Complex posterior urethral disruptions: management by combined abdominal transpubic perineal urethroplasty

PURPOSE: We present our short-term results of abdominal transpubic perineal urethroplasty for complex posterior urethral disruption. MATERIALS AND METHODS: From January 2000 to March 2005, 21 patients with complex posterior urethral disruption underwent abdominal transpubic perineal urethroplasty. Complex disruption was defined as stricture gap exceeding 3 cm or associated perineal fistulas, rectourethral fistulas, periurethral cavities, false passages, an open bladder neck or previous failed repair. Preoperative voiding cystourethrogram with retrograde urethrogram and cystourethroscopy were done to evaluate the stricture and bladder neck. Followup consisted of symptomatic assessment and voiding cystourethrogram. RESULTS: There were 11 adults and 10 prepubescent boys with an average age of 26 years (range 6 to 62). Mean followup +/- SD was 28 months (range 9 to 40). Mean stricture length was 5.2 +/- 1.4 cm. Of the 21 patients 12 had previously undergone failed urethroplasty. The mean period between original trauma/failed repair and definitive repair was 10.2 +/- 4.3 months. Urethroplasty was achieved through the subpubic route in 16 patients, while 5 required supracrural rerouting. In 20 of 21 patients (95%) postoperative cystourethrography showed a wide, patent anastomosis. Postoperative incontinence developed in 2 of 21 patients (9.5%). Seven of the 21 patients (33%) were impotent after the primary injury, while 3 of 14 (21.4%) had impotence postoperatively. There were no complications related to pubic resection, bowel herniation or periurethral cavity recurrence. CONCLUSIONS: Combined abdominal transpubic perineal urethroplasty is a safe procedure in children and adults. It allows wide exposure to create a tension-free urethral anastomosis without significantly affecting continence or potency. Complications of pubic resection are now rarely seen.     

口颊黏膜在尿道重建中的应用

随着尿道重建技术的不断改进,口颊黏膜替代尿道成形术逐渐成为前尿道缺损修复的最佳选择。本文主要对口颊黏膜的优势特点作一介绍,并阐述口颊黏膜替代尿道成形术在前尿道狭窄和尿道下裂中的临床应用和进展。     

Evaluation of erectile function after urethral reconstruction: a prospective study

We conducted a prospective study of erectile dysfunction (ED) after urethral reconstructive surgery, using the 5-item International Index of Erectile Function (IIEF-5), the Sexual Life Quality Questionnaire (SLQQ) and the Quality of Life Questionnaire (QoLQ). Between January 2003 and July 2007, 125 male patients with urethral strictures underwent urethroplasty, and pre- and post-surgery erectile function was assessed using these three questionnaires. A formula to predict the probability of ED after urethroplasty was derived. At 3 months post-operatively, there was a significant decrease in IIEF-5 (16.57 ± 7.98) and SLQQ scores (28.71 ± 14.84) compared with pre-operative scores (P < 0.05). However, the IIEF-5 scores rebounded at 6 months post-operatively (17.22 ± 8.41). Logistical regression analysis showed that the location of the urethral stricture, the recurrence of strictures and the choice of surgical technique were predictive of the post-operative occurrence of ED. This study identified the clinical risk factors for ED after urethroplasty. Posterior urethral stricture and end-to-end anastomosis were found to have a strong relationship with erectile function. The logistical model derived in this study may be applied to clinical decision algorithms for patients with urethral strictures.     

Treatment of pelvic fracture-related urethral trauma: a survey of current practice in the UK

OBJECTIVE: To quantify experience of pelvic fracture-related urethral trauma (PFUT), a condition not often encountered and managed by urologists. METHODS: The consultant urologists of the UK and Ireland were contacted informally to establish their experience with PFUT and its management, both immediate and delayed. In addition, particular individuals thought to have a specific interest in PFUT were targeted for more data. RESULTS: The overall response rate was 49% (235 responders), representing 78% of urological departments, including all the targeted individuals. Of the responders, 129 (55%) had never seen PFUT in 1-25 years of consultant practice. Only four urologists (2% of responders) saw three or more cases a year. Another four (2%) saw one or two cases per year and the remaining 98 (41%) saw PFUT less frequently. Acutely, 69% of urologists who treated PFUT did so by placing a urethral catheter. Subsequent strictures were treated endoscopically for as long as this was possible. The other 31% inserted a suprapubic catheter and referred the patient for reconstructive surgery if needed. Those who used urethroplasty for strictures after PFUT were identified and targeted; half used urethral mobilization and spatulated anastomosis alone. Only three surgeons performed more than five procedures a year. CONCLUSION: Whatever a specialist reconstructive unit might do, practice in the wider urological community is different. Even within specialized units, PFUT is rare and the surgical management is often significantly different from published 'expert' opinion.     

