Obliterative Strictures Research Articles

Mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty: a ventral modification for obliterative strictures.

To present a surgical modification for the repair of bulbar urethral strictures containing short, highly obliterative segments and report on long-term objective and patient-reported outcomes. We considered patients undergoing bulbar buccal mucosal graft urethroplasty (BMGU) between July 2016 and December 2019. Eligibility criteria for mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty were strictures of ≥2 cm with an obliterative segment of ≤1.5 cm. The stricture is approached ventrally to avoid extensive dissection and mobilisation. Dorsally, the scar is superficially excised and the spongiosum is left intact. Dorsal mucomucosal anastomosis is complemented by ventral onlay graft. Perioperative characteristics were prospectively collected including uroflowmetry data and validated patient-reported outcome measures on voiding, erectile, and continence function. We evaluated functional follow-up, incorporating patient-reported (lower urinary tract symptoms [LUTS] score) and functional success. Recurrence was defined as need of re-treatment. Of 641 men treated with anterior BMGU, 54 (8.4%) underwent MANTA urethroplasty. Overall, 26 (48%) and 45 (83%) had a history of dilatation and urethrotomy, respectively, and 14 (26%) were redo cases. Location was bulbar in 38 (70%) and penobulbar in 16 patients (30%), and the mean (SD) graft length was 4.5 (1.4) cm. At a median (interquartile range) follow-up of 41 (27-53) months, the functional success rate was 93%. Whereas the median LUTS score significantly improved from baseline to postoperatively (13 vs 3.5; P < 0.001), there was no change in erectile function (median International Index of Erectile Function - erectile function domain score 27 vs 24) or urinary continence (median International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form sum score 0 vs 0; all P ≥ 0.4). All patients were 'satisfied' (27%) or 'very satisfied' (73%) with the outcome of their operation. With excellent long-term objective and patient-reported outcomes, MANTA urethroplasty adds to the armamentarium for long bulbar strictures with a short obliterative segment.

The Efficacy and Safety of a Conservative Management Approach to Radiation-Induced Male Urethral Strictures in Elderly Patients With Comorbidities

Objectives To assess the outcomes of a conservative management approach to radiation-induced urethral stricture disease (R-USD) in an elderly population with comorbidities. Methods Patients with R-USD managed with endoscopic procedures and/or clean intermittent catheterization (CIC) between 2007 and 2019 were included. Patients were excluded if they had an obliterative stricture, prior urethral reconstruction/urinary diversion surgery, or &lt; 3 months follow-up. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, uroflowmetry/post-void residual, and urinary incontinence (UI). Failure was defined as progression to reconstructive surgery or permanent indwelling catheterization. Results Ninety-one men were analyzed with a median follow-up of 15.0 months (IQR 8.9 to 37.9). Median age was 75.4 years (IQR 70.0 to 80.0), body mass index was 26.5 kg/m2 (IQR 24.8 to 30.3), and Charlson comorbidity index was 6 (IQR 5 to 8). Median stricture length was 2.0 cm (IQR 2.0 to 3.0). Stricture location was bulbar (12%), bulbomembranous (75%), and prostatic (13%). A total of 90% underwent dilation, and 44% underwent direct visual internal urethrotomy (DVIU). For those that underwent these procedures, median number of dilations and DVIUs per patient was 2 (IQR 1 to 5) and 1 (IQR 1 to 3), respectively. Forty percent used CIC. Thirty-four percent developed a UTI, and 15% had an AUR episode requiring urgent treatment. Creatinine values, uroflowmetry measurements, and UI rates remained stable. Eighty percent avoided reconstructive surgery or indwelling catheterization. Conclusion Most elderly patients with comorbidities with R-USD appear to be effectively managed in the short-term with conservative strategies. Close observation is warranted because of the risk of UTIs and AUR. The potential long-term consequences of repetitive conservative interventions must be considered.

