Complicated male urethral strictures: Presentation and management

Among 104 patients with urethral strictures treated over a period of 3 years, sixty-five (63%) had complications such as inflammatory periurethral mass, watering-can perineum with discharging sinuses and fistulas, associated urethral calculi, periurethral abscesses and urethral diverticula. Seventy-four per cent of the stricutres were of inflammatory origin and they predominated in the region of the bulbar urethra. Thirty-two patients were treated by visual internal urethrotomy, 11 had two-stage urethroplasty and 9 had perineal urethrostomy. Other methods of treatment and their results are discussed. This paper was presented at a poster session in the spring meeting of the swedish Society of Urology held in Stockholm, May 26–27, 1988.     

经会阴实时三维超声在会阴区囊实性病变中的应用研究

目的探讨经会阴实时三维超声在会阴区囊实性病变诊断及鉴别诊断中的临床价值。 方法回顾分析219例经手术、临床确诊为会阴区囊实性病变并进行了经会阴实时三维超声检查的女性患者声像图表现,总结不同会阴区囊实性病变声像图特点。 结果经会阴实时三维超声可以清晰显示会阴区囊实性病变。219例被检者中,阴道壁囊肿33例、尿道旁囊肿7例、尿道憩室7例、膀胱膨出58例、阴道内肿瘤4例、子宫脱垂32例、会阴体过度运动52例、直肠膨出26例。阴道壁囊肿、尿道腺囊肿在声像图上均表现为尿道旁的类椭圆形无回声或低回声区,与尿道及阴道均不相通;尿道憩室在声像图上表现为尿道旁不规则的无回声或低回声区,与尿道相通;阴道内肿瘤表现为阴道内不规则的低回声区;膀胱膨出、子宫脱垂、会阴体过度运动、直肠膨出表现为相应器官下移至参考线下。 结论经会阴实时三维超声能够客观反映会阴区囊实性病变的不同声像特征,有助于临床诊断及鉴别诊断,具有一定的临床实用价值。     

One-stage urethroplasty for bulbomembranous urethral strictures

Summary A total of 23 patients with bulbomembranous urethral strictures (16 after pelvic fractures, 4 following direct perineal trauma, 3 after catheter drainage) were treated with a perineal one-stage anastomotic urethroplasty. The length of the stricture did not exceed 2 cm. The overall final success rate amounted to 95.6%. The one-stage perineal approach is recommended for short strictures of up to 2 cm in length, if mobilization of the distal urethra is possible and the periurethral scar tissue can be resected.     

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.     

Perineal subcutaneous dartos pedicled flap as a new technique for repairing urethrorectal fistula

PURPOSE: Urethrorectal fistulas are rare, and the etiology is usually traumatic or iatrogenic (postoperative). Several operative approaches and techniques have been used for fistulous repair but no procedure has proved to be the best or universally acceptable. We present a new technique for repairing urethrorectal fistulas. MATERIALS AND METHODS: We successfully treated 12 male patients 7 to 65 years old who presented with urethrorectal fistula from 1990 to 1997 using the perineal subcutaneous dartos pedicled flap procedure. Urethrorectal fistulas resulted from crush pelvic injury in 6 cases and gunshot in 2, and developed after prostatectomy in 4. The fistula was associated with urethral stricture in 4 cases. A perineal approach was used in all cases of urethrorectal fistula and combined with the transsymphyseal approach in the 4 patients with posterior urethral stricture. We interposed a subcutaneous dartos pedicled flap as a vascularized tissue flap between the repaired rectum and urethra. RESULTS: The results of our technique were excellent in all cases. No leakage or perineal collection developed and there was no fistula recurrence. In 1 patient urethral stricture was managed by visual internal urethrotomy. Loss of the internal and external sphincters resulted in urinary incontinence in 4 cases, involving gunshot injury (2), crush pelvic injury (1) and prostatectomy (1). Followup ranged from 9 to 42 months. CONCLUSIONS: Our technique of a perineal subcutaneous dartos pedicled flap fulfills all principles of the successful repair of urethrorectal fistula. We consider it to be an ideal solution to this urological dilemma.     

