Ultrasonic fragmentation in the treatment of male urethral calculi

In the last 8 months, 7 patients have presented with acute retention of urine due to impacted urethral stones. Four stones were in the posterior urethra, 2 in the penile urethra and 1 proximal to the external urethral meatus. The patients were managed as emergencies. Stone fragmentation by ultrasound (US) through a 24F obliquely offset eyepiece nephroscope was achieved with minimal urethral trauma. Follow-up was for 6 months and no evidence of urethral stricture or recurrent stones was found. It was concluded that US fragmentation of urethral calculi is a safe and efficient procedure with minimal complications when used in the management of impacted urethral stones.     

Meshgraft urethroplasty

Summary Repeated stricture formation of the urethra, especially after multiple previous operations, as well as long strictures in paraplegic patients almost completely obliterating the urethra cannot be adequately treated by an one-stage operation. Successful results are equally difficult to obtain in those cases requiring complete resection of the urethra, such as occur with chronic infection with long fibrous strictures or in stone or abscess formation. Since 1977, we have been using a two-stage operative technique in which free, meshed foreskin or split-skin is grafted in the first session and the urethra is reconstructed in the second. A total of 83 patients with strictures in the distal and proximal urethra were treated with this two-stage procedure. In 82 patients, excellent anatomic and functional results were achieved; only one patient developed a recurrent stricture. This technique is most useful in difficult situations, such as restricturization following repeated endourethral operations, in exceedingly long strictures associated with chronic infection of the paraurethral tissue and in problematic strictures in paraplegic patients. It is shown here that this two-stage operative technique is a reliable and successful method for the treatment of even the most difficult urethral strictures.     

Prostatic urethral strictures after transurethral microwave thermal therapy for benign prostatic hyperplasia

Prostatic urethral strictures are rare. We present 3 cases in a study group of 27 who underwent high energy transurethral microwave therapy for benign prostatic hyperplasia. In all 3 cases, midprostatic strictures with ectopic area proximal to the stricture were seen by cystoscopy. Two of the strictures were urodynamically significant. The most likely explanation for their occurrence is direct damage of the prostatic urethra due to ischemia or heat damage of the prostatic urethra. UROLOGY 50: 983-985, 1997.     

Strictures of the proximal urethra in men]

Stricture of proximal male urethra remains complicated problem of urology. Surgical intervention conducted at sphincter area is fraught with the damage of potential enuresis. A total of 250 patients with proximal urethra strictures were treated. Most of them could recover normal uresis. Unlike strictures of inflammatory origin, those of traumatic and secondary genesis presented great difficulties for management in view of both sphincters impairment. To be successful, urethral operations must follow the following main principles: maximal preservation of the sphincter apparatus, radical removal of the cicatricial tissue, adequate urine elimination, reliable hemostasis. None of operations could at present meet the above requirements, the worst results being obtained after Solovov's technique surgery (25% of enuresis outcomes in 4 out of 16 treated). Endourethral surgery can produce good results, especially effective interventions being reported in short strictures and underdevelopment in paraurethral tissue. Bougienage remains a forced measure in managing urethral strictures combined with infravesicular obstruction and sphincter insufficiency. Positive long-term results were achieved in 182 patients treated. It is suggested that controlled uresis could be reestablished in absolute majority of cases.     

The role of urethrography in urethral disease. Part II. Indications for transphincter urethroplasty in patients with primary bulbous strictures.

We herein outline the radiological and clinical criteria that will aid the surgeon in deciding whether transphincter urethroplasty is required in patients whose primary stricture is in the proximal bulbous urethra. Sinc proximal bulbous urethral strictures are common the urologist frequently is called upon to make this important decision. The criteria described herein will help him to do so and, thus, avoid urethroplasty failure because of proximal stenosis in the membranous urethra. The concept of paradoxical dilatation of the membranous urethra on voiding urethrography also is described. Paradoxical dilatation means that in the presence of a primary obstructive bulbous urethral stricture the membranous urethra, although containing significant scar tissue, is dilated on the voiding study because of the distal obstruction. Relief of the bulbous urethral stricture alone may result in rapid contraction and stenosis of the previously dilated membranous urethra.     

Traitement des sténoses de l’urètre par urétrotomie interne endoscopique: résultats anatomiques et fonctionnels d’une série de 244 cas

Objective

To evaluate the results of a homogeneous series of urethral strictures treated exclusively by endoscopic internal urethrotomy and to determine the factors that may predict the outcome.

