Management of traumatic urethral disruption in children: Oman experience, 1988-2000

Background: Traumatic urethral disruptions in children differ anatomically from those of adults. In children, the posterior urethra is not protected by the prostate and may be injured at any level. The management of traumatic rupture of the urethra still a matter of debate, and there is no agreement as to which is the best of 3 options. Methods: This was a retrospective analysis. Over a 12-year period the authors dealt with 21 urethral disruptions. The authors had detailed follow-up of 20 patients (14 posterior and 6 anterior). Trans-symphyseal urethroplasty (6 early primary repairs and 3 delayed repairs) for complete posterior urethral disruptions was performed. The early repairs were carried out within 7 days of the injury. Primary alignment was performed for 3 of the 4 partial ruptures of the posterior urethra and for all 6 anterior urethral disruptions. Postoperatively, the patients were evaluated for incontinence, penile erectile dysfunction, and stricture formation. Results: In one of the early repairs a stricture developed that responded to dilatations. A second patient with bladder neck injury had incontinence after the repair. She underwent a urethral lengthening procedure and still has stress incontinence. Erections were observed in all 4 boys. One of the delayed repairs developed a stricture postoperatively. Of the 9 partial ruptures (6 anterior and 3 posterior) that underwent primary alignment, 4 had strictures. Some of these strictures required up to 5 dilatations or internal urethrotomy for cure. One patient with complete rupture underwent primary alignment, which broke down, and a long stricture developed. This patient is still awaiting a delayed repair. One posterior partial rupture, repaired primarily at another hospital, had a stricture and an urethrocutaneous fistula that responded to curettage and dilatations. Conclusions: Primary repairs required less hopitalization and a shorter duration of indwelling catheters. In light of this experience the authors recommend a primary repair in patients with complete posterior urethral disruptions. J Pediatr Surg 37:1451-1455.     

Staged proximal hypospadias repair: Modified thiersch duplay with midline incision in urethral plate followed by Mathieu urethroplasty

Purpose: Functional results, complications, cosmesis, operating time, and hospital stay were analyzed after staged urethroplasty for proximal hypospadias. Methods: Seventeen consecutive boys, mean age 17.7 [plusmn] 1.6 months underwent a staged urethroplasty in the past 5 years. Urethral plate was tubularized and proximal hypospadias converted to distal. Hooded dorsal prepuce was buttonholed and transposed ventrally to cover the neo-urethra. Subsequently, a parameatal based flip flap urethroplasty completed the urethral reconstruction at mean age of 26.7 [plusmn] 4.1 months. Results: Mean follow-up time was 2.8 [plusmn] 1.7 years. Eighty-eight percent of boys who are now toilet trained and standing to void have a good caliber straight single stream of urine in a forward direction. Urethrocutaneous fistula was seen in 1 child (6%), and a simple fistulectomy with double layered closure was successful at first attempt of fistula closure. Cosmetic appearance of a natural vertical slit glanular meatus situated at normal position on the glans was achieved in all patients. Total mean operating time was 193.5 [plusmn] 42.9 minutes and total mean duration of hospital stay was 3.4 [plusmn] 0.6 days. Conclusion: Staged urethroplasty for proximal hypospadias results in a normal penis with good function, minimal complications, and excellent cosmesis.     

MANAGEMENT OF OBLITERATIVE POSTTRAUMATIC POSTERIOR URETHRAL STRICTURES AFTER FAILED INITIAL URETHROPLASTY

Purpose

We evaluate the problems encountered during surgery and assess the results of different endoscopic and open surgical methods following failed urethroplasty for posttraumatic posterior urethral stricture.

Materials and Methods

Since 1992 we have treated 23 patients in whom urethroplasty for posterior urethral strictures failed. Of these patients, 3 had undergone 2 previous repairs and 6 had additional complicating factors, such as fistula, periurethral cavity and false passage. End-to-end anastomosis was done in 14 patients via a transperineal (7) or transpubic (7) approach. In 1 patient substitution urethroplasty using a radial artery based forearm free flap was performed. In 3 patients a 2-stage urethroplasty was done, 4 underwent core-through optical internal urethrotomy and 1 underwent endoscopic marsupialization of a false passage.

