Urethral Reconstructive Surgery Research Articles

Dorsal tunica vaginalis graft plus onlay preputial island flap urethroplasty: Experimental study in rabbits

To assess the use of tunica vaginalis graft plus onlay preputial island flap in urethral reconstructive surgery in rabbits through histopathology. We developed an experimental model of urethroplasty that resembles one-stage complex hypospadias surgery with divided urethral plate. The tunica vaginalis graft is dorsally placed to recreate the urethral plate and the internal preputial island flap is placed onlay to complete the urethroplasty. Sixteen animals were divided into four equal groups and sacrificed at 2, 4, 8 and 12 weeks after surgery, the penis being sent for histopathological evaluation. There were no deaths related to the procedure or wound breakdown; all rabbits voided spontaneously after surgery. Two urethrocutaneous fistulae were found. Microscopically, good tissue integration was observed, the tunica vaginalis mesothelium was gradually replaced by a more stratified epithelial lining, similar to the urothelial lining of the native urethra. The stratified squamous non-keratinized lining of the internal preputial island flap also changed into a thinner epithelial lining with only 4-5 cell layers. Two urethral diverticula were found. A tunica vaginalis graft placed dorsally plus an onlay internal preputial island flap was shown to be a successful technique for urethroplasty in an animal model.

Anatomical approach for surgery of the male posterior urethra

To investigate, in a morphological study, the anatomy of the male rhabdosphincter and the relation between the membranous urethra, the rhabdosphincter and the neurovascular bundles (NVBs) to provide the anatomical basis for surgical approach of the posterior urethra as successful outcomes in urethral reconstructive surgery still remain a challenging issue. In all, 11 complete pelves and four tissue blocks of prostate, rectum, membranous urethra and the rhabdosphincter were studied. Besides anatomical preparations, the posterior urethra and their relationship were studied by means of serial histological sections. In the histological cross-sections, the rhabdosphincter forms an omega-shaped loop around the anterior and lateral aspects of the membranous urethra. Ventrally and laterally, it is separated from the membranous urethra by a delicate sheath of connective tissue. Through a midline approach displacing the nerves and vessels laterally, injuries to the NVBs can be avoided. With meticulous dissection of the delicate ventral connective tissue sheath between the ventral wall of the membranous urethra and the rhabdosphincter, the two structures can be separated without damage to either of them. This anatomical approach can be used for dissection of the anterior urethral wall in urethral surgery. Based on precise anatomical knowledge, the ventral wall of the posterior urethra can be dissected and exposed without injuring the rhabdosphincter and the NVBs. This approach provides the basis for sparing of the rhabdosphincter and for successful outcomes in urethral surgery for the treatment of bulbo-membranous urethral strictures.

Complications following urethral reconstructive surgery: a six year experience

We present a single institutional experience over 6 years of intra and postoperative complications following urethral reconstructive surgery, and the impact of these complications on overall results. From June 2000 through May 2006, 153 consecutive urethral reconstructive procedures were performed on 128 patients by one surgeon (CMG). Complication rates were determined, and subgroups were categorized based on stricture etiology, patient age, length of stricture, location of stricture, type of repair, and presence of various co-morbid conditions. Overall, 23 of 153 cases (15%) had an intra or postoperative complication with a mean follow-up time of 28.3 months (range 3 to 74). The most common complications were related to infection (n = 9). Other complications included repair breakdown (n = 4), bleeding (n = 4), fistulae (n = 3), thromboembolic (n = 2), positioning-related (n = 2), and Foley catheter malfunction (n = 1). Complication rates for anastomotic and substitution urethroplasty were 9.1% (4/44) and 17% (19/109), respectively. The number of patients with at least one year of follow-up who had a complication and eventual stricture recurrence was 20% (4/20), while only 7.4% (7/95) of those who did not have a complication recurred (p = 0.08). Complications following reconstructive surgery for urethral stricture disease were mostly related to infection or repair breakdown in the immediate postoperative period. It does not appear that an intra or postoperative complication following urethral reconstructive surgery impacts the chance of eventual stricture recurrence at intermediate follow-up.

