Urethroplasty by scrotal flap for long urethral strictures

Algorithmic Midline Approach to Perineal Urethrostomy is Associated With Long-term Success and High Patient Satisfaction

OBJECTIVE

To assess surgical success and patient-reported outcomes of perineal urethrostomy via midline approach.

MATERIALS AND METHODS

Charts of patients undergoing primary perineal urethrostomy between May 2008 and June 2022 were reviewed. Background characteristics were assessed; success was defined as freedom from re-intervention. Patient-reported outcome measures were assessed using a cross-sectional phone survey. Several validated questionnaires were used to assess lower urinary tract symptoms, quality of life, and erectile dysfunction.

RESULTS

Among 1768 urethroplasties performed over the study period, 103 patients (5.8%) underwent midline perineal urethrostomy. Surgery was successful in 95.1% of cases (98/103); 5 patients (4.9%) required re-intervention at a median of 8.7 months. Post-operative complications occurred in 5.8% of cases (6/103) and were both mild and self-limited. Forty-nine patients (47.6%) were reached via phone survey at a median of 61 months post-operatively. Some questions were not answered by all patients. Most patients (42/49, 86%) were satisfied or very satisfied with surgical results, and 82% (40/49) reported an improvement in their overall health. Most patients (31/41, 76%) were unbothered by sitting to urinate. Although 20% of patients (10/49) reported post-operative urinary symptoms that interfered "a lot" with their daily life, only 3 (6%) of these patients reported dissatisfaction with the outcome. Regarding sexual function, 64% (27/42) reported indifference to or increased satisfaction with sexual encounters vs before surgery. The rate of de novo erectile dysfunction was 24% (12/49).

CONCLUSION

The midline approach to perineal urethrostomy provides excellent, durable success rates with high levels of patient satisfaction.

Analysis of prognostic factors of failure in perineal urethrostomy

PURPOSE

To identify prognostic factors of failure in patients undergoing perineal urethrostomy (PU) with Blandy technique, with inverted U-shaped perineal flap.

METHODS

This is a retrospective study of PU of non-oncological causes (2001-2017). Data of age, BMI, history of diabetes mellitus, etiology of urethral stricture, type of stricture, previous surgeries, dilatation and suprapubic catheter were collected. Failure was defined as the need for any instrumentation after surgery. Variables were analyzed by Cox regression and Kaplan-Meier curves were used for survival analysis.

RESULTS

A total of 115 PU were performed. Median age was 61 years (IQR 53-68) and BMI 27.9 (IQR 25-30.9). The most frequent etiologies were: lichen sclerosus (30.4%), iatrogenic (27%), and idiopathic (25.7%). 62.6% had panurethral stricture. There were no complications in 73%. Clavien I complications occurred in 25.2%, Clavien II in 0.9% and Clavien IVa in 0.9%. The overall success rate was 51.3% with a median follow-up of 71 months. In the last 8 years, it was 75%. In the multivariate analysis, we found that age (p = 0.01), BMI (p = 0.01), date of surgery (p = 0.01), and suprapubic catheter (p = 0.003) were predictive variables. The voiding satisfaction rate was 88.7%.

CONCLUSIONS

PU with Blandy technique is a surgery with low morbidity. During the entire study period, it had a failure rate of 48.7% but the failure rate decreased to 25% over the last 8 years. Age, BMI, date of surgery and suprapubic catheter are the most important prognostic factor of failure.

Bilateral T-shaped Scrotoplasty as an Ancillary Technique of Staged Anterior Urethroplasty: The End Justifies the Means

Staged urethroplasty is performed to treat long-segment obliterating anterior urethral strictures. The technique is particularly challenging when the penobulbar junction is involved, as it requires the transection of the scrotum and the formation of lateral testicular fans. To date, there is no established surgical protocol for this ancillary technique in large volume scrotums with excess skin. We report a case of staged urethroplasty with the necessity of performing T-scrotoplasty due to bulky scrotum. After six months, the T-plasty was successfully resolved, and a new scrotum was formed from the two hemiscrota. In conclusion, scrotoplasty using a bilateral T-plasty is an excellent technique to overcome the necessity of splitting the scrotum by externalizing the urethra to allow for excellent buccal mucosal graft healing over a period of six months. The two separate testicular fans can be reapproximated along the raphe after re-tubularizing the urethra in the 2nd stage, shaping a new scrotum with satisfactory cosmetic results.