Results

At 1 to 5-year followup 3 of the 23 patients had restenoses (13%), including 2 in whom previous treatment failed. The remaining 87% of the patients void well and are continent, and there is no worsening of the preexisting potency status.

Conclusions

Previous failed urethral stricture repair complicates management due to fibrosis, impaired vascularity and limited urethra available for mobilization. Recurrent strictures less than 1.5 cm. can be managed successfully with core-through internal urethrotomy. End-to-end anastomosis is possible in the majority with generous use of inferior pubectomy or the transpubic approach with certain modifications. When residual inflammation or long strictures are present a 2-stage procedure is a safer option. Overall, reoperation can offer a successful outcome for the majority of these complex strictures.     

Guide wire-assisted urethral dilatation for urethral strictures in pediatric urology

Purpose: The aim of this study was to report the results of 32 cases of dilatation of urethral stricture using a guide wire and sheath dilator technique supplemented by clean intermittent catheterization if further stabilization of the urethral stricture was felt warranted.Methods: The procedure involves insertion of a straight flexi-tip lubricated guide wire through the urethral stricture under cystoscopic guidance followed by insertion of a series of sheath dilators. Dilatation was followed by insertion of a Foley catheter, which was left in situ for 1 to 3 days. Patients underwent repeat cystoscopy to evaluate the urethra for recurrent stricture and those with a recalcitrant stricture were commenced on clean intermittent catheterization (CIC) to stabilize the narrowing.Results: Thirty-two patients were included. They have been followed up for up to 2 years after their last cystoscopy (mean, 16 months). Thirteen of 32 patients had more than 4 dilatations under anesthesia. Twelve patients had undergone CIC postoperatively. Complications included a urinary tract infection in 3 boys and bladder spasms in one. No false passage or sepsis occurred with this approach.Conclusions: Guide wire-assisted urethral dilatation helps avoid risks associated with blind dilatation techniques and appears to be a safe and simple alternative for management of urethral strictures in pediatric urology.     

The management of old urethral injury in young girls: analysis of 44 cases

Background/purpose: Traumatic urethral injury in girls is rare, and there is no consensus on its management. The authors report their 22-year experience.Methods: Forty girls presented with urethrovaginal fistula. Twenty-six girls presented with cystostomy tube in place, whereas 17 girls presented with complete urinary incontinence. Incision and dilatation of the obliterated urethra was carried out in 7 patients. Vaginal repair of urethrovaginal fistula was performed in 4 patients. Transpubic reconstruction of the urethra using a modified Young-Dees-Leadbetter procedure with simultaneous repair of the urethrovaginal fistula was performed in 35 patients (once in 27, twice in 5, and 3 times in 3 patients).Results: Follow-up in 40 girls averaged 3.5 years. Twenty-nine patients have regained normal urinary control, and 11 patients have mild stress urinary incontinence. Four patients were lost to follow-up.Conclusions: Simple dilation of the obliterated urethra can reestablish satisfactory urethral patency if the obliterated segment is short. The vaginal approach to urethrovaginal fistula may be successful in patients without concomitant urethral stricture or in those with stricture amenable to simple dilation. The transpubic approach remains the method of choice for repairing complete urethral disruption and severe urethral stricture, especially when associated with urethrovaginal fistula.     