Urethroplasty for urethral strictures: Quality assessment of an in‐home algorithm

Objectives: To evaluate the outcome of different techniques of urethroplasty and to assess the quality of an in‐home algorithm. Methods: Two hundred fifty‐two male patients underwent urethroplasty. Mean patient's age was 48 years (range 1–85 years). Data were analyzed for the failure rate of the different techniques of urethroplasty. An additional analysis was done based on an in‐home algorithm. Results: Median follow up was 37 months (range: 6–92 months). Global failure rate was 14.9%, with an individual failure rate of 11.7%, 16.0%, 20.7% and 20.8% for anastomotic repair, free graft urethroplasty, pedicled flap urethroplasty and combined urethroplasty, respectively. In free graft urethroplasty, results were significantly worse when extrapreputial skin was used. Anastomotic repair was the principle technique for short strictures (83.3%), at the bulbar and posterior urethra (respectively 50.8 and 100%). Free graft urethroplasty was mainly used for 3–10 cm strictures (58.6%). Anastomotic repair and free graft urethroplasty were more used in case of no previous interventions or after urethrotomy/dilation. Pedicled flap urethroplasty was the main technique at the penile urethra (40.7%). Combined urethroplasty was necessary in 41 and 47.1% in the treatment of, respectively, >10 cm or panurethral/multifocal anterior urethral strictures and was the most important technique in these circumstances. Two‐stage urethroplasty or perineostomy were only used in 2% as first‐line treatment but were already used in 14.9% after failed urethroplasty. Conclusion: Urethroplasty has good results at intermediate follow up. Different types of techniques must be used for different types of strictures.     

U-shaped prostatobulbar anastomosis for urethral injury after pelvic trauma

Background: We describe a technique of U‐shaped bulboprostatic anastomosis for urethral injury after pelvic trauma. Methods: Sixty‐eight male patients were included in our study. Suprapubic cystostomy was carried out initially, followed by U‐shaped prostatobulbar anastomosis after 6–12 weeks. Follow ups were carried out at 6, 12 and 18 months by assessing patient satisfaction rates along with preoperative and postoperative urethrogram, uroflowmetry and labelled as good, fair and poor. The surgical technique used was as follows: after an inverted Y‐shaped skin incision, subcutaneous tissue and Colle’s fascia was opened. Bulbospongiosum was mobilized to gain access to the stricture membranous urethra, which was excised and the bulbar urethra freed. A sound was passed through the suprapubic cystostomy and complete resection of the scar over the tip of the sound was carried out. A silicon catheter was then passed into the bladder and the anastomosis was completed in a ‘U’ shape; that is, there were no stitches from the 10 to the 2 o’clock position. Results: Good and fair results were considered as successful. Overall success rate was 97.05% immediately and after 6 months, but decreased to 95.6% at 12 months and 93.6% at 18 months. Conclusion: U‐shaped end‐to‐end prostatobulbar anastomosis markedly decreases the chance of restenosis and impotence.     

Staged urethroplasty in the management of complex anterior urethral stricture disease

Staged buccal mucosa graft urethroplasty has emerged as a reliable procedure for difficult anterior urethral strictures not amenable to one-stage graft or flap reconstruction. It has primarily been used for strictures and/or fistulae occurring after previous surgery for hypospadias or those related to lichen sclerosus (LS). Success rates in these patient populations have improved when compared to earlier techniques. However, prior studies have demonstrated a number of patients requiring more than two procedures to complete the reconstruction, as well as some who have been content with their voiding pattern after the first operation and therefore elected to forego second stage tubularization. In this setting, we have reviewed the surgical technique and summarized previously published work. There may be an opportunity to complete more of these repairs in two operations using additional oral mucosa at the time of tubularization.     

Reconstruction of urethral erosion in men with a neurogenic bladder

OBJECTIVE

To describe the surgical outcomes and operative technique for reconstructing catheter‐induced urethral erosion in men with a neurogenic bladder.

PATIENTS AND METHODS

This was a prospective study of 11 men (median age 45 years, range 26–52) who had elective urethroplasty for urethral erosion between 2004 and 2007 by one surgeon (C.M.G.). All men had a diagnosis of neurogenic bladder and indwelling catheter‐induced urethral erosion. Reconstructive techniques included primary closure in six men, substitution urethroplasty with a penile skin graft in three, penile skin flap in one and a buccal mucosa graft in one. A two‐stage approach was used in one man.

