Urethral Dilatation Research Articles

Female ventral-onlay buccal mucosal graft urethroplasty supported with martius labial fat pad flap: early results.

There is a growing interest in reconstructive urology and female urethroplasty. We aimed to report our experience in ventral-onlay buccal mucosa graft (BMG) urethroplasty supported with Martius flap (MF) in treating female urethral stricture disease. We retrospectively evaluated data of 18 female patients (ages 35-78) who were diagnosed with urethral stricture disease and underwent ventral-onlay BMG urethroplasty supported with MF by single surgeon in a tertiary referral centre between February 2019 and October 2022. Detailed history, international prostate symptom score (IPSS), pelvic examination, urine flow rate (rate and pattern), post void residual (PVR), storage and voiding phase urodynamic study, and voiding cystourethrography were recorded. At the last visit; the number of urethral dilatations before urethroplasty, time from urethral dilation to urethroplasty, hospital stay, urethral catheterization time, postoperative IPSS, PVR and uroflowmetry values were recorded. The presenting symptoms were obstructive voiding symptoms in 16 patients. While the mean number of urethral dilatation was 2.11 ± 1.93 (1-7), the mean time from dilatation to urethroplasty was 5.83 ± 5.00 (1-19months) months. Maximum flow rate increased from 8.36 ± 3.26ml/sec in preoperative uroflowmetry to 21.45 ± 5.27ml/sec at the last follow-up (p < 0.001). Post-void residual urine (PVR) decreased from preoperative mean 116.66 ± 105.88cc to 26.94 ± 22.69cc postoperatively (p < 0.004). None of the patients developed stricture recurrence, incontinence or vaginal fistula until the last follow-up. The mean follow-up period was 17.28 ± 11.65 (1-35) months. A ventral-onlay BMG urethroplasty supported with MF represents an effective and reproducible treatment option for FUS in the present study.

Surgery for female urethral stricture.

Female urethral stricture (FUS) is a rare entity that causes great morbidity and suffering in those affected. As the available scientific data is sparce, there are no formal guidelines or standard of care for this disease. This is a narrative review of the surgical management for female urethral stricture. The literature review was performed on PubMed. Articles were limited to English, but there was no limitation in terms of date. Management of FUS is divided between endoscopic and open surgical repair. Urethral dilation with or without urethrectomy can be offered as a first-line treatment. However, the rate of success of this procedure remains inferior to open surgical repair, and its efficacy decreases with the number of previous dilations. For distal urethral strictures, distal urethrectomy and advancement meatoplasty may be considered. Vaginal flaps are readily available, easy to harvest, well-vascularized, and allow for a dorsal or ventral orientation urethroplasty. The results of this procedure are promising, but most studies are small and retrospective. Labia flaps are easily accessible, wet, hairless, and elastic. The main limitations with the use of vaginal or labial tissues are co-existing conditions such as lichen sclerosis or vaginal atrophy, which may affect future results. Vaginal and labial graft urethroplasty can be used when it is not possible to mobilize an adequate flap. Stricture-free rates of this technique are variable. In cases of more severe stricture, an augmentation urethroplasty using buccal mucosa graft may be necessary. The techniques used in FUS replicate those for male urethral strictures, where both ventral and dorsal approaches can be utilized. Although there is growing interest in the field, the optimal management of FUS remains to be determined.

Breakage and detachment of the rigid cystoscope's distal tip: an unusual case of urological instrument malfunction.

Herein, we describe an unusual case of cystoscope damage during a planned laser cystolithotripsy in a 65-year-old male with a previous history of radical prostatectomy for prostate cancer and subsequent serial urethral dilations for bladder neck contracture. Upon crossing the penile urethra without exerting significant pressure, we noticed the cystoscope's distal metallic tip detachment. Therefore, we re-introduced another 22Fr cystoscope and removed the broken part with alligator forceps. Fortunately, no urethral injury or associated complications were noticed on gently re-entering the bladder. Hence, we managed to complete the endoscopic laser cystolithotripsy shortly thereafter. Review of the relevant literature revealed three similar cases. All related to the same manufacturer. Urologists should not lose sight of the fact that such an unexpected instance may tremendously impact the procedure's success, requiring vigilance and adherence to safety protocols.

Dorsal onlay buccal mucosal graft urethroplasty for female urethral stricture: Techniques and outcomes

ObjectiveFemale urethral stricture (FUS) accounts for about 4%–13% of cases of female bladder outlet obstruction. FUS was and is still managed by repeated dilatations and/or direct visual internal urethrotomy. There are many alternative options for reconstruction like buccal or vaginal mucosal graft urethroplasty. Our aim was to describe the technique of dorsal onlay buccal mucosal graft (BMG) urethroplasty for FUS and present the outcomes. MethodsBetween January 2014 and December 2021, 37 patients who underwent dorsal onlay BMG urethroplasty were included in the study. Their pre-operative diagnosis was confirmed with uroflowmetry, micturating cystourethrogram, urethral calibration, and on table cystoscopy. Bladder catheter was removed after 2 weeks. Patients were followed up at 3 months, 6 months, 1 year, and then annually with urine analysis, uroflowmetry, and post-void residual assessment. We defined success as a maximum flow rate (Qmax) above 15 mL/s without the need for an additional instrumentation. ResultsThe mean age of patients was 47.8 (standard deviation [SD] 11.3) years. Twenty patients had previously undergone urethral dilatations. The mean pre-operative Qmax was 7.79 (SD 3.73) mL/s. However, the mean Qmax improved to 23.20 (SD 8.25) mL/s after surgery. The mean post-void residual urine after surgery was 30.50 (SD 10.70) mL. This reduced from a mean value of 139.00 (SD 147.24) mL before surgery. The mean follow-up was 30.2 (SD 18.3, range 18–44) months. There was no post-operative incontinence. There were Clavien–Dindo Grade 1 complications in 6 out of 37 (16.2 %) patients during hospital stay. The only long-term complication was recurrence of stricture in 4 (10.8%) patients. ConclusionDorsal onlay BMG urethroplasty in females is a safe, effective technique which can avoid repeated painful dilatations and multiple urethrotomies. One should always consider reconstruction in FUS without any fear of incontinence.

