Proximal Bulbar Urethra Research Articles

Validation Study of the LSE Classification and Scoring System in Comparison With U-Score

OBJECTIVETo validate the value of the LSE classification and scoring system in predicting surgical outcomes for male anterior urethral stricture cases. METHODSA retrospective review was conducted on 566 patients who underwent urethroplasty between August 2004 and March 2022. After excluding pelvic fracture urethral injury and non-stricture diseases and incomplete data, 358 patients were classified according to the LSE classification system, and both U score and LSE score were calculated. We investigated the relationship between LSE score and U score in predicting recurrence. Recurrence was defined as any instance requiring re-intervention. To identify factors contributing to recurrence, logistic regression analysis was performed on the LSE score and variables not included in the scoring system. RESULTSThe breakdown of S, and E components showed external trauma as the most common cause of strictures, with proximal bulbar urethra being the most common segment. Significant associations were observed between stricture etiology and segment, as well as between surgical technique and segment. A strong correlation (r = 0.73) was found between U score and LSE score, with no significant difference in predicting recurrence between the two scores. Surgical complexity differed significantly between LSE score groups, but surgical duration did not. Patients with LSE < 7 showed a better recurrence rate in Kaplan-Meier analysis. Multivariate logistic analysis identified LSE ≥ 7 as an independent risk factor for recurrence. CONCLUSIONThe LSE classification system and scoring system demonstrate validity in characterizing anterior urethral strictures and predicting surgical outcomes.

A New Proximal Adjustable Sling ATOMS SSP® Implantation Technique with Focus on the Urethral Bulb: Lessons Learned from Revision Surgery.

Adjustable sling ATOMS-SSP results in ventral compression of the urethra with favorable results in the treatment of men with mild to moderate stress incontinence. However, with transobturator tunneling and mesh fixation, the surgeon has a range of options, which leads to different results and sometimes unfavorable positioning of the silicone cushion. Using retrograde urethrography (RUG), we identified ATOMS patients with considerable misplacement. We then modified the implantation technique when we performed the revision, and now present here our first experiences with this new surgical technique. Patients after ATOMS-SSP implantation at our clinic were systematically subjected to a RUG if incontinence persisted after adjustments. In case of unfavorable positioning, a revision was performed with the aim of achieving an idealized urethroproximal position of the silicone pad. During follow-up, a repeat RUG was performed, and both subjective and objective outcome parameters were recorded. Four men met the above criteria and underwent revision with reimplantation using our new technique. All patients postoperatively experienced significantly improved continence. RUGs demonstrated an ideal ATOMS position immediately below the proximal bulbar urethra. Our proximal implantation technique, presented here for the first time, allows optimal positioning of the ATOMS SSP, which is reflected in the objective parameters and RUG. Its use in primary implantation should also be considered and an expansion to the indication of severe stress incontinence seems possible, but this should only be done in studies.

Missed urethral duplication associated with hypospadias, post-hypospadias repair urethral stenosis, and recurrent urinary tract infections in an adult: a case report

BackgroundDuplication of urethra is a very rare congenital disorder. Several types of this anomaly have been reported around the world, and are also discussed in this report. However, the mechanism of this anomaly is still unclear.CaseA 45-year-old Persian man with a complaint of recurrent urinary tract infection was referred to our clinic. He had a history of repairing penoscrotal hypospadias in childhood along with obstructive and irritating symptoms in adolescence. On his last voiding cystourethrogram and retrograde urethrogram, stenosis was observed in the proximal bulbar urethra along with a double urethra in the dorsal region of the main urethra. The double urethra was removed with operation, and he was followed for 1 month after surgery. He had no complaints of recurrence or urinary incontinence.ConclusionsThis report shows the different classification systems, types of double urethra, and approach and management, which mainly involves surgery; however, surgical management should be done according to the anatomical findings of the abnormality.

