Stricture Length Research Articles

Safety of open airway reconstruction in high-risk post-COVID patients: A case-matched control study

ObjectivesCOVID-19 pneumonia patients may have high rates of intubation and reduced pulmonary function once recovered. Poor pulmonary function is a relative contraindication to open airway reconstruction, post-COVID patients may extrapolate as high-risk for open airway reconstruction. This presents challenges in airway stenosis management of post-COVID pneumonia patients. This study reports the safety and outcomes of open airway reconstruction in carefully selected post-COVID patients. MethodsA retrospective case-matched control study of six post-COVID tracheal stenosis cases treated with tracheal resection and six matched controls. Controls were matched based on age, length of stenosis, and comorbidities. Primary outcomes are peri-operative safety events and need for future airway interventions. ResultsPost-COVID cases and non-COVID controls were closely matched on age, length of stenosis, and comorbidities (p > 0.05). Duration of follow-up was not significantly different (p = 0.1894). No patients required reintubation, tracheostomy, ICU admission, or ventilator placement in the peri-operative period. There was one allergic reaction to antibiotics in a case and one aspiration pneumonia in a control. One case required in-office steroid injection and injection augmentation post-operatively, but no patients from either group required future operative airway intervention during the follow-up period. ConclusionPost-COVID tracheal stenosis cases had comparably excellent outcomes with matched controls after open tracheal construction, with few peri-operative safety events and minimal need for future interventions. These data indicate open airway reconstruction is a safe and effective option for the treatment of tracheal stenosis in carefully selected post-COVID patients. Level of evidence4

Assessment of predictive factors in endoscopic internal urethrotomy for bulbar urethral strictures

IntroductionDirect vision internal urethrotomy (DVIU) is usually the first treatment offered to patients with bulbar urethral strictures (US). Advances in devices and surgical techniques have contributed to reducing associated complications. Despite the favorable success rate of DVIU, various factors predicting better outcomes have been studied, including patient characteristics, stricture features, and procedural aspects. The main aim of our study is to assess predictive factors for success. MethodsWe conducted a retrospective descriptive study of patients who underwent endoscopic internal urethrotomy at our hospital over a 30 year period. Out of 788 DVIU performed, we selected 491 (62.3%) conducted for bulbar US with a minimum follow-up of 12 months. We examined clinical outcomes obtained, and assessed the relationship between different patient characteristics, stricture-related factors and procedural aspects related with clinical success -considered as the avoidance of further interventions for stricture recurrence-. Descriptive statistics were calculated and parametrical and non-parametrical comparative tests were applied. Kaplan-Meier survival analysis was used for evaluating time until recurrence. ResultsMean stricture length was 1.2 cm (SD 0.5), with only 12 patients presenting with more than 1 US in the bulbar area during DVIU. After a median follow-up of 170 months, 67.4% of patients did not experience clinical recurrence. Severe postoperative complications appear in 0.4% of cases, and need for overnight admission was 4.5%. A positive association was observed between clinical recurrence and a history of prior pelvic radiotherapy (OR 2.8, 95%IC 1.3-22.2), active smoking (OR 2.1, 95%IC 1.6-2.4), infectious etiology of stricture (OR 2.3, 95%IC 1.6-8), history of previous urethroplasty (OR 2.5, 95%IC 1.7-3.2), and higher postoperative urinary catheter sizes (OR 1.8 95%IC 1.1-2.9). Median time until recurrence after the first DVIU was 65 months, after the second was 60 months, after the third was 32 months, and after the fourth was 6 months. ConclusionsBulbar US could be safely managed with DVIU. The best clinical success is achieved in non-irradiated, non-smoker patients, without prior urethroplasties. The repetition of the procedure is significantly associated with a shorter time to clinical recurrence.

