Fossa Navicularis Research Articles

Giant Fossa Navicularis Calculus with Urethro-Cutaneous Fistula and Renal failure

Urethral calculus is a rare form of urolithiasis with an incidence lower than 0.3%. Most of urethral calculus present in posterior urethra, few in anterior urethra and only 4-11% found at fossa navicularis. Urethral calculi usually results from migration from bladder, upper tract or it may arise de novo. We report a 56-years old male with a large fossa navicularis stone leading to urethro-cutaneous fistula and renal failure. The patient underwent meatotomy, stone extraction and primary repair of urethro-cutaneous fistula.

Author Reply

Although we have traditionally performed a classic Bracka 2-stage urethroplasty for obliterative strictures, the hybrid approach to an isolated obliterated fossa navicularis and distal penile stricture with a 2-stage of the distal aspect and 1-stage approach for the remaining proximal stricture is an appealing option and should be considered. We agree that this has the advantage of using less overall graft than if a longer 2-stage approach would otherwise have been performed. This further illustrates the highly variable severity of disease in this group of patients, and the number of reconstructive techniques required for optimal patient outcomes.

047 Recovery of Glans Sensation Following Combined Dorsal and Ventral Onlay with a Glans Splitting Technique for Strictures of the Fossa Navicularis

047 Recovery of Glans Sensation Following Combined Dorsal and Ventral Onlay with a Glans Splitting Technique for Strictures of the Fossa Navicularis

V12-01 TRANSURETHRAL VENTRAL BUCCAL MUCOSA GRAFT (BMG) INLAY URETHROPLASTY FOR DISTAL URETHRAL STRICTURES

You have accessJournal of UrologyReconstruction1 Apr 2016V12-01 TRANSURETHRAL VENTRAL BUCCAL MUCOSA GRAFT (BMG) INLAY URETHROPLASTY FOR DISTAL URETHRAL STRICTURES Mourad Abouelleil, Michael Daneshvar, and Dmitriy Nikolavsky Mourad AbouelleilMourad Abouelleil More articles by this author , Michael DaneshvarMichael Daneshvar More articles by this author , and Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2127AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Traditional options for distal urethral stricture repair involve penile skin incision to achieve access to urethra for various forms of external urethrotomy and subsequent repair with flaps or grafts. These incisions then require meticulous closure and are at risks of fistula formation, glans dehiscence and poor cosmetic outcomes. We introduce a novel surgical technique to repair fossa navicularis stricture without a need for skin incision. Our approach, a modified Naude technique, employs a ventral internal urethrotomy and precise transurethral delivery and fixation of BMG to the surface of the urethrotomy. METHODS Surgical technique: a ventral urethrotomy is performed transurethrally and a shallow wedge of the obstructive tissue is removed to achieve access to a proximal patent lumen. Appropriate size BMG is then harvested and prepared for delivery. A double arm 6-0 polydioxanone suture is used: each arm of the suture is passed through the proximal apex of the graft then through the urethra at the proximal apex of the urethrotomy and externalized through the skin. By pulling on the arms of the suture externally the graft is delivered precisely into its place in the urethra. Additional 6-0 double armed sutures are used to quilt the graft at its mid portion and their knots tied externally. The distal edge of the graft is sutured to the edge of the meatotomy with absorbable sutures. A retrospective chart review was conducted of all the patients after a fossa navicularis/ distal urethral stricture repair since March 2014 by a single surgeon (DN). Surgical and functional outcomes including complications were reviewed. Uroflow and SHIM scores were evaluated pre- and post-operatively. RESULTS This surgery was performed for 7 patients including 3 circumcised males, 2 uncircumcised males with lichen sclerosus (LS) and 2 transgender patients with neophallus. Mean patient age was 39 years (25-55), mean stricture length 2.6 cm (1-4). At a mean follow up of 8.8 month (4-18), there were no stricture recurrences, fistula, penile chordee or adverse effects on sexual function. Mean uroflow pre-op was 5.5 (0-13), post-op 22 (16-37). SHIM score pre-op 19 (23-25), post-op 23 (22-25). CONCLUSIONS We demonstrated the feasibility of incisionless distal urethral/fossa navicularis stricture repair with ventral inlay BMG. This single stage technique allows avoiding skin incision or urethral mobilization. It prevents glans dehiscence or fistula formation. It avoids the use of genital skin flaps in patients affected with LS and is a viable option for patients with distal strictures in a neophallus. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1066 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Mourad Abouelleil More articles by this author Michael Daneshvar More articles by this author Dmitriy Nikolavsky More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Clival Osteomyelitis with Retropharyngeal and Epidural Abscesses in a Child