Evaluation of the efficacy of perineal urethrostomy for patients with anterior urethral stricture: insights from surgical and patient-reported outcomes

PURPOSE

To examine the efficacy of perineal urethrostomy (PU) in patients with anterior urethral stricture.

METHODS

Patients who underwent PU for anterior urethral stricture between 2013 and 2020 were retrospectively reviewed (n = 56). Surgical success was defined as no need for additional intervention. Uroflowmetry and measurement of residual urine volume (PVR) were examined postoperatively, and the patients were asked to fill out sexual health inventory for men (SHIM) and the validated Urethral Stricture Surgery Patient-reported Outcome Measure questionnaires before and after PU. The overall patient satisfaction was also assessed.

RESULTS

PU was successful in 92.9% of patients (n = 52), with a median follow-up of 34 months. Two of four were salvaged by re-do PU, and one was salvaged by forming a composite stoma using a penile skin graft. Thirty-nine patients (69.6%) filled out the questionnaires 6 months after surgery. The mean maximum flow rate, PVR, lower urinary tract symptoms (LUTS)-total score, LUTS-specific quality of life, and EuroQol-visual analog scale scores improved significantly from 3.8 mL/s, 77.6 mL, 12.9, 2.6, and 53.6 at baseline to 17.6 mL/s, 21.3 mL, 4.1, 0.9, and 74.9 postoperatively (p = 0.003, p = 0.004, p = 0.005, p < 0.0001, p < 0.0001, respectively). The SHIM score did not change significantly (from 2.6 at baseline to 2.3 postoperatively; p = 0.59). As for patient satisfaction, 84.6% of patients (33/39) were "satisfied" (46.1%) or "very satisfied" (38.5%) with the outcome.

CONCLUSIONS

PU had a high surgical success rate, and significantly improved patients' subjective symptoms and achieved a high level of satisfaction.

Outcomes of perineal urethrostomy for penile cancer: A 20-year international multicenter experience

PURPOSE

Perineal urethrostomy (PU) is often the definitive form of urinary diversion in patients with locally-advanced or anatomically unfavorable penile cancer (PC) requiring total penectomy. Here, we report post-operative PU-related complications and PU stenosis rates after total penectomy with PU in a large multicenter cohort of PC patients.

METHODS

We retrospectively reviewed the medical records of 299 patients who underwent PU as a means of urinary diversion for primary PC across seven international centers from 2000 to 2020. The Clavien-Dindo grading system was used to record 30-day post-operative complications. Cumulative incidence of stenosis was evaluated using the Kaplan-Meier method.

RESULTS

Median patient age was 67 years (interquartile range (IQR) 58-74), and median follow-up was 19 months (IQR 7.2-57). A total of 58 patients (19%) developed a 30-day post-operative complication, of which 45 (79%) were deemed minor (CD Grade I and II). Wound infection (11%; CD grade I-III) and dehiscence (4.0%; CD grade I-III) were the more common complications. The overall incidence of stenosis was 12% (35/299 patients), of which 26 (74%) needed surgical revision (probability of stenosis revision at one year of 9.3%, median time until the revision: 6.1 months (IQR 3.0-13)). Only two stenoses were seen after two years of follow-up.

CONCLUSION

We present the most extensive series of PU in the management of PC to date. Wound infections of the primary surgical site were the most common complication. Stenosis occurred mostly within one and a half years after treatment.

Propeller Flap Perineal Urethrostomy Revision

OBJECTIVE

To describe a technique for perineal urethrostomy (PU) revision using a posterior thigh propeller flap for a complex repair at high risk for stenosis.

METHODS

Our technique utilizes the consistent posterior thigh perforators for a local flap with ideal length and thickness for repair. The stenotic PU is incised. Potential flaps are marked around a perforator blood supply closest to the defect. The flap is then elevated and rotated on its pedicle with its apex placed directly in the defect. Absorbable sutures partially tubularize the flap apex at the level of the urethrotomy which is calibrated to 30 Fr. We subsequently monitored the patient's clinical progress.

