Urethral Manipulation Research Articles

Complications and salvage options after laser lithotripsy for a vesical calculus in a tetraplegic patient: a case report

BackgroundLaser lithotripsy of vesical calculi in tetraplegic subjects with long-term urinary catheters is fraught with complications because of bladder wall oedema, infection, fragile urothelium, bladder spasms, and autonomic dysreflexia. Severe haematuria should be anticipated; failure to institute measures to minimise bleeding and prevent clot retention can be catastrophic. We present an illustrative case.Case presentationA tetraplegic patient underwent laser lithotripsy of vesical stone under general anaesthesia. During lithotripsy, severe bladder spasms and consequent rise in blood pressure occurred. Bleeding continued post-operatively resulting in clot retention. CT revealed clots within distended but intact bladder. Clots were sucked out and continuous bladder irrigation was commenced. Bleeding persisted; patient developed repeated clot retention. Cystoscopy was performed to remove clots. Patient developed abdominal distension. Bladder rupture was suspected; bed-side ultrasound scan revealed diffuse small bowel dilatation with mild peritoneal effusion; under-filled bladder containing small clot. Patient developed massive abdominal distension and ileus. Two days later, CT with oral positive contrast revealed intra-peritoneal haematoma at the dome of bladder with perforation at the site of haematoma. Free fluid was noted within the peritoneal cavity. This patient was managed by gastric drainage and intravenous fluids. Patient's condition improved gradually with urethral catheter drainage. Follow-up CT revealed resolution of bladder rupture, perivesical haematoma, and intra-peritoneal free fluid.ConclusionIf bleeding occurs, bladder irrigation should be commenced immediately after surgery to prevent clot retention. When bladder rupture is suspected, CT of abdomen should be done instead of ultrasound scan, which may not reveal bladder perforation. It is debatable whether laparotomy and repair of bladder rupture is preferable to nonoperative management in tetraplegics. Anti-muscarinic drugs should be prescribed prior to lithotripsy to control bladder spasms; aspirin and ibuprofen should be omitted. If significant bleeding occurs during lithotripsy, procedure should be stopped and rescheduled. Percutaneous cystolithotripsy using a wide channel could be quicker to clear stones, as larger fragments could be retrieved; lesser stimulant for triggering autonomic dysreflexia, as it avoids urethral manipulation. But in patients with small, contracted bladder, and protuberant abdomen, percutaneous access to urinary bladder may be difficult and can result in injury to bowels.

Bladder urothelial neoplasms in pediatric age: Experience at three tertiary centers

Urothelial bladder neoplasms (UBN) typically occur in patients in their sixth or seventh decade of life while they are infrequent in children and young adults. They occur in 0.1-0.4% of the population in the first two decades of life. Their management is controversial and paediatric guidelines are currently unavailable. To further expound the available data on the outcome of patients younger than 18 year old diagnosed with UBN. We retrospectively reviewed the files of all the consecutive paediatric patients with UBN treated in three tertiary paediatric urology units from January 1999 to July 2013. Lesions were classified according to the 2004 WHO/ISUP criteria as urothelial papillomas (UP), papillary urothelial neoplasm of low malignant potential (PUNLMP), low-grade urothelial carcinoma (LGUC), and high-grade urothelial carcinoma (HGUC). The table shows the results. Management after TURB varied among centres. One centre recommended only follow-up US at increasing intervals whereas another follow-up US plus urine cytologies and endoscopies, every three months in the first year, and at increasing intervals thereafter. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed disease recurrence or progression. UBN is an uncommon condition in children and adolescents and, unlike in adults, its incidence, follow-up and outcome still controversial. Paediatric guidelines are currently lacking and management varies among centres. Gross painless haematuria is the most common presenting symptom. Therefore, this symptom should never be underestimated. US is generally the first investigation and additional imaging seems unnecessary. TURB often allows for complete resection. Lesions are generally solitary, non-muscle invasive, and low-grade (mainly UP and PUNLMP). Ideal follow-up protocol is the most controversial point. Reportedly, recurrence or progression during follow-up is uncommon in patients under 20 years, recurrence rate 7% and a single case of progression reported so far. Accordingly, a follow-up mainly based on serial US might be considered in this age group compared to adults where also serial endoscopies and urine cytologies are recommended. In the selection of the follow-up investigations, it should also be taken into consideration that urine cytology has a low sensibility in the detection of low-grade lesions while cystoscopy in young patients requires a general anaesthesia and hospitalization, and carries an increased risk of urethral manipulation. UBN is a rare condition in children. Ultrasound is generally accurate in order to visualize the lesion, and TURB can treat the condition. Lesions are generally low-grade and non-muscle invasive, but high-grade lesions can also be detected. In present series, after TURB, follow-up US monitoring at increasing intervals was used at all centres, follow-up cystoscopies were added in two centres, but with different schedules. Urine cytologies were considered only at one centre. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed recurrence or progression of the disease.

