An unusual complication of urethral stent

A 62-year-old man with recurrent urethral stricture and an indwelling urethral stent presented to us with symptoms of difficult voiding. Retrograde urethrogram confirmed narrowing of the lumen of the urethra and a visual internal urethrotomy was done. However, during the urethrotomy, dense fibrosis around the stent was encountered making the incision difficult and leading to breakage of the blade of the urethrotome.     

Management of adult anterior urethral stricture disease: nationwide survey among urologists in the Netherlands

Background

Adult anterior urethral stricture disease is most often treated with dilatation or direct vision internal urethrotomy (DVIU). Although evidence suggests that anastomotic urethroplasty for short bulbar strictures is more efficient and cost effective in the long term, no consensus exists. It is unclear by whom and how often urethroplasties are performed in The Netherlands and how results are being evaluated.

Objective

To determine national practice patterns on management of anterior urethral strictures among Dutch urologists. This information will help to define the nationwide need for training in urethral surgery.

Design, setting, and participants

We conducted a 16-question survey among all 323 Dutch urologists.

Results and limitations

The response rate was 74%. DVIU was practised by 97% of urologists. Urethroplasty was performed at least once yearly by 23%, with 6% performing more than five urethroplasties annually. In the group of urologists younger than 50 yr of age, 13% performed urethroplasty, with 3% of those performing more than five annually. In the case of a 3.5-cm-long bulbar stricture, DVIU was preferred by 49% of responders. Even after two recurrences, 20% continued to manage a 1-cm-long bulbar stricture endoscopically. Of responders, 79% believed that urethroplasty should be proposed only after a failed endoscopic attempt. Diagnostic workup and evaluation of success varied greatly.

Conclusions

Most Dutch urologists believe that urethroplasty is an option only after failed DVIU. Endoscopic procedures are widely used, even when the risk of recurrence is virtually 100%. The definition of success is hampered by nonstandardised methods of follow-up. Only a small group of mainly older urologists frequently performs urethroplasties. Training programmes seem necessary to guarantee a high standard of care for stricture disease in The Netherlands. A pan-European practice survey might be interesting to clarify the need for centralised fellowship programmes.     

Initial and long-term management of posterior urethral valves

Posterior urethral valves are the most common cause of congenital obstructive uropathy, resulting in renal failure in childhood. Nowadays, in most cases, diagnosis is suggested by antenatal ultrasound. However, antenatal intervention has not resulted in a significantly improved outcome. Endoscopic valve ablation is the initial treatment in most of these neonates, but others procedures, like vesicostomy or ureterostomy, can also be justified in some particular cases in order to improve renal function prognosis. Different factors like bladder dysfunction, VUR, polyuria and proteinuria, can be responsible for the slow and progressive deterioration in renal function that some of these patients show over the years. By treating them all, we may prevent or delay the onset of end stage renal disease.     

A method to assess posterior urethral valve ablation

PURPOSE: There are few published reports addressing the assessment of posterior urethral valve ablation. This study was performed to provide a ratio to measure successful treatment of posterior urethral valves. MATERIALS AND METHODS: A total of 35 patients with posterior urethral valves were treated by a single surgeon between 1995 and 2004. Of these patients 23 were younger than 1 year at diagnosis and were selected for this study. A urethral ratio was calculated by dividing the posterior urethral diameter by the anterior urethral diameter. A total of 31 males undergoing cystography for urinary tract infections were evaluated as normative controls. The urethral ratio was also measured and calculated for these patients. RESULTS: Median patient age was 1.5 months. In 13 patients preoperative cystograms were available and in 20 patients postoperative cystograms were available for review. Measurements were made of the posterior urethral and anterior urethral diameters. Median preoperative ratio in 13 patients was 8.6. This ratio decreased postoperatively to 3.1 in 15 patients who only required 1 ablation and 8.0 in 5 patients who required a second ablation. After a second ablation the ratio decreased to 3.1. The 5 cases requiring a second ablation were initially managed by cystoscopy and a flexible electrode. None of the patients treated initially with a resectoscope required a second ablation. Urethral ratio was 2.6 in 31 normal males undergoing cystogram for investigation of a urinary tract infection. CONCLUSIONS: Calculating urethral ratio in patients with posterior urethral valves allows objective measurement of the technical success of valve ablation.     