The penis transposed to the perineum with penile-prostatic anastomotic urethroplasty for the treatment of a long segment complex urethral strictures

BackgroundTo present our experience of transposing the penis to the perineum, with penile-prostatic anastomotic urethroplasty, for the treatment of complex bulbo-membranous urethral strictures.MethodsBetween January 2002 and December 2018, 20 patients with long segment urethral strictures (mean 8.6 cm, range 7.5 to 11 cm) and scarred perineoscrotal skin underwent a procedure of transposition of the penis to the perineum and the penile urethra was anastomosed to the prostatic urethra. Before admission 20 patients had unsuccessful repairs (mean 4.5, range 2 to 12); five patients were associated urethrorectal fistula; 16 patients reported severe penile erectile dysfunction (PED) or no penile erectile at any time and four reported partial erections.ResultsThe mean follow-up period was 45.9 (range 12 to 131) months. Nineteen patients could void normally with a mean Qmax of 22.48 (range 15.6 to 31.4) mL/s. One patient developed postoperative urethral stenosis. After 1 to 10 years of the procedure, nine patients underwent the second procedure. Of the nine patients, four underwent straightening the penis and one-stage anterior urethral reconstruction using a penile circular fasciocutaneous skin flap, and five underwent straightening the penis and staged Johanson urethroplasty. Seven patients could void normally, one developed urethrocutaneous fistula and one developed urethral stenosis.ConclusionsTransposition of the penis to the perineum with pendulous-prostatic anastomotic urethroplasty may be considered as a salvage option for patients with complex long segment posterior urethral strictures.     

Reconstruction of Membranous Urethral Strictures

Purpose of Review

Due to the proximity of the rhabdosphincter and cavernous nerves to the membranous urethra, reconstruction of membranous urethral stricture implies a risk of urinary incontinence and erectile dysfunction. To avoid these complications, endoscopic management of membranous urethral strictures is traditionally favored, and bulboprostatic anastomosis is reserved as the main classical approach for open reconstruction of recalcitrant membranous urethral stricture. The preference for the anastomotic urethroplasty among reconstructive urologists is likely influenced by the familiarity and experience with trauma-related injuries. We review the literature focusing on the anatomy of membranous urethra and on the evolution of treatments for membranous urethral strictures.

Recent Findings

Non-traumatic strictures affecting bulbomembranous urethra are typically sequelae of instrumentation, transurethral resection of the prostate, prostate cancer treatment, and pelvic irradiation. Being a different entity from trauma-related injuries where urethra is not in continuity, a new understanding of membranous urethral anatomy is necessary for the development of novel reconstruction techniques. Although efficacious and durable to achieve urethral patency, classical bulboprostatic anastomosis carries a risk of de-novo incontinence and impotence. Newer and relatively less invasive reconstructive alternatives include bulbar vessel-sparing intra-sphincteric bulboprostatic anastomosis and buccal mucosa graft augmented membranous urethroplasty techniques. The accumulated experience with these techniques is relatively scarce, but several published series present promising results. These approaches are especially indicated in patients with previous transurethral resection of the prostate in which sparing of rhabdosphincter and the cavernous nerves is important in attempt to preserve continence and potency. Additionally, introduction of buccal mucosa onlay grafts could be especially beneficial in radiation-induced strictures to avoid transection of the sphincter in continent patients, and to preserve the blood supply to the urethra for incontinent patients who will require artificial urinary sphincter placement. The evidence regarding erectile functional outcomes is less solid and this item should be furtherly investigated.

     

A New Biaxial Epilated Scrotal Flap for Reconstructive Urethral Surgery

Purpose

We describe a new type of perineum based scrotal flap with biaxial vascularization supplied by both superficial perineal arteries. Flap length of up to 20 cm. may be attained for urethral reconstruction.

Materials and Methods

A total of 37 men with complex urethral stenosis of different etiologies underwent surgery using 1 of 3 urethroplasty techniques based on this new flap. The whole anterior urethra, including pendulous and bulbar segments, was reconstructed with a scrotal patch in 10 patients. A scrotal tubular flap was used as a substitute for the bulbar urethra in 7 patients and for the membranous portion in 4. Bulbar urethroplasty with a scrotal island patch was performed in 16 patients.

Results

Of the patients 86% achieved normal voiding after 1-stage urethroplasty. Mean followup was 39.5 months.

