Muscular,myocutaneous, and fasciocutaneous flaps in complex urethral reconstruction

The ability to achieve a long-term, stable, stricture-free, hairless urethral lumen in patients with complex anterior stricture and compromised genital skin is one of the ongoing challenges of reconstructive urologic surgery. The conservative approach by endoscopic urethrotomy or dilatation with a self-catheterization schedule rarely affects a definitive cure except in the short filmy superficial strictures of the bulbous portion of the urethra. Genital fasciocutaneous island flaps are currently the golden standard for definitive, reliable resolution of anterior urethral strictures in patients who have not undergone a prior surgical procedure that may alter the penile or scrotal circulation, or those with skin loss from trauma, decubiti, radiation, or balanitis xerotica obliterans.     

Electrical stimulated graciloplasty in the male goat: An animal model for urethral pressure measurement

The feasibility of dynamic urinary graciloplasty as a treatment for incontinence is currently investigated. Therefore an animal model is developed to improve the technique of dynamic urinary graciloplasty. This article is a report of the urethral pressure measurements in the male goat. This study compares the graciloplasty around the bulbous urethra with the graciloplasty around the bladderneck. The male goat as an animal model of urethral pressure measurements is discussed. Under anaesthesia in ten male goats the penile shaft outside the pelvis was dissected. Urethral pressure profilometry was performed. The bulbous urethra was dissected and a split sling graciloplasty was performed around the bulbous urethra. The contralateral gracilis was used for bladderneck graciloplasty. Urethral pressure profilometry was done without and with electrical muscle stimulation. The highest native urethral pressure was 136 cm water at the pelvic outrance. Without stimulation the bladderneck graciloplasty pressure was 97 cm water. The bulbous urethra graciloplasty pressure was 122 cm water. These pressures were not significantly different from the pelvic outrance pressure. With stimulation the highest bladderneck and bulbous urethra graciloplasty pressures were 183 cm water and 294 cm water respectively. The stimulated bulbous urethra graciloplasty pressure was significantly higher than the highest native urethral pressure. In conclusion, the male goat is a suitable animal model for urethral pressure measurement. The highest native urethral pressure is located at the pelvic outrance. A nonstimulated graciloplasty acts like a sling with regard to generated urethral pressure. With stimulation sphincterlike activity of the graciloplasty can be observed. In male goats the graciloplasty around the bulbous urethra is superior to the bladderneck graciloplasty. © 1996 Wiley-Liss, Inc.     

Primary anastomosis for complete bulbar urethral rupture with rectal laceration caused by straddle injury: A case report

IntroductionThe initial management of urethral trauma remains disputed, and there are several suitable techniques, including delayed repair and suprapubic urinary diversion as well as primary endoscopic or open alignments. The treatment choice used depends on the rupture’s location and length as well as the accompanying trauma.Case presentationA 33-year-old male patient was referred to the department of emergency, with the chief complaint of inability to void experienced 1 day before being admitted, after falling from a height of approximately three meters. There was a laceration to the perineum 3 cm long to the rectum, with no active bleeding. After the incident, the patient could not void, but the lower abdomen was not painful. Upon retrograde urethrography examination, contrast extravasation of the bulbous urethra was seen through the anorectal laceration. Immediate debridement and repair for the anorectal wound, then primary anastomosis for the bulbous urethra, was performed.DiscussionThe likelihood of an injury to the anterior urethra increases with certain clinical features, including blood in the urethral meatus, palpable bladder distention, and a butterfly appearance on the perineum. Immediate exploration and reconstruction of the urethra is recommended in urethral traumas associated with penile fractures and non-life-threatening penetrating injuries. Furthermore, small lacerations are repaired primarily, while total ruptures are treated with anastomosis.ConclusionProper identification and management of urethral rupture determines the outcome. Initial urethral trauma management is disputed; however, a bulbous urethra rupture with anorectal lacerations can be treated safely and effectively with primary anastomosis.     

