One-stage urethral reconstruction for stricture recurrence after urethral stent placement

PURPOSE: We report our 8-year experience with 1-stage open urethral reconstruction in 10 patients with recurrent bulbar and/or membranous strictures after UroLume urethral stent placement. MATERIALS AND METHODS: Ten consecutive referral patients underwent preoperative contrast imaging and urethroscopy followed by primary anastomotic repair or substitution urethroplasty, with concomitant open UroLume removal (when the stent was still present). Postoperative evaluation included contrast imaging 3 weeks after surgery, urethroscopy 4 months after surgery, uroflowmetry, and American Urological Association symptom score assessment. RESULTS: At a medium followup of 51.2 months all patients remain free of bulbar or membranous stricture recurrence. No patient has required dilation or any other intervention. CONCLUSIONS: One-stage open reconstruction with stent extraction offers a definitive treatment option with a high success rate for patients with recurrent bulbar and/or membranous strictures following urethral stent placement.     

UroLume stents: lessons learned

PURPOSE: The UroLume (American Medical Systems, Minnetonka, Minnesota) endoprosthesis has been commercially available since 1990 and has been advocated for use in men with urethral stricture disease and detrusor-sphincter dyssynergia due to spinal cord injury. Despite reports of its success and ease of removal, we have noted management problems in several complex cases. MATERIALS AND METHODS: We retrospectively analyzed the outcome of 10 men who required several additional procedures or experienced complications following UroLume placement. RESULTS: Of the patients 4 had detrusor-sphincter dyssynergia and 6 had urethral stricture disease. All patients with detrusor-sphincter dyssynergia required hospitalization for management of urosepsis within 4 to 10 months of stent placement, and all 4 experienced stent migration requiring placement of a tandem stent (3), bladder neck resection (3) or sphincterotomy (1). Two men were in retention following placement of a second stent and required stent explantation. Of the other 6 men 2 had bulbar and 3 had membranous urethral disease, and 1 had a severe bladder neck contracture following radical retropubic prostatectomy. Strictures recurred within the stent lumen in all 6 men and/or adjacent to it in 3. At least 1 repeat procedure was required in all 6 men (within 6 months in 5), and 1 experienced significant bleeding during open explantation which required perineal urethrostomy. CONCLUSIONS: In our referral experience stent migration and recurrent stenosis were noted following UroLume insertion. Placement of a tandem stent was associated with urethral obstruction. In many cases these adverse outcomes may be secondary to improper patient selection. Therefore, judicious use of the UroLume stent and proper case selection are essential since stent removal is not always straightforward.     

Experience with urethral stent explantation

PURPOSE: We examined the timing, causes and results of the explantation of UroLume (American Medical Systems, Minnetonka, Minnesota) urethral stents. MATERIALS AND METHODS: The North American Study Group enrolled 465 patients in a trial of UroLume stent placement, including 69 (14.8% of the series) who required removal of a total of 73 stents (15.6% of stents) in 7 years. The time of explantation, reason for stent removal and local histological findings were determined from patient charts and reviewed in relation to the indication for stent placement. RESULTS: In patients treated for bladder outlet obstruction secondary to benign prostatic hyperplasia 23% of the stents were removed, as were 5% of those implanted in patients with bulbar urethral stricture and 22% of those in patients with detrusor-sphincter dyssynergia (see figure). Of the explantations 43.8% were done during year 1. Migration and/or inappropriate placement was the cause in 38.4% of cases. The most common stent site tissue finding was focal inflammation with a hyperplastic tissue response. Stent specific malignant changes were not observed. Stent removal was feasible with no sequelae. CONCLUSIONS When used appropriately, the UroLume endoprosthesis has a low incidence of failure. Stent removal is technically feasible and options are available for subsequent therapy. Local tissue reaction is minimal.     