Treatment algorithm for the comprehensive management of severe lichen sclerosus in boys based on the pathophysiology of the disease

It is estimated that approximately one out of 200 boys has the diagnosis of lichen sclerosus (LS), previously referred to as BXO (balanitis xerotica obliterans). Severe progressive disease is rare however, mismanagement of urethral tissues may contribute to progression of LS. The current literature regarding the management of severe lichen sclerosus was reviewed alongside our management of seven patients with ages ranging from six to ten years of age with severe lichen sclerosus who required surgical intervention. These patients were identified out of a busy pediatric practice that saw 5507 patients during the four-year span. Based on the pathophysiology of lichen sclerosus, urethral anatomy, and our management an algorithm was developed for medical and surgical management. All patients received initial medical treatment with topical steroids. Three patients underwent urethral mobilization and serial biopsy. One of these patients with severe disease required a second distal urethral mobilization. Three patients were treated with circumcision, and one is responding well to topical steroids after complex reconstruction. None developed postoperative urethral disease. Lichen sclerosus affects squamous epithelium but can extend to unaffected tissue if traumatized via the Koebner phenomenon. There are no randomized control trials for the management of the disease. Thus, appropriate early management with avoidance of urethral dilation or incision may prevent extension down the urethra that can lead to severe stricture disease. Several authors identified this as one of the worst forms of stricture diseases to manage. Based on the pathophysiology of the disease and our 4-year experience treating patients, we propose an algorithm for management of severe lichen sclerosus in boys. The diagnosis of lichen sclerosus in boys requires a high level of suspicion, and early biopsies should be obtained if suspected. If identified before circumcision or meatotomy, initial treatment should be medical. If the patient fails topical steroid therapy, circumcision and biopsy are the initial recommended surgical approach. Optimally, a biopsy with the first meatotomy establishes the diagnosis. If the disease persists, urethral mobilization may represent a curative treatment as it advances healthy urethra and allows complete removal of distal squamous epithelium instead of traumatic repeated dilations or incisions. This paper summarizes the available literature on the management of severe LS and provides a flow diagram based on the pathophysiology of the disease and our experience sever cases.

Progressive urethral dilation in male horses undergoing perineal urethrotomy for cystolith removal: 22 cases

This retrospective case series describes the use of progressive urethral dilation in 22 client-owned male horses undergoing perineal urethrotomy (PU) for cystolith removal. Medical records of horses undergoing PU and urethral dilation for treatment of cystolithiasis were reviewed. Dilation of the pelvic urethra was performed following PU and using customized dilators with the same length (30cm) and with various outer diameters (25 to 45mm). Analyzed data included: signalment, cystolith size, renal ultrasound findings, method used for cystolith removal, diameter of urethral dilators, intra- and post-operative complications, and hospitalization time. Cystolith size ranged between 37mm and 90mm. Dilation of the pelvic urethra was as follows: 35mm (n=8), 25mm (n=6), 39mm (n=3), 33mm (n=2), 28mm (n=2) and 45mm (n=1). In 6 cases, the cystolith was removed without fragmentation. In the remaining 16 horses, lithotripsy was performed with forceps (n=9) or a pneumatic scaler (n=7). In 15 horses a retrieval device was used to aid in calculi removal. Hospitalization time ranged between 1 and 5 days. Intra-operative complications occurred in one horse. No post-operative complications were recorded. Follow-up information was available for 21 horses (range 1-8 years). Urethral dilation via PU may be a viable option for cystolith removal in male horses.

OUTCOMES OF URETHRAL DILATION WITH AMPLATZ DILATORS IN THE MANAGEMENT OF URETHRAL STRICTURES

This study aimed to determine the outcomes of urethral dilation with amplatz dilators in managing urethral strictures. We conducted this descriptive case series at multiple centers, including Waseem Medical Centre Batkhaila and Mercy Teaching Hospital Peshawar, from November 2022 to April 2023. A total of 30 male patients presented with urethral strictures were treated with urethral dilation using amplatz dilators. The outcomes assessed were maximum urinary flow and Post-void residual urine. Paired samples T-test was used for numerical variables. Mean age of patients was 64.87±11.96 years. Preoperative mean uroflowmetry flow (Qmax) was 8.6±2.97 mL/sec, while the PVR preoperatively was 198.4±59.19 mL. Qmax improved in 1st month at 18.87±2.64 mL/sec, in the 6th month at 17.50±2.99 mL/sec, and in the 12th month at 15.37±2.17 mL/sec (P = 0.0001). PVR improved in 1st month at 50.13±23.56 ml, 6th month at 64.47±23.31, and 12th month at 69.17±25.53 ml compared to the preoperative PVR (P = 0.0001). Urethral dilatation using amplatz renal dilators represents a technique that mitigates the inherent risks associated with blind dilatation methods. This approach is characterized by its safety, ease of application, high patient tolerance, and cost-effectiveness, rendering it a favorable alternative for treating urethral strictures.

