Re-stricture Rate Research Articles

Comparison of the efficacy and complications of endoscopic incisional therapy and balloon dilatation for benign esophageal strictures

Background: Benign esophageal strictures are treated endoscopically, often with balloon dilatation (BD) or bougie dilators. However, recurrent esophageal strictures have been reported after BD, and severe complications sometimes occur. The aim of this study was to compare the efficacy and complications of endoscopic incisional therapy (EIT) and BD for benign esophageal strictures.Methods: We retrospectively reviewed patients who underwent BD or EIT as primary treatment for benign esophageal strictures between July 2014 and June 2021. Technical success was defined as restoration of the lumen diameter with <30% residual stenosis. Clinical success was defined as no recurrence of dysphagia within 1 month after BD or EIT and an increase of 1 grade or more on the Functional Oral Intake Scale.Results: Thirty patients with benign esophageal stricture were enrolled. There were 16 patients in the BD group and 14 patients in the EIT group. No significant differences in technical and clinical success rates were found between the two groups. Furthermore, no significant differences in the re-stricture rate were observed between the groups. There was one complication in the EIT group and three complications in the BD group. Three patients who underwent BD had re-stricture and underwent EIT thereafter, and we regrouped patients who underwent EIT at least once. The clinical success rate was significantly higher in patients regrouped to the EIT group than in patients who underwent BD only.Conclusions: EIT is not inferior to BD as the primary treatment for benign esophageal strictures, especially for recurrent cases.

Uretroplastia con injerto de mucosa oral para la estenosis de uretra bulbar: resultados y factores predictivos asociados al éxito

Introduction and objectiveThe bulbar urethra is the location where urethral stricture is most commonly observed. The most successful method for long and recurrent urethral stenosis is graft urethroplasty. The most successful graft source is buccal mucosa, with advantages like easy adaptation to the corporeal bed, thick epithelium, thin lamina propria with rich vascular structure and easy ability to obtain the graft. In this study we aimed to retrospectively assess the outcomes and predictive factors affecting surgical success of our buccal mucosal graft urethroplasty surgery performed for bulbar urethra stenosis with moderate length. Material and methodIn this study, we monitored 51 patients with mean 4.4cm bulbar urethral stricture length for mean 17 months follow-up. From operative and postoperative data, stenosis length, operation duration, Qmax, International Prostate Symptom Score, International Index of Erectile Function-Erectile Function and OF, success rates in total and in subgroups (age, according to DVIU, etiology, BMI and DM), follow-up duration, complications, re-stricture time and number were assessed. ResultsThe total success of the operations was 86.3%. In 17 months, the re-stricture rate was 13.7%. Oral and urethral complications were all minor. The complications with longest duration (6 months) were ejaculation, erection problems and urethral fístula. Mean time to re-stricture was 11 months. All re-stricture patients were relieved by one DVIU session each. ConclusionFor bulbar urethral stricture longer than 2cm and with recurrence, the dorsal buccal mucosa graft replacement is a very successful method with low complication rates.

Endoscopic radial incision versus endoscopic balloon dilation as initial treatments of benign esophageal anastomotic stricture.

We aim to evaluate the efficacy and safety of endoscopic radial incision (ERI) versus endoscopic balloon dilation (EBD) treatment of naïve, recurrent, and refractory benign esophageal anastomotic strictures. One hundred and one ERI, 145 EBD, and 42 ERI combined with EBD sessions were performed in 136 consecutive patients with benign esophageal anastomotic stricture after esophagectomy at Zhongshan Hospital from January 2016 to August 2021. Baseline characteristics, operational procedures, and clinical outcomes data were retrospectively evaluated. Parameters and recurrence-free survival (RFS) were compared between ERI and EBD in patients with naïve or recurrent or refractory strictures. Risk factors for re-stricture after ERI were identified using univariate and multivariate analyses. Twenty-nine ERI versus 68 EBD sessions were performed for naïve stricture, 26 ERI versus 60 EBD for recurrent strictures, and 46 ERI versus 17 EBD for refractory stricture. With comparable baseline characteristics, RFS was greater in the ERI than the EBD group for naïve strictures (P=0.0449). The ERI group had a lower 12-month re-stricture rate than the EBD group (37.9% vs 61.8%, P=0.0309) and a more prolonged patency time (181.5±263.1 vs 74.5±82.0, P=0.0233). Between the two interventions, recurrent and refractory strictures had similar RFS (P=0.0598; P=0.7668). Multivariate analysis revealed initial ERI treatment was an independent predictive factor for lower re-stricture risk after ERI intervention (odds ratio=0.047, P=0.001). Few adverse events were observed after ERI or EBD (3.0% vs 2.1%, P=0.6918). ERI is associated with lower re-stricture rates with better patency and RFS compared with EBD for naive strictures.

