Single-stage reconstruction of complex anterior urethral strictures using overlapping dorsal and ventral buccal mucosal grafts

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? This technique has been reported to have an excellent success rate in the bulbar urethra, although no data exists for its use in the penile urethra. This is the first study to report successful use of the technique in the reconstruction of penile urethral strictures.

OBJECTIVE

• ? To review our initial experience with single‐stage overlapping dorsal and ventral buccal mucosa graft (BMG) urethroplasty for the reconstruction of complex anterior urethral strictures.

PATIENTS AND METHODS

• ? Among 696 urethroplasties performed at two tertiary urethroplasty centres from October 2007 to September 2010, single‐stage urethral reconstruction using urethral plate incision and/or excision and overlapping dorsal and ventral BMGs was used in 36 men (5%) with complex urethral strictures (mean length 4.5 cm).
• ? Demographic and perioperative data was tabulated and outcomes were analysed.

RESULTS

• ? Stricture location was bulbar (61%), penile (19%), or both bulbar and penile (20%).
• ? Dorsal grafts, applied only within the most severely strictured segment, measured a mean 42% of the opposing ventral graft length.
• ? At a mean follow‐up of 15.7 months, 32 of the 36 cases were successful (89%).
• ? Repeat urethroplasty was performed in all four recurrences, three of which were successful at a mean follow‐up of 16 months.

CONCLUSION

• ? Single‐stage reconstruction of focally obliterative long urethral strictures using overlapping dorsal and ventral BMGs is safe and effective.

     

Single-stage segmental urethral replacement using combined ventral onlay fasciocutaneous flap with dorsal onlay buccal grafting for long segment strictures

Study Type – Therapy (case series) Level of Evidence 4

What's known on the subject? and What does the study add?

Single‐stage urethral segment replacement has historically poor outcomes and two‐stage repairs are now more common. We present a novel approach to the single‐stage repair with initial outcomes similar to two‐stage repairs.

OBJECTIVE

• ? To present our experience with repairing long‐segment urethralstrictures in a single‐stage using a combined tissue‐transfer technique.

PATIENTS AND METHODS

• ? In all, 14 men underwent urethroplasty where a segment of urethra was completely replaced using a dorsal onlay buccal mucosa graft and a ventral onlay fasciocutaneous flap in a singlestage.
• ? Primary success was defined as an open urethra at >6 months follow‐up with no need for additional surgical intervention.
• ? Secondary success was defined as the need for a single postoperative endoscopic procedure before stricture stabilization.
• ? Failure was the need for multiple endoscopic procedures, repeat urethroplasty, urinary diversion or intermittent dilatation.

RESULTS

• ? The mean (sd ) stricture length was 9.75 (4.6) cm. The mean (sd ) neourethral length was 5.4 (2.7) cm. Stricture location was penile/bulbar in 12men, and bulbar alone in two. Primary success was achieved in nine of the 14 men at a median (range) follow‐up of 2.5 (0.5–9.43) years.
• ? The mean (sd ) time to recurrence in the five initial failures was 340 (376) days.
• ? Secondary success was achieved in two men after a single endoscopic procedure for an overall success in 11 of 14 men.
• ? Patients that recurred had longer strictures (12.8 vs 8.7 cm, P= 0.04) than initial successes, but neourethral lengths were similar (6.2 vs 5.1 cm, P= 0.5).
• ? In all, three of the 14 men failed, two of whom required a repeat urethroplasty.

CONCLUSIONS

• ? Our initial outcomes were favourable using the combined tissue‐transfer technique for segmental urethral replacement with initial and secondary success rates similar to those reported for two‐stage repairs.
• ? This technique is not suitable for all patients as it requires healthy penile skin, but appears to be effective when a single‐stage repair is desirable.

     

Safer urethral catheters: how study of catheter balloon pressure and force can guide design

What's known on the subject? and What does the study add? The urethal catheter is a ubiquitous device that has not been modified or improved for safety in the last 20 years, although it can be associated with significant patient harm. This study utilizes force and pressure measurements of the urethral catheter in order to aid in future safety modifications.

OBJECTIVES

• ? To better define urethral catheter balloon pressures and extraction forces during traumatic placement and removal of urethral catheters.
• ? To help guide design for safer urethral catheters.

