Urethral Repair Research Articles

Urethral Injury and Other Urologic Injuries During Transanal Total Mesorectal Excision: An International Collaborative Study.

To identify risk factors for urethral and urologic injuries during transanal total mesorectal excision (taTME) and evaluate outcomes. Urethral injury is a rare complication of abdominoperineal resection (APR) that has not been reported during abdominal proctectomy. The Low Rectal Cancer Development Program international taTME registry recently reported a 0.8% incidence, but actual incidence and mechanisms of injury remain largely unknown. A retrospective analysis of taTME cases complicated by urologic injury was conducted. Patient demographics, tumor characteristics, intraoperative details, and outcomes were analyzed, along with surgeons' experience and training in taTME. Surgeons' opinion of contributing factors and best approaches to avoid injuries were evaluated. Thirty-four urethral, 2 ureteral, and 3 bladder injuries were reported during taTME operations performed over 7 years by 32 surgical teams. Twenty injuries occurred during the teams' first 8 taTME cases ("early experience"), whereas the remainder occurred between the 12th to 101st case. Injuries resulted in a 22% conversion rate and 8% rate of unplanned APR or Hartmann procedure. At median follow-up of 27.6 months (range, 3-85), the urethral repair complication rate was 26% with a 9% rate of failed urethral repair requiring permanent urinary diversion. In patients with successful repair, 18% reported persistent urinary dysfunction. Urologic injuries result in substantial morbidity. Our survey indicated that those occurring in surgeons' early experience might best be reduced by implementation of structured taTME training and proctoring, whereas those occurring later relate to case complexity and may be avoided by more stringent case selection.

Analysis of early treatment of multiple injuries combined with severe pelvic fracture

PurposeTo summarize and analyze the early treatment of multiple injuries combined with severe pelvic fractures, especially focus on the hemostasis methods for severe pelvic fractures, so as to improve the successful rate of rescue for the fatal hemorrhagic shock caused by pelvic fractures. MethodsA retrospective analysis was conducted in 68 cases of multiple trauma combined with severe pelvic fractures in recent 10 years (from Jan. 2006 to Dec. 2015). There were 57 males and 11 females. Their age ranged from 19 to 75 years, averaging 42 years. Causes of injury included traffic accidents in 34 cases (2 cases of truck rolling), high falling injuries in 17 cases, crashing injuries in 15 cases, steel cable wound in 1 case, and seat belt traction injury in 1 case. There were 31 cases of head injury, 11 cases of chest injury, 56 cases of abdominal and pelvic injuries, and 37 cases of spinal and limb injuries. Therapeutic methods included early anti-shock measures, surgical hemostasis based on internal iliac artery devasculization for pelvic hemorrhage, and early treatment for combined organ damage and complications included embolization and repair of the liver, spleen and kidney, splenectomy, nephrectomy, intestinal resection, colostomy, bladder ostomy, and urethral repair, etc. Patients in this series received blood transfusion volume of 1200–10,000 mL, with an average volume of 2850 mL. Postoperative follow-up ranged from 6 months to 1.5 years. ResultsThe average score of ISS in this series was 38.6 points. 49 cases were successfully treated and the total survival rate was 72.1%. Totally 19 patients died (average ISS score 42.4), including 6 cases of hemorrhagic shock, 8 cases of brain injury, 1 case of cardiac injury, 2 cases of pulmonary infection, 1 case of pulmonary embolism, and 1 case of multiple organ failure. Postoperative complications included 1 case of urethral stricture (after secondary repair), 1 case of sexual dysfunction (combined with urethral rupture), 1 case of lower limb amputation (femoral artery thrombosis), and 18 cases of consumptive coagulopathy. ConclusionThe early treatment of multiple injuries combined with severe pelvic fractures should focus on pelvic hemostasis. Massive bleeding-induced hemorrhagic shock is one of the main causes of poor prognosis. The technique of internal iliac artery devasculization including ligation and embolization can be used as an effective measure to stop or reduce bleeding. Consumptive coagulopathy is difficult to deal with, which should be detected and treated as soon as possible after surgical measures have been performed. The effect of using recombinant factor VII in treating consumptive coagulopathy is satisfactory.

