Treatment of Complex Anterior Urethral Stricture Disease With Mesh Graft Urethroplasty

Long-term outcomes for 2-stage urethroplasty: an analysis of risk factors for urethral stricture recurrence

Purpose

To report long-term results and patient reported outcomes of staged anterior urethroplasties, and isolate risk factors for recurrence.

Methods

 We reviewed urethroplasty database for all patients who underwent staged urethroplasty from 2000 to 2017. Follow-up included a cystoscopy 4 months after their 2nd stage to assess early success, and then annual follow-up thereafter with post-void residual and symptom assessment. Stricture characteristics, etiology and graft type were analyzed with regards to success.

Results

 Forty-nine patients were eligible for inclusion. The median stricture length was 7 cm (3–17 cm). The early success rate demonstrated by cystoscopy at 4 months was 100%. Long-term success was 96.4% in buccal graft (BMG) only patients; however, long-term success fell considerably to 53% in patients requiring any use split thickness skin graft (STSG) in the first stage. Median follow up time was 57 months (6–240 months). On analysis, age, increased stricture length and especially the use of STSG all appeared to be associated with late recurrence. The recurrence group had longer stricture length and were more likely to be panurethral. All recurrences occurred after the initial 4-month cystoscopy with a median time to recurrence of 78 months.

Conclusion

Staged repairs that are amenable to BMG-only repairs have high long-term success rates. Increasing stricture length and the addition of split-thickness skin graft were associated with lower success rate in staged urethral reconstruction. Patients requiring staged repairs often experience recurrence in a very delayed fashion reinforcing the need for close, long-term follow up.

Tissue transfer techniques in reconstructive urology

Tissue transfer techniques are an essential part of the reconstructive urologist's armamentarium. Flaps and graft techniques are widely used in genital and urethral reconstruction. A graft is tissue that is moved from a donor site to a recipient site without its native blood supply. The main types of grafts used in urology are full thickness grafts, split thickness skin grafts and buccal mucosa grafts. Flaps are transferred from the donor site to the recipient site on a pedicle containing its native blood supply. Flaps can be classified based on blood supply, elevation methods or the method of transfer. The most used flaps in urology include penile, preputial, and scrotal skin. We review the various techniques used in reconstructive urology and the outcomes of these techniques.

Transpubic urethroplasty: a single center experience

Objective. To evaluate the long-term results of transpubic urethroplasty for pelvic fracture urethral distraction defects. Patients and Methods. Sixteen patients who had undergone transpubic urethroplasty for posttraumatic complex posterior urethral disruptions between 2007 and 2013 were analyzed retrospectively and prospectively. Patients were followed up for a mean (range) of 24 (6–60) months by history, urinary flow rate estimate, retrograde urethrography, and voiding cystourethrography. Results. The mean age of the patients was 30.4 years. The estimated radiographic stricture length before surgery was 4.3 cm. Transpubic urethroplasty was successful in 14 out of 16 patients. Postoperative complications were recurrent stricture (12.5%), urethrocutaneous fistula (12.5%), incontinence (31.25%), impotence (25%), and wound infection (18.75%). Failed repairs were successfully managed endoscopically in one patient and by perineal anastomotic repair in the other, giving a final success rate of 100%. Five out of 16 patients were incontinent of which 3 of them resolved and 2 had permanent incontinence. Impotence was seen in 4 out of 16 patients. There were no reported complications of pubectomy in any of our patients. Conclusions. Though considered obsolete now, transpubic urethroplasty for complex posterior urethral disruptions is still a viable alternative with excellent results and minimal morbidity.

Current management of urethral stricture

The surgical treatment of urethral stricture diseases is continually evolving. Although various surgical techniques are available for the treatment of anterior urethral stricture, no one technique has been identified as the method of choice. This article provides a brief updated review of the surgical options for the management of different sites and different types of anterior urethral stricture. This review also covers present controversies in urethral reconstruction. Among the various procedures available for treating urethral stricture, one-stage buccal mucosal graft urethroplasty is currently widely used. The choice of technique for urethroplasty for an individual case largely depends on the expertise of the surgeon. Therefore, urologists working in this field should keep themselves updated on the numerous surgical techniques to deal with any condition of the urethra that might surface at the time of surgery.

Urethral 'cripples': two-staged procedures

PURPOSE OF REVIEW

To review the current literature on staged procedures in patients with previous urethral interventions ('urethral cripples').