MATERIALS AND METHODS

• ? Measurements of balloon pressure were made upon filling within the urethra vs the bladder.
• ? Extraction forces were measured upon removal of a catheter with a filled balloon from the bladder.
• ? Models for the bladder and urethra included an ex vivo model (funnel, ‘bladder’, attached to a 30 F tube, ‘urethra’) and fresh human male cadavers.
• ? The mean (sem ) balloon pressures and extraction forces were calculated.

RESULTS

• ? In the ex vivo model, the mean (sem ) pressures upon filling the balloon with 10 mL were on average three‐times higher within the ex vivo‘urethra’ (177 [6] kPa) vs ‘bladder’ (59 [2] kPa) across multiple catheter types.
• ? In the human cadaver, the mean balloon pressure was 1.9‐times higher within the urethra (139 [11] kPa) vs bladder (68 [4] kPa).
• ? Balloon pressure increased non‐linearly during intraurethral filling of both models, resulting in either balloon rupture (silicone catheters) or ‘ballooning’ of the neck of the balloon filling port (latex catheters).
• ? Removal of a filled balloon per the ex vivo model ‘urethra’ and cadaveric urethra, similarly required increasing force with greater balloon fill volumes (e.g. 9.34 [0.44] N for 5 mL vs 41.37 [8.01] N for 10 mL balloon volume).

CONCLUSIONS

• ? Iatrogenic complications from improper urethral catheter use is common.
• ? Catheter balloon pressures and manual extraction forces associated with urethral injury are significantly greater than those found with normal use.
• ? The differences in pressure and force may be incorporated into a safer urethral catheter design, which may significantly reduce iatrogenic urethral injury associated with catheterization.

     

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.

     

Prospective randomized trial of barbed polyglyconate suture to facilitate vesico-urethral anastomosis during robot-assisted radical prostatectomy: time reduction and cost benefit

Study Type – RCT (randomized trial) Level of Evidence 2b What's known on the subject? and What does the study add? In a previous randomized controlled trial, barbed polyglyconate suture for vesico‐urethral anastomosis was associated with more frequent cystogram leaks, longer mean catheterization times and greater suture costs per case. In the current randomized controlled trial, we show that barbed polyglyconate suture is associated with decreased anastomosis time, decreased need to readjust suture tension, cost reduction, and equal continence and early/late urinary complication rates.

OBJECTIVE

• ? To examine the effectiveness of barbed polyglyconate suture (V‐Loc 180; Covidien, Mansfield, MA, USA) compared with standard monofilament for posterior reconstruction (PR) and vesico‐urethral anastomosis (VUA) during robot‐assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

• ? A prospective randomized controlled trial was conducted in 70 consecutive RARP cases by a single surgeon (K.C.Z.).
• ? Standard VUA was performed using three 4‐0 poliglecaprone 25 (Monocryl; Ethicon Endosurgery, Cincinnati, OH, USA) sutures secured with absorbable suture clips (LapraTy, Ethicon; one single 6‐inch [15.2 cm] for PR and two attached 6‐inch [15.2 cm] for VUA).
• ? Barbed suture VUA was performed using two 3‐0 6‐inch (15.2 cm) barbed polyglyconate sutures.
• ? Time to complete the suture set‐up by the nursing team, anastomosis time and need to adjust suture tension were recorded. Suture‐related complications, validated‐questionnaire continence and cost were also examined.

RESULTS

• ? Compared with a conventional reconstruction technique, there was a significant reduction in mean nurse set‐up time (31 vs. 294 s; P < 0.01) and reconstruction time (13.1 vs. 20.8 min; P < 0.01) for the barbed suture technique.
• ? Need to readjust suture tension or to place additional suture clips for watertight closure was greater in the standard monofilament group than in the barbed suture group (6% vs. 24%; P= 0.03).
• ? A cost reduction was recorded at our institution (48.05 vs. 70.25 $CAN) with the barbed suture technique.
• ? With a mean follow‐up of 6.2 months, no delayed anastomotic leak or bladder neck contracture was observed in either group.
• ? Pad‐free continence outcomes for the monofilament suture vs the barbed suture groups at 1 (64 vs. 69%, P= 0.6), 3 (76 vs. 81%, P= 0.5) and 6 months (88 vs. 92%, P= 0.7) were similar.