Management Patterns of Male Urethral Stricture Disease among Urologists: What Do the Guidelines Say? What Do Urologists Do?

The aim of the present study is to evaluate and analyze the daily clinical practice for male urethral stricture disease (MUSD) among urologists. Considering the latest guidelines on urethral stricture disease, a survey was developed regarding the various treatment options and preferences in different sites of male urethral stricture disease. The survey was sent to urologists via e-mail and phone application. A total of 266 urologists completed the survey and were included in the final analysis. In regard to workplace, 62 (23.3%), 58 (21.8%), 71 (26.7%), and 75 (28.2%) respondents worked in university hospitals, training and research hospitals, state hospitals, and private practice hospitals, respectively. In regard to the diagnostic method used in male urethral strictures, 88.7% of the participants would choose uroflowmetry + postvoiding residual (UF + PVR), and 64.6% would choose retrograde urethrography (RUG). Direct vision internal urethrotomy (DVIU) was the most frequently chosen method in penile urethral strictures (PUS), being chosen by 72.9%. Direct vision anterior internal urethrotomy was the most common method for both ≤2 cm and >2 cm strictures, 63.1%, and 30.8%, respectively. The most preferred graft for augmentation urethroplasty was buccal mucosa (75.8%). Endoscopic incision/resection (transurethral resection (TUR)) is the most frequently applied treatment method for posterior urethral/vesicourethral anastomotic strictures (86.4%). The present study clearly shows that most urologists still prefer DVIU and urethral dilatation to urethroplasty in MUSD, which contradicts current guidelines. Urologists should be encouraged to perform urethroplasty and/or refer patients to experienced centres for recurrent MUSD.

To assess the impact of prior urethral dilatation or DVIU on the outcome of anterior urethroplasty.

Background: Male urethral stricture has remained the major problem in urologic practice. Patients presenting with urethral stricture disease are commonly managed by dilatation, DVIU, and urethroplasty.&#x0D; Methodology: This is a descriptive study of male patients who underwent anterior urethroplasty at our setup from 5th August 2021 to 25th February 2022. We analyzed the age, duration, type, length, and location of the stricture and the surgical treatment outcome after urethroplasty. The post-operative catheter was removed after 3 weeks, and UFM is advised. Qmax (max flow rate) &gt; 15 ml/sec was measured on UFM (uroflowmetry) on the 1st week, 6 weeks, and followed on 3 months. Final outcome in terms of success was assessed by uroflowmetry. A maximum urine flow greater than 15mL/s after 3 months’ treatment assessed by uroflowmetry was considered as success.&#x0D; Results: In our study, the blood loss in group A and group B patients, those patients who had DVIU or dilation in the past, had more bleeding during surgery than those who did not have a history of surgery. 66.67% of group B patients have bleeding from 200 ml to 500 ml, which is higher than group A patients. In our study, we found that if the patient had undergone surgery or no surgery had taken place before urethroplasty, the results in terms of UFM were quite similar, as in group A, 96.69% of patients had UFM more than 15 ml/sec, and in group B 87.88% had UFM more than 15 ml/sec.&#x0D; Conclusion: Urethral dilatation or DVIU delays definitive treatment and increases operative challenges by increasing the length of stricture, more adhesion, and more fibrosis but has minimal impact on the outcome of urethroplasty success.

Comparison of oral morbidity and mid-term efficacy of anterior urethroplasty using an autologous tissue-engineered graft (MukoCell®) versus native oral mucosa graft.

Our study aimed to compare surgical success rate (SR) and oral morbidity of augmentation urethroplasty for anterior urethral strictures using autologous tissue-engineered oral mucosa graft (TEOMG) named MukoCell® versus native oral mucosa graft (NOMG). We conducted a single-institution observational study on patients undergoing TEOMG and NOMG urethroplasty for anterior urethral strictures >2 cm in length from January 2016 to July 2020. SR, oral morbidity, and potential risk factors of recurrence were compared between groups were analyzed. A decrease of maximum uroflow rate < 15 mL/s or further instrumentation was considered a failure. Overall, TEOMG (n = 77) and NOMG (n = 76) groups had comparable SR (68.8% vs. 78.9%, p = 0.155) after a median follow-up of 52 (interquartile range [IQR] 45-60) months for TEOMG and 53.5 (IQR 43-58) months for NOMG. Subgroup analysis revealed comparable SR according to surgical technique, stricture localization, and length. Only following repetitive urethral dilatations, TEOMG achieved lower SR (31.3% vs. 81.3%, p = 0.003). Surgical time was significantly shorter by TEOMG use (median 104 vs. 182 min, p < 0.001). Oral morbidity and the associated "burden" in patients' quality of life were significantly less at 3 weeks following the biopsy required for TEOMG manufacture, compared to NOMG harvesting and totally absent at 6 and 12 months postoperatively. The SR of TEOMG urethroplasty appeared to be comparable to NOMG at a mid-term follow-up but taking into account the uneven distribution of stricture site and the surgical techniques used in both groups. Surgical time was significantly shortened, since no intraoperative mucosa harvesting was required, and oral complications were diminished through the preoperative biopsy for MukoCell® manufacture.

