatic hyperplasia (BPH) surgery. We present outcomes of a novel reconstructive procedure, incorporating a recent anatomic discovery revealing a connective tissue sheath between the external sphincter and membranous urethra, which provides a surgical plane allowing for intrasphincteric bulbo-prostatic urethroplasty (ISBPA) with continence preservation. Stricture at or near the membranous urethra after transurethral resection (TURP) or open simple prostatectomy (OSP) was reconstructed with ISBPA. The bulbomembranous junction is approached dorsally with a bulbar artery sparing approach and the external sphincter muscle is carefully reflected, exposing the wall of the membranous urethra. Gentle blunt dissection along this connective tissue plane allows separating the muscle away up to the prostatic apex, where healthy urethra is found for anastomosis. From January 2010 to August 2019, 40 men (18 after TURP and 22 after OSP) underwent ISBPA at a single institution. Mean age was 67years (54-82). Mean stricture length was 2.6cm (1-6) with obliterative stricture identified in 10 (25%). At a mean follow-up of 53months (10-122), 36 men (90%) are free of stricture recurrence and 34 (85%) were completely dry or using one security pad. This novel intrasphincteric urethroplasty technique for stricture following BPH surgery is feasible and safe, allowing successful reconstruction with continence preservation in most patients. A larger series and reproduction in other centers is needed.

MP60-06 HIGH-FREQUENCY ULTRASOUND AND SHEAR WAVE ELASTOGRAPHY (SWE): UTILITY FOR PRE- AND POST-URETHRAL STRICTURE SURGERY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II (MP60)1 Apr 2020MP60-06 HIGH-FREQUENCY ULTRASOUND AND SHEAR WAVE ELASTOGRAPHY (SWE): UTILITY FOR PRE- AND POST-URETHRAL STRICTURE SURGERY Paul H Chung*, Joon Yau Leong, Corinne E Wessner, Priscilla Machado, Edouard J Trabulsi, Ethan J Halpern, Flemming Forsberg, and John R Eisenbrey Paul H Chung*Paul H Chung* More articles by this author , Joon Yau LeongJoon Yau Leong More articles by this author , Corinne E WessnerCorinne E Wessner More articles by this author , Priscilla MachadoPriscilla Machado More articles by this author , Edouard J TrabulsiEdouard J Trabulsi More articles by this author , Ethan J HalpernEthan J Halpern More articles by this author , Flemming ForsbergFlemming Forsberg More articles by this author , and John R EisenbreyJohn R Eisenbrey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000929.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The ability to identify and quantitate peri-urethral fibrosis is limited prior to urethral stricture surgery. Shear wave elastography (SWE) is a quantitative and reproducible method to measure a tissue’s elastic properties. We examined the utility of SWE for the evaluation of corpus spongiosum elasticity pre- and post-urethral stricture surgery. METHODS: Patients with a single, bulbar urethral stricture diagnosed on preoperative cystoscopy or retrograde urethrogram, who elected to undergo surgical repair provided informed consent to participate in this ongoing, IRB-approved study from October 2018 to September 2019. SWE imaging was performed under anesthesia prior to open surgical repair using an Aplio i800 scanner (Canon Medical Systems, Tustin, CA) and an i8CX1 transducer with the system’s proprietary SWE package. Upon acquisition of stricture images, 4 regions of interest (ROI) were placed on the corpus spongiosum – 2 on the stricture, 2 on healthy tissue. Tissue elasticity (in kPa) was averaged across the ROIs. SWE and the associated data analysis were then repeated for each patient during their 3-month post-operative appointment. Pre- to post-procedure results were compared using paired student’s t-tests. RESULTS: Twelve men (mean age 57.1±18.1 years and BMI 29.2±6.8 kg/m2) have been enrolled. Nine (75%) patients had previously undergone a median of 2 stricture dilation procedures. Seven (58%) patients have undergone post-operative follow-up imaging, 6 of which revealed no evidence of stricture recurrence. One patient (8%) did not undergo urethroplasty as his stricture was passively dilated on cystoscopy. Mean elasticity among the strictured urethra was lower before surgery (27.9±5.8 kPa) compared to after surgery (36.8±4.2 kPa) (n=7, p=0.56). Mean elasticity of the strictured portion was lower (27.9±5.8 kPa) than that of the healthy urethra (29.9±4.3 kPa) before surgery (n=12, p=0.19) and after surgery (36.8±4.2 vs. 37.5±3.4 kPa, n=7, p=0.32). CONCLUSIONS: SWE may help to assess peri-urethral fibrosis in the initial characterization and post-operative follow-up of urethral stricture disease. Further studies assessing the utility of SWE and optimizing the protocol should be performed in larger cohorts. Source of Funding: Material Support Grant from Bracco Diagnostics, Provost’s Pilot Clinical Research Award from Thomas Jefferson University © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e891-e891 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Paul H Chung* More articles by this author Joon Yau Leong More articles by this author Corinne E Wessner More articles by this author Priscilla Machado More articles by this author Edouard J Trabulsi More articles by this author Ethan J Halpern More articles by this author Flemming Forsberg More articles by this author John R Eisenbrey More articles by this author Expand All Advertisement PDF downloadLoading ...