Outcomes of bulbar artery sparing during anastomotic urethroplasty for pelvic fracture urethral injury

ObjectiveTo the present long-term outcomes of the vascular-sparing approach during reconstruction of pelvic fracture urethral injuries (PFUI) described by Gomez et al. Material and methodsAnastomotic reconstruction of PFUI is performed without transecting the bulb of the spongiosum, to preserve the antegrade flow of the bulbar arteries. After exposure of the urethra, the bulbar arteries are located using a Doppler stethoscope. The bulb is mobilized dorsally and unilaterally, sacrificing the artery with the weaker Doppler signal to preserve the best contralateral artery. Occasionally, both arteries can be preserved. Removal of all fibrosis and anastomosis is performed as described in the traditional transecting technique. ResultsA total of 60 patients were included, with a mean age of 37 years (IQR 22-48). The median time from trauma to urethral reconstruction was 16 weeks, and the mean stenosis length was 2.5 cm (IQR 2-3). The left bulbar artery was preserved in 27 cases, the right bulbar artery in 8, and both in 24. There were postoperative complications in 14 cases (23%), but only one of them was Clavien ≥ III. With a mean follow-up of 56 months (IQR 12-87), only one patient failed due to stenosis (98% success). ConclusionPreservation of antegrade arterial flow to the corpus spongiosum during PFUI reconstruction is feasible and safe. Although slightly more elaborate, this technique could reduce the risk of ischemic failure of reconstruction.

Retrograde urethrography (RUG) combined with voiding cystourethrography (VCUG) versus surgical findings in assessment of urethral strictures length

Background and objective: Retrograde urethrography (RUG) combined with voiding cystourethrography (VCUG) is the most common and preferred imaging modality for evaluating urethral strictures, despite its well-known limitations and disadvantages. In this study, we assessed the clinical relevance of RUG + VCUG, along with intraoperative assessment in measuring male urethral strictures. Method: This study was a single-center retrospective study involving 134 male patients diagnosed with urethral stricture disease. All participants underwent RUG + VCUG before the intervention, and the results were interpreted by a single radiologist. The location and length of urethral strictures were assessed. The accuracy of urethral stricture measurements obtained from combined VCUG and RUG imaging was compared to intraoperative measurements, which served as the reference standard. Urethral strictures were classified into three types: membranous and bulbomembranous, bulbar, and penile. Results: A total of 130 patients were included (38.14 ± 12.05 years) in the study. For patients with membranous and bulbar strictures, there were statistically significant differences in stricture length measurements between VCUG + RUG and surgical evaluation ( p < 0.05). However, for patients with penile strictures, the differences in stricture length measurements between VCUG + RUG and surgical evaluation were not statistically significant ( p = 0.448). Conclusion: This study suggests that RUG + VCUG may underestimate urethral stricture, particularly in the membranous and bulbar regions.

Long-term results of intensive care patients with post-intubation tracheal stenosis: 7 years follow-up

Background/aimBenign tracheal stenosis (TS) is a potentially life-threatening condition caused by iatrogenic events resulting from endotracheal intubation and tracheostomy. The study aimed to determine the clinical characteristics, management, and long-term outcomes of patients with simple or complex post-intubation tracheal stenosis (PITS) who were admitted to the intensive care unit (ICU).Materials and methodsRetrospective analysis of patients admitted to the ICU between June 2016 and June 2022 and diagnosed with PITS were performed until June 2023.Results76 patients (mean age 54.9 ± 17.3%, 63.2% male, 61.8% complex stenosis) admitted to the ICU were analysed. The diagnosis of PITS was made by fiberoptic bronchoscopy (FOB) in 53.9% and computed tomography (CT) in 46.1%. The most common location of stenosis was the upper trachea area (57.9%, n = 44). The median stenosis length of the TS was 1.9 cm (median 2 cm for complex stenosis, 1 cm for simple stenosis, p < 0.001). Complex stenosis was associated with longer intubation time and multiple intubation history (p = 0.011, p = 0.028). At the same; complex stenosis was associated with prolonged and high stenosis percentage (p < 0.001). While dilatation and cryotherapy were sufficient for treatment in all patients with simple stenosis, the stent was applied to 34% patients with complex stenosis. Recurrence was higher in complex stenosis after bronchoscopic procedure (complex stenosis 95.7%, simple stenosis 17.2%). 19 (25%) patients required surgical operation, and all of these patients had complex stenosis (p < 0.001). Median follow-up was 33 months for simple stenosis and 34 months for complex stenosis. ICU length of stay (LOS) was longer in patients with complex stenosis. There was no statistically significant difference between TS classes in terms of ICU mortality (p = 0.466), 1-year mortality (p = 0.951), and mortality during follow-up (p = 0.608).ConclusionPITS is a challenging situation in ICU patients. In patients with a preliminary diagnosis of PITS, bronchoscopy should be performed without delay, and it should be known that interventional bronchoscopy is not only a diagnostic tool but an effective strategy in treatment management after the diagnosis is finalised. The advantage of interventional bronchoscopy is that it alleviates symptoms that necessitate hospitalisation in the ICU and eliminates the need for ICU of patients.