Synchronous Urethral Repair During Prosthetic Surgery: Safety of Planned and Damage Control Approaches Using Suprapubic Tube Urinary Diversion

BackgroundUrethral injury during inflatable penile prosthesis (IPP) or artificial urinary sphincter (AUS) placement is rare, and traditionally most prosthetic surgeons abort prosthetic implantation when urethral repair is necessary. AimTo report our experience with synchronous urethroplasty (SU) as a planned or damage control surgery during urologic prosthetic surgery, to evaluate the safety and outcomes of the procedure. MethodsA retrospective review of our IPP and AUS database was completed to identify patients who underwent an SU between 2007 and 2018. We included patients who underwent an SU during prosthetic surgery in either a planned procedure for known stricture or diverticulum or a “damage control” procedure after intraoperative injury. OutcomePatient characteristics and surgical outcomes were assessed, with success defined as the absence of urethral stricture and revision surgery. ResultsFrom our database of 1,508 prosthetic cases, we identified 7 patients (0.46%) who had an SU in the same setting as complete prosthesis placement (4 AUS and 3 IPP [1 combined IPP/AUS], and 1 sling). Three patients underwent planned repair of a known urethral abnormality (urethral diverticulum, urethrocutaneous fistula, and urethral stricture), and 4 underwent repair of an intraoperative urethral injury. Among the patients who experienced an intraoperative urethral injury, contributing etiologies included previous anti-incontinence surgery with periurethral fibrosis (n = 2), severe corporal fibrosis from priapism, and previous urethral disruption from pelvic fracture. Nearly all of the urethroplasties (6 of 7; 86%) were completed with a primary closure. The average indwelling duration of suprapubic tube (SPT) catheters was 4.1 weeks (range, 7 to 47 days). The average duration of follow-up was 21.5 months, and all patients were continent at follow-up. No device infections or urethral complications were identified. Clinical ImplicationsOur study illustrates the safety of concomitant urethral repair at time of prosthetic placement as an option to avoid the use of 2 anesthetics and prevent further scarring in high-risk patients. Strengths & LimitationsThis is the first study to address definitive urethral reconstruction during anti-incontinence procedures along with planned concomitant urethroplasty during IPP placement. This promising initial experience is relevant for surgeons who may encounter concomitant urethral pathology in the setting of complex reoperative prosthetic cases. The need for SU is rare, and thus our cohort size was limited in this retrospective, single-institution experience. ConclusionSU with prolonged SPT urinary diversion offers a safe damage control approach for men with concomitant urethral pathology during prosthetic surgery without conferring an increased risk of infection or stricture.Yi YA, Fuchs JS, Davenport MT, et al. Synchronous Urethral Repair During Prosthetic Surgery: Safety of Planned and Damage Control Approaches Using Suprapubic Tube Urinary Diversion. J Sex Med 2019;16:1106–1110.

045 Combined Urethral Surgery at Time of Penile Prosthesis Implantation does not Increase Risk of Device Infection

Urethral surgery for stricture disease or urethral trauma sustained at the time of inflatable penile prosthesis (IPP) implantation is thought to significantly increase rates of device infection. The classic teaching requires procedure abortion, urethral repair and a future, delayed IPP implantation. We report our experience with patients who had urethral surgery at the time of IPP implantation in order to further elucidate potential risk factors associated with device complications. Consecutive records of patients who underwent IPP implantation at our institution between May 2007 and March 2017 were queried retrospectively. Medical records of patients with a history of urethral surgery at the time of IPP implantation were evaluated. Patient demographics, pre-operative workup, intra-operative maneuvers and post-operative follow-up data were analyzed with use of standard statistics. Records of thirteen men were identified. Average patient age was 63.9 years (range: 40-81yo), and 11 of men (84.6%) were Caucasian. Two men who sustained intra-operative urethral injuries underwent complex repairs with suprapubic tube (SPT) placement. The remaining eleven men had stricture disease and required either stricture dilation, incision or urethroplasty. IPP revision (explantation/ implantation) was performed in two of the men undergoing urethral dilation for stricture disease. There were no device infections or erosions. (Table 1)

