Urethral Fibrosis Research Articles

Recovery of Urinary Continence after Radical Prostatectomy: Association with Urethral Length and Urethral Fibrosis Measured by Preoperative and Postoperative Endorectal Magnetic Resonance Imaging

BackgroundLimited data on endorectal magnetic resonance imaging (MRI) features and urinary continence after radical prostatectomy (RP) are available. ObjectiveTo assess whether recovery of urinary continence after RP is associated with endorectal MRI findings regarding preoperative and postoperative membranous urethral length (MUL), percent change in MUL, and postoperative urethral and periurethral fibrosis. Design, setting, and participantsSixty-four patients who received an MRI scan before and after RP for localized prostate cancer were evaluated in a retrospective study at a single institution. InterventionAll patients underwent RP. MeasurementsThe postoperative scan was performed to detect local recurrence in patients with rising levels of prostate-specific antigen. Urinary continence was graded on a five-point scale. MUL was measured on T2-weighted images. Urethral and periurethral fibrosis was graded from 0 to III based on axial T2-weighted images. Univariate Cox proportional hazards regression was performed to assess variables associated with continence. Results and limitationsForty-eight patients regained continence following surgery. The median follow-up for patient who were incontinent at their last assessment was 7 mo. The median interval from RP to postoperative endorectal MRI was 10 mo. A longer preoperative or postoperative MUL was associated with superior continence (both p<0.01). The MUL loss ratio was significantly associated with postoperative continence (p=0.02). Patients with a high grade of postoperative periurethral fibrosis tended to have worse postoperative continence; nevertheless a statistical correlation was not reached (hazard ratio: 0.64, p=0.16). This is a retrospective study. ConclusionsPreoperative and postoperative MUL and the MUL loss ratio are related to the recovery time and level of urinary continence after RP. Therefore, preservation of urethral length during surgery is recommended. Periurethral fibrosis might impede the recovery of continence after RP by altering the elasticity of the external sphincter.

Editorial Comment on: Recovery of Urinary Continence after Radical Prostatectomy: Association with Urethral Length and Urethral Fibrosis Measured by Endorectal Magnetic Resonance Imaging

Editorial Comment on: Recovery of Urinary Continence after Radical Prostatectomy: Association with Urethral Length and Urethral Fibrosis Measured by Endorectal Magnetic Resonance Imaging

Thread embedded into penile tissue over time as an unusual hair thread tourniquet injury to the penis: a case report.

IntroductionHair thread tourniquet syndrome has been recognized since the 1960s. Since then, sporadic reports have appeared in the literature describing different degrees of strangulation and/or amputation of the penis caused by a hair thread being inadvertently tied around the penis.Case presentationA 9-year-old boy presented with a 3-year history of hair thread tourniquet injury to his penis. Instead of the usual strangulation or amputation, the tourniquet had become embedded into the penile tissue, manifesting with exuberant granulation tissue and a tight urethral stricture. At surgery, the intact tourniquet was still in place, embedded in dense fibrous tissue and associated with a dense urethral fibrosis which measured about 2 cm long. The tourniquet was divided and removed, the fibrotic urethra excised and a distal penile pedicled skin flap used to perform a single-stage substitution urethroplasty. The patient has been voiding well for 28 months.ConclusionThis case is unusual and is the first report of its kind. It is also the first report of a hair thread tourniquet as the cause of pediatric penile injury in Nigeria.

Urethral fibrosis with pyonephrosis in a patient with situs inverse totalis

Urethral fibrosis with pyonephrosis in a patient with situs inverse totalis

Autologus satellite cell transplantation into the striated sphincter in exstrophy-epispadias children: an evolving modality in incontinence management?

Purpose Incontinence is still a challenging problem in children with the exstrophy-epispadias complex (EEC) and satisfactory results using conventional management has not yet been achieved. Recent advances in cell therapy and tissue engineering techniques have been promising. We investigated autologous, heterotopic targeted muscle precursor cell donation in the recovery of external urethral sphincter function in children with the EEC and urinary incontinence (UI). Material and methods Following extensive animal model studies at our laboratory and approval of the study protocol by the local bioethical committee, 5 children (4 boys and 1 girl, mean age: 9.6 years) with severe urinary incontinence due to exstrophy/epispadias were enrolled in May 2006. Autologous skeletal muscle precursor cells were obtained from the pelvic floor and cultured in vitro for cell expansion. Before transurethral injection of the cells into the sphincter, microbiological control and karyotyping were performed. The continence status of the patients prior to and following satellite injection was evaluated according to incontinence score, biochemical parameters, urodynamic studies and changes in quality of life. Results An average of 0.2-8x10 7 cells (>70% Pax7+/ MyoD+/ Desmin+) were obtained after a mean period of 18 days and implanted uneventfully. Neither microbial infection nor chromosomal change was detected in the specimens prior to cell implantation. During 4 months follow-up the incontinence score improved in 4 patients but 1 female patient with a very short urethral length and fibrosis had no change in continence status. Conclusions This data confirms the potential application and outcome of satellite cell transplantation in functional reconstruction in UI by compensating for the cell loss. Although it can provide a new therapeutic approach for incontinence therapy with a reasonable success rate, long-term follow-up is still required.