RESULTS

With 17 months of follow-up the patient is voiding well without complaint, reports improved quality of life with a patent PU. Post void residuals have been less than 100cc. The patient, who has had a long history of urinary tract infections requiring hospitalization, has only reported one infection during follow up which was treated as an out-patient.

CONCLUSION

For challenging PU revisions a distant local propeller flap of healthy tissue outside the zone of injury is the ideal choice for length, thickness, and minimal morbidity resulting in excellent clinical results for our patient.

Permanent perineal urethrostomy for anterior urethral strictures: A critical appraisal of long-term outcomes and erectile function

OBJECTIVE

In complex strictures, especially in elderly patients, perineal urethrostomy (PU) provide excellent voiding function. This study aimed at evaluating the long-term voiding and erectile function of PU as a permanent procedure for such strictures.

MATERIAL AND METHODS

We retrospectively evaluated 146 patients who underwent permanent PU at our institution from January 2000 to December 2018. All patients had complex urethral strictures. Patients with posterior urethral involvement were excluded. Patients were followed up at 3 months and then yearly. Failure was defined as the need for any additional procedures. They were also evaluated with the International Index of Erectile Function (IIEF-5) questionnaire. Fisher's exact test and χ² test were used for statistical analysis.

RESULTS

The median age at the time of surgery was 58±7.3 years. The mean stricture length was 6.5±2.1 cm. All the patients had a history of previous surgery, and the average number of procedures per patient was 2.4. The median follow-up period was 26 months. The most common early and late postoperative complications were bleeding and stenosis of the urethrostomy, respectively. A total of 129 (88.3%) patients had a successful surgery. The number of patients with no erectile dysfunction increased from 55.4% to 67.8% after PU. The mean IIEF-5 score improved from 20.07 to 21.31 after PU, but this did not achieve statistical significance (p=0.3558).

CONCLUSION

Permanent PU is an acceptable option for complex long-segment anterior urethral strictures, especially in elderly patients, with an excellent long-term outcome. A majority of patients also maintain a satisfactory erectile function.

Scrotal Tissues: The Perfect Material for Urogenital Reconstruction

Correction of male urogenital pathology of different severity is complicated by the anatomical aspects of the penis. Skin texture, internal structures, and perfusion dynamics of the urogenital area make it a difficult area to reconstruct. We provide our experience with axial scrotal flaps for correction of penile defects of different severity and believe that these local flaps offer sufficient tissue characteristics for proper restoration of this complex region.

METHODS

Forty-eight patients were divided into 3 groups depending on penile defect genesis and severity. Axial scrotal flap reconstruction was used for the correction of defects in all cases, when necessary in combination with other flaps.

RESULTS

Axial scrotal flaps for total and subtotal penile reconstruction serve as valuable material for reconstruction of the urogenital area, and are to be combined with other flaps for restoration of bulk tissues. Localized defects of the penis and urethra reconstructed by axial scrotal flaps provide excellent aesthetic results with minimal scaring, stable perfusion dynamics, and high satisfaction rate.

CONCLUSIONS

Scrotal tissues provide an excellent reconstruction material for penile defects because of their highly similar tissue structure as that of the penis. Scrotal axial flaps do not provide excess bulking in the postoperative period and are recommended for reconstruction of urethral and localized penile defects. Multistage surgery is recommended in cases of severe tissue damage, in combination with other flaps (inguinal, thoracodorsal, and radial).

[A CASE OF NEO-MEATAL STENOSIS AFTER PENECTOMY FOR PENILE CANCER, REPAIRED BY BLANDY PERINEAL URETHROSTOMY]

