Internal urethrotomy and intraurethral submucosal injection of triamcinolone in short bulbar urethral strictures

Objectives

In clinical practice, internal urethrotomy is an easy procedure and is offered as a first modality for treatment of short urethral strictures. Internal urethrotomy refers to any procedure that opens the stricture by incising or ablating it transurethrally. The most common complication of internal urethrotomy is stricture recurrence. The curative success rate of internal urethrotomy is approximately 20%. Triamcinolone has antifibroblast and anticollagen properties. This study evaluated the efficacy of triamcinolone in the prevention of anterior urethral stricture recurrence after internal urethrotomy.

Methods

Fifty male patients with anterior urethral stricture were randomized to undergo internal urethrotomy with or without urethral submucosal injection of triamcinolone. Using general anesthesia urethrotomy was performed. Triamcinolone (40 mg) was injected submucosally at the urethrotomy site in 25 patients. The patients were followed for at least 12 months and the stricture recurrence rate was compared between the two groups.

Results

23 patients in the triamcinolone group and 22 in the control group completed the study. There were no significant differences in the baseline characteristics of the patients or the etiology of the stricture between the two groups. Mean follow-up time was 13.7 ± 5.5 months (range: 1–25 months). Urethral stricture recurred in five patients (21.7%) in the triamcinolone group and in 11 patients (50%) in the control group (P = 0.04).

Conclusions

Injection of triamcinolone significantly reduced stricture recurrence after internal urethrotomy. Further investigations are warranted to confirm its efficacy and safety.     

Traitement des sténoses de l’urètre par urétrotomie interne endoscopique: résultats anatomiques et fonctionnels d’une série de 244 cas

Objective

To evaluate the results of a homogeneous series of urethral strictures treated exclusively by endoscopic internal urethrotomy and to determine the factors that may predict the outcome.

Patients and Methods

Between 1989 and 2007, 244 patients were treated for urethral stricture. All of them were subjected to endoscopic direct vision internal urethrotomy (DVIU).

Results

34.3% of good results were achieved after the first DVIU. Mean follow-up was 3.5 years. No mortality was encountered, while the rate of morbidity was 5%. Better results were achieved in patients with short (< 2 cm) and single strictures in the proximal urethra. Mean post-operative catheterization was 2 days; a further extension of the catheterization time did not yield any significant improvement. Unsatisfactory results (65.5%) were found in patients with large urethral strictures located in the distal urethra or in elderly patients. 62.5% of the patients showed a satisfactory outcome after a second urethrotomy, while the other patients required urethral dilatation or urethroplasty.

Conclusion

DVIU is a simple procedure which does not have a high rate of morbidity and requires short hospitalization. With a steady success rate of around 75.4% after a follow-up of 3.5 years we feel that DVIU can be recommended as treatment of choice for all short, single and proximal urethral strictures, preferably in young patients without previous interventions on the urethra     

Normal anatomy of urethral sphincter complex in young Chinese males on MRI

Purpose

In this research, the normal anatomy of urethral sphincter complex in young Chinese males has been studied.

Methods

The sagittal, coronal, and axial T2-weighted non-fat suppressed fast spin-echo images of pelvic cavities of 86 Chinese young males were studied.

Result

Urethral sphincter complex is a cylindrical structure surrounding the urethra and extending vertically from bladder neck to perineal membrane. Urethral striated sphincter covers the anteriolateral urethra like a hat from bladder neck to verumontanum, while it surrounds the urethra in a ring shape from verumontanum to perineal membrane and backwards ends in central tendon of the perineum. From bladder neck to perineal membrane, the thickness of urethral smooth sphincter decreases gradually, and it extends forward to surround urethra with urethral striated sphincter as a ring. The length of urethral striated sphincter is 12.26–20.94 mm (mean 16.59 mm) at membranous urethra: 27.88–30.69 mm (mean 28.99 mm) from verumontanum to perineal membrane. The thickness of striated sphincter at membranous urethra is 4.29–6.86 mm (mean 5.56 mm) for the muscle of the anterior wall and 2.18–2.34 mm (mean 2.26 mm) for the muscle of the posterior wall.

