MANAGEMENT OF URETHRAL STRICTURES AFTER HYPOSPADIAS REPAIR

Purpose

We conducted a retrospective study of patients with strictures after hypospadias repair to identify factors contributing to the development of strictures and to attempt to define an optimal strategy for management.

Materials and Methods

patients with the diagnosis of hypospadias who had undergone direct vision internal urethrotomy, urethral dilation or urethroplasty were identified. The original location of the meatus, type of initial repair, subsequent procedures and outcome of the interventions were recorded.

Results

A total of 38 patients were identified. Of the 29 patients who were initially treated with direct vision internal urethrotomy or urethral dilation 23 (79%) ultimately required open urethroplasty and did well. Of the 8 patients treated with initial urethroplasty 7 had successful outcomes. Overall success, defined as asymptomatic voiding without fistula or residual stricture, was 78% at a mean followup of 6.3 years.

Conclusions

Stricture disease continues to be a significant complication of hypospadias reconstruction. Initial therapy should be urethral dilation but it should be recognized that the majority of these patients will ultimately require open urethroplasty.     

CONGENITAL BULBAR URETHRAL STRICTURES OCCURRING IN THREE BROTHERS

Three brothers with identical congenital bulbar urethral strictures are presented. These rare lesions are distinct from posterior urethral valves although the exact embryological origin is uncertain. The current literature is also reviewed.     

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.     

吻合口腹侧成形术修复尿道下裂术后狭窄

目的 探讨吻合口腹侧成形术治疗尿道下裂术后狭窄的效果。方法 2000年8月～2005年12月，对20例尿道下裂术后吻合口狭窄患者以腹侧成形术进行矫冶。年龄2～27岁，中位年龄6，4岁。均表现为尿道下裂矫正术后排尿困难、尿线无力；除3例排尿呈线外，17例排尿呈滴状，其中3例出现急性尿潴留，4例反复出现尿频、尿急、尿痛。16例行尿道逆行造影及排尿性膀胱尿道造影，尿道狭窄段长0．5～1．0cm，平均0．7cm．合并近段尿道不同程度扩张，其中9例形成明显憩室。尿常规检查，16例白细胞＋＋～＋＋＋，13例脓细胞±～＋＋。结果 术后伤口愈合良好，排尿顺畅。获随访2个月～4年，平均2．3年。患者排尿困难均消失，排尿有力，尿线粗细正常，无再次狭窄及尿瘘，阴茎无弯曲，外观满意，尿常规检查恢复正常。结论 吻合口腹侧成形术治疗尿道下裂术后短段吻合口狭窄，操作简便，效果确切。     

PENILE CIRCULAR FASCIOCUTANEOUS SKIN FLAP IN 1-STAGE RECONSTRUCTION OF COMPLEX ANTERIOR URETHRAL STRICTURES

Purpose

We review the applications and outcomes of penile circular fasciocutaneous flap urethroplasty in 66 patients at our institution.

Materials and Methods

We used a circular distal penile skin flap for urethral reconstruction in 66 men with complex urethral strictures. Average stricture length in this series was 9.08 cm. and mean followup was 41 months (range 1 to 7 years).

Results

The initial overall success rate was 79% (52 of 66 cases). Recurrent stenosis was noted in 7 of the 54 onlay (13%) and 7 of the 12 tubularized repairs (58%). Most recurrent strictures were successfully treated with a single subsequent procedure, including repeat urethroplasty in 5 cases and optical urethrotomy or dilation in 6. Two patients required perineal urethrostomy and 1 awaits further reconstruction. Including subsequent procedures, the overall long-term followup success rate was 95%. Neurovascular lower extremity complications developed in 4 patients after prolonged high lithotomy positioning.

Conclusions

Circular fasciocutaneous flap urethroplasty is a highly effective 1-stage method of reconstructing complex urethral strictures. Onlay repairs appear to be more successful than those involving flap tubularization. Limiting the time that the patient spends in the high lithotomy position appears to prevent neurovascular extremity complications.     

