Staged pendulous-prostatic anastomotic urethroplasty followed by reconstruction of the anterior urethra: an effective treatment for long-segment bulbar and membranous urethral stricture

OBJECTIVES: To describe a novel surgical technique for male long-segment urethral stricture after pelvic trauma using the intact and pedicled pendulous urethra to replace the bulbar and membranous urethra, followed by reconstruction of the anterior urethra. METHODS: Two patients with long-segment post-traumatic bulbar and membranous urethral strictures with short left pendulous urethras who had undergone several failed previous surgeries were treated with staged pendulous-prostatic anastomotic urethroplasty followed by reconstruction of the anterior urethra. This procedure was divided into three stages. First-stage surgery was mobilization of the anterior urethra down to the coronary sulcus and then rerouted to the prostatic urethra followed by pendulous-prostatic anastomotic urethroplasty with transposition of the penis to the perineum. Second-stage surgery was transecting the anterior urethra at the revascularised coronary sulcus 6 mo later, followed by straightening of the penis and urethroperineostomy. Third-stage surgery was reconstruction of the anterior urethra 6 mo later. RESULTS: Postoperatively, the two patients reported satisfactory voiding. For patient 1, retrograde urethrography showed that the urethra was patent, and that the mean maximal flow rate (MFR) was 18.4 ml/s with no postvoiding residual urine after the third-stage surgery and at 3-yr follow-up. For patient 2, a 22F urethral catheter could pass smoothly through the urethra, and the MFR was 19.5 ml/s with no postvoiding residual urine at 2-yr follow-up. CONCLUSIONS: This procedure was an effective surgical option for men with complex long-segment post-traumatic bulbar and membranous urethral strictures, especially for those who had undergone failed previous surgical treatments.     

前尿道代后尿道成形术治疗男性复杂性后尿道狭窄

目的探讨长段复杂性后尿道狭窄治疗新方法。方法采用分期前尿道代后尿道成形术治疗3例复杂性后尿道长段狭窄（6．5—10．0cm）患者。第一期行阴茎转位尿道端端吻合术，术后3—6个月行二期阴茎伸直、尿道会阴造口术，6个月后行第三期前尿道成形术（Johanson Ⅱ期尿道成形术）。结果例1术后排尿通畅，膀胱尿道造影检查示尿道通畅，双侧输尿管返流近消失，最大尿流率18．8ml／s，随访2年，最大尿流率18ml／s，无剩余尿。例2术后排尿通畅，最大尿流率19．5ml／s，无剩余尿，尿道扩张可顺利通过22F尿道探子。例3经会阴一耻骨联合径路行第一期阴茎转位尿道端端吻合术、尿道直肠瘘、尿道会阴瘘切除、修补术，术后尿道直肠瘘及尿道会阴瘘治愈，但因耻骨联合切口感染致吻合口狭窄，有待进一步治疗。结论分期前尿道代后尿道加前尿道重建方法是治疗男性长段复杂性尿道狭窄的有效方法。     

Radical bulbar dissection to correct severe chordee and proximal hypospadias

PURPOSE: We describe a technique of proximal hypospadias correction that involves freeing the proximal normal bulbar urethra from perineal attachments to lengthen the ventral penis and decrease chordee. MATERIALS AND METHODS: Correction was performed in 9 patients with a mean age of 11.5 months who had proximal hypospadias and severe chordee that was perineal in 2, mid scrotal in 6 and penoscrotal in 1. After the penis was degloved the bulbar urethra was detethered to or beyond the perineal body without lifting the urethra from the corpora cavernosa. Any remaining penile chordee was corrected and the urethral plate was transected only when chordee persisted. When the urethral plate was intact and the penis straight, tubularized incised plate urethroplasty was done to correct hypospadias in 1 stage. Otherwise 2-stage repair was performed. RESULTS: Using this maneuver penile straightening was achieved in 2 of the 9 patients, resulting in a glanular urethral or penoscrotal meatus. Dorsal plication sutures required in 4 cases resulted in a mid shaft and penoscrotal meatus in 1 and 3, respectively. Residual chordee in the remaining 3 patients necessitated division of the urethral plate and 2-stage repair despite aggressive mobilization of the proximal urethra. Simultaneous tubularized incised plate urethroplasty was then performed in the 4 penoscrotal and 1 mid shaft meatus. All 6 patients who underwent a successful 1-stage procedure have excellent cosmetic results, while 1 required meatotomy. No fistula or chordee was present at a mean of 13.8 months of followup (range 3.9 to 27.1). CONCLUSIONS: This safe, rapid technique may compensate for significant penile tethering and chordee in a subpopulation of patients with proximal hypospadias, such as 6 of the 9 in our study. It also allows successful tubularized incised plate urethroplasty to be done simultaneously.     

Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection

OBJECTIVES: We evaluated the applications and outcomes of substitution urethroplasty, using a variety of techniques, in 65 patients with complex, long-segment urethral strictures. METHODS: From January 1995 to December 2005, 65 patients with complex urethral strictures >8cm in length underwent substitution urethroplasty. Of the 65 patients, 43 underwent one-stage urethral reconstruction using mucosal grafts (28 colonic mucosal graft, 12 buccal mucosal graft, and 3 bladder mucosal graft), 17 patients underwent one-stage urethroplasty using pedicle flaps, and 5 patients underwent staged Johanson's urethroplasty. RESULTS: The mean follow-up time was 4.8 yr (range; 0.8-10 yr), with an overall success rate of 76.92% (50 of 65 cases). Complications developed in 15 patients (23.08%) and included recurrent stricture in 7 (10.77%), urethrocutaneous fistula in 3 (4.62%), coloabdominal fistula in 1 (1.54%), penile chordee in 2 (3.08%), and urethral pseudodiverticulum in 2 (3.08%). Recurrent strictures and urethral pseudodiverticulum were treated successfully with a subsequent procedure, including repeat urethroplasty in six cases and urethrotomy or dilation in three. Coloabdominal fistula was corrected only by dressing change; five patients await further reconstruction. CONCLUSIONS: Penile skin, colonic mucosal, and buccal mucosal grafts are excellent materials for substitution urethroplasty. Colonic mucosal graft urethroplasty is a feasible procedure for complicated urethral strictures involving the entire or multiple portions of the urethra and the technique may also be considered for urethral reconstruction in patients in whom other conventional procedures failed.     

Transperineal end-to-end anastomotic urethroplasty for traumatic posterior urethral disruption and strictures in children

OBJECTIVE: To report the long-term results of transperineal end-to-end anastomotic urethroplasty for post-traumatic posterior urethral stenosis in children. METHODS: From 1975 to 1996, 25 boys [aged 3 to 12 years] with post-traumatic posterior urethral stenosis or obliteration, and one boy [aged 7 years] with disrupted posterior urethra were treated with transperineal end-to-end anastomotic urethroplasty. Final follow-up assessments including voiding status, urinary continence and erectile function were performed in June 1999. RESULTS: Smooth voiding was restored in 25 boys postoperatively. one child failed an ill-prepared repair and was waiting for further intervention. Among the 25 patients, seven were lost to the final follow-up. All seven boys had a single urethroplasty for simple urethral stenosis and had been followed for 3 to 5 years postoperatively with smooth voiding. The other 18 boys, including seven with complex urethral stenosis [three with a history of failed previous urethroplasties, three with urethrorectal fistula and one with urethroperineal fistula], underwent a total of 22 end-to-end anastomotic urethroplasties [one successful primary repair, 17 successful delayed repairs and four failed repairs]. Of the 17 patients with successful delayed repair, 14 succeeded with one repair, two with two repairs and one with three repairs. The success rate per repair for simple urethral strictures was 94.7% [18 of 19], and for complex strictures 63.6% [7 of 11]. Stress incontinence was found in three cases, impotence in two. Concomitant impotence and stress incontinence were found in one of the five patients.CONCLUSION: Transperineal end-to-end anastomotic urethroplasty can achieve good long-term outcomes in children with simple post-traumatic posterior urethral stenosis. In experienced hands, good results can also be achieved for complex urethral strictures.     