Conclusions

In this paper, we summarized the normal anatomy of urethral sphincter complex in young Chinese males with no urinary control problems.     

Female urethral stricture: a contemporary series

Purpose

To report the etiology, presenting symptoms and outcomes of the different treatments performed in female patients with recurrent urethral stricture.

Materials and methods

Twenty-six patients with refractory LUTS were diagnosed with a urethral stricture. The symptoms, the treatment performed and the outcomes were prospectively recorded. Sixteen patients were treated with a urethroplasty using a buccal mucosal graft (BMG) in 14 cases (54 %) and a vaginal flap in 2 (8 %). Urethral dilatation, optical urethrotomy and meatoplasty were performed in 8 (31 %), 1 (3.8 %) and 1 (3.8 %) patients, respectively.

Results

Strictures were idiopathic in 11 patients (42 %). Previous urethral instrumentation and traumatic vaginal delivery were the commonest causes of urethral stricture (42 and 15 %, respectively). The most frequent symptoms were reduced flow (93 %), detrusor overactivity (50 %) and UTIs (42 %). The stricture was cured in 93 % of patients treated with a BMG urethroplasty and in all the patients in which a vaginal flap urethroplasty was performed. In the same group, the improvement in urethral pain was observed in the 67 and the 88 % of patients were cured from recurrent UTIs. All the patients treated with urethral dilatation needed further dilatations; hence, the cure of the stricture was achieved in none of them. Improvement in urethral pain, UTIs and detrusor activity was not recorded in the latter group.

Conclusion

Urethroplasty in its various forms has demonstrated in the present series the highest cure rate for the treatment of recurrent urethral stricture.

     

Internal Urethrotomy Versus Dilation as Treatment for Male Urethral Strictures: A Prospective, Randomized Comparison

Purpose

We compared the efficacy of dilation versus internal urethrotomy as initial outpatient treatment for male urethral stricture disease.

Materials and Methods

A total of 210 men with proved urethral strictures was randomized to undergo filiform dilation (106) or optical internal urethrotomy (104) with local anesthesia on an outpatient basis.

Results

Life table survival analysis showed no significant difference between the 2 treatments with regard to stricture recurrence. Hazard function analysis showed that the risk of stricture recurrence was greatest at 6 months, whereas the risk of failure after 12 months was slight. The recurrence rate at 12 months was approximately 40% for strictures shorter than 2 cm. and 80% for those longer than 4 cm., whereas the recurrence rate for strictures 2 to 4 cm. long increased from approximately 50% at 12 months to approximately 75% at 48 months. Cox regression analysis showed that for each 1 cm. increase in length of the stricture the risk of recurrence was increased by 1.22 (95% confidence interval 1.05 to 1.43).

Conclusions

There is no significant difference in efficacy between dilation and internal urethrotomy as initial treatment for strictures. Both methods become less effective with increasing stricture length. We recommend dilation or internal urethrotomy for strictures shorter than 2 cm., primary urethroplasty for those longer than 4 cm. and a trial of dilation or urethrotomy for those 2 to 4 cm. long.     

COLOR DOPPLER ULTRASOUND ASSESSMENT OF URETHRAL ARTERY LOCATION: POTENTIAL IMPLICATION FOR TECHNIQUE OF VISUAL INTERNAL URETHROTOMY

Purpose

We assessed the location of urethral arteries in patients with urethral stricture using color Doppler ultrasound.

Materials and Methods

We performed 41 color ultrasound studies of the urethra in 33 patients 17 to 76 years old. The linear array transducer was placed on the ventral surface of the penis and perineum to image the urethra and periurethral structures. In addition of evaluating the extent of stricture disease, color Doppler ultrasound determined the location of the urethral arteries at the segment with stricture.

Results

The number and site of the urethral arteries vary among individuals. Contrary to the common belief that these arteries are located at the 3 and 9 o'clock positions, we have found that in the bulbous urethra the arteries are at the 1 to 2 o'clock positions in 14% of cases, 3 to 4 in 22%, 5 to 6 in 17%, 7 to 8 in 18%, 9 to 10 in 18% and 11 to 12 in 11%. The arteries may be close to the surface of the urethral lumen, especially in patients who have undergone previous urethral procedures. Preoperative evaluation of urethral artery location may be helpful for preventing arterial bleeding at visual internal urethrotomy.