Purpose: Osteomyelitis of the clivus is a rare, life threatening infection in children and can develop from adjacent sinonasal and temporal bone infection. It has been postulated that patients with congenital anomalies of the clivus including fossa navicularis may be at increased risk for extension of nasopharyngeal infections into the clivus. This is the first report describing association with both intracranial and retropharyngeal collections.

Morphological variations in the basioccipital region of the South Indian skull

Background: The craniovertebral junction is a transitional region of spine that exhibits extensive structural variability. Variations of basiocciput are of interest for anatomists and clinicians because they produce clinical symptoms or lead to misinterpretations of radiological images.Materials and Methods: The study was conducted on 202 dry human skull bone (12 occipital bone and crania 190) belonging to south Indian population for variations of basiocciput over a period of six years.Results: Prevalence of hyperostotic variants was significantly higher than hypostotic variants in present study. Most common type observed was of precondylar tubercle (2.48%) followed by fossa navicularis (1.49). The prevalence of other variations such as prebasioccipital arch, third occipital condyle, exostosis and basioccipital cleft was similar (0.5%) in the study population.Conclusions: These cranio-vertebral anomalies will be useful not only to anatomists, radiologists and surgeons while dealing with base of the skull and basiocciput in particular but also to study anthropological significance and may guide the future researchers in comparative human anatomy.Nepal Journal of Medical Sciences Vol.3(2) 2014: 124-128

Dorsal Island Penile Fasciocutaneous Flap for Fossa Navicularis and Meatal Strictures: Short and Intermediate Term Outcome in West African Men.

The aim of this study was to evaluate the use of a dorsal island penile fasciocutaneous flap in the man­agement of resistant fossa navicularis strictures in circumcised West African men. From January 2004 to December 2013 there were twenty-one patients with fossa navic­ularis strictures (FNS) with or without meatal stenosis who underwent urethroplasty using a previously described technique and a dorsal island penile fasciocutaneous flap. The average patient follow-up was 25.9 months. Urethral catheterization was the most common cause of FNS. All of the patients had successful urethral function and acceptable cosmetic results. One patient had partial dorsolateral skin necrosis that healed with con­servative measures. All patients, including the five patients with meatal stenosis, retained the natural shape of the external meatus and had a natural urine stream. The penile cap technique uses a dorsal island fasciocutaneous flap and provides satisfactory function­al and cosmetic outcomes in the management of fossa navicularis and meatal strictures.

A Review of Lesions of the Posterior Fourchette, Posterior Vestibule (Fossa Navicularis), and Hymen.

Lesions specific to the posterior fourchette, posterior vestibule (fossa navicularis), and hymen are reviewed. Knowledge of these regional lesions will be helpful if such a patient is encountered.

Author reply on: Relationship between development of urethral stricture after transurethral resection of prostate and glycemic control.

Sir, We have read the original article titled “relationship between development of urethral stricture after transurethral resection of the prostate and glycemic control.” by Kumsar et al.[1] with great interest. Incidence of post transurethral prostatectomy (TURP) stricture of urethra varies between 4% and 10%.[2] We would like to congratulate the authors for trying to find a new etiologic factor for post-TURP stricture. However, we would like to bring to the notice of authors that postoperative infection is most important factor in post-TURP stricture.[3] Study groups were not compared for postoperative infection and poor glycemic control being a risk factor for infection it can be an indirect cause leading to urethral stricture. Post TURP strictures occur at navicular fossa, penobulbar junction and proximal bulbar urethra which is most common site. Case distribution according to the site of stricture is not given. The site of stricture has a bearing on the time to presentation and time to internal urethrotomy so each group should be subdivided according to location of the stricture. The relationship between post-TURP strictures and preoperative glycemic control needs to be proven in a prospective study taking into account above mentioned factors with those studied by authors.