Dorsal on-lay preputial graft urethroplasty for anterior urethra strictures repair

Objectives To report the long-term results and evaluate the effectiveness of the dorsal on-lay preputial graft urethroplasty in patients suffering from anterior urethra strictures. Methods A total of 21 male patients, mean age 46.3 years (range 17–67), with anterior urethral strictures, underwent the dorsal on-lay preputial graft urethroplasty during the last 8 years, from October 1997 to September 2005. Strictures were located in bulbar urethra in 16 patients and in penile urethra in the remaining 5. The aetiology the stricture was traumatic injury of the anterior urethra in 12 patients and iatrogenic in 9 patients.␣A direct vision dorsal urethrotomy and the insertion of an urethral Foley catheter right before the procedure, facilitated the corpus spongiosum dissection and the preparation for urethroplasty. A voiding cystogram was performed on the day of urethral catheter removal to exclude extravasation and estimate the postoperative result. Results Mean follow-up time has been 49.9 months (range 6–95) and the outcome was favourable in 15 patients (71.43%). There were 3 recurrences in penile urethra strictures managed conservatively and three in bulbar urethroplasties, treated with internal urethrotomy followed by urethral dilatations. Conclusion Our results indicate that dorsal on-lay urethroplasty using preputial graft is an easy to learn and perform procedure, and offers the patient durable␣results with rather minimal complications.     

A method for the surgical treatment of extended strictures of the anterior urethra

The original one-staged technique was reported a success in two patients with long (8 and 10 cm) strictures of anterior urethra. In line with the dissection of stenosed parts and the following ureteroureteral anastomosis, a circular reduplication of tunica albuginea penis was made and invaginated in presence of intact spongy bodies. The given technique of urethroplasty (in patients with urethral stenosis from 3 to 10 cm) prevented penile distortion and anastomosis tension, and therefore the relapse of strictures and obliteration of urethra, as well as urinary fistula development. The advantages of the method are a 2-3-fold decrease in the treatment duration and the preservation of the copulative function despite the shortening of the penile body.     

成人尿道下裂分期手术探讨

目的:探讨成人尿道下裂分期手术的必要性,提高成人尿道下裂的手术成功率。方法:回顾性分析我院泌尿外科2004年1月至2012年1月收治成人尿道下裂患者52例。52例男性患者,平均年龄22岁,所有患者过去均有尿道成形手术史,患者局部阴茎皮肤有瘢痕组织,均有阴茎下弯。术中行阴茎包皮脱鞘切除腹侧瘢痕纤维索带切断尿道板,仍存在阴茎下弯患者行阴茎背侧海绵体白膜折叠伸直阴茎,伸直阴茎后前尿道缺损长度占阴茎长度比例大于50%。根据术中是否行分期手术将患者分为两组,1组(20例)患者行I期包皮带蒂皮瓣卷管术尿道成型,2组(32例)患者阴茎伸直后将整个阴茎多余包皮转移至腹侧,做成形缝合为II期尿道成型预留尿道板,6¹2个月后行阴茎腹侧皮管卷管尿道成形术。结果:两组患者分别在Ⅰ期和Ⅱ期尿道成形术后发生尿瘘比例为50%、21.9%,尿道狭窄15%、9.4%,伤口感染30%、25%,尿道裂开20%、12.5%,尿道成形手术成功率分别为25%、56.3%。两组尿道成形术后发生尿瘘和尿道成形成功率的差异有统计学意义(P<0.05),术后发生尿道狭窄、伤口感染及尿道裂开并发症的差异无统计学意义。结论:对有尿道下裂手术史的成人患者,尤其对那些阴茎下弯明显,前尿道缺损长且局部包皮材料不足的患者分期手术更适合,Ⅱ期尿道成形的成功率得到提高。     

Comparison of short-term complications between Onlay and Duckett urethroplasty and the analysis of risk factors

Aims

To compare the short-term complications between Onlay and Duckett urethroplasty and to analyze the various risk factors cause the complications.

Methods

The children with hypospadias who underwent treatment with Onlay or Duckett urethroplasty from November 2014 to June 2016 were followed up. The difference in complications between the two groups was analyzed. Moreover, a single-factor ANOVA was performed to analyze the length and curvature of the penis and the length of the urethral defect.