Deferred endoscopic urethral realignment: Role in management of traumatic posterior urethral disruption

ObjectivesThe aim of our study is to assess the value of deferred endoscopic urethral realignment after traumatic posterior urethral disruption.Patients and methodsBetween June 2001 and August 2011, we evaluated 28 patients who presented 3–6 weeks (mean 27 ± 6 days) after experiencing traumatic posterior urethral disruptions and pelvic fractures; immediate and early realignment were overdue in these cases. Patient variables included mode of presentation, mechanism of trauma, type of pelvic fracture, and Abbreviated Injury Scale (AIS). Under fluoroscopic guidance, a guidewire was passed into the injured urethral segment from the distal to proximal injured ends using a long Chiba needle, and realignment was performed using endoscopic urethrotomy. The follow-up period ranged from 18 to 98 months (mean 43 ± 22.5 months).ResultsAfter the procedure, 46% of patients were stricture free. After one visual internal urethrotomy (VIU) and two VIU's, 60% and 64% of patients were stricture free. No cases of post-procedural incontinence occurred, and impotence was reported in only 14% of patients. Type of pelvic fracture was the only variable that significantly affected the success rate, where the success rate decreased from 100% in stable pelvic fracture to 25% in bilateral rotationally and vertically unstable pelvic fracture.ConclusionWhen early realignment is postponed for any reason, deferred endoscopic realignment is considered an adequate substitute because urethral continuity can be achieved in a group of patients without increase incidence of impotence and incontinence.     

Outcome of valve ablation in late-presenting posterior urethral valves

OBJECTIVE: To explore the symptoms, radiological findings and outcome after valve ablation in patients who present late with posterior urethral valves (PUV) and who typically have mild forms of the disease with often minimal upper tract changes; these patients frequently escape detection by ultrasonography in utero and the diagnosis may be delayed to as late as adolescence. PATIENTS AND METHODS: The charts of 70 boys (mean age 7.46 years, range 2-14) diagnosed late with PUV and treated with value ablation were retrospectively reviewed. Before ablation, history of voiding habits, voiding frequency, presence of enuresis, dysuria and the incidence of gross haematuria was recorded. Findings of a physical examination, laboratory testing (urine analysis and serum creatinine levels), ultrasonography and voiding cysto-urethrography (VCUG) were noted. After valve ablation, a review included a detailed voiding history and re-examination of abnormal variables including an assessment of enuresis, voiding frequency and ultrasonography. The mean (range) follow-up was 25 (1-78) months. One patient was lost after his first follow-up visit, but data were included to that time. RESULTS: The most common presenting symptom was voiding dysfunction; 47 (67%) presented with nocturnal enuresis, 42 (60%) with urinary frequency and 12 (17%) with a history of urinary tract infection. On physical examination 12 (17%) had mild age-corrected hypertension. Microhaematuria was present in 21 (30%) but all patients had normal serum creatinine levels. Ultrasonography showed hydronephrosis in 33 (47%) and a postvoid residual volume in 57 (81%). On VCUG, 52 (79%) patients had clear evidence of PUV, 22 (31%) bladder trabeculation, 11 (16%) vesico-ureteric reflux and eight (11%) diverticula. On cystoscopy, 67 (96%) patients presented with the classic sail-shaped PUV and three a ring-shaped valve. After surgical ablation of the valve most patients dramatically improved; 31 of 42 (74%) had resolution of urinary frequency, 24 of 33 (73%) of diurnal enuresis and 17 of 47 (38%) nocturnal enuresis. Of 57 patients, 39 (68%) established good bladder emptying. Of 33 affected, 20 (60%) had some reduction of hydronephrosis but 63% continued to have some symptoms of voiding dysfunction. CONCLUSION: PUV should be considered in boys presenting with voiding dysfunction. After valve ablation most patients improve dramatically. Despite surgery, enuresis, urinary frequency and poor bladder emptying persisted in some and required further treatment. The continued bladder dysfunction suggested that irreversible urinary tract damage may have occurred. Even in this apparently mildly affected group, long-term follow-up is essential.     