Outcomes after Urethroplasty for Radiotherapy Induced Bulbomembranous Urethral Stricture Disease

We recently demonstrated that radiotherapy induced urethral strictures can be successfully managed with urethroplasty. We increased size and followup in our multi-institutional cohort, and evaluated excision and primary anastomosis as treatment for radiotherapy induced urethral strictures. A retrospective review was performed of 72 patients from 3 academic institutions treated for radiotherapy induced bulbomembranous strictures. Outcome parameters of successful repair included recurrence, incontinence and erectile dysfunction. Among the 72 men treated for radiotherapy induced strictures 66 (91.7%) underwent excision and primary anastomosis. Mean followup was 3.5 years (median 3.1, range 0.8 to 11.2). Prostate cancer was the most common reason for radiotherapy (in 64 of 66, 96.9%). External beam radiotherapy and brachytherapy were performed in 28 of 66 men (42.4%) each, and a combination of both was performed in 9 (13.6%). Mean time from radiation to excision and primary anastomosis was 6.4 years (range 1 to 20) and mean stricture length was 2.3 cm (range 1 to 6). Successful reconstruction was achieved in 46 men (69.7%). Mean time to recurrence was 10.2 months (range 1 to 64) with new onset of incontinence observed in 12 men (18.5%). This was associated with stricture length greater than 2 cm (p = 0.013) and treatment center (p <0.001). The rate of erectile dysfunction remained stable (preoperative 45.6%, postoperative 50.9%, p = 0.71). Radiotherapy type did not affect stricture length (p = 0.41), recurrence risk (p = 0.91), postoperative incontinence (p = 0.88) or erectile dysfunction (p = 0.53). Radiotherapy induced bulbomembranous urethral strictures can be successfully managed with excision and primary anastomosis. Substitution urethroplasty with graft or flap is needed infrequently. Patients should be counseled on the potential risks of urinary incontinence and erectile dysfunction.

The effect of a 6 Fr catheter in women: Are they obstructive?

Our objective was to evaluate the effect of a 6 Fr transurethral catheter on the uroflowmetry and to assess whether it potentially contributes to the bladder outlet obstruction (BOO) in women. We reviewed the charts of 1367 women who underwent an urodynamic study. We included patients with a non-invasive free-flow study (NIFFS) and pressure flow study (PFS) performed through a 6 Fr double lumen transurethral catheter. In total, 120 women met the inclusion/exclusion criteria. Mean maximal flow rate (Qmax) was significantly higher (p < 0.001) in the NIFFS (27.2±11.1 mL/s) than in the PFS (19.3±10.6 mL/s). The mean difference between both Qmax was 7.9±12.0 mL/s. Of these women, 92.3% (24/26) with a Qmax <12 mL/s during PFS were found to have a Qmax ≥12 mL/s during the NIFFS. Ten of the 72 women with an available Pdet.Qmax were deemed to have a BOO according to the PFS and all of them had a Qmax >12 mL/s during the NIFFS. Of the 10 patients, only 2 reported obstructive symptoms. The presence of 6 Fr transurethral catheters alters the PFS and results in a significant reduction of the Qmax in patients who voided more than 250 mL. We believe that NIFFS should be performed in all patients before any urethral manipulation to lower a possible overdiagnosis of BOO and findings should always be correlated to clinical symptoms.