291 Synchronous Urethral Reconstruction During Urologic Prosthetic Surgery

Conventional dogma suggests that management of urethral pathology should not be conducted in the same setting as prosthetic urologic procedures. Recent rare reports of successful urethral repair at the time of device implantation have shown promise. We report our initial favorable experience with synchronous urethroplasty (SU) during urologic implant surgery for patients with urethral injury or other pathology. We retrospectively reviewed patients undergoing inflatable penile prosthesis (IPP) or artificial urinary sphincter (AUS) with SU (2010-2018). Success was defined as absence of complication, urethral stricture and revision surgery. From our database of over 1200 urologic prosthetic patients, we identified seven patients who underwent SU as either (a) “damage control” for intraoperative urethral injury (4/7), or (b) planned repair of urethral abnormality (3/7). Three patients underwent concomitant IPP, four patients had an AUS and one patient had a sling. Urethral injury occurred during urethral dissection (two multiple prior AUS with erosion) or corporal dilation (one recurrent priapism). Planned SU was performed in patients with urethral diverticulum (AUS), urethral stricture (distal bulb repaired with buccal graft and IPP pump revision) and urethroscrotal fistula (pre-existing AUS/IPP with IPP pump revision). Patients were managed postoperatively with suprapubic tube (85.7%, 6/7) or urethral Foley (14.3%, 1/7) for a median of 4 weeks (range 2-6). No patients developed prosthetic infection or urethral stricture during a median follow-up of 38 months (range 4.5-85).

Delayed presentation of Penile tourniquet syndrome due to hair coil as complete urethral transection: A devastating complication

Penile tourniquet syndrome (PTS) is a condition in which a hair coil is wrapped around the penis causing damage to the urethra and penis. The spectrum of complications due to PTS may range from simple oedema of the penis to complete penile necrosis. We are reporting an 8-year-old boy who presented late to us with complete urethral transection having history of hair coil around penis 3 years back. Examination of the external genitalia revealed complete urethral transection at the coronal sulcus and deeply grooved cut mark at the dorsal part of the glans. The coronal sulcus was shallow and the glans overhanging. The urethral defect was about 0.5 cm. Following evaluation the patient underwent urethral repair by end to end anastamosis and was able to pass urine through the native urethral meatus postoperatively. Most of the cases reported in literature presented soon after the urethral injury unlike the index case which was discovered after 3 years.

Research progress of urethral repair after prostatectomy

Research progress of urethral repair after prostatectomy

Robotic-assisted Urethra-sparing Simple Prostatectomy Via an Extraperitoneal Approach

ObjectiveTo present an original technique of robotic-assisted urethra-sparing simple prostatectomy (RAUSP) for treating patients with benign prostatic hyperplasia. Materials and MethodsFrom April 2015 to December 2016, 27 patients underwent RAUSP via an extraperitoneal approach. Baseline patient characteristics, perioperative outcomes, pathologic outcomes, postoperative Clavien complications, International Prostate Symptom Score, International Index of Erectile Function, and ejaculatory function were assessed. ResultsTwenty-six patients (96.3%) successfully underwent RAUSP, one patient (3.7%) was converted to simple prostatectomy. Median operative time was 169 minutes (interquartile range: 150-185); median estimated blood loss was 235 mL (interquartile range: 180-300). Seven cases (26.9%) required urethral repair secondary to inadvertent urethrotomy. Mean catheterization time was 1.6 days (range 1–5). Clavien complications were reported, 6 being low grade (grade 1 or 2) with a single 3a complication (gross hematuria requiring bladder irrigation). Mean follow-up duration was 16.4 months (range 9-30). Postoperative questionnaire demonstrated that international prostate symptom score (P < .001) and quality of life score (P < .001) were significantly improved postoperatively. A total of 14 patients reported erectile function, 13 of which had normal ejaculation, only 1 complained retrograde ejaculation. ConclusionRAUSP is technically feasible for patients with benign prostatic hyperplasia. Our data indicate that patients have short catheterization time, an acceptable risk profile, significant improvements of voiding function and maintaining antegrade ejaculation following this urethral-sparing technique.