An unusual complication of penile prosthesis following urethroplasty

We report a case of an adult who had undergone transpubic urethroplasty for a 5-cm long posterior urethral stricture. A malleable penile prosthesis (AMS 600R) was implanted 19 months later for the trauma-related impotence. The patient was discovered to develop a complete obliteration of the urethra after removal of infected penile prosthesis 18 months later. Perineal urethroplasty cured his restricture. Suggestions are made to prevent urethral restricture if penile prosthesis is required after urethroplasty.     

Management of impacted urethral stones in children

Objective: To find out the clinical presentation, site of impaction, management and outcome of children presenting with urinary retention due to urethral stone. Study Design: Case series. Place and Duration of Study: Surgical Unit B of National Institute of Child Health (NICH), Karachi, from April 2009 to January 2010. Methodology: All the patients under the age of 12 years, who presented with urinary retention due to impacted urethral stones were included. Urinary retention due to other causes like trauma, stricture, pelvic masses etc. were excluded. Diagnosis was made on clinical examination (palpable stone in penile urethra) and with the help of radiology. Surgical procedure was tailored according to the site of impaction in urethra. All stones were sent for chemical analysis and patients were followed in Nephrology OPD (stone clinic) for further work-up. Results: There were a total of 19 patients with mean age of 3.94 ± 2.27 years. All were males. Twelve patients (63.1%) had stones impacted in anterior urethra while 7 (36.9%) were found in posterior urethra. Stones in penile urethra were removed in emergency either by meatotomy (when impacted at urethral meatus, n = 3) or following initial supra-pubic decompression of urinary bladder (using wide bore cannula) by urethrolithotomy (n = 6). Stones in bulbous (n = 3) and posterior urethral (n = 7) locations were pushed back into bladder and later removed on elective list by supra-pubic vesicolithotomy. No patient had proximal urinary tract calculi on further work-up. All patients remained well except one who developed retention of urine after a week of discharge. He had urinary tract infection and was treated with antibiotics. All the stones were of calcium oxalate type. Conclusion: Urethral stones must be kept in differential diagnosis in a child who presents with acute urinary retention. Clinical examination can identify causes in significant number of cases. Simple procedures like meatotomy, supra-pubic bladder decompression and urethrolithotomy can relieve the misery in these children.     

Urethral injury in the multiple-injured patient

A total of 74 patients with urethral injury due to external trauma consisted of 48 posterior urethral injuries (25 complete rupture, 23 partial rupture) and 26 anterior urethral injuries (two complete rupture, 16 partial rupture, and eight contusion). The diagnosis was made by retrograde urethrography. All 48 patients with posterior urethral injury had associated injuries, including a fractured pelvis in 46, and a mortality rate of 33%. Only seven of the 26 patients with anterior urethral injury had associated injuries and a mortality rate of 14%. The management of posterior urethral injury is changing from primary realignment of the ruptured urethra to suprapubic cystostomy alone and followed later by urethral surgery for the resulting stricture. The impotence rate is significantly lower with management with suprapubic cystostomy alone. However, the type of pelvic fracture, the urethral injury itself disrupting neurovascular structures, and the surgical dissection (initial primary realignment or delayed urethroplasty) must be investigated before it can be determined whether the impotence associated with pelvic trauma is caused by the injury itself or by the surgical dissection undertaken to reconstruct the urethra.     

Management of urethral lesions in penile blunt trauma

BACKGROUND: Traumatic lesions to the penis may extend into the corpus spongiosum, causing laceration or complete transection of the urethra. Blunt penile trauma is usually related to sexual intercourse or manipulation. The aim of this paper was to report the authors experience with the management of urethral injuries in patients with penile blunt trauma. METHODS: The charts from 77 patients with penile blunt trauma were retrospectively reviewed, and the cases associated with urethral injuries associated were selected. Patient age ranged from 18 to 63 years (mean 33 years). RESULTS: From 77 cases assessed, 11 (14.2%) patients had urethral injury, 62 (80.5%) had injury of the corpora cavernosa and four (5.2%) had injury of the dorsal vein. The etiology of urethral injuries was sexual intercourse in 10 patients (91%) and direct trauma to the flaccid penis in one patient (9%). A partial urethral disruption was presented in eight patients (72.8%) and a total disruption in three patients (27.2%). Preoperative urethrogram was performed in seven patients with a suspicion of urethral trauma. When a partial injury was present the urethra was closed over the catheter, and in the presence of a total injury an end-to-end anastomosis was performed. CONCLUSION: The data support the reported incidence of urethral injury associated with blunt penile trauma. No clinically apparent urethral structures were appreciated with primary urethral repair after a follow up of more than 6 months.     