Is cystourethroscopy a crucial preoperative step in severe and complex types of hypospadias?

Proximal hypospadias is considered the most severe subtype of the hypospadias spectrum and represents approximately one-fifth of the total cases. It is well-evidenced by many studies that the rate of postoperative complications following the repair of this complex subtype is significantly higher when compared to the distal variants. Few reports described the proximal hypospadias from the other perspective which is the preoperative one. Most pediatric surgeons notice an unexplained incidence of lower urinary tract infection and occasional difficulty of urinary catheterization in those children. This sometimes requires the use of additional measures such as the use of urethral sounds, filiforms and followers, and even catheterization under anesthesia. The aim of the work is to evaluate the role of preoperative cystourethroscopy in detecting associated anomalies in cases of proximal and severe hypospadias. This prospective study was conducted in the pediatric surgery unit at Alexandria Faculty of Medicine between July 2020 and December 2021 and included all children with severe grades of hypospadias. After thorough evaluation, all children underwent cystourethroscopy just before the procedure. Any abnormalities in the urethra, urinary bladder, or ureteric openings were recorded if present. Finally, the definitive operation was performed as per schedule. Fifty-two patients (41 fresh and 11 redo patients) with a median (range) age at presentation of 5 (1-16) years were enrolled in this study. The intraoperative cystourethroscopy was done in all of the patients. Significant abnormal findings were recorded in 32 patients (61.5%), while the other 20 patients (38.5%) were revealed to be normal. The most common abnormal findings were dilated prostatic utricle opening and hypertrophied verumontanum (in 23 and 16 cases, respectively). Although most of the associated anomalies with proximal hypospadias are asymptomatic, cystourethroscopy is better used owing to a high incidence of these anomalies. This can facilitate an early diagnosis as well as early detection and intervention at the time of repair.

Efficacy of Urethral dilatation with Uttarbasti in the management of Recurrent Urethral Stricture-A Single Case Study

Urethral stricture disease is the common problem occurred in the patients after chronic urinary tract infection, urethral injury or post-surgical interventions performed through per urethra. In Ayurvedic literature urethral stricture may be correlated as mutrotsanga mentioned in Sushruta Samhita. There are advance surgeries available as the science advances with technology various surgeries like Urethroplasty, Visual Internal Urethrotomy, and Dilatation of urethra. The way to overcome this problem is surgery i.e. urethroplasty. But the recurrence rate is high enough to think the alternative. In this case study, 40 years old Male patient suffering from recurrent urethral stricture was came to Shalya Tantra OPD. Patient also undergone repeated urethral dilatations two times but not relieved. So after clinical examination and investigations the case diagnosed as urethral stricture and treated with Ayurvedic Para-surgical procedure i.e uttarbasti to avoid recurrent urethral stricture. In Ayurvedic literature Uttarbasti is the procedure in which some medicinal preparations are introduced per urethra. (As per reference given in sushruta samhita) Uttarbasti was done at 3 days interval for 4 weeks. In this particular study urethral dilatation done by urethral dilatators After that Uttarbasti has been given. After 3rd sitting patient got 70% relief. Thus we can conclude that uttarbasti can be considered as a golden choice of treatment for urethral stricture in Ayurved.

(434) Value of Office Pre-Operative Cystoscopy Prior to Penile Prosthesis Surgery

Abstract Introduction Discovery of obstructive urethral pathology, such as urethral stricture, benign prostatic hyperplasia (BPH), or bladder neck contracture (BNC), during inflatable penile prosthesis (IPP) placement may result in aborted prosthetic implantation. Routine pre-operative office cystoscopy to evaluate for obstructive urethral pathology would likely prevent aborted implant cases. However, routine cystoscopy would also represent a substantial cost to the patient and healthcare system, especially since urethral pathology resulting in aborted cases is anecdotally rare. Objective Our objective was to evaluate the incidence of unexpected obstructive urethral pathology resulting in aborted IPP cases and then compare the cost of aborted cases to the cost of routine pre-operative office cystoscopy for all planned implants. Methods We retrospectively evaluated completed and aborted IPP placements by a high-volume surgeon from 1/1/2014 through 5/23/2022 for both virgin (CPT 54405) and revision (54410) IPPs, with further selected assessment of cases with concomitant cystoscopy (52000), urethral dilation (52281), and direct vision internal urethrotomy (55276). Selected cases were reviewed for additional patient information including prior urologic surgery, pelvic radiation, and clinical information regarding intra-operative cystoscopy. Cost analysis was conducted for office cystoscopy and operative costs associated with IPP cases based on institutional cost data. Outcomes evaluated included incidence of unexpected obstructive urethral pathology requiring aborted IPP placement, break-even points for office cystoscopy compared to cost of aborted IPP cases, and ‘number needed to scope’ to avoid an aborted implant. Results From a total of 822 IPP cases performed, 17 (2.1%) had concomitant cystoscopy, of which 11 (1.3%) were unplanned. Nine cystoscopies (1.1%) resulted from inability to place a urethral catheter secondary to urethral stricture (n=5), BNC (n=2), BPH (n=1), and no identifiable pathology (n=1). Three IPPs (0.4%) were aborted due to dense urethral stricture at a total cost of $42,982, with ‘number need to scope’ of 274 to avoid an aborted implant. With total calculated cost for office cystoscopy for all planned IPPs of $164,498 ($200.12 per patient), the rate of aborted IPP due to urethral pathology would need to exceed 1.4% to make routine office cystoscopy cost saving (Figure 1). Alternatively, at the observed incidence of aborted IPP (0.4%), routine office cystoscopy would need to cost $50.50 to break-even with the cost of aborted IPPs. Conclusions Unexpected obstructive urethral pathology resulting in aborted IPP is rare. As a result, routine pre-operative office cystoscopy for asymptomatic men prior to IPP does not provide cost savings at our institution. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Dr. Aaron Lentz is a speaker, preceptor, and consultant for Boston Scientific and Coloplast. Dr. Faysal Yafi is a speaker, advisor and consultant for Coloplast, Antares Pharma, Clarus Therapeutics, Promescent, Acerus, Sprout and Cynosure.