Buccal mucosa graft urethroplasty for bulbar urethral stricture: Outcomes andpredictive factors affecting success

Introduction and objectiveThe bulbar urethra is the location where urethral stricture is most commonly observed. The most successful method for long and recurrent urethral stenosis is graft urethroplasty. The most successful graft source is buccal mucosa, with advantages like easy adaptation to the corporeal bed, thick epithelium, thin lamina propria with rich vascular structure and easy ability to obtain the graft. In this study we aimed to retrospectively assess the outcomes and predictive factors affecting surgical success of our buccal mucosal graft urethroplasty surgery performed for bulbar urethra stenosis with moderate length. Material and methodIn this study, we monitored 51 patients with mean 4.4 cm bulbar urethral stricture length for mean 17 months follow-up. From operative and postoperative data, stenosis length, operation duration, Qmax, International Prostate Symptom Score, International Index of Erectile Function-Erectile Function and OF, success rates in total and in subgroups (age, according to DVIU, etiology, BMI and DM), follow-up duration, complications, re-stricture time and number were assessed. ResultsThe total success of the operations was 86.3%. In 17 months, the re-stricture rate was 13.7%. Oral and urethral complications were all minor. The complications with longest duration (6 months) were ejaculation, erection problems and urethral fistula. Mean time to re-stricture was 11 months. All re-stricture patients were relieved by one DVIU session each. ConclusionFor bulbar urethral stricture longer than 2 cm and with recurrence, the dorsal buccal mucosa graft replacement is a very successful method with low complication rates.

Laparoscopic management of post pancreaticoduodenectomy benign hepaticojejunostomy stricture: A case report

Hepaticojejunostomy (HJ) stricture following pancreaticoduodenectomy (PD), though rare, can have serious consequences as they can present with recurrent cholangitis. Percutaneous interventional procedures are the usual first line treatment options but have high re-stricture rates and require multiple sittings. We present a case of 64 year old gentleman who underwent open PD for ampullary adenocarcinoma in 2010 and received 6 cycles of adjuvant chemotherapy. He had recurrent attacks of cholangitis since June 2019 and was managed initially with medical therapy. He was diagnosed to have a stricture of HJ with multiple stones in the biliary system proximally. After failed conservative therapy, the patient was subjected to laparoscopic revision of HJ. After adhesiolysis, the previous HJ was dismantled, ducts cleared off stones and an end to side HJ was done using PDS 3-0 sutures. The total operating time was 165 minutes and the total blood loss was about 100 mL. The patient developed fever on post-operative day (POD) 2 and was managed with antibiotics. He was discharged on POD 6. He has been on follow-up for more than three months now and has been asymptomatic. Laparoscopic revision of HJ stricture following PD appears to be feasible with good outcome when performed by an experienced hepatobiliary surgeon. Long term follow-up is needed before firm conclusions can be drawn.

Comparison of the Efficacy and Safety of Endoscopic Incisional Therapy and Balloon Dilatation for Esophageal Anastomotic Stricture

BackgroundBenign esophageal anastomotic strictures have typically been treated using endoscopic methods, often with balloon dilatation (BD). However, recurrent esophageal strictures after BD have been reported. We evaluated the efficacy and safety of endoscopic incisional therapy (EIT) and BD for treating an anastomotic stricture after a total gastrectomy. MethodsSubjects who underwent EIT or BD as a first treatment for esophagojejunostomy anastomotic stricture after a total gastrectomy between January 2010 and December 2018 were eligible. The medical records of these cases were retrospectively reviewed. Stricture was defined as an inability to pass a normal diameter endoscope (10.2 mm). The stricture area was incised under direct vision with the nano-insulated-tip knife in a radial fashion parallel to the longitudinal axis of the esophagus. ResultsTwenty-one patients in our database presented with benign anastomotic stricture after a total gastrectomy for advanced gastric cancer. The BD group included 12 patients. The remaining nine patients underwent EIT, and three of these cases received an immediate additional BD. The re-stricture rate was significantly different between the BD and EIT groups (41.7% vs. 0%, respectively; P = 0.045). There were no significant differences in procedure time, interval from surgery to first stricture, hospitalization period, or complication rates between the groups. One patient developed a microperforation during BD and was treated without surgical intervention. ConclusionsEIT is a safe and effective primary treatment modality compared with BD for esophagojejunostomy anastomotic stricture after a total gastrectomy as it shows a significantly lower re-stricture rate.

