Urethral stricture

Urethral stricture in the tropics may be a serious public health problem; the majority of cases are caused by the gonococcus. The pathology is varied, and many advanced cases with complications are seen. Most strictures are seen in the posterior urethra, where fibrosis and narrowing may extend from a short length of under 5 mm to well over 10 cm. A wide variety of complications occurs. Diagnosis is easy when the patient presents in acute retention or with a history of difficult micturition, but more difficult when stricture is the underlying cause of perianal abscess, gangrene of the scrotum caused by extravasation, uremia or hypertension, hernia or rectal prolapse, urinary infection, or elephantiasis of scrotum with multiple fistulae. A careful history is helpful, paricularly if previous gonorrhea is involved. Physical examination varies according to mode of presentation and complications; a rectal examination and neurological examination should be included. Definitive investigation to prove the presence of a stricture includes urethrography and urethroscopy, if facilities are available. Indirect methods of diagnosis include tests for hemoglobin, blood urea, plain X-ray of the whole urinary tract, urinalysis, and others. It is preferable to leave instrumentation until last in diagnostic cases, to avoid infection, but a diagnostic bougie may be passed under strict aseptic conditions prior to treatment. The mainstay of treatment is regular bouginage for life, which is best done in a bougie clinic held at regular intervals. Equipment for bouginage, in order of desirability, includes soft plastic bougies, straight metal bougies, or curved metal bougies in larger sizes, a large stainless steel instrument tray, a basin for sterile water, and lubricant. Care should be taken during bouginage not to pass bougies into acutely inflamed strictures, and not to overstretch the urethra. Plastic bougies are preferable, until a stable situation has been reached. Surgery is indicated for a persistently impassable stricutre, for 1 requiring difficult bouginage at frequent intervals with many failures, for an established false passage, and for complications, especially bladder neck stenosis. Instructions for intravenous pyelograms and for urethrography from below and above, and diagrams of urethrograms indicating various pathological states and a diagnostic schema for urethral stricture are included.     

Female Urethral Reconstruction

Female urethral strictures are rare; thus, the literature describing stricture management in women is sparse. Although urethral dilation continues to be performed at a high frequency in women despite lack of proven efficacy, this procedure is used for a variety of voiding complaints other than stricture. Hence, the long-term utility of dilation and urethrotomy for urethral stricture in women is unknown. This review describes the various urethroplasty techniques used in the management of female urethral stricture. Although grafts using a dorsal approach have been shown to be feasible in women, ventral flap techniques offer good long-term outcomes with minimal morbidity. Acute and delayed management of pelvic fracture–associated urethral distraction defects in women is also described. Unlike in men, immediate urethroplasty in women should be performed once the patient is hemodynamically stable.     

Urethral injury in body donor TaTME training

Background

Urethral injury is one of the major risks in transanal total mesorectal excision (TaTME). To provide surgeons with experience in and management of potential critical surgical scenarios, urethral and prostate injuries were intentionally created during a body donor workshop under standardized training conditions.

Methods

We conducted a 2-day structured TaTME body donor training workshop. The theoretical module included lectures on topographic anatomy, clinical evidence, and surgical technique and pitfalls. Practical modules started with an interactive demonstration of crucial landmarks for the transanal approach using predissected formalin-fixed specimens. Next, surgical teams underwent proctored surgical training that implemented the key steps of TaTME on simulators and four male body donors. Strategies to avoid urethral damage involved intentional dissection and injury of the urethra and prostate, with subsequent demonstration of these lesions.

Results

After emphasizing the critical anatomical landmarks, the proctored surgical teams performed TaTME successfully without any urethral lesions. To demonstrate worst-case scenarios, two major pitfalls associated with TaTME, i.e., urethral injury and mobilization of the prostate, were simulated. These deliberate injuries proved to be critical learning experiences for all participants.

Conclusion

Appraisal of crucial anatomical landmarks and deliberate implementation of urethral/prostatic injury scenarios in preclinical TaTME training workshops is an effective way to teach surgeons how to avoid those injuries in patients. Structured and supervised training should be offered to all surgeons prior to implementing TaTME procedures in order to acquire skills necessary to address the delicate structures at risk during transanal approach.

