Urethroplasty Research Articles

The Impact of Hypogonadism on Surgical Outcomes Following Primary Urethroplasty: Analysis of a Large Multi-institutional Database

ObjectivesTo compare surgical outcomes among a cohort of eugonadal and hypogonadal patients undergoing primary urethroplasty (UP). MethodsA retrospective cohort study was conducted using TriNetX between 2008-2023. Patients that were eugonadal and hypogonadal (symptoms plus testosterone <300ng/dL) prior to UP were compared. A subgroup analysis of hypogonadal patients was performed to compare those with testosterone replacement therapy (TRT) vs. TRT-naïve prior to UP. Propensity-score matching was used to adjust for differences in comorbidities. Outcomes were 5-year revision rates and revision-free survival (RFS) for endoscopic revision and redo UP following primary UP. ResultsWe identified 12,556 eugonadal and 488 hypogonadal patients (153 TRT+, 335 TRT-) undergoing UP. Median age at UP and follow-up was 55 years and 5 years, respectively. After propensity-score matching, we compared 477 eugonadal and 477 hypogonadal patients. Hypogonadal patients had a statistically significantly higher 5-year redo UP rate (11% vs. 6%, RR 1.5 [95%CI, 1.2-2.2];p=0.01) when compared to eugonadal patients however there was no difference in 5-year rates of endoscopic revision (11% vs. 11%, RR 1.0 [95%CI, 0.7-1.5];p=1.0). We observed no difference in 5-year RFS time for endoscopic revision or redo UP between groups. Hypogonadal patients treated with TRT had a significantly higher 5-year redo UP rate (15% vs. 7%, RR 1.8 [95%CI, 1.1-3.3];p=0.02) compared to hypogonadal patients that were TRT-naïve prior to UP. There was no difference in rates of endoscopic revision (14% vs. 10%, RR 1.3 [95%CI, 0.7-2.4];p=0.2) between subgroups. ConclusionsPre-existing hypogonadism may modestly adversely affect surgical outcomes following primary urethroplasty based on data from a large, retrospective cohort study.

Advantages of Urethroplasty Terminating at the Corona for Severe Hypospadias: Complications, Uroflowmetry, and Esthetics

PurposeMid-shaft/proximal (msp) and penoscrotal/scrotal/perineal (pssp) hypospadias treated by urethroplasty (UP) terminating at the corona (UPC) or UP terminating at the tip of the glans (UPG) were compared. MethodsUP performed at a single institute (n = 234) between 2003 and 2020 were grouped as: msp-UPC (n = 23), msp-UPG (n = 75), pssp-UPC (n = 81), and pssp-UPG (n = 55) to compare data obtained from medical records for post-UP complications (PUC; urethral stenosis, urethrocutaneous fistula, diverticulum formation, and bleeding; n = 234), post-UP uroflowmetry (PUF; average flow rate (Qave), maximum flow rate (Qmax), voiding time (VT), voided volume (VV) and urine flow curves) in 57 UP patients [msp-UPC (n = 5), msp-UPG (n = 12), pssp-UPC (n = 32), pssp-UPG (n = 8)] and 9 controls, and post-UPC esthetics (EST; n = 104). P < 0.05 was considered significant. ResultsMean ages at UP (years) were: msp-UPC (3.1 ± 3.0), msp-UPG (3.3 ± 1.4), pssp-UPC (4.6 ± 2.4), and pssp-UPG (3.4 ± 1.4); p < 0.0001 by ANOVA test. Overall, there were significantly more PUC in pssp-UPG compared with pssp-UPC except for bleeding.Ages at PUF assessment were similar. Mean Qave (mL/s) for pssp-UPG (4.0 ± 1.0) was significantly less than pssp-UPC (5.9 ± 2.5; p < 0.05) and both were significantly less than controls (6.9 ± 1.8; p < 0.05, p < 0.01, respectively). Mean Qmax (mL/s) for pssp-UPC (11.4 ± 4.8) was significantly better than pssp-UPG (7.8 ± 2.3; p < 0.05) and for controls (14.9 ± 4.4) was significantly better than pssp-UPG (7.8 ± 2.3; p < 0.01). All VT (seconds) were similar to controls; all urine flow curves were normal. For EST in UPC (n = 104), 3 cases requested meatal advancement. ConclusionsUPC may be a valid option for treating pssp hypospadias because of significant differences in PUC/PUF and minimal EST issues compared with UPG. Level of evidencePrognosis Study Level-Ⅱ