The motor nerve supply of the external urethral sphincter muscles: An electrophysiologic study

The term “intrinsic external urethral sphincter” has recently been applied to the striated muscle immediately surrounding the membranous urethra, thus distinguishing and separating it from the periurethral striated muscle which is a component of the pelvic floor. The innervation of the intrinsic external urethral sphincter is still controversial. Six male patients with a sustained spinal cord lesion above D-4 underwent electrophysiological evaluation of the reflex and direct evoked responses to stimulation of the pudendal nerve branches in the perineal region. Recording of the motor unit potentials was performed using a catheter-mounted concentric needle introduced into the intrinsic external urethral sphincter transurethrally. The results of this study indicate that the pudendal nerve, i.e., somatic, plays an important role in the innervation of the intrinsic external urethral muscle. It does not, however, exclude the possibility that the autonomic nervous system also innervates this muscle.     

睾丸鞘膜瓣在尿道修复中的应用

目的探讨睾丸鞘膜瓣覆盖技术在尿道畸形和尿道瘘修复中的效果。方法2002年起对38例尿道下裂手术和术后尿道瘘,采用睾丸鞘膜下组织蒂鞘膜瓣覆盖修复。结果术后随访半年至1年,除1例尿道上裂术后瘘修复后再次发生尿道瘘外,其余均获成功,未再出现尿道瘘或尿道狭窄,阴茎外观满意,勃起正常。结论采用该方法可有效防止尿瘘再发生,提高手术成功率且易于获取,对睾丸无不良影响。     

Bulbocavernosus muscle flap in the repair of complicated vesicovaginal fistula

AIM: To investigate the transposition of the bulbocavernosus muscle flap for repairing complicated vesicovaginal fistulas. METHODS: Vesicovaginal fistulas were repaired via combined abdominal and perineal approaches. Through an abdominal approach, the fistula and surrounding scar tissue were excised thoroughly. A perineal incision was made between the orifices of the urethra and the vagina, dissecting until the fistula. The vaginal defect was closed through either the abdominal or the perineal approach depending upon its position. Through the abdominal approach, the bladder defect was closed in two layers with the suture lines vertical to each other. The bulbocavernosus muscle was freed through an incision between the labium majus pudendi and the labium minus pudenda, without damaging the pudendal vascular supply. The bulbocavernosus muscle flap was tunneled beneath the labium minus pudendi, and was sutured in place on the bladder wall over the fistula repair site. RESULTS: Nine patients with complicated vesicovaginal fistulas were treated using this technique. After surgery, no symptoms of vagina leakage, urinary incontinence, or urethral stricture were reported by any of the patients, and they reported normal sexual function. CONCLUSIONS: Transposition of the bulbocavernosus muscle flap is an excellent technique with low morbidity and high success rate for repairing complicated vesicovaginal fistulas.     

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。     

男童外伤性后尿道狭窄的治疗(附210例分析)

目的　总结男童外伤性后尿道狭窄的诊治经验。　方法　陈旧性后尿道外伤患儿 2 10例。其中经尿道内切开 (TUR) 112例 ,经耻、会阴联合修复尿道 4 4例 ,经会阴修复尿道 32例 ,会阴尿道造瘘及两尿道断端间插入带蒂阴囊皮管做吻合 2 0例 ,可控性尿流改道 (Mitrofanoff术 ) 1例 ,经直肠会阴修复尿道 1例。　结果　 2 10例随访 6个月～ 14年 ,获正常排尿 187例 (89% ) ,有不全尿失禁 17例 ,会阴尿道造瘘尚未修复 5例 ,需清洁间歇导尿 1例。　结论　后尿道外伤的急症处理非常重要 ,单纯膀胱造瘘仅用于不全性尿道断裂。经尿道内切开适用于绝大多数单纯性后尿道狭窄 ,经耻、会阴联合修复尿道适用于复杂性后尿道狭窄或 (和 )闭锁段 >2cm者。     