PREPUBIC URETHRECTOMY WITH URETHRAL STRIPPING

PURPOSE: Prepubic urethrectomy is a simple, safe alternative to perineal urethrectomy. The lithotomy position can be avoided and, thus, operative time and risk of deep venous thrombosis are decreased. We developed a simple modification because of difficulty in dissecting the bulbous urethra. MATERIALS AND METHODS: From 1996 through 1998 prepubic urethrectomy was performed using a modified procedure in 21 patients with invasive bladder carcinoma undergoing radical cystectomy and supravesical diversion. After periurethral mobilization the urethra was cannulated with an 18F catheter, sutured distal and stripped free. RESULTS: Operative time decreased to 20 to 30 minutes with no significant postoperative complications. CONCLUSIONS: Our modification of prepubic urethrectomy is safe, fast and easy.     

乳房松弛下垂23例矫治体会

目的：探讨单纯性乳房松驰下垂手术方法的选择以及影响疗效的相关因素。方法：选择新月形或双环形切口,将乳腺上缘固定于肋骨骨膜上。结果：本组23例患者,术后医患双方均满意,随访14例,外形良好。结论：选择合适的手术方法,采用隐蔽的切口以及乳腺悬吊固定,可使乳房松垂矫治取得满意效果和良好的远期疗效。     

MID-COLON OESOPHAGOCOLOPLASTY FOR CORROSIVE OESOPHAGEAL STRICTURES

Corrosive strictures of the oesophagus are common and being long and dense frequently require surgical replacement of the oesophagus. Presently available techniques of oesophagocoloplasty are associated with a significant mortality and major morbidity, such as a high rate of ischaemic necrosis of the colon, cervical salivary fistula or oesophagocolic stenosis. A method of mid-colon oesophagocoloplasty using an isoperistaltic colonic segment from the mid-ascending to the mid-descending colon is reported. The procedure was carried out in 33 patients. The conduit was placed retrosternally in 27 patients and subcutaneously in the rest. The essential steps of the procedure are simultaneous neck and abdominal dissection, near-total mobilization of the colon from the ileocaecal segment to the sigmoid colon and sequential clamping of ileocolic, right colic and usually the middle colic vessels leaving the left colic vessels as the major vascular pedicle. The divided ileum is used to pull the colon into position thus avoiding traumatization of the colon and leaving the whole length of the mobilized colon available for anastomosis. A wide side to side oesophagocolic anastomosis in the neck, resection and discarding of the bulky terminal ileocaecal segment after completion of the cervical anastomosis, closure of the terminal end of the colon and its placement adjacent to the hypopharynx and end to side cologastric anastomosis complete the procedure. There was no mortality and there was no instance of colonic necrosis. The procedure restored an ability to eat normal food in 93.9% of patients compared to only 39.2% of patients with bougienage. The major advantages of this procedure are a uniformly adequate length of colon, excellent vascularity, avoidance of a potentially ischaemic colonic end in the oesophagocolic anastomosis, with its attendant sequelae such as cervical fistulae or oesophagocolic stenosis, low incidence of complications and the possibility of easy correction of oesophagocolic stenosis should it occur after the procedure. Cervical fistulae occurred in 10 patients and spontaneously closed in nine. Cervical anastomotic stenosis occurred in only one instance. The functional results and complication rate reported here are superior to most other series of oesophagocoloplasty for corrosive strictures reported in the literature. The operation is technically easy and is a significant improvement on existing methods of oesophageal replacement.     

MULTICENTER EXPERIENCE WITH THE MITCHELL TECHNIQUE FOR EPISPADIAS REPAIR

Purpose

We present a multicenter experience using the Mitchell epispadias technique to determine if satisfactory results could be obtained by various pediatric urologists at multiple centers using the same technique to repair epispadias. This particular technique involves complete disassembly of the penis into 2 separate hemicorporeal glandular bodies and a separate urethral plate, and relies on the unique blood supply to the epispadiac phallus.

Materials and Methods

A total of 17 boys 11 months to 21 years old underwent the Mitchell procedure for epispadias at 4 institutions by 6 different surgeons between 1994 and 1996. One patient in this group had undergone prior epispadias repair, which had failed.