Tubularización e incisión de la placa uretral para reparación de hipospadias distal primario en 473 casos: evaluación de los resultados según la cobertura y el tipo de sonda

AimWe have previously employed the tubularized incised plate (TIP) repair technique in distal hypospadias cases with a few modifications because of its excellent cosmetic results. In this study, we aimed to evaluate the effects of spongioplasty and dorsal dartos flaps, in addition to short urethral stents on the outcomes of TIP repair.Materials and methodsOnly distal hypospadias cases were involved in this study. Eligible patients were divided into two groups: group A included patients repaired with both spongioplasty and dorsal dartos flap placement, while group B included patients repaired with dorsal dartos flap placement alone. Group A was further divided into two subgroups according to the type of catheter used (bladder catheter or short urethral stent).ResultsA total of 473 patients were included in this study. There was no statistically significant difference observed in the complication rates between the two groups. In Group A, a bladder catheter was used in 107 patients and a short urethral stent was used in 135 patients. When the results of the two groups were compared, there was no statistically significant difference.ConclusionsSpongioplasty could be combined with dorsal dartos flap placement to reduce the need for dorsal plication rather than to reduce the fistula rate. Short urethral stents can be used safely with no postoperative effects in children who have completed toilet training.     

Radical bulbar dissection to correct severe chordee and proximal hypospadias

PURPOSE: We describe a technique of proximal hypospadias correction that involves freeing the proximal normal bulbar urethra from perineal attachments to lengthen the ventral penis and decrease chordee. MATERIALS AND METHODS: Correction was performed in 9 patients with a mean age of 11.5 months who had proximal hypospadias and severe chordee that was perineal in 2, mid scrotal in 6 and penoscrotal in 1. After the penis was degloved the bulbar urethra was detethered to or beyond the perineal body without lifting the urethra from the corpora cavernosa. Any remaining penile chordee was corrected and the urethral plate was transected only when chordee persisted. When the urethral plate was intact and the penis straight, tubularized incised plate urethroplasty was done to correct hypospadias in 1 stage. Otherwise 2-stage repair was performed. RESULTS: Using this maneuver penile straightening was achieved in 2 of the 9 patients, resulting in a glanular urethral or penoscrotal meatus. Dorsal plication sutures required in 4 cases resulted in a mid shaft and penoscrotal meatus in 1 and 3, respectively. Residual chordee in the remaining 3 patients necessitated division of the urethral plate and 2-stage repair despite aggressive mobilization of the proximal urethra. Simultaneous tubularized incised plate urethroplasty was then performed in the 4 penoscrotal and 1 mid shaft meatus. All 6 patients who underwent a successful 1-stage procedure have excellent cosmetic results, while 1 required meatotomy. No fistula or chordee was present at a mean of 13.8 months of followup (range 3.9 to 27.1). CONCLUSIONS: This safe, rapid technique may compensate for significant penile tethering and chordee in a subpopulation of patients with proximal hypospadias, such as 6 of the 9 in our study. It also allows successful tubularized incised plate urethroplasty to be done simultaneously.     

5对孪生子尿道下裂的尿道修复术

目的 探讨孪生子尿道下裂的临床特点及尿道修复术疗效.方法 自1997年1月至2009年9月本院收治的5对孪生子的尿道下裂患者,进行一期尿道修复术,其中6例应用镍钛记忆合金尿道支架行尿道再造.结果 5对孪生子患者随访6个月～3年,术后尿瘘1例,尿道憩室1例,总并发症发生率为20.0%,其中6例应用镍钛合金尿道支架者无尿瘘、尿道狭窄等并发症,其余患者排尿通畅而无尿瘘,阴茎无下弯畸形,尿道口位置良好.结论 镍钛记忆合金尿道支架可减少尿道下裂术后并发症的发生,尿道下裂患者如有孪生背景者,需鉴别是否为同卵双生,有利于进一步的病因分析,对双胎共患者建议同期行尿道修复术.     

镍钛尿道支架管在尿道下裂修复术中的作用

目的探讨镍钛记忆合金尿道支架管在预防尿道下裂术后尿瘘及尿道狭窄中的作用.方法 2001年1月～2004年12月,应用镍钛记忆合金尿道支架管作为尿道支架修复63例尿道下裂,其中阴茎近端型19例,阴茎阴囊型22例,阴囊会阴型8例,为一期尿道重建;尿道下裂术后尿瘘行尿瘘修补术10例;尿道下裂术后尿道狭窄再次重建尿道4例.结果 63例伤口均Ⅰ期愈合,术后获随访2个月～2年,排尿通畅,均无尿瘘和尿道狭窄发生.其中62例于术后2～3个月后拔除尿道支架,1例于12个月后拔除.结论镍钛记忆合金尿道支架管可有效预防尿道下裂术后尿瘘及尿道狭窄的发生.     