Bile duct injury repairs: progressive outcomes in a tertiary referral center

Background: Bile duct injury associated with cholecystectomy persists as a significant problem in general surgery. There exist concerns over referral for definitive management of complex injuries in order to minimize complications, including re-stricture. Methods: Our group analyzed our experience in bile duct repairs at a tertiary referral center over two eras 1987–2001 (n = 59) and 2002–2016 (n = 51) using regression analysis to evaluate re-stricture rates. Results: Patient demographics and presentation were similar between the two eras with respect to age, gender, race, BMI, incidence of arterial injury and Bismuth grade. The latter era demonstrated a lower incidence of attempted outside repairs (47% vs. 68%; p = 0.046), a higher incidence of cholecystitis (51% vs. 32%; p = 0.038), PTC placement (59% vs. 27%; p = 0.022), and more complex repairs (47% vs. 19%; p = 0.001) The latter era exhibited an increased length of stay (9.6 vs 8.3 days; p = 0.026), equivalent complications (16% vs. 14%; p = 0.07) and mortality (5% vs. 2%; p = 0.13), but a lower re-stricture rate (8% vs. 29%; p = 0.005). Regression analysis identified: higher Bismuth grade (p = 0.026), cholecystitis, (p = 0.007), and PTC (p = 0.009) were associated with increased of length of stay. Advanced age (p = 0.043) was associated with complications. Higher injury (p = 0.005), and earlier era of repair (p = 0.020) were associated with recurrent stricture. High injuries (Bismuth III-V) required more complex repairs and resulted in overall higher complication rates (29% vs. 24%; p = 0.07), but a lower re-stricture rate was noted in the latter era (11% vs. 21%; p = 0.060). Conclusion: Our data identified there were no significant changes in the demographics or clinical presentation of bile duct injury over the two eras. However, the second era realized an increased use of complex reconstructions resulting in a significantly lower incidence of re-stricture. Regression confirmed surgical experience rather than complex repairs were the etiology, reaffirming the benefits to referral of bile duct injuries to a specialty center.Tabled 1VariableCoefficientStd Errz-valuep-valueAge at repair0.00902120.01585080.5690.5693Male Gender–0.13409340.6476022–0.2070.836Caucasian0.00512180.61864160.0080.9934BMI0.05491090.0494671.110.267Bismuth Grade–0.19489290.2567286–0.7590.4478Arterial injury0.30054490.77263270.3890.6973PTC placed0.08323910.5711970.1460.8841Prior repair0.84388290.60633441.3920.164Repair date–0.00043930.000189–2.3250.0201Complex Repair–0.24534470.761525–0.3220.7473 Open table in a new tab

Assessment of the Heineke–Mikulicz anoplasty for skin level postoperative anal strictures and congenital anal stenosis

IntroductionAcquired skin-level strictures following posterior sagittal anorectoplasty (PSARP) and some rare cases of congenital anal stenosis can be managed using a Heineke–Mikulicz like anoplasty (HMA). We hypothesized that this procedure was an effective, safe, and durable outpatient procedure in select patients. MethodsWe retrospectively reviewed all patients who underwent HMA for skin level strictures following PSARP or for certain congenital anal stenoses from 2014 to 2017. ResultsTwenty-eight patients (19 males, 9 females) with a mean age of 5.8 years (range 0.5–24.4) underwent HMA. Twenty-six had a prior PSARP, of which 18 were redo, and 8 were primary procedures. Two patients had congenital skin level anal stenosis. The mean follow up was 1.0 years (range 0.4–2.9). The average preprocedure anal size was Hegar 8, which after HMA increased 8 Hegar sizes to 16 (95% CI 7–9, p < 0.001). There were no operative complications. One patient restenosed and required a secondary procedure. ConclusionHMA is a safe procedure for skin-level anal strictures following PSARP (primary and redo) and can also be used in some rare cases of congenital anal stenosis. Long-term follow up to determine the restricture rate is ongoing. A plan to do an HMA if a stricture develops may offer an alternative to routine anal dilations, particularly after a redo PSARP in an older child. Type of studyCase series. Level of evidenceLevel IV.

