Perineal transpubic repair: a technique for treating post-traumatic prostatomembranous urethral strictures

A perineal, 1-stage, end-to-end anastomotic repair is the preferred method to treat short (2 cm. or less) prostatomembranous urethral strictures. For longer strictures a combined perineal and abdominal transpubic approach is required. We describe a technique that has allowed a 1-stage perineal repair of such strictures, up to 5 cm. long, by wedge excision of the inferior portion of the pubis. This technique has been used in 4 patients with prostatomembranous strictures 2 to 5 cm. long. The results were uniformly good in all of these patients.     

Urethroplasty using the pedicled island flap technique in complicated urethral strictures

Many techniques have been described for the repair of recurrent urethral strictures. Experience with 1-stage correction of hypospadias and epispadias, using a vascularized island flap technique, has led to its increased application for complicated adult urethral strictures. The advantage of the vascularized island flap technique is that reconstruction can be completed with only 1 operation, and it provides good subjective and objective results. Analysis of 50 consecutive cases treated by this approach has proved its validity. Of the 50 cases fistulas occurred in 20%, of which 12% required surgical correction, and stricture recurred in 32%. The largest proportion of recurrence was noted in patients who were primarily treated with 3 or more urethrotomies within a short time. Therefore, we recommend open surgical repair when 1 or 2 internal urethrotomies fail to produce a good result.     

One-stage reconstruction of moderately severe hypospadias

Single stage repair of moderately severe degrees of hypospadias with correction of chordee and reconstruction of the neourethra presents a difficult challenge for the surgeon. Traditionally, a 2-stage approach to correct these defects has been used. However, more recently a 1-stage repair with correction of chordee and creation of a neourethra has increased in popularity. From 1978 to 1985 we treated 86 patients with moderately severe hypospadias and chordee with a 1-stage technique using either a transverse island pedicle flap, a Hodgson III hypospadias repair or a free preputial skin graft. Despite an over-all complication rate of 50 per cent, our final results based on cosmesis and function were deemed excellent in 90 per cent of the cases. Of the 44 complications 23 were strictures, most frequently at the proximal anastomosis. Two-thirds of these strictures responded to a single dilation with the patient under anesthesia. Our fistula rate was 10 per cent and flap necrosis, meatal stenosis or prolapse and residual chordee accounted for the remaining 12 complications. Our experience indicates that a 1-stage repair for moderately severe hypospadias and chordee can be performed in patients with a satisfactory success rate of more than 90 per cent, minimal morbidity and an acceptable complication rate.     

The management of strictures of the membranous urethra

We present 40 cases of posterior urethral stricture resulting from pelvic fracture injury or prostatectomy. The strictures were managed according to various factors but most important were stricture length and the absence of pathological conditions in the anterior urethra. Post-traumatic obliterative strictures less than 2 cm. long can be managed with excellent success via a 1-stage perineal bulboprostatic anastomotic repair. Combined abdominoperineal procedures are equally successful but are reserved for patients in whom the stricture is more than 2 cm. long or who have an associated bladder neck pathological condition. When associated anterior urethral disease mitigates against mobilization and extension of the urethra to accomplish an anastomotic repair, the vascularized island flap or 2-stage scrotal inlay procedure appears to be the optimal choice. Of 3 failures with full thickness skin grafts 2 may have been owing to suboptimal graft beds in the scarred pelvic floor and perineum. Direct vision urethrotomy is advocated for nonobliterative posttraumatic strictures, and the rationale for dilation rather than urethroplasty management of postprostatectomy strictures is presented.     

MANAGEMENT OF OBLITERATIVE POSTTRAUMATIC POSTERIOR URETHRAL STRICTURES AFTER FAILED INITIAL URETHROPLASTY

Purpose

We evaluate the problems encountered during surgery and assess the results of different endoscopic and open surgical methods following failed urethroplasty for posttraumatic posterior urethral stricture.

Materials and Methods

Since 1992 we have treated 23 patients in whom urethroplasty for posterior urethral strictures failed. Of these patients, 3 had undergone 2 previous repairs and 6 had additional complicating factors, such as fistula, periurethral cavity and false passage. End-to-end anastomosis was done in 14 patients via a transperineal (7) or transpubic (7) approach. In 1 patient substitution urethroplasty using a radial artery based forearm free flap was performed. In 3 patients a 2-stage urethroplasty was done, 4 underwent core-through optical internal urethrotomy and 1 underwent endoscopic marsupialization of a false passage.