Surgical resection is the standard treatment for the management of localized penile cancer and a neo-urethral meatus is generally created on the penile stump or perineum. Neo-urethral meatus is often stenosed and requires repeated transurethral manipulations such as dilation and urethrotomy. These procedures are generally futile and are associated with poor quality of life. Here, we report a case of penile cancer that developed a neo-meatal stenosis after total penectomy, which was subsequently salvaged by perineal urethrostomy using Blandy technique. A 72-year-old male who was diagnosed with localized penile cancer, underwent total penectomy and creation of neo-meatus on the perineum. Neo-meatus stenosis had developed in the patient and he received repeated urethral dilations without any success. Finally, when the patient was unable to void, he was referred to us for the amelioration of meatal stenosis through the placement of a suprapubic catheter. Because the condition of the residual bulbar urethra was adequate and its length was enough, we planned to create a non-transecting perineal urethrostomy by Blandy technique. An inverted U-shaped perineal incision was made, and a skin flap was created. The scarred neo-meatus and spongiofibrosis at the distal bulbar urethra were completely excised. The residual bulbar urethra was exposed, and a longitudinal ventral incision of 4 cm was made. The edge of the bare urethral mucosa and tunica albuginea of the corpus spongiosum were sutured by 4-0 PDS for hemostasis. The apex of the U-shaped skin flap was brought to the proximal margin of the urethrotomy and a tension-free anastomosis was created between the skin flap and the urethral plate. Thereafter, the skin of the perineum was sutured to the open longitudinal urethrotomy. The patient started to void on the 5^th day post-surgery. The subject could void without the help of any intervention and did not require any instrument, sixteen weeks after the surgery.

A Comprehensive Review Emphasizing Anatomy, Etiology, Diagnosis, and Treatment of Male Urethral Stricture Disease

To date, urethral stricture disease in men, though relatively common, represents an often poorly managed condition. Therefore, this article is dedicated to encompassing the currently existing data upon anatomy, etiology, symptoms, diagnosis, and treatment of the disease, based on more than 40 years of experience at a tertiary referral center and a PubMed literature review enclosing publications until September 2018.

Analysis of anastomotic urethroplasty for pelvic fracture urethral distraction defect: Decadal experience from a high-volume tertiary care center

Context:

Pelvic fracture urethral distraction defect (PFUDD) may be challenging for the treating urologist. Anastomotic urethroplasty is the established surgical procedure for the treatment of PFUDD. Few studies in literature focus purely on PFUDD, and majority of the studies include anterior urethral stricture as well. The period of these studies is relatively short. We conducted a retrospective analysis of patients who underwent primary or redo anastomotic urethroplasty for PFUDD over a period of 12 years at a tertiary care center in northern India.

Aims:

The aim is to study anastomotic urethroplasty for pelvic fracture urethral distraction defect with regard to long-term success rate and complications.

Settings and Design:

This was a retrospective study. Subjects and

Methods:

This retrospective study was conducted in the Department of Urology, King George's Medical University, Lucknow, India, from August 2004 to July 2016. All patients who underwent progressive perineal anastomotic repair of PFUDD were included in this study. Demographic findings, type of pelvic fracture, length of distraction defect as per retrograde urethrography (RUG) and micturating cystourethrography, any history of erectile dysfunction in the preoperative or postoperative phase, and urinary incontinence in postoperative phase were analyzed. Decision regarding catheter removal was taken after pericatheter RUG at 4 weeks. Follow-up was done at 3 and 6 months in postoperative period.

Results:

A total of 226 anastomotic repairs were done in 221 patients. Of the 221 patients, 51 (23%) were redo urethroplasty. The mean age of patients was 27.6 years. The mean length of distraction defect was 2.7 cm. The mean duration of hospital stay was 6 days. Primary urethroplasty was successful in 163 (93.14%) of 175 patients and redo urethroplasty in 44 (86.27%) of 51 patients. Out of 165 patients, 18 (10.9%) patients reported occasional incontinence while 6 (3.63%) patients reported mild incontinence.

Conclusions:

Anastomotic urethroplasty is the definitive procedure for PFUDD. Our success rate for primary deferred anastomotic urethroplasty is 93.14% and for redo anastomotic urethroplasty is 86.27%.

Outcomes for Management of Lichen Sclerosus Urethral Strictures by 3 Different Techniques

OBJECTIVE

To evaluate the intermediate-term outcomes from a large, single institution series of patients with lichen sclerosus (LS) who underwent surgical management of their urethral strictures.

MATERIALS AND METHODS

We retrospectively reviewed 79 patients who underwent surgical management of their LS urethral strictures from 2003 to 2014, comparing outcomes of patients undergoing a single-stage buccal mucosa graft (BMG) urethroplasty, 2-stage BMG urethroplasty, or perineal urethrostomy (PU). Demographic and surgical outcomes data were collected for all patients.