PD35-06 PRE-EXISTING HYPOGONADISM DOES NOT IMPACT SURGICAL OUTCOMES FOLLOWING PRIMARY URETHROPLASTY

You have accessJournal of UrologyCME1 Apr 2023PD35-06 PRE-EXISTING HYPOGONADISM DOES NOT IMPACT SURGICAL OUTCOMES FOLLOWING PRIMARY URETHROPLASTY Matthew Shneyderman, Andrew Gabrielson, Logan Galansky, and Andrew Cohen Matthew ShneydermanMatthew Shneyderman More articles by this author , Andrew GabrielsonAndrew Gabrielson More articles by this author , Logan GalanskyLogan Galansky More articles by this author , and Andrew CohenAndrew Cohen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003333.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Decreased urethral vascularity due to a hypogonadal state may be a risk factor for complications following urethroplasty (UP). We compare reoperation and surgical site infection (SSI) rates among patients with hypogonadism with or without testosterone replacement therapy (TRT) prior to first UP. METHODS: A retrospective cohort study was conducted using the TriNetX research network between 2006-2022. Hypogonadal patients needed a diagnosis of hypogonadism and confirmatory T level <300 ng/dL preceding UP. We defined 4 groups: 1) Eugonadal patients undergoing UP 2) Hypogonadal patients with and without TRT, 3) Hypogonadal patients receiving TRT prior to UP, 4) Hypogonadal patients without TRT prior to UP. Propensity-score matching was used to adjust for differences in comorbidities listed in Table 1. Outcomes were 5-year rates and revision-free survival (RFS) for endoscopic (dilation, DVIU), surgical (repeat UP), and all-cause revision (endoscopic or surgical revision), as well as SSI within 90 days. RESULTS: We identified 12,556 eugonadal patients and 488 hypogonadal patients (147 [30%] with TRT, 341 [70%] without TRT) undergoing UP. Median age at UP and follow-up time was 55 years and 5 years, respectively. Comparing the propensity-score matched cohort of eugonadal patients to all hypogonadal patients, there was no difference in 90-day SSI (2.7% vs. 2.5%), nor were there differences in 5-year all-cause (19.4% vs. 19.6%), endoscopic (12.4% vs. 11.5%), or surgical revision (8.9% vs. 11.8%) [all p>0.05] (Table 1). Kaplan-Meier analysis found no difference in 5-year RFS rate for all-cause, endoscopic, or surgical revision (all log-rank p>0.05). Comparing hypogonadal patients who received TRT prior to UP versus hypogonadal patients who did not receive TRT, we found no difference in 5-year rates and RFS for all-cause (22.4% vs. 17.9%), endoscopic (11.6% vs. 11.2%), and surgical revision (14.3% vs. 9.7%) [all p>0.05] (Table 1). Post-UP, 83 (56%) patients in the TRT arm received additional TRT, whereas only 23 (6.7%) patients in the non-TRT arm received new TRT. CONCLUSIONS: Pre-existing hypogonadism does not appear to be an adverse predictor of surgical outcomes following primary urethroplasty based on data from a large, retrospective cohort study. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e976 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Shneyderman More articles by this author Andrew Gabrielson More articles by this author Logan Galansky More articles by this author Andrew Cohen More articles by this author Expand All Advertisement PDF downloadLoading ...

Outcomes of urethroplasty (UP), 10 years after surgery

Outcomes of urethroplasty (UP), 10 years after surgery

MP22-14 A MIXED METHODS APPROACH TO EXPLORING PATIENT MOTIVATIONS FOR DELAYING DEFINITIVE TREATMENT OF URETHRAL STRICTURE DISEASE

You have accessJournal of UrologyCME1 May 2022MP22-14 A MIXED METHODS APPROACH TO EXPLORING PATIENT MOTIVATIONS FOR DELAYING DEFINITIVE TREATMENT OF URETHRAL STRICTURE DISEASE Abimbola Ayangbesan, George Koch, Helen Gambrah, Rohan Bhalla, Jackson Cabo, Stephen Hill, and Niels Johnsen Abimbola AyangbesanAbimbola Ayangbesan More articles by this author , George KochGeorge Koch More articles by this author , Helen GambrahHelen Gambrah More articles by this author , Rohan BhallaRohan Bhalla More articles by this author , Jackson CaboJackson Cabo More articles by this author , Stephen HillStephen Hill More articles by this author , and Niels JohnsenNiels Johnsen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002561.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urethroplasty (UPL) for urethral stricture disease (USD) has high success and satisfaction rates, yet many patients trial endoscopic management with either dilation or urethrotomy. Access to care, surgeon expertise and counseling, and patient health literacy all play a role in the decision to defer UPL. Mixed methods research using both qualitative and quantitative data may allow for a more comprehensive understanding of patient's motivations to defer UPL. We hypothesize that decreased access to care and the logistical ease of endoscopic procedures will be associated with delayed UPL. METHODS: Retrospective review of our institutional UPL database was performed. Patients were categorized based on whether or not they had undergone at least two endoscopic procedures prior to UPL. Demographic data were collected, including median household income (MHI). Multivariable logistic regression using an a priori model was used to determine the odds of undergoing ≥2 prior endoscopic procedures. Telephone interviews were conducted with patients who had undergone ≥2 procedures in order to better understand their experiences and to identify motivations for delaying UPL. RESULTS: One hundred and five patients who underwent UPL from September 2019 to July 2021 were included in the study. Of these, 50 (47.6%) had previously undergone ≥2 endoscopic procedures (IQR 3-5), with 6 patients undergoing ≥10 procedures. On multivariable analysis, age at UPL (OR 1.03 [95% CI 1.01-1.06] p=0.02) and referral from non-teaching facility (OR 2.90 [95% CI 1.07-7.83] p=0.04) were predictors of delayed definitive treatment. Conversely, MHI >$100,000 was protective (OR 0.07 [95% CI 0.01-0.72] p=0.03). When interviewed, 83% of patients expressed a desire to have undergone UPL sooner and 61% were unaware of the lower success rates for repeated endoscopic treatments. Reasons for delaying UPL included not wanting to be admitted overnight due to being sole provider for family members, scheduling conflicts/times constraints, and fear of a more involved recovery. CONCLUSIONS: Predictors of delayed definitive treatment included age and referral from non-teaching facility, while higher MHI was protective. Most patients who underwent multiple endoscopic procedures prior to UPL expressed a desire to have pursued definitive management sooner. Patients in the delayed group cited logistical issues with a more involved procedure, as well as fear of longer recovery. These results illustrate the need for improved patient counseling and access to care for urethral stricture patients. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e376 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Abimbola Ayangbesan More articles by this author George Koch More articles by this author Helen Gambrah More articles by this author Rohan Bhalla More articles by this author Jackson Cabo More articles by this author Stephen Hill More articles by this author Niels Johnsen More articles by this author Expand All Advertisement PDF DownloadLoading ...