CONCLUSIONS

• ? Compared with standard monofilament suture, the unidirectional barbed polyglyconate suture appears to provide safe, efficient and cost‐effective PR and VUA during RARP.
• ? Use of the interlocked barbed polyglyconate suture technique prevents slippage, precluding the need for assistance, knot‐tying and constant reassessment of anastomosis integrity.

     

York-Mason procedure for repair of recto-urinary fistulae: a 40-year experience

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Our previous report, almost 10 years ago, on the York‐Mason procedure was the largest series on this procedure. That report concluded that the York‐Mason posterior, trans‐anal, trans‐rectal correction of iatrogenic recto‐urinary fistula was highly successful, reliable and safe – when employed for small fistulas following prostate surgery. Since then, many other smaller case series have confirmed our success. This study provides a continuing body of evidence of the success, reliability, and safety by the largest York‐Mason series in the literature, and our numbers have now doubled in less than 10 years. Avoiding preliminary fecal diversion after surgical injury, which we proposed on our previous report, has now been observed to be safe and reliable with long‐term follow up. We also tried to push the limits of the surgery into larger, radiated fishtulas, but unfortunately were met with poorer outcomes.

OBJECTIVE

• ? To review the use of the York‐Mason transanal, transrectal procedure, used in properly selected patients over a 40‐year period, for repairing recto‐urinary fistulae.

PATIENTS AND METHODS

• ? We retrospectively reviewed the medical records of all patients who underwent acquired recto‐urethral or rectovesical fistula repair at our institution.
• ? A total of 51 patients have undergone York‐Mason recto‐urinary fistula repair at our institution during this time.

RESULTS

• ? Since our last report in 2003, we have performed this procedure an additional 27 times.
• ? We continue to have good results, with 25 of these patients having resolution of their fistulae after one procedure.
• ? Failures in the updated cohort were radiation‐induced fistulae.
• ? We continue to find no evidence of faecal incontinence or stenosis after this procedure.

CONCLUSIONS

• ? Over a period of 40 years, the York‐Mason posterior, transanal, transrectal correction of iatrogenic recto‐urinary fistula has been highly successful, reliable and safe, when used for fistulae occurring after prostate surgery.
• ? Preliminary faecal diversion can often be avoided in selected patients.

     

Urethral pressure reflectometry; a novel technique for simultaneous recording of pressure and cross-sectional area: a study of feasibility in the prostatic urethra

Study Type – Diagnostic (case series) Level of Evidence 4 What's known on the subject? and What does the study add? In the 1980s and 1990s, a method for direct measurement of pressure and cross‐sectional area in women and men was developed. It was successful in terms of obtaining meaningful results in several studies. But the technique, which was based on the field gradient principle, was never implemented in the clinical setting because of technical limitations. In 2005, urethral pressure reflectometry was introduced as a new technique in female urodynamics. The technique has been shown to be more reproducible than conventional urethral pressure profilometry, when measuring incontinence in women. In 2010 it was also introduced as a new measuring technique in the anal canal. This study, adds a new and interesting technique to the field of male urodynamics. For the first time, sound waves have been used to measure pressure and cross‐sectional area simultaneously, directly in the prostatic urethra. The results from this first trial with urethral pressure reflectometry are promising, in terms of obtaining meaningful physiological parameters. Our hope is that, future trials will help us to be able to identify specific areas of obstruction or rigidity in the prostatic urethra, making treatment more direct and side effects from surgery less severe. However, further studies are needed to evaluate the technique with regards to clinical usefulness in men with benign prostatic obstruction.

OBJECTIVE

• ? Urethral Pressure Reflectometry (UPR) was introduced in 2005, and it has since been used in the female urethra for simultaneous measurement of pressure (P) and cross‐sectional area (CA). It has shown to be more reproducible than conventional pressure measurement and reintroduced direct measurement of pressure and elastance in the urethra as important parameters when assessing incontinent women.
• ? To test the feasibility of UPR in the prostatic urethra.