Results

40 patients were treated by Duckett, while 54 by Onlay. In comparison to the Onlay group, the Duckett group showed the initial penile length was shorter (P?=?0.044), the initial urethral defect (P?=?0.024) and after the correction of chordee was longer (P?<?0.001), and the initial penile curvature (P?<?0.001) and after degloving (P?<?0.001) was greater. Furthermore, the incidence of urethra percutaneous fistula (P?=?0.041) and urethral stenosis (P?<?0.001) in Duckett group was significantly higher. The analysis of risk factors showed that the age at the time of surgery, the initial penile curvature, the initial urethral defect, and the urethral defect after the correction of chordee were not correlated with the complications. The degree of penile curvature after skin degloving and urethra stenosis was significantly correlated (P?=?0.019).

Conclusion

The incidence of complications of urethra percutaneous fistula and urethral stenosis after 1 year of Duckett was higher than that by Onlay approach. The greater the curvature of the penis after skin degloving, the more likely the occurrence of urethral stenosis after surgery.

     

尿道板矫形术治疗先天性尿道下裂11例报告

目的:探讨尿道板矫形术对阴茎型尿道下裂进行I期修复的疗效。方法:沿尿道板两侧,绕尿道口呈U形切开,留取尿道板皮肤0.8cm以上,分离尿道板,切除白膜外的纤维组织,伸直阴茎,将尿道板固定于阴茎白膜上,形成尿道板皮条,留置F10～12硅胶支架管,新尿道开口于阴茎头,转移背侧包皮皮肤覆盖创面,膀胱造瘘,支架管保留2周。结果:11例阴茎型尿道下裂,阴茎伸直满意;有3例合并尿瘘,其中1例自愈,2例经手术修补,尿瘘痊愈。9例尿道开口于冠状沟。结论:该方法矫正阴茎型尿道下裂方法较简单,效果好,有较好的应用价值;但尿道口的整复尚待进一步探讨。     

Chordee without hypospadias: experience with 33 cases.

We treated 33 patients 6 months to 19 years old with penile chordee without hypospadias from 1966 to 1990. In all cases the penile shaft was degloved, the urethra was widely mobilized and chordee was resected. The shaft skin then was closed, usually using Byars' flaps to shift some preputial skin ventrally. This method sufficed to straighten the penis in 10 patients. In 3 patients urethral mobilization plus placement of a dermal graft to the shaft accomplished straightening of the penis. A total of 20 patients also required lengthening of the penile urethra. Lengthening was done with a graft taken from the prepuce in 14 patients, bladder in 2 and arm in 4. Four of those patients also required a dermal graft to the shaft. There were 8 complications in 7 patients, including anastomotic stenosis, ballooning of a graft, balanitis xerotica obliterans in a graft, urethral fistula and persistent chordee. Reoperation corrected each complication. All end results were satisfactory.     

尿道下裂术后尿道狭窄在青春期后的处理经验(附71例报告)

目的:探讨尿道下裂术后尿道狭窄在青春期后的处理经验。方法:回顾性分析2015年1月至2019年12月上海交通大学附属第六人民医院收治的71例青春期后就诊的尿道下裂术后尿道狭窄患者的临床资料。年龄平均27.7(12～65)岁;病程平均33.4(1～240)个月。既往手术次数平均2.5(1～9)次;尿道异位开口32例,其中...     

复杂性尿道下裂修复失败后的治疗

目的 探讨不同游离黏膜、带蒂皮瓣或二种组织拼接尿道成形术治疗复杂性尿道下裂修复失败后病例的效果.方法 采用3种游离黏膜或带蒂阴茎皮瓣尿道成形治疗尿道下裂修复失败后患者36例,其中带蒂阴茎皮瓣尿道成形7例,舌黏膜与阴茎皮瓣拼接重建尿道3例.结肠黏膜重建尿道2例,1条舌黏膜重建尿道9例,1条颊黏膜重建尿道7例,采用2条口腔内黏膜拼接重建尿道8例.阴茎用弹力绷带包扎4 d,每天用抗生素液冲洗尿道1次.结果 36例术后随访3～84个月,平均32.6个月.术后2～3周发牛尿瘘4例.术后2～3个月新尿道发生狭窄3例,其中吻合口狭窄1例.经尿道扩张5次后排尿通畅;尿道外口狭窄2例,经手术矫正后均排尿通畅,Q_(max)分别为37.3和28.7 ml/s.余者排尿通畅,尿线粗,Q_(max) 18.0～46.0 ml/s,平均26.8 ml/s.结论 舌黏膜与颊黏膜具有取材方便、创伤小的特点,较适合于尿道下裂修复失败后皮源少患者的尿道重建.     