Conclusions

The excellent axial vascularization of this new flap permits successful resolution of the most complex urethral stenoses regardless of extension, location and etiology.     

Avoidance of leakage and strictures when creating an invisible conduit for antegrade colonic enemas

Background: Antegrade enemas have been proven to minimize problems with stool control for many incontinent patients; however, foreign bodies are unsightly, and native tissues have been shown to leak or stricture. Methods: Using a limited laparotomy incision, the appendix or a rolled cecal tube was sutured to the apex of the everted umbilical skin using a V-shaped incision. The skin then was inverted to hide the mucosa. The cecum was plicated around the base of the appendix or cecal tube and then tested by filling the cecum with saline to a pressure of 30 cm H₂O. Results: Twenty patients (aged 4.8 to 41 years) with fecal incontinence caused by imperforate anus (17 cases) and other causes underwent this procedure. Two patients had minor strictures that resolved with home dilatations, and one cecal tube necrosed, and the patient has refused reoperation. One patient had minor prolapse and underwent revision. None of the conduits leak. Two patients achieved continence and stopped cannulating their stomas. With adjustment and customization of each enema regimen, stool accidents are infrequent. Follow-up is 22 [plusmn] 14 (mean [plusmn] SD) months. Conclusion: A catheterizeable colocutaneous conduit has been developed that allows for an invisible, leak-proof, and relatively stricture-free means through which antegrade enemas can be given.     

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.     

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     

Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection

OBJECTIVES: We evaluated the applications and outcomes of substitution urethroplasty, using a variety of techniques, in 65 patients with complex, long-segment urethral strictures. METHODS: From January 1995 to December 2005, 65 patients with complex urethral strictures >8cm in length underwent substitution urethroplasty. Of the 65 patients, 43 underwent one-stage urethral reconstruction using mucosal grafts (28 colonic mucosal graft, 12 buccal mucosal graft, and 3 bladder mucosal graft), 17 patients underwent one-stage urethroplasty using pedicle flaps, and 5 patients underwent staged Johanson's urethroplasty. RESULTS: The mean follow-up time was 4.8 yr (range; 0.8-10 yr), with an overall success rate of 76.92% (50 of 65 cases). Complications developed in 15 patients (23.08%) and included recurrent stricture in 7 (10.77%), urethrocutaneous fistula in 3 (4.62%), coloabdominal fistula in 1 (1.54%), penile chordee in 2 (3.08%), and urethral pseudodiverticulum in 2 (3.08%). Recurrent strictures and urethral pseudodiverticulum were treated successfully with a subsequent procedure, including repeat urethroplasty in six cases and urethrotomy or dilation in three. Coloabdominal fistula was corrected only by dressing change; five patients await further reconstruction. CONCLUSIONS: Penile skin, colonic mucosal, and buccal mucosal grafts are excellent materials for substitution urethroplasty. Colonic mucosal graft urethroplasty is a feasible procedure for complicated urethral strictures involving the entire or multiple portions of the urethra and the technique may also be considered for urethral reconstruction in patients in whom other conventional procedures failed.     

Perineal reconstruction of female conjoined twins

Background/Purpose: Conjoined twins are some of the most challenging patients faced by surgeons. Pygopagus and ischiopagus twins present particular gastrointestinal and genitourinary reconstructive challenges. This study reviews the authors' experience with the perineal reconstruction of these types of conjoined twins. Methods: Retrospective analysis was performed for 3 sets of female conjoined twins undergoing separation between 1999 and 2001. Particular attention was given to the separation and reconstruction of the distal gastrointestinal and urogenital structures. Results: Three sets of female conjoined twins underwent successful separation 2 pygopagus, one ischiopagus tripus) with 5 surviving infants. The sixth infant died of congenital anomalies incompatible with life. Four of the 5 surviving infants had diverting enterostomies. Two of these enterostomies have been closed. Perineal reconstruction consisted of anoplasty (5 of 5), vaginoplasty (4 of 5), and urethroplasty (4 of 5). Although fecal and urinary continence are not completely measurable at this age ([lt ]3 years), all 5 survivors void spontaneously. Three infants with intestinal continuity have apparently normal defecation without the need of a bowel regimen. Conclusions: With careful preoperative planning and a multidisciplinary team of pediatric surgeons and urologists, satisfactory reconstruction and functional outcome of the female perineum can be achieved in conjoined twins.     