Double-face urethroplasty in patients with obliterative bulbar strictures post-transurethral resection of the prostate mid-term outcomes in high-volume referral center

ObjectiveIncidences of post-transurethral resection of the prostate (post-TURP) strictures are between 2.2% and 9.8%. Stricture commonly occurs within the first 6 months. Our objective was to assess the outcomes of patients with obliterative strictures post-TURP that underwent a double-face urethroplasty. MethodsThis is a single-center prospective study of 17 patients with obliterative proximal bulbar stricture post-TURP who underwent double-face graft urethroplasty by two surgeons between January 2014 and January 2020. We defined post-TURP obliterative strictures as those patients who presented with complete or almost complete obstruction of the urethral lumen and who have had a history of acute urine retention. We have excluded patients with bladder neck contracture. Primary outcome was treatment success, defined as the no need for further treatments. Secondary outcome was post-urethroplasty continent rate. ResultsSeventeen patients were included in the study with median age of 66 (interquartile range 40–77) years; median time of follow-up was 24 (interquartile range 12–84) months; median stricture length was 4 (interquartile range 2–6) cm. Of the 17 patients, 15 (88.2%) were successful. All patients were continent after urethroplasty. ConclusionWith mid-term follow-up, treatment of obliterative proximal bulbar strictures with double-face buccal mucosa graft is a safe and effective procedure. Obliterative proximal bulbar strictures merit double-face urethroplasty with high-rate success and functional outcomes.

V10-07 URETHROPLASTY WITH ILEAL FREE FLAP

You have accessJournal of UrologyLower Tract Reconstruction (V10)1 Sep 2021V10-07 URETHROPLASTY WITH ILEAL FREE FLAP Alice Drain, Nabeel Shakir, Jordan Frey, Min Suk Jun, Jamie Levine, and Lee Zhao Alice DrainAlice Drain More articles by this author , Nabeel ShakirNabeel Shakir More articles by this author , Jordan FreyJordan Frey More articles by this author , Min Suk JunMin Suk Jun More articles by this author , Jamie LevineJamie Levine More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002061.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Salvage urethroplasty of a recurrent urethral stricture presents a technical challenge. Our objective is to present the evaluation, surgical approach and outcomes of urethral reconstruction with ileal free flap. METHODS: We present a 35 year old male with obliterative stricture which was repaired with ileal free flap urethroplasty. The patient had previously undergone multiple endoscopic and open attempts including excision and primary anastomosis, buccal mucosa, gracilis flap and split thickness skin flap and perineal urethrostomy with recurrence. Reconstruction with ileal free flap was performed with success. The medical record and intraoperative photographs and video were reviewed to create this presentation. RESULTS: Urethroplasty with ileal free flap was successfully performed. At seven months post-operatively the patient reported normal erections and strong stream with low post void residual. CONCLUSIONS: Reconstruction of extensive urethral stricture after failed endoscopic and open attempts can be successfully accomplished with the use of an ileal free flap urethroplasty. Source of Funding: No funding © 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 Alice Drain More articles by this author Nabeel Shakir More articles by this author Jordan Frey More articles by this author Min Suk Jun More articles by this author Jamie Levine More articles by this author Lee Zhao More articles by this author Expand All Advertisement Loading ...

