Urethrotomy Research Articles

Is neutrophil to lymphocyte ratio a predictive factor for recurrence of urethral stricture?

Due to spongiofibrosis and inflammatory processes underlying the pathogenesis of urethral stricture, it is possible that the neutrophil-lymphocyte ratio (NLR) may give essential information about the course of the disease and recurrence possibilities. Our study aims to evaluate the correlation between NLR and recurrence rates. A total of 512 patients who underwent direct visual internal urethrotomy (DVIU) due to urethral stricture in our clinic between February 2010 and January 2018 were evaluated retrospectively. The median follow up for non-recurrent and recurrent groups after DVIU was 30 and 36 months, respectively. During the follow-up, 280 (54.7%) of the patients had recurrences, and 232 (45,3%) had no recurrences. The mean time for recurrence after DVIU was 6,5±1,4 months, with a range of 1-36 months. The mean NLR in the non-recurrence group was 2,02±0,87, with a median of 1.9, and 3,66±2,30, with a median of 3 in the recurrence group. A highly significant statistical difference was observed between two groups in terms of neutrophil count and NLR (p: 0.000 - both). The area under curve value for NLR was 0.767, with a standard error of 0.021 (95% CI 0.727-0.808). The cut-off value of NLR was determined as 2.25, with a 70% sensitivity and 67,7% specificity. By using NLR, the inflammatory features of the urethral tissue can be predicted, and possible recurrences after surgery can be estimated. Consequently, open urethroplasty techniques can be used in cases with a significant NLR value instead of the recurrent endoscopic procedure.

Primary Urothelial Carcinoma of the Anterior Urethra

We report the case of an 89-year-old male with an isolated anterior urethral invasive urothelial carcinoma. This is a rare primary tumour of the anterior urethra, as this area is not lined by urothelium. It was managed with radical penectomy and perineal urethrostomy, and the patient has no recurrence to date.

About malpraxis, with love

About malpraxis, with love

Urethral Reconstruction in a Reference Center in Eastern Colombia

Abstract Introduction and Objectives Urethral stricture is a complex pathology of multiple etiologies, and of unknown incidence in our country. There are multiple options for the management of urethral stricture, from minimally invasive procedures, like urethral dilation or direct vision internal urethrotomy, to open surgical reconstruction using excision and primary anastomosis (EPA), or augmented urethroplasty with tissue graft.The aim of the present study is to describe the characteristics of the patients managed with urethral reconstructive surgery in a reference center in eastern Colombia. Methods Observational retrospective cohort study. Data was obtained from patients undergoing urethral reconstructive surgery at the institution from August 2013 to December 2017. All of the surgeries were performed by the same surgical team. The clinical and demographic variables were collected, and the validated urethral stricture surgery patient-reported outcome measure (USS-PROM) questionnaire was applied. Results A total of 56 patients were included in the study, 26 patients (46.4%) underwent excision and primary anastomosis (EPA), and 30 (53.6%) underwent graft urethroplasty. The average age at the time of the intervention was 53.3 years old. The most frequent etiology was trauma, and the mean length of the stenosis was 1.7 cm for the EPA group, and 3 cm for the graft urethroplasty group (p = 0.009). A history of previous surgery was found in 66% of the patients, and radiotherapy in 2 patients.The mean follow-up was of 14 months (range: 0–52 months), observing similar success rates for both techniques. Despite of the small sample size, when analyzing the Kaplan-Meier curves, we observed a tendency of a better response in the group without previous treatments and with stenosis with a length < 2 cm.The rate of postoperative complications was of 23%, with no statistical difference between the 2 groups. The USS-PROM questionnaire was applied to 29 patients, finding that 27 out of 29 respondents were satisfied with the results of the procedure, and all of them would recommend it to another person. Conclusions The results of our study show that urethral reconstruction surgery performed in an experienced center is associated with a good success rate, and that patients are satisfied with the result of the procedure.

A Novel Method of Local Anesthesia for Optical Internal Urethrotomy.