Use of human fibrinogen and human thrombin for urethral reconstructive surgery

The objective of the present study is to test the use of a haemostatic sponge for urethral reconstructive surgery and to assess the relevant benefits. METHODS. The haemostatic sponge is made up of collagen with human fibrinogen and human thrombin. When the sponge gets in contact with fluids, such as blood, lymph or saline solution, the fibrinogen and thrombin are activated and form a fibrin net able to achieve local haemostasis and tissue regeneration. This kind of product was used in 30 selected patients (pts.), aged 19 - 70 (mean age: 35), who underwent single-stage anastomotic urethroplasty from January 2006 to March 2007: 22 bulbar end-to-end anastomoses and 8 bulbo- prostatic anastomoses. All operations were performed due to post-traumatic stricture of bulbar and posterior urethra. The main selection criterion for the use of the haemostatic sponge has always been the tendency to and/or the presence of bleeding in the different surgical stages. The sponge imbibed in saline solution and suitably modeled for all specific requirements was differently placed: sleeve-shaped in the case of bulbar anastomoses (16 pts.); as a "patch" in the centre of spongioplasty in bulbo-prostatic anastomoses (8 pts.), and within the widening incisions of the urethral roof performed between the two cavernous bodies at level of the intercrural septum (5 pts.). In 1 case (obese patient) a single sponge was placed after the deep perineal reconstruction on the bulbo-cavernous muscle- subcutaneous layers because of massive bleeding. RESULTS. In all cases a perfect control of haemostasis could be achieved, with immediate end of bleeding in the points where the haemostatic sponges were used. The dressings performed on day 3 upon removal of the compressive scrotum-perineal bandages did not show any late post-operative bleeding. The follow-up visits at month 1 and 3 yielded positive outcomes for all 30 patients, who achieved complete wound healing by first intention, and a perfect anastomosis especially in the bulbar end-to-end urethroplasty, confirmed by urethrografy at one month. CONCLUSIONS. The association of human fibrinogen and human thrombin in haemostatic sponges represents a manageable, useful product, apparently sure, not negatively interfering in repairing and regenerating tissue processes, and allowing a simple and direct control of important bleeding events occurring during urethral reconstructive surgery as well as other operations. It is therefore advisable to more widely use the product after a suitable followup period.

Erectile function after urethral reconstruction

Advances in urogenital plastic surgical tissue transfer techniques have enabled urethral reconstruction surgery to become the new gold-standard for treatment of refractory urethral stricture disease. Questions remain, however, regarding the long-term implications on sexual function after major genital reconstructive surgery. In this article, we review the pathologic features of urethral stricture disease and urologic trauma that may affect erectile function (EF) and assess the impact of various specific contemporary urethroplasty surgical techniques on male sexual function.

A Prospective, Randomized Trial Evaluating the Use of Hydrogel Coated Latex Versus All Silicone Urethral Catheters After Urethral Reconstructive Surgery

The superiority of silicone over latex based catheters following urethral reconstructive surgery for stricture disease has been theorized, and yet data comparing their use in this group of patients are lacking. We present our findings from a prospective, randomized trial comparing silicone to hydrogel coated latex catheters in patients following urethral reconstructive surgery. From February 2004 to August 2006 men undergoing urethral reconstructive surgeries were randomized to receive an all-silicone or a hydrogel coated latex urethral catheter for postoperative bladder drainage. Patient demographics and the various reconstructive procedures used were analyzed. Complications and stricture recurrence were evaluated in the 2 groups. A total of 85 men were randomized to receive a silicone (43) or a latex (42) catheter following reconstructive surgery. Median followup was 20 months (range 10 to 36). Mean patient age, urethral stricture length, complication rate and type of reconstructive procedure did not significantly differ between the 2 groups. Five patients (11%) per group required repeat instrumentation for stricture recurrence (p = 0.97). Median time to stricture recurrence was not statistically different between the 2 groups. The theoretical benefit of silicone catheters over hydrogel coated latex catheters does not appear to translate into a clinical advantage after urethral reconstructive surgery since we found no difference in the rate of recurrence or operative complications at intermediate term followup. It appears that the 2 types of catheter are appropriate for urethral stenting following urethral reconstructive surgery.