Hypospadias repair without a bladder drainage catheter

We report on 44 consecutive patients who underwent 1-stage hypospadias repair based on a urethral splent (silicone pleated stent). The severity of hypospadias ranged from subcoronal in 12 cases and distal in 23 to midshaft in 4 and penoscrotal in 5. In the first 15 patients of this series the splent was used with a suprapubic tube. All patients were able to void within the first 36 hours postoperatively. The next 29 patients underwent repairs without the use of a bladder catheter, including 15 who had outpatient procedures. None of the 44 patients has required subsequent catheterization or hospitalization. There have been 2 fistulas in this series. The urethral splent permits normal voiding through and drainage of the neourethra in a variety of hypospadias repairs. The splent expands and contracts with the degree of edema and permits catheterization should this be necessary. The advantages of hypospadias repair without bladder drainage, such as short hospital stay, total ambulation, and decreased potential for infection and bladder spasm, can be realized with the use of a urethral splent.     

Long-term results of permanent urethral stent Memotherm implantation in the management of recurrent bulbar urethral stenosis

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Milroy reported 84% success at a mean of 4.5 years follow‐up by usage of a permanently implantable “urolume” spent in 1993. Memotherm was developed later, especially for urologic use. Our study is one of the largest in this urea, with a high number of patients and a long follow‐up period.

OBJECTIVE

? To evaluate the effectiveness and long‐term results of permanent urethral stent (Memotherm) implantation in the treatment of recurrent bulbar urethral stricture.

PATIENTS AND METHODS

? In all, 47 patients with a history of previous unsuccessful treatment for bulbar urethral stricture were treated using Memotherm bulbar urethral stents between 1998 and 2002. ? Long‐term follow‐up data was analysed and discussed.

RESULTS

? At the end of the 7‐year period 37 of 47 patients (78.7%) had been treated successfully. ? Post‐micturition dribbling incontinence lasting up to 3 months after stent placement occurred in 32 (68.1%) patients, but this was reduced to only seven patients (14.9%) by the 7‐year follow‐up. ? There was stress incontinence of various severities in nine (19.2%) patients at the 1‐year follow‐up. These patients were those who had stenosed urethral segments adjacent to the external sphincter. At the long‐term follow‐up <10% of the patients had stress incontinence complaints.

CONCLUSION

? Memotherm is a good treatment option in patients with recurrent bulbar urethral stricture of any cause.     

De-epithelialized scrotal flap in repair of urethrocutaneous fistula and hypospadias

Eight cases of closure of urethrocutaneous fistula and 15 cases of urethroplasty for hypospadias are reviewed. Most of the fistulas were present in the penoscrotal level. Fistula and hypospadias opening were closed by re-enforcement using a de-epithelialized scrotal skin flap. Of 8 patients with fistula, there was no recurrence, and 3 procedures were performed without urinary diversion or urethral stent. Of 15 patients with hypospadias, there was no fistula formation in the original urethral opening area but a fistula distal to the original urethral opening developed in 3 patients. This technique is satisfactory in repairing complicated as well as noncomplicated urethrocutaneous fistula and can be done without urinary diversion or urethral stent. It appears to be useful in reducing fistula formation following urethroplasty in hypospadias or urethral fistula repair.     

The use of octyl cyanoacrylate (superglue) in hypospadias repair including its use as a fixator for urethral stents

Background

Octyl cyanoacrylate has been used for many years for simple skin closure, but its use in hypospadias repair and as a urethral stent fixator has not been previously reported. We report our experience.

Method

A retrospective study was performed of all children undergoing hypospadias surgery from July 2007 to July 2011. Octyl cyanoacrylate was used for skin closure after placing a few sutures to align the skin edges. No other dressing was used. A urethral stent, if used, was glued to the penis and removed after one week.

Results

Seventy two procedures were performed on 37 patients. Eight distal hypospadias (22%) underwent single stage repair. Seventeen (46%) underwent staged repair for severe hypospadias, and twelve (32%) “hypospadiac cripples” underwent various salvage procedures.One patient (1/72) had partial dehiscence, and one stent dislodged. There were no wound infections. Four (4/25) tabularized urethroplasties developed a fistula (16%).