Patients and Methods

Between 1989 and 2007, 244 patients were treated for urethral stricture. All of them were subjected to endoscopic direct vision internal urethrotomy (DVIU).

Results

34.3% of good results were achieved after the first DVIU. Mean follow-up was 3.5 years. No mortality was encountered, while the rate of morbidity was 5%. Better results were achieved in patients with short (< 2 cm) and single strictures in the proximal urethra. Mean post-operative catheterization was 2 days; a further extension of the catheterization time did not yield any significant improvement. Unsatisfactory results (65.5%) were found in patients with large urethral strictures located in the distal urethra or in elderly patients. 62.5% of the patients showed a satisfactory outcome after a second urethrotomy, while the other patients required urethral dilatation or urethroplasty.

Conclusion

DVIU is a simple procedure which does not have a high rate of morbidity and requires short hospitalization. With a steady success rate of around 75.4% after a follow-up of 3.5 years we feel that DVIU can be recommended as treatment of choice for all short, single and proximal urethral strictures, preferably in young patients without previous interventions on the urethra     

The surgical treatment of closed injuries and strictures of the urethra]

Under analysis were results of operative treatment of 291 patients aged from 7 to 76 years with traumas and strictures of the urethra at the period from 1970 to 1990. Totally 325 operations have been performed. The primary suture of the urethra was successfully used in 8 of 36 patients with trauma of the urethra. Tunneling of the urethra for its strictures which was widely used in the clinic up to 1980 gave 46.2% of recurrences during the first 3 months after operation. It required the surgical methods to be changed. During the recent 11 years 161 operative interventions have been performed: 103 (64.0%) resections of the urethra, 45 (28.0%) internal optical urethrotomies and transurethral resections (TUR) of scarry tissues, 7 (4.3%) epidermoplasties of the urethra and 6 (3.7%) tunnelings of the urethra. The amount of recurrences dropped up to 13.7%. The primary suture of the urethra is necessary for penetrating ruptures of the urethra if the patient's state allowed. Resection of the urethra must be the operation of choice in patients with strictures and obliteration of the urethra. The endoscopic methods of treatment (urethrotomy and TUR) are indicated for short strictures and scarry deformity of the posterior urethra after operations on the prostate. The epidermoplasty is expedient for lengthy strictures.     

Balloon dilatation of urethral strictures

Balloon dilatation of the urethra in 9 male patients with either post-inflammatory or post-traumatic strictures was successfully performed. This procedure is primarily indicated in those patients with unsatisfactory results using conventional dilatation with metal sounds. A flexible endoscope was used for guide wire passage and fluoroscopic guidance for positioning the balloon and assuring complete dilatation of the urethral strictures or vesical neck contracture. In this manner, dilatation to 36 F can be performed in a relatively atraumatic manner with minimal discomfort.     

An experimental model for stricture studies in the anterior urethra of the male rabbit

In this study, an animal model was developed for the examination of urethral strictures (US). Through a resectoscope, a resection was made in the urethras of 15 male rabbits. After 30 days, the rabbits were evaluated with urethrography, impedance planimetry and either histology or the determination of collagen content. Fifteen rabbits serving as controls were evaluated in the same way. Three rabbits in the resection group and one in the control group died before evaluation. Urethrography demonstrated a stricture in the remaining 12 animals in the resection group. The urethras of the control animals were all normal. Impedance planimetry confirmed that the luminal cross sectional area (CSA) of the strictures was significantly smaller than the CSA of the corresponding part of the urethra in the control group. No difference in CSA was found 1 cm proximal to the stricture. The strictures consisted of densely woven collagen which sent tongues into the adjacent normal parts of the urethra. No difference in collagen content was found between the two groups either at the stricture site or 1 cm proximally. The described method of producing US in the rabbit model was very consistent with all operated animals developing a stricture. The model might prove valuable in evaluating new methods for the treatment of US.     

Percutaneous flexible fiberoptic nephroscopy

Summary The flexible fiberoptic nephroscope is a useful endourological tool. This paper describes the characteristics of this flexible nephroscope, various useful accessory devices and their limitations and the basic technique for percutaneous flexible nephroscopy. The limitations of the flexible nephroscope are outlined along with aids to overcome these shortcomings. Specific use of the flexible nephroscope for particular types and provisions of stones are also described. Finally, a summary of the utility of the flexible nephroscope in a busy endourological practice is outlined.     