螺旋CT尿道三维重建诊断后尿道狭窄或闭锁

目的 探讨螺旋CT尿道三维重建技术在后尿道狭窄或闭锁诊断中的应用价值.方法 对30例创伤性后尿道狭窄或闭锁患者术前行螺旋CT薄层扫描和尿道三维重建、X线尿道造影,观察狭窄或闭锁部位、长度以及尿道周围组织解剖结构的改变,并与开放性手术中发现的结果进行对比研究.结果 X线尿道造影检测狭窄或闭锁段长度为1.0～7.0 cm,平均4.0 cm,狭窄或闭锁长度相关系数为0.92,定位准确率为70%(21/30);螺旋CT尿道三维重建检测狭窄或闭锁段长度为1.2～7.6 cm,平均4.3 cm,狭窄或闭锁长度相关系数为0.96,定位准确率为93%(28/30);术中发现后尿道狭窄或闭锁长度为1.5～7.5 cm,平均4.2 cm.5例合并尿道直肠瘘者螺旋CT尿道三维重建可以清楚显示瘘管位置、长度及大小;X线尿道造影则无法清楚显示.结论 螺旋CT尿道三维重建对了解伤后尿道的解剖结构改变、测量尿道狭窄或闭锁部位和长度、指导手术方式选择有较高价值,尤其对合并尿道直肠瘘者有重要的诊断意义.     

Iontophoresis as a new method of delivering local anesthesia to the urethra: a pilot study

OBJECTIVES: To test the feasibility of using the iontophoretic catheter as a means of delivering local anesthetic (lidocaine hydrochloride) to the urethra for periurethral injection of collagen. METHODS: Eight women with urodynamically proven genuine stress incontinence underwent periurethral collagen injections. Local anesthesia was provided by 4% lidocaine with 1 in 100,000 epinephrine administered over 10 minutes using an iontophoretic catheter. Pain was assessed by Likert and visual analogue scales. Cystoscopic appearance of the urethra was noted. RESULTS: The periurethral bulking procedure was completed without further anesthetic in 7 women, 1 of whom had no pain. There was no evidence of urethral damage from the iontophoresis. CONCLUSIONS: Iontophoresis shows promise as a method of providing analgesia to the urethra. However, the degree of analgesia is variable, and further research is needed on catheter design to ensure transport of anesthetic agent into the periurethral tissues.     

Urethroplasty in female-to-male transsexuals

OBJECTIVE: Female-to-male transformation includes total phallic reconstruction. Construction of a neourethra is necessary to achieve the goal of voiding while standing; however urethral fistula and stricture formation occur in a significant percentage of patients. METHODS: 25 patients with primary female transsexualism underwent phalloplasty with a free radial forearm flap, vaginectomy and urethroplasty in a one-stage procedure. In 16 of these patients the fixed part of the neourethra ("bulbar urethra") was constructed from a vaginal flap. In 9 patients flaps of the labia minora (5 patients) or the "urethral plate" (4 patients) were used. RESULTS: In 14 (58%) patients fistulas and/or strictures in the newly constructed urethra occurred. 11 (69%) of 16 patients in whom the "bulbar urethra" was constructed from a vaginal flap experienced fistulas and/or stricture formation. Fistulas and/or strictures occurred in 3 of 5 patients with labia minora flaps and none of 4 patients with the urethral plate procedure. Repair of fistula and strictures was performed by primary closure of fistulas, staged urethroplasty with local pedicle flaps or distant tissue grafts using buccal mucosa (2-6 procedures). CONCLUSION: One-stage total phalloplasty and urethroplasty is associated with a significant rate of fistulas and strictures. However, these complications can be corrected by the techniques used in modern urethral surgery.     