The Significance of Periurethral Fibrosis and the Change of Nitric Oxide Synthase Containing Nerves in the Urethra of Diabetic Rats

We have previously demonstrated that increased urethral resistance was more prominent in diabetic rats than in controls. This may result from a compressive obstruction such as damage of the urethral nerve containing nitric oxide. Another possible cause for urethral obstruction could be a constrictive obstruction such as a periurethral fibrosis. In the present study, we investigated the changes in the expression of nitric oxide synthase(NOS) isoforms(compressive obstruction) and collagen subtypes (constrictive obstruction) in the urethral tissues of non-insulin dependent diabetic rats. Materials and Methods: Thirty-six male Sprague-Dawley rats(18 diabetic rats and 18 control rats), bred from birth, were included in this study. Diabetes mellitus was induced by intraperitoneal administration of streptozotocin(90mg/kg) on the second day after birth. Urethral tissues were harvested at 12, 24 and 36 weeks after induction of diabetes and were stained for neuronal NOS(nNOS) and Masson trichrome. We also performed reverse transcriptase-polymerase chain reaction or Western blot analysis to evaluate mRNA or protein expression of NOS isoforms and collagen subtypes in the urethral tissues. Results: Immunohistochemical staining and Western blot analysis of nNOS revealed that the immunoreactivity and nNOS expression in the urethra was lower in the diabetic rats than in the controls. The Masson trichrome staining showed that there was urethral fibrosis in the diabetic rats. The mRNA or protein expression of collagen subtypes, especially type I collagen, were higher in the diabetic rat urethra than in the controls. Conclusions: These data suggest that the increased urethral resistance in diabetic rats may be attributable to a decrease in the urethral nNOS expression and an increase in collagen content. Urethral dysfunction as well as a cystopathy may play an important role in the pathogenesis of diabetes- induced voiding dysfunction.

Methods and results of urethrolysis

Although occurring with somewhat less frequency now than historically reported, outlet obstruction after incontinence surgery continues to be a source of postoperative patient dissatisfaction and therapeutic dilemma. Several techniques have been described that fall under the rubric of urethrolysis, including sling incision, sling lysis with explantation, and formal vaginal or retropubic urethrolysis (incision and disruption of bladder neck and urethral fibrosis). Surgical approaches have included vaginal, retropubic, or combined techniques with or without the use of adjunctive steps such as graft interposition. However, evidence emanating from reports of these varied techniques has been incomplete due to variability in outcomes presentation, lack of longevity of follow-up, or problematic study design. Nonetheless, the bulk of clinical evidence supports the efficacy of urethrolysis as an intervention for outlet obstruction after stress incontinence surgery. However, persistent irritative bladder symptoms remain bothersome for some women and, in addition, the recurrence of stress incontinence also may complicate the technique of urethrolysis. Management of these potential adverse outcomes also has been inconsistent, with some authorities routinely performing repeat incontinence surgery at the time of urethrolysis and others preferring to assess continence status after convalescence from urethrolysis. The differences among the types of urethrolysis and the results of each type are reviewed in this article in light of evolving definitions of outlet obstruction, diagnosis, and definition in women.