RECENT FINDINGS

Five studies published during the past 18 months could be identified, the majority with short-term follow-up and small patient numbers. Four studies investigated the outcome after redo surgery in hypospadias patients, one study after urethral stricture disease.

SUMMARY

The few data published suggest acceptable complication rate and success rate for surgical outcome. Long-term and prospective data with special respect to sexual function, patient satisfaction, and quality of life are still lacking.

Single-stage dorsal inlay split-skin graft for salvage anterior urethral reconstruction

OBJECTIVE

To report our initial experience and extended follow-up of single-stage dorsal inlay skin-graft urethroplasty for salvaging recurrent anterior urethral stricture (AUS), as urethral reconstruction remains a challenge, particularly in patients with recurrent AUS after previous surgery, and a paucity of local skin frequently requires free graft reconstruction techniques.

PATIENTS AND METHODS

In all, 27 patients (mean age 48.12 years, range 17-79) with recurrent AUS had a dorsal inlay urethroplasty using extragenital split-thickness skin grafts. An electrical dermatome was used for graft harvesting. All patients had contraindications for buccal mucosal grafting (e.g. radiotherapy, leukoplakia). The assessment before repair comprised a clinical investigation, urine analysis, uroflowmetry, retrograde and voiding cystogram, urethral ultrasonography and endoscopy. The follow-up was based on an assessment of flow rate and postvoid residual volume. Success was defined by the absence of symptoms and stable maximum flow rate, while any further instrumentation was considered a failure.

RESULTS

The mean (range) stricture length was 8.35 (3-14) cm. The overall complication rate was 7%, with no complications during surgery. During the mean (range) follow-up of 32.43 (5-46) months, 25 (93%) of the patients were successfully cured in one operation. Two patients required further treatment for recurrence and fistula. No long-term complications were noted at the graft donor sites. There was no case of intraurethral hair growth during the extended follow-up.

CONCLUSION

If there are contraindications for buccal mucosal grafting, a split-thickness skin can be used for dorsal inlay urethroplasty in recurrent AUS. A well-vascularized recipient bed on the corpora cavernosa is required for reliable graft take. Intra-urethral hair growth is avoided by using split-skin grafts. Although the complication rates are equivalent to those of buccal mucosa, we await the longer follow-up to assess the ultimate value of this alternative single-stage technique.

Complex urethral disruptions: in pursuit of a successful reconstruction

OBJECTIVES

We analyzed the methods and outcomes of urethroplasty in men with complex urethral disruptions.

METHODS

The medical records of 40 men with complex urethral disruptions were analyzed. Surgical methods were individualized according to stricture location, severity and length of the stricture, bladder neck characteristics and presence of complicating factors. Patients were divided into four groups based on the above characteristics.

RESULTS

End-to-end urethroplasty performed in six patients with short bulbar strictures (<3 cm) was successful in all. Elaborated perineal repair was performed in 10 patients with intermediate (3-6 cm) strictures with or without complicating factors. Elaborated perineal repair with urethral substitution was performed in nine patients with long segment stricture (>6 cm). Abdominal transpubic repair was successfully applied to patients with rectourethral fistula or lacerated bladder neck. Success rate of anastomotic urethroplasty was 95% while over all success rate was 85%.

CONCLUSION

Guidelines for urethral reconstruction of complex urethral disruptions are predicated on stricture length, location, bladder neck characteristics and associated complicating factors. End-to-end urethroplasty with stricture excision is highly reliable for short strictures for which previous operative repair have failed. Elaborated perineal repair is extremely versatile for intermediate and longer strictures with associated complicating factors. Abdominal transpubic urethroplasty is effective for patients with rectourethral fistula or lacerated bladder neck.

Outcome of buccal mucosal graft urethroplasty for long and repeated stricture repair

OBJECTIVES

To evaluate the efficacy of one-stage buccal mucosal tubed graft in long and repeated urethroplasty.

METHODS

Thirty-four patients with long and repeated strictures of the urethra underwent buccal mucosal urethroplasty from 2000 to 2003. For all patients, one-stage buccal mucosal tubed graft urethroplasty was performed by releasing and extracting the fibrous tissue around the stricture, harvesting buccal mucosa from the inner cheek, tubing the graft, and interposing it in the defect. The urethral catheter was removed 3 weeks postoperatively. Suprapubic drainage was in place until urethral patency was confirmed by antegrade cystourethrography. The patients were followed up with clinical history and symptom reporting, urinalysis and culture, periodic uroflowmetry, ultrasonography, and cystourethrography at 1, 3, and 6 months and yearly thereafter. The urinary flow rates before and after surgery, postvoid residual urine volumes, restricture rates, and incidence of incontinence, erectile dysfunction, fistula, and diverticulum were assessed.