Intracavernous therapy in impotence after pelvic trauma. A preliminary study

Pelvic trauma, especially when complicated by a posterior urethral disruption, may cause impotence in 50% of patients. The treatment of this kind of impotence has always been troublesome for the urologist. In fact penile prostheses or the revascularization procedures have sometimes been failures. We present a series of 6 patients with impotence after pelvic trauma managed by intracavernous injection of papaverine and we describe here the preliminary results obtained.     

Urethral condyloma acuminata following urethral instrumentation in an elderly man

A 70-year-old man had undergone urethral dilatation with bougie for 8 months following transurethral resection of the prostate and complained papillary masses at the urethral meatus. Physical and endoscopic examination revealed multiple tumors from the urethral meatus to the bulbous urethra. These tumors were resected transurethrally and 5-FU cream was instilled into urethra. Microscopic examination revealed urethral condyloma acuminata. Human papillomavirus types 6/11 were detected in the condylomas. As high prevalence rate of genital human papillomavirus was reported in penile skin of healthy men, urethral instrumentation including transurethral surgery might cause dissemination of penile skin human papillomavirus into the urethral lumen.     

Pelvic fracture urethral injuries: the unresolved controversy

PURPOSE: The unresolved controversies about pelvic fracture urethral injuries and whether any conclusions can be reached to develop a treatment plan for this lesion are determined. MATERIALS AND METHODS: All data on pelvic fracture urethral injuries in the English literature for the last 50 years were critically analyzed. Studies were eligible only if data were complete and conclusive. RESULTS: The risk of urethral injury is influenced by the number of broken pubic rami as well as involvement of the sacroiliac joint. Depending on the magnitude of trauma, the membranous urethra is first stretched and then partially or completely ruptured at the bulbomembranous junction. Injuries to the prostatic urethra and bladder neck occur only in children. Injury to the female urethra usually is a partial tear of the anterior wall and rarely complete disruption of the proximal or distal urethra. Diagnosis depends on urethrography in men and on a high index of suspicion and urethroscopy in women. Of the 3 conventional treatment methods primary suturing of the disrupted urethral ends has the greatest complication rates of incontinence and impotence (21 and 56%, respectively). Primary realignment has double the incidence of impotence and half that of stricture compared to suprapubic cystostomy and delayed repair (36 versus 19 and 53 versus 97%, respectively, p <0.0001). CONCLUSIONS: In men surgical and endoscopic procedures do not compete but rather complement each other for treatment of different injuries under different circumstances, including indwelling catheter for urethral stretch injury, endoscopic stenting or suprapubic cystostomy for partial rupture, endoscopic realignment or suprapubic cystostomy for complete rupture with a minimal distraction defect and surgical realignment if the distraction defect is wide. Associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair but does not necessarily indicate exploration of the urethral injury site. In women treatment modalities are dictated by the level of urethral injury, including immediate retropubic realignment or suturing for proximal and transvaginal urethral advancement for distal injury.     

Urethral injury due to external trauma

Fifty-six patients with urethral injuries comprised 35 involving the posterior urethra and 21 involving the anterior urethra. Immediate retrograde urethrography confirmed the clinical diagnosis made when blood was found at the external urinary meatus after external trauma. Traffic accidents caused most of the posterior urethral injuries and were associated with severe injuries to multiple systems and a significant mortality rate (34 per cent). Primary realignment of the urethral injury by a urethral catheter in all cases of urethral rupture (plus a suprapubic cystostomy in most of these cases) resulted in a stricture rate of 62 per cent on follow-up. However, only half of these strictures required surgical correction. The incidence of incontinence was 10 per cent and of impotence 38 per cent.     