PD22-06 A MODIFIED APPROACH TO MEDIUM-LENGTH OBLITERATIVE BULBAR STRICTURES: TECHNIQUE AND OUTCOMES OF THE MUCOMUCOSAL ANASTOMOTIC NON-TRANSECTING AUGMENTATION (MANTA) URETHROPLASTY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II (PD22)1 Sep 2021PD22-06 A MODIFIED APPROACH TO MEDIUM-LENGTH OBLITERATIVE BULBAR STRICTURES: TECHNIQUE AND OUTCOMES OF THE MUCOMUCOSAL ANASTOMOTIC NON-TRANSECTING AUGMENTATION (MANTA) URETHROPLASTY Phillip Marks, Roland Dahlem, Maryam Khonsari, Lennart Kühnke, Frederik König, Margit Fisch, and Malte W. Vetterlein Phillip MarksPhillip Marks More articles by this author , Roland DahlemRoland Dahlem More articles by this author , Maryam KhonsariMaryam Khonsari More articles by this author , Lennart KühnkeLennart Kühnke More articles by this author , Frederik KönigFrederik König More articles by this author , Margit FischMargit Fisch More articles by this author , and Malte W. VetterleinMalte W. Vetterlein More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002011.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: For short and obliterative bulbar strictures, non-transecting excision and primary anastomosis (EPA) has come of age to avoid disrupting spongiosal blood flow. Longer obliterative strictures may be treated by a combined "double" ventral + dorsal graft (Palminteri et al. 2008) or an augmented anastomotic approach, which was recently refined by a non-transecting technique combining EPA and a dorsal graft (Welk et al. 2012; Bugeja et al. 2016). We here present the initial experience with our ventral modification of this technique, the mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty. METHODS: We included patients with an obliterative bulbar segment (≤2 cm) and mild to moderate spongiofibrosis undergoing MANTA between 2016-2019. The stricture is approached by ventral stricturotomy to avoid extensive urethral dissection and mobilization from the corpora cavernosa. Dorsally, the scar is superficially excised and the spongiosum is left intact. Dorsal mucomucosal anastomosis (excluding sponge tissue) is performed, which is complemented by a ventral onlay buccal mucosal graft. Perioperative characteristics were prospectively collected including uroflowmetry data and validated PROMs (6-item LUTS score of the USS PROM). We evaluated the postoperative improvement of objective (uroflowmetry at three weeks postoperatively) and functional follow-up, which incorporated patient-reported parameters (LUTS score) and functional success, whereas recurrence was defined as the symptomatic need of any re-intervention. RESULTS: Median age in 54 men undergoing MANTA was 51 yr, 83% and 26% had a history of ≥1 urethrotomy and urethroplasty, respectively. Stricture location was bulbar in 70% and penobulbar in 30%. Median operative time and graft length was 55 min and 4 cm, respectively. In 35 patients with measurable uroflowmetry data, median Qmax significantly improved (7.7 ml/s preoperatively to 31 ml/s three weeks postoperatively; p<0.001). Cross-sectional functional follow-up was performed at a median of 40 mo (range 5-57) postoperatively and was available in 50/54 patients (93% response rate). Preoperative median 6-item LUTS score was 12 (IQR 8–14) and improved significantly after surgery to a postoperative median of 1 (IQR 0-3; p<0.001). Overall success was 93% with 4/54 patients suffering from functional stricture recurrence and the need of a re-intervention. CONCLUSIONS: MANTA urethroplasty using a ventral onlay provides excellent mid-term results in patients with bulbar strictures with an obliterative segment ≤2 cm and adds to the surgical armamentarium of non-transecting techniques by minimizing extensive mobilization. Source of Funding: n/a © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e382-e382 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Phillip Marks More articles by this author Roland Dahlem More articles by this author Maryam Khonsari More articles by this author Lennart Kühnke More articles by this author Frederik König More articles by this author Margit Fisch More articles by this author Malte W. Vetterlein More articles by this author Expand All Advertisement Loading ...

Conservative Management of Lichen Sclerosus Male Urethral Strictures: A Multi-Institutional Experience