Contrast-Enhanced Urodynamic Vector Projectile Imaging (CE-UroVPI) for Urethral Voiding Visualization: Principles and Phantom Studies

To devise a new urodynamic imaging framework that can provide time-resolved visualization of urinary flow and urethral deformation during the initiation phase of voiding. Contrast-enhanced urodynamic vector projectile imaging (CE-UroVPI) was devised using the principles of high-frame rate ultrasound, microbubble contrast agents, and flow vector mapping. CE-UroVPI was implemented using a research-purpose ultrasound scanner (5 MHz frequency) and commercial contrast agents (USphere Prime). The performance of CE-UroVPI was evaluated using 2 custom-designed deformable urethra phantoms - a healthy model and a diseased model with benign prostatic hyperplasia (BPH) - that respectively simulate urodynamics in the urinary tract with and without mechanical obstruction. The corresponding spatiotemporal urodynamics were investigated and analyzed. Using a frame rate of 1,250 fps that corresponds to 0.8 ms time resolution, CE-UroVPI effectively depicted the transient urodynamic events during the initiation phase of voiding. Anomalous spatiotemporal characteristics were observed in the urodynamics of the BPH-obstructed urethra. Specifically, upstream from the obstruction site, a transient surge in flow speed was observed in the first 100 ms of voiding. Also, downstream from the obstruction site, complex urodnyamics had emerged in the forms of flow jet and vortices. These anomalies were not found in the healthy urethra. CE-UroVPI is the first imaging framework that can visualize complex urodynamics over an entire voiding episode including its initiation phase. This new tool may be used to potentially gain new insight into the causal relationships between urethral morphokinetic factors and lower urinary tract symptoms.

Гистологическое исследование уретральной площадки: поиск оптимального пластического материала для хирургического лечения гипоспадии у детей

to study the microstructure of the urethral plate in patients with a proximal form of hypospadias to justify the use of tissues from the ventral penile surface when creating an artificial urethra. A histological study of surgical specimens from 10 patients with proximal hypospadias was carried out. The urethral plate, a strip of tissue from the ectopic external urethral orifice located in the penoscrotal angle, to the coronary sulcus, was completely excised and processed by various techniques. A staining with hematoxylin and eosin, picrofuchsin according to Van Gieson, as well as immunohistochemical typing of CD 34, collagen (type I, III, and IV), fibronectin, and smooth myocytes using alpha-smooth muscle actin was performed. All elements which are present in a healthy urethra, such as epithelial cells, blood vessels, normal collagen fibers, smooth muscle cells and complexes of glands, were found in the microstructure of the urethral plate. The cytoarchitectonic features of the ventral penile tissues are similar to the microstructure of the healthy urethra, which provides a rationale to consider the urethral plate as a material with optimal bioresistant properties for urethroplasty.

Autologous granulation tissue tubes for replacement of urethral defects: An experimental study in male rabbits