Which Are the Commonest Sites and Characteristics of Post-Transurethral Prostate Surgery Strictures in a High-Volume Reconstructive Center?

Background: Urethral stricture is a well-known complication after transurethral prostate surgery (TPS) and it is usually considered an easy-to-treat condition. We aimed to examine characteristics of post-TPS urethral stricture cases that were referred for urethroplasty at our tertiary center. Methods: We identified 201 patients with TPS-induced stricture treated with urethroplasty at our institution from 2017 to 2021. First, stricture length and location were evaluated during preoperative assessment. Second, multiple sets of multivariable logistic regression (MLR) analyses were run to assess whether clinical variables were associated with the location of the stricture. Results: Median stricture length was 5 cm (4-7). One hundred forty-one (70.1%) patients received previous no-invasive treatments (dilatation and/or direct visual internal urethrotomy). Proximal bulbar urethra was the commonest site for stricture, whereas panurethral stricture (≥10 cm) was diagnosed in 41 (20.4%) patients. Lichen sclerosus was more common in patients with penile stricture location, compared with patients with other involved segments (26% vs 19%, p = 0.03), and it was the only predictor of penile and midbulbar urethra location at MLR. Surgical approaches were augmented urethroplasty in 94% of patients, especially for patients with previous treatment including urethroplasty (95.8% vs 82.5% for naive, p = 0.004). Dorsal onlay was the preferred approach for bulbar (53.4%) and penile urethra (90.7%), whereas ventral onlay (38.2%) and double face augmentation (20.6%) were the preferred approaches in membranous strictures. Conclusions: Most patients who were referred for TPS-induced stricture attempted previous noninvasive managements. Referred TPS-induced urethral strictures were long and frequently involving multiple segments of urethra. Augmentation urethroplasty was our preferred surgical approach because of the characteristics and complexity of these strictures. The presence of lichen may increase the risk of post-TPS stricture in a specific segment of urethra, namely the penile and midbulbar urethra.

Migrated Sewing in Urethra in a Young Male, Tricky Situation Sorted with Cystoscope

The self-insertion of sewing needles into the urethra is an unusual emergency faced by a urologist. The most common cause for self-insertion of urethral foreign bodies is unknown however autoerotism/psychological impairment has been implicated. Because of guilt and embarrassment, patients usually do not take medical advice unless he is symptomatic. A 24-year male inserted a sewing needle through the urethra for autoerotic stimulation which has impacted at proximal bulbar urethra and piercing the post wall of the urethra towards the rectum. The needle was successfully removed by cystoscope assistance with difficulty after grasping with forceps. Follow-up after cystourethroscopy is important for diagnosing urethral stricture. The main objective of this case reports that foreign bodies inserted especially in the urethra can migrate. Milking of a needle is contraindicated as it may pierce the urethra and migrate to adjacent structures. Removal of these needles under cystoscopy guidance is mandatory.

Urethral reconstruction for iatrogenic urethral stricture after transurethral prostate surgery: An analysis of surgical and patient-reported outcomes.

We investigated the efficacy of urethral reconstruction in male patients with iatrogenic urethral stricture after transurethral prostate surgery. We retrospectively reviewed the cases of 82 patients who underwent urethral reconstruction for iatrogenic urethral stricture caused by transurethral prostate surgery between August 2011 and July 2021. Patients were followed up postoperatively with uroflowmetry, postvoid residual urine measurement, and questionnaires using Peeling's picture score, International Prostate Symptom Score, International Consultation on Incontinence Questionnaire Short Form, Sexual Health Inventory for Men, EuroQol-5 dimensions, and EuroQol-5 dimensions visual analog scores. Successful urethral reconstruction was defined as the absence of a postoperative decrease in urinary force and any additional treatment. The median patient age was 72 years, and the stricture site was the urethral meatus in eight (9.8%) patients, penoscrotal junction in 42 (51.2%), and proximal bulbar urethra in 26 (31.7%). Six patients (7.3%) had synchronous urethral strictures. Urethral reconstruction was successful in 78 patients (95.1%), with a median follow-up of 43 months. The mean maximum flow rate (P < 0.0001), postvoid residual urine (P = 0.004), Peeling's picture score (P < 0.0001), the score for each question and total International Prostate Symptom Score and International Prostate Symptom Score-quality of life scores (P < 0.0001 for all comparisons), and EuroQol-5 dimensions and EuroQol-5 dimensions visual analog scores (P < 0.0001 for both) significantly improved postoperatively. However, the Sexual Health Inventory for Men and International Consultation on Incontinence Questionnaire Short Form scores remained unchanged (P = 0.09 and 0.70, respectively). Urethral reconstruction was effective for urethral stricture due to transurethral prostate surgery in both subjective and objective aspects.