Periurethral Abscess Following Urethral Reconstruction: Clinical Features and Prognosis

ObjectiveTo evaluate the clinical and prognostic details of periurethral abscess (PUA) formation following urethroplasty (UP). MethodsA retrospective review was performed to identify men who developed PUA after UP between 2007 and 2019 at a single tertiary care referral center. Patient demographics, stricture characteristics, and UP technique were recorded. Outcomes included time to PUA, presenting symptoms, wound cultures, imaging, and ultimate management. Comparative analysis between PUA and non-PUA patients was performed using Fisher's Exact test and Student's t-test. ResultsAmong 1499 UP cases, 9 (0.6%) developed PUA. Mean stricture length was 4.6 cm with most located in the bulbar urethra (5/9, 56%), while 4/9 (44%) had undergone prior UP. PUA rates were 7/288 (2.4%) and 2/815 (0.3%) for substitution and anastomotic UP respectively. Voiding cystourethrogram (VCUG) demonstrated extravasation in 67% (4/6) of available UP cases imaged. Subsequent VCUG confirmed leak improvement or resolution in all cases. Wound cultures were frequently polymicrobial (4/6, 67%). Management included antibiotics with (6/9) and without (3/9) incision and drainage (I/D). Urinary drainage was performed in 5 patients using suprapubic tube (3/5) and foley placement (2/5). PUA resolution was observed in all patients while stricture symptom recurrence was observed in 2/9 (22%) patients with mean time to recurrence of 15 months. Overall mean follow-up time was 22 months. ConclusionPUA is a rare complication of UP that may be more common in setting of postoperative urine leak. PUA is safely managed with I/D, urethral rest, and antibiotics, with low risk of recurrent stricture formation thereafter.

Long-Term Outcomes Following Surgical Management of Urethral Catheter Injuries in Men With Spinal Cord Injury

Objective: To evaluate the outcomes of surgical management of men with spina cord injury (SCI) with subsequent catheter damage to the urethra that prevents clean intermittent catheterization (CIC). Methods: We performed a retrospective analysis of male SCI individuals on CIC with catheter-induced urethral injuries who had undergone an operative intervention in the last 30 years at our institution. The offered surgical managements were direct vision internal urethrotomy (DVIU) or urethroplasty (UP). Continent diversion (CDIV) was indicated when reconstruction was not possible. Results: A total of 43 male SCI patients were identified. Median age was 50 years (IQR 41 to 57), and follow-up was 69 months (IQR 34 to 125). Inability to perform CIC was due to urethral stricture (25), false passages (11), fistula (4), diverticulum (2), and urethral erosion (1) . Primary intervention techniques were DVIU, UP, and CDIV. Overall primary success, defined by the ability to return to continent CIC, was 25/43 (58%); secondary surgery (10 CDIV, 3 UP, 1 DVIU) rescued 14/18 failures for a final 91% success rate. Conclusion: Urethral injuries in men with SCI are complex, but individualized continued surgical management can be successful in up to 90% of patients. Therefore, reconstruction should be considered in this population to restore continent intermittent catheterization.

MP60-07 DO POST-VOID DRIBBLING AND EJACULATORY DYSFUNCTION AFTER URETHROPLASTY SHARE THE SAME ETIOLOGY?

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II (MP60)1 Apr 2020MP60-07 DO POST-VOID DRIBBLING AND EJACULATORY DYSFUNCTION AFTER URETHROPLASTY SHARE THE SAME ETIOLOGY? Ayman Soubra*, Shawn Grove, Joseph Pariser, Bryan Voelzke, Jeremy Myers, Bradley Erickson, Nejd Alsikafi, Benjamin Breyer, Alex Vanni, Jill Buckley, Joshua Broghammer, Keith Rourke, and Sean Elliott Ayman Soubra*Ayman Soubra* More articles by this author , Shawn GroveShawn Grove More articles by this author , Joseph PariserJoseph Pariser More articles by this author , Bryan VoelzkeBryan Voelzke More articles by this author , Jeremy MyersJeremy Myers More articles by this author , Bradley EricksonBradley Erickson More articles by this author , Nejd AlsikafiNejd Alsikafi More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , Alex VanniAlex Vanni More articles by this author , Jill BuckleyJill Buckley More articles by this author , Joshua BroghammerJoshua Broghammer More articles by this author , Keith RourkeKeith Rourke More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000929.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Post-void dribbling (PVD) and ejaculatory dysfunction (EjD) are common after urethroplasty (UP). Although the etiology remains unknown, they are thought to share a similar etiology because they are both due to a failure to express small volumes of urethral fluid. Theories include damage to the bulbospongiosus muscle (BS) or adjacent nerves, graft sacculation and loss of urethral elasticity. We sought to determine whether post-UP PVD and EjD are associated with each other and whether that association varies with BS damage or graft placement. METHODS: From the TURNS database, we included men who underwent anterior UP with ≥1 follow-up visit, 2-12 months after surgery, with completed questionnaires. We excluded men with prior UP or hypospadias repair. From the Male Sexual Health Questionnaire we used question 2 (“How would you rate the strength or force of your ejaculation”). From the Jackson et al urethral stricture patient reported outcome measure we used question 6 (“How often have you had a slight wetting of your pants a few minutes after you had finished urinating and had dressed yourself?”). The association between the frequency distribution of scores on these questions was compared using Chi square. Subset analysis compared the frequency distribution in bulbar UP (as a surrogate for BS damage), penile UP, and bulbar UP with graft vs. excision and primary anastomosis (EPA). RESULTS: Among 772 men who met the inclusion criteria, PVD and EjD were associated (p< 0.01; Figure). The association persisted in all of the following subsets: bulbar UP (p< 0.01), penile UP (p= 0.03), bulbar onlay graft UP (p= 0.03), penile onlay graft UP (p= 0.3) and bulbar EPA (p< 0.01). There were too few ventral graft procedures to compare dorsal vs. ventral onlay. CONCLUSIONS: Post-UP PVD and EjD are associated, supporting the theory of a common etiology. The association persists whether the UP is in the penile or bulbar urethra, suggesting that BS damage is not the primary cause. The association persists whether the bulbar UP is done with a graft vs EPA, suggesting that graft placement is not the cause; but we were unable to compare dorsal vs. ventral graft. By exclusion, these symptoms may be due to a loss of elasticity that is inherent to any UP (with or without a graft) or due to a neurologic cause. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e891-e892 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ayman Soubra* More articles by this author Shawn Grove More articles by this author Joseph Pariser More articles by this author Bryan Voelzke More articles by this author Jeremy Myers More articles by this author Bradley Erickson More articles by this author Nejd Alsikafi More articles by this author Benjamin Breyer More articles by this author Alex Vanni More articles by this author Jill Buckley More articles by this author Joshua Broghammer More articles by this author Keith Rourke More articles by this author Sean Elliott More articles by this author Expand All Advertisement PDF downloadLoading ...

