Long-Term Followup of Visual Internal Urethrotomy for Management of Short (Less Than 1 Cm) Penile Urethral Strictures Following Hypospadias Repair

Erectile dysfunction in patients undergoing multiple attempts at hypospadias repair: Etiologies and concerns

INTRODUCTION

One-third of adult patients presenting for the repair of persistent penile defects after failing multiple hypospadias repair attempts during childhood will complain of erectile dysfunction (ED). The goal of this paper is to identify possible etiological causes of its onset.

MATERIALS AND METHODS

Five selection criteria were used for entrance into the study: 1) Patients had to have failed ≥ three prior hypospadias repair attempts. 2) Present for evaluation between 18 and 40 years of age. 3) No known congenital or medical anomaly could be present that could have predisposed to erectile dysfunction. 4) Sexual history inventory for men (SHIM-5 score) completed. 5) All patients with moderate to severe ED (SHIM scores ≤ 16) underwent psychological screening; individuals with good quality spontaneous or self-stimulated erections, experiencing major life events, or had documented psychological problems were excluded from the study. One hundred consecutive patients meeting these criteria were assessed. We evaluated multiple factors to discern if they were associated with the onset of ED: the initial location of the urethral meatus, if a corporoplasty was performed, the type of corporoplasty used, if the urethral plate was divided or resected, the use of a ventral corporal graft, the total number of open reparative procedures performed before referral, the number of direct visual internal urethrotomies (DVIU) performed, the length of a urethral stricture at the time of the referral and whether lichen sclerosus was present. Statistical evaluations used chi-square analysis, two-tailed t-tests, or a logistic regression model where indicated, p-values < 0.05 were considered significant.

RESULTS

37% (37/100) of our patients complained of moderate to severe ED (SHIM score ≤16). Statistical analysis comparing patients with ED to those without ED (63%:63/100), revealed patients with ED were older, median age 34 yrs (range 20-40) vs 26 yrs (range 18-40) p = 0.0212, had undergone division of the urethral plate 70.3% (26/37) vs 47.6% (30/63), p = 0.0276, had placement of a ventral corporal graft, 24% (8/33) vs 1.5% (1/67), p = 0.0003 or had undergone repetitive DVIU's to manage urethral stricture disease, median number 4 (range 0-15) vs 0 (range 0-6), p < 0.0001, see table.

CONCLUSIONS

The early onset of ED in patients that failed multiple attempts at hypospadias repair in childhood is associated with advancing age, division of the urethral plate, and prior ventral corporal grafting. Especially significant is the association of ED to the use of repetitive internal urethrotomy to manage urethral stricture disease.

From Acellular Matrices to Smart Polymers: Degradable Scaffolds that are Transforming the Shape of Urethral Tissue Engineering

Several congenital and acquired conditions may result in severe narrowing of the urethra in men, which represent an ongoing surgical challenge and a significant burden on both health and quality of life. In the field of urethral reconstruction, tissue engineering has emerged as a promising alternative to overcome some of the limitations associated with autologous tissue grafts. In this direction, preclinical as well as clinical studies, have shown that degradable scaffolds are able to restore the normal urethral architecture, supporting neo-vascularization and stratification of the tissue. While a wide variety of degradable biomaterials are under scrutiny, such as decellularized matrices, natural, and synthetic polymers, the search for scaffold materials that could fulfill the clinical performance requirements continues. In this article, we discuss the design requirements of the scaffold that appear to be crucial to better resemble the structural, physical, and biological properties of the native urethra and are expected to support an adequate recovery of the urethral function. In this context, we review the biological performance of the degradable polymers currently applied for urethral reconstruction and outline the perspectives on novel functional polymers, which could find application in the design of customized urethral constructs.