V04-04 NEW SURGICAL TECHNIQUE: A SINGLE LONG SPIRAL PREPUTIAL GRAFT FOR PANURETHRAL STRICTURE

You have accessJournal of UrologyCME1 May 2022V04-04 NEW SURGICAL TECHNIQUE: A SINGLE LONG SPIRAL PREPUTIAL GRAFT FOR PANURETHRAL STRICTURE Pankaj Joshi, Marco Bandini, Shreyas Bhadranawar, Vipin Sharma, Sandeep Bafna, and Sanjay Kulkarni Pankaj JoshiPankaj Joshi More articles by this author , Marco BandiniMarco Bandini More articles by this author , Shreyas BhadranawarShreyas Bhadranawar More articles by this author , Vipin SharmaVipin Sharma More articles by this author , Sandeep BafnaSandeep Bafna More articles by this author , and Sanjay KulkarniSanjay Kulkarni More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002560.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Management of panurethral stricture is challenging. Etiology is usually either Lichen Sclerosus or Iatrogenic. Single stage dorsal onlay with Kulkarni Technique is a preferred approach. In lichen sclerosus, local genital skin cannot be used. We describe a new spiral preputial graft dorsal onlay single stage Urethroplasty for non LS Panurethral strictures. METHODS: Ours is a tertiary care referral center for urethroplasty with experience of more than 6000 Urethroplasties in last 2 decades. This is a prospective study from Jan 2020-July 2021.9 patients of Panurethral stricture were included. None of them had LS. Stricture length was 14 cm. Urethrogram was performed prior to Urethroplasty. Perineal incision, penile invagination, dorsal onlay approach was performed. A outer circumcision incision was made just deep to the skin. The prepuce was harvested with dissection above the dartos. This was continued to the inner prepuce. Inner circumcision incision was made. The prepuce was harvested like a cylinder. The prepuce was then slided over a 20 cc disposable syringe. A spiral incision was made and a long continuous 1.5 cm wide and 20 cm long graft was made. This was described by Anderson et el. This graft was applied as dorsal onlay like Kulkarni technique from meatus till proximal bulbar urethra. Catheter was removed after 4 weeks. RESULTS: At follow up, all the patient passed urine within normal uroflow. At 6 months follow up, uroflow remained excellent with a Qmax of 22.3ml/sec. 1 patient had proximal narrowingThere was no chordee, urinary tract infections or sexual dysfunction. There were no local complications. CONCLUSIONS: BMG Urethroplasty is the preferred augmentation material for strictures. The results of Penile skin and BMG are almost comparable. In Asian subcontinent, many men have an intact prepuce. By harvesting a spiral long graft, we avoid junctional strictures (which can take place at the site of 2 BMG). The graft is long and there is no need to harvest another graft. There is no oral morbidity. We also preserve the preputial dartos, which preserves the neurovascular supply. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e367 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pankaj Joshi More articles by this author Marco Bandini More articles by this author Shreyas Bhadranawar More articles by this author Vipin Sharma More articles by this author Sandeep Bafna More articles by this author Sanjay Kulkarni More articles by this author Expand All Advertisement PDF downloadLoading ...

