Histological changes associated with long-term urethral stents

Urethroplasty After Urethral Urolume Stent: An International Multicenter Experience

OBJECTIVE

To evaluate the outcomes and factors affecting success of urethroplasty in patients with stricture recurrence after Urolume urethral stent.

MATERIAL AND METHODS

This is a retrospective international multicenter study on patients treated with urethral reconstruction after Urolume stent. Stricture and stent length, time between urethral stent insertion and urethroplasty, age, mode of stent retrieval, type of urethroplasty, complications and baseline, and posturethroplasty voiding parameters were analyzed. Successful outcome was defined as standard voiding, without need of any postoperative adjunctive procedure.

RESULTS

Sixty-three patients were included. Stent was removed at urethroplasty in 61 patients. Reconstruction technique was excision and primary anastomosis in 14 (22.2%), dorsal onlay buccal mucosa graft (BMG) in 9 (14.3%), ventral onlay BMG in 6 (9.5%), dorsolateral onlay BMG in 9 (14.3%), ventral onlay plus dorsal inlay BMG in 3 (4.8%), augmented anastomosis in 5 (7.9%), pedicled flap urethroplasty in 6 (9.5%), 2-stage procedure in 4 (6.4%), and perineal urethrostomy in 7(11.1%). Success rate was 81% at a mean 59.7 ± 63.4 months. Dilatation or internal urethrotomy was performed in 10 (15.9%) and redo-urethroplasty in 5 (7.9%). Total International Prostate Symptom Score, quality of life, urine maximum flow, and postvoid residual significantly improved (P <.0001). Complications occurred in 8 (12.7%), all Clavien-Dindo ≤2. Disease-free survival rate after reconstruction was 88.1%, 79.5%, and 76.7% at 1, 3, and 5 years, respectively. Explant of individual strands followed by onlay BMG is the most common approach and was significantly advantageous over the other techniques (P = .018).

CONCLUSION

Urethroplasty in patients with Urolume urethral stents is a viable option of reconstruction with a high success rate and very acceptable complication rate. Numerous techniques are viable; however, urethral preservation, tine-by-tine stent extraction, and use of BMG augmentation produced significantly better outcomes.

[Temporary urethral stents ALLIUM BUS "BULBAR URETHRAL STENT" for the treatment of detrusor sphincter dyssynergia]

INTRODUCTION

The temporary prosthetic sphincterotomy is a possible treatment for neurologic detrusor sphincter dyssynergia (DSD). The purpose of the study was to verify the feasibility and effectiveness of the urethral stent (US) Temporary ALLIUM BUS "BULBAR URETHRAL STENT".

PATIENTS AND METHODS

A prospective, non-comparative, single-center starting in 2015 was conducted. Were included patients over 18 years, with a neurologic DSD proved urodynamically for which medical treatment was not indicated or failed. The primary endpoint was the percentage of patients who had a voiding method considered as improved or much improved at 1 month and the feasibility of the procedure.

RESULTS

From January to June 2015, 7 patients, (mean age 47.9 years [24-76 years]) were prospectively enrolled. One patient was lost to sight at one month and therefore excluded. The median follow-up was 8.1 months (1-10 months). All procedures were technically successful. At 1 month, there were 57% of grade 2 complications (Clavien-Dindo), 1 of 6 patients had a migration of the US. At one month, quality of life and the urologic situation was considered good in 3 patients, unchanged in 2 patients and decreased in 1 patient. The study was stopped after the inclusion of seven patients. At the date of the latest news, 5 of 6 patients had a migrated or an explanted US.

CONCLUSION

The temporary urethral stent ALLIUM BUS does not seem to be a possible surgical alternative for the treatment of detrusor sphincter dyssynergia.

LEVEL OF EVIDENCE

4.