Conclusion

Octyl cyanoacrylate is easy to apply on difficult hypospadias contours. It forms a strong, waterproof adhesive bond which separates from epithelial surfaces in 7 to 10 days and makes it an effective urethral stent fixator and an ideal dressing for hypospadias surgery.     

尿道下裂尿道成形术后尿道狭窄的处理

目的 探讨尿道下裂尿道成形术后尿道狭窄的病因及治疗方法。方法 对１９８５－１９９８年７７例尿道下裂术后尿道狭窄患者的临床资料进行回顾性分析。结果 单纯尿道扩张９例,治愈２例（２２％）;尿道扩张放钛镍合金支架２２例,治愈１７例（７７％）;狭窄段尿道切开皮肤造瘘２３例,其中１８例行二期尿道成形术,治愈１６例;５例待手术;切开狭窄段同期尿道成形术２３例,治愈１２例。     

Management of Urethral Stent Failure for Recurrent Anterior Urethral Strictures

Background

Urethral stent placement for recurrent anterior urethral strictures may cause restenosis and complications.

Objective

To describe our experience with patients who had restenoses and complications following urethral stent placement for the treatment of recurrent anterior urethral strictures.

Design, setting, and participants

We evaluated retrospectively the records of 13 men with anterior urethral stricture who experienced restenosis and complications after stent insertion. We recorded stent position, prestent and poststent urethral procedures, restenosis location, stent-related complications, and management of stent failures.

Surgical procedure

The stent was removed en bloc with the whole strictured urethral segment or wire by wire after a ventral or a double-ventral plus dorsal-sagittal urethrotomy and stent section.

Measurements

Successful outcome was defined as standard voiding, without need of any postoperative procedure, and full recovery from complications.

Results and limitations

Four patients did not undergo surgery and the stent was left in situ. Of these patients, two required permanent suprapubic cystostomy. Nine patients underwent challenging surgical stent removal and salvage urethrostomy: After the first stage, three patients are waiting for further reconstructive steps, five elected the urethrostomy as a permanent diversion, and one completed the staged reconstruction using a buccal mucosa graft at the second stage. After surgery, seven of the nine patients (77.8%) were free of strictures and stent-related complications, while a restenosis occurred in two of the nine (22.2%) cases.

Conclusions

The management of urethral stent failure represents a therapeutic challenge. The stent risks converting a simple stenosis into a complex stenosis requiring a staged urethroplasty, a definitive urethrostomy, or a permanent suprapubic diversion.     

镍钛记忆合金尿道支架管在尿道下裂修复中的应用（附128例报告）

目的：探讨镍钛记忆合金尿道支架管在尿道下裂修复中的优点及应用前景。方法：2007年1月～2010年6月应用镍钛记忆合金尿道支架管作为尿道支架修复128例尿道下裂患者,均为一期尿道重建。结果：术后1～3个月自行脱落或拔除尿道支架,所有患者随访6～24个月,7例出现尿瘘,1例术后发生尿道狭窄,其余均获成功,手术成功率为93．75％（120／128）。结论：镍钛记忆合金尿道支架管可有效预防尿道下裂术后尿瘘及尿道狭窄的发生。     

Long-term results of a self-expanding wallstent in the treatment of urethral stricture

OBJECTIVE: To report the long-term outcome over 12 years of using the urethral Urolume wallstent (AMS, Minnetonka, MI, USA) for treating recurrent bulbar urethral stricture disease. PATIENTS AND METHODS: The case-notes of 60 consecutive men with urethral Urolume wallstents placed for treating recurrent bulbar strictures were reviewed retrospectively. Information was collected on patient demographics, stricture aetiology, stent-related complications and the need for further surgery to treat stent- or stricture-related complications. RESULTS: The mean (range) age of the men was 58 (32-76) years. The most common cause of stricture was iatrogenic, arising after previous endoscopic surgery or after an indwelling catheter (45%). Thirty-five men had complications, with re-operation required in 27 (45%) of them. The most frequent nonsurgical complications were post-micturition dribble (32%) and recurrent urinary tract infections (27%). The most common surgical interventions required were transurethral resection of obstructing stent hyperplasia (32%), urethral dilatation or urethrotomy for stent obstruction or stricture (25%) and endoscopic litholapaxy for stent encrustation or stone (17%). CONCLUSIONS: The Urolume wallstent should only be used in patients who are unfit for or who refuse a bulbar urethroplasty.     