The Effectiveness of Tamoxifen in the Prevention of Recurrent Urethral Strictures Following Internal Urethrotomy

Objective: Tamoxifen was not used earlier in clinical practice to decrease the urethral re-stricture rate after visual internal urethrotomy (VIU). In this study, we are the first to report the use of Tamoxifen as an adjuvant therapy to decrease the re-fibrosis and stricture recurrence post-VIU. Patients and Methods: Between 2015 and 2017, 60 patients underwent VIU for post-traumatic bulbar urethral stricture ≤1 cm. They were randomly divided into 2 groups (30 patients each). The Tamoxifen group cases received Tamoxifen 10 mg twice daily for 6 months post-VIU. The control group did not receive any medications. All patients were evaluated using the IPSS score, uroflowmetry, and perineal ultrasonography preoperatively at 3 and 6 months. Results: At presentation, there was no significant difference between patients of both groups in terms of IPSS score, Qmax, stricture width, and length. At 6 months follow-up, the mean IPSS score for the Tamoxifen group was 12.3 (8–19) in comparison with 20 (12–26) in the control group (p < 0.001). The Tamoxifen group had mean Qmax 11.1 mL/s (9–14), while those of the control group had mean Qmax 8.2 mL/s (6–10; p < 0.001). Using perineal ultrasound, only stricture width showed to be significantly smaller in the Tamoxifen group (p = 0.001). Conclusion: Tamoxifen seemed to be effective in reducing the recurrence of urethral stricture post-VIU. There was a significant improvement of the clinical outcome regarding Qmax and IPSS score after Tamoxifen adjuvant therapy.

Pelvic fracture urethral injury in males-mechanisms of injury, management options and outcomes.

Pelvic fracture urethral injury (PFUI) management in male adults and children is controversial. The jury is still out on the best way to manage these injuries in the short and long-term to minimise complications and optimise outcomes. There is also little in the urological literature about pelvic fractures themselves, their causes, grading systems, associated injuries and the mechanism of PFUI. A review of pelvic fracture and male PFUI literature since 1757 was performed to determine pelvic fracture classification, associated injuries and, PFUI classification and management. The outcomes of; suprapubic catheter (SPC) insertion alone, primary open surgical repair (POSR), delayed primary open surgical repair (DPOSR), primary open realignment (POR), primary endoscopic realignment (PER), delayed endoscopic treatment (DET) and delayed urethroplasty (DU) in male adults and children in all major series have been reviewed and collated for rates of restricture (RS), erectile dysfunction (ED) and urinary incontinence (UI). For SPC, POSR, DPOSR, POR, PER, DET and DU; (I) mean RS rate was 97.9%, 53.9%, 18%, 58.3%, 62.0%, 80.2%, 14.4%; (II) mean ED rate was 25.6%, 22.5%, 71%, 37.2%, 23.6%, 31.9%, 12.7%; (III) mean UI rate was 6.7%, 13.6%, 0%, 14.5%, 4.1%, 4.1%, 6.8%; (IV) mean FU in months was 46.3, 29.4, 12, 61, 31.4, 31.8, 54.9. For males with PFUI restricture and new onset ED is lowest following DU whilst UI is lowest following DPOSR. On balance DU offers the best overall outcomes and should be the treatment of choice for PFUI.

Describing the learning curve for bulbar urethroplasty.