Airway Management With Congenital Tracheal Stenosis: Surgical and Anesthetic Consideration.

To investigate demographic data and airway management techniques for patients with congenital tracheal stenosis (CTS) during the preoperative, intraoperative, and postoperative periods. A retrospective chart review. This study was a retrospective case series at a single tertiary care pediatric medical center. It encompassed all children diagnosed with CTS who underwent slide tracheoplasty from January 2001 through December 2018. Exclusion criteria were acquired stenosis, tracheomalacia, patients without a confirmed diagnosis of CTS, and those with missing data. Patient demographics and details of airway management were collected and analyzed. A total of 148 patients met the inclusion criteria. The most common etiology of CTS was congenital tracheal rings (90.5%). The median age at surgery was 9 months (interquartile range [IQR] 3.3-35.4), and the median stenosis length was 4.0 cm (IQR 3.5-5.4). The most frequent comorbidities were genetic diseases, prematurity, and preoperative intubation. The most common related cardiac comorbidities were pulmonary artery sling, patent ductus arteriosus, atrial septal defect, ventricular septal defect, and tetralogy of Fallot. Most of the patients with CTS exhibited 50% to 80% stenosis. Most of the patients underwent thoracic approach slide tracheoplasty. Airway management was primarily accomplished using an oral or nasal endotracheal tube preoperatively, cardiopulmonary bypass during surgical repair, and an oral or nasal endotracheal tube during closure and the postoperative period. Slide tracheoplasty is an effective treatment for congenital tracheal stenosis. Coordinated airway management between the anesthesia and surgical teams is crucial. Appropriate planning yields the best patient outcomes. 4 Laryngoscope, 2024.

The outcome of nontransecting anastomotic urethroplasty in recurrent bulbar urethral stricture and its impact on sexual functions: A prospective observational study

Purpose: The management of recurrent bulbar urethral stricture had no consensus and faced many challenges such as the risk of failure, ischemia, and sexual dysfunction. Therefore, this study aimed to assess the outcome of nontransecting anastomotic urethroplasty in recurrent bulbar urethral stricture disease (USD) less than 3 cm and its impact on sexual functions. Material and methods: This is a prospective descriptive study that included patients with recurrent bulbar USD ≤ 3 cm. Full history taking and clinical examination, including International Prostate Symptoms Score (IPSS) and International Index of Erectile Function (IIEF-5), were documented. Moreover, retrograde urethrogram, uroflowmetry, and penile Doppler were undergone. The nontransecting urethroplasty techniques were performed: Heineke-Mikulicz principle stricturoplasty for stricture ≤1 cm without excision of the stricture and nontransecting excision and primary anastomosis without transecting the corpus spongiosum for stricture 1 to 3 cm. Each patient was routinely evaluated through a 12-month follow-up using IPSS and IIEF, uroflowmetry, and postvoiding residual urine. Results: Thirty-three patients were included in the study with a mean stricture length of 1.45 ± 0.7 cm. Twelve patients had failed previous urethroplasty, while 21 patients had previous visual internal urethrotomy. Nontransecting excision and primary anastomosis in 14 patients and Heineke-Mikulicz principle stricturoplasty in 19 patients were performed. There was no recurrence of stricture urethra, except for one patient, who required visual internal urethrotomy at a 3-month follow-up, with mean postoperative IPSS of 3.04 ± 2.745, Qmax 23.89 ± 2.714 mL/s, and postvoiding residual urine 26 ± 33 cc. No significant differences were reported between pre- and postoperative IIEF (18.61 ± 5.448 versus 19.33 ± 5.599, respectively, P = 0.236). Conclusion: Nontransecting urethroplasty can achieve a high success rate in short recurrent bulbar USD without the potential sexual morbidity.

Is There a Difference between Intralesional Treatments Combined with Internal Urethrotomy?