MODERN METHODS OF TREATING DISEASES OF THE BULBO-MEMBRANOUS PART OF URETHRA

Strictures of the bulbous-membranous urethra are a common cause of obstructive urination disorder. Modern trends in the development of medicine lead to a wider application of endoscopic method, a more frequent cause of iatrogenic injury of the urethra. At present, conservative, endourologic and reconstructive methods of care are used to treat urethral strictures. There are several conservative, endourological and reconstructive methods for treating patients with urethral stricture. Conservative methods include interventions that do not involve the destruction of urethral stricture or its reconstruction, such as stenting, blind dilatation, and recanalization of the urethra. Performing blind dilatation strictures of the bulbo-membranous urethra is not recommended because of the high risk of false path formation and low efficiency. Endourological operations refer to surgical methods of care and suggest the natural restoration of urethral tissues after the destruction of stricture. Because of the low effectiveness of correction of strictures of the posterior urethra (more than 90 % of relapses in five years), this method is a variant of temporary or palliative care. Currently, two approaches to the reconstruction of the bulbo-membranous urethra are used: anastomotic and replacement operations. Anastomotic surgery involves excision of the affected area and juxtaposition of healthy urethral tissues without tension. Replacement plastic allows to restore patency of the urethra by increasing the diameter of the lumen due to the implantation of various grafts. The article shows that, based on international clinical studies, the most effective method of reconstructing the bulbomembranous urethra is reconstructive surgical methods.

Contemporary outcomes of hypospadias retrieval surgery in adults

OBJECTIVE

To describe the surgical approach and outcomes in the treatment of adult patients with complications of childhood hypospadias surgery, as such patients present a significant reconstructive challenge due to the combination of anatomical and cosmetic deformity, which often results in major functional and psychosexual sequelae.

PATIENTS AND METHODS

We analysed prospectively collected data on 79 adults with complications of childhood hypospadias surgery, who were operated on between 2004 and 2016. Of the 79 patients, 48 underwent a two-stage urethroplasty using a buccal mucosa graft, and 31 underwent a one-stage distal urethroplasty.

RESULTS

Patients were followed up using flexible cystoscopy (every 6-9 months). The mean (range) follow-up was 48 (12-96) months. Of the 48 patients who underwent a two-stage repair, eight (16%) needed a revision of the first-stage graft. In total, nine of the 48 patients (16%) developed fistula requiring closure after the second stage; all but one was closed successfully on the first attempt, whilst one required two attempts before closure. Only two of the 48 patients that underwent a two-stage procedure required a re-do urethroplasty within 3 years. Of the 31 patients who underwent a one-stage repair, six (19%) needed fistula closure, all of which were successful. No patient required a further urethroplasty during follow-up.

CONCLUSIONS

Despite the significant surgical challenges found in this patient group, excellent long-term functional outcomes can be achieved. As expected there is a need for additional intervention, either for revision of the first stage or to close fistulae and less commonly for further reconstruction for stricture recurrence.

[Urethral reconstruction in patients with failed hypospadia repair]

BACKGROUND

The tasks involved in reconstructing the urethra after failed hypospadias repair range from correction of a trivial meatal stenosis to reconstruction of the entire anterior urethra.

OBJECTIVES

To describe pathological findings in the urethra after failed hypospadias repair and the respective surgical methods used for their correction.

MATERIALS AND METHODS

The various pathological findings after unsuccessful hypospadias surgery are classified according to their location and complexity.

RESULTS

The general rules of reconstruction that should be applied in each particular situation are described.

CONCLUSIONS

Successful reconstruction of the urethra in patients with failed hypospadias surgery requires experience and good knowledge of the anatomy of the normal and hypospadic urethra and penis. Mastery of plastic surgical techniques and profound knowledge of the various surgical methods of hypospadias surgery are essential.

Intermittent self-dilatation for urethral stricture disease in males: A systematic review and meta-analysis

BACKGROUND

Intermittent self-dilatation (ISD) may be recommended to reduce the risk of recurrent urethral stricture. Level one evidence to support the use of this intervention is lacking.

OBJECTIVES

Determine the clinical and cost-effectiveness of ISD for the management of urethral stricture disease in males.

SEARCH METHODS

The strategy developed for the Cochrane Incontinence Review Group as a whole (last searched May 7, 2014).

SELECTION CRITERIA

Randomised trials where one arm was a programme of ISD for urethral stricture.