Value of Preoperative Urethral Ultrasound in Optic Internal Urethrotomy

Introduction and Objectives: The recurrence rate of internal urethrotomy (IU) is still high (long-term curative success rate between 20 and 45% after the first IU). We aimed to establish in a prospective randomized trial the value of urethral ultrasound in inflammatory urethral stricture (IUS) diagnosis and treatment. Patients and Methods: Between June 1994 and January 2004, we performed IU in 562 cases with IUS (under 1.5 cm). In order to evaluate the results obtained by guided incision according to the echographic evaluation, patients have been divided into 2 groups. For the first group (319 cases), the IU technique has been adapted to the echographic aspect of the stricture zone, and to the fibrosis location on the urethral circumference. For patients of the second group (243 cases) we practiced IU with a “classical” 12 o’clock incision. The mean follow-up period was 38.7 months (range 4–71 months) and 37.9 months (range 5–69 months) for the second group. We used the SPSS 8.0 for Windows statistical analysis (Cox regression) with Kaplan–Meier curves in order to compare the recurrence-free survival time. Results: In the first group (44.5% recurrence rate) we found 4 specific locations of urethral stricture fibrosis according to ultrasound evaluation: dorsal urethral fibrosis (274), ventral urethral fibrosis (36), circular urethral fibrosis (136), dorsal and ventral fibrosis (114). The best results have been obtained for the dorsal and ventral location of the spongious fibrosis (45/153 recurrences, 29.4% and 9/22 recurrences, 41%). The recurrence rate was higher in the circular and concomitant dorsal and ventral location of the spongious fibrosis: 67.5% (52/77 cases) and 55.2% (37/67 cases). Cox regression (−2LL = 360.859, χ 2 = 47.670, Sig = 0.137) demonstrated statistical significance in these series ( p < 0.5). In the second group (51.5% recurrence rate) we found 64.2% recurrences for the ventral location, 83% for the circular location and 72.3% for the dorsal and ventral location of the spongious fibrosis. Conclusions: According to our experience, the high recurrence rate of IUS after IU may be explained by the inadequate type of incision. So, urethral ultrasound could improve the IU technique by better location of the fibrosis area.

EFFECTS OF SELECTIVE AUTONOMIC AND PUDENDAL DENERVATION ON THE URETHRAL FUNCTION AND DEVELOPMENT OF RETENTION IN FEMALE DOGS

This trial is an experimental approach to the possible causes of continence and voiding problems after urethra sparing radical cystectomy and orthotopic bladder substitution in women. Between January 1996 and January 1999 we included 24 mongrel female dogs in this 4-phase study of 6 dogs each. The effects of autonomic denervation of the urethra (phase 1) and urethral transection just distal to the bladder neck (phase 2) on the urethral pressure profile were recorded. In phase 3 the effects of autonomic denervation, urethral transection and pharmacological manipulation of the denervated transected urethra on the urethral pressure profile were studied in succession. In phase 4 the effects of pudendal nerve transection and pharmacological blockade were recorded. In the 12 phases 2 and 3 dogs the transected urethra was re-anastomosed to the bladder neck. Acute experiments were repeated after 2 and 6 months, urethrocystoscopy was done and post-void residual urine was estimated. Two of the latter dogs were sacrificed 6 months after the acute experiment and the urethras were histopathologically examined. Autonomic denervation resulted in a 46% to 48% decrease in mean maximal pressure in the proximal urethra in phases 1 and 3 (p <0.001) with no significant effect on the distal urethra. Urethral transection in phase 2 did not affect the urethral pressure profile. Phentolamine injection after urethral denervation and transection in phase 3 produced a further reduction of 11.3% and 46.3% in mean resting pressure in the proximal and distal urethra, respectively, while succinyl choline produced a 38.1% further decrease in the distal urethra. Unilateral and bilateral pudendal denervation reduced pressure in the distal urethra significantly but not in the proximal urethra. When phentolamine was given thereafter, a further decrease of 38% and 2.4% resulted in resting pressure values in the proximal and distal urethra, respectively. The change in distal urethral pressure was marginally significant after succinyl choline injection (p = 0.05). Results were reproducible after 2 and 6 months. The proximal urethra remained patent with no post-void residual urine after autonomic denervation. There was no significant urethral fibrosis after realignment of the transected urethra in the 2 sacrificed phases 2 and 3 dogs. From this study we concluded that autonomic denervation reduced pressure in the proximal urethra by less than 50%. Continuity of the urethra with the bladder is not necessary for proper urethral function. After autonomic denervation the proximal urethra remained patent with no subsequent fibrosis. In addition, no post-void residual urine was noted. Bilateral pudendal denervation did not completely block activity of the distal urethra. The nonneuromuscular components had a small role in the creation of urethral closure function.