RESULTS

Of the 79 patients, the mean follow-up was 32.4 months, mean age was 50.1 years, and the mean body mass index was 35.7, with morbid obesity (body mass index > 35) in 48% of the cohort. The mean stricture length was 9.6 cm (1.5-21 cm), with 62% of patients having a bulbopendulous stricture. Of the 37 patients who were planned for a 2-stage BMG urethroplasty, 9 (24%) patients had stricture recurrence or recurrent LS in the first-stage BMG. Single-stage BMG urethroplasty was performed in 20 patients with a mean stricture length of 9.47 cm (4-21 cm) and a success rate of 75%. Fourteen patients from the cohort received a PU as the primary treatment, with a success rate of 93%.

CONCLUSION

Management of LS strictures continues to pose challenges to the reconstructive surgeon due to the high rate of stricture recurrence and often progression. Patients undergoing single-stage or 2-stage reconstruction often require revision and must be carefully observed for recurrent urethral stricture. PU offers the highest degree of success and should be considered for all patients.

7-flap perineal urethrostomy

Perineal urethrostomy (PU) has been performed with success for the treatment of refractory and advanced urethral stricture disease for at least the past six decades. Here, we review the indications and outcomes of PU for indications such as complex hypospadias repair and urethral stricture disease resulting from trauma, infection, and failure of prior urethroplasty. We also describe the role of 7-flap PU, a novel alternative to the conventional approach that offers the surgeon added flexibility in tailoring urethrostomy creation based on intraoperative findings. The authors’ updated experience with 7-flap PU demonstrates a comparable 95% success rate in patients with a wide variety of stricture etiology. PU through either a conventional approach or a 7-flap technique is a valuable option for improving the quality of life in patients with debilitating urethral stricture disease.

Perineostomy: the last oportunity

Objective

To review the technique and outcome of perineal urethrostomy or urethral perineostomy and to identify factors related to the procedure failure.

Material and methods

We studied 17 patients who underwent perineal urethrostomy between 2009-2013 in a single hospital. Success was defined as no need for additional surgical treatment or urethral dilatation. We reviewed the clinical data related to age, weight, previous urethral surgery, diabetes, hypertension, ischemic cardiopathy, lichen sclerosus and other causes and studied their association with the procedure failure (univariate analysis). We completed the analysis with a multivariate test based on binary regression.

Results

The average follow-up was 39.41 months. From all the causes, we found Lichen Sclerosus in 35%, idiopathic etiology in 29% and prior hypospadia repair in 18%. Postoperative failure occurred in 3 patients, with a final success of 82.4%. The binary regression model showed as independent risk factors ischemic cardiopathy (OR: 2.34), and the presence of Lichen Sclerosis (OR: 3.21).

Conclusions

The success rate with the perineal urethrostomy technique shows it to be a valid option above all when we preserve the urethral blood supply and plate. Lichen sclerosus and ischemic vascular problems are risk factors to re-stenosis.

Perineal urethrostomy: surgical and functional evaluation of two techniques

Introduction. PU is an option to manage complex and/or recurrent urethral strictures and is necessary after urethrectomy and/or penectomy. PU is generally assumed to be the last option before abandoning the urethral outlet. Methods. Between 2001 and 2013, 51 patients underwent PU. Mean age (± standard deviation) was 60 ± 15 years. Only 13 patients (25.5%) did not undergo previous urethral interventions. PU was performed according to the Johanson (n = 35) or Blandy (n = 16) technique and these 2 groups were compared for surgical failure, maximum urinary flow (Q_max), urinary symptoms, and quality of life (according to the International Prostate Symptom Score). Results. Both groups were similar for patient's and stricture characteristics. Only follow-up duration was significantly longer after Johanson PU (47.9 months versus 11.1 months; P = 0.003). For the entire cohort, 11 patients (21.6%) were considered a failure (9 or 25.7% for Johanson group and 2 or 12.5% for Blandy group; P = 0.248). There was a significant improvement of Q_max in both groups. Quality of life after PU was comparable in both groups. Conclusions. PU is associated with a 21.6% recurrence rate and the patient should be informed about this risk.