Surgical Management and Post-Operative Outcomes of Urinary Outflow Obstruction: Experience of 50 Cases in Bangladesh

Background: Management of urinary outflow obstruction is very crucial.Objective: The purpose of the present study was to see the different management of urinary outflow obstruction with their post-operative outcomes.Methodology: This non-randomized clinical trial was conducted in the Department of Surgery at Rajshahi Medical College, Rajshahi, Bangladesh from September 1994 to December 1995 for a period of one year and three months. All the patients who were presented with bladder outflow obstruction and were admitted in the general surgical unit of the hospital were taken as study population. These patients were surgically managed in different procedures. The follow up was done to record the post-operative surgical outcomes.Result: A total number of 50 patients were recruited for this study. Benign enlargement of prostate was found in 13 cases of which 11(22.0%) cases were managed by suprapubic transvesical prostatectomy. Impacted urethral stone was found in 13 cases of which 4(8.0%) cases were managed by urethro-lithotomy followed by repair of urethra and indwelling catheter. Stricture urethra was found in 11 cases and all cases (100.0%) cases were managed by intermittent dilatation under general anesthesia. In 7 cases of rupture urethra, initially all patients were managed by suprabpublic cystostomy which was 7(14.0%) cases in number. All the 3 cases of carcinoma prostate were managed by prostatectomy and radiotherapy plus hormone therapy. A total number of 16 patients were managed by prostatectomy of which 1(2.0%) case was developed immediate postoperative hemorrhage which was managed by blood transfusion and continuous irrigation with normal saline. One patient developed postoperative clot retention due to blockage of Foley’s catheter, two patients developed postoperative incontinence, immediately after removal of the catheter. Out of 11 patients of impacted urethral stone, one developed urethral fistula and one developed UTI. Recurrent stricture urethra occurred in 3 patients. Seven patients with rupture urethra, 3 developed stricture urethra and 3 developed stricture urethra.Conclusion: In conclusion different surgical procedure are employed during the management of urinary outflow obstruction and immediate postoperative hemorrhage, postoperative clot retention, postoperative incontinence, urethral fistula, UTI and recurrent stricture urethra are the most common complication after surgical management of urinary outflow obstruction patients.Journal of National Institute of Neurosciences Bangladesh, 2017;3(2): 84-88

PD26-12 PROSPECTIVE ANALYSIS OF URETHRAL STRICTURE OCCURRENCE AFTER CUFF EROSION WITH AMS ARTIFICIAL SPHINCTER DEVICES

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy I1 Apr 2018PD26-12 PROSPECTIVE ANALYSIS OF URETHRAL STRICTURE OCCURRENCE AFTER CUFF EROSION WITH AMS ARTIFICIAL SPHINCTER DEVICES Tim Ludwig, Katharina Kuhlencord, Valentin Maurer, Phillip Marks, Clemens Rosenbaum, Oliver Engel, Silke Riechardt, Margit Fisch, and Roland Dahlem Tim LudwigTim Ludwig More articles by this author , Katharina KuhlencordKatharina Kuhlencord More articles by this author , Valentin MaurerValentin Maurer More articles by this author , Phillip MarksPhillip Marks More articles by this author , Clemens RosenbaumClemens Rosenbaum More articles by this author , Oliver EngelOliver Engel More articles by this author , Silke RiechardtSilke Riechardt More articles by this author , Margit FischMargit Fisch More articles by this author , and Roland DahlemRoland Dahlem More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1351AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES AMS implantation is a standard treatment for severe urinary stress incontinence (SUI). Handling of complications, especially complications after cuff erosion remain unclear. Since Rozanski et al. (J. Urol, 2014) and other groups showed high urethral stricture rates after erosion and suggesting a primary urethral reconstruction and we assessed our prospective AMS database to investigate stricture rates after cuff erosion and explantation of the cuff(s). METHODS Since 2009, we prospectively collect data for all patients who undergo AMS 800 implantation due to SUI at our tertiary center. Activation of AUS is performed 6 weeks postoperatively at our institution. Further follow-up (FU) consisting of pad test, maximal urinary flow rate (Qmax), post void residual urine (PVR), radiography, and standardized questionnaire is scheduled 6, 24 months and every two years thereafter. In case of explantation due to cuff erosion c. spongiosus is sutured and a catheter is inserted for 3 weeks. Afterwards radiographic examination is performed to check whether there is some stricture disease. Further FU consisting of maximal urinary flow rate and post voiding residual urine was performed on a regular base. Qmax lower than 10ml/s or a reduction of 25% was suspected a stricture disease and a radiography was performed. In this analysis only patients who underwent a cuff explantation and who were in further treatment of SUI in our department were included. Primary endpoint was urethral stricture rate. RESULTS A total of 24 patients with a mean FU of 18.7 months (IQR 6-23.25) were available for analysis. At baseline mean age was 71 yrs (range 52-87). Within FU 2 Patients (8.3%) suffered from urethral stricture disease. 22 Patients without suspicion for urethral stricture disease showed a median Qmax of 17 ml/s (IQR 15-27 ml/s) and a median PVR of 0 ml (IQR 0-0). CONCLUSIONS At midterm FU we could not proof any urethral stricture rate after cuff explantation justifying a primary repair since the stricture rate is lower as described for primary urethroplasty. We observed lower stricture rate than in published data so far. The different stricture rate observed might be caused by slightly different techniques for implantation and explantation. Cuff explantation without urethral repair seems to be safe and effective without any high risk of urethral stricture disease. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e556 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Tim Ludwig More articles by this author Katharina Kuhlencord More articles by this author Valentin Maurer More articles by this author Phillip Marks More articles by this author Clemens Rosenbaum More articles by this author Oliver Engel More articles by this author Silke Riechardt More articles by this author Margit Fisch More articles by this author Roland Dahlem More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD21-01 SURGICAL APPROACHES AND LONG-TERM OUTCOMES IN ADULTS WITH COMPLEX RE-OPERATIVE HYPOSPADIAS REPAIR