Sphincteric Incontinence: The Primary Cause of Post-Prostatectomy Incontinence in Patients With Prostate Cancer

Post-prostatectomy incontinence in patients with cancer of the prostate is often the result of sphincteric injury. However, recent studies have emphasized the role of detrusor instability and decreased bladder compliance in the etiology of post-prostatectomy incontinence. To further clarify the primary cause of incontinence, we reviewed the urodynamic studies of 39 patients referred for evaluation of incontinence after prostatectomy (35 radical, 4 TURP and radiation) for prostate cancer. Multichannel videourodynamic studies were performed to characterize bladder function, and sphincteric incontinence was assessed by Valsalva leak point pressure (VLPP). Flexible cystourethroscopy was used to evaluate the vesicourethral anastomosis. A pad scoring system was used to measure symptom severity. Sphincteric damage was found to be the sole cause of urinary incontinence in 23 patients (59%) and a major contributor in 14 others (36%). Twenty-seven patients (69%) had VLPP less than 103 cmH2O (mean = 55) with a urethral urodynamic catheter in place. An additional 10 (26%) had VLPP less than 150 cmH2O (mean = 63) upon removal of the catheter. VLPP is an indication of the severity of sphincteric damage. The importance of removing the urodynamic catheter during measurement of the VLPP is emphasized. Urethral fibrosis was confirmed by cystourethroscopy in 26 (67%) patients. Bladder dysfunction characterized by detrusor instability and/or decreased bladder compliance was seen in 15 patients (39%). In contrast to previous studies, our results indicate that sphincteric damage, and not bladder dysfunction, accounts for the vast majority of post-prostatectomy incontinence in patients with prostate cancer. However, it is essential to identify and treat bladder dysfunction in order to optimize the outcome of treatment for sphincteric incontinence.

LATE ONSET RECURRENT PENILE CHORDEE AFTER SUCCESSFUL CORRECTION AT HYPOSPADIAS REPAIR

Purpose Artificial erections are induced at hypospadias repair to prevent recurrent chordee. We describe the development and etiology of late onset recurrent chordee greater than 10 years after the initial surgery. Materials and Methods We reviewed the medical records of 22 patients with a median age of 4 years at surgery who were referred for evaluation of chordee 10 years after successful hypospadias repair. Results Of the 22 patients with recurrent chordee 13 had penoscrotal and 9 had proximal penile hypospadias at the initial operation. All originally required corporoplasty for the release of chordee, including Nesbit procedure in 19 and tunica vaginalis graft in 3. Successful artificial erections were induced after corporoplasty in all cases. Urethral reconstruction was performed with full-thickness preputial free grafts in 11 cases, bladder mucosal grafts in 7 and transverse island flap urethroplasty in 4. Although chordee developed during puberty (median age of onset 16 years, range 12 to 18), the median age at presentation for surgical correction was 21 years. Recurrent chordee was due to extensive fibrosis of the reconstructed urethra in 7 cases (32%), corporeal disproportion in 8 (36%) and both conditions in 7 (32%). Conclusions A successful artificial erection induced at hypospadias surgery does not prevent the delayed onset of recurrent chordee. Recurrent chordee may be secondary to the redevelopment of corporeal disproportion and/or extensive urethral fibrosis.

Late onset recurrent penile chordee after successful correction at hypospadias repair.

Artificial erections are induced at hypospadias repair to prevent recurrent chordee. We describe the development and etiology of late onset recurrent chordee greater than 10 years after the initial surgery. We reviewed the medical records of 22 patients with a median age of 4 years at surgery who were referred for evaluation of chordee 10 years after successful hypospadias repair. Of the 22 patients with recurrent chordee 13 had penoscrotal and 9 had proximal penile hypospadias at the initial operation. All originally required corporoplasty for the release of chordee, including Nesbit procedure in 19 and tunica vaginalis graft in 3. Successful artificial erections were induced after corporoplasty in all cases. Urethral reconstruction was performed with full-thickness preputial free grafts in 11 cases, bladder mucosal grafts in 7 and transverse island flap urethroplasty in 4. Although chordee developed during puberty (median age of onset 16 years, range 12 to 18), the median age at presentation for surgical correction was 21 years. Recurrent chordee was due to extensive fibrosis of the reconstructed urethra in 7 cases (32%), corporeal disproportion in 8 (36%) and both conditions in 7 (32%). A successful artificial erection induced at hypospadias surgery does not prevent the delayed onset of recurrent chordee. Recurrent chordee may be secondary to the redevelopment of corporeal disproportion and/or extensive urethral fibrosis.

Sphincteric incontinence: the primary cause of post-prostatectomy incontinence in patients with prostate cancer.