Results

At 1 to 5-year followup 3 of the 23 patients had restenoses (13%), including 2 in whom previous treatment failed. The remaining 87% of the patients void well and are continent, and there is no worsening of the preexisting potency status.

Conclusions

Previous failed urethral stricture repair complicates management due to fibrosis, impaired vascularity and limited urethra available for mobilization. Recurrent strictures less than 1.5 cm. can be managed successfully with core-through internal urethrotomy. End-to-end anastomosis is possible in the majority with generous use of inferior pubectomy or the transpubic approach with certain modifications. When residual inflammation or long strictures are present a 2-stage procedure is a safer option. Overall, reoperation can offer a successful outcome for the majority of these complex strictures.     

Buccal mucosa graft urethroplasty for anterior urethral stricture repair: evaluation of the impact of stricture location and lichen sclerosus on surgical outcome

PURPOSE: We report our experience with buccal mucosa grafts for anterior urethral strictures. We compared outcomes in the pendulous and bulbar urethra as well as the impact of lichen sclerosus on success. MATERIALS AND METHODS: A total of 53 men underwent buccal mucosa graft urethroplasty from 1997 to 2004 for strictures of all etiologies, including lichen sclerosis in 13. Of the patients 46 underwent 1-stage repair and 7 with full-thickness circumferential disease underwent multistage repair. For 1-stage repair strictures were limited to the bulb in 33 cases and they involved the pendulous urethra in 13. A dorsal onlay was used in 24 cases and a ventral onlay was used in 22. For multistage urethroplasty 2 strictures were in the bulbar urethra and 5 were in the pendulous urethra. Success was defined as no postoperative procedures or complications. RESULTS: The success rate of all urethroplasties was 81% (43 of 53 cases) at a mean followup of 52 months. For bulbar vs pendulous urethroplasty the success rate was 86% (30 of 35 cases) vs 72% (13 of 18, p = 0.23). For 1-stage urethroplasty by graft location success was achieved in 20 of 24 cases (83%) for dorsal onlay vs 17 of 22 (77%) for ventral onlay (p = 0.61), in 18 of 21 (86%) for bulbar-dorsal onlay, in 10 of 12 (83%) for bulbar-ventral onlay, in 2 of 3 (66%) for pendulous-dorsal onlay and in 7 of 10 (70%) for pendulous-ventral onlay. For multistage urethroplasty success was achieved in 2 of 2 cases (100%) for bulbar repair vs 4 of 5 (80%) for pendulous repair. In the 13 patients with lichen sclerosus success was achieved in 4 of 8 (50%) with 1-stage repair vs 4 of 5 (80%) with multistage repair (p = 0.28). Complications developed in 10 of 53 cases (19%), including fistula in 1, urinary tract infection in 1 and stricture in 8 that required treatment, including dilation in 3, internal urethrotomy in 4 and perineal urethrostomy in 1. Five of these 8 recurrent strictures (63%) developed in patients with lichen sclerosus, including 4 in urethras in which 1-stage repair was done for lichen sclerosus. There were no donor site complications, postoperative erectile dysfunction or chordee. CONCLUSIONS: A buccal mucosa graft placed dorsally or ventrally remains an excellent graft material in the bulbar and pendulous urethra. When lichen sclerosus is present, careful consideration should be given to complete excision of the diseased urethra with multistage repair vs accepting a higher rate of stricture recurrence with 1-stage repair.     

The vascularized skin island urethroplasty: its role and results in urethral stricture management

We report 11 vascularized island skin flap urethroplasties. Results appear to be excellent when the procedure is used for strictures of the pendulous urethra. Use of vascularized skin flap urethroplasties for the repair of bulbar and membranous strictures has been complicated by pseudodiverticula and stone formation, and in this portion of the urethra the technique probably should be reserved for cases in which local factors mitigate against alternative 1-stage procedures.     

A comparison of the Mustardé and Horton-Devine flip-flap techniques of hypospadias repair

We compared the results and complications of the Horton-Devine flip-flap and Mustardé techniques for 1-stage repair of distal hypospadias. Followup has been for at least 1 year so that long-term complications could be included. Urethral fistulas occurred in 6 of 20 patients treated with the Horton-Devine flip-flap and 3 of 20 who underwent the Mustardé repair. No strictures were noted with either procedure. In our opinion the meatus had a better configuration after the Mustardé repair. We conclude that the Mustardé procedure provides a more satisfying cosmetic and clinical result.     