游离黏膜尿道成形治疗硬化性苔藓样病所致尿道狭窄的疗效观察

目的 提高对硬化性苔藓样病( lichen sclerosus,LS)导致尿道狭窄的认识,观察游离黏膜尿道成形治疗LS所致尿道狭窄的疗效. 方法 2007年1月-2010年12月收治LS所致前尿道狭窄患者36例,年龄27～75岁,平均41岁.尿道狭窄段长5.0 ～20.0 cm,平均11.5 cm.根据尿道狭窄段长短和严重程度选择不同的黏膜组织,其中行口腔内黏膜(舌、颊黏膜)尿道成形27例,结肠黏膜尿道成形8例,另1例老年患者行前尿道劈开.在行尿道重建术前对病变累及的阴茎头、尿道口、尿道行病理学检查. 结果 36例患者术后3周拔除导尿管,排尿通畅;活检结果提示上皮基底部特征性病变,过度角化,上皮层变薄,淋巴细胞浸润等.术后随访6 ～ 50个月,平均22个月.出现尿道外口狭窄3例(8.3％),其中口腔内黏膜尿道成形者2例,结肠黏膜重建尿道者1例,行尿道外口切开后排尿通畅.余患者术后排尿通畅,最大尿流率17.2～47.0 ml/s,平均23.4 ml/s. 结论 采用游离黏膜尿道成形治疗LS所致尿道狭窄疗效较好,但需密切随访,因病变迁延可致尿道再狭窄,尤其是尿道口再狭窄.     

Urethroplasty for refractory anterior urethral stricture.

PURPOSE: We present our results managing anterior urethral strictures previously treated with urethroplasty and/or urethrotomy. MATERIALS AND METHODS: During a 32-month period 69 males 10 to 76 years old (mean age 36) underwent treatment for anterior urethral stricture, including 32 (46%) and 26 (38%) previously treated with urethroplasty and urethrotomy, respectively. In 11 patients (16%) no previous procedures had been done. Anastomotic and dorsal patch urethroplasty was performed for bulbar stricture in 13 and 14 cases, respectively, while in 4 a penile skin flap was placed for penile stricture and in 38 a 2-stage procedure was done with urethral substitution using buccal mucosa or post-auricular skin grafts. Patients were followed with ascending urethrography at 3 weeks, and 12 and 18 months as well as with uroflowmetry. Symptoms were assessed for 6 months to 4 years. RESULTS: Only 1 stricture recurred in patients treated with anastomotic or patch urethroplasty, or a skin flap. Of the patients scheduled for a 2-stage procedure stage 1 revision was required due to graft scarring or stenosis at the urethrostomy site in 21% and stage 2 revision was required in 23%. Other complications in this series included fistula in 3% of cases, wound infection in 3% and post-void dribbling in 12%. CONCLUSIONS: Overall early results are good in our urethroplasty series in patients with a previously instrumented urethra. Patients should be advised of the possible need for multiple revisions of planned staged procedures. The increased rate of revision in these staged procedures compared with the excellent outcome of 1-stage procedures appears to be inherent in this operation in patients with multiple previous procedures rather than due to surgeon experience.     

Congenital penile curvature (chordee without hypospadias)

We treated 30 patients aged six months to nine years with congenital penile curvature from 1988 to 1993. Twenty-four patients appeared to have a primary curvature with normal corpus spongiosum. In 12 of these 24 patients dissecting skin and dartos fascia were adequate to straighten the penis. In the other 12 patients, artificial erection demonstrated a varied degree of convexity of the penis after the skin and dartos fascia release, implying a disproportion of the corpora cavernosa bodies. We corrected this deformity using dorsal tunica albuginea plications (TAP). The remaining 6 patients presented with a primary curvature and hypoplastic urethra. In 5 of these patients we divided the hypoplastic midportion of the urethra leaving the meatus naturally on the glans and replaced the midurethral segment using a tubularized island flap. Of these 5 patients 2 required TAP for penile straightening. The final patient with a hypoplastic urethra was managed by preserving the urethral plate and applying an onlay island flap urethroplasty. Complications were one fistula and two mild ventral penile curvatures, presently not severe enough for reoperation (mean follow-up 2.6 years). We present a systematic approach for the repair of congenital penile curvature using intraoperative artificial erection, TAP, and the island flap urethroplasty when needed.     