DATA COLLECTION AND ANALYSIS

At least two independent review authors carried out trial assessment, selection, and data abstraction.

RESULTS

Data from six trials that were pooled and collectively rated very low quality per the GRADE approach, indicated that recurrent urethral stricture was less likely in men who performed ISD than those who did not (RR 0.70, 95% CI 0.48-1.00). Two trials compared programmes of ISD but the data were not combined and neither were sufficiently robust to draw firm conclusions. Three trials compared devices for performing ISD, results from one of which were too uncertain to determine the effects of a low friction hydrophilic catheter versus a polyvinyl chloride catheter on risk of recurrent urethral stricture (RR 0.32, 95% CI 0.07 to 1.40); another did not find evidence of a difference between 1% triamcinolone gel for lubricating the ISD catheter versus water-based gel on risk of recurrent urethral stricture (RR 0.68, 95% CI 0.35 to 1.32). No trials gave cost-effectiveness or validated PRO data.

CONCLUSIONS

ISD may decrease the risk of recurrent urethral stricture. A well-designed RCT is required to determine whether that benefit alone is sufficient to make this intervention worthwhile and in whom. Neurourol. Urodynam. 35:759-763, 2016. © 2015 Wiley Periodicals, Inc.

Intermittent self-dilatation for urethral stricture disease in males

BACKGROUND

Intermittent urethral self-dilatation is sometimes recommended to reduce the risk of recurrent urethral stricture. There is no consensus as to whether it is a clinically effective or cost-effective intervention in the management of this disease.

OBJECTIVES

The purpose of this review is to evaluate the clinical effectiveness and cost-effectiveness of intermittent self-dilatation after urethral stricture surgery in males compared to no intervention. We also compared different programmes of, and devices for, intermittent self-dilatation. .

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 7 May 2014), CENTRAL (2014, Issue 4), MEDLINE (1 January 1946 to Week 3 April 2014), PREMEDLINE (covering 29 April 2014), EMBASE (1 January 1947 to Week 17 2014), CINAHL (31 December 1981 to 30 April 2014) OpenGrey (searched 6 May 2014), ClinicalTrials.gov (6 May 2014), WHO International Clinical Trials Registry Platform (6 May 2014), Current Controlled Trials (6 May 2014) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials where one arm was a programme of intermittent self-dilatation for urethral stricture were identified. Studies were excluded if they were not randomised or quasi-randomised trials, or if they pertained to clean intermittent self-catheterisation for bladder emptying.