Surgical treatment of anterior urethral stricture diseases: brief overview

We performed an up-to-date review of the surgical techniques suggested for the treatment of anterior urethral strictures. References for this review were identified by searching PubMed and MEDLINE using the search terms "urethral stricture" or "urethroplasty" from 1995 to 2006. Descriptive statistics of the articles were provided. Meta-analyses or other multivariate designs were not employed. Out of 327 articles, 50 (15%) were determined to be germane to this review. Eight abstracts were referenced as the authors of this review attended the meetings where the abstract results were presented, thus it was possible to collect additional information on such abstracts. Urethrotomy continues to be the most commonly used technique, but it does have a high failure rate and many patients progress to surgical repair. Buccal mucosa has become the most popular substitute material in urethroplasty; however, the skin appears to have a longer follow-up. Free grafts have been making a comeback, with fewer surgeons using genital flaps. Short bulbar strictures are amenable using primary anastomosis, with a high success rate. Longer strictures are repaired using ventral or dorsal graft urethroplasty, with the same success rate. New tools such as fibrin glue or engineered material will become a standard in future treatment. In reconstructive urethral surgery, the superiority of one approach over another is not yet clearly defined. The surgeon must be competent in the use of various techniques to deal with any condition of the urethra presented at the time of surgery.

Erectile function, sexual drive, and ejaculatory function after reconstructive surgery for anterior urethral stricture disease

To evaluate the effect of urethral reconstructive surgery on sexual drive, erectile function and ejaculation. The study group consisted of 52 men with a median (range) age of 44 (18-79) years who underwent 59 urethral reconstructive procedures for anterior urethral stricture disease between 2001 and 2004. We evaluated sexual functioning using the O'Leary Brief Male Sexual Function Inventory (BMSFI) before and after surgery. The mean (sd) follow-up was 22.3 (14.8) months. The mean BMSFI scores were only statistically significantly different for an improvement in ejaculation after surgery (P = 0.04). When separated by age, only the men aged 50-59 years reported decreased erectile function after surgery (P < 0.001) and only those aged <40-49 years reported an improvement in ejaculatory function (P = 0.05). Men at <1 year after surgery reported lower sexual drive (P = 0.025) and erectile function (P = 0.05) than men with longer periods of recovery. The BMFSI is useful for evaluating sexual function after urethroplasty. Overall, the men did not report a decline in erectile function or sexual drive after surgery; however, older men might have a higher incidence of erectile dysfunction after surgery. Erectile function might recover with time. Younger men had the most pronounced improvement in ejaculatory function, but further studies are necessary to evaluate the clinical significance of this.

Urethral reconstruction

To present an up-to-date review on the main surgical techniques used to treat urethral strictures. Anterior urethroplasty can be treated in outpatient surgical settings, thus decreasing the impact of urethroplasty. To improve outcome in adult patients, reconstructive surgeons have learned to apply the principles of hypospadias surgery, such as delicate tissue handling, avoidance of overlapping suture lines, tissue and the development of preputial skin flaps, to adult urethral surgery. Penile skin has been used as a free graft or harvested as a flap for some time, thanks to its location, hairless skin and durability. Since the early 1990s the use of buccal mucosa was introduced in genital reconstructive surgery and has become popular for complex urethral reconstructions. The use of fibrin glue was recently suggested to fix the buccal mucosal graft in a better way and to cover the anastomosis between the graft and urethral plate. Urethral reconstructive surgery is changing rapidly and this change has posed problems for surgeons who see the principles that previously defined their profession becoming obsolete or unworkable. New techniques, new tools, such as fibrin glue, and new engineered material are a part of our future.

V-05.08: The use of buccal mucosal grafts in reconstructive urethral surgery

Buccal mucosa has become an increasingly popular graft tissue for anterior urethroplasty because is readily available from all patients and is easily harvested from the inner cheek or lower lip with a concealed donor site scar. In the video the authors present a wide view of the one stage or multistage procedures for the repair of anterior urethral strictures using buccal mucosal grafts.