Role of Serum Total PSA (Prostate Specific Antigen) and Free to Total PSA Ratio in the Diagnosis of Carcinoma Prostate

The objective of the study was to evaluate and compare the role of total and free/total ratio of serum prostate specific antigen level in diagnosing carcinoma prostate. A cross sectional study was conducted at the Department of Biochemistry, Dhaka Medical College (DMC) with collaboration of the Department of Urology, Dhaka Medical College Hospital (DMCH), Dhaka from July 2008 to June 2009. This study was carried out on 60 patients above 50 years of age who attended the Department of Urology, Dhaka Medical College Hospital, complaining of irritative or obstructive lower urinary tract symptoms (LUTS) suspected as clinically benign prostatic hyperplasia (BPH) or cancer prostate. It was aimed to assess the role of total and free/total ratio of serum PSA in diagnosis of BPH and carcinoma prostate with reference to histological diagnosis. All the cases were evaluated by history, physical examination including digital rectal examination, serum prostate specific antigen level, transabdominal/ trans-rectal ultra- sonogram. From all patients, blood sample were collected before digital rectal examination or any per urethral manipulation. Final diagnosis was obtained by histo-pathological examination, specimen being obtained by perrectal biopsy with biopsy-gun. Histopathological examination detected prostate cancer in 20 out of 60 patient and 17 of these Cap 20 have a total PSA ? 4 ng/ml and only 3 have total PSA ? 4 ng/ml. 18 of these 20 have free to total ratio ?0.16 and 02 have f/t ratio ?0.16. Among 60 patients, 40 patients were detected BPH on histopathological diagnosis. 20 of these BPH patient have tPSA ? 4 ng/ml and 20 of BPH have tPSA ? 4 ng/ml. 38 of 40 BPH patient have f/t ratio &gt;0.16 and 2 of 40 patient are f/t ratio ?0.16. Receiver operating characteristic analysis indicated a threshold f/t ratio ? 0.16 was optimum discriminatory level. The sensitivity of total serum PSA (at cut off value of &gt;4 ng/ml) in correctly differentiating prostatic carcinoma of those who have the condition is 85%, while the specificity of the test in correctly detecting those who do not have the disease is 50%. The PPV is 45.9%, NPV is 87% and accuracy is 61.7%. The sensitivity of free/total serum PSA (at cut off value of 0.16 ng/ml) in correctly differentiating prostatic carcinoma from BPH is 90%, while the specificity of the test in correctly detecting those who do not have prostatic carcinoma is 95%. The PPV of the test is 90% and the NPV of the test is 95%. The overall accuracy of the test is 93.3%. This study showed significant difference of total and free/total ratio of serum prostate specific antigen (PSA) in differentiating benign prostatic hyperplasia (BPH) from carcinoma prostate. Receiver operating characteristic curves showed advantage for the f/t PSA ratio when compared with total PSA in detecting prostate cancer. From the study it may be concluded that total and f/t ratio of prostate specific antigen (PSA) is a useful marker in diagnosis of carcinoma prostate. Free/total ratio is more accurate than total PSA. DOI: http://dx.doi.org/10.3329/bjmb.v4i1.13778 Bangladesh J Med Biochem 2011; 4(1): 21-26

Severe Penile Curvature following Otis Urethrotomy

Urethral stricture is a common urological pathology with a high recurrence rate after treatment. Urethral manipulations are among its main causes. In this paper, urethral stricture developed secondary to urethral catheterization and was treated with cold-knife internal urethrotomy and the Otis urethrotomy procedure. During the follow-up period, severe ventral penile curvature preventing sexual intercourse developed due to fibrosis of the corpus spongiosum and tunica albuginea of the penis. This ventral penile curvature was corrected with a separate operation using a tunica vaginalis flap harvested from the left scrotum.