PATIENTS AND METHODS

• ? We tested the technique in ten male patients, median age 73 and range 51–91.
• ? Measurements were performed in the supine position, with less than 50 ml of urine in the bladder.
• ? The UPR valuables measured were opening and closing pressure, opening and closing elastance and hysteresis.

RESULTS

• ? The PVC tube was easy to insert to the same degree as a normal KAD.
• ? Opening pressure and opening elastance were measured on all patients.
• ? The sphincter area was easily identified during measurements.
• ? UPR provides results compatible with previous techniques.
• ? A standardized method for measurements was developed.

CONCLUSION

• ? UPR has been shown feasible in the prostatic urethra.
• ? Further studies on healthy volunteers and patients with lower urinary tract symptoms and benign prostatic obstruction (BPO) are needed, to determine if UPR has a future role in urodynamic diagnostics of male patients with BPO.

     

Augmented anastomotic urethroplasty

PURPOSE: During substitution urethroplasty, if the stricture contains a 1 to 2 cm region that is particularly narrow and/or fibrotic, that portion may be excised with subsequent anastomosis of the dorsal or ventral aspect of the urethra to shorten, widen and optimize the urethral wall onto which an onlay graft is to be placed. This procedure is termed augmented anastomotic urethroplasty. To determine the effectiveness of this approach we reviewed our experience with augmented anastomotic urethroplasty in an 8-year period. MATERIALS AND METHODS: We reviewed the records of patients who underwent augmented anastomotic urethroplasty between October 1997 and April 2005. Perioperative characteristics were compared between successes and failures using the Wilcoxon/Kruskal-Wallis and Fisher exact tests. RESULTS: Of 69 patients who underwent augmented anastomotic urethroplasty for recurrent urethral strictures 5 had undergone previous urethroplasty using a genital skin flap or graft. At a median followup of 34 months (range 13 to 103) 62 patients had no evidence of stricture recurrence and required no further intervention for an overall success rate of 90%. Stricture recurrence, defined as the inability to easily pass a standard flexible cystoscope through the area of repair, occurred in 7 patients (10%). Patients with stricture recurrence were significantly older (mean age 52 vs 39 years, p = 0.02) and more likely to experience postoperative urinary tract infection (28% vs 3.2%, p = 0.05) than patients without repeat stricture. CONCLUSIONS: Augmented anastomotic urethroplasty is an effective technique that allows the use of a shorter onlay graft. It may optimize overall results due to improvement in the urethral wall and the associated corpus spongiosum.     

Construction of tissue‐engineered corpus cavernosum with muscle‐derived stem cells and transplantation in vivo

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? The tissue‐engineered research of corpus cavernosum has been studied, but an ideal method was not carried out. In the study, muscle‐derived stem cells were used as seeding cells to construct tissue‐engineered corpus cavernosums. The result demonstrated MDSCs could be seeded on three‐dimensional scaffolds of acellular corporal collagen matrices and developed into tissues similar to native corpus cavernosum in vivo.

OBJECTIVE

• ? To investigate the feasibility of tissue‐engineered corpus cavernosum (TECC) with muscle‐derived stem cells (MDSCs) as seed cells and determine the growth potential in vivo.

MATERIALS AND METHODS

• ? Acellular corporal collagen matrices (ACCMs) were obtained from adult rabbit penis by a cell removal procedure. MDSCs were separated and purified using a digestion method and Preplate technique, then seeded on ACCMs at a concentration of 30 × 10⁶ cells/mL to construct TECCs. After 5 days of culture, seeded ACCMs were implanted with albuginea of rabbits. The implants were retrieved at 2, 4 and 6 months after implantation.
• ? Histochemistry, immunohistochemisry and scanning electron microscopy were performed to analyse the morphological characteristics of the TECCs.

RESULTS

• ? The decellularization process successfully extracted all cellular components while preserving the original collagen fibres.
• ? Histological analyses of the explants at all time points in the experimental group had more cells and better arranged growth than the control group. α‐Smooth muscle actin and endothelial nitric oxide synthase‐positive cells were more prevalent in the experimental group.

CONCLUSION

• ? Our study showed that MDSCs can be seeded on three‐dimensional ACCM scaffolds and develop tissues that are similar to native normal corpus cavernosum.