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) I1 Apr 2018PD21-01 SURGICAL APPROACHES AND LONG-TERM OUTCOMES IN ADULTS WITH COMPLEX RE-OPERATIVE HYPOSPADIAS REPAIR Christopher Morrison, Davide Cina, Christopher Gonzalez, and Matthias Hofer Christopher MorrisonChristopher Morrison More articles by this author , Davide CinaDavide Cina More articles by this author , Christopher GonzalezChristopher Gonzalez More articles by this author , and Matthias HoferMatthias Hofer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1156AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Patients with failed hypospadias repair are a challenging population for both pediatric and reconstructive urologists. In this study, we describe our long-term outcomes and factors associated with complications in repeat hypospadias repairs. METHODS A retrospective review of adult patients with a history of hypospadias repair who required re-operative urethroplasty between 2002 and 2012 was performed. Presenting complaint, past medical and surgical history, demographic data, surgical approach, intraoperative findings, and complications were collected and analyzed. RESULTS The patients ranged in age from 16 to 63, with a median age of 32 (Table 1). 24 (75%) patients reported interim endoscopic procedures and/or re-do hypospadias repairs. A urethral stricture was present in 31/32 patients, with the penile urethra being the most common location. 30 patients underwent urethroplasty for stricture treatment, 1 patient had a perineal urethrostomy, and 1 had a diverticulectomy. Of those who underwent urethroplasty, 27 (90%) had a two-staged repair. Initial success rate was 83% in patients who underwent urethroplasty. After a median follow-up of 9.5 years, complications included 4 recurrent strictures and 1 fistula. Age of patient, previous interventions, length of stricture, hair present at the time of repair, and the need to excise the urethral plate were not associated with complications or recurrence. In addition, there was no significant difference in complications between those who underwent a 1- or 2-staged repair (0% vs. 18.5%, p=1.00), albeit this is limited by the low number of 1-staged repairs. However, if a graft was required, the use of skin was associated with stricture recurrence compared to buccal mucosa (50% vs. 0%, p=0.002) (Table 2). CONCLUSIONS Excellent outcomes can be achieved using a two-staged approach with replacement or augmentation of the urethral plate in adults with failed hypospadias repair. In our experience, buccal mucosa appears to be associated with fewer complications and stricture recurrence than skin grafts. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e467-e468 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Christopher Morrison More articles by this author Davide Cina More articles by this author Christopher Gonzalez More articles by this author Matthias Hofer More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Current Status of Tissue Engineering in the Management of Severe Hypospadias.