Repeat Transurethral Manipulation of Bulbar Urethral Strictures is Associated With Increased Stricture Complexity and Prolonged Disease Duration

We examined the association of previous transurethral manipulation with stricture complexity and disease duration among men referred for bulbar urethral reconstruction. We retrospectively reviewed the records of 340 consecutive urethroplasties performed by a single surgeon between July 2007 and October 2010. Only men treated with initial open surgery for bulbar strictures were included in analysis, thus excluding those with hypospadias, lichen sclerosus, pelvic radiation, prior urethroplasty, incomplete data, or pure penile or posterior urethral stenosis. Cases were divided into 2 groups based on the history of transurethral treatment for urethral stricture before urethroplasty, including group 1-0 or 1 and group 2-2 or greater treatments. Of 101 patients with bulbar urethral stricture and all data available 50 and 51 underwent 0 to 1 and 2 or greater previous transurethral treatments, respectively. Repeat transurethral manipulation was strongly associated with longer strictures and the need for complex reconstruction. Repeat transurethral manipulation of bulbar urethral strictures was also associated with an eightfold increase in disease duration between stricture diagnosis and curative urethroplasty. Repeat transurethral manipulation of bulbar strictures is associated with increased stricture complexity and a marked delay to curative urethroplasty.

Comparison of Immediate Primary Repair and Delayed Urethroplasty in Men with Bulbous Urethral Disruption after Blunt Straddle Injury

PurposeThe aim of this study was to analyze the outcomes of immediate primary repair (IPR) compared with delayed repair (DR) after initial suprapubic cystostomy.Materials and MethodsWe reviewed the records of 60 patients with bulbous urethral disruption after blunt trauma from February 2001 to March 2011. Seventeen patients who presented in an acute injury state underwent IPR; 43 patients underwent DR after the initial suprapubic cystostomy. None of the patients had undergone previous urethral manipulation. We compared the outcomes, including stricture, impotence, and incontinence, between the two management approaches. We also measured the time to spontaneous voiding, the duration of suprapubic diversion, and the number of days spent in the hospital.ResultsThe median follow-up was 20.5 months (range, 13 to 59 months; mean, 23.3 months). Among 17 patients in the IPR group, strictures developed in 2 patients (11.7%), and among 53 patients in the DR group, strictures developed in 8 patients (18.6%, p=0.709). The incidences of impotence and incontinence were similar in both groups (17.6% and 0% in the IPR group vs. 27.9% and 4.6% in the DR group, p=0.520 and 1.000, respectively). The time to spontaneous voiding and the duration of suprapubic diversion were significantly shorter in the IPR group (average 27.3 and 33.4 days, respectively) than in the DR group (average 191.6 and 198.1 days, respectively; p<0.001 and <0.001).ConclusionsIPR may provide comparable outcomes to DR and allow for shorter times to spontaneous voiding and reduce the duration of suprapubic diversion.

204 IMPACT OF PRIOR URETHRAL MANIPULATION ON OUTCOME OF ANASTOMOTIC URETHROPLASTY FOR POST-TRAUMATIC URETHRAL STRICTURE

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery1 Apr 2011204 IMPACT OF PRIOR URETHRAL MANIPULATION ON OUTCOME OF ANASTOMOTIC URETHROPLASTY FOR POST-TRAUMATIC URETHRAL STRICTURE Aziz Abdullah Aziz AbdullahAziz Abdullah Karachi, Pakistan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.275AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To determine the impact of earlier urethral interventions on the outcomes of anastomotic urethroplasty in post-traumatic stricture urethra. METHODS From Jan 2008 to Feb. 2010, a total of 42 patients with post-traumatic posterior urethral stricture underwent anastomotic urethroplasty. Eighteen patients had earlier undergone urethral intervention in the form of urethrotomy (5), endoscopic realignment (7), or open urethroplasty (6). Success was defined as no obstructive urinary symptoms, maximum urine flow rate > or = 15 mL/s, normal urethral imaging and/or urethroscopy, and no need of any intervention in the follow-up period. Patients who met the above objective criteria after needing 1 urethrotomy following urethroplasty were defined to have satisfactory outcome and were included in satisfactory result rate along with patients who had a successful outcome. Results were analyzed using unpaired t test, chi-square test, binary logistic regression, Kaplan-Meier curves, and log rank test. RESULTS Previous interventions in the form of endoscopic realignment or urethroplasty have significant adverse effect on the success rate of subsequent anastomotic urethroplasty for post-traumatic posterior urethral strictures (P <.05). Previous intervention in the form of visual internal urethrotomies (up to 2 times) did not affect the outcome of subsequent anastomotic urethroplasty. Length of stricture and age of patient did not predict the outcome in traumatic posterior urethral strictures in logistic regression analysis. CONCLUSIONS Previous failed railroading or urethroplasty significantly decrease the success of subsequent anastomotic urethroplasty. Hence, a primary realignment or urethroplasty should be avoided in suboptimal conditions and the cases of post-traumatic urethral stricture should be referred to centers with such expertise. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e84-e85 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aziz Abdullah Karachi, Pakistan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Expression of Monocyte Chemotactic Protein 3 Following Simulated Birth Trauma in a Murine Model of Obesity