     

Technique of anterior urethra urethroplasty using tunica albuginea of corpora cavernosa

OBJECTIVE: Over previous years, urethral stricture has constantly created a great problem in efforts to find a permanent cure for it. We describe a technique of anterior urethroplasty using tunica albuginea of corpora cavernosa. METHODS: After a midline penoscrotal incision, the bulbar or penile urethra along with corpus spongiosum was dissected from the corpora cavernosa. Urethra was then rotated dorsally and the stricture was opened along its whole length. The walls of the slit urethra, along with the tunica albuginea of the corpus spongiosum, were sutured to the tunica albuginea of the corpora cavernosa at the 5 and 7 o'clock position after passing an all silicon catheter. We performed this technique on 79 male patients, having anterior urethral stricture, ranging 18-60 years of age (mean, 46 years). The etiology of stricture was trauma in 54, instrumentation in 12, infection in 10 and unknown in three. Follow ups were done at 4, 12 and 24 months by assessing patients' satisfaction rate along with a pre- and postoperative urethrogram, labeled as "good", "fair" and "poor". RESULTS: Good and fair results were considered as successful. The overall success rate was 94.9%. The success rate remained same at 4 months (64 + 11) and decreased to 93.7% (63 + 11) at 12 months and 89.9% (61 + 10) at 24 months. CONCLUSION: These observations show that anterior urethroplasty using tunica albuginea of corpora cavernosa have produced satisfactory results and are comparable with any other technique of urethroplasty. Thus, we strongly recommend the use of tunica albuginea of corpora cavernosa for anterior urethroplasty, which is histologically similar and anatomically located near the stricture.     

Perineal anastomotic urethroplasty for managing post-traumatic urethral strictures in children: the long-term outcome

OBJECTIVE

To evaluate the long‐term results of one‐stage perineal anastomotic urethroplasty for post‐traumatic paediatric urethral strictures.

PATIENTS AND METHODS

Thirty‐five boys who had a perineal anastomotic urethroplasty for post‐traumatic bulbous or posterior urethral strictures between 1991 and 2003 were analysed retrospectively. Patients were followed up for a mean (range) of 46 (6–132) months by a history, urinary flow rate estimate, retrograde urethrography and voiding cysto‐urethrography.

RESULTS

The mean (range) age of the patients was 11.9 (6–18) years. The estimated radiographic stricture length before surgery was 2.6 (1–5) cm. The perineal anastomotic repair was successful in 31 of 35 (89%) patients. All treatment failures were at the anastomosis and were within the first year. Failed repairs were successfully managed endoscopically in two patients and by repeat perineal anastomotic repair in the remaining two, giving a final success rate of 100%. All boys are continent except two who had early stress incontinence, and that resolved with time. There was no chordee, penile shortening or urethral diverticula during the follow‐up.

CONCLUSIONS

The overall success of a one‐stage perineal anastomotic repair of post‐traumatic urethral strictures in boys is excellent, with minimal morbidity. Substitution urethroplasty or abdomino‐perineal repair should be reserved for the occasional patients with concomitant anterior urethral stricture disease or a complex posterior urethral stricture, respectively.

     

Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews

Male anterior urethral stricture is scarring of the subepithelial tissue of the corpus spongiosum that constricts the urethral lumen, decreasing the urinary stream. Its surgical management is a challenging problem, and has changed dramatically in the past several decades. Open surgical repair using grafts or flaps, called substitution urethroplasty, has become the gold standard procedure for anterior urethral strictures that are not amenable to excision and primary anastomosis. Oral mucosa harvested from the inner cheek (buccal mucosa) is an ideal material, and is most commonly used for substitution urethroplasty, and lingual mucosa harvested from the underside of the tongue has recently emerged as an alternative material with equivalent outcome. Onlay augmentation of oral mucosa graft on the ventral side (ventral onlay) or dorsal side (dorsal onlay, Barbagli procedure) has been widely used for bulbar urethral stricture with comparable success rates. In bulbar urethral strictures containing obliterative or nearly obliterative segments, either a two‐sided dorsal plus ventral onlay (Palminteri technique) or a combination of excision and primary anastomosis and onlay augmentation (augmented anastomotic urethroplasty) are the procedures of choice. Most penile urethral strictures can be repaired in a one‐stage procedure either by dorsal inlay with ventral sagittal urethrotomy (Asopa technique) or dorsolateral onlay with one‐sided urethral dissection (Kulkarni technique); however, staged urethroplasty remains the procedure of choice for complex strictures, including strictures associated with genital lichen sclerosus or failed hypospadias. This article presents an overview of substitution urethroplasty using oral mucosa graft, and reviews current topics.     