This study aimed to compare the efficacy of various injection therapy agents used in combination with internal urethrotomy in preventing fibrosis and stricture recurrence. Patients who underwent direct vision internal urethrotomy (DVIU) in our clinic between 2017 and 2022 were retrospectively screened. The patients were divided into four groups: DVIU + intralesional platelet-rich plasma (DVIU + PRP group, n = 21), DVIU + intralesional mitomycin-C (DVIU + MMC group, n = 21), DVIU + intralesional prednisolone (DVIU + prednisolone group, n = 21), and DVIU alone (control group, n = 21). The length (mm) and diameter (mm) of the recurrent urethral strictures and maximum urinary flow rate (Qmax) on uroflowmetry evaluation were measured at 1, 3, and 6 months postoperatively and compared between the four groups. Urethral stenosis recurred in two (9.5%) patients in the DVIU + PRP group, three (14.3%) in the DVIU + MMC group, seven (33.3%) in the DVIU + prednisolone group, and nine (42.9%) in the control group. The reduction in stenosis recurrence significantly differed between the four groups (p = 0.040). A significant group difference in stenosis length (p = 0.047) but not in stenosis diameter (p = 0.385) was observed in patients with recurrent stenosis. Furthermore, no significant difference in Qmax was found between the groups at 1, 3, and 6 months postoperatively (p = 0.588, p = 0.047, p = 0.067, respectively). Different intralesional treatments combined with internal urethrotomy demonstrate varying efficacy in reducing urethral stricture recurrence. Considering its high success rate, low cost, and reduced side effects, PRP may be the preferred intralesional treatment option in combination with DVIU.

A Mathematical Modeling of Newtonian Blood Flow Through Arterial Mild Stenosis

Mathematical models in health science are usually used to study the blood flow behaviors into the artery. The blood flow through the artery is modeled as an incompressible and homogenous Newtonian fluid, and the flow is assumed to be steady and laminar. Stenosis is an abnormal narrowing in arteries for excess fat deposition that restricts the normal pattern of blood flow through arteries and may cause a heart attack. It is evident that the stenosis in artery may develop due to the accumulation of fat, cholesterol, and abnormal intravascular growth of tissue. The stenosis is to be symmetric about the axis of artery and the flow of blood is axisymmetric. The shear stress has direct proportional relation with both length and height of stenosis. This study uses Navier-Stokes equations in a cylindrical coordinate system and assumes axial symmetry under laminar flow to discuss the blood flow through the mild stenosis artery.

Evaluación de los factores predictivos tras uretrotomía interna endoscópica para estenosis de uretra bulbar

Introduction: Direct vision internal urethrotomy (DVIU) is usually the first treatment offered to patients with bulbar urethral strictures (US). Advances in devices and surgical techniques have contributed to reducing associated complications. Despite the favorable success rate of DVIU, various factors predicting better outcomes have been studied, including patient characteristics, stricture features, and procedural aspects. The main aim of our study is to assess predictive factors for success.Methods: We conducted a retrospective descriptive study of patients who underwent endoscopic internal urethrotomy at our hospital over a 30 year period. Out of 788 DVIU performed, we selected 491 (62.3%) conducted for bulbar US with a minimum follow-up of 12 months. We examined clinical outcomes obtained, and assessed the relationship between different patient characteristics, stricture-related factors and procedural aspects related with clinical success -considered as the avoidance of further interventions for stricture recurrence-. Descriptive statistics were calculated and parametrical and non-parametrical comparative tests were applied. Kaplan-Meier survival analysis was used for evaluating time until recurrence.Results: Mean stricture length was 1.2 cm (SD 0.5), with only 12 patients presenting with more than 1 US in the bulbar area during DVIU. After a median follow-up of 170 months, 67.4% of patients did not experience clinical recurrence. Severe postoperative complications appear in 0.4% of cases, and need for overnight admission was 4.5%. A positive association was observed between clinical recurrence and a history of prior pelvic radiotherapy (OR 2.8, 95%IC 1.3-22.2), active smoking (OR 2.1, 95%IC 1.6-2.4), infectious etiology of stricture (OR 2.3, 95%IC 1.6-8), history of previous urethroplasty (OR 2.5, 95%IC 1.7-3.2), and higher postoperative urinary catheter sizes (OR 1.8 95%IC 1.1-2.9). Median time until recurrence after the first DVIU was 65 months, after the second was 60 months, after the third was 32 months, and after the fourth was 6 months.Conclusions: Bulbar US could be safely managed with DVIU. The best clinical success is achieved in non-irradiated, non-smoker patients, without prior urethroplasties. The repetition of the procedure is significantly associated with a shorter time to clinical recurrence.