Analysis of risk factors for recurrent urethral stricture after excision and primary anastomotic urethroplasty

Objective To analysis the risk factors for stricture recurrence after excision and primary anastomotic urethroplasty(EPA). Methods 209 urethral stricture cases managed with EPA were retrospectively studied from January 2017 to December 2018 in our center. Of all the patients, 183 cases were diagnosed as posterior urethral stricture and 26 cases were diagnosed as bulbar urethral stricture. Their age ranged from 5 to 78 years(mean 42.1 years). 25 cases(12.0%) were defined as the obesity, whose BMI was more than 28 kg/m2. 12 cases(5.7%) has the history of diabetes mellitus. 103 cases(49.3%) smoked at least three months before operation. 127 cases(60.8%) didn't have the history of dilation. 42 cases(20.1%)had the history of dilation once or twice. 40 cases (19.1%)had the history of dilation more than three times. The history of urethroplasty included once in 38 cases(18.2%)and more than twice in 8 cases(3.8%). The location of stricture included posterior urethral stricture in 183 cases and bulbar stricture in 26 cases. The history of stricture ranged from 1 to 360 months(mean 35.1 months). The stricture length was(3.19±0.65)cm. The causes including trauma in 190 cases, iatrogenic urethral injury in 12 cases, inflammatory in 2 cases and others in 5 cases. The standard of stricture recurrence were defined as the urination difficulty after removal of catheter and endoscopic or radiographic evidence of obstruction in the area of repair. Univariate and multivariate analysis were performed by the use of Cox′s proportional hazards regression model to identify the related factors for stricture recurrence. Result The following up period was ranged from 3 to 32 months(average 18.78 months). Recurrence occurred in 31 cases in the period of 1.0 to 18.0 months(average 5.34 months). Factors had statistical differences in univariate analysis including stricture period(HR=1.007, P<0.001), stricture length(HR=5.334, P<0.001), history of direct vision internal urethrotomy (DVIU)(HR=2.901, P=0.003), history of urethral dilation ≥3 times(HR=6.214, P<0.001), history of urethroplasty 1 time, ≥2 times(HR=4.175, P=0.001, HR=9.885, P<0.001), 3 months smoking before surgery(HR=2.605, P=0.016), suprapubic cystostomy(HR=0.231, P=0.006), inferior pubectomy(HR=6.603, P<0.001). In multivariate analysis stricture length(HR=4.911, P<0.001), history of urethroplasty 1 time, ≥2 times(HR=2.387, P=0.045, HR=3.688, P=0.015), 3 months smoking before surgery(HR=2.730, P=0.030)were independent risk factors. Conclusion The urethral stricture recurrence mainly occurred within 6 months after surgery. The length of stricture, history of urethroplasty and 3 months smoking before surgery were the independent risk factors for stricture recurrence. Key words: Urethral stricture; Anastomotic urethroplasty; Stricture recurrence; Risk factors

A comparative analysis of Bracka and Duckett in the treatment of primary proximal hypospadias repair