Surgical treatment of aortic valve endocarditis: a 26-year experience

Objective

We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years.

Methods

From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years.

Results

Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up.

Conclusion

Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.     

内镜电切治疗小儿后尿道瓣膜30例临床分析

目的探讨内镜电切治疗小儿后尿道瓣膜的临床效果。方法对30例施行内镜电切治疗的小儿后尿道瓣膜进行回顾分析。本组均为男性,确诊时年龄1个月～14岁,中位年龄2岁3个月。婴幼儿用6/7.5F输尿管镜或9F膀胱尿道镜和针状电极,大龄儿用12F或13F膀胱尿道镜和钩状电极,在5点及7点处电切后尿道瓣膜。术后定期进行随访。结果依据Young分型,本组中Ⅰ型29例(96.7%),Ⅲ型1例(3.3%)。手术过程均顺利,术后排尿通畅度、尿白细胞、尿隐血、血肌酐水平、肾积水程度及膀胱输尿管反流程度均较术前有明显改善。结论选择合适的内镜、电极和电切部位,内镜电切治疗小儿后尿道瓣膜是安全、有效的。     

颈椎后纵韧带骨化症的手术并发症分析

目的:探讨颈椎后纵韧带骨化症(ossification of the posterior longitudinal ligament,OPLL)的手术并发症原因以及防治措施。方法:对2000年1月至2007年2月收治的126例颈椎OPLL手术治疗患者进行回顾性分析。将所有患者分为前路组和后路组,记录两组患者术中术后所有并发症的发生情况、干预措施及恢复情况。结果:前路组51例患者中,脑脊液漏7例(13.7%),均因对骨化的后纵韧带进行打磨、分离所致,经腰大池置管并在切口局部加压后愈合,3例术后出现轻微头痛,余4例无特殊症状;喉返神经损伤4例(7.8%),未予特殊治疗,均在术后10d～3周内恢复正常,短期吞咽困难2例(3.9%),均于1周内缓解,其原因与术中显露术野时过度牵拉有关;喉上神经损伤1例(2%),限制患者进水及含水食物,加强护理,2周后恢复,主要原因与手术节段位置较高、显露困难和操作粗暴有关;食管瘘1例(2%),予禁食水、静脉加强营养,局部保持通畅引流等治疗,于术后6周痊愈,可能与牵拉过度和操作不慎有关;2年随访时发现邻近节段退变8例和内置物下沉2例,均无临床症状,继续密切观察。后路组75例患者中,颈项部疼痛9例(12%),给予对症治疗,2年随访时均有所缓解,其原因与后方软组织剥离或椎小关节破坏有关;颈部屈伸活动明显受限7例(9.3%),主要因为长节段内固定所致,未对日常生活造成明显影响,未特殊处理;C5神经根麻痹6例(8%),通过加强患肢力量训练,辅以神经营养药物,术后3～8个月恢复,主要与减压后脊髓持续移位对C5的牵拉效应有关;骨化明显进展5例(6.7%),发生机制包括术后局部应力改变、不稳等,颈椎生理前凸消失3例(4%),二者均未诱发或加重症状,继续密切随访;硬膜外血肿1例(1.3%),术后13h及时再次手术清除血肿后症状迅速缓解,主要原因与第一次手术止血不佳有关。结论:颈椎OPLL前路或后路手术治疗均可发生多种并发症,术前仔细分析病情,术中细心操作,术后加强管理,才能最大限度地降低并发症的发生率。     

Operative techniques of anastomotic posterior urethroplasty for traumatic posterior urethral strictures