Urethral catheter induced pseudoaneurysm of the bulbar artery

Injuries of the urethra due to urethral catheter have been well recognised. We report a case of pseudoaneurysm of the artery to the bulb of the penis which formed due to necrosis of the arterial wall secondary to prolonged pressure due to a wrongly placed urethral catheter. The catheter was inflated in the bulbar urethra and left during surgery for 4 hours. The patient developed intermittent severe urethral bleeding. An angiogram of internal iliac artery showed a pseudo aneurysm involving the bulbar artery with arteriovenous communication. Super selective embolization of the feeding vessel was performed with cessation of the blood fl ow immediately. To our knowledge, pseudoaneurysm of the bulbar artery of penis has not previously been described.     

Urethral stricture in children: treatment by urethroplasty with bladder mucosa graft.

Urethral strictures in children, which are not frequent, often require urethroplasty when dilations and/ or urethrotomies have failed. A bladder mucosa graft was used successfully for urethral reconstruction to treat posterior hypospadias. We describe our experience with a bladder mucosa graft during urethroplasty for acquired urethral strictures in 8 children. Urethral strictures secondary to the treatment of hypospadias were excluded. Bladder mucosa was used successfully as an onlay or patch graft urethroplasty in 7 patients. One patient had a tubularized graft with secondary stenosis treated successfully by dilation.     

尿道下裂术后尿道狭窄继发附睾炎的诊治

【摘要】〓目的〓探讨尿道下裂术后尿道狭窄继发附睾炎的临床特点与疗效。方法〓2005年1月至2011年2月收治的尿道下裂术后尿道狭窄46例患者中8例继发附睾炎,对该类患者予抗感染及对症治疗后,尽早行尿道探查、尿道狭窄段切开或切除及组织瓣移植尿道成形术等方法修复尿道狭窄。结果〓8例尿道狭窄继发急性附睾炎患者术后8天内附睾炎症状基本消失。1例患者阴茎伤口感染致阴茎中部尿瘘于3月后成功行尿瘘修补术,余7例患者伤口愈合良好,无尿瘘发生,排尿通畅,尿线粗。随访3~12月,8例患者均无尿道狭窄复发,无急性附睾炎复发,慢性附睾炎者临床症状较术前明显改善。结论〓本组患者中,尿道下裂术后尿道狭窄继发附睾炎见于严重的尿道狭窄患者及年龄偏大患者;尿道下裂术后尿道狭窄应积极处理,一旦出现急性附睾炎时应在抗感染等保守治疗前提下,尽早行尿道成形修复狭窄段尿道,恢复正常尿流。     

The use of free grafts for correcting penile chordee

PURPOSE: Patients with extensive penile chordee may require free graft placement to create a straight phallus. We review our experience with those who underwent primary (no previous surgery) and secondary repair using dermal and tunica vaginalis grafts to correct penile chordee. MATERIALS AND METHODS: Between 1992 and 1998, 28 patients required free graft placement to correct penile chordee. In 8 cases (29%) primary repair was done using tunica vaginalis in 2 and a dermal graft in 6, while in 20 (71%) secondary repair was performed due to recurrent chordee with or without hypospadias. Tunica vaginalis was used in 3 patients and dermal grafts in 17. Grafts were used when straightening did not result from penile shaft degloving, dorsal plication and urethral plate division. Mean followup was 2 years. RESULTS: Residual chordee developed in 1 of 8 patients after primary and in 2 of 20 after secondary repair. Tunica vaginalis grafts had been placed at repair in all patients with residual chordee but there was no recurrent chordee after dermal graft placement. Chordee recurred in 60% of the patients who received a tunica vaginalis graft. CONCLUSIONS: Conventional techniques, such as penile degloving and dorsal plication, may be used to correct penile chordee in most cases, while free grafts are more likely to be required for secondary repair. We believe that dermal grafts result in more successful repair than tunica vaginalis grafts, which seem to be associated with a higher incidence of residual chordee.