DATA COLLECTION AND ANALYSIS

Two authors screened the records for relevance and methodological quality. Data extraction was performed according to predetermined criteria using data extraction forms. Analyses were carried out in Cochrane Review Manager (RevMan 5). The primary outcomes were patient-reported symptoms and health-related quality of life, and risk of recurrence; secondary outcomes were adverse events, acceptability of the intervention to patients and cost-effectiveness. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Eleven trials were selected for inclusion in the review, including a total of 776 men. They were generally small; all were of poor quality and all were deemed to have high risk of bias. Performing intermittent self-dilatation versus not performing intermittent self-dilatation The data from six trials were heterogeneous, imprecise and had a high risk of bias, but indicated that recurrent urethral stricture was less likely in men who performed intermittent self-dilatation than men who did not perform intermittent self-dilatation (RR 0.70, 95% CI 0.48 to 1.00; very low quality evidence). Adverse events were generally poorly reported: two trials did not report adverse events and two trials reported adverse events only for the intervention group. Meta-analysis of the remaining two trials found no evidence of a difference between performing intermittent self-dilatation and not performing it (RR 0.60, 95% CI 0.11 to 3.26). No trials formally assessed acceptability, and no trials reported on patient-reported lower urinary tract symptoms, patient-reported health-related quality of life, or cost-effectiveness. One programme of intermittent self-dilatation versus another We identified two trials that compared different durations of intermittent self-dilatation, but data were not combined. One study could not draw robust conclusions owing to cross-over, protocol deviation, administrative error, post-hoc analysis and incomplete outcome reporting. The other study found no evidence of a difference between intermittent self-dilatation for six months versus for 12 months after optical urethrotomy (RR 0.67, 95% CI 0.12 to 3.64), although again the evidence is limited by the small sample size and risk of bias in the included study. Adverse events were reported narratively and were not stratified by group. No trials formally assessed acceptability, and no trials reported on patient-reported lower urinary tract symptoms, patient-reported health-related quality of life, or cost-effectiveness. One device for performing intermittent self-dilatation versus another Three trials compared one device for performing intermittent self-dilatation with another. Results from one trial at a high risk of bias were too uncertain to determine the effects of a low friction hydrophilic catheter and a standard polyvinyl chloride catheter on the risk of recurrent urethral stricture (RR 0.32, 95% CI 0.07 to 1.40). Similarly one study did not find evidence of a difference between one percent triamcinolone gel for lubricating the intermittent self-dilatation catheter versus water-based gel on risk of recurrent urethral stricture (RR 0.68, 95% CI 0.35 to 1.32). Two trials reported adverse events, but one did not provide sufficient detail for analysis. The other small study reported fewer instances of prostatitis, urethral bleeding or bacteriuria with a low friction hydrophilic catheter compared with a standard polyvinyl chloride catheter (RR 0.13, 95% CI 0.02 to 0.98). 'Happiness with the intervention' was assessed using a non-validated scale in one study, but no trials formally assessed patient-reported health-related quality of life or acceptability. No trials reported on patient-reported lower urinary tract symptoms or cost-effectiveness. GRADE quality assessment The evidence that intermittent self-dilatation reduces the risk of recurrent urethral stricture after surgical intervention was downgraded to 'very low' on the basis that the studies comprising the meta-analysis were deemed to have high risk of bias, and the data was imprecise and inconsistent. Insufficient evidence No trials provided cost-effectiveness data or used a validated patient-reported outcome measure, and adverse events were not reported rigorously. Acceptability of the intervention to patients has not been assessed quantitatively or qualitatively.

AUTHORS' CONCLUSIONS

Performing intermittent self-dilatation may confer a reduced risk of recurrent urethral stricture after endoscopic treatment. We have very little confidence in the estimate of the effect owing to the very low quality of the evidence. Evidence for other comparisons and outcomes is limited. Further research is required to determine whether the apparent benefit is sufficient to make the intervention worthwhile, and in whom.

Role of visual internal urethrotomy in pediatric urethral strictures

PURPOSE

To evaluate the efficiency of visual internal urethrotomies (VIUs) in pediatric patients.

PATIENTS AND METHODS

Thirty-four patients aged 0.2-16.3 years were treated with VIUs as a primary treatment for urethral stricture at our institution during 1980-2010. The stricture characteristics and need for repeat treatments as well as the results of repeat VIUs or dilatations were evaluated in a long-term follow-up.

RESULTS

Each time first VIUs or repeat treatments were carried out there was a 22-33% success rate at 5 years. Twenty-four patients (71%) were treated successfully after repeat VIUs or dilatations at a median of 6.6 years' follow-up. None of the five patients with strictures longer than 2 cm were successfully treated, compared with 24 of 29 patients with shorter strictures (p = 0.001). However, stricture etiology or location did not have an impact on success. Currently four patients have undergone an open operation because of stricture and six patients are on a home dilatation program.

CONCLUSION

Single VIU is successful for about one-quarter of pediatric patients with a urethral stricture. With repeated VIUs or dilatations 71% of the patients can achieve success. In strictures less than 2 cm, up to three VIUs can be attempted, but longer strictures need open correction if the patient does not wish to follow the home dilatation program.