Conclusions

Color Doppler ultrasound can effectively assess the extent of stricture disease and urethral artery sites. Because the location of the urethral arteries varies among patients, individual preoperative assessment is advisable. Color Doppler ultrasound is currently our imaging method of choice for evaluating strictures of the pendulous and bulbous urethra.     

Urethral obstruction from dislodged bladder Diverticulum stones: a case report

Background

Secondary urethral stone although rare, commonly arises from the kidneys, bladder or are seen in patients with urethral stricture. These stones are either found in the posterior or anterior urethra and do result in acute urinary retention. We report urethral obstruction from dislodged bladder diverticulum stones. This to our knowledge is the first report from Nigeria and in English literature.

Case presentation

A 69 year old, male, Nigerian with clinical and radiological features of acute urinary retention, benign prostate enlargement and bladder diverticulum. He had a transurethral resection of the prostate (TURP) and was lost to follow up. He re-presented with retained urethral catheter of 4months duration. The catheter was removed but attempt at re-passing the catheter failed and a suprapubic cystostomy was performed. Clinical examination and plain radiograph of the penis confirmed anterior and posterior urethral stones. He had meatotomy and antegrade manual stone extraction with no urethra injury.

Conclusions

Urethral obstruction can result from inadequate treatment of patient with benign prostate enlargement and bladder diverticulum stones. Surgeons in resource limited environment should be conversant with transurethral resection of the prostate and cystolithotripsy or open prostatectomy and diverticulectomy.     

One-Stage Urethroplasty for Urethral Strictures at the Ladoke Akintola University of Technology Teaching Hospital, Osogbo, South Western Nigeria

Background

Urethral stricture, a common urologic condition, is probably the most common cause of urinary retention in tropical Africa and a frequent cause of lower urinary tract symptoms worldwide. This study aimed at presenting our experience with one-stage urethroplasty at the Ladoke Akintola University of Technology Teaching Hospital Osogbo, Nigeria.

Methods

All male patients who underwent one-stage urethroplasty between December 2005 and December 2011 were studied retrospectively. Details of their presentation and management were reviewed.

Results

A total of 50 patients aged 2–75 years (mean ± SD 44.2 ± 21.53 years) with a urethral stricture underwent one-stage urethroplasty. The modal age group was 61–75 years (26 %). In all, 27 (54 %) patients were >40 years. Strictures following previous urethritis were more common (29, 58 %) than those seen after trauma (21, 42 %). Strictures following trauma were more common in men ≤40 years (52.2 %), and 69 % of strictures in men >40 years were infective in origin. Altogether, 88 % of strictures were exclusively found in the anterior urethra. In all, 32 (64 %) patients had bacteriuria at presentation. Strictures ≥2 cm with extensive fibrosis were noted in 21 (42 %). Excision of scar tissue was done, followed by end-to-end anastomosis in 32 (64 %), penile pedicle flap in 16 (32 %), and buccal mucosal graft in 2 (4 %) of the patients. Wound infection was the most common complication. Overall, 76 % of patients achieved a urine flow rate of 15 ml/s and postvoid residual urine of ≤50 ml.

Conclusions

One-stage urethroplasty offered satisfactory results in the study group. It is recommended for urethral reconstruction in men with urethral stricture.     

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.     

Die Striktur der vesikourethralen Anastomose nach radikaler Prostatektomie

Background

The development of a stricture of the vesicourethral anastomosis is a serious complication after radical prostatectomy. Strictures occur in 5–8% of patients after radical prostatectomy.

Symptoms

Usually the clinical symptoms include an irritative and obstructive component similar to benign prostatic hyperplasia. In rare cases, patients suffer from partial or complete stress incontinence as a result of the anastomotic stricture.