Dorsal buccal mucosal graft urethroplasty by a ventral sagittal urethrotomy and minimal-access perineal approach for anterior urethral stricture

OBJECTIVE: To present the technique of dorsal buccal mucosal graft urethroplasty through a ventral sagittal urethrotomy and minimal access perineal approach for anterior urethral stricture. PATIENTS AND METHODS: From July 2001 to December 2002, 12 patients with a long anterior urethral stricture had the anterior urethra reconstructed, using a one-stage urethroplasty with a dorsal onlay buccal mucosal graft through a ventral sagittal urethrotomy. The urethra was approached via a small perineal incision irrespective of the site and length of the stricture. The penis was everted through the perineal wound. No urethral dissection was used on laterally or dorsally, so as not to jeopardize the blood supply. RESULTS: The mean (range) length of the stricture was 5 (3-16) cm and the follow-up 12 (10-16) months. The results were good in 11 of the 12 patients. One patient developed a stricture at the proximal anastomotic site and required optical internal urethrotomy. CONCLUSION: Dorsal buccal mucosal graft urethroplasty via a minimal access perineal approach is a simple technique with a good surgical outcome; it does not require urethral dissection and mobilization and hence preserves the blood supply.     

Fulguration-ablation of atypical accessory urethra

A male adolescent presented with perineal dribbling during voiding. Evaluation revealed an accessory urethra originating from the prostatic urethra. There was persistent anatomical and functional dominance of the dorsal orthotopic urethra, constituting a reversal of the arrangement most commonly described for urethral duplication. Successful ablation of the accessory urethra was accomplished by electrofulguration. The salient features of urethral duplication are reviewed.     

Complications associated with surgical repair of urethrovaginal fistula

We present 4 patients seen in the last five years with urethrovaginal fistulas involving the mid or proximal urethra. Our experience in the transvaginal repair of these fistulas has been disappointing. The best chance for the development of a functioning continent urethra is by suprapubic bladder flap technique or bladder tube replacement with suprapubic urinary diversion. We suggest that no urethral catheter be placed. Complications following surgical repair have been fistula recurrence, urethral shortening and retraction, persistent reflux, bladder calculi, and bladder cancer.     

CONSTRUCTION OF FEMALE URETHRA USING BUCCAL MUCOSA GRAFT

PURPOSE: We reviewed our experience with buccal mucosa grafts for reconstructing difficult female urethral problems. METHODS AND METHODS: Since 1994, we have used a buccal mucosa graft to reconstruct the urethra in 7 girls 3 to 13 years old. The underlying pathological condition was a fibrotic urethra after previous operations for cloacal exstrophy, cloacal malformation, iatrogenic urethral stricture, and multiple false passages in a previously reconstructed urethra of vaginal mucosa that made clean intermittent catheterization difficult. A full-thickness buccal mucosa graft was tubularized in situ as the neourethra to the base of the clitoris. In patients with cloacal exstrophy and cloacal malformation the bladder neck and urethra were widely exposed transabdominally by splitting the pubic symphysis. The fibrotic mucosa was excised and the tubularized buccal mucosa graft was wrapped with periurethral tissues. Other patients underwent transvaginal surgery in the prone position and the graft was covered with a buttock flap. RESULTS: Patients were followed for 12 to 58 months (mean 34.7). Those with cloacal exstrophy and cloacal malformation had been completely incontinent before urethral reconstruction but all attained complete continence postoperatively. They and the girl who underwent urethral reconstruction for difficult catheterization performed clean intermittent catheterization easily. The patient with urethral stricture voided via the urethra without difficulty. CONCLUSIONS: In select female patients with difficult urethral reconstructive problems a tubularized free graft obtained from the buccal mucosa may be effectively used when local tissue is fibrotic and unsuitable for creating a supple new urethra.     

Adrenergic innervation and stimulation of canine urethra

Sympathetic nervous innervation of the canine urethra was studied using catecholamine histofluorescent staining and the in vitro muscle bath. Morphologically, adrenergic nerves were found terminating on the urethral smooth muscle. Pharmacologically, urethral strips responded like muscle strips from the bladder base to adrenergic stimulation. This evidence supports the concept that the sympathetic nervous system supplies and modulates the function of the smooth muscle of the urethra and that urethral changes noted with adrenergic stimulation are not secondary solely to stimulation of the rich periurethral vaculature nerve supply.     

Cause of deviation of the erectile penis after urethral manipulations (Kelami syndrome)--demonstration of ultrasound findings and case reports

The cause of deviation of the erectile penis after urethral manipulations is shown to be periurethral scarring which can be outlined by ultrasound investigation of the urethra and periurethral structures. Sonographic findings are demonstrated. 6 case reports are presented.     

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.