Experiencia en reconstrucción postraumática de uretra posterior en niños. Hospital Universitario San Vicente de Paúl. Medellín 1987-2007

ObjectiveIn order to evaluate the efficacy of different surgical techniques for the correction of traumatic lesions of the urethra, we performed a retrospective study in those patients, and evaluated different complications such as postsurgical stenosis of the urethra, incontinence and impotence (erectile dysfunction).MethodsA retrospective study was conducted, reviewing the clinical charts of 43 patients admitted to the San Vicente of Paul Hospital, with diagnosis of traumatic rupture of the posterior urethra from 1987 to 2007. We analyzed different demographic data, type of surgical correction, early and late complications.ResultsThe average age of the patients was 7.7 years, the average follow up was 30.6 months, and all the patients were male with a posterior urethral rupture.27 Patients underwent a primary urethral repair (63%), 13 patients underwent a cistostomy with later urologic reconstruction (30%), in 3 patients (7%) other surgical procedures were made.Overall complication rate was 39.5%. These complications were: Urethral stenosis, 26 patients (60.5%), urinary retention secondary to obstruction, 10 patients (23.3%), incontinence 10 patients (23.3%) and impotence 7 patients (16.3%).Patients treated with a primary urethral repair presented a significantly less development of infection, obstruction and stenosis. (p<0.05). Patients with pelvis fracture associated to urethral trauma had a significant higher risk of developing stenosis and impotence. (p<0.05).ConclusionsBoth different surgical techniques compared showed a similar complication and morbidity rates in middle follow up. Each procedure should be selected according to clinical condition of the patient, the extension of the urethral damage, the associated traumatic lesions and the surgeon`s expertise. In our searched patients, treated with a primary urethral repair we found a significantly less development of infection, obstruction and stenosis.Keywords: Trauma of urethra posterior. Children. Primary urethral repair. Cistostomy with later urologic reconstruction.     

Malignant priapism associated with metastatic urethral carcinoma

We present a 40-year-old man with malignant priapism secondary to urethral squamous cell carcinoma. Magnetic resonance imaging revealed the tumor originating from the bulbous urethra, extending into the penile urethra and corpora spongiosa and cavernosa. A penile biopsy confirmed poorly differentiated squamous cell carcinoma of the urethra. Despite administration of systemic chemotherapy, the prognosis of the patient has worsened due to the extensive metastatic disease.     

New surgical approach for operative management of penile fracture and penetrating trauma.

We have seen 2 cases of penile fracture and 2 of penetrating penile trauma without urethral injury surgically managed with an incision originally described for the operative treatment of venogenic impotence. This incision afforded excellent exposure of all three corporeal bodies and facilitated operative repair. Postoperative results were excellent with return of normal erectile function, minimal edema, and a well-healed, barely visible scar. This incision represents another operative approach for the surgical management of penile fracture and penetrating trauma when urethral injury is not present.     

Location of urethral arteries by colour Doppler ultrasound

STUDY DESIGN: A case report. SETTING: Regional Spinal Injuries Centre, Southport, UK. CASE REPORT: A 56-year-old male with complete paraplegia at T-4 underwent visual internal urethrotomy of bulbous urethral stricture with a cold knife at 12 o'clock position. There was brisk arterial bleeding. Despite receiving antibiotics, this patient developed hypotension, tachycardia and tachypnoea. He was resuscitated and mechanical ventilation was instituted. After he recovered from this life-threatening episode of urinary tract-related sepsis, colour Doppler ultrasound imaging of bulbous urethra was performed to locate urethral arteries. In the bulbous urethra, single urethral artery was seen at 12 o'clock position. CONCLUSION: Since the sites of urethral arteries vary among patients, it is advisable to assess individually the location of urethral arteries preoperatively and plan the site of incision accordingly. Persons with injury to cervical or upper dorsal spinal cord have decreased cardiac and respiratory reserve as well as alteration in immune function. Therefore, all possible measures should be taken to prevent acute blood loss and bacteraemia in this group of patients.     