A review of intrathecal morphine therapy related granulomas

The development of catheter associated granulomatous masses in intrathecal morphine therapy is an uncommon, but potentially serious problem. While these systems have historically been used in patients with short life expectancies, more recently patients with pain from a benign source have benefited from this therapy, and new complications are being encountered secondary to the patients' longer life spans. Morphine is the most commonly used intrathecal opioid and evidence exists that the formation of granulomatous masses are related to the use of higher doses. When the patients' requirement of morphine increases significantly, the physician should be alert for signs of spinal cord compression, such as new neurological deficits, myelopathy, or radiculopathy. Patients that require these higher doses should be properly informed of the association with granulomas and their associated risks. Indolent infection may also be the etiology of granulomatous masses, and the presence of organisms, both aerobic and anaerobic, should be routinely investigated. Patients with catheter-associated granulomas appear to share several features. They exhibit the onset of symptoms several months following the initiation of intraspinal opioids and commonly present with an increase in pain that precedes signs and symptoms of neurological deterioration. While MRI might be the preferred method of detection of intrathecal granulomas, its cost and availability are prohibitive for routine screening. CT myelogram via pump side port injection of contrast can also be performed to detect catheter tip related granulomas/obstructions. Serial neurological examinations for new deficits may be performed and recorded during pump refill visits to recognize a granulomatous mass in its early stages. If an abnormality is identified, imaging studies are appropriate. Awareness of the condition and vigilance are the keys to successful management of this complication.

Differential expression of A-type and B-type lamins during hair cycling

Multiple genetic disorders caused by mutations that affect the proteins lamin A and C show strong skin phenotypes. These disorders include the premature aging disorders Hutchinson-Gilford progeria syndrome and mandibuloacral dysplasia, as well as restrictive dermopathy. Prior studies have shown that the lamin A/C and B proteins are expressed in skin, but little is known about their normal expression in the different skin cell-types and during the hair cycle. Our immunohistochemical staining for lamins A/C and B in wild-type mice revealed strong expression in the basal cell layer of the epidermis, the outer root sheath, and the dermal papilla during all stages of the hair cycle. Lower expression of both lamins A/C and B was seen in suprabasal cells of the epidermis, in the hypodermis, and in the bulb of catagen follicles. In addition, we have utilized a previously described mouse model of Hutchinson-Gilford progeria syndrome and show here that the expression of progerin does not result in pronounced effects on hair cycling or the expression of lamin B.

Chapitre B-3 A - Traitement chirurgical des dysfonctions neurologiques des sphincters urinaires

The treatment of neurogenic detrusor-sphincter dyssynergia is primarily medical (drugs and catheterization). Some patients may not be eligible for or fail to respond to these treatment options and endoscopic sphincterotomy or permanent prosthesis may be indicated. In this article, the authors review the indications, results and contraindications of these various treatments.

Evaluation of the Effects of Temporary Covered Nitinol Stent Placement in the Prostatic Urethra: Short-Term Study in the Canine Model

PURPOSE

To evaluate the effect of temporary stent placement on the canine prostatic urethra.

METHODS

Retrievable PTFE-covered nitinol stents were placed in the prostatic urethras of 8 beagle dogs under fluoroscopic guidance. Retrograde urethrography was obtained before and after stenting. Retrograde urethrography and endoscopy were performed 1 and 2 months after deployment. The endoscopic degree of hyperplasia was rated on a scale of 0 to 4 (0 = absence, 4 = occlusion). On day 60, stents were removed and urethrography was performed immediately before euthanasia. Pathologic analysis was performed to determine the degree of glandular atrophy, periurethral fibrosis, and urethral dilation.

RESULTS

Stent deployment was technically successful in 7 animals, and failed in 1 dog due to a narrow urethral lumen. Complete migration was seen in 2 animals at 1 month, and an additional stent was deployed. On day 30, endoscopy showed slight hyperplasia (grade 1) in 3 animals. On day 60, moderate hyperplasia (grade 2) was evidenced in 4 cases. No impairment of urinary flow was seen during follow-up. Retrieval was technically easy to perform, and was successful in all dogs. The major histologic findings were chronic inflammatory cell infiltrates; prostate glandular atrophy, with a mean value of 1.86 (SD 0.90); periurethral fibrosis, with a mean ratio of 29.37 (SD 10.41); and dilatation of the prostatic urethra, with a mean ratio of 6.75 (SD 3.22).

CONCLUSION

Temporary prostatic stent placement in dogs is safe and feasible, causing marked enlargement of the prostatic urethral lumen. Retrievable covered stents may therefore be an option for bladder outlet obstruction management in men.