Urologic injuries associated with repair of anorectal malformations in male patients

Background/Purpose: Serious injuries to the urinary tract may occur during the repair of an anorectal malformation, especially in boys. This review of a large series of patients characterizes factors that may either lead to, or prevent, those injuries. Methods: A retrospective review of 1,003 boys with anorectal malformations was performed. Results: A total of 129 injuries in 1,003 patients were identified. Five hundred seventy-two of the 1,003 patients (group A) underwent definitive repair at the authors' institution. In this group, there were 19 urologic injuries; 1 bladder perforation, 1 divided ureter, 2 divided vas defera, 1 prostatic injury, 7 seminal vesicles were opened and closed, and in 7 cases, the urethra was opened and closed during the repair. Follow-up ranges from 15 years to 1 month and no late sequelae have been observed. The second group (B) consisted of 431 patients who underwent various operations at other institutions. In this group, 110 urologic injuries in 97 patients were noted. These included neurogenic bladder (n = 27), persistent, recurrent or acquired recto-urethral fistulae (n = 30), posterior urethral diverticulae that required reoperation (n = 23), urethral injuries leading to stenosis or aquired atresia (n = 19), pull-through of major urinary structures (n = 2), injured ureter (n = 1), opened seminal vesicle (n = 1), divided vas defera (n = 4), impotence (n = 1), and loss of ejaculation (n = 2). Several significant associations were noted. The most significant was that all 27 patients with neurogenic bladder and all 19 of those in group B with urethral injuries did not undergo a distal colostogram to define the level of the fistula before repair. Posterior urethral diverticulae were seen only in cases of recto-bulbar urethral fistulae repaired via an abdominal-perineal approach. Conclusions: Significant urologic injuries are associated with the repair of anorectal malformations. The risk of injury is increased in those patients who undergo repair without a distal colostogram.     

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.

     

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.

     

Single Stage Reconstruction of Complex Anterior Urethral Strictures: Combined Tissue Transfer Techniques

Purpose

Reconstruction of most urethral strictures is possible with anastomotic, graft or skin flap procedures alone. We describe the combination of tissue transfer techniques to preserve the urethral plate and reconstruct long and complex urethral strictures in 1 stage.

Materials and Methods

We reviewed the results in 25 patients who underwent anterior urethroplasty requiring more than 1 tissue transfer technique to achieve urethral reconstruction in 1 stage.

Results

Outcome was excellent in 22 patients (88%). Seven patients with pan-urethral strictures (mean length 19 cm.) required a fasciocutaneous flap combined with a buccal mucosa, bladder epithelium or skin graft. A total of 13 patients with focally dense strictures underwent excision of the most severe portion of the stricture with dorsal reapproximation, thereby improving the quality of the urethral plate and allowing simultaneous flap or graft onlay reconstruction. Five patients with multiple separate strictures required a distal onlay fasciocutaneous flap with excision and end-to-end anastomosis of a separate, more proximal stricture.

Conclusions

A thorough knowledge of the vascular supply of the urethra allowed creative application of different tissue transfer techniques, enabling 1-stage reconstruction of complex urethral strictures. An excellent outcome was achieved by preserving or revising the urethral plate and avoiding the problems associated with hair-bearing flaps and 2-stage procedures.     