Direct vision internal urethrotomy (DVIU) is the treatment of choice for short anterior urethral strictures. It is performed under spinal or general anesthesia although it can also be done under local anesthesia. We describe a novel method of local anesthesia for internal urethrotomy. The technique described is feasible in morbid patients who are deemed unfit for spinal or general anesthesia and achieves good analgesia.

Vesicourethral Anastomotic Stenosis after Prostate Cancer Treatment

To describe the epidemiology, pathogenesis, and management of vesicourethral anastomotic stenosis after prostate cancer treatment. Injectable scar modulating agents administered at the time of direct visual internal urethrotomy of vesicourethral anastomotic stenoses have been shown to improve endoscopic treatment outcomes. Trials are ongoing to find the optimal agent and delivery system. Novel tissue engineering techniques are in development and hold promise. Vesicourethral anastomotic stenosis after the treatment of prostate cancer is a challenging complication for patients and urologists. Stenoses are prone to recurrence after endourologic treatment. Open repair is technically demanding and carries substantial patient morbidity. The need for adjuvant or salvage radiation therapy after radical prostatectomy worsens outcomes of both endourologic and formal repairs. Postoperative worsening of urinary incontinence is common after vesicourethral anastomotic stenosis repair and can ultimately require placement of an artificial urinary sphincter or male sling. Occasionally urinary diversion, indwelling foley catheter, or clean intermittent catheterization is necessary when reconstructive options have been exhausted. Adjunctive measures to improve endourologic management such as hyperbaric oxygen and transurethral injection of anti-fibrotic agents have been an area of interest in recent years and show promise.

Anterior urethral erosion: report of a malfunctioned and infected artificial urinary sphincter

Background: Since its introduction in less than a century, artificial urinary sphincter (AUS) remains the gold standard in the treatment of severe male sphincter weakness incontinence. It is an extremely reliable prosthesis and patient's satisfaction rate is high after successful implantation. However, complications can occur following implantation and one of the most feared complications is anterior urethral erosion from sphincter malfunction and failure. As patients embark on medical tourism, Urologists in our environment may be challenged with complications resulting from various interventions not readily available in our environment.Case Summary: A 15 year old male student presented to our facility with fever of one week duration and painful scrotal swelling which ruptured spontaneously discharging purulent foulsmelling fluid two (2) months following successful implantation of AUS at a hospital in India. He was febrile with temperature of 38.70C, respiratory rate 32 cycles/minute, pulse rate 110 beat per minutes and blood pressure of 100/60mmHg. His packed cell volume was 34 % other laboratory parameters were not remarkable. He was managed for urosepsis with intravenous infusion, parenteral antibiotics, and initial wound debridement and subsequent AUS ex-plantation and perineal urethrostomy. Patient did well and he is awaiting urethroplasty and AUS placement.Conclusion: Artificial urinary sphincter removal and perineal urethrostomy is a viable option for the emergency management of anterior urethral erosion due to malfunctioned infected artificial sphincter.Keywords: Anterior urethral erosion, artificial urinary sphincter, Urosepsis, perineal urethrostomy, urethroplastySavannah Journal of Medical Research and Practice 2018;7(1):23-27

A Retrospective Analysis of Carcinoma Penis Patients Treated at a Cancer Center in Nepal in a Period of Five Years