Objective： To elucidate the details of operative technique of anastomotic posterior urethroplasty for traumatic posterior urethral strictures in attempt to offer a successful result. Methods： We reviewed the clinical data of 106 patients who had undergone anastomotic repair for posterior urethral strictures following traumatic pelvic fracture between 1979 and 2004. Patients＇ age ranged from 8 to 53 years （mean 27 years ）. Surgical repair was performed via perinea in 72 patients, modified transperineal repair in 5 and perineoabdominal repair in 29. Follow-up ranged from 1 to 23 years （ mean 8 years ）. Results： Among the 77 patients treated by perineal approaches, 69 （95.8 % ） were successfully repaired and 27 out of the 29 patients （93. 1% ） who were repaired by perineoabdominal protocols were successful. The successful results have sustained as long as 23 years in some cases.Urinary incontinence did not happen in any patients while impotence occurred as a result of the anastomotic surgery. Conclusions： Three important skills or principles will ensure a successful outcome, namely complete excision of scar tissues, a completely normal mucnsa ready for anastomosis at both ends of the urethra, and a tension-free anastomosis. When the urethral stricture is below 2. 5 cm long, restoration of urethral continuity can be accomplished by a perineal procedure. If the stricture is over 2. 5 cm long, a modified perineal or transpubic perineoabdominal procedure should be used. In the presence of a competent bladder neck, anastomotic surgery does not result in urinary incontinence. Impotence is usually related to the original trauma and rarely （5.7 % ） to urethroplasty.     

Pediatric valve replacement, 15 years experience in Oman

Background Despite improving surgical techniques, treatment of heart valve disease in children remains controversial. Somatic growth and adequate anticoagulation are of concern when children undergo valve replacement. We conducted this study to evaluate the performance of valves in this age group. Methods 42 children under the age of 13 years who underwent valve replacement were included in this study. Totally, 50 valves were implanted in 42 patients: 48 were mechanical prostheses, two were bioprosthetic both in pulmonary position. 37 (74%) valves were implanted in mitral position, 10 (20%) in aortic position, 1 (2%) in tricuspid position and 2 (4%) in pulmonary position. Preoperatively, 14 (33,3%) patients were in New York Heart Association (NYHA) class IV, while 27 (64.2%) were in NYHA class III. Results There were 2 (4.7%) hospital deaths and 2 (4.7%) late deaths while 2 (4.7%) patients were lost to follow up. The mean follow up period was 9.4 yrs. 35 (83.3%) patients are in NYHA Class I and free of all medications except warfarin. 3 (7.1%) patients have undergone 5 successful pregnancies. The median INR was 2.23. Major thrombo-embolic episode occurred in 1 (2.3%) patient. Conclusions In view of the problems of sizing, anticoagulation and need for re-operation at an early age, there is a reluctance to replace valves in children. This study shows that despite these problems, valve replacement can be undertaken safely and successfully in children, when repair has failed or not technically feasible.     

后尿道损伤的早期,亚早期手术治疗

１９７３－１９９４年５月共收治骨盆骨折所致的后尿道断裂５４例，其中行早期尿道吻合３３例，亚早期尿道吻合９例，占７７．８％（４２．５４），均取得满意效果，尿道断早期组织弹性好，无粘连，无瘢痕，可以达到解剖对位。手术同时可以清除血肿及外渗尿液，减少感染及狭窄机会，对合并休克的病人在休克纠正后，处理其他复合伤的同时急尽早行尿道对端吻合术。对伤严重的的病人经抢救休克处理复合伤，生命指标平稳后行亚早期手术仍     

Case report: Nonobstructive giant urethral stone with two safety pins

The urethra can be the site of various types of foreign bodies. A 61-year-old man having a giant urethral stone with two safety pins was evaluated according to the literature. To our knowledge, we report the first case of foreign bodies in urethra in which existing non-obstructive giant urethral stone with two safety pins. This revised version was published online in August 2006 with corrections to the Cover Date.     

Surgical Treatment of 31 Complex Traumatic Posterior Urethral Strictures Associated with Urethrorectal Fistulas

Background

Urethrorectal fistulas (URF) in patients with complex posterior urethral strictures are rare and difficult to repair surgically. There is no widely accepted standard approach described in the published literature.

Objective

The aim of this study was to describe the outcomes of various operative approaches for the repair of URFs in patients with complex posterior urethral strictures.

Design, setting, and participants

From January 1985 to December 2007, 31 patients (age: 6–61 yr; mean: 28.4) with URFs secondary to posterior urethral strictures were treated using a perineal or combined abdominal transpubic–perineal approach.