All in one, a rare case presentation of genitourinary tuberculosis

BackgroundThe kidneys are the most common site of urogenital tuberculosis. Tuberculosis of the urethra and bladder is caused by a descending infection through the urinary collecting system. Urogenital tuberculosis affects 2% to 10% of pulmonary tuberculosis cases in developed countries, but 15% to 20% in developing countries.Case presentationA 55-year-old male referred to us with bilateral percutaneous nephrostomy, which was done for obstructive uropathy with raised creatinine of 4.5 mg/dl. He was diagnosed with pulmonary tuberculosis two years back and took antitubercular therapy for one year. His routine blood parameters were within normal limits. On evaluation with bilateral nephrostograms, he was found to have right-sided pelvic ureteric junction stricture and left-sided vesicoureteric junction stricture. On retrograde urethrography, there was evidence of 4-cm stricture at proximal bulbar urethra. On contrast-enhanced CT whole abdomen, he was found to have small-sized right kidney and findings in par with nephrostogram with thickened, small capacity bladder (thimble bladder). Patient underwent urethroscopy and urethral dilatation followed by augmentation ileocystoplasty with left ureteric reimplantation and right nephrectomy done at 3 months of follow-up.ConclusionOnly 1.9 percent to 4.5 percent of all cases of urogenital tuberculosis are urethral tuberculosis, and it never happens alone. For urogenital tuberculosis diagnosis, imaging techniques are up to 91.4 percent sensitive, with intravenous urography and abdominal computerised tomography being the most widely used. Diagnosis relies on a range of signs such as “caliceal irregularities; infundibular stenosis; pseudotumor or renal scarring; nonfunctioning kidney; renal cavitation; urinary tract calcification (present in 7% to 19% of cases); collecting system thickening, stenosis, or dilatation; contracted bladder”.

Excessive fibrosis and non-function after ATOMS (adjustable transobturator male system): A case of capsular contracture?

The adjustable transobturator male system (ATOMS) treats post-prostatectomy urinary incontinence by compression of the proximal bulbous urethra. It reminds of the Kaufman prosthesis described in 1978. We describe a case where an excessive fibrotic reaction occurred around the cushion. Furthermore, the bulbous urethra underneath, developed severe atrophy devoid of any visible blood supply. We suspect ongoing shear forces around the cushion while sitting resulting in a chain reaction of acute through chronic inflammation and progressive fibrosis and encapsulation. Does the encapsulation lead to capsular contracture resulting in non-function?