Tubularized urethroplasty is commonly performed in clinical practice using genital skin flaps, bladder mucosa, and buccal mucosa. However, the long-term effects are not satisfying, and donor site morbidities remain a problem. Besides, those grafts are unavailable with malignant conditions of the urinary tract, a history of lichen sclerosis, or oral disease. An autologous granulation tissue tube of any required length and diameter can be produced by implanting foreign objects subcutaneously (Summary Fig.). The current study aimed to investigate to what extent of length this fully autologous tissue could be used for tubularized urethroplasty, satisfying urethral patency and tissue regeneration, in male rabbits. Twenty-seven New Zealand male rabbits were randomly divided into three groups. Silastic tubes were implanted subcutaneously in Group 1 and Group 2. By 2 weeks the granulation tissue encapsulating the tubes was harvested. In Group 1, pendulous urethral segments of 1cm were excised, and urethroplasty was performed with the granulation tissue tube in an end-to-end fashion. In Group 2, a pendulous urethral segment of 1.5cm was replaced with the tissue tube. In Group 3, a pendulous urethral defect of 1cm was repaired by re-anastomosis as control. Serial urethrograms were performed at 1, 2 and 6 months postoperatively. Meanwhile, the neo-urethra were harvested and analyzed grossly and histologically. The urethrograms showed that all animals in Group 1 maintained a wide urethral caliber. In contrast, animals in Group 2 and Group 3 developed progressive strictures. Histologically, an intact urothelium with one to two cell layers lined the graft by 1 month, which was surrounded by increasing organized smooth muscle in Group 1. By 6 months, the grafts were completely integrated into native urethra. Nevertheless, extensive fibrosis occurred in Group 2 and Group 3. The tissue successfully maintained patency and guided urethral regeneration across a distance of 1cm. As an epithelium-free graft, the tissue showed better results than acellular matrix for tubularized urethroplasty compared with previous studies. Nevertheless, several limitations existed: (1) the urethral defect was created in healthy urethra, which could not fully simulate the clinical situation; (2) as a small animal model, rabbit was less informative for clinical problems; (3) the tissue was inadequate for long segmental urethral replacement. Further study is needed before the procedure is used clinically. An autologous granulation tissue tube grown subcutaneously could be successfully used to repair urethral defects of 1cm in male rabbits.

Urine Collection And Transport

The most common urine specimen received is the per-urethral voided urine. Healthy urethra is unsterile and it is extremely critical that urine specimens be collected carefully to minimise urethral contamination. There are several types of urine specimens and the results of each type are determined by different guidelines. Therefore, it is essential that each urine specimen received by the laboratory is clearly labelled as to the type of collection of urine specimen. JMS 2017; 20(1):52-53

V1-04 RECONSTRUCTION OF BULBO-MEMBRANOUS URETHRAL STRENOSIS AFTER SURGERY FOR BENIGN PROSTATIC HYPERPLASIA WITH PRESERVATION OF CONTINENCE

You have accessJournal of UrologyReconstruction Lower Tract (I)1 Apr 2017V1-04 RECONSTRUCTION OF BULBO-MEMBRANOUS URETHRAL STRENOSIS AFTER SURGERY FOR BENIGN PROSTATIC HYPERPLASIA WITH PRESERVATION OF CONTINENCE Cristina Baeza, Reynaldo Gomez, Rodrigo Campos, and Laura Velarde Cristina BaezaCristina Baeza More articles by this author , Reynaldo GomezReynaldo Gomez More articles by this author , Rodrigo CamposRodrigo Campos More articles by this author , and Laura VelardeLaura Velarde More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.236AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bulbo-membranous urethral stenosis after surgery for benign prostate hyperplasia (BPH) are challenging because the internal sphincter has been removed and continence depends on the function of the external sphincter, which is located just at the site of the stenosis; any attempt for reconstruction may jeopardize continence. Anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. We developed a novel technique performing a meticulous dissection of this sheath to separate the muscle from the urethral wall, thus performing an intra-sphincteric anastomosis without disturbing the sphincteric function METHODS A 67 year old patient underwent a transvesical simple prostatectomy for BPH. He developed an early bulbo-membranous stenosis managed initially with repeated dilation until he went into complete retention needing a suprapubic tube. The bulbar urethra is exposed through a vertical perineal incision with splitting of the bulbo-spongiosum muscle and then separated from the corpus cavernosum. Opening of the perineal membrane and splitting of the intercrural space in the midline, provides access to the dorsal aspect of the bulbo-membranous junction. The bulb is then mobilized to the left side, without detachment from the perineal body and the bulbar vessels are retracted. The sheath of the membranous urethra is now opened circumferentially at the bulbo-membranous junction, carefully reflecting the circular muscle fibers of the external sphincter until exposure of the urethral wall is obtained and the connecting tissue plane is identified. Gentle blunt proximal dissection along this plane allows separating the muscle away from the urethra towards the prostatic apex until healthy urethra is found to perform the bulbo-prostatic anastomosis, which is completed with a standard parachute technique. Finally the sphincteric muscle ring is anchored to the anastomosis with interrupted absorbable stitches RESULTS The patient was discharged on PO day 3 and the urethral catheter was removed at 3 weeks. He recovered normal continent micturition and is voiding symptoms free at 3 months of follow-up CONCLUSIONS Excision and bulbo-prostatic anastomosis with sphincter sparing for bulbo-membranous stenosis after BPH surgery is feasible and safe. Our technique allows repairing the urethra preserving continence and to our knowledge it has not been described before. A larger series and reproduction in other centers are needed to validate this technique © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e68-e69 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Cristina Baeza More articles by this author Reynaldo Gomez More articles by this author Rodrigo Campos More articles by this author Laura Velarde More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Urethral lumen occlusion by artificial sphincteric devices: a computational biomechanics approach.