To determine the effect of obesity on simulated birth trauma in leptin-deficient obese mice as measured by relative monocyte chemotactic protein 3 (MCP-3) expression. A total of 25 wild-type and 25 obese C57BL/6 virgin female mice underwent 1 hour of vaginal distension (VD), sham VD, or anesthesia without VD. Pelvic organ tissues were then harvested either immediately or 24-hours post VD and subsequent real-time polymerase chain reaction analysis was performed. Urethral MCP-3 levels in wild-type mice were elevated from baseline at 0 hours with a return to baseline at 24 hours in both VD and sham VD groups. In obese mice, there was a 6-fold elevation in MCP-3 levels at 0 hours after sham VD vs control (P <.05), which then returned to baseline levels at 24 hours. After undergoing VD, MCP-3 levels increased to 6-fold baseline values (P = .002) at 0 hours, with continued elevation in MCP-3 levels to 15 times control levels (P = .0003) at 24 hours. MCP-3 is significantly over-expressed in the urethral tissues of both wild-type and obese mice immediately after any urethral manipulation. At 24 hours, the MCP-3 expression patterns become divergent between VD and sham VD in obese mice. With a greater degree of trauma, MCP-3 continued to rise at 24 hours, suggesting that the underlying obesity resulted in alterations in response to tissue injury, paralleling the degree of injury. Such associations warrant further investigation into the role of MCP-3 as a chemokine for stem cell migration, with implications for subsequent tissue repair mechanisms after birth trauma.

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 ...