English

BACKGROUND: Previously retrograde urethrography and micturating cystoure- thrography were used for the evaluation of urethral strictures. Lack of radiation, ability to assess of mucosal and periurethral abnormality and more precise measurement of stricture length makes the sonourethrography an alternative to conventional urethrography. In this article we had reported our experience regarding sonourethrography in cases of anterior urethral strictures. OBJECTIVES: Role of sonourethrography in evaluation of anterior urethral abnormalities (especially strictures), Staging and grading of anterior urethral strictures. To compare the utility of sonourethrography as compared to conventional retrograde urography. Role of sonourethrography in diagnosis, management and follow-up of anterior urethral disorders (especially strictures). MATERIAL AND METHOD: 70 male patients with obstructive urinary symptoms reffered from urology department for retrograde urethrography were selected. Sonourethrographic studies were performed using high frequency probe while injecting saline solution through 12 F Foley's catheter with bulb inflated in the fossa navicularis. Findings were compared with retrograde urethrography and urethroscopy. RESULT: Out of total 70 patients who underwent sonourethrogram, 33 patients were diagnosed to have 39 strictures. Out of these 39 strictures, 2 strictures were mild (5.12%), 16 were moderate (41.02%) and 21 were severe (53.84%). 20 strictures were short (focal) while 13 were long (diffuse). One patient had 3 large urethral calculi within the urethral lumen area which were visualised on sonourethrogram. These 39 strictures were also classified under five grade classification proposed by Chiou et al. Of these 39 strictures, 2 classified as GRADE I (5.12%), 6 classified as GRADE II (15.38%), 11 classified as GRADE III (28.20%), 4 classified as GRADE IV (10.25%), 16 came under GRADE V (41.02%). CONCLUSION: Sonourethrography can be used as an alternative to retrograde urethrography in the diagnosis of urethral disorder, characterization of urethral strictures and

Anterior Urethral Valve and Diverticulum in a Neonate with Urinary Tract Infection

Introduction:Anterior urethral valve (AUV) is a rare congenital anomaly that can cause obstructive uropathy. AUV can lead to variable urinary tract symptoms, and if left untreated, it can result in end-stage renal disease. AUV should be immediately evaluated and managed. Herein, we present a neonate with AUV and diverticulum, who was treated by cystoscopy. Case report:A 11-day-old boy was referred to the nephrology department for evaluation of urinary tract infection, which was developed 2 days prior to admission. Pregnancy and routine ultrasound (US) were normal, and urinalysis showed pyuria. Routine investigations included blood urea nitrogen, serum creatinine, electrolyte panel, urine analysis (UA), and urine culture (UC). Abdominal US examination displayed a normal bladder with normal kidneys. A voiding cystourethrogram (VCUG) showed an anterior urethra diverticulum with dilation of the proximal urethra and trabeculated bladder; however, no vesicoureteral reflux was observed. Finally, the patient underwent endoscopy. Discussion: AUV is a congenital mucosal fold, located distally to the membranous urethra. AUV can be located anywhere distal to the membranous urethra and is found in bulbar urethra (40%), penoscrotal junction (30%), pendulous urethra (30%), and occasionally in the fossa navicularis, respectively. The exact etiology of this disease is unclear. AUV with associated diverticulum is a rare congenital urethral anomaly that can lead to penile swelling, urethral obstruction, urinary retention, incontinence, nocturnal enuresis, bladder rupture, and end-stage renal disease. Depending on the severity of anatomical obstruction, this condition may present soon after birth or later during childhood. VCUG is the most important imaging technique for the evaluation of urethral abnormalities. Congenital AUV in children has a generally good prognosis, but may occasionally result in poor renal outcomes such as renal insufficiency, renal failure, and patient‘s death.