The action induced by artificial sphincteric devices to provide urinary continence is related to the problem of evaluating the interaction between the occlusive cuff and the urethral duct. The intensity and distribution of the force induced within the region of application determine a different occlusion process and potential degradation of the urethral tissue, mostly at the borders of the cuff. This problem is generally considered in the light of clinical and surgical operational experience, while a valid cooperation is established with biomechanical competences by means of experimental and numerical investigation. A three-dimensional model of the urethra is proposed aiming at a representation of the phases of the urethral occlusion through artificial sphincters. Different conformations of the cuff are considered, mimicking different loading conditions in terms of force intensity and distribution and consequent deformation caused in soft tissues. The action induced in the healthy urethra is investigated, as basis for an evaluation of the efficacy and reliability of the sphincteric devices. The problem is characterized by coupled nonlinear geometric and material problem and entails a complex constitutive formulation. A heavy computational procedure is developed by means of analyses that operate within an explicit finite element formulation. Results reported outline the overall response of the urethral duct during lumen occlusion, leading to an accurate description of the phenomenon in the different phases.

PD44-01 RECONSTRUCTION OF BULBO-MEMBRANOUS URETHRAL STRICTURES AFTER SURGERY FOR BENIGN PROSTATIC HIPERPLASIA WITH PRESERVATION OF CONTINENCE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) III1 Apr 2016PD44-01 RECONSTRUCTION OF BULBO-MEMBRANOUS URETHRAL STRICTURES AFTER SURGERY FOR BENIGN PROSTATIC HIPERPLASIA WITH PRESERVATION OF CONTINENCE Reynaldo Gomez, Juan Carlos Castaño, Laura Velarde, and Rodrigo Campos Reynaldo GomezReynaldo Gomez More articles by this author , Juan Carlos CastañoJuan Carlos Castaño More articles by this author , Laura VelardeLaura Velarde More articles by this author , and Rodrigo CamposRodrigo Campos More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1793AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bulbo-membranous urethral strictures (BMUS) after surgery for BPH are challenging because the internal sphincter has been removed and continence relay on the external sphincter, which is located just at the site of the stricture; any attempt to reconstruction may jeopardize continence. Anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue [1]. We developed a novel technique performing a meticulous dissection of this sheath to separate the muscle from the urethral wall, thus performing an intra-sphincteric anastomosis without disturbing the sphincteric function METHODS Patients with BMUS after TURP or open prostatectomy (OP) who failed dilation and/or internal urethrotomy were reconstructed with a BPA with preservation of the external sphincter. The bulbo-membranous junction is approached dorsally and the bulb is mobilized only from one side, without detachment from the perineal body. The bulbo-membranous junction is isolated with a vessel loop and the bulbar vessels retracted posteriorly. The sheath of the membranous urethra is opened circumferentially, carefully reflecting the circular muscle fibers of the external sphincter until exposure of the urethral wall is obtained. Gentle blunt proximal dissection along this connective tissue plane allows separating the muscle away from the urethra up to the prostatic apex, where healthy urethra is found to perform the anastomosis RESULTS From January 2010 to October 2015 we operated 23 patients, 14 after TURP and 9 after OP. All had membranous or bulbo-membranous strictures; bladder neck contractions were excluded. Mean age was 68 years (57 – 81). Except 4 patients, all have been treated with either dilation and or one or more DVIUs; seven were with a suprapubic tube. Mean length of stricture was 3 cm (1 - 4.5), mean time from surgery to reconstruction was 30 months (2 - 153). At a mean follow-up of 34 months (1 - 68) 19/23 patients were completely dry or using only one security pad (83% success). There were two Clavien I and one Clavien III complications and no stricture recurrence. CONCLUSIONS Excision and bulbo-prostatic anastomosis with sphincter sparing for BMUS after BPH surgery is feasible and safe. Our technique allows preserving continence in most patients and to our knowledge it has not been described before. A larger series and reproduction in other centers are needed to validate our results. 1. Dalpiaz O et al. Anatomical approach for surgery of the male posterior urethra. BJU Int 2008; 102: 1448-1451. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e998 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Reynaldo Gomez More articles by this author Juan Carlos Castaño More articles by this author Laura Velarde More articles by this author Rodrigo Campos More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V12-07 RECONSTRUCTION OF A SIXTEEN-CENTIMETER ANTERIOR URETHRAL STRICTURE: DOUBLE DORSAL BUCCAL MUCOSA GRAFT WITH THE ASOPA TECHNIQUE