Post-prostatectomy incontinence in patients with cancer of the prostate is often the result of sphincteric injury. However, recent studies have emphasized the role of detrusor instability and decreased bladder compliance in the etiology of post-prostatectomy incontinence. To further clarify the primary cause of incontinence, we reviewed the urodynamic studies of 39 patients referred for evaluation of incontinence after prostatectomy (35 radical, 4 TURP and radiation) for prostate cancer. Multichannel videourodynamic studies were performed to characterize bladder function, and sphincteric incontinence was assessed by Valsalva leak point pressure (VLPP). Flexible cystourethroscopy was used to evaluate the vesicourethral anastomosis. A pad scoring system was used to measure symptom severity. Sphincteric damage was found to be the sole cause of urinary incontinence in 23 patients (59%) and a major contributor in 14 others (36%). Twenty-seven patients (69%) had VLPP less than 103 cmH2O (mean = 55) with a urethral urodynamic catheter in place. An additional 10 (26%) had VLPP less than 150 cmH2O (mean = 63) upon removal of the catheter. VLPP is an indication of the severity of sphincteric damage. The importance of removing the urodynamic catheter during measurement of the VLPP is emphasized. Urethral fibrosis was confirmed by cystourethroscopy in 26 (67%) patients. Bladder dysfunction characterized by detrusor instability and/or decreased bladder compliance was seen in 15 patients (39%). In contrast to previous studies, our results indicate that sphincteric damage, and not bladder dysfunction, accounts for the vast majority of post-prostatectomy incontinence in patients with prostate cancer. However, it is essential to identify and treat bladder dysfunction in order to optimize the outcome of treatment for sphincteric incontinence.

Collagenous Colitis: A Case Report of Associated Hypothyroidism, Chronic Inflammatory Arthropathy, and Possible Urethral Fibrosis With Response to Corticosteroids and Review of the Literature

Collagenous Colitis: A Case Report of Associated Hypothyroidism, Chronic Inflammatory Arthropathy, and Possible Urethral Fibrosis With Response to Corticosteroids and Review of the Literature

Intracavitary Irradiation of Prostatic Carcinoma by a High Dose-Rate Afterloading Technique

A high dose-rate (60Co) afterloading technique was evaluated in a series of 73 patients with prostatic carcinoma stages I-IV. The intraurethral irradiation was combined with external pelvic radiotherapy. A minimum total dose of 78 Gy was delivered to the target volume. In a subgroup of patients estramustine (Estracyt) was given as adjuvant chemohormonal therapy during irradiation. The median follow-up for the whole group was 63 months. The crude 5-year survival rate was 60% and the corrected survival rate 90%. Survival was related to the tumor grade. Local pelvic recurrences were recorded in 17.8%. 'Viable cells' in posttherapy aspiration biopsy were not associated with tumor recurrences or survival. Four patients (5%) had grade 3 late radiation reactions with urethral stricture or bladder fibrosis. Urinary tract infections and prior transurethral resections were not associated with a higher frequency of reactions. Concurrent estramustine therapy seemed to increase the frequency of both acute and chronic radiation reactions. Local control, recurrence, and survival were not affected by chemohormonal therapy. The use of tomography, magnetic resonance, and ultrasound as aids to computerized dosimetry may improve local dose distribution and reduce the irradiated volume.

Sonourethrography in the Evaluation of Urethral Stricture Disease

Ultrasonography of the anterior urethra offers a dynamic three-dimensional study that can easily be repeated. It holds the promise of defining accurately, not only the exact length and severity of the strictured urethral segment, but also the extent of urethral fibrosis and the anatomy of the periurethral structures. A significant reduction in the incidence of recurrent stricture may be obtained by selecting patients for treatment on the basis of the findings of sonourethrography. Moreover, the potential exists for the use of this imaging method during internal urethrotomy to ensure a more accurate and aggressive incision of the stricture.

Collagenous colitis: physiologic and histopathologic studies in seven patients.

Collagenous colitis is a clinicopathologic syndrome with chronic watery diarrhea, diffuse colitis with surface epithelial injury, and a distinctive collagen band beneath the surface epithelium especially in the proximal colon. The cases of seven patients (including six middle-aged women) with chronic, watery, noninfectious diarrhea were studied. Roentgenographic and endoscopic findings were not diagnostic. Two patients had rectal mucosal inflammation but sparing of the distal colon from subepithelial collagen. Other findings included thyroid disease (four patients), urethral fibrosis (three), elevated erythrocyte sedimentation rate (six), and eosinophilia (three). The colon was thought to be the main source of diarrheal fluid, but bile salt malabsorption, steatorrhea, and net small-bowel secretion were additive factors in some patients. With antiinflammatory treatment the diarrhea abated, the surface epithelial injury decreased, and the subepithelial collagen resolved (two patients), but lamina propria inflammation persisted. Collagenous colitis seems to be a chronic systemic, and perhaps autoimmune, disorder.