Management of advanced primary urethral carcinomas

Primary urethral carcinoma (PUC) is a rare malignancy accounting for <1% of genitourinary cancers, with a predilection for men and African-Americans. The sites and histology of urethral carcinoma vary by gender and anatomical location. Squamous cell carcinoma is most common among both genders but adenocarcinomas are noted in 15-35% of cases among women. Obstructive or irritative symptoms and haematuria are common modes of presentation. Clinical evaluation includes cystourethroscopy with biopsy and examination under anaesthesia. Magnetic resonance imaging provides a highly effective method to image the primary tumour while defıning the potential involvement of surrounding structures. Most tumours are localised, with regional metastases to nodal sites seen in up to 30% of cases in both genders, while distant metastases at presentation are rare (0-6%), but occur in up to 40% of cases with recurrent disease. Among men, the two most important prognostic factors are disease location and stage. Low-stage tumours (T1-2) and tumours involving the fossa navicularis or the penile urethra have a better prognosis than higher stage tumours (>T2 or N+) and lesions involving the bulbomembranous urethra. In women, in addition to stage and location, the size of the tumour has also prognostic implications. While surgery and radiation therapy (RT) are of benefit in early stage disease, advanced stage PUC requires multimodal treatment strategies to optimise local control and survival. These include induction chemotherapy followed by surgery or RT and concurrent chemoradiation with or without surgery. The latter strategy has been used successfully to treat other human papillomavirus-related cancers of the vagina, cervix and anus and may be of value in achieving organ preservation. Given the rarity of PUC, prospective multi-institutional studies are needed to better define the optimal treatment approach for this disease entity.

V2-06 RECONSTRUCTION OF THE STRICTURES OF FOSSA NAVICULARIS AND URETHRAL MEATUS BY USING TRANSVERSE ISLAND FASCIOCUTANEOUS PENILE FLAP (TIFP) WITH THE GLANS CAP TECHNIQUE

INTRODUCTION AND OBJECTIVES: Urethral strictures involving the fossa navicularis and external meatus require the reconstruction of both a functional and a cosmetic outlet. We describe our experience with ventral TIFP in the management of distal urethral strictures. METHODS: Between 1997 and 2012, 46 men (mean age: 54 years) with distal urethral strictures confined to the fossa navicularis and urethral meatus underwent ventral TIFP urethroplasty with the glans cap technique. The etiology of the stricture was iatrogenic in 40 (transurethral resection of the prostate or bladder tumor) and inflammatory/ idiopathic in 6. All except 4 patients had undergone multiple previous urethral dilatations. Preoperative evaluation included uroflowmetry with residual urine volume determination, retrograde urethrography (RU) and voiding cystourethrography (VCUG), and urethrocystoscopy with a pediatric ureterorenoscope. During surgery, a subcoronal incision was made on the ventral penile skin and carried down through Buck’s fascia until the urethra. Fossa navicularis and meatus were exposed by dissecting the urethra under the glans. The strictured urethra was then incised ventrally, including the meatus. A ventral fasciocutaneous island flap was mobilized and anastomosed to the edges of the urethral incision, augmenting the urethra to admit a 24-26F sound without difficulty. Urethral catheter was removed after 2 weeks. Patients were followed for obstructive symptoms and 3 monthly uroflowmetric studies in the first year and annually thereafter. Cure was defined as patient satisfaction and the absence of any restenosis requiring additional intervention. RESULTS: Stricture length ranged between 7 to 25 mm. Mean operation time was 50 min. Flap necrosis developed in one patient with subsequent fistula formation. Cure was achieved in 43 (93.4%) men at a mean follow-up of 78 months (range: 3-144). The procedure failed in 2 patients due to lichen sclerosus, which was diagnosed after the recurrence and managed with a 2-stage buccal mucosa graft urethroplasty. The mean Qmax was increased from 7.2 ml/sec preoperatively to 19.4 ml/sec at the last follow-up visit (p1⁄40.001, Wilcoxon sign test). CONCLUSIONS: TIFP is an effective technique for the reconstruction of urethral strictures involving the fossa navicularis and external meatus. It restores a functional and cosmetic outcome with preservation of the glandular integrity. Inflammatory genital skin diseases must be carefully evaluated before surgery to achieve optimum success with this technique.