Introduction: Carcinoma Penis is not an uncommon condition in a developing country like Nepal and comprises 1-10% of all the malignancies in males. In this study we analyzed the demographic and clinicopathological profile of penile cancer patients who visited our cancer center during specified period.
 Methods: This is a descriptive cross-sectional study, that altogether included 218 patients from January 2012 to December 2016 with penile cancer conducted at B P Koirala Memorial Cancer Hospital, Nepal. All the demographic and clinico-pathological data were collected and analyzed using SPSS 16.0 software. Tumor staging was standardized according to the American Joint Committee on Cancer system. Quantitative data were represented as mean and standard deviation whereas categorical variables were expressed as frequencies and percentages of an appropriate denominator.
 Results: Among 218 patients, the mean ± SD age was 53.94 ± 13.69 years. Most were married (88.07%), smokers (67.88%), had poor personal hygiene (70.64%) and had not completed primary school (71.64%). The predominant profession was agriculture (81.65%). Most of the patients (56.88%) were diagnosed in clinical stage III b (T1-3, N2). Management was circumcision alone in 5.5%, Wide local excision in 6.88%, partial penectomy in 66.97% patients, total penectomy with perineal urethrostomy in 11% of patients and 9.63% patients were sent for chemotherapy after initial biopsy for fixed and fungating inguinal nodes. Bilateral inguinal lymph node dissection was performed in 87.15% patients. Most of our patients were uncircumcised (90.82%) Squamous cell carcinoma was the commonest histopathology (98.6%).
 Conclusion: Penile cancer is more common among farmer with low socioeconomic status. The disease is already locally advanced and at the time of diagnosis. Surgery is the main modality of treatment.

Welfare of cats 5-29 months after perineal urethrostomy: 74 cases (2015-2017).

The objective of this study was to evaluate the long-term quality of life in cats following perineal urethrostomy. This study comprised a retrospective case series of 74 cats with urinary obstructions that received perineal urethrostomies at the American Society for the Prevention of Cruelty to Animals (ASPCA) Animal Hospital between September 2015 and July 2017. Medical records were reviewed for information on the number of obstructions prior to surgery, urinary tract problems at the time of surgery and other potential factors influencing long-term welfare. Owners were surveyed by telephone and text 5-29 months after their cat's surgery. Responses were compiled and analyzed to determine owner perception of welfare postsurgery, and to identify patterns in medical history and welfare outcomes. In total, 105 cat owners were eligible for the survey; 74 responded. Altogether, 100% of responding individuals reported at least the same quality of life postsurgery compared with the cat's quality of life before demonstrating urinary problems (48% reported better). On a quality-of-life scale of 1-10 (10 = excellent), 100% of responding cat owners reported at least 7; 75% reported 10. Quality-of-life outcomes for cats 5-29 months after receiving perineal urethrostomy surgery were reported to be very good. Given this finding, and that perineal urethrostomy surgery should mitigate future blockages, we suggest considering perineal urethrostomy surgery as a standard tool to manage urinary obstructions in cats. The needs of the specific client and patient, including risks, costs and welfare of the cats, should drive the options for management of urinary obstructions in male cats.

The value of definitive perineal urethrostomy for the treatment of complex adult anterior urethral strictures

Objective To analyze the clinical outcome of definitive perineal urethrostomy for the treatment of complex adult anterior urethral strictures. Methods From June 2012 to February 2018, 28 patients who underwent the definitive perineal urethrostomy for a complex anterior urethral stricture were retrospectively reviewed. The mean age of the patients was 62.3 (range 34 to 77) years and stricture etiology was lichen sclerosus in 46.4%(13/28) of the cases, iatrogenic stricture after transurethral resection of the prostate in 35.7%(10/28), failed hypospadias repair in 10.7%(3/28), infection 3.6%(1/28) and idiopathic etiology 3.6%(1/28). The mean stricture length was 9.6 (range 4.5 to 16.0) cm and the stricture length 10 cm in 57.1%(16/28). Of 28 patients 21 (75%) underwent prior urethral dilation, 4 (14.3%) underwent direct vision internal urethrotomy (DVIU) and 17 (60.7%) underwent urethroplasty. Among the medical history of interest, hypertension was observed in 17 patients (60.7%), chronic ischemic heart disease in 11 patients (39.3%), diabetes mellitus in 9 patients (32.1%) and chronic obstructive pulmonary disease (COPD) in 9 patients (32.1%). All patients completed the perineal urethrostomy with inverted U-shaped perineal skin flap. The patient was placed in a normal lithotomy position and an inverted U-shaped perineal incision was made. We can get an inverted U-shaped perineal skin flap after dissecting along the bulbospongiosus muscle. The bulbar urethra was opened along the ventral surface and the margins of the spongiosum tissue were closed with perineal skin flap. We analyzed the clinical characteristics of the patients, the outcome of the technique and investigated the satisfaction rates of the patients by outpatient follow-up or telephone interview. Surgical success was defined as functional voiding without the need for further procedures. Results The perioperative complications included 3 cases of urinary tract infection, 1 case of bleeding and 1 case of wound dehiscence. Mean follow-up length was 27.2(range 6.0 to 64.0)months. Of 28 cases 26 (92.9%) were successful and the mean maximum urinary flow rate was 26.5(range 17.0 to 40.0)ml/s. Postoperatively, 2 cases of urethrostomy strictures were found in 2 months and 4 months, respectively. They required periodic outpatient dilation and the younger one was in the waiting list for revision of the perineostomy and the older one refused the revision. Of 28 patients 24 (85.7%) were satisfied with the results obtained with surgery, 15 were very satisfied, 9 cases satisfied and 4 cases dissatisfied. Conclusions The successful rate of the definitive perineal urethrostomy for the complex adult anterior urethral strictures was high and patients were satisfied with the outcome of the surgery. The definitive perineal urthrostomy is a well-tolerated treatment option for patients with complex anterior urethral strictures, especially for those aged and with extensive comorbidities. Key words: Urethral stricture; Anterior urethral; Perineal urethrostomy; Urinary diversion