BackgroundLearning curves have been described for a number of urological procedures including radical prostatectomy and laparoscopic nephrectomy but rarely for urethroplasty. We describe the learning curve for bulbar urethroplasty in a single surgeon series.MethodsA retrospective case note review was performed of 91 consecutive men median age 32 years (range, 15–66 years) having bulbar urethroplasty performed by a single surgeon. Data was collected on type of urethroplasty, restricture rate (as defined by urethrogram and/or flow rate) and duration of follow up. The restricture rates were compared by quartiles and statistical analysis was by ¦Ö2 between the first and fourth quartiles.ResultsThe 91 men had 42 dorsal onlay buccal mucosal graft (Dorsal BMG), 20 BMG augmented bulbobulbar anastomotic (Augmented Rooftop) and 29 bulbobulbar anastomotic (BBA) urethroplasties performed. Median follow up was 39 months for the first quartile, 42 months for the second, 36 months for the third, and 35 months for the fourth. The restricture rate was 17% in the first quartile, 8.7% in the second and third quartiles and 4.5% in the fourth quartile. There were no restrictures noted after 24 months. There were 4 restrictures in the first quartile and 1 restricture in the fourth quartile (¦Ö2 P<0.01).ConclusionsThere is a statistically and clinically significant difference in restricture rates between first and fourth quartiles with rates falling from 17% to 4.5%. There is a learning curve for bulbar urethroplasty with a reduced restricture rate each quartile and it may take as many as 90 cases to reach optimum restricture rates.

Buccal mucosal graft urethroplasty in men-risk factors for recurrence and complications: a third referral centre experience in anterior urethroplasty using buccal mucosal graft.

BackgroundUrethral stricture disease is a challenging condition to treat and several approaches including direct visual internal urethrotomy (DVIU) and anastomotic or augmentation urethroplasties based on the use of flaps and graft have been reported. The aim of this study is to determine risk factors for stricture recurrence and complications in patients having buccal mucosal graft (BMG) urethroplasty for anterior urethral stricture under a single surgeon in a third referral centre in UK.MethodsWe conducted a retrospective review of a prospectively gathered database of 128 patients having various forms of BMG urethroplasty between 2001 and 2015. Success and failure in terms of stricture recurrence, patient demographics, stricture aetiology and anatomy, and the adverse outcomes of: post-micturition dribbling (PMD), erectile dysfunction (ED) >12 months and complications were recorded in order to determine risk factors for recurrent stricture and complications.ResultsThe mean age of all patients was 42.8 years (range, 16–74 years). Average follow-up was 45 months (range, 3–159 months). The total re-stricture rate was 19% (24 men). PMD was reported in 16% (n=20) and ED in 12.5% (n=16). All ED was none organic and responded to oral PDE5 inhibitor treatment. Post-operative complications were reported in 16 patients (12.5%). The most frequent complications recorded were urinary fistula (n=4; 3.1%), graft contracture (n=4; 3.1%) and graft failure (n=4; 3.1%), all reported after penile urethroplasty. Univariate analysis indicated that age at surgery, stricture length, site and aetiology were all significant risk factors for stricture recurrence. On multivariate analysis penile site was the only significant independent variable for restricture.ConclusionsBMG urethroplasty represents a reliable therapeutic option for patient with urethral strictures with a success rate of 81% at 45 months of follow-up. Complications are more common in complex stricture of the penile urethra. On multivariate analysis penile site was the only significant independent variable for re-stricture.

Surgical management of biliodigestive dysfunction is superior over percutaneous management. Six year experience of an HPB center in Colombia

Objective: The rate of success in biliodigestive anastomosis BDA- (choledochoduodenostomy CD- or Hepaticojejunostomy HJ-) in patients with biliary injuries postcholecystectomy or benign biliary strictures is above 90%. However, the dysfunction of this diversion leads to complication such as: recurrent pyogenic cholangitis, hepatolithiasis, secondary sclerosing cholangitis or cirrhosis. Its management has become a challenging topic for surgeons nowadays. Describe the social, demographic and clinic characteristics of patients with biliodigestive anastomosis dysfunction and their prognosis after surgical management. Methods: We performed an observational and retrospective study from September of 2010 to May of 2016, it included all patients with biliodigestive anastomosis made at our institution or at other hospitals presenting with complications after the reconstruction. The outcomes evaluated were: rate of cholangitis per year, re-stricture rate and mortality. Results: We identified 60 patients with BDA (5 CD and 55 HY). 24 had a dysfunctional diversion: 5 CD and 19 HY. Seven of them where managed with internal-external percutaneous diversion and 17 needed a new Hepp – Couinaud hepaticojejunostomy. Five patients demanded hepatectomy after the reconstruction. Of the 7 patients managed by percutaneous diversion, 4 ended in liver transplantation. Of the 17 patients managed surgically, just two called for a new percutaneous management. None patients have a Dindo Clavien grade V complication. Conclusion: Surgical management of biliodigestives dysfunction are safe and superior compared with percutaneuos management.