V2-03 THE MALONE MEATOPLASTY: A DORSAL APPROACH TO MEATAL STENOSIS IN PATIENTS WITH LICHEN SCLEROSUS

INTRODUCTION AND OBJECTIVES: The treatment of meatal stenosis associated with lichen sclerosus is traditionally treated either by meatal dilatation or ventral meatotomy. These operations have high recurrence rates or create a hypospadiac meatus. We present an established technique in the use of a dorsal approach. METHODS: Initially a small ventral meatotomy is performed. The epithelium of the urethra and glans is opposed with 3, 6-zero polyglactin (PG) sutures. This acts to widen the meatus slightly without making it hypospadiac but more importantly it allows the insertion of forceps to assess and ensure that the stricture does not extend significantly into the navicular fossa. Next a deeper dorsal meatotomy is performed. Again the epithelium of the urethra/glans are opposed. The combination of small ventral and deeper dorsal meatotomies should completely open the stenosed meatus but the cosmetic appearance at this stage is poor since the sutures of the dorsal meatotomy pucker the glans due to the thickness of the corpus spongiosum. This is overcome by an inverted V-shaped relieving incision with the apex of the V close to the proximal limit of the dorsal meatotomy. The edges of the relieving incision are freed by sharp dissection. The opposing left and right inner edges are closed with continuous PG to form the roof of the distal neourethra. The outer glans layer is opposed with interrupted PG. RESULTS: The final result is a slit-like but good calibre meatus at the tip of the glans. CONCLUSIONS: During a follow-up of 4.2 years there were recurrences in 6/116 patients, 5 of whom required re-operation (4.3%). 93% patients were either happy or very happy with the cosmetic result. Conclusion: This technique can achieve excellent aesthetic results, with low incidence of a spraying stream.

MP13-01 THE MALONE MEATOPLASTY FOR PURE MEATAL STENOSIS ASSOCIATED WITH LICHEN SCLEROSUS: RESULTS OF AN INTERNATIONAL, MULTICENTRIC STUDY

INTRODUCTION AND OBJECTIVES: The treatment of pure meatal stenosis associated with lichen sclerosus (LS) is traditionally treated either by meatal dilatation or ventral meatotomy. These operations have a high recurrence rate and/or create a hypospadiac meatus. We present a well established operation in the use of a dorsal approach first described by the senior author in 2004. METHODS: 116 consecutive patients with stenosis of the external urinary meatus underwent a Malone meatoplasty in between 1989-2011. Mean age was 40.5 years (range 4-87 years). Range of follow up was between 6 weeks and 21 years (mean 4.2 years). Patients were followed up by questionnaire. The questionnaire ascertained if the patients were happy with the post-operative cosmetic appearance, if he sprayed when he passed urine and if so to what extent. RESULTS: 90 (78%) patients responded to a questionnaire. There were recurrences in 6 patients, 5 of whom required re-operation (4.3%). 93% patients were either happy or very happy with the cosmetic result. 87% patients never sprayed or sprayed only occasionally. Of those who sprayed only 2 patients described it as severe, one of whom had declined circumcision and had progressive LS of his foreskin. CONCLUSIONS: These results confirm that the Malone meatoplasty reliably relieves pure meatal stenosis in the long term. It is reproducible and can be performed under local anaesthetia. It can achieve excellent aesthetic results, with a low incidence of a spraying stream. Given these findings, it is not justified to perform more complex urethroplasties for strictures that do not involve the navicular fossa. Equally it seems better to perform this meatoplasty as the primary procedure rather than as salvage after failed meatal dilatation or ventral meatoplasty.