Conservative management of iatrogenic bladder rupture and uroperitoneum in a gelding with urolithiasis

SummaryThis report details a case of iatrogenic bladder rupture in a gelding that was successfully treated with conservative management. Rupture occurred at the time of attempted cystoscopy, whilst the bladder was being insufflated with air for further investigation of stranguria and suspected urolithiasis. The gelding was treated with temporary perineal urethrostomy, peritoneal lavage and drainage of urine from the bladder and made a complete recovery.

Long-term efficacy of oral mucosa urethroplasty (report of 324 cases)

Objective To summarize the long-term efficacy of oral mucosal urethroplasty. Methods The clinical data of 324 patients with anterior urethral stricture who underwent oral mucosal urethroplasty from January 2013 to May 2018 were retrospectively analyzed. The patients were 27-65 years old with an average age of 47 years. Among them, 51 patients had urethral meatal stenosis, 174 patients had penile urethral stricture and 99 patients had bulbar urethral stricture. The length of urethral stricture was 2.8-14.0 cm, with an average of 6.4 cm. The preoperative maximal urinary flow rate Qmax was 3.2-8.4 ml/s, with an average of 4.8 ml/s. In the urethral meatal stenosis group (51 patients), 15 underwent urethrotomy and 36 underwent meatal urethroplasty. In the penile urethral stricture group (174 patients ), ventral sagittal incision was done in 21 patients, subcoronal circumferential incision in 49 patients and midline perineal incision in 104 patients. The perineal incision or verted Y incision were done in all the bulbar urethral strictures. Results The patients were followed-up for 3-75 months, with an average of 35.0 months. The results were satisfied in 290(89.5%)patients. The post-operative maximal urinary flow rate Qmax was 15.8-32.2ml/s, with an average of 21.5 ml/s. Thirty-four patients (10.5%)developed recurrent urethral stricture, including 7 patients in the urethral meatus, 17 patients in the penile urethra and 12 patients in the bulbar urethra. Among the recurrent urethral stricture patients, 18 treated with the dilatation and 16 treated with the urethroplasty. Five patients (1.5%)developed fistula, including 2 patients in the ventral sagittal incision, 1 patient in the circumferential incision and 2 patient in the perineal incision. Conclusions The long-term effect of oral mucosal urethroplasty is realistic. The rate of urethral stricture recurrence and fistula is low. The recurrence can be treated again by urethroplasty. The surgical approach for oral mucosa urethroplasty depends on the location and length of the anterior urethral stricture. Key words: Urethral stricture; Oral mucosa; Urethroplasty; Surgical approach; Long-term efficacy

Endoscopic management of anterior urethral strictures by use of direct visual internal urethrotomy with mitomycinC and clean intermittent catheterization

Endoscopic management of anterior urethral strictures by use of direct visual internal urethrotomy with mitomycinC and clean intermittent catheterization

Liquid buccal mucosa graft endoscopic urethroplasty: a validation animal study.