Application of the principles of myotomy and strictureplasty for treatment of esophageal strictures

Background/Purpose: Strictures of the esophagus in the pediatric population may be congenital or acquired. Regardless of the etiology, the treatment goal is to relieve the symptoms and allow patients to eat normally. The cornerstone of nonoperative management is repeated esophageal dilatations. However, when nonoperative management fails, operative intervention becomes necessary. In this report the authors present 4 cases of severe upper esophageal strictures managed by applying the principles of myotomy and strictureplasty. Methods: Retrospective review of 4 patients undergoing esophageal stricturotomy from January 1, 1993 to January 1, 2000 was conducted at Childrens Hospital Los Angeles, with a mean follow-up period of 5 years. Results: Three of the 4 patients reported in this report are doing well and have not required any further surgical intervention. One patient in whom additional strictures developed has had a microvascularized free jejunal graft and also is doing well. Conclusions: Currently accepted surgical management of strictures includes resection of the affected segment with end-to-end anastomosis or esophageal replacement. The authors propose that before embarking on a long and technically hazardous operation, consideration should be given to stricturotomy. In cases of isolated strictures, this may be the preferred approach.     

Tissue-Engineered Buccal Mucosa Urethroplasty—Clinical Outcomes

Introduction

Whilst buccal mucosa is the most versatile tissue for urethral replacement, the quest continues for an ideal tissue replacement for the urethra when substantial tissue transfer is needed. Previously we described the development of autologous tissue-engineered buccal mucosa (TEBM). Here we report clinical outcomes of the first human series of its use in substitution urethroplasty.

Methodology

Five patients with urethral stricture secondary to lichen sclerosus (LS) awaiting substantial substitution urethroplasty elected to undergo urethroplasty using TEBM, with full ethics committee support. Buccal mucosa biopsies (0.5 cm) were obtained from each patient. Keratinocytes and fibroblasts were isolated and cultured, seeded onto sterilised donor de-epidermised dermis, and maintained at air–liquid interface for 7–10 d to obtain full-thickness grafts. These grafts were used for urethroplasty in a one-stage (n = 2) or a two-stage procedure (n = 3). Follow-up was performed at 2 and 6 wk, at 3, 6, 9, and 12 mo, and every 6 mo thereafter.

Results

Follow-up ranged from 32 to 37 mo (mean, 33.6). The initial graft take was 100%, as assessed by visual inspection. Subsequently, one patient had complete excision of the grafted urethra and one required partial graft excision, for fibrosis and hyperproliferation of tissue, respectively. Three patients have a patent urethra with the TEBM graft in situ, although all three required some form of instrumentation.

Conclusions

Whilst TEBM may in the future offer a clinically useful autologous urethral replacement tissue, in this group of patients with LS urethral strictures, it was not without complications, namely fibrosis and contraction in two of five patients.     

What is the Best Technique for Urethroplasty?

Context

There is no clear evidence that determines which type of urethroplasty to perform under which particular circumstance.

Objective

To review the options for urethroplasty at different sites in the urethra and for different types of stricture indicating which procedure should be used in which circumstances according to the best available evidence.

Evidence acquisition

Recent publications have been reviewed and supplemented with the authors’ personal experience.

Evidence synthesis

Currently, in the developed world, the most common types of stricture are relatively short and are situated in the bulbar urethra. There is good evidence that these are best treated by excision and end-to-end anastomosis if they are short enough or by patch urethroplasty using a buccal mucosal graft if they are longer.Distal penile urethral strictures are the next most common type of stricture, but the evidence base is weaker, although there is agreement that penile strictures due to lichen sclerosus often require a staged approach to reconstruction, again using buccal mucosal grafts.Urethroplasty for pelvic fracture urethral injury is an altogether different type of technique for an altogether different type of pathology. There is good evidence that this is best treated by bulbo-prostatic anastomotic urethroplasty.Other types of strictures and salvage surgery have no good evidence base and are specialised areas where experience and judgement are necessary.

Conclusions

The evidence base for urethral surgery has been developed for the more common types of urethral strictures in the last 20 yr, but it is still as much an art as it is a science.