Results

At followup (mean 13.5 months) 3 boys had pinpoint penopubic fistulas, which resolved spontaneously in 2. The 21-year-old patient had a complete wound dehiscence. All boys with intact repairs have straight erections, orthotopic meatus and satisfactory appearances. There were 15 boys with a conical glans appearance and 1 exhibiting glandular disproportion. There was 1 episode of postoperative pyelonephritis.

Conclusions

The Mitchell technique for repair of epispadias is reproducible and successful in the hands of pediatric urologists from different centers. Chordee is reliably corrected, erectile function preserved, the urethra ventrally situated in an anatomically precise fashion and satisfactory cosmesis achieved.     

应用聚四氟乙烯修复腹壁缺损

目的　探讨应用聚四氟乙烯 (PTFE)生物材料修复腹壁大面积缺损 ,预防腹壁疝的临床效果。　方法　自 1999年 3月以来 ,应用片状 PTFE修复腹壁肿瘤切除术后腹壁缺损 6例。腹壁缺损范围最大为 2 5 cm× 15 cm,最小为 9cm× 6 cm,其中 2例伴有皮肤缺损 ,使用带蒂皮瓣或肌皮瓣移位进行修复。　结果　术后腹部伤口 期愈合 ,移位皮瓣全部成活 ,修复材料无暴露。随访 6个月～ 3年 ,无排异反应及腹壁疝等并发症。　结论　临床应用片状 PTFE修复腹壁缺损具有良好的效果。     

INITIAL EXPERIENCE WITH ENDOSCOPIC HOLMIUM LASER LITHOTRIPSY FOR PEDIATRIC UROLITHIASIS

PURPOSE: Due to the unavailability of suitable pediatric instruments children have not benefited from advances in endoscopic lithotripsy. This limitation may be overcome by the holmium: YAG laser. We evaluated the indications for, and efficacy and complications of holmium:YAG laser lithotripsy. MATERIALS AND METHODS: We retrospectively reviewed all cases of laser lithotripsy. Access to the calculus was antegrade or retrograde. A solid state holmium:YAG laser was used. RESULTS: Eight patients 4 to 14 years old underwent laser lithotripsy during the study period. Average calculous surface area was 357.13 mm.2 (range 14 to 1,645). Five patients required 1 procedure to render them stone-free, while the remaining 3 required multiple procedures. No complications were associated with laser lithotripsy. CONCLUSIONS: The ability of the holmium:YAG laser to pulverize urinary calculi makes it an alternative choice for lithotripsy. In our series all patients are stone-free with stable renal function. The advantages of the holmium:YAG laser are that it may be precisely applied via small fibers, and it pulverizes calculi with minimal scattering of energy and retropulsion of the calculus, decreasing trauma to tissues at the perioperative site. There is also a lower risk of residual fragments, which is associated with a lower incidence of calculous regrowth. Holmium: YAG laser is safe and effective for treating pediatric urolithiasis.     

METHOXYFLURANE ANALGESIA FOR BURNS DRESSINGS: EXPERIENCE WITH THE ANALGIZER

Methoxyflurane has been used to provide analgesia for burnsdressings on sixty occasions in eleven patients. It was administeredby way of a new, disposable vaporizer, the Analgizer, whichis described. Three patients required either supplementary analgesicsor tranquillizers. No side effects were noted, and patient acceptanceof the Analgizer was good. This method is thought to representan advance over previous methods of analgesia for burns dressings,since there is no undue sedation, pre-operative starvation isunnecessary, and venepunctures are avoided. ^*This device is not yet marketed in the United Kingdom. Present address:Department of Anaesthesia, Royal HampshireCountyHospital, Romsey Road,Winchester Present address:Department of Surgery, University of Chicago,Chicago,Illinois 60637     