Comparison of Angiogenic Activity after Urethral Reconstruction Using Free Grafts and Pedicle Flap: An Experimental Study

An experimental study was undertaken in order to estimate the angiogenic activity in different free grafts and pedicle flap in urethral reconstruction in an animal model. Twenty-eight white New Zealand rabbits were randomly divided into five groups (O, A, B, C and D). A ventral urethral defect was created in all groups. In the group O, (n = 4), a simple closure of the defect was performed. Free penile skin graft (group A, n = 6), buccal mucosal graft (group B, n = 6), bladder mucosal graft (group C, n = 6), and pedicle penile skin graft (group D, n = 6) were used to bridge the urethral defect as an onlay patch. The animals were euthanized on the 21st postoperative day. The angiogenic activity was assessed with immunohistochemistry, using the anti-CD31 MoAb and the alkaline phosphatase antialkaline phosphatase procedure. The native vascularity of penile skin as well as buccal and bladder mucosa was assessed in rabbits from group O (n = 3). Statistical analysis was performed using one-way ANOVA. The angiogenesis seen with a magnification of x 200 in groups O, A, B, C, and D was 34.1 +/- 4.1 (mean +/- SD), 61.7 +/- 6.4, 94.3 +/- 6.4, 91.5 +/- 7.2, and 30.8 +/- 5.2 vessels per optical field, respectively. There were statistically significant differences (p < 0.001) between group O and groups A, B, C and between group A and groups B, C, D, but not (p > 0.5) between groups B and C and groups O and D. The native vascularity of penile skin, buccal mucosa and bladder mucosa was 23.3 +/- 3.0, 24.6 +/- 3.7 and 17.0 +/- 2.6 vessels per optical field, respectively. Buccal and bladder mucosal grafts exhibit a higher angiogenic activity than free and pedicle penile skin flap when transplanted in urethral defects. As the buccal mucosal graft showed the higher angiogenic activity and its harvesting is easier than bladder mucosa, we propose that in urethral reconstruction surgery the use of this graft might offer more reliable results.

120: Single Institution Experience of Complications Related to Urethral Reconstructive Surgery: Multivariate Analysis of Independent Risk Factors

120: Single Institution Experience of Complications Related to Urethral Reconstructive Surgery: Multivariate Analysis of Independent Risk Factors

BULBAR URETHROPLASTY USING BUCCAL MUCOSA GRAFTS PLACED ON THE VENTRAL, DORSAL OR LATERAL SURFACE OF THE URETHRA: ARE RESULTS AFFECTED BY THE SURGICAL TECHNIQUE?

The use of buccal mucosa graft onlay urethroplasty represents the most widespread method of bulbar urethral stricture repair. The graft may be placed on the ventral or dorsal urethral surface according to surgeon experience and preference. We investigated whether the results are affected by the surgical technique by comparing the outcome of 3 types of bulbar urethroplasty using buccal mucosa graft. We repaired 50 bulbar urethral strictures with buccal mucosa grafts from 1997 to 2002. Mean patient age was 42 years. The etiology of stricture was ischemia in 12 cases, trauma in 6, instrumentation in 4 and unknown in 28. Patients with lichen sclerosus, failed hypospadias or urethroplasty and stricture extending into the penile urethra were not included. A total of 47 patients (94%) had undergone previous urethrotomy or dilation. The buccal mucosa graft was always harvested from the cheek using a 2 team approach. Mean graft length was 4.2 cm. The graft was placed on the ventral, dorsal and lateral bulbar urethral surface in 17, 27 and 6 cases, respectively. Clinical outcome was considered a success or failure at the time that any postoperative procedure was needed, including dilation. Mean followup was 42 months (range 12 to 76). Of 50 cases 42 (84%) were successful and 8 (16%) failed. The 17 ventral grafts provided success in 14 cases (83%) and failure in 3 (17%). The 27 dorsal grafts provided success in 23 cases (85%) and failure in 4 (15%). The 6 lateral grafts provided success in 5 cases (83%) and failure in 1 (17%). No surgical complications were observed. Failures involved the anastomotic site (distal in 2 and proximal in 3) and the whole grafted area in 3 cases. They were treated with urethrotomy in 5 cases and 2-stage urethroplasty in 3. In our experience the placement of buccal mucosa grafts into the ventral, dorsal or lateral surface of the bulbar urethra showed the same success rates (83% to 85%) and the outcome was not affected by the surgical technique. Moreover, stricture recurrence was uniformly distributed in all patients.