RESULTS

The median (range) length of erosion from the meatus before surgery was 6 (4–10) cm. The repair was successful in seven men at a mean (range) follow‐up of 25 (8–46) months. Of those with recurrence of erosion, the median length of the resultant defect was 2 (2–3) cm. All recurrences were in the first five patients of this series. The median time to recurrence of erosion was 1 month and recurrence did not appear to be related to any particular surgical technique. Urethral catheter traction after surgery appeared to be one of the factors related to repair breakdown.

CONCLUSION

The reconstruction of catheter‐induced urethral erosion in men with a neurogenic bladder is feasible. Primary closure appears to be the best reconstructive method for urethral erosion, and avoiding catheter traction after surgery contributes to successful urethroplasty.     

切断尿道口保留并加长尿道板尿道成形术治疗尿道下裂的初步研究

目的:探讨用切断尿道口保留并加长尿道板尿道成形术治疗尿道下裂的可行性。方法:选择尿道下裂患者48例,其中冠状沟下型18例,阴茎体型21例,阴囊阴茎交界型8例,阴囊型1例,采用切断尿道口保留并加长尿道板尿道成形术治疗,并观察其术后效果。结果:术后随访6～27个月,一期手术成功44例,2例出现尿瘘,2例出现尿道狭窄,尿瘘以及尿道狭窄均再次治疗而治愈。阴囊阴茎外观满意,阴茎伸展自如。结论:切断尿道口保留并加长尿道板尿道成形术是操作简单,安全有效的术式,可广泛应用于治疗尿道下裂。     

Objective assessment of urinary incontinence after successful implantation of the ams artificial urethral sphincter

We selected 34 patients who had been fitted with the AMS artificial sphincter (models 742, 791, 792) in 1978–1982, who claimed to have a satisfactory result and compared their subjective feeling of continence to the objectively measured urine loss by a 1-hour padweighing test. Furthermore, we related the measured urine loss to the position and size of the cuff and the balloon pressure; 19 patients claimed to be completely dry, ten patients experienced varying degrees of incontinence with physical activity, and five patients did wear some kind of protection, but all patients were satisfied with the operation. The results of the pad-weighing test showed that 22 patients were completely dry and 12 patients had some measurable urine loss. Patients with an artificial sphincter at the bladder neck had better continence than patients with the sphincter at the bulbous urethra, possibly because of a better transmission of pressure to the cuff from the abdominal cavity. The level of the closure pressure in the balloon in patients with sphincters at the bladder neck was not significantly related to the amount of urine loss. We conclude that patients might be subjectively satisfied with an artificial sphincter operation despite some objectively measured urine loss and that the subjective feeling of continence correlates fairly well with the objective pad-weighing test. When regarding postimplant continence in isolation the bladder neck position of the prosthesis is superior to the bulbous urethra position.     

Female urethral injuries associated with pelvic fracture: a systematic review of the literature

To review systematically the literature on female urethral injuries associated with pelvic fracture and to determine the optimum management of this rare injury. Using Meta‐analysis of Observational Studies in Epidemiology criteria, we searched the Cochrane, Pubmed and OVID databases for all articles available before 30 June 2016 using the terms ‘female pelvic fracture urethroplasty’, ‘female urethral distraction’, ‘female pelvic fracture urethral injury’ and ‘female pelvic fracture urethra girls.’ Two authors of this paper independently reviewed the titles, abstracts, and articles in duplicate. We identified 162 individual articles from the databases. Fifty‐one articles met our criteria for full review, including 158 female patients with urethral trauma. Of these injuries, 83 (53%) were managed with immediate repair; 17/83 (20%) via primary alignment and 66/83 (80%) via anastomotic repair. The remaining 75/158 (47%) were managed with delayed repair. Rates of urethral stenosis and fistula were highest after primary alignment. Urethral integrity appears to be similar after both primary anastomosis and delayed repair; however, patients experienced significantly more incontinence and vaginal stenosis after delayed repair. Patients who underwent delayed urethral repair were more likely to undergo more extensive reconstructive surgery than those who underwent primary repair. The optimum management of female urethral distraction defects is based on very‐low‐quality literature. Based on our review of the available literature, primary anastomotic repair of a female urethral distraction defect via a vaginal approach as soon as the patient is haemodynamically stable appears to be optimal.     