Bladder drainage and glandular epithelial morphometry of the prostate in benign prostatic hyperplasia with severe symptoms

OBJECTIVE

Morphometrically analyze the cells nuclei of the basal layer of the prostatic glandular epithelium in 20 patients aged between 57 and 85 years presenting benign prostatic hyperplasia with severe symptoms, catheterized or not.

MATERIALS AND METHODS

Patients with score of severe prostatic symptoms (with indication for transurethral resection of the prostate) were distributed according to the presence or absence of bladder drainage previous to the surgery, in the treated group (n = 10, catheter during 3 months) and in the control group (n = 10, without catheter). After obtaining prostate fragments through transurethral resection and the use of morphometric techniques, 100 nuclei of prostatic glands epithelium cells were studied (as to size and form), and compared to 500 nuclei from patients submitted to catheter drainage and 500 nuclei of non-catheterized patients.

RESULTS

Significantly reduced values of the major, medium and minor nuclear diameters, volume, area and perimeter, contour index and nuclear volume-nuclear area ratio were observed in the treated group in relation to the control group. As to the form, eccentricity and coefficient of nuclear form, there were significant differences between treated and control groups.

CONCLUSION

Long-term catheter bladder drainage in patients presenting benign prostatic hyperplasia with severe symptoms is associated to the reduction of morphometric parameters of the nuclei of prostatic glands' epithelial cells, suggesting a likely decompressive duct effect.

Epithelial abnormalities and precancerous lesions of anterior urethra in patients with penile carcinoma: a report of 89 cases

Urethral and penile tissues and their neoplasms are considered anatomically and pathogenetically different. Since we observed urethral dysplastic lesions and some similarities between noninvasive and invasive lesions of the anterior urethra and glans, we designed this study to document epithelial urethral abnormalities in patients with penile squamous cell carcinoma. We examined urethral epithelia from 170 penectomies with invasive squamous cell carcinoma finding a variety of primary epithelial abnormalities in 89 cases (52%) and secondary invasion of penile carcinoma to urethra in 42 cases (25%). Patients' average age was 68 years. Primary tumors measured 4 cm in average diameter and the majority were squamous cell carcinoma of the usual (67%) or verrucous type (15%). Primary epithelial abnormalities found were squamous intraepithelial lesions, metaplasias and microglandular hyperplasias. Urethral squamous intraepithelial lesions of high grade was found in six patients and of low grade in eight cases. Squamous metaplasia, seen in 69 cases, was the most frequent finding. Metaplasias were classified as nonkeratinizing and keratinizing. Nonkeratinizing metaplasias (57 cases) were variegated in morphology: simplex (26 cases), hyperplastic (12 cases), clear cell (11 cases) and spindle (8 cases). Keratinizing metaplasias (12 cases) showed hyperkeratosis and were more frequently associated with verrucous than nonverrucous penile squamous cell carcinoma. Microglandular hyperplasia was present in eight cases. Lichen sclerosus was associated with simplex squamous metaplasia in four cases. Despite the large size of the primary tumors, direct urethral invasion by penile carcinoma was present in only 25% of the cases. The presence of precancerous lesions in urethra of patients with penile carcinoma indicates urethral participation in the pathogenesis of penile cancer. Simplex squamous metaplasia is a common finding probably related to chronic inflammation. Keratinizing and hyperplastic squamous metaplasias may be important in the pathogenesis of special types of penile carcinomas such as verrucous carcinoma.

A novel temporary prostatic stent for the relief of prostatic urethral obstruction

OBJECTIVES

To determine the effect of a novel temporary prostatic stent (The Spanner, AbbeyMoor Medical, Inc., Minnesota, USA) on variables of voiding function and quality of life among patients with prostatic urethral obstruction.

PATIENTS AND METHODS

The stent design is very similar to the proximal 4-6 cm of a Foley catheter; this includes a proximal balloon to prevent distal displacement, a urine port situated cephalad to the balloon, and a reinforced stent of various lengths to span most of the prostatic urethra. There is also a distal anchor mechanism attached by sutures, and a retrieval suture which extends to the meatus and deflates the proximal balloon when pulled. The stent was inserted under topical anaesthesia in 30 patients. The maximum flow rate (Qmax), voided volume (W), postvoid residual (PVR), the International Prostate Symptom Score (IPSS) and stent position were assessed.