Revision of perineal urethrostomy using a meshed split-thickness skin graft

Perineal urethrostomy is considered to be the last option to restore voiding in complex/recurrent urethral stricture disease. It is also a necessary procedure after penectomy or urethrectomy. Stenosis of the perineal urethrostomy has been reported in up to 30% of cases. There is no consensus on how to treat a stenotic perineal urethrostomy, but, in general, a form of urinary diversion is offered to the patient. We present the case of a young male who underwent perineal urethrostomy after urethrectomy for urethral cancer. The postoperative period was complicated by wound dehiscence with subsequent complete obliteration of the perineal urethrostomy. Revision surgery was performed with reopening of the obliterated urethral stump and coverage of the skin defect between the urethra and the perineal/scrotal skin with a meshed split-thickness skin graft. To date, this patient is voiding well and satisfied with the offered solution.

Post-traumatic urethral strictures in children: what have we learned over the years?

BACKGROUND

Urethral stricture presents an uncommon but difficult urological problem in the pediatric population. Treatment protocols are different from in adults due to anatomical considerations.

MATERIAL AND METHODS

A thorough manual and Medline search was conducted to review the existing literature on post-traumatic pediatric urethral strictures, with key words: stricture, children, post-traumatic, urethroplasty, pediatric.

RESULTS

Opinion early on was that, due to the confined perineum, high incidence of supramembranous injury resulting in less predictable distraction defects of the posterior urethra and a high incidence of prostatic displacement, transperineal urethroplasty is technically more difficult than in adults and thus the transpubic approach is more feasible. Recent reports revealed that both approaches resulted in almost the same clinical outcomes for children with post-traumatic posterior urethral strictures.

CONCLUSION

The ideal reconstruction for the treatment of post-traumatic posterior urethral strictures in children is bulboprostatic anastomosis. This procedure should be initially attempted through the perineum in every case. A transpubic procedure should be done only when tension-free anastomosis cannot be accomplished through the perineum.

The "7-flap" perineal urethrostomy

OBJECTIVES

Perineal urethrostomy is a well-accepted reconstructive option for complex anterior urethral stricture disease. We present a novel technique for the construction of a perineal urethrostomy that allows the surgeon greater control when managing all levels of anterior urethral stricture disease.

METHODS

A perineal urethrostomy is constructed by advancing a 7-shaped laterally based perineal skin flap to the amputated bulbar or membranous urethra.

RESULTS

Ten men between the ages of 48 and 79 underwent the 7-flap perineal urethrostomy for advanced urethral stricture disease; one had 7-flap revision of an existing perineal urethrostomy. Each patient was treated in an outpatient setting without perioperative complications. Nine of ten patients (90%) are voiding spontaneously without the need for urethrostomy revision or proximal urinary diversion.

CONCLUSIONS

The 7-flap perineal urethrostomy is versatile, safe, and effective. It allows the surgeon maximal flexibility in the management of complex anterior urethral stricture disease.

The outcomes of perineal urethrostomy with preservation of the dorsal urethral plate and urethral blood supply

OBJECTIVES

To describe the surgical technique and outcomes for perineal urethrostomy. We sought to identify factors that predicted surgery failure within our patient cohort and to describe key aspects of the operation aimed at preservation of the dorsal urethral plate and longitudinal blood supply within the urethra.

METHODS

We reviewed our prospectively collected database and identified 45 men who underwent definitive perineal urethrostomy from 1989 to 2009. Primary success was defined as no need for additional treatment. If 1 urethral dilation was performed, outcome was defined as a secondary success. Statistical analyses were performed to determine variables associated with failure.

RESULTS

Urethral pathology was varied and included idiopathic strictures (20%), lichen sclerosis (20%), infection (16%), radiation for prostate cancer (13%), prior hypospadias repair (11%), instrumentation or catheter trauma (11%), and penile cancer or condyloma (9%). Of these men, 21 (48%) had prior urethroplasty. Forty patients had follow-up greater than 3 months (median, 31 months). Postoperative stenosis occurred in 7 (18%) patients. Previous radiation therapy was a significant risk factor for postoperative stenosis on univariate (OR 12.4, 95% CI 1.8-84.3, P <.01) and multivariate analysis (OR 11.2, 95% CI 1.4-87.2, P <.02). Primary success rate for perineal urethrostomy was 83% (33/40 patients) and secondary success rate was 93% (37/40).