(544) Incidental Findings of Pre-Operative Cystoscopy Procedure prior to IPP

Abstract Introduction Inflatable Penile Prosthesis (IPP) is a common treatment modality for Erectile Dysfunction (ED). Previous studies have advocated the importance of undergoing a cystoscopy prior to an IPP procedure and whether the costs outweigh the benefits. Cystoscopies assist in diagnosing Lower Urinary Tract Obstructions (LUTO) such as BPH with obstruction, urethral strictures, bladder stones, and bladder tumors. These pathologies can cause complications in patients who undergo IPP, as well as unnecessary costs for canceling or aborting surgery. Due to these risks, cystoscopies may be a necessary pre-operative procedure prior to implantation. However, cystoscopies can be costly and there is an increased risk of infection. As a result, the cost-benefit analysis of performing this procedure in patients prior to IPP placement remains controversial. Objective To evaluate the prevalence of incidental findings found during cystoscopy, to determine if this procedure should be routinely implemented in clinical practice prior to IPP placement Methods We performed a retrospective study which identified all patients undergoing “de novo” IPP surgery, performed from May 2019 until May 2022, by two high volume implant surgeons. A review of all patients who underwent direct vision internal urethrotomy, or cystoscopy procedure prior to surgery was performed. The study population consists of men who underwent cystoscopy procedure prior to inflatable penile prosthesis (IPP) surgery in the office setting. Only patients who had no previous history of penile implantation were included. All clinical notes, patient demographics, comorbidities and surgical outcomes were reviewed. Results 224 patients met the inclusion criteria. Of the 224 patients who underwent cystoscopy, prior to implantation, 153 (68%) had no previous history of cystoscopy procedure, while 28 (12%) had prior robotic assisted laparoscopic prostatectomy (RALP). This cohort consisted of 40 (18%) patients whose cystoscopy findings lead to other urological procedures prior to IPP surgery. These findings included 15 patients with bladder outlet obstruction due to BPH, which required a TURP, 18 patients with previously unknown bladder tumors, which required a TURBT, and 7 patients with bladder stones which required cystolithotomy. Other incidental findings which did not require surgery included 24 (11%) patients found to have urethral strictures treated with traditional urethral dilation, with only 3 requiring cold knife therapy. 27 patients diagnosed with prostatic strictures secondary to previous prostatic procedures including TURP, Urolift, Microwave Therapy, cryotherapy, etc. These patients were dilated with the scope at the time of procedure. There were 3 patients that presented with kidney stones in the bladder which did not require additional procedures. Of this cohort, 8 (3.5%) patients had post-procedural infections that were treated with a conservative course of antibiotics and did not require further treatment. Conclusions In patients with no previous history of urologic evaluation, a pre-operative cystoscopy procedure can be an invaluable tool to help prevent unnecessary complications or misdiagnosed pathology, such as bladder cancer or urethral strictures. Unplanned intraoperative cystoscopies and interventions can be costly and may be avoided with a simple in office cystoscopy prior to penile implantation. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific

(214) Female bmg Urethroplasty and 2nd Degree Vaginal Tear Repair

Abstract Introduction Pregnancy and childbirth bring biological, psychological, and social changes which may influence women's health. Objective Second degree tears are the most common type of tear. A female urethral stricture is a less common condition. Buccal mucosa graft (BMG) is widely used tissue for urethral stricture repair. Methods We present a 38-year old female who suffered a 9-year long history of urethral stricture disease and dyspareunia after two vaginal child births. The patient (pt) had urethral injury and 2nd degree tear in vaginal wall and pelvic muscle. Despite repeated attempts of urethral dilations, the stricture and the obstructive complaints persisted. Additionally, lack of sexual arousal and painful intercourses, affected the patient’s quality of life. The pt was treated with a dorsal onlay urethroplasty using a buccal mucosa graft, excision of vaginal wall scar, pelvic floor muscle repair, and repair of vaginal opening The surgery was carried out with a suprameatal approach. A semicircular incision was performed and the urethra was dissected from the ventral aspect of the clitoris with a sharp and blunt dissection up to the proximal part of stricture. Then, a dorsal sagittal incision is performed over the stricture and the BMG is sutured dorsally for the edges and quilted with 4.0 polyglactin sutures. A 16Fr Foley catheter was left in place for two weeks. Then, we performed hydrodissection of posterior vaginal wall, scar excision from episiotomy and 2nd degree tear, approximation of levator ani muscle, vaginal wall and opening repair. Results Two weeks after surgery the patient urinates without strain and with no post voiding residual urine. Uroflow 6 weeks after surgery showed Qmax of 28ml/sec and urethra was easily passable for 20Fr Nelaton catheter. Eight weeks after surgery the patient reported having a normal sexual life without pain and lack of sexual satisfaction Conclusions Female dorsal onlay urethroplasty and vaginal wall tear repair are feasible and give great functional and aesthetical results Disclosure No