Transperineal bulbo-prostatic anastomosis for posterior urethral stricture associated with false passage: a single-centre experience

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? The emergency treatment of patients with PFUDD in developing countries is not currently codified and the majority of these patients have been treated using incorrect procedures that add iatrogenic damage to the trauma. Sometimes urethral dilatation gruffly and repeatedly wound lead to formation of urethral false passage which results in infection and incontinence. The treatment of urethral false passage is still a major challenge for urologists. False passage can lead to prolonged unhealed infections, increase the scar around the urethra, increasing stricture significantly. If preoperative examination was careless, it leads to identify false passage difficultly intra‐operative, the variation of direction when the curved sound was used as internal guidance, anastomosis between distal urethra and bladder wall near the orificium urethrae internum, leading to surgical failure. Cystourethrogram, flexible cystocopy pre‐operatively and dissect urethral bulb carefully are key points of urethroplasty for posterior urethral stricture with false passage. Then to pass a curved sound via the suprapubic tract into the posterior urethra to act as a guide for subsequent excision of all scar tissue.

OBJECTIVE

? To evaluate the management of traumatic posterior urethral stricture associated with false passage, as this remains a challenge for urologists.

PATIENTS AND METHODS

? From January 2000 to February 2010, 19 patients (mean (range) age 34 [25–52] years) with traumatic posterior urethral obliteration associated with false passage were evaluated and treated at our centre. ? All patients underwent perineal excision and primary anastomotic urethroplasty using cystoscopy by the suprapubic route to insert a guidewire into the original bladder neck, allowing exposure of the normal posterior urethra. ? Patients underwent voiding cysto‐urethrography 1 month after the procedure. When symptoms of decreased force of stream were present and uroflowmetry was <15 mL/s, urethrography and urethroscopy were repeated. ? Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilatation.

RESULTS

? The mean (range) follow‐up was 12 (9–14) months. The overall success rate was 84%. ? Three patients (16%) with persistent voiding difficulty developed a short anastomotic stricture 1–3 months after surgery. ? The mean maximum urinary flow rate after surgery was 20.01 mL/s and no patient had urinary incontinence.

CONCLUSION

? The preoperative use of flexible cystoscopy via the suprapubic route represented a successful key point of urethroplasty for posterior urethral stricture associated with false passage.     

Volar onlay urethroplasty for reconstruction of female urethra in recurrent stricture disease

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? In spite of several suggestions that have been published recently, there is no standard procedure for therapy of recurrent female urethral stricture disease. Most of the published procedures are characterized by the time‐consuming use of an oral mucosal graft. In the current study we present an effective and simple new technique for reconstruction of strictured female urethra, using a free labium minus graft.

OBJECTIVE

? To report our experience with a new and simple method of urethral repair with a volar onlay of free labium minus graft. Strictures of the female urethra are rare, and it is well accepted that the therapeutic options of dilation and urethrotomy are not lasting solutions as a result of their high recurrence rates. However, there is no consensus regarding the best way to reconstruct the female urethra in the case of stricture disease.

PATIENTS AND METHODS

? Four consecutive female patients with a long lasting history of recurrent urethral strictures underwent open urethroplasty with a volar situated free split thickness epidermal graft from the labium minus. ? The surgical technique is described and a short‐term follow‐up is presented.

RESULTS

? Operating time was 40–140 min (mean 105 min), and the graft measured between 2 × 1.5 cm and 3 × 2.5 cm. Follow‐up time was 11–19 months. Maximum urinary flow rate could be improved from a baseline of 9.4–11.2 mL/s (preoperatively, after intermittent use of dilation) to 19–23 mL/s. ? Postvoid residual urine volume was 0–50 mL preoperatively and no postvoid residual urine volume postoperatively. ? Urinary catheters were removed after 21 days. Urinary stress incontinence did not occur postoperatively. No complications related to the graft donor site were found.