63 SINGLE-STAGE SALVAGE URETHROPLASTY AFTER PREVIOUS OPEN SURGERY

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 201063 SINGLE-STAGE SALVAGE URETHROPLASTY AFTER PREVIOUS OPEN SURGERY Kathy Vander Eeckt and Steven Joniau Kathy Vander EecktKathy Vander Eeckt More articles by this author and Steven JoniauSteven Joniau More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.110AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There is no common practice in the treatment of urethral strictures after previous open urethral reconstruction in adults. We aimed to assess the results of single-stage salvage urethroplasty after previous open surgery. METHODS 185 patients underwent urethral surgery at our institution between 2003 and 2009. Of those, 35 who had undergone previous open urethral reconstruction (excluding cripple hypospadias) underwent single-stage salvage urethroplasty and were included in the analysis. Different pre- and postoperative parameters were collected: pre- and postoperative maximum flow rate (Qmax), previous urethral manipulations, stricture length, postoperative complications, preoperative remembered IIEF-5 score (r-IIEF-5) and prospectively collected IIEF-5 (p-IIEF-5) score and IPSS at last follow-up. Any urethral instrumentation after surgery was considered a treatment failure. One-way ANOVA, Chi-square and Kaplan-Meier with log-rank test were used for statistical analysis. RESULTS Four patients underwent an end-to-end urethroplasty (12.1%), 6 received a fascio-cutaneous flap reconstruction (18.2%), 19 had a buccal mucosa free graft repair (57.6%) and 4 had an excision of a fistula (12.1%). The mean stricture length was 3.3 cm (SD+/- 2.2). Median preoperative and postoperative maximum flow rate was 8.2 and 18.4 ml/s respectively (p=0.0004). 26.5% of the patients had postoperative complications. (UTI: 2.9%, wound problems: 20.6% and cardiovascular problems: 2.9%). The mean follow-up was 22.3 months (SD+/- 20.5). The 5-year estimated overall failure-free rate was 96.8%. There were no significant differences in outcome comparing different surgical approaches. The median IPSS score at last follow-up was 7 (IQR 2-18). 31.2% of the patients had new onset postmicturation dribbling. There was no significant difference between r-IIEF-5 (mean 19.3 (SD +/-7.4)) and p-IIEF-5 (mean 19.5 (SD +/-8.0)) (p=0.86). CONCLUSIONS The results of salvage single-stage urethroplasty after previous open surgery are very good with a success rate of 96.8%. This high success rate is not at the cost of erectile function decline. Leuven, Belgium© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e26-e27 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kathy Vander Eeckt More articles by this author Steven Joniau More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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In this study, it was clear that the patients who underwent urethroplasty for the first time showed good results. However, there has been evidence of poor results in patients undergoing urethroplasty after realignment or urethroplasty. In case of realignment, this could be either because of adverse effect of the procedure itself or severe primary urethral injury, which may explain the failure of realignment as well as subsequent urethroplasty. Realignment can worsen the injury in many ways. First, it may physically exaggerate the urethral injury. 1 Mundy A.R. Pelvic fracture injuries of the posterior urethra. World J Urol. 1999; 17: 90-95 Crossref Scopus (50) Google Scholar , 2 Mundy A.R. Reconstruction of the urethra after pelvic trauma. Acta Urol Belg. 1998; 66: 48 Google Scholar This may be especially true when realignment is done in suboptimal conditions (without flexible cystoscopy and expertise, overzealous multiple attempts) or in an early phase when traumatized urethral margins are edematous, friable, and ischemic. Second, putting the catheter across the urethral margins will prevent the free drainage of resolving hematoma and inflammatory exudate, which is present near traumatized urethral ends and would have otherwise gradually drained through either of the urethral ends. This will cause more inflammatory injury and fibrosis. Third, there is a risk of introducing an infection into the hematoma by realignment. Editorial CommentUrologyVol. 75Issue 1PreviewThis manuscript addresses the following question: “do prior urethral manipulations adversely affect the outcomes of urethral reconstruction, for traumatic posterior urethral strictures?” This question is of some importance as it relates to 2 issues, should these patients be treated in the acute phase with primary catheter realignment as has been suggested in recent years? And who should perform urethral reconstruction in these patients with posterior urethral traumatic strictures? The manuscript is based on a relatively small group of patients (58 patients during 13 years); thus, the study may not be robustly powered to make strong negative statements where statistical significance has not been reached. Full-Text PDF Impact of Prior Urethral Manipulation on Outcome of Anastomotic Urethroplasty for Post-traumatic Urethral StrictureUrologyVol. 75Issue 1PreviewTo determine the impact of earlier urethral interventions on the outcomes of anastomotic urethroplasty in post-traumatic stricture urethra. Full-Text PDF

Impact of Prior Urethral Manipulation on Outcome of Anastomotic Urethroplasty for Post-traumatic Urethral Stricture

To determine the impact of earlier urethral interventions on the outcomes of anastomotic urethroplasty in post-traumatic stricture urethra. From October 1995 to March 2008, a total of 58 patients with post-traumatic posterior urethral stricture underwent anastomotic urethroplasty. Eighteen patients had earlier undergone urethral intervention in the form of urethrotomy (3), endoscopic realignment (7), or open urethroplasty (8). Success was defined as no obstructive urinary symptoms, maximum urine flow rate > or = 15 mL/s, normal urethral imaging and/or urethroscopy, and no need of any intervention in the follow-up period. Patients who met the above objective criteria after needing 1 urethrotomy following urethroplasty were defined to have satisfactory outcome and were included in satisfactory result rate along with patients who had a successful outcome. Results were analyzed using unpaired t test, chi-square test, binary logistic regression, Kaplan-Meier curves, and log rank test. Previous interventions in the form of endoscopic realignment or urethroplasty have significant adverse effect on the success rate of subsequent anastomotic urethroplasty for post-traumatic posterior urethral strictures (P <.05). Previous intervention in the form of visual internal urethrotomies (up to 2 times) did not affect the outcome of subsequent anastomotic urethroplasty. Length of stricture and age of patient did not predict the outcome in traumatic posterior urethral strictures in logistic regression analysis. Previous failed railroading or urethroplasty significantly decrease the success of subsequent anastomotic urethroplasty. Hence, a primary realignment or urethroplasty should be avoided in suboptimal conditions and the cases of post-traumatic urethral stricture should be referred to centers with such expertise.