HF01-10 EVOLUTION TO EXTINCTION?: THE SAGA OF FEMALE URETHRAL DILATION

You have accessJournal of UrologyCME1 Apr 2023HF01-10 EVOLUTION TO EXTINCTION?: THE SAGA OF FEMALE URETHRAL DILATION Jasmine Kashkoush and Brant Fulmer Jasmine KashkoushJasmine Kashkoush More articles by this author and Brant FulmerBrant Fulmer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003243.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Historically, many women have reported bothersome urinary symptoms and recurrent urinary tract infections (UTIs). The challenge in managing these symptoms led to the practice of urethral dilation in the 1920s, despite the rarity of a female urethral stricture. With little scientific data to support its efficacy, this practice should have gone to extinction; however, it is still very common. This represents a historical review of urethral dilation in women and its penetration in modern day practice patterns. METHODS: A literature review was performed to evaluate the history of female urethral dilation. RESULTS: In 1923, Stevens theorized the culprit behind bothersome urinary symptoms was a narrow urethral meatus, initially presenting the idea of urethral dilation/incision. He advocated for urethral meatotomy with a scalpel up to 30 Fr. This was refined by Davis in the 1950s with the use of an Otis urethrotome to incise the urethra up to 45 Fr. This was popularized in the 1960s when Keitzer, Lyon, and Kerr thought persistent UTIs were due to a “contraction ring in the distal urethra of little girls.” They used sounds and Otis urethrotomes in infants to dilate and/or incise the entire urethra. Eventually, this practice lost scientific backing due to complications of urinary incontinence as well as favorable outcomes with less invasive options. In fact, the last reference to using urethral dilation without a urethral stricture was in 1970. Interestingly, despite the lack of data to support its use, Medicare reimbursement still shows high utilization and cost expenditures. Almost $70 million was spent in 2000 despite only ∼40 documented cases of female urethral stricture. Furthermore, when surveying urologists, those who completed residency after 1989 rarely performed urethral dilation when compared to their predecessors who find it a useful practice. CONCLUSIONS: A wide variety of treatment modalities have been used to manage recurrent UTIs and irritative lower urinary tract symptoms. Female urethral dilation was common despite the rarity of a female urethral stricture. Urinary incontinence and a better understanding of bladder function have decreased the data in favor of female urethral dilation, putting into question its practice. Evidence based medicine supports medical management, vaginal estrogen, and pelvic floor physical therapy more favorably. One would hope that this practice would go into extinction; however, Medicare data still shows high utilization. Perhaps updated guideline statements and better education of patients that have had prior dilations will help in debunking this practice. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e259 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jasmine Kashkoush More articles by this author Brant Fulmer More articles by this author Expand All Advertisement PDF downloadLoading ...

MP35-02 CLINICAL MEASUREMENT OF MAXIMUM SAFE URETERAL DISTENSIBILITY USING A NOVEL FORCE SENSOR

You have accessJournal of UrologyCME1 Apr 2023MP35-02 CLINICAL MEASUREMENT OF MAXIMUM SAFE URETERAL DISTENSIBILITY USING A NOVEL FORCE SENSOR Amanda McCormac, Minh-Chau Vu, Andrew S. Afyouni, Zachary E. Tano, Sohrab N. Ali, Pengbo Jiang, Roshan M. Patel, Michael Klopfer, Jaime Landman, and Ralph V. Clayman Amanda McCormacAmanda McCormac More articles by this author , Minh-Chau VuMinh-Chau Vu More articles by this author , Andrew S. AfyouniAndrew S. Afyouni More articles by this author , Zachary E. TanoZachary E. Tano More articles by this author , Sohrab N. AliSohrab N. Ali More articles by this author , Pengbo JiangPengbo Jiang More articles by this author , Roshan M. PatelRoshan M. Patel More articles by this author , Michael KlopferMichael Klopfer More articles by this author , Jaime LandmanJaime Landman More articles by this author , and Ralph V. ClaymanRalph V. Clayman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003269.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior clinical studies, using a novel UCI ureteral access sheath (UAS) force sensor have indicated that passage of a ureteral access sheath at <6 Newtons (N) results in no harm to the ureter. Armed with this information, we sought to define, for the first time, the natural distensibility of the human ureter using sequential urethral dilators in combination with the UCI force sensor while limiting the applied force to 6 N. METHODS: Seventy-five patients (46 females and 29 males) undergoing either ureteroscopy and/or percutaneous stone removal underwent ureteral sizing by passing a series of 35 cm long, urethral dilators in 2 Fr increments within the pre-defined force threshold limit of <6 N. After 6 N was attained, the size of the urethral dilator was recorded and then ureteroscopy was performed and a post-ureteroscopic lesion scale (PULS) was determined. Next, a similar sized UAS, up to 16 Fr was inserted as part of the planned procedure. A multivariable logistic regression analysis was performed assessing the impact of age, gender, tamsulosin, stents, and the combination of tamsulosin and stents on the ability to pass dilators >16 Fr. RESULTS: Among 75 patients, urethral dilators were successfully passed at the 6 N threshold in 37.3% at ≤12 Fr, 24% at 14 Fr, 24% at 16 Fr, and 14.6% at >18 Fr (18-24 Fr). The mean maximum dilator diameter was 14 Fr. Logistic regression revealed that preprocedural ureteral stenting favored passage of >16 Fr dilators (OR 15.47, 95% CI 1.44 – 166.86; p=0.024). Neither gender nor age were significant differentiators. The effect of tamsulosin alone was not statistically significant (OR 0.60, 95% CI 0.15 – 2.32; p=0.454). The interaction effect was not significant suggesting that the effect of stent plus tamsulosin did not differ from stent alone (OR for interaction = 1.85, range 0.089 – 38.63; p=0.690). CONCLUSIONS: The unstented human ureter can be safely sized to an average circumference of 14Fr; this increases to 16 Fr in the prestented ureter. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e468 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amanda McCormac More articles by this author Minh-Chau Vu More articles by this author Andrew S. Afyouni More articles by this author Zachary E. Tano More articles by this author Sohrab N. Ali More articles by this author Pengbo Jiang More articles by this author Roshan M. Patel More articles by this author Michael Klopfer More articles by this author Jaime Landman More articles by this author Ralph V. Clayman More articles by this author Expand All Advertisement PDF downloadLoading ...