     

Urethral stricture: complex surgery

The optimal management strategy for urethral stricture remains controversial. The therapeutic indication and surgery technique are still as much an art as they are a science. It is often unclear which type of urethroplasty to perform under which particular circumstance, but some evidence basis for urethral surgery has been developed in the last 20 years at last. This article reports the options for urethroplasty at different sites in the urethra and for different types of stricture, indicating which procedure should be used in which circumstances according to best available publications on urethral stricture management.     

Urethral Reconstruction in Patients with Neurogenic Bladder Dysfunction

Prolonged urethral catheterization can lead to significant urethral defects, including strictures, diverticula, erosions, and fistulas. Although it is a potentially challenging procedure, urethral reconstruction can allow patients with neurogenic bladder dysfunction to continue clean intermittent catheterization, improve or maintain their cosmetic appearance, and improve sexual function. There is a paucity of literature focusing specifically on urethral reconstruction in patients with neurogenic bladder dysfunction, with most studies involving small, heterogeneous populations. This article reviews published outcomes of urethral reconstruction and comments on the technical aspects of repair in patients with neurogenic bladder dysfunction.     

Simultaneous Treatment of Female Urethral Diverticulum and Stress Urinary Incontinence with Urethral Diverticulectomy and Suburethral Synthetic Mesh Sling

Objectives: Pubovaginal fascial sling along with urethral diverticulectomy has been advised as the most appropriate anti‐incontinence procedure for female stress urinary incontinence (SUI) with concomitant urethral diverticula (UD). We believe that suburethral synthetic mesh tape sling can also be safely used in some patients with concomitant SUI and UD. Herein, we present our experience for simultaneous treatment of UD and SUI with urethral diverticulectomy and suburethral synthetic mesh tape sling. Methods: From 2003 to 2008, there are three patients with UD and SUI in our institution. They received transvaginal urethral diverticulectomy and suburethral synthetic mesh tape sling simultaneously. Videourodynamics was done before and three months after the surgery. Results: Preoperative pelvis magnetic resonance imaging and videourodynamic study showed UD over distal urethra and SUI in all three patients. Urinalysis disclosed mild pyuria in two of the patients, and they both received intravenous antibiotics treatment to eradicate the infection prior to the surgery. They all underwent urethral diverticulectomy with suburethral synthetic mesh tape sling. The postoperative videourodynamic study showed no recurrence of UD and SUI. With a mean follow up of 33.3 months, there was no infection or exposure of synthetic mesh tape. Conclusions: In patients with UD and SUI, suburethral sling using synthetic mesh can be as effective and safe as facial sling in selected patients.     

Evaluation and Treatment of Urethral Stricture Disease

Any process causing trauma to the urethral tissue or underlying corpus spongiosum can lead to urethral stricture disease. The traditional treatment algorithm for urethral strictures, also known as the reconstructive ladder, begins with minimally invasive interventions, including urethral dilation and endoscopic urethrotomy. Inevitably, endoscopic incision and dilation fails, resulting in stricture recurrence. After the expenditure of valuable time and resources, physician and patient frustration finally leads to tertiary center referral with reconstructive urologic expertise. With dramatic advances in urethral surgery, many experts are abandoning the once-favored reconstructive ladder. In light of the excellent success rates for urethroplasty, the controversy continues, as reconstructive specialists now support open surgical treatment over endoscopic management for most urethral strictures.     