Re: Perineal Anastomotic Urethroplasty for Posttraumatic Urethral Stricture with or without Previous Urethral Manipulations: A Review of 61 Cases with Long-term Followup

Re: Perineal Anastomotic Urethroplasty for Posttraumatic Urethral Stricture with or without Previous Urethral Manipulations: A Review of 61 Cases with Long-term Followup

Outcome after repair of congenital penile malformations.

Penile malformations seen and treated during childhood may result in voiding disorders and sexual malfunction in adults. Preputial synechia and phimosis will seldom be the reason for these problems, although some men do seek treatment to correct radical circumcision. Little is known about the satisfaction of men with neonatal or childhood circumcision. Congenital penile curvature is seen in 0.4-0.6% of men. Slight bends do not need any operative treatment and young men should be given advice and counselling accordingly. If treatment is needed, a standard Nesbit procedure or one of its modifications is used in order to avoid urethral manipulation. A hypospadiac position of the urethral meatus together with a more or less prominent ventral bending of the penis is seen in another 0.3-0.5% of boys. Reports on more than 200 operations to correct this deformity have been published. Between 5 and 25% of early complications such as fistula formation, stenosis of the neourethra and skin problems result from hypospadias repair. Long-term follow-up studies have shown that adulthood satisfaction with respect to voiding and sexual function is achieved in 2/3 and some degree of dissatisfaction in 1/3 of cases. Epispadias repair is a much more complicated procedure and long-term results are seldom reported. Nevertheless, quite good results with respect to continence (approximately 80%) and sexual function may be achieved.

Perineal Anastomotic Urethroplasty for Posttraumatic Urethral Stricture With or Without Previous Urethral Manipulations: A Review of 61 Cases With Long-Term Followup

We retrospectively analyzed cases of anastomotic urethroplasty for posttraumatic urethral strictures that were done at our center. Surgical and functional outcomes were evaluated. The impact of previous urethral manipulations was assessed. Between 1993 and 2006, 61 males were treated with anastomotic urethroplasty because of urethral trauma after pelvic fracture. Mean followup was 67 months (range 19 to 173). In 21 of the 61 cases (34.4%) urethral manipulation had been performed previously (secondary cases) but had failed. All patients were treated via the perineal approach. In 9 patients (14.8%) recurrence was reported. The recurrence rate was higher in patients who underwent former treatment than in primary patients (19% vs 12.5%). Posttraumatic impotence was reported by 20 patients (32.8%) but in 2 erectile function was restored after treatment. One patient had minor stress incontinence. In 2 secondary cases the rectum was injured during the procedure but could be repaired. Anastomotic urethroplasty via the perineal approach is an excellent treatment for posttraumatic urethral stricture. Results are good at long-term followup. Although statistical significance has not been attained, failures and complications seem to be higher in patients who have already undergone failed urethroplasty.