Unusual cause of urethral bleeding in an adolescent: a case in dilemma

Numerous cases of self-inflicted foreign bodies in the male urethra have been reported. A case of a self-inflicted urethral injury or hemangioma in an adolescent that presented a dilemma is described here. An adolescent male of 14 years presented with a complaint of intermittent urethral bleeding for a week. He attributed this to blunt trauma sustained while playing in school. On examination, there was no sign suggestive of any trauma or any abnormal lesion on the genitalia or surrounding area. On cystourethroscopy, there was a solitary hemorrhagic lesion of 0.5 cm with a bluish base on the ventral surface of the pendular urethra, 1 cm proximal to the fossa navicularis, which was ablated using Ho:YAG laser fiber (365 μm) through a working channel mounted in an OIU (optical internal urethrotomy) sheath. The absence of any sign of external trauma or presentation after 1 week of the incident suggests an element of falseness in the history. It may be due to embarrassment or fear, which contributes to self-insertion of foreign bodies into the urethra as the primary cause, especially in adolescent males. However, the trauma can be coincidental, with the bleeding of the urethra caused by a urethral lesion like a hemangioma and might present after a long gap of 1 week due to a lack of understanding or lack of severe symptoms. Most patients of self-inflicted injuries are too ashamed to admit that they inserted any object. A psychiatric evaluation is recommended for all these adolescents, with appropriate medical therapy when indicated.

Single stage ventral onlay buccal mucosal graft urethroplasty for navicular fossa strictures

Introduction:The correction of fossa navicularis strictures poses a distinct reconstructive challenge as it requires attention to cosmesis, in addition to urethral patency. Different graft and flap based repairs have been described with variable success rates. However, the ideal management remains unclear. The feasibility and efficacy of a single stage ventral onlay buccal mucosa graft urethroplasty (VOBMGU) for navicular fossa strictures (NFS) was evaluated in the present study.Subjects and Methods:All patients with NFS attending urology out-patient department from March, 2009 onward accepting VOBMGU were evaluated prospectively. Patients with minimum 1 year of follow-up were included for analysis. The technique involves opening the diseased stenosed meatus ventrally up to the corona. The diseased mucosa is excised leaving a midline strip of native urethral mucosa on the dorsal side. The buccal mucosal graft (BMG) is fixed on either side of this strip over a 24 Fr. silicone catheter. The glans wings are apposed in midline taking anchoring bites on the mucosal graft ventrally. Post-operatively patients were reviewed at 1, 3, 6 and 12 months and annually thereafter. Cosmetic acceptance and splaying of the urinary stream was assessed with individual questionnaires.Results:A total of six patients underwent VOBMGU. Average flow rate at 3 months post-operatively was 12 ml/s. The end result was cosmetically highly acceptable. There was no fistula in any of the cases. With a median follow-up of 37 months, only one patient had a recurrence of stricture in a proximal site.Conclusions:VOBMGU is a viable technique for reconstruction of NFS with promising short term results. However, long-term follow-up is necessary.

Multiple urethral stones causing penile gangrene.

Penile urethral stones are a rare occurrence resulting from a number of causes including migration of stones within the urinary tract, urethral strictures, meatal stenosis, and obstructing tumours such as adenomatous metaplasia of the uroepithelium, hypospadias, urethral diverticulum, and very rarely primary fossa navicularis calculi. We report the case of a 54-year-old male presenting with penile gangrene and sepsis resulting from impaction of multiple stones within the penile urethra. This paper summarises the topic and discusses the pathophysiology of this unusual condition.

The Lowinger probe to remove a spherical foreign body at the cricopharyngeus

Fossa navicularis magna is a congenital anomaly representing persistent dehiscence of the basiocciput. This tract from the nasopharynx to the brain is common and carries a potential risk for infection. Nevertheless reports on such dissemination are very rare. We present a child with brain infection via a fossa navicularis magna, the first description to our knowledge, and review the literature on this anomaly.

An intracranial complication of acute isolated sphenoid sinusitis

Fossa navicularis magna is a congenital anomaly representing persistent dehiscence of the basiocciput. This tract from the nasopharynx to the brain is common and carries a potential risk for infection. Nevertheless reports on such dissemination are very rare. We present a child with brain infection via a fossa navicularis magna, the first description to our knowledge, and review the literature on this anomaly.