Objective To compare the efficacy of Bracka method and Duckett method in the treatment of proximal hypospadias. Methods Forty patients with hypospadias were treated by 2 stages(Bracka), 42 patients treated by transverse preputial island flap (Duckett) from January 2014 to January 2016. Mean age at first stage surgery were (19.70±6.62) months and (20.33±5.03) months in Bracka group and Duckett group, respectively. There were 10 cases of proximal penile type, 25 cases of penoscrotal type, 5 cases of perineal type in group 1. There were 11 cases of proximal penile type, 27 cases of penoscrotal type, 4 cases of perineal type in group 2. There was no significant difference in age and hypospadias classification between the two groups(P>0.05). All operations were performed by the same doctor. Urethral plate reconstruction with preputial graft was performed in group 1; stage Ⅱ Duplay urethroplasty repair was carried out 6-8 months after stage Ⅰ. Results Urine tube was placed for 2 weeks after operation and followed up for 36-63 months(mean 47.6 months). After stage I repair, penile straightening and wide, smooth appearance of graft were confirmed. There was no fistula, split, urethral diverticulum or other complications, one case with urethral opening stenosis who was restored after urethral dilatation .After stage II repair, urethral fistula was noted in 3 cases(7.5%), stricture in 1 cases(2.5%). No other complications occurred . The total rate of complications was 10%(10/40). Urethral fistula was noted in 7 cases(16.7%), stricture in 3 cases(7.1%), penile head dehiscence in 3 cases(7.1%) and diverticulum in 1 case(2.4%) in group 2. The total rate of complications was 33.3%(14/42). The incidence of total complications between the two groups was statistically significant (P=0.011). Conclusions Bracka method can be used to treat proximal hypospadias. It has high safety and low incidence of complications. Key words: Hypospadias; Proximal; Staged repair; Autograft repairt

Analysis of the effect about tubularized urethral plate disassembly for one-stage midshaft epispadias repair in infant

Objective To evaluate the safety and efficacy of tabularized urethral plate disassembly for epispadias repair in infant. Methods From January 2016 to September 2018, 10 boys aged between 18 to 36 months old with mishaft epispadias were included. The main complaint was that the urethral opening was found on the dorsal side of the penis. Preoperative cystography revealed that 3 of them had unilateral vesicoureteral reflux (Grade Ⅰ), and white blood cells in routine urinary in all 10 patients were negative. Physical examination: the penis is short and flat, the width is 17-25 mm, average is 20.7 mm, the penis curvature is 15°-30°, average is 21.5°, and the urethral opening located on the dorsal side of the penis. The anesthesia method was selected for tracheal intubation, intravenous anesthesia combined with caudal anesthesia, and the surgical position was supine position. The surgical method: one stage of tabularized urethral plate disassembly urethroplasty: during the operation, the penile curve was corrected by free urethral plate and penile degloving. Two of them were unsatisfied with the correction of the curvature, and the ventral tunica folded was applicate. To avoid urethral plate ischemia, attention should pay to blood supply protection. The two corpus cavernosum are separated in the root, and the urethra is completely displaced to the ventral side of the cavernous body. The ventral side of the urethral under glans is shaped into a fissured that conforms to the anatomy. The prognosis and surgical choice of the midshaft epispadias were discussed combined with literature. Result The operation time was 130-200 min with an average of 157 mins. Intraoperative hemorrhage 5-30 ml, average is 16 ml, 1 case of glans skin was black one day after surgery, with enhanced dressing change. After 1 month, the glans was local atrophy and scar formation. No skin incision infection case. After discharge from the hospital, the follow up through the internet and outpatients for 3-40 months, average is 21 months, 2 cases with urethral fistula, more surgery to repair the fistula successfully after 6 months. The penile curvature was corrected in 8 cases, and the residual curvature of 2 cases was about 10-15°, which was temporarily observed. Patients with unilateral vesicoureteral reflux preoperatively, they still suffered from vesicoureteral reflux in the 6-12 months regular review after surgery without any intervention due to white blood cell was negative in urine routine. All cases had urinary patency and no cases with urethral stricture. Conclusion Tubularized urethral plate disassembly is a effective and simple procedure that can correct the midshaft epispadias in infant. Key words: Epispadias; Prognosis; Penis

Undermining the epidermis around the U-shaped skin incision preserves thick, well-vascularized tissue that effectively prevents posturethroplasty complications

PurposeWe modified the U-shaped skin incision technique (UIT) during urethroplasty (UP) to prevent post-UP complications (post-UPC). Patients and methodsOur modified UIT (mUIT) involves undermining the epidermis for 5–7 mm around the U-shaped incision to create a thicker, better vascularized tissue layer for suturing the neourethra compared with UIT. To prevent injury to underlying connective tissue and avoid compromising blood perfusion, the scalpel should be held at a more slanted angle than is conventional. After the urethral plate is incised in the midline, stay sutures are placed to the middle of the penile shaft as a landmark, and three to five sutures are placed through the thick layer created by undermining. To facilitate mobilizing connective tissue during neourethroplasty, relaxing incisions may be used on the edges of the connective tissue. We compared 207 hypospadias patients who had primary or staged UP using either mUIT (n = 110) or UIT (n = 97) between 2003 and 2017 for incidence of post-UPC. ResultsmUIT had significantly less post-UPC than UIT after a mean follow-up of 6.44 ± 0.26 years after final UP, 1/110 (0.9%) versus 15/97 (15.5%) (p < .0001). ConclusionsUndermining the edges of the U-shaped incision during mUIT would appear to prevent post-UPC. Level of evidenceLevel III.