V06-04 NEW SURGICAL TECHNIQUE: INTRAURETHRAL TUBE IN TUBE PEDICLED PREPUTIAL FLAP FOR OBLITERATIVE STRICTURES

You have accessJournal of UrologyLower-Tract Reconstruction I: Sling/ Sphincter/ Penile & Urethral Reconstruction (V06)1 Apr 2020V06-04 NEW SURGICAL TECHNIQUE: INTRAURETHRAL TUBE IN TUBE PEDICLED PREPUTIAL FLAP FOR OBLITERATIVE STRICTURES Pankaj Joshi* and Sanjay Kulkarni Pankaj Joshi*Pankaj Joshi* More articles by this author and Sanjay KulkarniSanjay Kulkarni More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000885.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Management of Obliterative and recurrent long segment bulbar strictures is challenging. Few options exist such as double face urethroplasty or combined use of graft and flap. In majority of reported literature, the native urethra is excised and reconstruction is performed. This native urethra actually carries retrograde blood flow through bulbourethral arteries. We describe a new technique of preserving the native spongiosa and using it as cover for substitution decreasing the risk of diverticulum formation. METHODS: Ours is a tertiary care referral center for urethroplasty with experience of more than 4500 Urethroplasties in last 2 decades. This is a series of 3 patients operated between Jan 2019-March 2019.All had near Obliterative proximal bulbar stricture. Etiology was idiopathic in 1 patient and post TURP in 2 patients.2 patients had prior dorsal Onlay urethroplasties. RGU and MCU were performed. Perineal incision with ventral urethrotomy in proximal bulbar urethra was performed. The scarred urethral plate was excised. There was a gap of 3 cm between the healthy mucosal ends proximally and distally. Pedicled preputial flap was performed, transposed to perineum and tubularised over a 14 Fr Silicone catheter .The tube was anastomosed to the proximal urethral mucosa and then distally. The ventral urethrotomy which now had the spongiosa was closed over as a cover . RESULTS: Foleys catheter was kept for 6 weeks. On catheter removal, Uroflow was performed. Patients were followed up every 3 months with Uroflow, Ultrasound and urine culture .All 3 patients had good flow till last follow up.None of them developed infections.All complained of minimal post micturition dribbling. CONCLUSIONS: Obliterative redo urethral strictures merit reconstruction. Proximal post TURP strictures are not recommended to be treated with dorsal approach. Urethral substitution would require urethra transection, compromising the blood flow. This is a novel intraurethral tube in tube, flap technique which is vascular preserving and useful for management for such subset of patients. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e557-e557 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pankaj Joshi* More articles by this author Sanjay Kulkarni More articles by this author Expand All Advertisement PDF downloadLoading ...

Repair of panurethral stricture: Proximal ventral and distal dorsal onlay technique of buccal mucosal graft urethroplasty

ObjectiveTo report the surgical details and results of our technique of buccal mucosal graft (BMG) urethroplasty for panurethral stricture, as many studies have reported repair of panurethral stricture by single-stage BMG urethroplasty by placing buccal mucosa ventrally, dorsally or dorsolaterally. Patients and methodsThis was an observational analysis of 38 patients with panurethral stricture treated by placing two BMGs, one as a ventral onlay in the proximal bulbar urethra and the other as a dorsal onlay in the distal bulbar and penile urethra. Success was defined as asymptomatic state with or without need for a postoperative single intervention such as dilatation or internal urethrotomy. ResultsThe 38 patients had a mean age of 44 years, with lichen sclerosus as the predominant cause of stricture. The ultimate success rate was 84.2% at the end of 3 months and 89.5% at the end of 1 year. Recurrent strictures appeared only in the failed cases during the follow-up period of 11 months. None of the patients needed redo urethroplasty during the follow-up period. ConclusionsA proximal ventral and distal dorsal onlay technique of BMG urethroplasty is an available alternative for repairing panurethral stricture. The technique described is simple and easily reproducible with encouraging results compared to other similar techniques.

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OBJECTIVES/SPECIFIC AIMS: Perineal urethral sling placement is an option for men with mild to moderate post-prostatectomy stress urinary incontinence (SUI). However, men with persistent incontinence after sling placement often require secondary artificial urinary sphincter (AUS) placement, made difficult by the sling occupying the proximal bulbar urethra. This proximal section has a thicker corpus spongiosum which may mitigate cuff-induced ischemia and subsequent urethral atrophy. The authors report a series of AUS placements after failed sling, using sling revision or removal to access the proximal urethra. METHODS/STUDY POPULATION: Cutting the sling arms during urethral cuff placement increased urethral exposure and mobility. If feasible, completely removing the sling allowed the most proximal cuff site; but if dissection was felt unsafe, the mesh was left in situ and the cuff placed distally. This study is a retrospective cohort design of patients with SUI who underwent AUS placement after failed sling from 2010 to 2016. Variables included baseline patient characteristics, SUI severity, intraoperative variables, and postoperative outcomes. AUS failure, defined as infection, erosion or urethral atrophy, was analyzed at 12 and 96 months using univariate and multivariable logistic regression. RESULTS/ANTICIPATED RESULTS: Over the study period, 29 patients underwent AUS placement after failed sling. At the time of AUS placement, mean urethral circumference was 6.2 cm and 68% of patients had a 4.5 cm cuff placed; no cases required a 3.5 cm cuff. Seventy-three percent of cases were after transobturator sling placement (27% bone-anchored) and 45% of slings were explanted. AUS failure rate at 12 and 96 months was 17.8% and 45%, respectively; atrophy was the most common indication. Prior transobturator sling placement had lower rates of both 12 month (9.1% vs. 57%, p=0.006) and 96 month (36% vs. 71%, p=0.11) failure, though the latter was not statistically significant. Sling explant was not a significant predictor of 12 month (p=0.12) or 96 month failure (p=0.17). DISCUSSION/SIGNIFICANCE OF IMPACT: Sling revision during AUS placement helps expose the wider proximal urethra, allowing larger cuff size placement. This procedure appears safe, with low rates of erosion and short-term failure—albeit with high rates of long-term urethral atrophy possibly due to more significant dissection causing devascularization. However, sling removal was not a significant predictor of failure. The transobturator sling’s smaller profile may result in less trauma to urethra—possibly explaining the improved outcomes.