ObjectiveTo assess the outcomes and safety of conservative management of lichen sclerosus urethral stricture disease (LS-USD). MethodsThis multi-institutional study included patients with LS-USD managed with endoscopic procedures or clean intermittent catheterization (CIC) regimens between 2005 and 2019. Those with an obliterative stricture, a history of prior urethral reconstruction, or <3 months follow-up was excluded. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, and uroflowmetry values. Secondary outcome measures included patient-reported outcome measure questionnaires on urinary and sexual function. Failure was defined as progression to reconstructive surgery or permanent indwelling catheterization. Results112 men were analyzed with a median follow-up of 30.0 months (IQR 12.0-55.5). Median age was 52.5 years (IQR 42.6-61.0) and median body mass index was 34.5 kg/m2 (IQR 29.9-40.7). Median stricture length was 12.0 cm (IQR 2.8-20.0). 89% of patients underwent urethral balloon dilation, with a median of 2 (IQR 1-3) per patient. CIC was performed in 46% of patients, with 31% of this subgroup using intraurethral steroids. 84% of patients avoided invasive surgery or permanent indwelling catheterization, with an improvement in urethral stricture patient-reported outcome measure scores (P = .0013). Those who failed were more likely to have a history of UTI (P = .04), urosepsis (P = .03), AUR (P <.001), and more likely to perform CIC (P = .01). ConclusionsOver medium-term follow-up, most patients with LS-USD were safely managed with conservative techniques. Caution is warranted in those who develop UTIs, urosepsis, and AUR and the potential long-term consequences of repetitive conservative interventions must be considered.

Outcome of Anastomotic Urethroplasty: Single-Center Experience

Objective: To determine the short term outcome of anastomotic urethroplasty. Material and Methods: From January 2013 to June 2015, 25 male patients underwent anastomotic urethroplasty at our center and were analyzed prospectively. Mean age was 28.1 years (range 13-50), average stricture length was 2.5 cm (range 1.5-2.5). Patients with post-prostatectomy stricture, stricture more than 2.5 cm in length or patients of stricture with neurogenic bladder and patients with any perineal disease were excluded from the study. Retrograde urethrogram and voiding cysto-urethrogram was done in every patient to assess stricture length and location. Stricture excision and end-to-end anastomosis of urethra with spatulation was performed in every patient. Minimum followup period was 6 months and maximum 30 months. All patients had obliterative stricture. Results: The mean operative time was 105 min (range 90-120). Four patients (16%) developed complications postoperatively. Wound infection occurred in 01 (04%) patient. Stricture recurrence found in 02 (08%) patients and erectile dysfunction in 01 (04%) patients. Twenty one patients (84%) had excellent outcome, Two (08%) needed optical internal urethrotomy and of them one (04%) failed to respond. Conclusion: Anastomotic urethroplasty has a high success rate of 92%. It is technically straightforward with minimal morbidity. Long term follow-up is strongly recommended for ultimate success. Bangladesh Journal of Urology, Vol. 19, No. 1, Jan 2016 p.38-42

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.

MP35-03 CONSERVATIVE MANAGEMENT OF LICHEN SCLEROSUS-INDUCED MALE URETHRAL STRICTURES

INTRODUCTION AND OBJECTIVE: Lichen sclerosus-induced urethral stricture disease (LS-USD) creates surgical challenges for the reconstructive urologist due to the high risk of stricture recurrence and disease progression. We reviewed the outcomes of such patients at our institution to determine if conservative management can be an effective strategy. METHODS: We retrospectively identified patients with LS-USD who were managed with urethral balloon dilation or clean intermittent catheterization (CIC) +/- intraurethral steroids. Any patient who had an obliterative stricture, underwent urethral reconstruction as the primary means of USD treatment, or had less than 3 months follow-up was excluded. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, and uroflowmetry values. Secondary outcome measures were Sexual Health Inventory for Men (SHIM) and Male Sexual Health Questionnaire (MSHQ) scores. RESULTS: A total of 109 men met inclusion criteria between 2005-2019 with a median follow-up of 24 months (IQR 8-49). Median age was 52.2 years, body mass index was 35.5 kg/m2, and Charlson comorbidity index was 1. Median stricture length on retrograde urethrogram was 10 cm (IQR 2-20). Stricture location was: meatus/fossa navicularis (33%), pendulous (9%), and bulbopendulous (58%). The most common urinary symptoms were slow flow (50%), sitting to void (25%), and spraying (23%). A total of 77 (71%) patients underwent subsequent urethral dilation. Median number of dilations per patient was 1 (IQR 1-3). CIC was utilized in 32% of patients, with 32% of this subgroup applying steroids intraurethrally via CIC. Uroflowmetry values and sexual health questionnaires showed no significant change between first and last visits (Table 1). Median serum creatinine at first and last visits remained unchanged at 1.0 mg/dL. Eight (7%) patients had an AUR episode requiring urgent treatment and 20 (18%) had a stricture-related UTI. CONCLUSIONS: Although certain patients will desire or require urethral reconstruction, many patients with LS-USD, across a wide range of stricture lengths and locations, appear to be safely managed with urethral dilation or CIC +/- intraurethral steroids. Close observation is warranted due to the risk of stricture-related UTIs and AUR episodes.Source of Funding: None