You have accessJournal of UrologyReconstruction1 Apr 2016V12-07 RECONSTRUCTION OF A SIXTEEN-CENTIMETER ANTERIOR URETHRAL STRICTURE: DOUBLE DORSAL BUCCAL MUCOSA GRAFT WITH THE ASOPA TECHNIQUE Alvaro Saavedra, Alejandro Rojas, Jose Arenas, Laura Velarde, and Reynaldo Gomez Alvaro SaavedraAlvaro Saavedra More articles by this author , Alejandro RojasAlejandro Rojas More articles by this author , Jose ArenasJose Arenas More articles by this author , Laura VelardeLaura Velarde More articles by this author , and Reynaldo GomezReynaldo Gomez More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2133AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Multiple surgical techniques have been described for long segment anterior urethral strictures (LSAUS), including staged urethroplasty, dorsal buccal mucosa graft (DBMG), fasciocutaneous flap, perineal urethrostomy and flap plus graft. In 2001 Asopa et al. described a new technique for dorsal graft by exposing the stricture through a ventral urethrotomy and a wide midline incision of the urethral plate to acommodate the dorsal graft. Compared to DBMG a randomized study showed significantly less blood loss and less operative time for Asopa technique with a similar 2-year success rate over 85%. Theoretically, in this approach blood supply is better preserved. In addition, it has been claimed that it is easier to learn and may provide a better visualization of the diseased urethra. The aim of this video is to provide a detailed demonstration of the Asopa technique to solve a LSAUS which required a double sequential BMG graft METHODS A 60 year-old patient with long-standing lower urinary tract symptoms presented with acute urinary retention; urethral catheterization was impossible and a suprapubic cystostomy was placed. Urethrocystoscopy and retrograde urethrogram confirmed a LSAUS, with severe spongiofibrosis. Surgical Technique: A vertical perineal incision and midline splitting of the bulbospongiosum muscle allow for wide exposure of the corpus spongiosum. Urethroscopy was used to determine the distal end of spongiofibrosis. Then, a ventral urethrotomy along penile and bulbar urethra is performed until healthy urethra is found. A deep midline dorsal urethrotomy is done dissecting urethral plate with an ophthalmic scalpel in order to accommodate a double tandem BMG affixed to the underlying corpus cavernosum with absorbable running sutures. Interrupted stitches are placed in the midline to facilitate graft take. A 16F urethral catheter is placed and standard closure by layers is performed using running sutures RESULTS Operative time was 173 minutes and blood loss was 200cc. Total stricture length was 16 cm. Patient was discharged on the 4th postoperative day with a suprapubic tube and a silicone urethral catheter. There were no postoperative complications. Pericatheter retrograde urethrogram at 3 weeks showed minimal extravasation so urethral catheter was removed. Cystostomy was left one more week and then removed. Six months after surgery his AUA-IPSS questionnaire was 5 and Qmax was 17 ml/sec CONCLUSIONS For LSAUS, the Asopa technique appears to be a reproducible, safe and effective choice to be considered in these complex cases © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1068 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Alvaro Saavedra More articles by this author Alejandro Rojas More articles by this author Jose Arenas More articles by this author Laura Velarde More articles by this author Reynaldo Gomez More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Ventral bladder mucosa onlay graft urethroplasty for the treatment of panurethral stricture