Diagnostics

The diagnostic workup is similar to the procedure for urethral strictures. In addition to uroflowmetry, a cystourethrogram (CUG) or, if necessary, a micturating cystourethrogram (MCU) can be performed. A urethrocystoscopy can be performed to ensure the diagnosis.

Therapy

In most cases, endoscopic procedures were performed for treatment. Beside a transurethral dilation of the stricture or the Sachse urethrotomy, the most common procedure is transurethral resection to treat the stricture. However, all procedures are associated with a high recurrence rate. In recurrent strictures, open surgical procedures, usually a perineal reanastomosis, should performed early.

Conclusion

Endourological procedures like transurethral resection are a good treatment option, but due to the high recurrence rates, open surgical procedures should be discussed and if necessary should be performed early.

     

Endoscopic Evaluation and Treatment of Anastomotic Strictures After Radical Retropubic Prostatectomy

Purpose

We describe endoscopic findings and treatment outcome in 17 men who presented with a symptomatic anastomotic stricture after radical prostatectomy.

Materials and Methods

Endoscopic evaluation revealed an immature stricture in 6 men, which was treated by initial dilation and subsequent cold-knife urethrotomy. The 11 men with a mature anastomic stricture were treated by initial cold-knife urethrotomy (10) or dilation followed by urethrotomy (1).

Results

There were no long-term complications from treatment, which was successful in 15 of the 17 men (88 percent).

Conclusions

Initial dilation with subsequent urethrotomy for immature or initial urethrotomy for mature anastomotic strictures is a safe and effective treatment plan.     

Clinical presentation and treatment of urethral stricture: Experience from a tertiary hospital in Port Harcourt,Nigeria

Introduction

Urethral stricture disease (USD) is a common urological problem. The aetiology of strictures has been changing. Different treatment modalities are available.

Die gestielte Vorhautlappenplastik

Background

Operative interventions of the urethra remain challenging procedures. The vascular onlay flap of the inner prepuce is a possible technique for short and long segment urethral defects.

Patients and methods

A total of 195 patients were surgically treated with a vascular prepuce flap between 1994 and 2010 at the Urology Department of Essen Medical University. Patient data were analyzed retrospectively and a questionnaire was sent to all patients.

Results

Of the patients 115 answered the questionnaires and were included in the study. Of these 61 patients were treated in childhood due to hypospadias and 54 patients suffered from acquired urethral stricture. Major complications were postoperative fistulas in 8.2 % and 7.4 % and hematomas in 6.6 % and 11.1 % of cases, respectively. Operative revision had to be performed in 13.1 % and 14.8 % of cases and severe obstructive micturition problems (IPSS score ≥20) were observed in only 3.3 % and 11.1% of patients, respectively. Subjective overall satisfaction with the result of the operation was high (67.2 % and 88.9 %, respectively).

Conclusion

The vascular prepuce flap is a reliable method for correction of short and long segment urethral defects and is associated with high patient satisfaction.     

Single-stage dorsal inlay for reconstruction of recurrent peno-glandular stenosis

Objective

To evaluate the validity of a single-stage dorsal inlay for recurrent peno-glandular stenosis following previous endourological or open urethroplastic surgery. Urethral glanular reconstruction included a deep dorsal incision followed by complete scar excision to create a deep groove presenting well-vascularized recipient bed ensuring appropriate graft healing.

Materials and methods

Between April 2002 and January 2008, a total of 34 patients (mean age 51.5 years, 14–85 years) were enrolled in the study. Congenital anomalies included hypospadia (n = 19, 53%) and epispadia (n = 2, 6%). Condition of strictures was either iatrogenic (n = 7), due to infection (n = 5), or traumatic (n = 1). Foreskin grafts were used in 13 cases, foreskin and buccal mucosa in one case, penile skin in 6 cases, and inguinal skin/thigh (harvested by electrodermatom) in 14 cases. The combination of meticulous scar excision with a deep incision of the glans was used to provide a well-vascularized grafting bed, thus ensuring excellent graft healing. The outcome analysis included urinary flow, urethral calibration >18 ch, voiding cystometry, and patient’s satisfaction in a follow-up regime every 3 months.