Dorsal oral mucosa graft in combination with ventral penile flap as an alternative to repair obliterative stenosis of the anterior urethra in a single surgical time.

ABSTRACTPurpose:Obliterative urethral stenosis is a type of urethral lesion that compromises the whole corpus spongiosum's circumference. We present our experience in resolving complex long segment urethral obliteration in a single procedure using a combination of dorsal onlay oral mucosa graft (OMG) and ventral fasciocutaneous penile skin flap.Materials and methods:A prospectively maintained database was reviewed, which included data of men presenting long, obliterative strictures. Patients were excluded if they were lost to follow-up before one year. Failure was defined as need for further urethral instrumentation.The surgical technique used consisted on the fixation of OMG to the tunica albuginea of the corpus cavernosum, thus creating a new urethral plate. Penile or foreskin flaps were employed to complete the ventral aspect. Postoperative follow-up was done with a voiding cystourethrography at week 3.Results:A total of 21 patients were included with a median age of 49 years. Mean follow-up was 25 months. Failure was found for 3 patients (2 of them needing dilations and only one required a new urethral reconstruction).Conclusion:Single stage combination of dorsal OMG with ventral fasciocutaneous penile flap showed good results for selected patients affected with obliterative urethral stenosis.

EDITORIAL COMMENT

Obliterative stricture disease of the pendulous urethra presents a unique technical challenge given the potential for iatrogenicpenile curvature if the scarred segment is completely excised. The authors of the manuscript “Excision and primary anastomosis reconstruction for traumatic stricture of the pendulous urethra,” should be commended for challenging the dictum that anastomotic repairs are contraindicated for penile urethra strictures. 1 Hagedorn J.C. Voelzke B.B. Patient selection for urethroplasty technique. Urol Clin N Am. 2017; 44: 27-37 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The authors hypothesized that for short strictures in the penile urethra, anastomotic repair would be a safe, feasible alternative to 1- or 2-stage substitution urethroplasty.

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.

MP52-14 NATURAL HISTORY OF PATIENTS WITH HYPOSPADIAS WHO UNDERWENT SURGICAL REPAIR: AN OBSERVATIONAL DESCRIPTIVE ANALYSIS WITH A FINAL SURPRISE