Bulbomembranous anastomotic urethroplasty for strictures of the proximal bulbar urethra unassociated with pelvic trauma.

Bulbomembranous anastomotic urethroplasty for strictures of the proximal bulbar urethra unassociated with pelvic trauma.

Our experience with progressive perineal urethroplasty and anastomotic urethroplasty in post-traumatic urethral strictures in pediatric patients

Background: Confined perineum and elevated prostate and bladder in children make management of post-traumatic stricture in children technically difficult.Methods: A retrospective study of patients from 2007 till September 2016 was conducted. 15 pediatric patients with a mean age of 7.3 years presented with post traumatic urethral stricture or distraction defect. 11 patients had pelvic fracture urethral distraction defect (PFUDD) and underwent PPU. Four had bulbar stricture caused by straddle injury and underwent EEU. Post operatively patients were evaluated using uroflowmetry at 3, 6 and 12 months. Maximum velocity of less than 10 ml/s and symptoms of straining was considered as recurrence and such cases were evaluated further with MCU, RGU and cystoscopy.Results: Mean stricture length was of 2.3 cm and was at bulbo-membranous junction in 11 and in proximal bulbar urethra in 4. Of the 11 PPUs, crural separation was done in nine and inferior pubectomy in six patients. Transpubic approach was required in one patient. Gracilis flap was placed in one patient as an onlay over anastomotic urethroplasty. Of the 11 PPUs, 2 patients and 1 of 4 EEU patients had recurrence. All recurrent strictures were &lt;1.5 cm long and at the site of the anastomosis. Two patients were managed with anastomotic urethroplasty. The remaining one patient could be managed with laser visual internal urethrotomy.Conclusions: PPU and EEU are treatment of choice in paediatric patients with PFUDD and proximal bulbar strictures respectively. Both are technically feasible, have good outcome and have an acceptable morbidity.

Can separation of the scrotal sac in proximal hypospadias reliably predict the need for urethral plate transection?