Resultado de la preservación de las arterias bulbares durante la uretroplastia anastomótica para la lesión uretral por fractura de pelvis

ObjectiveTo the present long-term outcomes of the vascular-sparing approach during reconstruction of pelvic fracture urethral injuries (PFUI) described by Gomez et al. Material and methodsAnastomotic reconstruction of PFUI is performed without transecting the bulb of the spongiosum, to preserve the antegrade flow of the bulbar arteries. After exposure of the urethra, the bulbar arteries are located using a Doppler stethoscope. The bulb is mobilized dorsally and unilaterally, sacrificing the artery with the weaker Doppler signal to preserve the best contralateral artery. Occasionally, both arteries can be preserved. Removal of all fibrosis and anastomosis is performed as described in the traditional transecting technique. ResultsA total of 60 patients were included, with a mean age of 37years (IQR: 22-48). The median time from trauma to urethral reconstruction was 16weeks, and the mean stenosis length was 2.5cm (IQR: 2-3). The left bulbar artery was preserved in 27cases, the right bulbar artery in 8, and both in 24. There were postoperative complications in 14cases (23%), but only one of them was Clavien ≥III. With a mean follow-up of 56months (IQR: 12-87), only one patient failed due to stenosis (98% success). ConclusionPreservation of antegrade arterial flow to the corpus spongiosum during PFUI reconstruction is feasible and safe. Although slightly more elaborate, this technique could reduce the risk of ischemic failure of reconstruction.

Predictors of urethral stricture recurrence following internal urethrotomy: A systematic review.

To estimate the factors associated with urethral stricture recurrence in patients undergoing internal urethrotomy by direct vision. A systematic review was performed in MEDLINE (Ovid), EMBASE, LILACS, and central databases. Clinical, quasi-experimental, cohort, case-control, and cross-sectional trials were included. The search strategy found 402 studies, and 6 were finally included. All of them were clinical trials. A total of 1723 patients diagnosed with urethral stricture undergoing internal urethrotomy were included. The primary associated factor was the association between the length of stricture and recurrence. Other factors described were post-RTU as etiology, previous interventions for urethral stricture management, and previous Qmax on uroflowmetry less than 5 ml/s. The length of urethral stricture was identified as the leading association with stricture recurrence following internal urethrotomy. Other associated factors were post-URT as etiology, previous interventions for managing stricture, and Qmax less than 5 ml/s. However, studies with better methodology are required.

Streamlined surgical approach for coexistent urethral stricture and benign prostatic enlargement: feasibility, safety and patency results.

To evaluate the technical feasibility, safety, and patency results of a simultaneous surgical approach to repair urethral stricture and treat benign prostatic enlargement endoscopically in a highly selected group of patients at a tertiary referral center. We hypothesize that this is technically feasible, safe, and does not affect urethroplasty outcomes. A retrospective review of adult men who underwent simultaneous urethroplasty and endoscopic prostatic surgery between May 2017 and May 2024 at our institution was conducted. Patients with strictures < 15 French and prostates with adverse prognostic features of response to medical treatment were included. The primary outcome was technical feasibility and safety. The secondary outcome was stricture-free survival. Twenty men were treated during the study period. The median length of the urethral stricture was 3.0cm (IQR 2.0-5.0), and the median size of the prostate was 95.0cc (IQR 63.3-128.3). All patients were treated successfully with a median operative time of 194.5min (IQR 180.0-246.8), and no procedures required conversion to a staged procedure or open prostatectomy. There were seven Clavien-Dindo I-II complications and one Clavien-Dindo IIIb complication (hematuria requiring endoscopic clot evacuation). At 22months follow-up, two cases of urethral re-stricture were diagnosed, with one case requiring redo urethroplasty, though none had previous major complications. The combination of urethroplasty and endoscopic surgery for benign prostatic enlargement at the same stage appears to be technically viable and safe, and it does not compromise medium-term urethral patency results in a carefully selected group of patients.