结肠黏膜尿道成形治疗复杂性超长段尿道狭窄的长期疗效

目的 观察结肠黏膜尿道成形术治疗复杂性超长段尿道狭窄的长期效果和影响因素. 方法 2000年10月至2009年9月采用结肠黏膜尿道成形治疗复杂性超长段尿道狭窄46例.年龄17 ～70岁,平均39岁.尿道狭窄段长10.0～20.0 cm,平均15.2 cm.术前有平均2.7次不成功的尿道修复史.通过定期门诊或电话随访进行术后疗效评估,包括排尿情况和尿流率检查,部分患者行尿道造影和尿道镜检查等.以不需要任何处理包括尿道扩张,能正常排尿,尿流率在正常范围内者视为手术成功. 结果 结肠黏膜重建尿道的长度为11.0～21.0 cm,平均15.4 cm.1例失访,余45例随访20～120个月,平均62个月.发生与手术相关的并发症4例(8.9％),其中3例于术后3、8和24个月发生尿道外口狭窄,1例术后29个月发生结肠黏膜新尿道与尿道近端吻合口狭窄.另2例发生与结肠黏膜尿道成形术无关的尿道狭窄. 结论 结肠黏膜尿道成形术治疗复杂性超长段尿道狭窄术后长期效果理想;影响术后效果的因素是尿道口狭窄和吻合口狭窄.     

纵行阴茎腹外侧肉膜瓣在远端尿道下裂Ⅰ期修复术中的应用

目的:探讨阴茎纵行腹外侧肉膜瓣在远端尿道下裂Ⅰ期修复术中的应用价值。方法:对55例阴茎远端型尿道下裂患者先行尿道板纵切卷管尿道成形术(TIP)修复尿道,然后采用阴茎纵行腹外侧阴茎肉膜瓣对修复新尿道进行覆盖。结果:55例患者均获得类似包皮环切术后样外观,尿道外口开口于阴茎头顶端呈裂隙状;仅4例(7.3%)于冠状沟处发生尿道瘘。结论:在远端尿道下裂Ⅰ期修复术中,以阴茎纵行腹外侧肉膜瓣对新尿道加以覆盖,能有效降低尿道瘘的发生率,且修复后阴茎获得类似包皮环切术后样外观。     

Dorsal or ventral placement of the preputial/penile skin onlay flap for anterior urethral strictures:does it make a difference?

OBJECTIVE: To report our experience in managing complex anterior urethral strictures with a dorsally/dorsolaterally placed penile/preputial vascularized flap, and to discuss the advantages of this procedure over a traditional ventrally placed flap. PATIENTS AND METHODS: Between 1995 and 1999, 40 patients (mean age 40.5 years) with recurrent strictures of the pendulous and/or bulbar urethra were treated with longitudinal penile/circumpenile flap substitution urethroplasty. Nineteen patients underwent dorsal placement of the flap as an onlay (DO), whereas 21 patients had a ventral onlay (VO). Five patients needed inferior pubectomy to facilitate high proximal placement of the flap. RESULTS: Both groups had statistically similar ages, number of previous interventions, stricture site, length and follow-up. After a median follow-up of 27.5 months, the stricture recurred in three (24%) of the VO and two (11%) of the DO groups (P > 0.05). One patient in the VO group required surgical closure of the urethral fistula. Flap pseudo-diverticulum and/or sacculation with postvoid dribble occurred in six patients in the VO and none in the DO group (P = 0.01). CONCLUSIONS: Dorsal placement of the pedicled flap is anatomically and functionally more appropriate than the traditional VO placement. DO preputial/penile flap urethroplasty is a versatile procedure and can be applied even for long anterior urethral strictures, including reconstruction of the meatus and high proximal bulbar strictures.     

Standing the test of time: the long-term results of urethroplasty

The principle indication for urethral surgery is stricture disease. There are a number of factors that influence the outcome of surgery including location of the stricture, stricture length, aetiology, previous surgery and selection of procedure. Outcomes for different techniques are summarised. The gold standard remains anastomotic urethroplasty, where appropriate, with patch urethroplasty or two-stage stage procedures for more complicated strictures especially the penile urethra.