One of the main challenges in proximal hypospadias repair is correcting curvature. The best technique to achieve this remains the object of debate. Indeed, some authors believe the urethral plate should be kept and used as often as possible. In some cases, however, even after extensive mobilization and dorsal plication, significant curvature remains and it is necessary to transect the urethral plate. Having a reliable pre-dissection marker of the need for urethral transection would be useful in choosing a technique.We wanted to determine if presence of marked separation of the scrotal sac (SSS), also referred to as bifid scrotum, could reliably predict the need for urethral plate transection. We prospectively enrolled a series of boys with proximal hypospadias. We noted age, degree of hypospadias, meatal position, presence of cryptorchidism, and presence or absence of SSS. During surgery we fully degloved the penile shaft, freeing all ventral tissues, and radically dissected the more proximal bulbar urethra. We then performed an erection test. If there was residual curvature <30° we performed a dorsal plication, if it was >30° we transected the urethral plate. Twenty-nine patients were included, of whom 18 presented SSS. The average age was comparable in both groups, as was type of hypospadias and meatal position. We estimated transection of the urethral plate to be necessary in 15 out of the 18 children with SSS, and 2 out of the 11 children without SSS. The relative risk for requiring urethral plate transection in case of SSS in this series was 4.58. Techniques that commit to urethral plate transection are criticized because they preclude using the urethral plate. In our study presence of SSS was predictive for the need to transect the plate. Obviously one can decide to keep the urethral plate at all cost, and mobilize it more than we did, or accept more residual curvature, but in reality our aim was to determine a preoperative marker allowing us to define a patient category. We believe presence of SSS is a marker of severity, and that this "severity" translates into "a less usable urethra". As recent studies caution us about the evolution of the reconstructed native urethra and the possibility that it may not grow as well as the other penile tissues, we believe this extra information could influence the surgeon's decision as to the most appropriate technique for each patient.

Non-transecting anastomotic urethroplasty (surgical atlas)

Non-transecting anastomotic urethroplasty – is three types of urethroplasty, which are united on the principle resection of bulbar urethra with sparing of corpus spongiosum and antegrade blood flow through it. The article describes the surgical technique of urethroplasty: dorsal strictureplasty by Heineke–Mikulicz; strictureplasty by Mundy; vessel-sparing anastomotic urethroplasty by Jordan. Obligatory conditions of the non-transecting anastomotic urethroplasty are a non traumatic etiology, length of the stricture not more than 1–1.5 cm, and its localization in the proximal bulbar urethra. Strictureplasty by Heineke–Mikulicz is a dorsal longitudinal incision of the urethra on the area of stricture and subsequent suturing the defect transversely. Strictureplasty by Mundy is a dorsal longitudinal urethrotomy, excision of the affected mucosa inside the lumen of the urethra and transversely urethral closure according to Heineke–Mikulicz, s principle. Vessel-sparing anastomotic urethroplasty by Jordan is circular excision of the urethral mucosa without crossing of corpus spongiosum and incoming into it bulbar arteries and thereby preserving the antegrade blood flow through the urethra.

Does Use of a Second Cuff Improve Artificial Urinary Sphincter Effectiveness? Evaluation Using a Comparative Cadaver Model

The artificial urinary sphincter is the gold standard long-term solution for male stress incontinence. Some urologists believe that including a second urethral cuff at the time of placement can improve efficacy but strong evidence is lacking. We compared the functionality of a single vs a tandem cuff in a cadaver model. Artificial urinary sphincter reservoir pressure was confirmed at 61 to 70 cm H2O. The bulbar urethra was dissected through a perineal approach in each of 4 cadavers. Distal and proximal bulbar urethral circumference was measured. The membranous urethra was transected. Cuffs sized based on circumference measurements were placed distal and proximal, and connected to the reservoir and pump. Retrograde leak point pressure was measured sequentially across the distal, proximal and tandem cuffs. We used the Friedman test to compare retrograde leak point pressure among the 3 cuff positions, the paired t-test to compare distal and proximal urethral circumferences and the Spearman correlation to compare urethral circumference to retrograde leak point pressure. Mean retrograde leak point pressure across the distal, proximal and tandem cuffs was 73.5, 77.75 and 79.25 cm H2O, respectively (p=0.44). Mean urethral circumference of the distal and proximal bulbar urethra was 4.78 and 5.83 cm, respectively (p=0.019). There was a strong positive correlation between urethral circumference and retrograde leak point pressure (rs=0.5). The tandem cuff did not improve retrograde leak point pressure. Proximal bulbar urethral circumference was greater than distal circumference and increasing urethral circumference correlated with increasing retrograde leak point pressure. Therefore, the perceived benefit of tandem cuffs may reflect more proximal placement of one of the cuffs.