RESULTS

The procedure was technically successful in all patients. The mean operative time was 150 minutes. During 28 months (range 12 to 39) of follow-up, the success rate was 76.5%. Restricture occurred in 5 patients during the first year postoperatively. Urethrocutaneous fistula, erectile dysfunction, and diverticulum occurred in 2, 1, and 1 patient, respectively. The mean urinary flow rate and postvoid residual urine volume improved significantly. Patient satisfaction was good.

CONCLUSIONS

Buccal mucosal grafts are tough, resilient, easy to harvest, and leave no scar. They appear to be an optimal substitute for anterior and posterior long urethral strictures in repeated urethroplasty.

Bulbar Urethroplasty with Dorsal Onlay Buccal Mucosal Graft and Fibrin Glue

OBJECTIVES

We describe a new surgical technique with the use of fibrin glue for bulbar urethra reconstruction using a dorsal buccal mucosal onlay graft.

METHODS

Six patients with a mean age of 43 yr underwent bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue. The urethra was mobilised from the corpora cavernosa and opened along its dorsal surface. The buccal mucosal graft was applied on the corpora cavernosa using 2 ml of fibrin glue. Two interrupted polyglactin 5-0 sutures were used to fix the apices of the graft to the underlying albuginea of the corpora cavernosa. The urethra was rotated back to cover the graft and an adjunctive fibrin glue was injected over the urethra.

RESULTS

The mean operative time was 100 min (range, 90-120 min). No intraoperative or postoperative complications were observed. Voiding cystourethrography was performed when the catheter was removed 2 wk after surgery. Urine culture, uroflowmetry, and urethrography were repeated after 6 and 12 mo and annually thereafter. Mean follow-up was 16 mo (range, 12-24 mo). No restrictures at the anastomotic sites were demonstrated in any of the patients 6 and 12 mo after surgery.

CONCLUSIONS

The use of fibrin glue represents a slight but significant step toward perfecting the surgical technique of bulbar urethral reconstruction.

Anterior urethral strictures

The surgical treatment of adult anterior urethral strictures has developed continuously. Recently considerable changes have been introduced, involving the cause of the urethral disease and surgical techniques. The criteria for selecting the reconstructive surgical technique are presented according to the cause and a new classification of urethral strictures. The main surgical procedures are presented and fully illustrated, with an updated and comprehensive review of recent publications.

One-stage circumferential buccal mucosa graft urethroplasty for bulbous stricture repair

A one-stage onlay urethroplasty, using a buccal mucosa graft, is presented for patients with bulbous strictures in whom the urethral mucosa is seriously involved in the disease. Of 40 patients who underwent a dorsal buccal mucosa graft urethroplasty for bulbous urethral strictures, 5 required complete removal of the urethral mucosa and its replacement by a buccal mucosa graft. All these patients had undergone previous urethrotomy with a false passage inside the bulbous urethra and had a suprapubic tube in place. The goal of removal and replacement of the urethral mucosa in each case was to create a new, wide urethral mucosal bed to promote successful one-stage reconstruction. All patients voided spontaneously without problems after removal of the catheter. After 4 months, the mean peak flow was 21 mL/s. After 6 months, urethroscopy did not show any stricture recurrence. None of the patients required instrumentation or dilation. In patients with bulbous urethral strictures and false passage into the mucosa and spongiosum tissues, the complete removal and replacement of the urethral mucosa using a circumferential buccal mucosa graft promotes successful one-stage urethral reconstruction.

Which urethroplasty for which results?

PURPOSE OF REVIEW

Urethral surgery is rapidly changing because of developments in techniques. The aim of this paper is to provide an update and a review of the most significant surgical options and their outcomes in the treatment of urethral strictures.

RECENT FINDINGS

Indications and results of anastomotic repair, pedicled flap, free graft and complex urethral reconstruction are reported. New trends such as dorsal urethroplasty and the use of buccal mucosa are reviewed.

SUMMARY

Most urethral strictures can be managed successfully by urethral surgery. A wide spectrum of effective procedures is available. To obtain optimal results, adequate knowledge and experience of the most common techniques are required.