PD44-06 WHAT CONSTITUTES COMPLEXITY IN THE SURGICAL RECONSTRUCTION OF PELVIC FRACTURE-RELATED URETHRAL INJURIES?

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) III1 Apr 2016PD44-06 WHAT CONSTITUTES COMPLEXITY IN THE SURGICAL RECONSTRUCTION OF PELVIC FRACTURE-RELATED URETHRAL INJURIES? Simon Bugeja, Stella Ivaz, Anastasia Frost, Enrique Fes, Felix Campos, Daniela Andrich, and Anthony Mundy Simon BugejaSimon Bugeja More articles by this author , Stella IvazStella Ivaz More articles by this author , Anastasia FrostAnastasia Frost More articles by this author , Enrique FesEnrique Fes More articles by this author , Felix CamposFelix Campos More articles by this author , Daniela AndrichDaniela Andrich More articles by this author , and Anthony MundyAnthony Mundy More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1798AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bulbo-prostatic anastomotic urethroplasty (BPA) for urethral injuries associated with traumatic disruption of the pelvic ring is notoriously a surgical challenge, often requiring various manouvres to straighten the course of the bulbar urethra and bridge the resulting defect. There are however other factors which may render the reconstructive procedure more complex. This study investigates these factors. METHODS 360 BPAs were performed in a single tertiary referral centre between October 1996 and October 2014. 77 (21%) were revision procedures. Mean patient age was 37.9 years. Mean follow-up was 51 months (range 9-115 months). Recurrence was defined radiologically and/or by the need for any further surgical intervention including dilatation or urethrotomy. RESULTS 286 (79%) procedures were carried out transperineally (Step 1-4) while 74 (21%) required additional abdominal exposure to mobilise the bladder bladder base (n=16), repair associated injuries (n=41) or perform an entero-urethroplasty (n=17). 29 of 74 (39%) abdomino-perineal (AP) procedures were revisions. 48 of 77 revisions (62%) were performed via a transperineal approach. The restricture rate was higher for revision procedures compared to primary ones when approached transperineally (15% vs 8%) but not for AP procedures (21% in both primary and revision cases). Overall, the recurrence rate for AP procedures was 21% compared to 9% for the transperineal approach. Associated bladder neck injury (n=18), uro-rectal/perineal fistulae (n=15), perineal degloving injury (n=6), anterior urethral stricture (n=19) and osteomyelitis/pelvic sepsis (n=10) were identified as factors adding complexity to the procedure. CONCLUSIONS A longer defect and revisional surgery often require corporal separation, inferior wedge pubectomy and rerouting of the urethra around the crura in a stepwise fashion in order to guarantee a tension-free anastomosis. These render the procedure more difficult but do not necessarily imply increasing complexity. Factors necessitating a change in approach (usually but not exclusively requiring additional abdominal exposure) to deal with multiple pathologies such as the need for bladder neck reconstruction or concominant anterior urethral strictures are what render the procedure complex. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1000 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Simon Bugeja More articles by this author Stella Ivaz More articles by this author Anastasia Frost More articles by this author Enrique Fes More articles by this author Felix Campos More articles by this author Daniela Andrich More articles by this author Anthony Mundy More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Durability of Memokath™ urethral stent for stabilisation of recurrent bulbar urethral strictures – medium‐term results

To examine the durability after 3 months deployment of a urethral (Memokath™) stent in conjunction with endoscopic treatment of recurrent bulbar urethral strictures, as repeated endoscopic treatment of urethral strictures can cause worsening of underlying spongiofibrosis. Prospective series of 22 patients with recurrent bulbar strictures requiring repeat endoscopic treatment were included. The median age was 38 years and the mean stricture length was 2.4 cm. The median number of previous dilatation or direct visual internal urethrotomy (DVIU) procedures was three with a mean time to stricture recurrence of 2 months. After endoscopic dilatation or DVIU, the urethral (Memokath™) stent was deployed and left situ for 3 months. Re-stricture rates were examined with uroflowmetry at 3, 6 and 12 months and confirmed with 17-F cystoscopy at 1 year after stent removal. A telephone survey was conducted at >1-year follow-up. Five of the 22 (22%) patients had stricture recurrence after stent removal. In all, 17/22 (78%) patients remained stricture-free at a median (range) follow-up of 23 (9-31) months. Uroflowmetry showed significantly improved flow rates, which were sustained at 12 months after stent removal. On Kaplan-Meier analysis, there was a significant delay (23 vs 2 months) in stricture or symptom recurrence after stent removal. The medium term results of temporary urethral stent placement are encouraging with 78% of patients remaining stricture-free at a median follow-up of 23 months.