Postoperative bile duct strictures

Bile duct strictures are an uncommon but serious complication of primary operations on the gallbladder or biliary tree. Most strictures occur as a result of injury to the bile duct during cholecystectomy. In addition, strictures can occur at the site of previous biliary anastomoses for reconstruction of the biliary tree. Most patients with benign bile duct strictures present soon after their initial operation; however, in some cases, presentation is delayed for years. Cholangiography is essential for defining the anatomy of the biliary tree prior to management. In many cases, nonoperative biliary drainage is useful to treat sepsis and biliary fistulas. A number of alternatives exist for elective repair of bile duct strictures. Experience would suggest, however, that a choledochojejunostomy or hepaticojejunostomy performed through a Roux-en-Y limb of jejunum is the preferable management in most cases. Postoperative biliary stenting may be valuable in optimizing the results. Nonoperative management by percutaneous transhepatic or endoscopic balloon dilatation has been reported to be successful in a number of small series. Long-term results are limited, however. Comparative data suggest that surgical repair for benign postoperative strictures is associated with fewer long-term problems and with similar overall morbidity and costs.     

Urinary continence after repair of membranous urethral stricture in prostatectomized patients.

Prostatectomy by open or transurethral techniques usually destroys the function of the internal sphincter (bladder neck), which is the first line of defense against incontinence. Urinary continence then depends upon the intrinsic smooth muscle sphincter of the membranous urethra and the striated external sphincter. Unfortunately, a significant incidence of membranous urethral stricture occurs after a prostatic operation. Most such strictures can be managed with periodic dilatation but some are difficult and dangerous to dilate. Complications such as recurrent acute retention, bacteremia, false passages, stone formation, fistulas and so forth are indications for surgical cure of the stricture. However, can urethroplasty of the membranous urethra be carried out in these patients without inevitable incontinence? At our center 33 prostatectomized patients have had a 2-stage urethroplasty for refractory membranous urethral strictures. Nine patients had troublesome stress incontinence after the first-stage operation but only 4 of these had continuing incontinence after the second-stage operation. These patients had been noted to have transient postoperative stress incontinence after the prostatectomy. Although there is a risk of incontinence after urethroplasty of the membranous urethra in prostatectomized patients, the risk is sufficiently low that the operation should not be denied patients with refractory strictures in whom the only alternative eventually will be some form of urinary diversion.     

Buccal mucosal urethroplasty for balanitis xerotica obliterans related urethral strictures: the outcome of 1 and 2-stage techniques

PURPOSE: Balanitis xerotica obliterans (BXO) related strictures are complex and generally managed by 2-staged urethroplasty. We present our results with 1-stage dorsal onlay and 2-stage buccal mucosal urethroplasty for such strictures. MATERIALS AND METHODS: Between January 2000 and April 2004, 39 patients underwent buccal mucosal urethroplasty for BXO related anterior urethral strictures. The 25 patients with a salvageable urethral plate (group 1) were treated with 1-stage dorsal onlay urethroplasty using a cosmetic incision. The 14 patients with a severely scarred urethral plate, focally dense segments or active infection (group 2) underwent 2-stage urethroplasty. Outcomes in terms of cosmetic appearance, stricture recurrence and complications in the 2 groups were assessed. RESULTS: At a mean followup of 32.5 months (range 3 to 52) 3 patients (12%) in group 1 had recurrent stricture, of which 2 and 1 were treated with optical urethrotomy and urethral dilation, respectively. All patients had a normal slit-like meatus and none had chordee or erectile dysfunction. Four group 2 patients (28.6%) required stomal revision and 2 had glans cleft narrowing after stage 1 urethroplasty. Following stage 2, 3 patients had recurrent stricture, of whom 2 were treated with optical urethrotomy and 1 underwent repeat urethroplasty. CONCLUSIONS: In BXO related strictures with a viable urethral plate 1-stage dorsal onlay buccal mucosal urethroplasty provides excellent intermediate term results. The cosmetic incision described provides a normal, wide caliber, slit-like glans. Two-stage procedures provide satisfactory outcomes but they are associated with a higher revision rate.     