The value of definitive perineal urethrostomy for the treatment of complex adult anterior urethral strictures

Objective To analyze the clinical outcome of definitive perineal urethrostomy for the treatment of complex adult anterior urethral strictures. Methods From June 2012 to February 2018, 28 patients who underwent the definitive perineal urethrostomy for a complex anterior urethral stricture were retrospectively reviewed. The mean age of the patients was 62.3 (range 34 to 77) years and stricture etiology was lichen sclerosus in 46.4%(13/28) of the cases, iatrogenic stricture after transurethral resection of the prostate in 35.7%(10/28), failed hypospadias repair in 10.7%(3/28), infection 3.6%(1/28) and idiopathic etiology 3.6%(1/28). The mean stricture length was 9.6 (range 4.5 to 16.0) cm and the stricture length 10 cm in 57.1%(16/28). Of 28 patients 21 (75%) underwent prior urethral dilation, 4 (14.3%) underwent direct vision internal urethrotomy (DVIU) and 17 (60.7%) underwent urethroplasty. Among the medical history of interest, hypertension was observed in 17 patients (60.7%), chronic ischemic heart disease in 11 patients (39.3%), diabetes mellitus in 9 patients (32.1%) and chronic obstructive pulmonary disease (COPD) in 9 patients (32.1%). All patients completed the perineal urethrostomy with inverted U-shaped perineal skin flap. The patient was placed in a normal lithotomy position and an inverted U-shaped perineal incision was made. We can get an inverted U-shaped perineal skin flap after dissecting along the bulbospongiosus muscle. The bulbar urethra was opened along the ventral surface and the margins of the spongiosum tissue were closed with perineal skin flap. We analyzed the clinical characteristics of the patients, the outcome of the technique and investigated the satisfaction rates of the patients by outpatient follow-up or telephone interview. Surgical success was defined as functional voiding without the need for further procedures. Results The perioperative complications included 3 cases of urinary tract infection, 1 case of bleeding and 1 case of wound dehiscence. Mean follow-up length was 27.2(range 6.0 to 64.0)months. Of 28 cases 26 (92.9%) were successful and the mean maximum urinary flow rate was 26.5(range 17.0 to 40.0)ml/s. Postoperatively, 2 cases of urethrostomy strictures were found in 2 months and 4 months, respectively. They required periodic outpatient dilation and the younger one was in the waiting list for revision of the perineostomy and the older one refused the revision. Of 28 patients 24 (85.7%) were satisfied with the results obtained with surgery, 15 were very satisfied, 9 cases satisfied and 4 cases dissatisfied. Conclusions The successful rate of the definitive perineal urethrostomy for the complex adult anterior urethral strictures was high and patients were satisfied with the outcome of the surgery. The definitive perineal urthrostomy is a well-tolerated treatment option for patients with complex anterior urethral strictures, especially for those aged and with extensive comorbidities. Key words: Urethral stricture; Anterior urethral; Perineal urethrostomy; Urinary diversion

Long-term efficacy of oral mucosa urethroplasty (report of 324 cases)

Objective To summarize the long-term efficacy of oral mucosal urethroplasty. Methods The clinical data of 324 patients with anterior urethral stricture who underwent oral mucosal urethroplasty from January 2013 to May 2018 were retrospectively analyzed. The patients were 27-65 years old with an average age of 47 years. Among them, 51 patients had urethral meatal stenosis, 174 patients had penile urethral stricture and 99 patients had bulbar urethral stricture. The length of urethral stricture was 2.8-14.0 cm, with an average of 6.4 cm. The preoperative maximal urinary flow rate Qmax was 3.2-8.4 ml/s, with an average of 4.8 ml/s. In the urethral meatal stenosis group (51 patients), 15 underwent urethrotomy and 36 underwent meatal urethroplasty. In the penile urethral stricture group (174 patients ), ventral sagittal incision was done in 21 patients, subcoronal circumferential incision in 49 patients and midline perineal incision in 104 patients. The perineal incision or verted Y incision were done in all the bulbar urethral strictures. Results The patients were followed-up for 3-75 months, with an average of 35.0 months. The results were satisfied in 290(89.5%)patients. The post-operative maximal urinary flow rate Qmax was 15.8-32.2ml/s, with an average of 21.5 ml/s. Thirty-four patients (10.5%)developed recurrent urethral stricture, including 7 patients in the urethral meatus, 17 patients in the penile urethra and 12 patients in the bulbar urethra. Among the recurrent urethral stricture patients, 18 treated with the dilatation and 16 treated with the urethroplasty. Five patients (1.5%)developed fistula, including 2 patients in the ventral sagittal incision, 1 patient in the circumferential incision and 2 patient in the perineal incision. Conclusions The long-term effect of oral mucosal urethroplasty is realistic. The rate of urethral stricture recurrence and fistula is low. The recurrence can be treated again by urethroplasty. The surgical approach for oral mucosa urethroplasty depends on the location and length of the anterior urethral stricture. Key words: Urethral stricture; Oral mucosa; Urethroplasty; Surgical approach; Long-term efficacy

A modified two-stage procedure strategy treat severe hypospadias with preputial flap

Objective To investigate the effect of a modified preputial flap urethroplasty in two-stage treatment of severe hypospadias. Methods The clinical characteristics of the severe hypospadias patients (41 cases) who underwent the staged urethroplasty by using the procedure of preset urethral plate with preputial flap from January 2015 to December 2016 were analyzed retrospectively. We used a modified method (modified group, 23 cases ): Form the distal urethra with the transected distal urethral plate by using tubularize incised plate (TIP) procedure during the first stage operation, after completely straightened the penis, urethral plate was preseted with transverse preputial flap at the penis shaft. While in the traditional group (18 cases), urethral plate was preseted with preputial flap by using Bracka procedure after transecting urethral plate. The corresponding missing part of urethra underwent urethroplasty at the second stage operation six months later. The patients in the modified group were 9 to 18 months old, and the median age was 13 months; meatus were located at the penis shaft in 10 cases, scrotum in 12 cases, perineum in 1 case. The patients in the traditional group were 9 to 18 months old, and the median age was 13 months; meatus were located at the penis shaft in 6 cases, scrotum in 10 cases, and perineum in 2 cases. There was no statistic difference in age and meatus position between the two groups. Results During the first stage operation, distal urethra was repaired by 13-19 mm, with an average of (14.5±1.3) mm, and the proximal urethra was repaired by 0-6 mm, with an average of (3.1±2.4) mm at the modified group. While at the traditional group, the length of proximal urethra was repaired of 0-9 mm, with an average of (5.6±2.9) mm. The urethral length required for reconstruction was measured during the second stage operation, with an average of (26.3±4.4) mm in the modified group and (40.5±3.3) mm in the traditional group (P 0.05). Conclusions The modified staged preputial flap method shorten the new forming urethra by making full use of its own materials at the second stage operation, which was helpful to reduce complications. Key words: Hypospadias; Staged repair; Preputial flap; Urethral plate