Treatment of urethral stricture by free full-thickness skin graft (Devine) urethroplasty

Eighteen patients with urethral stricture were treated with Devine urethroplasty and were followed for a period of nine to thirty-six months. There was one failure, and 15 patients had good or excellent results with one operative procedure. A second surgical procedure was performed in two patients with a good end-result. The procedure is applicable to strictures of any length and may be used for strictures in the anterior and bulbous urethra. It may be used also for strictures extending into the membranous urethra.     

Trauma to the anterior urethra: diagnosis and management

Injuries to anterior urethra are uncommon, mainly due to blunt trauma, and rarely associated with pelvic fractures or life threatening multiple lesions. Straddle type injury is the most frequent lesion, in which the immobile bulbar urethra is crushed or compressed on the inferior surface to the pubic symphysis. Diagnosis of urethral injury is easy, suspected due to trauma circumstances, presence of urethrorragy or initial hematuria, and eventually difficult micturition and penile scrotal for perineoscrotal hematoma. It should always be confirmed and classified by retrograde urethro-gram, realized either immediately or after a few days. Initial acute management is suprapubic cystostomy, if possible before any attempt of urethral catheterization or miction. Urethral contusions only require this urinary diversion or urethral catheter for a few days and usually heal without any sequelae. Management of partial and complete disruptions remains controversial: suprapubic diversion only and secondary endoscopic or open surgical repair of the urethral stricture that occurs in the great majority of the cases (always after complete disruption), early endoscopic realignment and prolonged urethral catheterization (4 for 8 weeks according to the lesion), in partial disruptions, more controversial in complete disruptions; delayed (after a few days) open surgical repair (urethrorraphy) that is the preferred European and French attitude for complete disruptions. Penetrating anterior urethral trauma and urethral lesions associated with penile fracture require immediate surgical exploration and repair if possible. After anterior urethral disruption, the main morbidity is urethral stricture very often requiring surgical treatment (visual urethrotomy if the structure is short, end to end spatulated urethrorraphy, flap or graft urethroplasty if longer).     

Penile fracture repair: assessment of early results and complications using color Doppler ultrasound

The aim of this study was to determine early results and complications of penile fracture treated with immediate surgical repair by means of color Doppler ultrasound study. Four patients with the clinical features of penile fracture were submitted to immediate surgical exploration via a subcoronal incision with repair of the torn cavernosal albuginea (unilateral in three cases, bilateral in one case) and anastomosis of the transected urethra (one case). Color Doppler ultrasound (CDUS) was performed by means of an Acuson 128XP/10 using a 7-10 MHz extended frequency linear array transducer. Erectile function at five months follow-up was reported as normal by two patients (age 59 and 55 y), slightly decreased in one case (bilateral partial cavernous fracture + total urethral transection in a 32 y old) and weak in one case (51 y old). In the latter two, the investigation included a dynamic phase following a 10 mcg PGE injection. B-mode ultrasound showed no fibrotic changes in relation to the long-term absorbable suture material. Baseline CDUS demonstrated full length integrity of the cavernous arteries in all patients. The CDUS dynamic study was entirely normal in the patient with weak erection while showed a continuous venous leak in the patient with bilateral cavernosal rupture and transected urethra. We conclude that despite the onset of erectile failure in two out of four patients, there was no evidence of arteriogenic impotence in any patients with major penile fracture and thus we advocate early simple repair without any microsurgical exploration of the cavernosal arteries.     

尿道板矫形术治疗先天性尿道下裂11例报告

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

Anterior urethral valves in the fossa navicularis in children

Anterior urethral valves are an uncommon cause of lower urinary tract obstruction in children. They have been noted in the bulbous (40 per cent) and penile (30 per cent) urethra, and at the penoscrotal junction (30 per cent). None has been reported in the fossa navicularis. We encountered 3 cases in which anterior valves were located in the glanular urethra. This entity may be misdiagnosed as meatal stenosis and without a high index of suspicion it might be overlooked. The combination of distal obstruction and a normal urethral meatus should lead one to suspect this entity. Observation of the voided stream is extremely helpful in the diagnosis, since voiding urethrography often fails to include the penile tip and urethroscopy of the distal urethra often is unsatisfactory. Treatment can be performed either transurethrally or by excision through the meatus.