Objective To investigate the efficacy of ventral bladder mucosa onlay graft urethroplasty for the management of panurethral stricture. Methods From August of 2005 to July of 2013, 11 cases of panurethral stricture were treated by ventral bladder mucosa onlay graft urethroplasty. The median age of the patients was 53 years ( 22-72 year ), The median stricture length was 15 cm (12-18 cm ). The patient was placed in the lithotomy position, Penile urethra was exposed by circumcoronal incision and degloving of skin, Bulbar urethra was exposed by inverted Y-shaped perineal incision. The strictured urethral segment was then opened ventrally in the midline up to at least 1 cm proximally into the healthy urethra. An appropriate size bladder mucosa graft was harvested, and was quilted to the splited urethra edge, the graft width was 1.5-2.0 cm. Two F10 fenestrated silicone catheters were left as urethral stents, a suprapupic cystostomy tube was left. The urethral stent was removed 4 weeks postoperatively. Follow-up was performed every 3 months for the first year, and annually thereafter. Success was defined as normal voiding with a maximum flow rates≥15 ml/s, and the patients required no further instrumentation, including dilation or urethrotomy. Results The mean follow-up was 18 months ( range, 9-36 months ), the overall success rate was 10/11. One patient developed urethral meatus stenosis 3 months postoperatively, and was managed by meatal dilatation. Conclusion Ventral bladder mucosa onlay graft urethroplasty can be used for the management of panurethral stricture, Bladder mucosa is an alternative substitution for complex urethral reconstruction. Key words: Bladder mucosa; Urethral strictures; Urethroplasty

V12-04 ONE-STAGE RECONSTRUCTION OF OBLITERATIVE DISTAL ANTERIOR URETHRAL STRICTURES WITH CIRCULAR BUCCAL MUCOSA GRAFT

You have accessJournal of UrologyReconstruction1 Apr 2015V12-04 ONE-STAGE RECONSTRUCTION OF OBLITERATIVE DISTAL ANTERIOR URETHRAL STRICTURES WITH CIRCULAR BUCCAL MUCOSA GRAFT Fikret Fatih Onol, Sinasi Yavuz Onol, Ahmet Bindayi, Ahmet Tahra, Ugur Boylu, and Eyüp Veli Küçük Fikret Fatih OnolFikret Fatih Onol More articles by this author , Sinasi Yavuz OnolSinasi Yavuz Onol More articles by this author , Ahmet BindayiAhmet Bindayi More articles by this author , Ahmet TahraAhmet Tahra More articles by this author , Ugur BoyluUgur Boylu More articles by this author , and Eyüp Veli KüçükEyüp Veli Küçük More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2774AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Distal urethral strictures are common in adult men due to susceptibility of the distal urethra to trauma, infection, and inflammatory diseases. Reconstruction of distal urethral strictures is a challenge for creating both a functional and a cosmetic outlet. Substitution urethroplasty for obliterative distal urethral strictures generally requires a two-stage approach or a complex urethral plate reconstruction combined with onlay augmentation. We report our experience with one-stage distal urethral reconstruction using circular buccal mucosa graft (cBMG). METHODS The data of 24 men (age: 25-72 years) treated with cBMG urethroplasty between 2001 and 2014 were reviewed. Patients were evaluated with AUA symptom score, uroflowmetry, and retrograde urethrography/voiding cystourethrography. The external meatus was involved and the stricture was confined to distal urethra in all cases. The etiology was iatrogenic in 9 and inflammatory in 15 men. Through a circum-meatal incision, the distal strictured urethra was dissected from the healthy glans tissue, and sectioned at the location of proximal healthy urethra. A rectangular BMG with 4 cm. length and 1 to 3 cm. width (depending on the length of the defect) was harvested. The BMG was rolled on a 24Fr urethral sound with its mucosa facing inward, and its long edge was sutured circumferentially to the healthy proximal urethral mucosa. Neo-meatus was then reconstructed with distal anastomosis of the cBMG circumferentially to the initial circum-meatal incision. Foley catheter was removed after 2 weeks. Postoperative data were recorded during an initial visit 7 days after urethral catheter removal and at 1st, 3rd, 6th months, then yearly thereafter. Preoperative AUA symptom score and Qmax measurements were compared with postoperative values obtained at the last follow-up using Wilcoxon sign test. RESULTS With a median follow-up of 36 months (range: 6 to 96), 19 (79.1%) patients were cured. One patient had early graft loss, 2 patients developed stricture at the proximal anastomotic site and 2 patients had re-stricture at the neo-meatus. Mean Qmax(ml/sec) increased from 6.9±5.2 preoperatively to 21.6±9.2 postoperatively (p=0.01), and mean AUA score decreased from 26.1±3.7 preoperatively to 7.8±3.6 postoperatively (p=0.002). CONCLUSIONS Our results suggest cBMG as a feasible alternative in one-stage reconstruction of obliterative distal urethral strictures urethra, since glans penis has a good blood supply that provides an efficient circumferential graft take. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e977-e978 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Fikret Fatih Onol More articles by this author Sinasi Yavuz Onol More articles by this author Ahmet Bindayi More articles by this author Ahmet Tahra More articles by this author Ugur Boylu More articles by this author Eyüp Veli Küçük More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Histopathological Characteristics of Buccal Mucosa Transplants in Humans after Engraftment to the Urethra: A Prospective Study