Interventions

A simple perineal approach was used in 4 patients; a transperineal inferior pubectomy approach was used in 18 patients; and a combined transpubic–perineal approach was used in 9 patients. A bulbospongiosus muscle and subcutaneous dartos pedicle flaps were interposed between the repaired rectum and urethra in 22 patients. The combined transpubic–perineal approach used either a gracilis muscle flap (one patient) or a rectus muscle flap (eight patients).

Measurements

Suprapubic catheterisation was used for bladder drainage, and a urethral silicone stent was left indwelling for 4 wk.

Results and limitations

One-stage repair was successful in 4 patients (100%) using the perineal approach, in 16 of 18 patients (88.9%) using the transperineal–inferior pubectomy approach, and in 7 of 9 patients (77.8%) using the transpubic–perineal approach. Recurrent urethral strictures developed in two cases; one patient required regular dilation, and the other patient was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent URFs developed in two additional patients.

Conclusions

Surgical approaches for the treatment of URFs associated with complex urethral strictures should be based on a number of considerations including the location of the URF, its aetiology, the length of the urethral strictures, and a history of previous unsuccessful repairs. These results demonstrate that the transperineal–inferior pubic approach may be appropriate as a first-line procedure.     

尿道会师牵引术加硅胶管持续尿道扩张治疗后尿道断裂

目的 提高骨盆骨折后尿道断裂手术治疗效果。方法 对５２例骨盆折后尿道断裂患者行尿道会师牵引，术后１２～１４天，尿道内置入三根直径２．４～３．０ｍｍ硅胶管，持续尿道扩张３个月。结果 ５２例患者治愈５０例，治愈率９６％，良好２例，良好率４％。结论 此术式简便易行，安全有效，可显著降低尿道感染及狭窄的发生。     

经皮热消融治疗肝脏恶性肿瘤Glisson系统相关并发症分析

目的探讨经皮热消融治疗肝脏恶性肿瘤术后Glisson系统相关并发症发生率及与肿瘤位置的关系。方法回顾性分析1 879例肝脏恶性肿瘤患者共2 218例次超声引导下经皮热消融治疗的资料。根据肿瘤与Glisson系统的位置关系分为4类,肿瘤邻近1、2、3级门静脉分支分别定义为Ⅰ、Ⅱ、Ⅲ类(邻近Glisson系统组),远离门静脉定义为Ⅳ类(非邻近Glisson系统组)。分析并发症(胆脂瘤、胆漏、胆管严重狭窄、胆管—支气管瘘、动脉—门静脉瘘及动脉瘤)的发生情况。结果共20例次(20/2 218,0.90%)患者发生Glisson系统相关严重并发症。邻近Glisson系统组Glisson系统相关严重并发症发生率[1.81%(16/886)]高于非邻近Glisson系统组[0.30%(4/1 332),P0.001]。Ⅰ、Ⅱ、Ⅲ、Ⅳ类患者Glisson系统相关严重并发症发生率[6.35%(4/63)、3.52%(5/142)、1.03%(7/681)、0.30%(4/1 332)]差异有统计学意义(P0.001)。Glisson系统相关轻微并发症包括肝功能损伤(280例次)、门静脉血栓形成(156例次)及消融区末梢胆管扩张(82例次),且发生率在Ⅰ~Ⅳ类患者中呈逐渐降低的趋势。结论经皮热消融治疗具有较高的安全性,但Glisson系统相关严重并发症的发生率随肿瘤靠近上级门静脉分支有增高趋势。     

小儿外伤性后尿道损伤急症处理与远期疗效观察

为了评价小儿外伤性后尿道损伤急症处理方法的效果，将１９例后尿道损伤患儿分为尿道会师组和单纯膀胱造瘘组，对二组的急诊处理方法及远期疗效进行了回顾性分析。结果：尿道会师组术后７５％出现尿道狭窄，单纯膀胱造瘘组为１００％，长期随访发现二组阳萎和尿失禁发生率之间无显著性差异。结论：（１）小儿后尿道损伤急症处理方法的选择应根据患儿全身情况，尿道损伤部位，断端移位情况等决定；（２）同单纯膀胱造瘘术相比，不加牵引的尿道会师术并不增加远期阳萎和尿失禁的发生率