stricture was approached through perineal incision with penile invaginationto provide access to the entire length of anterior urethra in 1 stage. One sided, dorsal onlay technique was performed. Two/three oral mucosal grafts were placed dorsally. In redo cases where prior dorsal approach was used, a full-length ventral incision with dorsal inlay grafts was inserted. Postoperatively catheter was removed at 4 weeks. Follow up interval was at 3,6,9,12 months and subsequently yearly. RESULTS: Median patient age was 48.8 years, mean stricture length 14 cm and median follow-up 46 months. 184(57.75%) patients had LS and 134(42.25%) had other causes. Success rate for LS and non-LS was same 85.2%. Retention with suprapubic catheter (SPC) suggests obliterative stricture. Success rate decreased to 57.10% if patient had retention or SPC. On analysis of retention, it was seen in 60.3% patients with iatrogenic cases. Last 3 years 26 patients were referred with retention and SPC. Of this 17(65.33%.) were because iatrogenic cause The outcome was considered a success if the patient required no further instrumentation, including dilation or urethrotomy. The success rate was 89.39% for primary urethroplasty and 57.85% in patients in redo group. Most recurrent strictures developed at the proximal end of the graft. Only 3/318 patients had raised creatinine/renal failure. So raised creatinine and renal failure is less likely with panurethral stricture. CONCLUSIONS: Repair of panurethral stricture in 1 stage with 1-side dissection and dorsal onlay of oral mucosa graft is a minimally invasive technique that is simple, fast, safe, effective and reproducible by any surgeon. The incidence of iatrogenic panurethral strictures is on the rise. Iatrogenic strictures are more likely to be obliterative with early presentation.

Surgical approach to vesicourethral anastomotic stricture following radical prostatectomy

IntroductionVesicourethral anastomotic stricture following prostatectomy is uncommon but represents a challenge for reconstructive surgery and has a significant impact on quality of life.The aim of this study was to relate our experience in managing vesicourethral anastomotic strictures and present the treatment algorithm used in our institution. Patients and methodsWe performed a descriptive, retrospective study in which we assessed the medical records of 45 patients with a diagnosis of vesicourethral anastomotic stricture following radical prostatectomy. The patients were treated in the same healthcare center between January 2002 and March 2015. Six patients were excluded for meeting the exclusion criteria. The stricture was assessed using cystoscopy and urethrocystography. The patients with patent urethral lumens were initially treated with minimally invasive procedures. Open surgery was indicated for the presence of urethral lumen obliteration or when faced with failure of endoscopic treatment. Urinary continence following the prostatectomy was determinant in selecting the surgical approach (abdominal or perineal). ResultsThirty-nine patients treated for vesicourethral anastomotic stricture were recorded. The mean age was 64.4 years, and the mean follow-up was 40.3 months. Thirty-three patients were initially treated endoscopically. Seventy-five percent progressed free of restenosis following 1–4 procedures. Twelve patients underwent open surgery, 6 initially due to obliterative stricture and 6 after endoscopic failure. All patients progressed favorable after a mean follow-up of 29.7 months. ConclusionsEndoscopic surgery is the initial treatment option for patients with vesicourethral anastomotic strictures with patent urethral lumens. Open reanastomosis is warranted when faced with recalcitrant or initially obliterative strictures and provides good results.

Urethral Stricture Disease: Challenges and Ongoing Controversies.

Urethral Stricture Disease: Challenges and Ongoing Controversies.

Resection of the Urethral Plate and Augmented Ventral Buccal Graft in Patients with Long Obliterative Urethral Strictures.

ABSTRACTThe treatment of long urethral strictures is based on the use of buccal mucosa graft (BMG). Postoperative failures commonly occur in patients with the obliterative strictures, and the long augmented part of the urethra which is prone to fibrotic changes.Combined approach with the resection of the obliterative part of the urethral plate located in the bulbar urethra, together with the ventral placement of BMG was performed in 36 patients. Etiology of the stricture was: idiopathic in 19/36 (52.7%), iatrogenic in 14/36 (38.8%), and other causes in 3/36 (8.3%). Mean length of the stricture was 7.2±1.6 cm, and the length of the augmented graft 4.5±1.2 cm (due to resected urethral plate) so, the single BMG was enough in 25/36 (69.4%) patients. The medium postoperative follow up was 24 months (20–28 months) months. Success of the surgery was defined as no need for additional surgery neither dilatation. Cystoscopy was performed 4–6 months after the surgery and additional follow up with IPSS and uroflowmetry.Overall success was achieved in 31/36 (86.1%) patients. Mean postoperative IPSS was 9.5±2.1 in these patients. Complications were according to Clavien Dindo scale: grade II in 11/36 (30.5%-infection, orchialgia, scrotal pain), grade III in 4/36 (11.1%-fistula) and grade IV in 5/36 (14.5% - restenosis). Postoperative Qmax= 13.2±1.2 ml/s. Bell shaped curve was present in 14/36(38.8%).Our results suggest that overall success rate is similar to the expected values for BMG surgery, and the number of the grafts used is lower due to reduced stricture length.