RESULTS

Stents remained in situ for a mean (range) of 57 (1-98) days. The mean overall Qmax at baseline and after insertion were 8.2 and 11.6 mL/s, representing a 42% improvement (P < 0.001); the respective mean overall Ws were similar, at 219.7 and 221.6 mL (0.9% increase, not significant) and the PVRs were 312.1 and 112.3 mL, representing a 64% decrease (P = 0.004). The overall mean IPSS declined from 22.3 before to 7.1 after insertion, representing a 68% decrease (P < 0.001). There were only minor adverse events. The stability, patency and lack of migration of the device were confirmed radiographically up to 12 weeks of use.

CONCLUSIONS

This early study shows that this temporary prostatic stent is easily inserted and removed, remains anchored in position, and significantly improves the Qmax, PVR and IPSS while preserving volitional voiding and continence.

A prospective, randomized protocol to examine the efficacy of postinternal urethrotomy dilations for recurrent bulbomembranous urethral strictures

OBJECTIVES

The high recurrence rate is still the major complication of endoscopic treatment of urethral stricture disease. To compare the outcome of patients who underwent direct vision internal urethrotomy (DVIU) and then followed a protocol that randomized them to either our urethral dilation protocol or consecutive DVIUs for the treatment of their urethral stricture.

METHODS

A total of 37 patients, who had undergone at least two DVIUs to treat their recurrent urethral strictures, were enrolled in this study. They were randomized into two groups. The etiology and location of the strictures were similar, and their length ranged from 0.5 to 2 cm in each group. In group 1 (n = 18), the patients were observed by regular visits and uroflowmetry profiles after the initial DVIU and consecutive DVIUs were considered when the stricture recurred. In group 2 (n = 19), patients received urethral dilations with Benique dilatators (maximal 21F) under intraurethral anesthesia, beginning 10 days after the initial internal urethrotomy, according to the following protocol: weekly for the first month, once after 3 and after 6 months, and then once each year.

RESULTS

After a median follow-up of 30 months, the urethral stricture recurred within 12 months in 55.6% (n = 10) of group 1, and consecutive DVIUs were indicated. During the same follow-up period, recurrence was observed in 2 patients (10.5%), 9 months and 2 years after randomization, in group 2 (P <0.05). The mean maximal urinary flow rate in groups 1 and 2 at last follow-up was 7.8 +/- 3.7 and 21.0 +/- 8.7 mL/s, respectively (P <0.01).

CONCLUSIONS

We suggest a regular, simple urethral dilation protocol for patients with recurrent bulbomembranous urethral stricture shorter than 2 cm, because this significantly allays the stricture recurrence rate, possibly eliminates the need for consecutive DVIU, and reduces morbidity.

Covered, retrievable, expandable urethral nitinol stent: feasibility study in dogs

PURPOSE

To evaluate the feasibility of using a retrievable urethral stent and to evaluate whether granulation tissue resolves after stent removal in a canine urethra.

MATERIALS AND METHODS

Polyurethane-covered retrievable 0.10-mm-thick (n = 11) or 0.15-mm-thick (n = 10) nitinol wire stents were placed in the urethras of 20 dogs. In one dog, a second stent was placed in the urethra because of complete migration of the first stent into the urinary bladder. The stents were removed with retrieval hook wires 4 weeks (n = 10) and 8 weeks (n = 10) after placement. Fourteen dogs were sacrificed just after stent removal, and the other six dogs were sacrificed 2 weeks after stent removal. Information concerning procedure success, stent migration, and tissue response was obtained.

RESULTS

Stent placement was technically successful in all dogs. Follow-up urethrograms showed partial (n = 4) or complete (n = 1) stent migration. Stent removal failed in two dogs due to partial or complete migration. Granulation tissue was observed at both ends of the stent in 17 dogs. Urethrograms and urethral specimens obtained 2 weeks after stent removal showed diminished granulation tissue and decreased thickness of the papillary projections of the epithelium compared with results obtained immediately after stent removal.

CONCLUSION

Although some design modifications are necessary to reduce current complications, the polyurethane-covered retrievable nitinol stent seems feasible for use in the urethra. Stent-induced granulation tissue formation improved after stent removal.