Hypospadias, characterized by misplacement of the urinary meatus in the lower side of the penis, is a frequent birth defect in male children. Because of the huge variation in the anatomic presentation of hypospadias, no single urethroplasty procedure is suitable for all situations. Hence, many surgical techniques have emerged to address the shortage of tissues required to bridge the gap in the urethra particularly in the severe forms of hypospadias. However, the rate of postoperative complications of currently available surgical procedures reaches up to one-fourth of the patients having severe hypospadias. Moreover, these urethroplasty techniques are technically demanding and require considerable surgical experience. These limitations have fueled the development of novel tissue engineering techniques that aim to simplify the surgical procedures and to reduce the rate of complications. Several types of biomaterials have been considered for urethral repair, including synthetic and natural polymers, which in some cases have been seeded with cells prior to implantation. These methods have been tested in preclinical and clinical studies, with variable degrees of success. This review describes the different urethral tissue engineering methodologies, with focus on the approaches used for the treatment of hypospadias. At present, despite many significant advances, the search for a suitable tissue engineering approach for use in routine clinical applications continues.

A systematic review of penile replantations: May it guide us in penile allotransplantation?

Introduction: Penis replantation cases may serve as a model for identifying important elements in developing clinical penile allotransplantation. Material and Methods: We reviewed 82 published cases of penis replantation. Results: Besides the basic repair of urethra and corpora, we found that dorsal artery and dorsal nerve repair was associated with significantly better sensory return. Deep dorsal vein repair was associated with decreased sensation and increased complication rates. Conclusion: Penile allotransplantation may need to incorporate these findings.

Pubourethral Stump Angle Measured on Preoperative Magnetic Resonance Imaging Predicts Urethroplasty Type for Pelvic Fracture Urethral Injury Repair

To examine whether the type of delayed urethroplasty required for pelvic fracture urethral injury, which is not easily predicted from conventional urethrography findings, can be predicted from preoperative magnetic resonance imaging (MRI) results. Records of 74 male patients with pelvic fracture urethral injury who underwent MRI of the pelvis at least 3 months after injury and, subsequently, delayed anastomotic urethroplasty were retrospectively analyzed. Pubourethral stump length (PUL) was defined as the distance between the distal end of the proximal urethral stump and the lower border of the inferior pubic ramus. Pubourethral stump angle (PUA) was defined as the angle between the long axis of the pubis and the line between the distal end of the proximal urethral stump and the lower border of the inferior pubic ramus. Both PUL and PUA were measured in sagittal T2-weighted MRI. Delayed urethroplasty was performed by a simple perineal approach in the 28 patients requiring only bulbar urethral mobilization with or without corporal splitting and by elaborate approach in the 46 additionally requiring inferior pubectomy or an abdominoperineal approach with urethral rerouting. The overall success rate defined as no recurrent stricture on urethroscopy was 94.6%. Disruption at the prostate apex, greater urethral gap length, longer PUL, and lower PUA were in univariate analysis significantly associated with an elaborate approach. In multivariate analysis, only low PUA was an independent predictor of the need for an elaborate approach. PUA measured on MRI is useful for predicting the type of reconstruction needed for urethral repair.

A novel method in decision making for the diagnosis of anterior urethral stricture: using methylene blue dye.

The use of methylene blue dye (MB) to highlight anatomical structures in urology has been well-established. Urethral stricture may extend about a centimeter beyond the abnormal area seen on urethrogram. Although the current literature suggests a tension-free and end- to- end anastomosis after excision of the strictured urethral segment with spongiofibrosis and surrounding corpus spongiosum in short bulbar strictures, some centers dealing with urethroplasty prefer anastomosis for short bulbar strictures while others prefer augmentation. With this study, use of MB for delineating stricture line and assessing spongiofibrosis in the diagnosis of urethral stricture was evaluated. Five cc MB including 10 mg/mL is diluted with 10 cc saline. In the first scenario, MB is gently injected into urethra via the meatus before the urethroplasty procedure. Meanwhile, the extent of urethral segment stained by MB is noted. In the second scenario (MB spongiosography) in short bulbar stricture, insulin needles are inserted in spongiosa of the stricture site distally and proximally. MB is gently injected with distal needle. The two remaining needles are then observed. Presence of MB efflux in proximal needle implies deficiency of significant spongiofibrosis, so buccal augmentation is performed. Absence of efflux of MB implies significant spongiofibrosis and anastomotik site excised. Four hundred and ninety-two consecutive cases prospectively evaluated between 2010 and 2014. Precise staining of stricture was successfully observed in 464 (94%) patients. Grossly normal appearing urothelium remained pink. Histopathology confirmed that the stained urethra had a stricture. Of the 22 short bulbar idiopathic strictures, in 18 (82%) MB was seen across the stricture and urethral transection was avoided. Anastomosis was performed in 4 (18%) cases where no MB went across the primary excision. There were no known allergic complications. MB aids in delineating the urethral lumen and exact site of stricture that needs augmentation. MB Spongiography in short bulbar strictures could be used as a beneficial guide in relation to the type of urethral repair to be performed in terms of augmentation versus excision and anastomosis.