Pelvic fracture urethral injuries in girls

PURPOSE: Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferential rupture. When disruption has occurred at the level of the proximal urethra, it is usually complete and often associated with vaginal laceration. We retrospectively reviewed the records of a series of girls with pelvic fracture urethral stricture and present surgical treatment to restore urethral continuity and the outcome. MATERIALS AND METHODS: Between 1984 and 1997, 8 girls 4 to 16 years old (median age 9.6) with urethral injuries associated with pelvic fracture were treated at our institutions. Immediate therapy involved suprapubic cystostomy in 4 cases, urethral catheter alignment and simultaneous suprapubic cystostomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with urethral avulsion at the level of the bladder neck and in 5 with a proximal urethral distraction defect, while a neourethra was constructed from the anterior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Concomitant vaginal rupture in 7 cases was treated at delayed urethral reconstruction in 5 and by primary repair in 2. The surgical approach was retropubic in 3 cases, vaginal-retropubic in 1 and vaginal-transpubic in 4. Associated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall postoperative followup was 6 months to 6.3 years (median 3 years). RESULTS: Urethral obliteration developed in all patients treated with suprapubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and substitution urethroplasty was 100%. In 1 girl complete urinary incontinence developed, while another has mild stress incontinence. Retrospectively the 2 incontinent girls had had an associated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of lateral labial flaps. CONCLUSIONS: This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck damage after traumatic pelvic fracture injury in female pediatric patients. Although our experience with the initial management of these injuries is limited, we advocate early cystostomy drainage and deferred surgical reconstruction when life threatening clinical conditions are present or extensive traumatized tissue in the affected area precludes immediate ideal surgical repair.     

Surgical treatment of biliary stricture with portal hypertension using veno-venous bypass

The surgical treatment of benign bile duct stricture with portal hypertension may be hazardous and, in some cases, involve a 2-stage procedure. An initial porta-systemic shunt is performed followed by surgical correction of the stricture at a second operation. The use of veno-venous bypass, as described, provides a temporary porta-systemic shunt, allowing a 1-stage repair of the stricture to be carried out.     

Secondary flexor tendon reconstruction, a review

As techniques have improved, primary repair of flexor tendon lacerations, including zone II injuries, have become more common. Secondary reconstruction, whether in 1 or 2 stages, remains an important and useful technique for the treatment of these injuries. Current indications and methods, including delayed treatment and 1-stage and 2-stage reconstruction, are reviewed. Future directions of tendon reconstruction are also discussed.     

Penile urethral reconstruction: concepts and concerns

Reconstruction of the penile urethra is a challenging exercise, and for many surgeons an ungratifying experience. The past three decades have seen us move from predominantly 2-staged surgery, through foreskin grafts, and then single stage flap reconstructions, and now in the 3rd millennium, for some situations 2-stage repair has again become the favoured option. Satisfying short-term solutions have sometimes resulted in poor long-term outcomes when reviewed 10 years later. Clearly there are still problems to be resolved, hence the need for continuing evolution in our surgical management. Lessons have been learned from the treatment of Lichen Sclerosus, from strictures following hypospadias repair, and strictures associated with severe spongiofibrosis. Management of these problems has traditionally been associated with not only a high incidence of restricture and fistula formation, but also with poor cosmetic results, something that men today find increasingly difficult to accept. Several considerations are fundamental to achieving the best functional and aesthetic results. These include the presence or absence of Lichen Sclerosus, the extent of urethral disease and its grade (i.e. mucosal disease or with accompanying spongiofibrosis); furthermore the use of non-genital grafts for urethral reconstruction when the local penile tissues are deficient or unhealthy. In arriving at our present strategy, a collaborative approach that integrates established urological practice with the different perspectives of a plastic surgeon (A.B.) has proved constructive and beneficial.     

医源性胆管损伤的治疗及疗效分析

目的探讨医源性胆管损伤的防治方法及疗效。方法回顾性分析30例医源性胆管损伤病人的临床资料。结果术中发现胆管损伤并及时修复9例,其中1例术后发生狭窄而再次手术治愈;另21例术后因胆管狭窄或胆漏确诊,2例行副肝管缝扎术,3例行胆管端端吻合T管引流术,16例行胆肠Roux-en-Y吻合。疗效优者22例、良5例、差1例、死亡2例(1例死于胆漏感染,1例死于胆汁性肝硬化)。结论医源性胆管损伤重要在于术中及时发现和及时处理,采取胆肠Roux-en-Y吻合治疗可取得较好疗效。     

Treatment of Complex Anterior Urethral Stricture Disease With Mesh Graft Urethroplasty

Purpose

Treatment of complex anterior urethral strictures complicated by a lack of sufficient penile skin for primary flap repair has generally consisted of 2-stage scrotal inlay urethroplasty. Scrotal skin has shortcomings, most notably hair formation, diverticula and stricture recurrence from urine induced dermatitis. As an alternative, we present our results with staged mesh graft urethroplasty using split-thickness skin, which is nonhair-bearing, easier to size and seemingly less permeable to urine penetration.