128: A Prospective Survay of Patients' Satisfaction with Urethral Reconstructive Surgery

128: A Prospective Survay of Patients' Satisfaction with Urethral Reconstructive Surgery

132: Male Sexual Function After Urethral Reconstructive Surgery for Stricture Disease

You have accessJournal of UrologyPodium, Saturday, May 21, 2005, 3:30 - 5:30 pm1 Apr 2005132: Male Sexual Function After Urethral Reconstructive Surgery for Stricture Disease Bradley A. Erickson, James S. Wysock, Thomas L. Jang, Kevin T. McVary, and Chris M. Gonzalez Bradley A. EricksonBradley A. Erickson More articles by this author , James S. WysockJames S. Wysock More articles by this author , Thomas L. JangThomas L. Jang More articles by this author , Kevin T. McVaryKevin T. McVary More articles by this author , and Chris M. GonzalezChris M. Gonzalez More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)34397-0AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "132: Male Sexual Function After Urethral Reconstructive Surgery for Stricture Disease." The Journal of Urology, 173(4S), p. 36 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 173Issue 4SApril 2005Page: 36 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Bradley A. Erickson More articles by this author James S. Wysock More articles by this author Thomas L. Jang More articles by this author Kevin T. McVary More articles by this author Chris M. Gonzalez More articles by this author Expand All Advertisement Loading ...

Editorial comment

The current standard of care for posterior urethral distraction defects is delayed open reconstruction with excision and primary reanastomosis using a perineal approach. Contemporary articles and abstracts published and presented by urologists who specialize in urethral reconstructive surgery report minimal blood loss and a success rate of greater than 95%. Success is defined as durable wide patency of the repair without the need for dilation, urethrotomy, or catheterization. Follow-up studies obtained to confirm a successful technical outcome are retrograde urethrography or urethroscopy no sooner than 3 to 4 months after surgery, in addition to subsequent long-term follow-up.

Use of oral ketoconazole to prevent postoperative erections following penile surgery.

Analgesics and topical agents ineffectively inhibit painful erections after penile and urethral surgery. Oral ketoconazole reversibly inhibits testosterone production and has been used empirically at our institution to decrease postoperative erections. We performed a retrospective review of 38 patients who had undergone penile and urethral reconstructive surgery. In all, 31 patients received 400 mg of ketoconazole three times daily for 10-14 days postoperatively (the study group) and seven patients did not receive ketoconazole (the control group). The incidence of postoperative erections, pain, side effects, surgical outcomes and patient satisfaction in each group were compared. Of the control group, 71% reported erections in the immediate postoperative period, and all these patients reported the erections were painful. Only 23% of the patient taking ketoconazole reported postoperative erections, and only 16% reported the erections were painful. We conclude that ketoconazole effectively prevents painful postoperative erections with minimal side effects.

Outcome of Urethral Reconstructive Surgery in a Series of 74 Women

We evaluated the results of vaginal flap reconstructive surgery of the female urethra. A series of 74 consecutive women who presented with urethral pathology requiring surgical reconstruction were assessed for anatomical and functional outcome. Followup was 1 to 15 years (median 1.5). Outcome assessment included success or failure of the anatomical repair based on physical examination as well as voiding habits and continence assessed by voiding diary, questionnaire and patient self-assessment. A total of 74 procedures were performed, including 72 vaginal flap repairs (56 with a concomitant pubovaginal sling). Five vaginal flap repairs were performed with a concomitant modified Pereyra procedure and 1 was done with Kelly plication. A patient in whom vaginal flap repair was planned underwent a Tanagho anterior bladder flap procedure, 1 underwent extensive lysis of urethral and periurethral scarring with primary urethral repair and 12 underwent vaginal flap repair without an incontinence procedure. A total of 72 women with an average age +/- SD of 54 +/- 13 years were followed a median of 1.5 years after vaginal flap reconstruction and 2 were lost to followup. Of the 62 patients with preoperative incontinence 54 (87%) considered themselves cured or improved. Successful anatomical repair by single procedure vaginal flap repair was achieved in all except 5 patients (93%). Single stage vaginal flap reconstruction with concurrent pubovaginal sling and Martius flap graft has a high degree of anatomical and functional success for treating a difficult surgical problem.