Replacing a smaller-size catheter after tubularized incised plate urethroplasty may decrease postoperative urethral complications

Objective To investigate the effect of replacing a smaller-size catheter after tubularized incised plate (TIP) urethroplasty on postoperative urethral complications. Methods The data of 116 hypospadias patients underwent TIP urethroplasty performed by the same urologist in our hospital from January 2014 to December 2017 were retrospectively analyzed. The age of patients ranged from 0.5-15.4 years, with the median age of 1.5 years. Meatal location was distal in 47(39.5%), midshaft in 62(52.1%) and proximal in 10(8.4%) patients. Unhealthy urethral plate occurred in 49(42.2%) patients. F8 catheter was used for urethroplasty in 92(79.3%) patients, F10 in 17(14.7%), and F12 in 7(6.0%). According to the pattern of urinary diversion, patients were divided into two groups. Conventional catheter group in 56 patients (group A): the catheter was chosen in as large size as possible for urethroplasty without tension. Replace a smaller-size catheter group in 60 patients (group B): replace a smaller-size catheter after urethroplasty on the basis of group A. There were no statistically significant differences in age, meatal location and catheter size between the two groups (P>0.05). Results The mean follow up was 23 months (range 6-66 months). There were 73(62.9%) cases of orifice overflow during indwelling catheterization. There were 5(4.3%) patients needed further reoperation result from postoperative urethral complications, including 4 cases of fistula and 1 case of meatal stenosis. The process of replacing a smaller-size catheter after urethroplasty in group B was simple and without adverse reactions. There were 15(26.8%) cases of orifice overflow in group A and 58(96.7%) in group B. There were statistically significant differences in orifice overflow between the two groups (P<0.05). There were 5(8.9%) cases of postoperative urethral complications in group A and 0 case in group B. There were statistically significant differences in postoperative urethral complications (P<0.05). Conclusions The process of replacing a smaller-size catheter after TIP urethroplasty in was simple and subsequently contributed to less postoperative urethral complications. The results of replacing a smaller-size catheter after TIP urethroplasty were superior to that of no replacing conventionally. Key words: Hypospadias; Tubularized incised plate urethroplasty; Catheter; Urethral complications

399 - Surgical treatment for recurrent bulbar urethral stricture: A randomised open label superiority trial of open urethroplasty versus endoscopic urethrotomy (The OPEN Trial): Abstracts EAU19 – 34th Annual EAU Congress

399 - Surgical treatment for recurrent bulbar urethral stricture: A randomised open label superiority trial of open urethroplasty versus endoscopic urethrotomy (The OPEN Trial): Abstracts EAU19 – 34th Annual EAU Congress

Surgical management of hypospadias in cases with concomitant disorders of sex development.

To review the surgical treatment of hypospadias (HP) associated with disorders of sex development (DSD). HP cases were assessed for DSD by gross examination for atypical external genitalia, and assessment of hormone levels and karyotype. There were 58 HP cases with concomitant DSD treated between 1999 and 2017. DSD classification, type of HP, sex assignment, hormonal abnormality, surgical strategy, and post-urethroplasty complications (post-UPC) were reviewed. DSD were sex chromosome abnormalities (n = 4), 46,XY (n = 51), 46,XX (n = 1), and 47,XY + 21 (n = 2). HP was perineal: (n = 26), scrotal: (n = 16), penoscrotal: (n = 15), and midshaft: (n = 1); repair was primary (n = 6) or staged (n = 52). Mean age at final urethroplasty (UP) was 4.12 ± 0.21 years; all cases had soft tissue interposition at UP. At mean follow-up 5.16 ± 0.56years after final UP, observed post-UPC (n = 8; 13.8%) were urethral stenosis (n = 3), urethral diverticulum (n = 2), urethrocutaneous fistula (n = 2), and curvature (n = 1). Mean onset of post-UPC was 1.24 ± 0.77years (range 0.1-6.3). The second half of our cases (n = 29; treated 2015 ~) had significantly less post-UPC (0/29; 0%) than the first half (8/29; 27.6%) (p = 0.0075). Although UP for HP + DSD was formidably challenging, we achieved a significant decrease in post-UPC through a combination of surgical techniques and experience.