Results

The average graft length was 4.7 cm (median 8, range 1.5–14). Mean follow-up was 70 months. In 31 patients (91%), no recurrent glanular stenosis was observed resulting in a post-operative flow of average 26.2 ml/s (11–53). Three post-operative wound infections occurred resulting in stricture recurrence, which was treated with internal urethrotomy, buccal mucosa, or penile skin inlay, respectively. Cosmetic results were satisfactory in all patients. Post-operative voiding parameters were significantly improved (P < 0.001).

Conclusion

The single-stage dorsal inlay for reconstruction of peno-glandular stenosis represents a reliable method even if the urethral plate is severely scarred or has been excised during previous surgery. The good results imply that a well-vascularized graft and the technical approach seem to be more important than the substitute material.     

The effect of abdominal and pelvic floor muscle activation patterns on urethral pressure

Purpose

Urethral pressure increases during voluntary pelvic floor (PF) muscle contractions in healthy women. As PF and abdominal muscle activity is coordinated, this study aimed to determine whether specific abdominal muscle actions also change urethral pressure.

Methods

Urethral pressures were measured in seven healthy women during lower abdominal in-drawing, abdominal bulging and PF muscle contractions, with the bladder empty and filled to 250 ml. A repeated measures multiple analysis of variance compared vesical, rectal and urethral pressure changes between bladder volumes and the three tasks.

Results

Urethral pressures increased by a similar amount during PF muscle contractions and abdominal in-drawing (p = 0.94) and did not differ between bladder status. During abdominal bulging, urethral pressures decreased by 12.6 (18.2) cmH₂O (full bladder) and 18.1 (11.5) cmH₂O (empty bladder) and were different from the other two manoeuvres (p < 0.001).

Conclusions

This study shows that specific abdominal actions are associated with increased or decreased urethral pressures, consistent with strategies for continence and voiding.     

Simple sling incision for the treatment of iatrogenic bladder outlet obstruction

Introduction and hypothesis

Bladder outlet obstruction (BOO) is reported to occur in 15 % of women after anti-incontinence surgery. In the past, iatrogenic BOO from slings was treated with urethrolysis. However, urethrolysis is not without morbidity, including significant bleeding, urethral injury, and recurrent stress urinary incontinence (SUI). Several studies have shown simple sling incision to be as effective as urethrolysis with less morbidity and lower rates of recurrent SUI. [1–3]

Methods

We demonstrate the technique of transvaginal simple sling incision in two patients, one with a synthetic midurethral sling, and one with a biologic bladder-neck sling.

Results

Simple sling incision is an effective and less morbid treatment than urethrolysis for iatrogenic urethral obstruction; 70–90 % of women will have significant improvement in obstructive voiding symptoms. Recurrent SUI is seen in approximately 20 % of women after sling incision.

Conclusions

This video shows that simple sling incision is an effective, simple, and safe treatment for women with iatrogenic BOO after sling surgery and should be used as a first-line treatment.     

What is the evidence for the management of urethral amyloidosis? A systematic review of the literature

What's known on the subject? and What does the study add? Urethral amyloidosis is rare and urethrotomy has been proposed as a suitable treatment option. By reviewing the literature and comparing our own experiences, we have shown urethroplasty to have good medium term outcomes in patients with urethral amyloidosis, whereas urethrotomy may lead to recurrence.

OBJECTIVE

• ? Urethral amyloidosis (UA) is a rare condition which may be encountered by an urological surgeon. We reviewed the literature regarding the presentation, investigation and management of UA.

PATIENTS AND METHODS

• ? A systematic review of the English literature on PubMed was conducted and we indentified 39 articles which reported 45 patients. We included our experience with four patients from our tertiary centre.

RESULTS

• ? The majority of patients reported symptoms consistent with a urethral structure. Most patients were treated with urethrotomy, only two patients have been reported to have had a urethroplasty in the literature. Medium and long term outcome data is lacking for urethrotomy and urethroplasty. We found recurrence in our patients after urethromoty and incomplete resection of UA. We describe short (6 month) and medium term (18 month) outcomes in two patients who underwent augmentation urethroplasty.