Failed hypospadias in paediatric patients

Failed hypospadias refers to any hypospadias repair that leads to complications or causes patient dissatisfaction. The complication rate after hypospadias repairs ranges from 5-70%, but the actual incidence of failed hypospadias is unknown as complications can become apparent many years after surgery and series with lifelong follow-up data do not exist. Moreover, little is known about uncomplicated repairs that fail in terms of patient satisfaction. Risk factors for complications include factors related to the hypospadias (severity of the condition and characteristics of the urethral plate), the patient (age at surgery, endocrine environment, and wound healing impairment), the surgeon (technique selection and surgeon expertise), and the procedure (technical details and postoperative management). The most important factors for preventing complications are surgeon expertise (number of cases treated per year), interposition of a barrier layer between the urethroplasty and the skin, and postoperative urinary drainage. Major complications associated with failed hypospadias include residual curvature, healing complications (preputial dehiscence, glans dehiscence, fistula formation, and urethral breakdown), urethral obstruction (meatal stenosis, urethral stricture, and functional obstruction), urethral diverticula, hairy urethra, and penile skin deficiency.

Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men

BACKGROUND

Strictures of the urethra are the most common cause of obstructed micturition in younger men and frequently recur after initial treatment. Standard treatment comprises internal widening of the strictured area by simple dilatation or by telescope-guided internal cutting (optical urethrotomy), but these interventions are associated with a high failure rate requiring repeated treatment. The alternative option of open urethroplasty whereby the urethral lumen is permanently widened by removal or grafting of the strictured segment is less likely to fail but requires greater expertise. Findings of Improved choice of graft material and shortened hospital stay suggest that urethroplasty may be under utilised. The extent and quality of evidence guiding treatment choice for this condition are uncertain.  

OBJECTIVES

To determine which is the best surgical treatment for male urethral stricture disease taking into account relative efficacy, adverse event rates and cost-effectiveness.  

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 21 June 2012), CENTRAL (2012, Issue 6), MEDLINE (January 1946 to week 2 June 2012), EMBASE (January 1980 to week 25 2012), OpenSIGLE (searched 26 June 2012), clinical trials registries and reference lists of relevant articles.

SELECTION CRITERIA

We included publications reporting data from randomised or quasi-randomised controlled trials comparing the effectiveness of dilatation, urethrotomy and urethroplasty in the treatment of adult men with urethral stricture disease.

DATA COLLECTION AND ANALYSIS

Two authors evaluated trials for appropriateness for inclusion and methodological quality. Data extraction was performed using predetermined criteria. Analyses were carried out using the Cochrane Review Manager software (RevMan 5).

MAIN RESULTS

Two randomised trials were identified. One trial compared the outcomes of surgical urethral dilatation and optical urethrotomy in 210 adult men with urethral stricture disease. No significant difference was found in the proportion of men being stricture free at three years or in the median time to recurrence. The second trial compared the outcomes of urethrotomy and urethroplasty in 50 men with traumatic stricture of the posterior urethra following pelvic fracture injury. In the first six months, men were more likely to require further surgery in the urethrotomy group than in the primary urethroplasty group (RR 3.39, 95% CI 1.62 to 7.07). After two years, 16 of 25 (64%) men initially treated by urethrotomy required continued self-dilatation or further surgery for stricture recurrence compared to 6 of 25 (24%) men treated by primary urethroplasty. There were insufficient data to perform meta-analysis or to reliably determine effect size.

AUTHORS' CONCLUSIONS

There were insufficient data to determine which intervention is best for urethral stricture disease in terms of balancing efficacy, adverse effects and costs. Well designed, adequately powered multi-centre trials are needed to answer relevant clinical questions regarding treatment of men with urethral strictures.

Salvage hypospadias repairs

Aim:

Review of our experience and to develop an algorithm for salvage procedures in the management of hypospadias cripples and treatment of urethral strictures following hypospadias repair.

Methods:

This is a retrospective review of hypospadias surgeries over a 41-month period. Out of a total 168 surgeries, 20 were salvage/re-operative repairs. In three children a Duplay repair was feasible, while in four others a variety of single-stage repairs could be done. The repair was staged in seven children – buccal mucosal grafts (BMGs) in five, buccal mucosal tube in one, and skin graft in one. Five children with dense strictures were managed by dorsal BMG inlay grafting in one, vascularized tunical onlay grafting on the ventrum in one, and a free tunical patch in one. Three children were treated by internal urethrotomy and stenting for four weeks with a poor outcome.