Staged urethroplasty: indications and techniques

There is still a place for staged urethroplasty. There are some indications for staged urethral reconstruction such as strictures associated with chronic inflammation, fistula, false passage, urethral stones, urethral diverticula, abscess, failed prior repair, complicated hypospadias, severe trauma, neurologic diseases, extensive BXO strictures and long strictures. Staging a urethroplasty should not be considered a step backwards rather instead we should learn from experience and realize there are some patients who are too complex to reconstruct in a single stage.

New 2-stage buccal mucosal graft urethroplasty

PURPOSE

Previously buccal mucosal grafts used for repairing adult bulbourethral stricture with the 1-stage dorsal technique has provided a satisfactory outcome in our experience. We present the wider use of buccal mucosal grafts for 2-stage urethroplasty.

MATERIALS AND METHODS

A total of 24 men 25 to 60 years old (median age 45) with a complex bulbar stricture underwent 2-stage urethroplasty using a buccal mucosal graft to repair the perineostomy. The primary etiology of stricture was traumatic in 4 cases, inflammatory in 16 and unknown in 4. The 2 x 6 cm. graft was harvested from the inner cheek and sutured to the left margin of the urethral mucosal plate with running 6-zero polyglactin suture. Patients were discharged from the hospital within 3 days with a 14Fr silicone urethral catheter in place. Radiological studies and urethroscopy were done 1 year after closure.

RESULTS

A final successful outcome with no recurrent stricture was achieved in 23 of 24 men (92.8%) at a median followup of 18 months (range 13 to 32). In 1 case a urethrocutaneous fistula at the initial radiological assessment closed spontaneously after 14 days of catheterization. No urethral diverticula developed. The mean postoperative peak flow rate is 22 ml. per second (range 18 to 25).

CONCLUSIONS

Our new 2-stage buccal mucosal graft urethroplasty may be an excellent technique for complex bulbar urethral stricture disease. Our suggestions may increase usefulness of the 2-stage technique for repairing complex strictures due to the avoidance of classic complications.

One-stage urethroplasty for strictures: Nigerian experience

PURPOSE

To analyze the effects on voiding and complications of one-stage urethroplasty for urethral stricture.

METHODS

All patients who underwent one-stage urethroplasty for stricture in two health institutions in Enugu, Nigeria, between January 1989 and December 1998, were included. The age of the patient, duration of symptoms and the cause of the stricture were noted. Retrograde urethrogram and, when necessary, micturating cystourethogram was done. Urethroplasty was either by substitution using pedicled penile skin flap or by end-to-end anastomosis. Patients were followed up monthly for 1 year during which the patient's ability to urinate satisfactorily was assessed and any complications were noted. One hundred and forty-four (144) men, aged between 11 and 76 years (mean 36.3 +/- 11.2 years), were studied. These included 121 cases who had rapidly recurring strictures after internal urethrotomy or dilatation and 23 cases of complete stricture. Etiology of the stricture included external trauma (43.8%), postinflammatory (36.1%) and iatrogenic (post-catheterization; 20.1%). Ninety-one (63.2%) strictures were in the anterior urethra, 47 (32.6%) in the posterior urethra and six (4.2%) bulbomembranous. The mean length of the strictures was 3.1 +/- 1.4 cm.

RESULTS

Anastomotic urethroplasty was performed in 98 (68.1%) patients and substitution in 46 (31.9%). Hospital stay was between 12 and 14 days, except in those who developed complications. Normal voiding was achieved in 124 (86.1%) patients. Urethral fistula was encountered in five (3.5%) patients and recurrent stricture in 15 (10.4%). There was no mortality.

CONCLUSIONS

One-stage urethroplasty affords an excellent cost-effective means of reconstruction of the urethra in patients with stricture of various etiologies. In our environment in particular, it avoids the fulminating infection often encountered after the first stage of a two-staged operation.

Evidence of a peripheral role of neurokinins in detrusor hyperreflexia: a further study of selective tachykinin antagonists in chronic spinal injured rats

PURPOSE

Spinal cord injury above the sacral micturition center usually leads to detrusor hyperreflexia, increased intravesical pressure and post-void residual urine. Detrusor hyperreflexia is believed to be mediated by afferent C fibers with tachykinins as neurotransmitters. We investigated the selective peptide tachykinin antagonists MEN 11420 and GR 82334 of NK-2 and NK-1 receptors, respectively, in a chronic rat model of detrusor hyperreflexia after suprasacral spinal cord injury.