A way to improve the quality of compression anastomoses of the urethra in children]

The paper presents the analysis of compression anastomosis establishment in surgical treatment of children with posttraumatic strictures of the posterior urethra. It is noticed that quality of the anastomoses deteriorates with enlargement of the interpolated tissues layer. Anastomosis is suggested to be formed between submucous layers. The new variant was tried in experiment on 9 dogs and in 5 patients with posttraumatic urethral strictures. As a result of more advanced anastomoses the thickness of the interpolated tissues reduced 2-3-fold. The techniques of the above surgery are discussed as well as the advantages of the proposed submucous compression anastomosis in posttraumatic strictures of the posterior urethra.     

Antegrade cystoscopic light source guided laser urethrotomy for the treatment of completely obliterated urethra

ObjectiveA urethral stricture is the narrowing of the urethra caused by scar formation. The etiologies include infection, trauma with total urethral disruption, and iatrogenic procedures. The impact of urethral stricture diseases is very high. Several kinds of endoscopic procedures have become available for managing the disease. Among them, complete obliteration of the urethra during endoscopic procedures remains a challenge for surgeons. We describe a modified procedure in which laser urethrotomy was guided under the light source from an antegrade flexible cystoscope for treating a short completely obliterated urethra. This procedure is indicated if the obliterated segment is less than 10 mm because longer strictures may increase the chance of extra false lumen formation and bleeding.Materials and MethodsForty-three male patients who underwent optical urethrotomy for urethral strictures at Kaohsiung Municipal Ta-Tung Hospital (Kaohsiung, Taiwan) between March 2013 and January 2015 were induced in the study. Five of these patients were diagnosed as having complete urethral obliteration.ResultsIn all five patients with a completely obliterated urethra, retrograde laser incision was performed successfully. Three patients had total bulbar urethral obstruction and two had penile obstruction. All patients experienced improved urination after the procedure.ConclusionOur preliminary data showed that our modified method for treating a completely obliterated urethra yielded satisfactory results. Long-term follow-up and large-scale studies should be conducted to better examine technique efficacy; however, our current results regarding the simple modification of endoscopic urethrotomy seem promising.     

Proximal bulbar urethroplasty via extended anastomotic approach--what are the limits?

PURPOSE: We report our initial experience with men who underwent EAU for strictures greater than 2.5 cm involving the proximal bulbar urethra. MATERIALS AND METHODS: Of the more than 250 men who underwent urethral reconstruction at our institution during 1997 to 2005 a select consecutive group of 22 in whom proximal bulbar urethral strictures were treated with primary bulbomembranous anastomosis were evaluated. Outcomes in men with strictures greater than 2.5 cm long (EAU) were compared to those in men with shorter strictures in the same proximal bulbar location. Cases of post-traumatic urethral disruption related to pelvic fractures were omitted. American Urological Association symptom index scores and erectile function questionnaires were completed more than 6 months postoperatively. Results of a prior study using the same erectile function questionnaire after various types of urethroplasty and circumcision were then compared to those of our series. RESULTS: Patients with EAU had an average stricture length of 3.78 cm (range 2.6 to 5.0) and 10 of 11 procedures (91%) were successful. Anastomotic urethroplasty performed for similar proximal bulbar strictures less than 2.5 cm (mean 1.5, range 1.0 to 2.3) was successful in 10 of 11 cases (91%). Mean followup was 22.1 months and all followups were more than 1 year. Men treated with EAU had no increased rate of stricture recurrence or erectile complaints compared to men in whom shorter proximal bulbar strictures were repaired using an identical surgical technique. Similarly no increased rate of erectile problems was identified compared to other types of urethroplasty and circumcision using an identical questionnaire. CONCLUSIONS: Urethral reconstructability is proportional to the length and elasticity of the distal urethral segment. Defects up to 5 cm may be successfully excised and primarily reconstructed in select young men with proximal bulbar strictures.     

Surgical treatment of strictures of the posterior urethra

The majority of strictures are treated by intermittent dilatations in order to achieve and maintain an adequate passage through the urethra. Some strictures are resistant to this treatment and call for a more radical therapy. Numerous surgical procedures have been designed with the goal of finding a method which would definitely remove urethral strictures. Strictures of the posterior urethra pose particularly serious problems. In this paper a surgical procedure is described which corrects strictures of the posterior urethra, based on marsupialization of the stricture by an inlay graft of the scrotal skin and on recontsruction of the urethra in a second stage. The author evaluates his own results in 22 patients and shows the adequacy of a radical solution in patients who are otherwise entirely dependent on life-long treatment by intermittent dilatations or on continuous derivation by cystostomy.     