CONCLUSION

• ? Although urethrotomy and dilatation have been proposed in the past, we found these may still lead to disease progression and therefore urethroplasty may be the most appropriate long term management option.

     

Long-Term Results of Internal Urethrotomy

Purpose

A retrospective analysis was done of long-term results of internal urethrotomy to evaluate risk factors of stricture recurrence.

Materials and Methods

Followup studies were performed of 937 patients with urethral strictures treated with internal urethrotomy. Of the patients 357 were treated at Mainz University between 1977 and 1989 (mean followup 4.6 years) and 580 were treated at Bonn University between 1974 and 1986 (mean followup 3.2 years).

Results

Strictures recurred in 96 of 357 (26.9 percent) and 260 of 580 (44.8 percent) patients, respectively. Risk factors for recurrence were etiology (post-transurethral resection and inflammation), stricture longer than 1 cm. and postoperative catheter drainage for longer than 3 days.

Conclusions

Urethroplasty should be considered in patients at high risk for stricture recurrence and with more than 1 treatment failure after urethrotomy.     

The application of tissue-engineered preputial matrix and fibrin sealant for urethral reconstruction in rabbit model

Background

To introduce the role of fibrin sealant and preputial acellular matrix (PAM) as a new source of inert collagen matrix for urethral reconstruction.

Methods

A ventral urethral segmental defect was created in 24 male rabbits divided into four groups. In group 1 (G1), urethrotomy was closed in layers. In group 2 (G2), closure was followed by applying fibrin sealant. In groups 3 (G3) and 4 (G4), urethroplasty was performed with a patch graft of PAM, and in G4, fibrin sealant was also applied. Serial urethrography was performed before and after the operation. Then, the animals were euthanized, and their urethra was excised 1, 3, and 9 months postoperatively for further electron microscopic examination, terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) technique, and immunohistochemical (IHC) staining with CD34, CD31, desmin, SMA, and α-actin.

Results

In G1 and G2, the fistula repair failed in all the time points. In G3 and G4, serial urethrography confirmed the maintenance of a wide urethral caliber without signs of strictures or extravasations. Satisfactory vascularity was observed in G3 and G4 during the whole study, which was more significant in G4 after 9 months of follow-up. The presence of a complete transitional cell layer was confirmed over the graft in G3 and G4 in all time points. IHC staining confirmed the effectiveness of fistula repair in G3 and G4, 3 months postoperatively.

Conclusion

This rabbit model showed that PAM combined with fibrin sealant may herald a reliable option for repairing segmental urethral defects.     

Distal urethrectomy for localized penile squamous carcinoma in situ extending into the urethra: an updated series

Introduction

The presence of squamous carcinoma in situ (CIS) of the distal penis extending into the urethral meatus is generally considered a contraindication for glans-sparing procedures. Distal urethrectomy with subsequent reconstruction can provide an alternative approach toward urethral resection while providing penile preservation in select cases. Unfortunately, long-term oncologic outcomes with this approach are ill-defined.

Materials and methods

Between 1988 and 2012, five patients at Indiana University Medical Center underwent distal urethrectomy with reconstruction for penile squamous CIS extending into the urethral meatus. This cohort was retrospectively reviewed to evaluate functional and oncological outcomes.

Results

Of the five patients, four presented with glanular lesions and were initially managed with Mohs procedure in three cases, and local excision in one. The final patient presented with extensive urethral disease and was managed with primary urethrectomy. Reconstruction was performed with penile skin pedicle grafts in four patients and perineal urethrostomy in one. Final pathologic stage was T1 in one patient and Tis in the remaining four. Follow-up ranged from 6 to 96 months. One local recurrence was verified; however, it occurred outside the urethral area. This was confirmed in the pathologic analysis after the patient underwent a partial penectomy. Meatal dilation was necessary in two patients 12 and 7 months after the procedure.

Conclusion

Distal urethrectomy for penile squamous CIS extending into the urethral meatus is a valid alternative to achieve negative surgical margins while preserving a penile function. Oncologic outcomes appear acceptable but larger series are still warranted to confirm our findings.