International expert guidance for defining and monitoring small bowel strictures in Crohn's disease on intestinal ultrasound: a consensus statement

Diagnostic imaging using CT enterography, magnetic resonance enterography, and intestinal ultrasound are important tools in evaluating stricturing Crohn's disease. Definitions of strictures have been developed for CT enterography and magnetic resonance enterography. However, expert recommendations for definitions and treatment response of strictures on intestinal ultrasound are not available. The aim of this study was to standardise definitions, diagnosis, and treatment response criteria in small bowel stricturing Crohn's disease on intestinal ultrasound. Using modified RAND-University of California Los Angeles Appropriateness Method, a diverse expert panel of 13 gastroenterologists, seven radiologists, and two patient representatives was assembled. A total of 466 statements on definitions and response to therapy of stricturing Crohn's disease on intestinal ultrasound were generated from a systematic review and from expert opinion, with subsequent rating for appropriateness. Two rounds of voting with an interposed survey result discussion were performed. Statements were classified as inappropriate, uncertain, or appropriate based on the median panel rating and degree of disagreement. Appropriateness was rated using a nine-point Likert scale (1 being inappropriate, 9 being highly appropriate). A naive or anastomotic small bowel Crohn's disease stricture on intestinal ultrasound is defined by the combination of bowel wall thickening, luminal narrowing, and pre-stenotic dilation. Bowel wall thickness is defined as being more than 3 mm. Luminal narrowing is defined as either a luminal diameter reduction of more than 50% in the narrowest area and relative to a normal adjacent bowel loop, or a luminal diameter of less than 1 cm. Pre-stenotic dilation is defined as more than 2·5 cm or an increase in bowel diameter relative to a normal adjacent bowel loop. Definitions for grading hyperaemia, inflammatory fat, wall stratification, intestinal ultrasound machine technical parameters, and image acquisition were also devised. Treatment response of strictures was defined as reduction in stricture length, bowel wall thickening, luminal narrowing, pre-stenotic dilation, and motility abnormalities. To our knowledge, this is the first intestinal ultrasound appropriateness rating exercise conducted for defining, diagnosing, and measuring response to therapy in small bowel stricturing Crohn's disease and informs future clinical use and intestinal ultrasound index development for clinical trials. Leona M and Harry B Helmsley Charitable Trust.

Management of Ureteral Stricture Disease After Radiation Therapy for Pelvic Malignancies: A Retrospective, Multi-Institutional Analysis.

A radiation-induced ureteral stricture (RIUS) is a challenging condition in urologic surgery, and the optimal surgical strategy is still a matter of debate. The aim of this study was to report post-operative outcomes of minimally invasive management of this condition from a multi-institutional cohort. Data of patients with diagnoses of RIUS at five referral robotic centers between January 2017 and December 2022 were retrospectively analyzed. Pre-, intra- and post-operative variables were collected. Recurrence was defined as the presence of flank pain combined with imaging findings for obstruction, and requiring further management. Univariate and multivariate logistic regression models were built to identify predictors of ureteral stricture recurrence. Fifty-three patients with a diagnosis of an RIUS were included. Primary pelvic malignancy was mostly cervical (42%). In 72% of cases (mostly mid-proximal and short strictures) endourological management was attempted, which was deemed successful in 74% of patients at stent removal. The endourology success rate at a median follow-up of 12 months was 59%. Twenty-five patients (47%) were scheduled for robotic surgery. The reconstructive techniques most often performed were end-to-end anastomosis (44%) and ureteral reimplantation (52%). Three low-grade Clavien-Dindo post-operative complications (12%) occurred. Robotic surgery was successful in all cases except one. Considering the entire cohort, eight patients (15%) developed recurrence at a median follow-up of 5 months. All patients with recurrence were managed by permanent drainage. A statistically significant improvement in eGFR with respect to baseline was found at a median follow-up of 12 months (p = 0.007). The univariate logistic regression model identified ureteral stricture length >2 cm (OR 6.4, 95% C.I. 1.1-36.9, p = 0.04) and concomitant chemotherapy (OR 8.9, 95% C.I. 1.6-49.9, p = 0.01) as predictors of recurrence. At multivariate analysis concomitant chemotherapy was confirmed as an independent predictor of recurrence (OR 7.8, 95% C.I. 1.3-49.0, p = 0.03). Endourological management of an RIUS is reasonable for short and mid-proximal ureteral strictures, while robotics is required in almost all the remaining cases. Up to 15% of recurrence develops within 6 months. Re-do reconstructive surgery is rarely performed, even in referral centers.

Intravascular Lithotripsy for Peripheral Artery Calcification: 30-Day Outcomes From the Disrupt PAD III Observational Study.