Posterior urethroplasty with tubularized bladder mucosal graft

Surgical management of long strictures of the posterior urethra is difficult and there is no concrete method that guarantees excellent results. The use of bladder mucosa has become established in the 1980s as treatment for anterior urethral reconstruction in hypospadias repair. We report 2 difficult cases (multioperations) of membranous urethral strictures treated with free tubularized bladder mucosal grafts with good initial results.     

Offene Harnr?hrenchirurgie bei der Frau

There are only a few disorders of the female urethra which have to be treated by open urethral surgery, urethral diverticula and urethral strictures. These diseases are rare and subsequently open surgery of the female urethra is also rare. However, these surgical techniques are an important part of the surgical armamentarium in urology, because this is the only method to preserve quality of life of patients concerned. Surgical therapy of urethral diverticula includes well-defined procedures, such as marsupialization and diverticula excision. In contrast, there is no established surgical therapy for female urethral strictures. Several suggestions to solve this problem have been made in recent years and will be presented in this article.     

Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures

PURPOSE: We report the results of urethroplasty with a free graft of buccal mucosa as a dorsal onlay for the treatment of bulbar urethral strictures. MATERIALS AND METHODS: Since June 1994, 30 patients with bulbar urethral strictures have been treated with buccal mucosa urethroplasty. Urethroplasty was performed with a free graft of buccal mucosa using a ventral onlay in the first 7 patients and a dorsal onlay in 23. Dorsal urethrotomy was performed with a Sachse urethrotome after the bulbar urethra was separated from the corpora. The buccal mucosa onlay was sutured to the urethra and corpora cavernosa to ensure a patent urethra. RESULTS: At 20-month followup (range 3 to 50) the success rate was 96% (29 of 30 patients). Urethral stricture recurred in only 1 of 7 patients in the ventral onlay and none of 23 in the dorsal onlay group. CONCLUSIONS: Preliminary results of urethroplasty for bulbar urethral strictures with a dorsal onlay graft of buccal mucosa are excellent. Longer followup is needed to evaluate definitive results.     

结肠黏膜尿道成形治疗复杂性超长段尿道狭窄的长期疗效

目的 观察结肠黏膜尿道成形术治疗复杂性超长段尿道狭窄的长期效果和影响因素. 方法 2000年10月至2009年9月采用结肠黏膜尿道成形治疗复杂性超长段尿道狭窄46例.年龄17 ～70岁,平均39岁.尿道狭窄段长10.0～20.0 cm,平均15.2 cm.术前有平均2.7次不成功的尿道修复史.通过定期门诊或电话随访进行术后疗效评估,包括排尿情况和尿流率检查,部分患者行尿道造影和尿道镜检查等.以不需要任何处理包括尿道扩张,能正常排尿,尿流率在正常范围内者视为手术成功. 结果 结肠黏膜重建尿道的长度为11.0～21.0 cm,平均15.4 cm.1例失访,余45例随访20～120个月,平均62个月.发生与手术相关的并发症4例(8.9％),其中3例于术后3、8和24个月发生尿道外口狭窄,1例术后29个月发生结肠黏膜新尿道与尿道近端吻合口狭窄.另2例发生与结肠黏膜尿道成形术无关的尿道狭窄. 结论 结肠黏膜尿道成形术治疗复杂性超长段尿道狭窄术后长期效果理想;影响术后效果的因素是尿道口狭窄和吻合口狭窄.     

Urethroplasty management in 100 cases of urethral stricture: a rationale for procedure selection

We performed 100 urethroplasties for urethral strictures that fulfilled our criteria for surgical intervention. Strictures were located in the pendulous urethra in 14 cases, bulbar urethra in 33 and membranous urethra in 32, while the entire urethra or multiple adjacent areas were strictured in 21. The etiology of the strictures was traumatic in 47 patients and inflammatory in 22, and no cause was identified in 31. One-stage repairs were performed in 76 cases. Anastomotic repairs were optimal for short traumatic strictures, with 1 failure among 29 cases. Full thickness skin graft repairs were performed for more lengthy inflammatory strictures in 34 cases, with 5 failures. Mitigating against success in these patients were extrapenile skin donor sites, tubed grafts and poor graft beds. Vascularized island flap repairs were performed in 13 patients with 1 failure but there was an associated problem of redundant repairs. Two-stage repairs were reserved primarily for long or multiple strictures, with 2 failures in 24 cases. We conclude that procedure selection should be determined by stricture characteristics, including location, etiology, length and the presence of local adverse factors. An over-all rate free of stricture of 91 per cent was achieved.