The protective effect of non-transecting urethroplasty on erectile function in patients with posterior urethral stricture

Objective To explore the erectile function preservational mechanism of Non-transecting urethroplasty(NTU)for posterior urethral stricture. Methods From May 2012 to September 2016, 62 patients with posterior urethral stricture, who were treated with NTU, were enrolled in this study. The mean age was 37.5 years old, ranging 18-48 years old. The causes were pelvic fracture urethral injury in 53 cases and iatrogenic injury in 9 cases. Preoperative urethrography and urethroscopy revealed the strictures located in posterior urethra, which was at the distal of verumontanum. The mean length of stricture was 2.1 cm, ranging 0.5-2.5 cm. The average period between trauma and surgery was 6.4 months, ranging 3 months-2 years. All patients had no previous history of urethroplasty. Their sexual hormones were in normal level. Among those patients, the IIEF-5 scores were more than 12 and number of events during NPT test were more than twice. Finally, 43 cases were underwent NTU and 19 cases accepted inferior pubectomy (IP)+NTU. All patients had a general anesthesia. The bulbar urethra was mobilized dorsally from the tunica albuginea of the corpora cavernosa and then extended proximally up toward the perineal membrane. Scar tissue surrounding the urethra was excised and inferior pubectomy (IP) was performed as a supplemental technique to keep the suturing position without tension. The ventral hemi-circumference was then sutured with interrupted 4-0 polyglycolic sutures with tension-free anastomosis. The 18-Fr indwelling catheter was inserted. Result Average follow-up was 20.2 months, ranged from 12 to 36 months. In NTU group, NPT test revealed no significant difference in number of events(2.7±0.7 vs. 3.0±1.0, P>0.05), duration of best episode [(16.4±3.5)min vs. (16.4±3.8)min, P>0.05)] or tip rigidity[(31.2±4.7)% vs. (30.8±3.5)%, P>0.05)] between pre- and post-operation, respectively. The IIEF-5 score(19.7±1.9 vs.20.4±2.1, P<0.05 )and Qmax [(8.7±4.0)ml/s vs. (25.5±4.7)ml/s, P<0.05)] increased significant pre- and post-operation, respectively. In IP+NTU group, Qmax [(8.4±4.4)ml/s vs. (23.1±3.5)ml/s, P<0.05)] increased significant pre and post operation. The NPT test revealed slight decrease in number of events(2.3±0.6 vs. 1.6±1.0, P<0.05), duration of best episode [(15.6±2.4)min vs. (14.5±2.4)min, P<0.05)] or tip rigidity [(29.8±3.0)% vs. (25.6±7.1)%, P<0.05)] between pre- and post-operation, respectively. However, the IIEF-5 scores(17.3±1.6 vs.16.5±2.1, P<0.05) didn't show significant difference pre- and post-operation. Stricture recurrence occurred in 3 patients, the success rate was 95.2%(59/62) during 12 months following. Conclusion NTU is not only a safe and promising procedure for posterior urethral stricture less than 2.5cm, but also a new minimally invasive approach to preserve erectile function. Key words: Posterior urethral stricture; Non-transecting corpus spongiosum; Erectile function

Surgical selection and outcome for treating the post-traumatic posterior urethral strictures via transperineal approach

Objective To evaluate the outcome of various operative selection for treating posterior urethral stricture via transperineal approach. Methods The clinical data of 5 000 patients with posterior urethral stricture or obstruction from January 1990 to January 2017 were analyzed retrospectively. All patients were male. The age of those patients ranged from 18 months to 77 years old, mean 36.6 years old. Pelvic crush injury caused by car accident occurred in 2010 cases. Falling injury occurred in 1680 cases. Pelvic compressed injury occurred in 1 310 cases. Accompanied visceral damage occurred in 2 590 cases, including the liver and spleen rupture in 920 cases, lower limb fracture in 1 200 cases. 2 200 cases accepted urethral realignment under emergency. 2 800 cases were treated with pubic cystostomy. All patients were undergone a retrograde and voiding urethrogram. 562 patients accepted urethral ultrasongraphy, and 2 448 patients accepted urethroscopy. 204 patients accepted MRI examination. The mean stricture length was 4.3 cm, ranged from 1.8 to 8.6 cm. Posterior urethral stricture was found in 810(16.2%)cases. The complete obstruction of posterior urethra was found in 4 190(83.8%)cases, of which the length of the distraction defects≤3 cm was found in 2 650(53.0%)cases and the length of the distraction defects>3 cm was found in 1 540(30.8%)cases. Bladder calculi was found in 2 300 cases. The perineal fistula or abscess was noticed in 290 cases. False passage was found in 460 cases. Urethra rectum fistula was found in 160 cases. Bladder neck open was noticed in 89 cases. Repairing was performed via a simple anastomosis after urethral mobilization in 1 700 patients, via separation of the corporeal bodies in 1 302 patients, via separation of the corporeal bodies and inferior pubectomy in 1 910 patients and via scrotal skin flap urethroplasty in 68 patients. Pull-through operation was performed in 20 patients. Results Postoperative follow-up were conducted from 6 to 72 months with average duration of 23 months. The overall successive results after operation was 92.2%(4 608/5 000), which the Qmax was more than 15 ml/s .The successive rate of urethroplasty were 97%(1 649/1 700 )in simple anastomosis; 93%(1 211/1 302 )in separation of the corporeal bodies; 88% (1 680/1 910) in separation of the corporeal bodies and inferior puberctomy; 78%(53/68) in scrotal skin flap urethroplasty and 83%(15/18) in pull-through operation. The successive rate were 96%(778/810)in posterior urethral stricture; 95%(2 517/2 650)in distraction with the length of obstruction less than 3 cm and 86%(1 324/1 540)in distraction with the length of obstruction more than 3 cm. Conclusions The transperineal end to end anastomotic urethroplasty has become the first-line therapy for posterior urethral atresia. The length of the strictures or distraction defect which is lower than 3 cm is much more successfully corrected. Key words: Urethral stricture; Urological surgical procedure; Transperineal; Wound and injuiry