Intravascular lithotripsy (IVL) has shown promising safety and effectiveness in calcified peripheral artery disease (PAD) in large trials and small real-world experiences. Real-world evidence from a larger cohort is lacking, so we aimed to evaluate the real-world acute performance of IVL in the treatment of calcified PAD. The Disrupt PAD III Observational Study (OS) is a prospective, multicenter, single-arm study. Patients with claudication or critical limb-threatening ischemia (CLTI) and at least moderate calcification were eligible. Independent predictors of procedural outcomes were assessed by multivariable analysis. Between November 2017 and June 2021 across 30 global sites, 1373 patients with 1677 lesions (1531, 91.3% core lab evaluable) were enrolled. Diameter stenosis and lesion length was 80.6±17.6% and 93.5±74.3 mm, respectively. Target vessels included femoropopliteal (61%), iliac (15.8%), common femoral (10.7%), and infrapopliteal arteries (12.8%). Lesion characteristics included 31.1% chronic total occlusions (CTOs) and 19.3% long lesions (≥15 cm). At final assessment, residual stenosis was 23.8±11.3%, with 0.9% serious angiographic complications, no abrupt closures, distal embolization, no flow, or thrombotic events. Independent predictors of ≤30% residual stenosis were lesion length ≥15 cm (odds ratio [OR]=0.384), female sex (OR=1.850), age ≤75 years (OR=1.625), IVL balloon to artery ratio ≥1.0 (OR=1.538), and CTO lesions (OR=0.638). Lesion length ≥15 cm (OR=16.076) was an independent predictor of procedural complications. The Disrupt PAD III OS represents the largest assessment of IVL periprocedural outcomes in calcified PAD. It confirmed excellent procedural safety and effectiveness in complex lesions across multiple peripheral vascular beds. This final analysis of the PAD III OS represents the largest report of peripheral IVL utilization in daily clinical practice. The outcomes of this study indicate that previously reported procedural results in clinical trial settings can be translated to a broader patient population. Treatment with peripheral IVL in severely calcified stenotic lower limb lesions demonstrated consistent acute safety and stenosis reduction, even in complex patients across multiple vessel beds. In addition, the importance of proper IVL balloon sizing to achieve excellent acute stenosis reduction was confirmed by multivariate analysis.

Single-Port Robotic Ureteroenteric Stricture Repair: A Retrospective Cohort Review.

Introduction The objective of this study is to present a series of 16 cases utilizing single-port robot-assisted repair for ureteroenteric anastomosis stricture (UES). To our knowledge, this is the first case series recorded detailing successful single-port UES revision. Methods A retrospective review of all patients under a single surgeon undergoing single-port robotic revision of ureteroenteric stricture following radical cystectomy with urinary diversion at our institutions from September 2020 through July 2024 was performed. Patient demographics and perioperative outcomes were assessed. Results The study consisted of 3 bilateral ureteroenteric strictures and 13 unilateral strictures, more commonly on the left. Stricture length averaged 2.2 cm on the left and 2.1 cm on the right. Surgeries were performed by a single surgeon using the da Vinci SP surgical system (Intuitive Surgical, Sunnyvale, California, US). The type of stricture repair included excision and primary anastomosis (EPA) with Bricker or Wallace reconstruction or Heineke-Mikulicz (HM) repair, although one case involved the necessity of revision ileocalycostomy. Two of the 16 cases were converted from robotic to open due to extensive adhesions. The average procedure length was 265 minutes (148-440). Length of stay (LOS) ranged from 0-46 days, averaging 4.9 days. There were five postoperative complications encountered including two seromas, two incisional hernias, and an episode of urosepsis. Pre- and postoperative changes in creatinine level ranged from -0.26 to 0.3 mg/dL. No renal units were lost.No patients were readmitted following initial surgical discharge. All patientsreturned for follow-up; none required repeat intervention. Conclusion SP robotic repair of ureteroenteric anastomoses is safe and feasible. The risk of complications is low with a high chance of success and possibly a lower length of stay;more research is warranted.

Does the suturing technique (barbed continuous versus conventional interrupted) impact the outcome of anastomotic urethroplasty?