Materials and Methods

Between 1990 and 1995, 20 men underwent mesh graft urethroplasty for complex strictures, most after failed urethroplasty. Meshed split-thickness skin graft from the thigh (17 men) or full-thickness foreskin (3) was used.

Results

Overall median time to closure was 5.5 months, and 6 men required revision before closure (revision of ostia in 3, chordee release in 2 and lysis of graft adhesions in 1). A successful outcome, as evidenced by retrograde urethrography and history, was achieved in 12 of 15 men (80%) with a median followup of 38 months. Five men have not undergone closure due to patient refusal (2) or because the graft is not ready to be closed (3). Of the failures 2 men had retrograde urethrographic evidence of stricture at the proximal anastomosis and 1 had recurrent stenosis of the entire neourethra by 2 years.

Conclusions

Mesh graft urethroplasty is not a panacea but it is a valuable adjunct in the treatment of complex urethral strictures, offering comparable results to and benefits over scrotal inlay procedures. In a significant percentage of cases it is a multistage rather than a 2-stage procedure.     

1-Stage delayed bulboprostatic anastomotic repair of posterior urethral rupture: 60 patients with 1-year followup

PURPOSE: The long-term results of delayed 1-stage bulboprostatic anastomotic urethroplasty for posterior urethral ruptures are evaluated. MATERIALS AND METHODS: A total of 63, 1-stage delayed repairs of complete posterior urethral ruptures in 60 men with at least 1-year followup were reviewed. Two ruptures were due to gunshot wounds and 58 were secondary to a pelvic fracture. There were 58 repairs done by the perineal approach and 5 required an abdominal perineal approach. RESULTS: Surgical complications included 2 (3%) rectal injuries, 3 (5%) repeat strictures that required reoperation and 20 (32%) repeat strictures that required dilation or visual internal urethrotomy. By 1 year after surgery all patients had a patent urethra and did not require further treatment. At 1 year 43 (72%) patients voided normally, 5 (8.3%) were areflexic and performed self-catheterization, 5 (8.3%) had urge incontinence and 5 (8.3%) had mild stress incontinence requiring no treatment. Moderate stress incontinence responded to imipramine in 1 case and collagen injection in 1. Of the patients who were potent preoperatively 31 (52%) remained potent postoperatively. Of the 29 (48%) patients who were impotent preoperatively and immediately postoperatively 9 regained potency at 1 year. However, at 1 year, the quality of erections of the 40 potent men was normal in only 22 (37%) and fair to poor in 18 (30%). CONCLUSIONS: The 1-stage delayed bulboprostatic anastomotic urethroplasty has a good long-term result with little morbidity for treatment of posterior urethral ruptures in men.     

Immediate and delayed use of arteriovenous fistulae in microsurgical flap procedures: a clinical series and review of published cases

In microsurgical flap procedures, creation of an arteriovenous fistula (AVF) is a technique of vein grafting where the vein graft is connected to recipient vessels as a flow-through loop prior to harvest and inset of the flap. Controversy exists whether this technique can be used as a 2-stage procedure with the loop and flap transfer accomplished in sequential operations or if the loop and flap transfer should be performed in a single operation.We performed 12 consecutive 1-stage AVF-flap procedures, with 1 flap failure. We combined this series with previously published reports to compare outcomes of 1-stage and 2-stage procedures. We found no significant difference in flap outcomes or complication rates between the 2 strategies. We conclude from our experience and this analysis that single-stage AVF-flap procedures are the optimum application of this technique.     

One-stage urethral reconstruction for stricture recurrence after urethral stent placement

PURPOSE: We report our 8-year experience with 1-stage open urethral reconstruction in 10 patients with recurrent bulbar and/or membranous strictures after UroLume urethral stent placement. MATERIALS AND METHODS: Ten consecutive referral patients underwent preoperative contrast imaging and urethroscopy followed by primary anastomotic repair or substitution urethroplasty, with concomitant open UroLume removal (when the stent was still present). Postoperative evaluation included contrast imaging 3 weeks after surgery, urethroscopy 4 months after surgery, uroflowmetry, and American Urological Association symptom score assessment. RESULTS: At a medium followup of 51.2 months all patients remain free of bulbar or membranous stricture recurrence. No patient has required dilation or any other intervention. CONCLUSIONS: One-stage open reconstruction with stent extraction offers a definitive treatment option with a high success rate for patients with recurrent bulbar and/or membranous strictures following urethral stent placement.