Posttraumatic Posterior Urethral Strictures in Children—Management and Intermediate-term Follow-up in Tertiary Care Center

To evaluate the management and intermediate-term follow-up of posttraumatic posterior urethral strictures in children. From March 2000 to November 2006, the surgical records of 28 children (< or = 18 years) who had been admitted for treatment of posttraumatic posterior urethral strictures were retrospectively reviewed. The patients had been followed up for a median of 36 months (range 3-58). The cause of trauma, extent of urinary tract injury, radiologic examination findings, previous treatment, and its effect on the final outcome, treatment complications,, and failures were evaluated. The mean age of the patients was 12.1 years (range 5-18) at the injury. The estimated radiographic mean stricture length before surgery was 3.41 cm (range 2-6). Of the 28 patients, 27 were treated with transperineal anastomotic urethroplasty, with a success rate of 75%. All treatment failures were at the anastomotic site and occurred within the first year of anastomotic urethroplasty. The failed repairs (7 cases) were successfully managed endoscopically in 4 patients and by redo urethroplasty in 3, for a final success rate of 100%. Of the 28 patients, 15 (80%) with urethral manipulation before anastomotic urethroplasty had a satisfactory result compared with 69.3% of patients without previous surgical treatment. The difference was not statistically significant. Most posttraumatic posterior urethral strictures in children can be managed through the perineal route. The transpubic approach should be reserved for more complex posterior strictures. Previous urethral manipulations did not affect the intermediate-term results of anastomotic urethroplasty.

Anastomotic Urethroplasty for Posttraumatic Urethral Stricture: Previous Urethral Manipulation Has a Negative Impact on the Final Outcome

We evaluated the long-term results of anastomotic urethroplasty for posttraumatic urethral stricture and assessed the impact of previous endourethral/surgical intervention on the subsequent outcome. From January 1988 to April 2005, 51 patients underwent anastomotic urethroplasty for posttraumatic urethral stricture following pelvic fracture (41) or perineal blunt trauma (10). Of these patients 28 (55%) underwent previous surgical procedures, including endoscopic urethrotomy with endoscopic realignment in 20 and open urethroplasty in 8. Median followup was 4.6 years. Results were evaluated. Success was characterized by a maximum urine flow of more than 15 ml per second, sterile urine, and normal urethral imaging and/or endoscopy. A satisfactory result was considered to be 1 episode of recurrence diagnosed on routine imaging/endoscopy that was successfully managed by 1 or 2 direct vision internal urethrotomies. Failure was characterized by the necessity for repeat instrumental and/or open surgery. Results were analyzed using Kaplan-Meier curves and the log rank test. At 1, 5 and 10 years overall success rates were 63%, 55% and 43%, while satisfactory result rates were 84%, 80% and 76%, respectively. However, the 23 patients without urethral manipulation before anastomotic urethroplasty had a satisfactory result of more than 90% vs more than 60% in patients with previous surgical treatment. These results were maintained for 100 months (p <0.05). Endoscopic and/or open urethral manipulation before anastomotic urethroplasty for posttraumatic urethral stricture has a significant impact on the outcome of urethral reconstruction. Cases of posttraumatic urethral stricture should preferably be referred to a center of expertise.

The use of local anesthetic gel during retrograde urethrography: does it cause a false negative result?

To investigate the implication of topical urethral anesthetic gel on the evaluation of retrograde urethrography (RGU) MATERIAL AND METHODS: In this prospective study, 20 patients with a mean age of 46 years were enrolled. All these patients were subjected to RGU because of suspecting a urethral stricture. Of these 13 had a history of open or endoscopic urethral manipulation, while seven had no such history. In all patients 10 ml of Gelicain gel 2% (lidocainhydrocloride) was used as local anesthetic gel at temperature of 22 degrees C. The injection was made gradually over 10 s. The first set of RGU was done without local anesthesia and the second image was taken after 10 min of instillation of 2% gelicain gel. All images were evaluated by the same radiologist. The diameter of the urethra was measured by capture screen during fluoroscopy immediately distal to the stricture site in case of urethral strictures and at the middle of the bulbous urethra in other cases. In all patients, the mean diameter of the urethra at the selected site was 8.7 +/- 2.5 mm before and 9.4 +/- 2.9 mm after instillation of local anesthetic gel (P = 0.005). The stricture was diagnosed in 13 cases while seven patients had no stricture. The clinical diagnosis of a possible stricture was the same before and after instillation of the local agent in all patients. Instillation of the local anesthetic gel before RGU produces a slight but statistically significant increase in the diameter of the urethra at the selected sites. However, neither the radiologic reading of RGU nor the clinical diagnosis of a possible stricture was changed because of this increment.