MP59-15 ANALYSIS OF RISK FACTORS FOR FORMATION OF BLADDER NECK CONTRACTURE AFTER HOLMIUM ENUCLEATION OF PROSTATE

You have accessJournal of UrologyCME1 Apr 2023MP59-15 ANALYSIS OF RISK FACTORS FOR FORMATION OF BLADDER NECK CONTRACTURE AFTER HOLMIUM ENUCLEATION OF PROSTATE Susan Talamini, Adam Ostergar, Hayden Hill, Alethea Paradis, Joel Vetter, and Charles Nottingham Susan TalaminiSusan Talamini More articles by this author , Adam OstergarAdam Ostergar More articles by this author , Hayden HillHayden Hill More articles by this author , Alethea ParadisAlethea Paradis More articles by this author , Joel VetterJoel Vetter More articles by this author , and Charles NottinghamCharles Nottingham More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003312.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Holmium laser enucleation of prostate (HoLEP) offers a size independent approach to the treatment of benign prostatic hyperplasia (BPH). Bladder neck contracture (BNC) is a known complication after endoscopic intervention for BPH. This study aims to evaluate the incidence and risk factors associated with the formation of postoperative BNC after HoLEP. METHODS: A retrospective review was conducted from 2020 to 2022 of men undergoing HoLEP by a single surgeon. Exclusion criteria included patients with follow up of less than 1 month. Patients with postoperative BNC were identified, and Chi-square and Mann-Whitney U tests were used to test for significant associations between categorical and continuous variables of interest and bladder neck contracture respectively. Pre- and perioperative factors were compared between groups including catheter dependence, history of radiation, previous outlet procedures, concurrent procedures, laser type, enucleated gland weight, and energy usage. RESULTS: A total of 184 men were identified for the study. An incidence of BNC occurred in 9% of patients (n=17). On univariate analysis, enucleated gland weight was significantly associated with BNC (70 vs 38.9, p=0.029), though this association was not seen on multivariate analysis. Amongst men with glands less than 40gm, 13.3% had BNCs. The presence of bladder stones at time of HoLEP was a significant risk factor associated with the development of BNC, as 17.6% of men with BNCs had bladder stones (p=0.039). Urethral dilation was also significantly associated with BNC (11.8%, p=0.023). Mean time to diagnosis of BNC was 6.5 months. Mean follow up was 6.5 months. CONCLUSIONS: Our study identified smaller gland size, as well as concurrent bladder stones and previous stricture disease, as significant risk factors for the development of BNC after HoLEP. This study underscores the importance of preoperative anatomical evaluation in patient counseling and discussion of individual risk factors. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e813 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Susan Talamini More articles by this author Adam Ostergar More articles by this author Hayden Hill More articles by this author Alethea Paradis More articles by this author Joel Vetter More articles by this author Charles Nottingham More articles by this author Expand All Advertisement PDF downloadLoading ...