CONCLUSIONS

? The reported data concerning a new therapeutic approach for the treatment of recurrent female urethral stricture show that a volar onlay urethroplasty represents a feasible, safe and simple surgical method. ? Larger series with long‐term follow‐up are needed for further evaluation.     

One‐sided anterior urethroplasty: a new dorsal onlay graft technique

OBJECTIVE

To investigate the feasibility, tolerability, safety and efficacy of using a new surgical technique for the repair of anterior urethral strictures to preserve vascular supply to the urethra and its entire muscular and neurogenic support.

PATIENTS AND METHODS

In all, 24 patients (mean age 46 years) underwent a new one‐sided anterior dorsal oral mucosal graft urethroplasty while preserving the lateral vascular supply to the urethra, the central tendon of the perineum, the bulbospongiosum muscle and its perineal innervation. The cause of stricture was instrumentation in three cases (12%), unknown in five (21%), infection in four (17%), and lichen sclerosus in 12 (50%). The stricture site was bulbar in 12 cases (50%) and panurethral in 12 (50%). The mean stricture length was 4.2 cm in patients with bulbar strictures and 10 cm in patients with panurethral strictures. Of 24 patients, 20 patients (83%) had received previous treatments. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilatation.

RESULTS

The overall mean (range) follow‐up was 22 (12–55) months. Of the 24 patients, 22 (92%) had a successful outcome and two (8%) were failures. One failure was treated using definitive perineal urethrostomy and another failure underwent successful internal urethrotomy.

CONCLUSIONS

The preservation of the one‐sided vascular supply to the urethra and its entire muscular and neurogenic support should represent a slight but significant step toward perfecting the surgical technique of urethral reconstruction using a minimally invasive approach.     

Reconstrucción uretral en pacientes previamente tratados con endoprótesis uretral Memokath™

Purpose

To evaluate the role and success rate of urethral reconstruction in patients with urethral stricture previously treated with thermos-expandable Memokath? urethral endoprosthesis.

Recreational urethral sounding is associated with high risk sexual behaviour and sexually transmitted infections

Study Type – Symptom prevalence (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Most of the medical literature regarding recreational urethral sounding pertains to foreign body retrieval. Very little is known about men who perform sounding and do not require medical attention. Of >2000 men, who responded to a urinary and sexual wellness survey, 10% had a history of recreational urethral sounding. Compared with men who did not sound, men who did reported higher risk sexual behaviours such as multiple sexual partners, sex with strangers and reported more sexually transmitted infections. Men who seek medical attention for complications resulting from sounding should be counselled regarding the hazards of the practice. Realistic strategies for risk reduction should be discussed with men who engage in recreational sounding.

OBJECTIVE

• ? To determine whether men who perform recreational sounding are at increased risk of engaging in unsafe sexual behaviours, developing sexually transmitted infections (STIs) and lower urinary tract symptoms (LUTS).

SUBJECTS AND METHODS

• ? In a cross‐sectional, international, internet‐based survey of the sexual practices of >2000 men who have sex with men, subjects were asked if they had engaged in urethral sounding for sexual gratification.
• ? We compared ethnodemographic and health‐related variables between the sounding and non‐sounding populations. The International Prostate Symptom Score and a modified validated version of the International Index of Erectile Function were used to quantify LUTS and erectile dysfunction (ED) in both populations.

RESULTS

• ? There were 2122 respondents with complete data, 228 (10.7%) of whom had engaged in recreational sounding.
• ? Men who had engaged in sounding were more likely to report certain high risk sexual behaviours (e.g. multiple sexual partners and sex with partners who were not well known) and had increased odds of reporting STIs.
• ? Men who had engaged in sounding had a slight but statistically significant increase in LUTS but no significant difference in prevalence of ED.

CONCLUSIONS

• ? Urethral sounding is a sexual practice that is associated with higher risk sexual behaviour and carries the potential for morbidity.
• ? Research on means for risk reduction for men who choose to engage in recreational sounding requires further study.