To evaluate and compare continuous suture (CS) and interrupted suture (IS) techniques applied in excision and primary anastomosis (EPA) urethroplasty in terms of surgical success and complication rates. A retrospective evaluation was conducted on patients with bulbar urethral strictures measuring ≤ 2.5cm who underwent EPA between April 2020 and December 2022. Patients with a history of urethral reconstruction, multiple strictures, a history of pelvic radiotherapy, a diagnosis of Lichen sclerosis, a history of surgery due to congenital penile curvature or Peyronie's disease, and a follow-up period of less than 12months were excluded. The patients were divided into two groups according to the suture technique used (CS or IS), and the groups were compared for demographic and perioperative data. A total of 97 patients (CS n = 52, IS n = 55) were included in the sample. The mean age of the entire patient group was calculated to be 56.2years and the mean stricture length was 19.3mm. Operation time and postoperative catheter time were shorter in the CS group (94.7 ± 7.3 vs. 117.2 ± 5.7min and 9.9 ± 1.6 vs. 15.8 ± 1.9min, p < 0.001, respectively). The groups were similar regarding anatomical success, stress urinary incontinence, penile numbness, curvature, and postoperative infection (p > 0.05). No significant difference was observed in terms of success or complications between the CS and IS techniques employed during EPA urethroplasty. However, in addition to reducing the operation time, the CS technique offers the advantage of safely removing the urethral catheter earlier.

Safety and efficacy of thermo-expandable metallic stent in ureteral stricture following gynecological malignancy surgery and radiotherapy: a single center experience with 33 cases.

The effectiveness of metallic stents in treating ureteral strictures following surgery and radiotherapy for gynecological tumors is currently uncertain. We aimed to investigate the efficacy and safety of thermo-expandable metallic stent (Memokath) in the treatment of ureteral stricture after radiotherapy for gynecological tumors. In this descriptive cross-sectional study, 27 patients with ureteral stricture were treated with Memokath stent after gynecological tumor radiotherapy with or without chemotherapy that was admitted to our hospital from August 2021 to August 2023. Clinical data on efficacy, safety, and complications during stent insertion and indwelling were analyzed. The successful insertion of thirty-three stents in twenty-seven patients studied. The stenosis length was 10.14 ± 6.76cm, and the hospitalization was 4.43 ± 1.83 days. One patient has died from the primary disease carrying a patency stent. The Kaplan-Meier graph showed that the cumilative patency rate of patients with thermo-expandable metallic stent were 92.4% (SD = 5.2%) in eight months, 77.4% (9.1%) in 12 months and 67.7% (SD = 12%) in 29 months, while the cumilative survival rate was 87.5% (SD = 11.5%) in 29 months. The stent patency was 81.48% and later complications of stent indwelling were 5/27, including refractory urinary tract infection (UTI) in three cases, stent migration, and stent intolerance respectively. The creatinine levels, hydronephrosis degree, and glomerular filtration rate improved after the operation, and the first two indicators were statistically significant. Memokath stent is a safe and effective treatment for ureteral stricture after surgery and radiotherapy with or without chemotherapy for gynecological tumors.

A decade's experience of robotic buccal ureteroplasty for post ureteroscopic laser lithotripsy induced strictures—Should this be the new standard?

ObjectiveTo present the surgical technique of robotic buccal ureteroplasty for strictures after laser lithotripsy and its outcomes. MethodsThis was a retrospective study conducted at the Department of Urology at Apollo Hospitals, Chennai, India from October 2012 to October 2022. Indications for surgery included worsening hydronephrosis, declining renal function, and recurrent urinary tract infections with obstruction. Apart from liberal exposure of the stricture, we stress upon the use of indocyanine green to assess vascularity and quilting of the graft to bare area of psoas muscle to increase the graft vascularity. ResultsAmong the 15 patients, ureteropelvic junction strictures were observed in eight (53.3 %), while five (33.3 %) had proximal stricture, and two (13.3 %) had mid-ureteral stricture. Notably, eight of the 15 (53.3 %) patients had previous unsuccessful double-J stenting. The median stricture length was 3.5 cm (range: 2–5 cm), with a mean operative time of 167 min (range: 126–214 min) and estimated blood loss of 140 mL (range: 40–200 mL). After a median follow-up of 12 months (range: 4–32 months), 13 out of 15 (86.7 %) patients showed significant improvement in their follow-up functional scans. ConclusionRobotic buccal ureteroplasty is a very effective technique for the management of laser-induced ureteral strictures with good long-term results and minimum morbidity. The results are comparable irrespective of previous failed stenting.