Female urethral injuries associated with pelvic fracture: a systematic review of the literature.

To review systematically the literature on female urethral injuries associated with pelvic fracture and to determine the optimum management of this rare injury. Using Meta-analysis of Observational Studies in Epidemiology criteria, we searched the Cochrane, Pubmed and OVID databases for all articles available before 30 June 2016 using the terms 'female pelvic fracture urethroplasty', 'female urethral distraction', 'female pelvic fracture urethral injury' and 'female pelvic fracture urethra girls.' Two authors of this paper independently reviewed the titles, abstracts, and articles in duplicate. We identified 162 individual articles from the databases. Fifty-one articles met our criteria for full review, including 158 female patients with urethral trauma. Of these injuries, 83 (53%) were managed with immediate repair; 17/83 (20%) via primary alignment and 66/83 (80%) via anastomotic repair. The remaining 75/158 (47%) were managed with delayed repair. Rates of urethral stenosis and fistula were highest after primary alignment. Urethral integrity appears to be similar after both primary anastomosis and delayed repair; however, patients experienced significantly more incontinence and vaginal stenosis after delayed repair. Patients who underwent delayed urethral repair were more likely to undergo more extensive reconstructive surgery than those who underwent primary repair. The optimum management of female urethral distraction defects is based on very-low-quality literature. Based on our review of the available literature, primary anastomotic repair of a female urethral distraction defect via a vaginal approach as soon as the patient is haemodynamically stable appears to be optimal.

Preputial mucosal graft for urethral repair

Urethral stricture disease is the commonest cause of morbidity in urology practice in sub-Saharan Africa. In contrast, prostate disease is commonly cited as the leading cause of urological disease in most urology practices in developed countries. In Africa, the aetiology of urethral stricture disease is compounded by a high prevalence of sexually transmitted infections (STIs), increasing levels of urethral trauma and over-stretched urological services. Thus, patients with prostate disease are treated with long-stay urethral catheters for periods often up to two years. This increases the risk of urethral stricture. The predominant aetiological factor is sexually transmitted infection due to gonococcus or chlamydia. This frequently leads to long severe strictures with spongiofibrosis, especially in the anterior urethra where the periurethral glands are located. These strictures respond poorly to urethral dilatation, optical urethrotomy or primary anastomosis. The majority of strictures in Africa are best treated by open substitution urethroplasty. The gold standard has been the use of buccal mucosa graft for this substitution procedure. This procedure poses a great challenge in most centres with limited resources. In these settings, we have found that the use of a dorsal onlay free preputial graft is easy to perform and gives good results.

Mechanical induction of bi-directional orientation of primary porcine bladder smooth muscle cells in tubular fibrin-poly(vinylidene fluoride) scaffolds for ureteral and urethral repair using cyclic and focal balloon catheter stimulation.

To restore damaged organ function or to investigate organ mechanisms, it is necessary to prepare replicates that follow the biological role model as faithfully as possible. The interdisciplinary field of tissue engineering has great potential in regenerative medicine and might overcome negative side effects in the replacement of damaged organs. In particular, tubular organ structures of the genitourinary tract, such as the ureter and urethra, are challenging because of their complexity and special milieu that gives rise to incrustation, inflammation and stricture formation. Tubular biohybrids were prepared from primary porcine smooth muscle cells embedded in a fibrin gel with a stabilising poly(vinylidene fluoride) mesh. A mechanotransduction was performed automatically with a balloon kyphoplasty catheter. Diffusion of urea and creatinine, as well as the bursting pressure, were measured. Light and electron microscopy were used to visualise cellular distribution and orientation. Histological evaluation revealed a uniform cellular distribution in the fibrin gel. Mechanical stimulation with a stretch of 20% leads to a circumferential orientation of smooth muscle cells inside the matrix and a longitudinal alignment on the outer surface of the tubular structure. Urea and creatinine permeability and bursting pressure showed a non-statistically significant trend towards stimulated tissue constructs. In this proof of concept study, an innovative technique of intraluminal pressure for mechanical stimulation of tubular biohybrids prepared from autologous cells and a composite material induce bi-directional orientation of smooth muscle cells by locally and cyclically applied mechanical tension. Such geometrically driven patterns of cell growth within a scaffold may represent a key stage in the future tissue engineering of implantable ureter replacements that will allow the active transportation of urine from the renal pelvis into the bladder.