Retrospective outcome analysis of urethroplasties performed for various etiologies in a single South African center

Objectives: To compare the results of anastomotic versus augmentation urethroplasty (buccal mucosa graft (BMG) onlay), as well as dorsal versus ventral BMG techniques. Methods: A retrospective audit of 69 patients who underwent urethroplasty at Eersteriver Hospital in Cape Town, South Africa between October 2004 and July 2011 was undertaken. Analysis included stricture etiology, location and length, type of surgery performed as well as complication rates over the follow-up period. Results: The predominant stricture etiologies were traumatic and infective causes (55%), with a mean stricture length of 3 cm (0.5–15 cm). Forty two patients had bulbar urethra strictures (61%), with 8 (11%) located in the posterior, and penile & bulbar regions, respectively. The remaining strictures were located in the penile urethra (16%). Surgery performed included bulbar (12) and membranous anastomotic (8) urethroplasty, ventral (13) and dorsal (22) buccal mucosa onlay grafts (BMG), and 2-stage urethroplasty (14). Overall stricture recurrence was seen in 9 patients (13%), including 1 patient (8%) of the anterior end-to-end anastomotic group compared to 2 patients (6%) of the onlay BMG group (p = 0.77). The re-stricture rates were 5% and 8% in the dorsal (1/22) and ventral BMG onlay groups (1/13), respectively (p = 0.72). Conclusions: Both anastomotic and BMG onlay techniques are safe and effective surgical options. Similar outcomes were demonstrated between ventral and dorsal BMG onlay groups.

Postcholecystectomy benign biliary stricture: Surgery is the gold standard

AbstractPost cholecystectomy bile duct strictures present a challenge to the treating physicians. Advancement in skills and technology offers alternative treatment modalities to the standard surgical repair. Contemporary series of surgical repair by experienced surgeons report excellent long-term results with &lt;5% restricture rates. Endoscopic therapy is conceptually flawed, is not applicable to all patients, requires prolonged duration of treatment with multiple interventions. Surgical repair by an experienced surgeon is the “Gold Standard” of care in management of postcholecystectomy bile duct strictures.

Surgical treatment of biliary ductal stricture complicating localized left hepatolithiasis.

To summarize the experience in the clinical treatment of biliary duct strictures complicating localized left hepatolithiasis in the last two decades. A retrospective analysis of 67 cases of biliary duct strictures complicating localized left hepatolithiasis treated in our center in the last two decades was made with regards to each patient's age, gender, results of various preoperative examinations, operative findings, treatment and postoperative courses. The incidence of left hepatic duct (LHD) stricture was 59.8% and that of a left external hepatic duct (LEHD) stricture was 84.0 % and 84.8% respectively, in which a severe degree dominated. Among the operative procedures used in the treatment of LHD strictures, plastic operation plus biliary enteric anastomosis ranks first in frequency (52.2%), with a re-stricture rate of 17.1%. Left lobectomy ranks third (19.4%) with no re-stricture. Simple plastic performance or dilation had a high occurrence rate of re-stricture and usually needed subsequent surgery. Most LEHD strictures were eradicated by lateral segmentectomy or lobectomy, whereas most LMHD strictures were just the opposite. The rate of preoperative diagnosis of LMHD by endoscopic retrograde cholangiography, percutaneous transhepatic cholangiography, computed tomography or intraoperative and postoperative trans-T-tube cholangiography was much lower than that of LEHD or extrahepatic duct. Too much attention paid to LEHD disorders in the treatment of localized left hepatolithiasis potentially results in negligence or omission in LMHD disorders. Malpractice treatments of LHD strictures are important factors affecting the long term results of localized left hepatolithiasis, for which left lobectomy is usually the therapy of choice.