MATERIALS AND METHODS

Adult female Sprague-Dawley rats weighing 200 to 250 gm. were used. The spinal cord was transected at the T10 level. The bladder was evacuated by the Credé maneuver 3 times daily. After 6 weeks the rats were implanted with femoral vein and bladder dome catheters 2 days before filling cystometry. The 5 rats in group 1 received 100 nmol./kg. of the NK-2 antagonist MEN 11420 intravenously. The 5 rats in group 2 received 100 nmol./kg. of the NK-1 antagonist GR 82334 intravenously. The 5 rats in group 3 received a combination of the same dose of each antagonist. Three repetitive micturition cycles were recorded before injection. Three micturition cycles were done 20 minutes after the injection of each antagonist. Mean cystometric parameters were reported, including bladder capacity, micturition pressure, baseline pressure, post-void residual urine and micturition volume, and the number and amplitude of hyperreflexic contractions greater than 15 cm. water.

RESULTS

MEN 11420 significantly reduced the frequency of hyperreflexic contractions and baseline bladder pressure (p <0.05). There was no statistically significant effect on the other cystometric parameters. GR 82334 reduced the amplitude of hyperreflexic contractions but not statistically significant. A combination of MEN 11420 and GR 82334 significantly reduced the frequency and amplitude of hyperreflexic contractions (p <0.05) with no significant effects on other cystometric parameters, although there was a tendency toward increased micturition volume and bladder capacity.

CONCLUSIONS

These results suggest that at the peripheral level there is an efferent role of tachykinins in detrusor hyperreflexia after spinal cord injury. NK-1 and NK-2 receptor selective antagonists reduced the frequency and amplitude of hyperreflexic contractions as well as baseline bladder pressure. This finding may lead to potential new therapeutic modalities using selective tachykinins antagonists with other pharmacological agents to combat detrusor hyperreflexia.

Late onset recurrent penile chordee after successful correction at hypospadias repair

PURPOSE

Artificial erections are induced at hypospadias repair to prevent recurrent chordee. We describe the development and etiology of late onset recurrent chordee greater than 10 years after the initial surgery.

MATERIALS AND METHODS

We reviewed the medical records of 22 patients with a median age of 4 years at surgery who were referred for evaluation of chordee 10 years after successful hypospadias repair.

RESULTS

Of the 22 patients with recurrent chordee 13 had penoscrotal and 9 had proximal penile hypospadias at the initial operation. All originally required corporoplasty for the release of chordee, including Nesbit procedure in 19 and tunica vaginalis graft in 3. Successful artificial erections were induced after corporoplasty in all cases. Urethral reconstruction was performed with full-thickness preputial free grafts in 11 cases, bladder mucosal grafts in 7 and transverse island flap urethroplasty in 4. Although chordee developed during puberty (median age of onset 16 years, range 12 to 18), the median age at presentation for surgical correction was 21 years. Recurrent chordee was due to extensive fibrosis of the reconstructed urethra in 7 cases (32%), corporeal disproportion in 8 (36%) and both conditions in 7 (32%).

CONCLUSIONS

A successful artificial erection induced at hypospadias surgery does not prevent the delayed onset of recurrent chordee. Recurrent chordee may be secondary to the redevelopment of corporeal disproportion and/or extensive urethral fibrosis.

Failed anterior urethroplasty: guidelines for reconstruction

PURPOSE

We analyzed the methods and outcomes of repeat urethroplasty in men with recurrent stricture after the failure of previous anterior urethroplasty.

MATERIALS AND METHODS

In 31 men with recurrent stricture after previous urethroplasty anterior urethral reconstruction was performed. Reconstructive methods varied according to stricture length and location.

RESULTS

End-to-end urethroplasty performed in 11 of 13 men with short (average 1.8 cm.) bulbar strictures was successful in all. Patch graft urethroplasty was successfully done in 4 men with intermediate (average 4.4 cm.) strictures. Penile circular fasciocutaneous flap urethroplasty performed in 13 of 14 men with long or distal strictures (average 8 cm.) was successful in 10 (79%). Overall excellent results were obtained in 28 of the 31 cases (90%).

CONCLUSIONS

Guidelines for urethral reconstruction after failed anterior urethroplasty are predicated on stricture length, location and severity. Circular fasciocutaneous flap urethroplasty is extremely versatile and effective for refractory long or distal strictures. End-to-end urethroplasty with stricture excision is highly reliable for less extensive bulbar strictures for which previous operative repair has failed. Grafts are best used selectively in the reoperative setting.