Congenital Urethral Stricture

No AccessJournal of UrologyPEDIATRIC UROLOGY: SOCIETY FOR FETAL UROLOGY1 Sep 2002Congenital Urethral Stricture Thomas S. Lendvay, Edwin A. Smith, Andrew J. Kirsch, and Mark Boddy Thomas S. LendvayThomas S. Lendvay More articles by this author , Edwin A. SmithEdwin A. Smith More articles by this author , Andrew J. KirschAndrew J. Kirsch More articles by this author , and Mark BoddyMark Boddy More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)64616-2AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Congenital Urethral Stricture." The Journal of Urology, 168(3), pp. 1156–1157 References 1 : Congenital obstruction of the posterior urethra. J Urol1919; 3: 289. Link, Google Scholar 2 : Congenital malformations of the urinary tract. New York: Praeger Publishers1983: 96. Google Scholar 3 : Urethral strictures in boys. J Urol1979; 121: 217. Link, Google Scholar 4 : Congenital urethral membrane causing urethral obstruction. J Urol1974; 111: 250. Link, Google Scholar From the Department of Urology, Section of Pediatric Urology, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia© 2002 by American Urological Association, Inc.FiguresReferencesRelatedDetailsCited by Bal H, Kurian J and Sen S (2017) The use of pedicled prepucial skin flap urethroplasty for proximal bulbomembraneous urethral stricture in childrenAnnals of Pediatric Surgery, 10.1097/01.XPS.0000503400.13933.ce, VOL. 13, NO. 1, (38-42), Online publication date: 1-Jan-2017. Johnson M, Brandes S and Coplen D (2014) Pediatric Urethral Strictures Advanced Male Urethral and Genital Reconstructive Surgery, 10.1007/978-1-4614-7708-2_37, (519-529), . Levin T, Han B and Little B (2007) Congenital anomalies of the male urethraPediatric Radiology, 10.1007/s00247-007-0495-0, VOL. 37, NO. 9, (851-862), Online publication date: 1-Sep-2007. Krishnan A, de Souza A, Konijeti R and Baskin L (2018) The Anatomy and Embryology of Posterior Urethral ValvesJournal of Urology, VOL. 175, NO. 4, (1214-1220), Online publication date: 1-Apr-2006. Volume 168Issue 3September 2002Page: 1156-1157 Advertisement Copyright & Permissions© 2002 by American Urological Association, Inc.Keywordsurogenital abnormalitiesurethral stricturecongenital, hereditary, and neonatal diseases and abnormalitiesurethraMetricsAuthor Information Thomas S. Lendvay More articles by this author Edwin A. Smith More articles by this author Andrew J. Kirsch More articles by this author Mark Boddy More articles by this author Expand All Advertisement PDF downloadLoading ...

Anastomotic Urethroplasty For Bulbar Urethral Stricture: Analysis Of 168 Patients

We reviewed our experience with anastomotic urethroplasty for anterior urethral stricture. A chart review revealed 168 patients 6 to 82 years old (mean age 38) with at least 6 months of followup (mean 70, range 6 to 291) after anastomotic urethroplasty. Average stricture length was 1.7 cm. Of the 168 patients stricture recurred in 8 (5%) but was managed by direct vision internal urethrotomy or a single dilation in 5, while repeat urethroplasty was required in 3 (2%). In these 3 cases extenuating circumstances included patient dislodgment of the catheter with attempts to replace it that disrupted repair, a history of urethrocutaneous fistula and periurethral abscess, and previous irradiation complicating the stricture in 1 each. Other complications were uncommon, such as transient thigh pain or numbness in 3 patients (2%), small wound dehiscence in 2 (1%), and scrotal hematoma, erectile dysfunction and self-limited pulmonary edema in 1 (less than 1%) each. Anastomotic urethroplasty for anterior stricture has a high success rate of 95%. It is technically straightforward and complications are uncommon. Cure by anastomotic urethroplasty should be strongly favored over long-term management by direct vision internal urethrotomy or dilation.