Abordaje quirúrgico de la estenosis de anastomosis vesicouretral posprostatectomía radical

IntroductionVesicourethral anastomotic stricture following prostatectomy is uncommon but represents a challenge for reconstructive surgery and has a significant impact on quality of life.The aim of this study was to relate our experience in managing vesicourethral anastomotic strictures and present the treatment algorithm used in our institution. Patients and methodsWe performed a descriptive, retrospective study in which we assessed the medical records of 45 patients with a diagnosis of vesicourethral anastomotic stricture following radical prostatectomy. The patients were treated in the same healthcare centre between January 2002 and March 2015. Six patients were excluded for meeting the exclusion criteria. The stricture was assessed using cystoscopy and urethrocystography. The patients with patent urethral lumens were initially treated with minimally invasive procedures. Open surgery was indicated for the presence of urethral lumen obliteration or when faced with failure of endoscopic treatment. Urinary continence following the prostatectomy was determinant in selecting the surgical approach (abdominal or perineal). ResultsThirty-nine patients treated for vesicourethral anastomotic stricture were recorded. The mean age was 64.4 years, and the mean follow-up was 40.3 months. Thirty-three patients were initially treated endoscopically. Seventy-five percent progressed free of restenosis following 1 to 4 procedures. Twelve patients underwent open surgery, 6 initially due to obliterative stricture and 6 after endoscopic failure. All patients progressed favourable after a mean follow-up of 29.7 months. ConclusionsEndoscopic surgery is the initial treatment option for patients with vesicourethral anastomotic strictures with patent urethral lumens. Open reanastomosis is warranted when faced with recalcitrant or initially obliterative strictures and provides good results.

Single-institution Outcomes of Open Reconstruction Techniques for Management of Pediatric and Adolescent Post-traumatic Urethral Strictures

To assess the long-term results and efficiency of open reconstruction techniques for pediatric and adolescent post-traumatic urethral strictures. A total of 75 patients who had undergone open reconstructive urethroplasty for post-traumatic bulbous or posterior urethral obliterative strictures resulting from pelvic fracture urethral injuries were retrospectively analyzed. The mean patient age was 12.3 years (range 6-17). Of the 75 patients, 38 had a bulbar stricture and 37 had posterior urethral obliteration. Perineal end-to-end anastomotic repair, urethral pull-through, and ureteral tube graft urethroplasty were performed in 54, 20, and 1 patient, respectively. All patients were followed up by medical history and a urinary flow rate evaluation at 6 and 12 months postoperatively. The patients were followed up for 12-94 months (mean 43.2). The urethral strictures were successfully treated with end-to-end anastomotic urethroplasty in 37 (68.5%) of 54 patients, urethral pull-through urethroplasty in 14 (70%) of 20 patients, and ureteral tube graft in 1 patient. The total primary success rate was 69.3% (52 of 75 patients). Recurrent stricture developed in 23 patients. Of these 23 patients, 7 and 11 were successfully treated with secondary end-to-end anastomosis and direct vision internal urethrotomy, respectively. The overall success rate was 93.3% (70 of 75 patients). Five patients with treatment failure were still in follow-up, with direct vision urethrotomy performed, as needed. No penile curvature, penile shortening, or urethral diverticula developed. The results of our study have shown that open urethral reconstruction techniques are effective for primary and secondary surgical interventions in pediatric and adolescent patients with post-traumatic urethral strictures in experienced centers. These techniques provide excellent long-term results with minimal morbidity.