MP88-18 DOES USE OF A SECOND CUFF IMPROVE ARTIFICIAL SPHINCTER EFFECTIVENESS? EVALUATION USING A COMPARATIVE CADAVER MODEL

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Male Incontinence: Therapy1 Apr 2015MP88-18 DOES USE OF A SECOND CUFF IMPROVE ARTIFICIAL SPHINCTER EFFECTIVENESS? EVALUATION USING A COMPARATIVE CADAVER MODEL Madeleine Manka and E. James Wright Madeleine MankaMadeleine Manka More articles by this author and E. James WrightE. James Wright More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1851AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The artificial urinary sphincter (AUS) has long been recognized as the most effective long-term solution for men with severe stress incontinence. It is widely believed that inserting a second (tandem) urethral cuff can improve device efficacy, but this supposition is backed by little empirical evidence. In this study, we directly compare the functionality of a single versus tandem cuff in a cadaver model. METHODS The AUS reservoir pressure was confirmed to be between 61-70 cm H2O via burette test. The bulbar urethra was dissected using a perineal approach in each cadaver (n=4). The resting urethral circumference of the distal and proximal bulbar urethra was measured. The membranous urethra was transected. Appropriately sized occlusive cuffs were placed in the distal and proximal positions and connected to the pressure reservoir and control pump. Retrograde leak point pressure (RLPP) was measured sequentially across the distally placed single cuff, the proximally placed single cuff, and two tandem cuffs by inserting a catheter in the occluded urethra and raising an attached bag of fluid until leakage was seen across the transected urethra. The height between the fluid and cuff was recorded (cm H2O). A Friedman test was used to compare RLPP between the three cuff configurations, a paired t test to compare distal and proximal urethral circumference, and a Pearson correlation to compare urethral circumference to RLPP. RESULTS Mean RLPP across the distal, proximal and tandem cuffs was 70.25, 77.75, and 76.75 cm H2O respectively (p=0.14). Mean urethral circumference of the distal and proximal bulbar urethra was 4.78 and 5.83 cm respectively (p =0.019). There was a strong positive correlation between urethral circumference and RLPP (r = 0.75). CONCLUSIONS The tandem cuff does not appear to improve leak point pressure. In addition, the proximal bulbar urethral circumference (below the crus) was found to be significantly greater than the distal urethral circumference. Increasing urethral circumference was strongly correlated with an increase in the pressure needed to overcome cuff occlusion (RLPP). Therefore, it would appear that the perceived benefit of a second urethral cuff reflects function of the more proximal cuff alone. In our model, a tandem cuff did not increase effectiveness of the AUS. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1098-e1099 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Madeleine Manka More articles by this author E. James Wright More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

International multi-institutional experience with the vessel-sparing technique to reconstruct the proximal bulbar urethra: mid-term results.

To present mid-term outcomes from an international, multi-institutional cohort of patients undergoing vessel-sparing excision and primary anastomosis urethroplasty for the reconstruction of the anterior urethra. From June 2003 to December 2011, 68 patients underwent vessel-sparing anterior urethral reconstruction at five different international institutions using the vessel-sparing technique described by Jordan et al. (J Urol 177(5):1799-1802, 2007). Patients' age range was from 3 to 82 years (mean 51.2). Stricture length ranged from 1 to 3 cm (mean 1.78). After a mean follow-up of 17.6 months, 95.6 % of patients had a widely patent urethral lumen. Three patients failed the procedure, requiring either direct vision internal urethrotomy or urethral dilation, after which all were free of symptoms and did not require further instrumentation. Complications were minimal and as expected following open urethroplasty. Preservation of blood supply is a noble pursuit in surgery; however, it can be technically difficult and often requires more time and effort. This vessel-sparing technique for anterior urethral reconstruction is reproducible and appears to be reliable in this international cohort. Larger studies and longer follow-up are needed to support these encouraging results.

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.