Results:

The age of children ranged from 1.5–15 years (mean 4.5). Follow-up ranged from 3 months to 3.5 years. Excellent results were obtained in 10 children (50%) with a well-surfaced erect penis and a slit-like meatus. Glans closure could not be achieved and meatus was coronal in three. Two children developed fistulae following a Duplay repair and following a staged BMG. Three repairs failed completely – a composite repair broke down, a BMG tube stenosed with a proximal leak, and a stricture recurred with loss of a ventral free tunical graft.

Conclusions:

In salvage procedures performed on hypospadias cripples, a staged repair with buccal mucosa as an inlay in the first stage followed by tubularization 4–6 months later provides good results. A simple algorithm to plan corrective surgery in failed hypospadias cases and obtain satisfactory results is devised.

[Surgical trends in secondary hypospadias]

The severity of secondary hypospadias can range from a mild cosmetic problem to severe functional impairment. Accordingly, surgical management of the defect can be either simple or extremely demanding. During the operation the penis should always be regarded as a functional unit so that the treatment goal of a good cosmetic and functional result can be achieved. In addition, the surgeon should have an extensive repertoire of operative techniques at his disposal and should be well versed in skin grafting methods so that he is able to adapt the procedure optimally to the intraoperative findings as necessary. If certain do's and don'ts of hypospadias correction are additionally observed good results can usually be obtained even in complicated hypospadias patients with multiple previous operations. Unreflected treatment, on the other hand, usually leads to further worsening of the problem resulting in the so-called hypospadias cripple.

Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men

BACKGROUND

Strictures of the urethra are the commonest cause of obstructed micturition in younger men and frequently recur after initial treatment. Standard treatment comprises internal widening of the strictured area by simple dilatation or by telescope-guided internal cutting (optical urethrotomy), but these interventions are associated with a high failure rate requiring repeated treatment. The alternative option of open urethroplasty whereby the urethral lumen is permanently widened by removal or grafting of the strictured segment is less likely to fail but requires greater expertise. Improved choice of graft material and shortened hospital stay suggest urethroplasty may be under used. The extent and quality of evidence guiding treatment choice for this condition is uncertain.

OBJECTIVES

To determine which is the best surgical treatment for male urethral stricture disease taking into account relative efficacy, adverse event rates and cost-effectiveness.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 26 March 2009), CENTRAL (2009, Issue 1), MEDLINE (January 1950 to March 2009), EMBASE (January 1980 to March 2009), OpenSIGLE (searched 26 March 2009), clinical trials registries and reference lists of relevant articles.

SELECTION CRITERIA

We included publications reporting data from randomised or quasi-randomised controlled trials comparing the effectiveness of dilatation, urethrotomy and urethroplasty in the treatment of adult men with urethral stricture disease.

DATA COLLECTION AND ANALYSIS

Two authors evaluated trials for appropriateness for inclusion and methodological quality. Data extraction was performed using predetermined criteria. Analyses were carried out using the Cochrane Review Manager software; RevMan 5.

MAIN RESULTS

Two randomised trials were identified. One trial compared the outcome of surgical urethral dilatation and optical urethrotomy in 210 adult men with urethral stricture disease. No significant difference was found in the proportion of men being stricture free at three years or in the median time to recurrence. The second trial compared the outcome of urethrotomy and urethroplasty in 50 men with traumatic stricture of the posterior urethra following pelvic fracture injury. After two years 16 of 25 (64%) men initially treated by urethrotomy required continued self-dilatation or further surgery for stricture recurrence compared to 6 of 25 (24%) men treated by primary urethroplasty. There was insufficient data to perform meta-analysis or to reliably determine effect size.

AUTHORS' CONCLUSIONS

There were insufficient data to determine which intervention is best for urethral stricture disease in terms of balancing efficacy, adverse effects and costs. Well designed, adequately powered multi-centre trials are needed to answer relevant clinical questions regarding treatment of men with urethral strictures.