To validate a novel method of urethral stricture treatment using liquid buccal mucosal grafts (LBMG) to augment direct vision internal urethrotomy (DVIU) in an animal model. A rabbit stricture model was used to test this method. Strictures were induced in 26 rabbits using electroresection of urethral epithelium. The animals were randomized into two groups: Group-1, treated with DVIU and LBMG in fibrin glue, and Group-2, DVIU with fibrin glue only. LBMG was prepared by suspension of mechanically minced buccal mucosa micrografts in fibrin glue. This LBMG-fibrin glue mixture was later injected into the urethrotomies of Group-1 animals. All animals were killed at 24weeks after repeat retrograde urethrogram (RUG) and urethroscopy by surgeon blinded to the treatment arm. Radiographic images and histological specimens were reviewed by a radiologist and a pathologist, respectively, blinded to the treatment arm. Stricture treatment was considered a success if a diameter measured on RUG increased by ≥ 50% compared to pre-treatment RUG diameter. Histological specimens were assessed for the presence of BMG engraftment. In Group-1, 8/12(67%) animals demonstrated engraftment of LBMG, compared to none in Group-2 (p = 0.0005). 7/12(58%) in Group-1 showed radiographic resolution/improvement of strictures compared to 5/13 Group-2 rabbits (38%, p = 0.145). The median percent change for the Group-1 was 59%, compared to 41.6% for Group-2 (p = 0.29). This proof-of-concept study demonstrates feasibility of LBMG for endoscopic urethral stricture repairs. Further studies are needed to establish the role of this novel concept in treatment of urethral strictures.

Multi-Institutional Outcomes of Minimally Invasive Harvest of Rectal Mucosa Graft for Anterior Urethral Reconstruction.

We report multi-institutional outcomes in patients who underwent urethroplasty with a rectal mucosa graft. We used the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) database to identify patients who underwent urethral reconstruction with transanal harvest of a rectal mucosa graft. We reviewed preoperative demographics, stricture etiology, previous management and patient outcomes. We identified 13 patients from April 2013 to June 2017. Median age at surgery was 54 years. The stricture etiology was lichen sclerosus in 6 of 13 patients (46%), idiopathic in 2 (15%), hypospadias in 1 (7%), prior gender confirming surgery in 3 (23%) and rectourethral fistula after radiation for prostate cancer in 1 (7%). Prior procedures included failed urethroplasty with a buccal mucosa graft in 9 of 13 patients (69%), direct vision internal urethrotomy in 2 (15%) and none in 2 (15%). Median stricture length was 13 cm. Stricture location in the 9 cisgender patients was panurethral in 5 (56%), bulbopendulous in 2 (22%) and bulbar in 2 (22%). It was located at the junction of the fixed urethra extending into the neophallus in all 3 patients (100%) who underwent prior gender confirming surgery. Mean rectal mucosa graft length for urethroplasty was 10.6 cm (range 3 to 16). Repair types included dorsal or ventral onlay, or 2-stage repair. Stricture recurred at a median followup of 13.5 months in 2 of 13 patients (15%). Postoperative complications included glans dehiscence, urethrocutaneous fistula and compartment syndrome in 1 patient each (7%). No rectal or bowel related complications were reported. Urethral reconstruction with a transanal harvested rectal mucosa graft is a safe technique when a buccal mucosa graft is unavailable or not indicated.