Histopathological changes in buccal mucosa transplants after engraftment to the urethra and exposure to urine remain nebulous. We investigated histopathological changes in buccal mucosa transplants integrated into the urethra in humans. We prospectively evaluated 22 patients withrecurrent urethral stricture after buccal mucosa urethroplasty between November 2012 and October 2013. All patients underwent repeat buccal mucosa urethroplasty performed by a single surgeon. Intraoperatively we harvested a sample of the integrated buccal mucosa transplant previously engrafted to the urethra, a sample of healthy urethra, a sample of freshly harvested buccal mucosa from the contralateral inner cheek and a sample of fibrotic tissue from the area of the current stricture. A dedicated uropathologist performed meticulous histopathological examination of all tissue samples using hematoxylin and eosin staining. Preoperative clinical data were also collected on all patients. The mean interval from previous to current buccal mucosa urethroplasty was 22.2 months (range 4.1 to 76.0). Mean stricture length at repeat urethroplasty was 52.7 mm (range 30.0 to 70.0). Histopathological characteristics of the integrated buccal mucosa transplants were completely preserved in allpatients, consisting of thick sheets of stratified nonkeratinized squamous epithelium with a stratum spinosum. Transplants were not partially or entirely overgrown with urothelium. Buccal mucosa transplants retain their histopathological characteristics and are not overgrown with urothelium after urethral engraftment andurine exposure in humans. These findings may explain the superiority of buccal mucosa transplants on the outcome of substitution urethroplasty compared to that of other materials.

Reconstruction of Distal Urethral Strictures Confined to the Glans With Circular Buccal Mucosa Graft

To report our results with 1-stage reconstruction in short distal urethral strictures using circular buccal mucosa graft (cBMG). The data of 19 patients (median age 41.8 years, range 25-58) operated between 2001 and 2010 were reviewed. Patients were evaluated with American Urological Association (AUA) symptom score, uroflowmetry, voiding cystourethrography (VCUG), and intraoperative urethroscopy. Stricture was limited to the glanular urethra (≤ 2 cm.) in all cases and 16 patients had lichen sclerosus. Strictured urethra was resected 0.5 cm proximal to the healthy urethra and a rectangular BMG with 4-cm length and 1.5- to 2.5-cm width (depending on the length of the defect) was rolled on a 24-Fr sound that calibrated the urethra. Proximal and distal edges of the cBMG were anastomosed circumferentially to the healthy mucosa and meatus, respectively. Foley catheter was removed within 10-14 days. Voiding symptoms, uroflowmetric parameters, and cosmesis were assessed at 1, 3, and 6 months, and yearly thereafter. With a median follow-up of 38 months (range 12-96), 16 (84.2%) patients were cured. One patient developed early graft loss, and 2 patients developed stricture at proximal anastomotic site. Mean Q(max) (mL/s) increased from 7.8 ± 5.4 preoperatively to 21.8 ± 9.2 postoperatively (P = .001), and mean AUA score decreased from 26.7 ± 3.9 preoperatively to 7.3 ± 3.8 postoperatively (P < .001). Our results suggest cBMG as a feasible alternative in 1-stage reconstruction of distal strictures confined to the glanular urethra because the glans penis has a good blood supply, providing an efficient circumferential graft take.