     

The male sling for post-prostatectomy urinary incontinence: a review of contemporary sling designs and outcomes

What's known on the subject? and What does the study add? Long‐term cure and improved rates for the bone anchored sling range from 40–88%. Midterm cure and improved rates for the retrourethral transobturator sling rage from 76–91%. Midterm cure and improved rates for the adjustable retropubic sling rage from 72–79%. Potential complications common to all urethral slings include postoperative urinary retention, perineal pain, and urethral erosion/device infection. All male urethral slings have primarily been studied in post radical prostatectomy patients, with inconsistent success among patients with prior pelvic radiation.

OBJECTIVE

• ? To examine the outcomes and adverse events associated with novel male sling designs described in the last decade.

METHODS

• ? A literature review was carried out using Medline, EmBase, Cochrane Registered Trials Database and the Center for Reviews and Dissemination Database.

RESULTS

• ? Three principal slings are described in the literature. The bone‐anchored sling has success rates of 40–88%, with some series having a mean follow‐up of 36–48 months. It is associated with a mesh infection rate of 2–12%, which usually requires sling explantation.
• ? The retrourethral transobturator sling has a success rate of 76–91% among three large case series with follow‐ups of 12–27 months. There is a low reported explantation rate.
• ? The adjustable retropubic sling has a success rate of 72–79% with follow‐ups of 26–45 months. Erosion (3–13%) and infection (3–11%) can lead to explantation.

CONCLUSIONS

• ? Most male slings have a similar reported efficacy. Most case series define success as either dry or improved. True cure rates are lower. Mid‐ and long‐term data are now available that indicate the male sling is a viable option for PPI.
• ? The use of male slings in severe UI, radiated patients, and non‐radical prostatectomy patients is still unclear. Further study is needed to try and define criteria for the use of male slings, and to directly compare different procedures.

     

Real-time magnetic resonance imaging (MRI): anatomical changes during physiological voiding in men

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Micturition cysturethrography or video urodynamics can show sequences of the micturition cycle, but are limited to show all participating structures at one. MRI is a non invasive imaging methodology to describe the anatomy of physiological voiding or voiding dysfunction. In our study we provide preliminary insight in anatomical changes in the lower urinary tract during physiological micturition in males. This imaging methodology may help detecting anatomical differences in individuals with voiding disorders. Further, we presume that the vertical contraction of the ventral prostate seem to contribute to the initiation of successful micturition, additionally to the funnelling of the bladderneck.

OBJECTIVE

• ? To investigate the interactions between the bladder, urethra, pelvic floor and the function of the prostate during ‘normal’ voiding.

PATIENTS AND METHODS

• ? In all, 16 men with no history of urinary incontinence, urgency or obstructive voiding dysfunction were enrolled. We analysed the interaction between the bladder, urethra, pelvic floor and changes in the prostate during the Valsalva manoeuvre and voiding using real‐time magnetic resonance imaging (rtMRI).
• ? The axis through the external sphincter (AES) to pubo‐coccygeal line (PC‐line) and the angle between the axis of the os pubis (AOP) and ventral prostate (VP) was measured before and at the end of voiding. Additionally, the angle between the AOP and the VP was measured during the Valsalva manoeuvre.
• ? Change of position, or contraction, of the VP was measured.

RESULTS

• ? The mean age of the men was 69.8 years and mean prostate volume 33.1 mL.
• ? Before voiding, the mean AES to PC‐line was 10.5 mm. At the end of voiding, the mean AES to PC‐line was 20 mm.
• ? The mean angle between AOP/VP was 31.6° in the storage phase and increased to a mean of 54.5° during voiding.
• ? During the Valsalva manoeuvre, the angle between the AOP/VP remained constant.
• ? There was a mean vertical contraction of the VP of 48.25 mm before voiding and a declining of the cranio‐caudal distance of the VP with a mean of 33.92 mm during voiding.

CONCLUSIONS

• ? All the men in our study showed relaxation of the pelvic floor, followed by a descent of the bladder neck. Voiding could not be initiated unless the prostate rotated around the symphysis.
• ? The study suggests that both the rotation and a vertical contraction of the prostate precede voiding.
• ? The anatomy of physiological voiding or voiding dysfunction can be investigated non‐invasively using rtMRI.