Review on Management of Urethral Stricture Disease at Tertiary Care Centre

Introduction: Urethral stricture disease remains a common cause of morbidity among men. Many questions about the etiology of urethral stricture disease remain unanswered till now. This study was done in a tertiary care center along with a review of the literature to evaluate the etiology of urethral strictures and to determine the factors that may influence possible preventive or curative strategies. Materials and Methods: Data collected from Patients visiting the OPD &/or admitted in the IPD for urethral stricture during the August 2015 to December 2017 this period at tertiary care centre with the help of relevant history, clinical examination, appropriate investigation including and treatment which includes medical and surgical intervention. Results: In study iatrogenic (40%) was main etiological factor for which H/O catheterization was main contributory factor for about 41% among iatrogenic cause. Direct visual internal urethrotomy was common surgical procedure performed with success rate (58%). Anastomotic urethroplasty was associated with success rate of 87.5%. Conclusion: Avoiding unnecessary urethral catheterization and repeated urethral instrumentation can reduce these iatrogenic strictures. Contrast urethrogram was the most common imaging modalities followed by Urethroscopy. Anastomotic urethroplasty had higher success rate as compared to DVIU and Urethral dilatation.

The outcomes of Kulkarni's one-stage oral mucosa graft urethroplasty in patients with panurethral stricture: a single centre experience.

To present the results of our one-stage oral mucosa graft urethroplasty series for panurethral strictures. We included the first 35 patients who had one stage oral mucosa graft urethroplasty with one side dissection of the urethra which was described by Kulkarni, between January 2015 and June 2018 and had at least 6months follow-up. From the first case, all data were recorded prospectively and patient age, etiology of the stricture, comorbidities, previous treatments, postoperative maximal flow rate, pre and post-operative erectile function, perioperative and postoperative complications and quality of life questionnaire for this study. The mean patient age was 58.8 and mean stricture length was 13.6 (10-16)cm. Patients had previously 1-17 procedures. Patients had a mean peak flow rate of 25.4ml/sec at the first postoperative visit. During the follow-up period, six patients had recurrence and managed with urethral dilation (1), direct vision internal urethrotomy (2), meatoplasty (1) and re-urethroplasty (2). The responses to the questions about satisfaction from the surgery showed that 31 (88.6%) patients were satisfied with the surgery, 33 (94.3%) would prefer this procedure again, if needed, and 31 (88.6%) patients recommended this procedure to others. When patients were grouped according to age, recurrence rate was 35.7% in patients older than 65years and 4.8% in patients ≤ 65years old. Our study showed that Kulkarni's one-stage oral mucosa graft urethroplasty technique has a high success rate. The patient satisfaction is high because of the good functional outcomes and low complication rate.

A Randomised Controlled Study to Compare the Efficacy and Safety of Intracorpospongiosal Anesthesia alone Versus Transperineal Urethrosphincteric Block and Intracorpos Spongiosal Anesthesia Combined in Direct Vision Internal Urethrotomy in Urethral Strictures

A Randomised Controlled Study to Compare the Efficacy and Safety of Intracorpospongiosal Anesthesia alone Versus Transperineal Urethrosphincteric Block and Intracorpos Spongiosal Anesthesia Combined in Direct Vision Internal Urethrotomy in Urethral Strictures

PD22-06 ONE-YEAR SAFETY AND EFFICACY OUTCOMES ON A NOVEL DRUG COATED BALLOON (DCB) FOR URETHRAL STRICTURE DISEASE - THE ROBUST I STUDY

INTRODUCTION AND OBJECTIVES:Introduction & Objective: Urethral strictures are most commonly treated via minimally invasive techniques such as dilation or direct vision internal urethrotomy (DVIU); ...

MP55-17 URINARY AND SEXUAL FUNCTION AFTER PERINEAL URETHROSTOMY FOR URETHRAL STRICTURE DISEASE: AN ANALYSIS FROM TRAUMA AND UROLOGIC RECONSTRUCTIVE NETWORK OF SURGEONS (TURNS)

INTRODUCTION AND OBJECTIVES:Perineal urethrostomy is a viable option for many complex urethral strictures; however, no comparison with anterior urethroplasty (AU) or complex AU regarding patient re...