CLINICAL EXPERIENCE OF LOWER URINARY TRACT RECONSTRUCTION USING A URETHRAL KOCK POUCH

The operative procedure used in the present series involved a nerve-sparing radical cystectomy, with anastomosis of the urethra using a pouch made of detubularized ileum. The 36 patients who underwent this operation were all male with an average age of 58. No deaths resulted from the operation. As far as late complications were concerned, malfunction of the antireflux nipple valve was noted in 1 patient and stenosis occurred between the urethra and pouch in 2. One patient was found to have multiple stones in the pouch and reservoir decompensation was recognized in 2. Thus, the late complication rate was 17%. There were no cases of total incontinence, but nocturnal incontinence appeared in 11 out of 31 (35%). A total of 20 out of 25 patients (80%) recovered their erectile function during the postoperative follow-up period and the disease-free survival rate at 5 years was 78%. Therefore, the urethral Kock pouch combined with nerve-sparing cystectomy has proved to be a useful procedure as far as the quality of life is concerned.     

LONG-TERM EXPERIENCE WITH SCLEROTHERAPY FOR TREATMENT OF EPIDIDYMAL CYST AND HYDROCELE

Background: Symptomatic testicular hydrocele and cyst of the epididymis may be treated with either operation or sclerotherapy. Methods: The current report presents the experience of a 9 year prospective study using sodium tetradecyl sulphate (STD) sclerotherapy for the treatment of symptomatic hydrocele and/or epididymal cyst. Results: A total of 102 lesions were treated during the study period, with an initial success rate of 76% which improved to 94% with multiple treatments. The overall median follow up during the study was 30 months (range 2–100). Conclusions: Sclerotherapy offers a cost-effective outpatient method for the treatment of symptomatic scrotal cysts.     

AN INITIAL EXPERIENCE WITH A POSTERIOR INTRAHEPATIC APPROACH FOR LIVER RESECTIONS

This is a report of an initial experience using a recently devised posterior approach to the intrahepatic Glissonian sheaths of the liver, for the purpose of hepatic resections. Between February 1991 and October 1903. 22 patients. median age 58 years (range 36–77) underwent either a right or a left hepatectoiny or a segmentectomy procedure of the liver using this technique. Seventeen of these patients underwent this operation for malignant disease of the liver. Median operating time was 930 min (range 100–285) with nine of the 22 patients requiring an intra-operative blood transfusion. There was one postoperative death, from liver failure, and 17 of the patients were alive at the early time of reporting. It is concluded that this technique is a useful addition to the surgeon's armamentarium for operating on the liver.     

BENIGN BILIARY STRICTURES ASSOCIATED WITH CHRONIC PANCREATITIS AND GALLSTONES

A series of twenty-seven patients with benign non-traumatic biliary strictures is presented. Fifteen strictures were associated with chronic pancreatitis, and were typically long, tapered Strictures of the intrapancreatic portion of the common bile duct. Twelve were associated with choledocho-lithiasis; these were usually short-segment and occurred both above and below stones in the duct. These strictures are important surgically, since they may produce pain, cholestasis and cholangitis, stone formation, and biliary cirrhosis. They may be difficult to distinguish from bile duct or pancreatic carcinomas. In the patients with chronic pancreatitis, treatment by biliary bypass was effective in the presence of cholestasis, but was ineffective for chronic pain. Treatment by biliary bypass or sphincteroplasty was highly effective in those patients with choledocholithiasis.     

EXPERIENCE WITH BILIARY AUDIT

Experience with an audit of surgery for gallstones is discussed. Three hundred and forty-six patients were treated in a three and a half year period. There was no mortality. There was a duct exploration rate of 17%. an infection rate of 8.6%. and a re-operation rate for retained bile duct stone of 1.6%. Bile was cultured from 278 gall-bladders and culture was positive in 66 cases (23.7%). The most common organisms grown were coliforms and streptococci. Our antibiotic policy has changed as a result of this study. Audit is becoming increasingly necessary in surgical practice, not only for research purposes, but also to monitor performance. The design can be broad, to identify groups of patients for further study, or narrow, to concentrate on a particular problem. Someone must be responsible for checking the completed forms for accuracy before the data are entered into the computer. It is important that the form be as simple as possible. Forms which are too detailed will be filled in inaccurately or not at all