61 END-TO-END REPAIR OR BUCCAL MUCOSA GRAFT FOR SINGLE-STAGE BULBAR URETHROPLASTY?

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 201061 END-TO-END REPAIR OR BUCCAL MUCOSA GRAFT FOR SINGLE-STAGE BULBAR URETHROPLASTY? Kathy Vander Eeckt, Paolo Gontero, and Steven Joniau Kathy Vander EecktKathy Vander Eeckt Leuven, Belgium More articles by this author , Paolo GonteroPaolo Gontero Turin, Italy More articles by this author , and Steven JoniauSteven Joniau Leuven, Belgium More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.108AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES It is common practice to use an end-to-end (ETE) urethroplasty in short (≤2cm) urethral strictures and a substitution urethroplasty in longer urethral strictures (>2cm). However, the restricture rates and functional outcomes of those 2 techniques have never been compared directly. We aimed to compare the restricture rates and erectile function changes after single-stage ETE versus buccal mucosa graft (BMG) repair for bulbar urethral stricture disease. METHODS 103 patients underwent a single-stage bulbar urethroplasty at our institution between 2003 and 2009: 42 patients had an ETE and 61 a BMG repair. Different clinical parameters were collected: pre- and postoperative maximum flow rate (Qmax), previous urethral manipulations, stricture length, postoperative complications, remembered preoperative IIEF-5 score (r-IIEF-5) and prospectively collected IIEF-5 (p-IIEF-5) and IPSS scores at last follow-up. Any urethral instrumentation after surgery was considered a treatment failure. RESULTS The mean stricture length was 1.34 cm in ETE versus 2.89 cm in BMG repair (p<0.001). 95 patients (92.2%) had undergone at least one previous urethral manipulation. Of the 17 patients who had undergone previous open surgery, 16 received a BMG repair. The mean pre- and postoperative Qmax of ETE versus BMG urethroplasty were 8.1 vs. 8.72 ml/s (p=0.6) and 20.4 vs. 19.9 ml/s (p=0.8) respectively. The mean follow-up was 25.3 months (SD +/- 22.3) and this was identical for the two groups (p=0.99). Complication rate was 9.7%, with no significant difference between groups. The estimated failure-free rate of the ETE and the BMG repair were 79.9% and 90.2% respectively (p=0.3). IPSS at last follow-up was in favor of the ETE (5.4 vs 8.8, p=0.046). 44% of the patients had new onset postmicturation dribbling with no significant difference between the 2 groups. (p=0.18). There was a significant difference between overall r-IIEF-5 (mean 20.6 (SD +/-5.7)) and p-IIEF-5 (mean 16.7 (SD +/-8.4)) (p=0.0008). No difference in r-IIEF-5 (p=0.16) and p-IIEF-5 (p=0.72) was noted between groups. CONCLUSIONS In bulbar urethral strictures, the failure-free rates and erectile function changes after end-to-end or BMG repair were comparable, even though stricture disease was more complex in the BMG group. These results have important implications for clinical practice, as when there is any doubt during surgery about the feasibility of performing an end-to-end urethroplasty, the threshold to take a BMG must be low. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e26 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kathy Vander Eeckt Leuven, Belgium More articles by this author Paolo Gontero Turin, Italy More articles by this author Steven Joniau Leuven, Belgium More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

What is an Acceptable Re-Stricture Rate after Urethroplasty?

Objective: To assess a single surgeon's re-stricture rate after urethroplasty in an unselected group of patients compared with a highly selected group of complex patients and so define a re-stricture rate that can be used for counselling patients preoperatively. Patients: In the 3-year period 2004–2007 the authors between them performed 554 urethral reconstructions and the senior author performed the 123 most complex cases. In the same 3-year period the senior author also performed 146 consecutive unselected urethral reconstructions in a separate unit alone. The results of these two sets of patients were compared. Results: In the combined unit the senior surgeon's overall re-stricture rate with complex cases was 11%. None occurred in the bulbar urethroplasty group and the re-stricture rate was the same in the primary cases and the revision cases. In the unselected group of patients the re-stricture rate was 4–11% and varied according to the location and complexity of the stricture. Conclusions: Case mix influences the results of surgery and can double the re-stricture rate from about 5% to about 10%. Bulbar urethroplasty has the lowest re-stricture rate. Penile urethral surgery for strictures of increasing length carries an increasingly high re-stricture rate. The re-stricture rate after transperineal repair of pelvic fracture urethral injuries is 5–10% again according to complexity. The surgery of posterior urethral strictures is an altogether different technical exercise which should be considered separately.