Con: bulbomembranous anastomotic urethroplasty for pelvic fracture urethral injuries

Current literature remains controversial regarding whether to treat patients sustaining pelvic fracture urethral injuries (PFUIs) with primary endoscopic realignment (PER) versus suprapubic tube (SPT) placement alone with elective bulbomembranous anastomotic urethroplasty (BMAU). Success rates for PER following PFUI are wide-ranging, depending on various authors’ definitions of what defines a successful outcome. At our institution, for SPT/BMAU patients, the mean time to definitive resolution of stenosis was dramatically shorter compared to PER cases. The vast majority of PER patients required multiple endoscopic urethral interventions and/or experienced various other adverse events which were rarely noted among the SPT/BMAU group. While PER does occasionally result in urethral patency without the need for further intervention, the risk of delay in definitive treatment and potential for adverse events has led to a preference for SPT and elective BMAU at our institution.     

Unstable urethral pressure: Toward a more relevant definition

There is confusion in the literature over the use of the terms unstable urethra and unstable urethral pressure, which are often held inappropriately to be synonymous. The importance of the former condition, as a cause of incontinence, is beyond doubt, although it appears to be an uncommon condition; the finding of unstable urethral pressure is reported much more frequently, although its clinical significance remains in debate. An analysis of urethral pressure recordings in a group of 131 women with urodynamically proven genuine stress incontinence, and 14 urodynamically normal women entirely free from urinary symptoms has been carried out in an attempt to define the differences between the two and thus to establish a more clinically relevant definition for the phenomenon of “unstable urethral pressure.” The variation in urethral pressure was calculated first in absolute terms, as the variation in cm H₂O above and below the mean maximum urethral closure pressure (MUCP), and second in relative terms, as a percentage of the mean MUCP itself; these two parameters are described as “delta-MUCP (absolute)” and “delta-MUCP (relative),” respectively. The mean delta-MUCP (absolute) values were 9.5 and 13.4 cm H₂O for the symptomatic and control groups, respectively (not significant); the mean delta-MUCP (relative) values were 27.0% and 17.1% of the MUCP (p < 0.001). Examination of various potential points of discrimination for the diagnosis of “unstable urethral pressure” showed a delta-MUCP (relative) of 30% to be the best discriminator, allowing the identification of a subgroup of stress incontinent women whose urethral pressure variation was likely to be of relevance in the determination of symptoms.     

尿道狭窄3种术式手术前后勃起功能状态的临床研究

目的:对3种术式治疗尿道狭窄患者手术前后勃起功能状态进行研究。方法:分别采用3种术式对126例尿道狭窄男性患者进行治疗。35例患者接受尿道狭窄部位阴茎皮瓣重建术,52例患者接受尿道端端吻合术,39例患者接受内窥镜下尿道内切开术。通过电话随访、面访方式,采用国际勃起功能指数问卷(IIEF-5)评分对每组患者术前、术后勃起功能的总体情况进行评价,同时利用夜间阴茎胀大实验(NPT)对患者进行诊断。结果:行尿道狭窄部位阴茎皮瓣重建术组IIEF-5评分术前与术后分别为(17.1±2.6)分和(13.5±4.5)分;行尿道端端吻合术组IIEF-5评分术前与术后分别为(17.1±3.0)分和(11.1±4.8)分;行尿道内切开术组IIEF-5评分术前与术后分别为(17.6±2.2)分和(14.5±4.4)分。与术前相比,3组患者术后IIEF-5评分均显著下降,其差异具有统计学意义(P0.05)。上述3种术式术后勃起功能障碍发生率分别为8.57%(3/35)、26.92%(14/52)、10.26%(4/39),尿道端端吻合术显著高于其他2种术式(P均0.05)。结论:3种术式治疗尿道狭窄术后IIEF-5评分均有所下降,与尿道端端吻合术相比,尿道狭窄部位阴茎皮瓣重建术与尿道内切开术术后勃起功能障碍的发生率较低,应注重对适宜术式的选择以确保对患者性功能的有效保护。     

The diagnosis and management of acquired urethral stricture disease

Urethral stricture disease is a commonly presenting problem to the urologist. Any condition that damages the urethral epithelium or underlying spongy tissue has the potential to cause a stricture. Patients with a urethral stricture can present either acutely or chronically with a range of urinary symptoms. An understanding of urethral stricture disease and a systematic approach to the history and investigations will enable clinicians to manage patients appropriately. This article aims to give an overview, appropriate for surgeons in their early years of training, on the aetiology, presentation and investigation of urethral stricture disease, as well as a basic understanding of the principles of management.