Incidence and Management of Lower Urinary Tract Symptoms After Urethral Stricture Repair.

Lower urinary tract symptoms (LUTS) after urethral stricture repair are not uncommon. Urgency has been reported in 40% of men and urge incontinence in 12% of men after anterior urethroplasty. De novo urgency and urge incontinence is seen in 9 and 5% of men, respectively, after urethroplasty. Once a complication of urethroplasty (such as recurrent urethral stricture or diverticulum) has been excluded as a cause, evaluation of LUTS in such patients should focus on differentiating bladder dysfunction (overactive bladder, underactive bladder), from other outlet obstruction (such as benign prostatic obstruction), dysfunctional voiding, or medical causes (such as nocturnal polyuria). Management of overactive bladder may include behavioural modification, physical therapy, anticholinergic and/or beta-3 agonist medications, intravesical onabolulinum toxin, sacral neuromodulation or peripheral tibial nerve stimulation. Definitive treatment for underactive bladder is limited. Treatment of benign prostatic obstruction may include alpha-blocker and/or 5-alpha reductase inhibitor medication, or surgery to cavitate the prostate. Minimally invasive prostatic procedures are also an option. Although management of LUTS for patients after urethral stricture repair can usually proceed similarly as for patients without prior history of urethral reconstruction, special consideration and alterations in management need to be made when instrumenting the urethra, as the urethral lumen may be narrower in these patients.

Buck's fascia repair with glanuloplasty in hypospadias surgery: A simple approach with excellent outcome

Hypospadias is a common problem encountered in surgical practice and its repair is challenging because of various complications. Urethro-cutaneous fistula is the most common postoperative complication (incidence of 0-33%). Different types of intermediate protective layers have been used in attempts to decrease UCF formation; however, no single surgical technique is ideal. The aim of this study was to compare use of dartos fascia and Buck's fascia as intermediate layers in prevention of the formation of UCF. This was a prospective, comparative study conducted over a period of 2 years from January 2014 to December 2015. Patients with primary hypospadias without or with mild ventral penile curvature were included in the study. Patients were categorised into two groups, A and B, with alternate patients assigned to each group. Patients in group A underwent Snodgrass repair with urethroplasty by two-layer subepithelial closure and dartos tissue as an intermediate layer. Patients in group B underwent a urethral repair followed by Buck's fascia repair as intermediate layer and glanuloplasty after excision of a triangular skin strip on either side of the urethral plate. Patients were followed at regular intervals for a minimum of 6 months and complications were noted. Over a period of 2 years, 160 patients were included in the study: 80 patients in group A and 80 patients in group B. The age of patients ranged from 1 year to 4.6 years, with a mean age of 1.8 years. Postoperative complications are listed in the summary table. A protective intermediate layer between the neourethra and the skin can be used to reduce fistula formation. We describe a technique of urethroplasty using Buck's fascia as intermediate layer and glanuloplasty, with excellent results. Buck's fascia over the corpora spongiosum which is deficient ventrally in hypospadias is not completely absent, and can be easily used to cover the neourethra, needs minimal dissection and hence vascularity of tissues is preserved (summary Fig.). We used this Buck's fascia as a second protective layer over the neourethra in an attempt to decrease UCF formation, and compared it with use of dartos fascia. In our study, UCF occurred in 2.5% of patients in the Buck's fascia group and 12.5% of patients in the dartos group, a statistically significant difference. We believe that the native Buck's fascia lateral to spongiosum is a more appropriate, natural, and strong layer to cover the neourethra. Use of Buck's fascia as an intermediate layer along with glanuloplasty is simple and very effective in preventing UCF formation and glanular dehiscence. We recommend the use of Buck's fascia as an intermediate layer to cover the neourethra to reduce incidence of postoperative complications and improve results.