男性慢性非淋菌性尿道炎的尿道需氧菌群的变化

目的　探讨尿道菌群的变化与慢性非淋菌性尿道炎 (NGU)的关系。方法　病例组为 12 8例排除了沙眼衣原体、解脲脲原体、人型支原体和阴道毛滴虫等病原体感染的男性慢性NGU患者 ,取其初段尿标本进行需氧菌分离培养 ,并与 14 1例健康男性进行比较。所有患者给予百令胶囊或添加优势菌敏感抗生素治疗 ,疗程 2个月。结果　NGU组与对照组分离出的 4种常见菌相同 ,为表皮葡萄球菌、金黄色葡萄球菌、肠球菌、棒状杆菌 ,但NGU组金黄色葡萄球菌分离率非常显著的高于对照组 (18 8% :7 8% ,χ2 =7 0 16 ,P <0 0 1) ,而NGU棒状杆菌的分离率非常显著的低于对照组 (94 % :2 3 4 % ,χ2 =9 4 80 ,P <0 0 1) ,NGU组表皮葡萄球菌和金黄色葡萄球菌≥10 4CFU/ml的检出率非常显著或显著的多于对照组 (χ2 =10 36 4 ,P <0 0 1;χ2 =4 .6 5 6 ,P <0 0 5 )。治疗后 119例获得随访 ,治愈率 19 3% (2 3/119) ,有效率 35 3% (42 /119)。结论　男性慢性NGU患者存在尿道微生态失调 ,尿道微生态失调有可能参与慢性NGU的发生及发展     

Urethral Diverticula, Urethro-Vaginal Fistulae, Vesico-Vaginal Fistulae

This review considers the management of urethral diverticula, urethro-vaginal fistulae, and vesico-vaginal fistulae. The aim of this is to provide the reader with an overview of the current management of these pathologies, with reference to pertinent literature.     

Urethral erosion following autologous rectus fascial pubovaginal sling

Urethral erosion following pubovaginal sling is a rare occurrence. When synthetic sling materials are used urethral erosion often necessitates removal of the sling and urethral reconstruction. The literature is sparse with respect to the best approach to fascial sling erosion. We report a case of a 73 year-old woman who underwent a pubovaginal sling using autologous rectus fascia for treatment of stress urinary incontinence (SUI). She developed urethral erosion following 2 weeks of clean intermittent catheterization (CIC). Visual internal urethrotomy (VIU) was performed to incise the sling and the prolene sutures were removed to eliminate any tension. The patient subsequently voided spontaneously and had resolution of her SUI. This case demonstrates that urethral erosion may occur even when fascial slings are used. Unlike synthetic slings, when autologous fascia is used, the tissue may be left in-situ. A minimally invasive approach may achieve an excellent result without the need for complex surgical repair.     

Evaluation and Treatment of Female Urethral Stricture Disease

Female urethral stricture disease is very rare, but can cause bothersome urinary tract symptoms. Because of rarity, knowledge of how to treat true female urethral strictures can be lacking. Strictures can be caused by infection, trauma, instrumentation, or prior urethral surgery. Treatment options vary depending on patient goals and overall health, as well as the location, length, and severity of the stricture. These include serial dilation, internal urethrotomy, or urethroplasty. Local vaginal flaps and buccal free grafts can be used for onlay urethroplasty with good success rates, although many other techniques are described. Pelvic fracture urethral distraction defects (PFUDs) in women are especially rare. Acutely, they may require urgent repair with primary anastomosis (in contradistinction to male PFUDs which are not reanastomosed acutely), and chronic cases may require urethroplasty.     

Urethral Trichomonas vaginalis infection and HIV-1 transmission

The authors' previous study of 504 male workers in Mombasa, Kenya, provides further documentation of an association between urethral infection and increased shedding of HIV in semen. In this study, Trichomonas vaginalis was isolated by culture in 30 men (6%) and was the most commonly isolated urethral pathogen. Men with Trichomonas vaginalis were significantly older than those with Neisseria gonorrhoeae, suggesting infection may be of long duration. 83% of men with unmixed infections were asymptomatic. Since guidelines for syndromic management of urethral discharge do not include Trichomonas vaginalis, even symptomatic men with this condition who seek treatment are unlikely to be diagnosed and properly treated. More research is needed to confirm whether Trichomonas vaginalis (especially long-standing, low-grade infection) enhances male to female HIV transmission. Since an effective, single-dose, low-cost treatment for Trichomonas vaginalis is available worldwide, mass treatment strategies for this sexually transmitted disease could play an important part in HIV prevention in developing countries.     

Urethral stricture as unusual complications of Wegener's granulomatosis

A patient with Wegener's granulomatosis is reported. The diagnosis was confirmed by parotid gland biopsy. The patient responded to treatment with cyclophosphamide and prednisone. After many years, urethral stricture and subglottic stenosis developed and responded satisfactorily to surgery.