65 SIX-YEAR EXPERIENCE WITH DORSAL BUCCAL GRAFTING TO RECONSTRUCT THE FOSSA AND/OR URETHRAL PLATE WITH SIMULTANEOUS ONLAY FLAP REPAIR

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 201065 SIX-YEAR EXPERIENCE WITH DORSAL BUCCAL GRAFTING TO RECONSTRUCT THE FOSSA AND/OR URETHRAL PLATE WITH SIMULTANEOUS ONLAY FLAP REPAIR Joel Gelman Joel GelmanJoel Gelman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.112AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES When penile skin is available, onlay flap reconstruction represents an excellent choice for one-stage repair for complex hypospadias and strictures involving the glans and fossa navicularis. When urethra is deficient circumferentially, tube flaps and staged repairs are options. During the reconstruction of an adult patient with untreated proximal hypospadias and disabling chordee in 1993, division of the urethral plate and excision of fibrous tissue corrected the majority of the curvature but created a 5 cm circumferential deficiency of the distal urethra. Given the success of dorsal buccal grafting of the treatment of stricture disease, buccal mucosa was used to recreate the urethral plate and a ventral penile skin flap was used to complete the one-stage repair. We now report our 6-year experience with this circumferential tissue transfer technique. METHODS Nine patients (Ages 22-77, mean 45) underwent dorsal buccal grafting with ventral flap repair. Three patients with untreated hypospadias and medium caliber stricture disease requested correction of disabling chordee. Three hypospadias patients underwent prior surgeries complicated by stricture disease and ventral displacement of the urethral meatus, and had redundancy of the dorsal penile skin. Two patients had recurrent obliterative strictures involving the urethral meatus, and one patient who sustained foley trauma developed a scrotal abscess and an 11 cm stricture of the penile/bulbar urethra. Buccal mucosa was quilted to the ventral corpora of the penis to reconstruct the dorsal aspect of the urethra and the majority of these surgeries included buccal graft reconstruction of the glans and fossa. Onlay penile skin flap repair was then performed to complete the reconstruction. RESULTS All patients are currently free of disabling chordee or obstruction at this time with a mean followup of 2-81 months (mean 28). One patient who underwent treatment of disabling chordee developed urethrocutaneous fistulas and recurrence of distal chordee and required staged re-do reconstruction. Two other patients developed fistulas that required closure and this was performed successfully. CONCLUSIONS Dorsal buccal grafting with ventral flap reconstruction appears to be an excellent option for the repair of circumferential urethral deficiency when penile skin is available, especially when chordee correction with urethral plate reconstruction is required. Orange, CA© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e27 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joel Gelman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcome of End-to-End Urethroplasty: Single-Center Experience

Objective: We review our experience of end-to-end urethroplasty for urethral strictures performed during the last 6 years. Material and Methods: From September 2001 to December 2006, 138 male patients underwent anastomotic urethroplasty at our center. Mean age was 28.1 years (range 6–71), average stricture length was 2.2 cm (range 0.7–6.0). One hundred and one patients (73.2%) had obliterative stricture while 37 (26.8%) still had some urethral passage. Ninety (65.2%) had a history of previous intervention. Sixty patients (43.5%) had associated complicating factors like urethrocutaneous fistula, rectourethral fistula, vesical calculus, blind tract and cavities, bony deformity, or urinary tract infection. Results: The mean operative time was 92 min (range 60–240). Average follow-up was 26.7 months (range 6–60). One hundred and fourteen (82.6%) had excellent outcome, 18 (13%) had acceptable outcome and 6 (4.3%) failed to respond. Seventeen patients developed complications: 5 developed wound infection, 3 epididymorchitis, 2 failed to void, 2 each had incontinence and perineal hematoma, and 1 each had erectile dysfunction, accidentally pulled his catheter out and had urethrocutaneous fistula. Conclusion: End-to-end urethroplasty is an ideal procedure for managing strictures of bulbous and posterior urethra in properly selected cases.