MP05-10 NATURAL HISTORY OF URETERAL INJURY IN AN IN-VIVO PORCINE MODEL

You have accessJournal of UrologyCME1 Apr 2023MP05-10 NATURAL HISTORY OF URETERAL INJURY IN AN IN-VIVO PORCINE MODEL Sohrab N. Ali, Paul Piedras, Seyed Amiryaghoub M. Lavasani, Seyed Hossein H. Sharifi, Antonio R. H. Gorgen, Andrei D. Cumpanas, Yi Xi Wu, Zachary E. Tano, Pengbo Jiang, Roshan M. Patel, Jaime Landman, and Ralph V. Clayman Sohrab N. AliSohrab N. Ali More articles by this author , Paul PiedrasPaul Piedras More articles by this author , Seyed Amiryaghoub M. LavasaniSeyed Amiryaghoub M. Lavasani More articles by this author , Seyed Hossein H. SharifiSeyed Hossein H. Sharifi More articles by this author , Antonio R. H. GorgenAntonio R. H. Gorgen More articles by this author , Andrei D. CumpanasAndrei D. Cumpanas More articles by this author , Yi Xi WuYi Xi Wu More articles by this author , Zachary E. TanoZachary E. Tano More articles by this author , Pengbo JiangPengbo Jiang More articles by this author , Roshan M. PatelRoshan M. Patel More articles by this author , Jaime LandmanJaime Landman More articles by this author , and Ralph V. ClaymanRalph V. Clayman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003216.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteroscopy (URS) accompanied by passage of a ureteral access sheath (UAS) is a common procedure for the treatment of urolithiasis; however, the ureter may sustain an injury during UAS placement. The post-ureteroscopic lesion scale (PULS) is a validated scoring system for endoscopic detection of ureteral injury. PULS Grade 3 (perforation with less than 50% partial transection) and Grade 4 (greater than 50% partial transection) are considered severe injuries generally requiring prolonged stent placement. The natural history of these lesions if left unstented, is unknown. METHODS: Female Yorkshire pigs underwent ureteral sizing with Cook® urethral dilators (10-24 Fr) using a validated force sensor with forces limited to < 6 N; passage of the urethral dilators resulted in PULS Grade ≥3 in 13 ureters. These animals were excluded from the original study but were survived for another week without stent placement. On the seventh day, URS was performed to assess ureteral healing and PULS grade. Exact fisher test and Two-Tailed T-test were used to evaluate differences in PULS grade, location (proximal, mid, or distal) and number of dilator passages. RESULTS: Among thirteen PULS lesion Grades ≥3 (nine Grade-3 and four Grade-4) in 10 pigs, URS one week later revealed healing in ten ureters (77%) (nine Grade-0 and one Grade-2) (Figure 1); however, three ureteral strictures were noted, all associated with prior Grade-3 lesions (23%). In addition, there was no difference in the location of primary lesions becoming strictures (50% in proximal, 0% in medial and 33% in distal, p=0.2133). Ureters without stricture formation had a higher mean number of dilator passages compared to those that did not stricture, (5.2 vs 3.0, p=0.0374). CONCLUSIONS: Despite PULS 3 or 4 lesions, in the absence of ureteral stenting, the urothelium in 75% of ureters healed completely within a week. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e47 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sohrab N. Ali More articles by this author Paul Piedras More articles by this author Seyed Amiryaghoub M. Lavasani More articles by this author Seyed Hossein H. Sharifi More articles by this author Antonio R. H. Gorgen More articles by this author Andrei D. Cumpanas More articles by this author Yi Xi Wu More articles by this author Zachary E. Tano More articles by this author Pengbo Jiang More articles by this author Roshan M. Patel More articles by this author Jaime Landman More articles by this author Ralph V. Clayman More articles by this author Expand All Advertisement PDF downloadLoading ...

V08-09 TRANSURETHRAL DORSAL BUCCAL GRAFT URETHROPLASTY FOR PROXIMAL FEMALE URETHRAL STRICTURES

You have accessJournal of UrologyCME1 Apr 2023V08-09 TRANSURETHRAL DORSAL BUCCAL GRAFT URETHROPLASTY FOR PROXIMAL FEMALE URETHRAL STRICTURES Francis Jefferson, Jonathan Warner, Maraika Robinson, and Brian Linder Francis JeffersonFrancis Jefferson More articles by this author , Jonathan WarnerJonathan Warner More articles by this author , Maraika RobinsonMaraika Robinson More articles by this author , and Brian LinderBrian Linder More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003306.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Treatment options for proximal female urethral strictures have significant limitations such as high recurrence rate (urethral dilation) and de novo stress urinary incontinence (flap/graft reconstruction). The objective of this video was to describe a novel dorsal inlay buccal graft urethroplasty technique that reduces technical difficulty and eliminates the need for urethral mobilization. METHODS: Stay sutures are placed at the urethral meatus, and a nasal speculum is placed into the urethra staying distal to the stricture. A beaver blade is then used to incise the urethra at the 12 o'clock, 10 o’clock, and 2 o’clock positions; these are superficial, non-full thickness incisions. A laparoscopic suture passing device is then used to pass a suture from the bladder to the urethral lumen at the 12:00 o'clock position. The suture is then passed through corresponding mid portion of the buccal graft ensuring that the mucosal side will be in the urethral lumen when the graft is deployed. This is repeated at the 10 o'clock and 2 o'clock positions with placement of the proximal suture at the level of the bladder neck and then through the corresponding location on the buccal graft. The graft is then parachuted into position at the level of the bladder neck. A laparoscopic knot pusher is then used to tie down the proximal sutures through the urethra. After trimming the excess buccal graft flush with the meatus, the distal aspect of the graft is sutured to the vaginal epithelium to recreate the urethral meatus. A wide-bore catheter is placed for 3 weeks postoperatively. RESULTS: In 6 consecutive patients treated with this technique with a median follow-up of 3.9 months, surgical success has been 100% as indicated by urethral patency on cystourethroscopy and subjective symptom improvement. There have been no cases of de novo stress urinary incontinence. Pre- and post-operative maximum urine flow rate (Qmax) and post-void residual volumes (PVR) are shown in the table. CONCLUSIONS: A transurethral inlay approach for dorsal buccal graft placement is a feasible option for management of female proximal urethral structure. Given decreased periurethral dissection compared to other techniques, this approach may decrease the risk of de novo stress urinary incontinence. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e751 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Francis Jefferson More articles by this author Jonathan Warner More articles by this author Maraika Robinson More articles by this author Brian Linder More articles by this author Expand All Advertisement PDF downloadLoading ...