CONCLUSIONS

During creation of perineal urethrostomy, when the longitudinal blood supply within the bulbar urethra is preserved rather than transected, stenosis of the perineal urethrostomy is a rare complication primarily in patients who have a history of radiation therapy.

Scrotal hitch procedure to prevent apical necrosis of scroto-perineal flap for urethroplasty

OBJECTIVE

To present our experience with scrotal hitch technique to prevent necrosis of apex of scroto-perineal flap during two staged open urethroplasty for long segment complex anterior urethral strictures.

PATIENTS AND METHODS

Over the past 6 years, 22 patients underwent two-staged urethroplasty at our institution. All the strictures were laid open during first stage along with scrotal hitch. The stitch was removed after 7 days.

RESULTS

The flap was healthy in all 22 patients at the time of second stage. Neo-meatal stenosis was not seen in any of the patients. One patient had local site collection, which was cured by topical antibiotics.

CONCLUSION

This technique is simple, cost effective, which minimizes the drag over the flap by the shaft of the Foley catheter and thus prevents its pressure necrosis. The technique is particularly helpful in cases of thick, bulky scrotum and does not cause any morbidity, instead allows for early, comfortable ambulation and obviates the need of cumbersome scrotal supportive dressings.

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.

Comparative study of dartos fascia and tunica vaginalis pedicle wrap for the tubularized incised plate in primary hypospadias repair

OBJECTIVES

To report a prospective comparative study on using dartos fascia, i.e. subcutaneous tissue of penile skin and tunica vaginalis pedicled wrap (TVPW) from the parietal layer of the tunica vaginalis of the testis, for a one-stage tubularized incised-plate (TIP) repair for hypospadias.

PATIENTS AND METHODS

Forty-nine patients (mean age 4.6 years, range 1-22) with hypospadias of different types (varying from coronal to penoscrotal) were repaired in one of three hospitals over 3 years. All patients were repaired using the TIP technique, with dartos fascia wrap used in 20 and TVPW in 29, without using a loupe or microscope during surgery. Urinary diversion and splinting were provided by a urethral catheter. The operative duration for both groups was similar at approximately 2 h.

RESULTS

In the dartos fascia group there were three (15%) fistulae, but there were none in the TVPW group.

CONCLUSIONS

Although the dissection for TVPW seems to be cumbersome theoretically, it is not difficult. The combination of TIP and TVPW in primary repair may be a good alternative to other techniques.

Perineal repair of pelvic fracture urethral distraction defects: experience in 120 patients during the last 10 years

PURPOSE

We report the long-term success of a 1-stage perineal anastomotic repair in patients with pelvic fracture urethral distraction defects.

MATERIALS AND METHODS

A retrospective analysis of 120 patients undergoing perineal bulboprostatic anastomotic repair of pelvic fracture urethral distraction defect in a single stage using our progressive approach between May 1991 and May 2001 was performed. Patients with posterior urethral stricture due to other etiologies, or those who underwent substitution urethroplasty or abdominoperineal repair were excluded from this review. Preoperative evaluation of the urethral defect included simultaneous retrograde urethrogram and voiding cystourethrogram. Postoperative retrograde urethrogram was performed at 3 weeks, 3 months, 12 to 18 months and as indicated thereafter.

RESULTS

Mean patient age was 32 (range 6 to 82) years. The estimated preoperative radiographic length of the distraction defect was 3.1 cm (range 0.5 to 10). Mean followup was 64 (range 9 to 128) months, mean hospital stay was 1.8 days and duration of urethral stenting was 3.4 weeks. Perineal anastomotic repair was successful in 103 of 109 (95%) adults, in 8 of 11 (73%) prepubescent boys and in 25 of 29 (86%) undergoing secondary repairs. All treatment failures were at the anastomosis and occurred within the first postoperative year. Successful management of failed repairs was accomplished endoscopically in 3 of 7 and by repeat perineal anastomotic repair in 2 of 2, resulting in a final success rate of 97% in adults, 91% in prepubescent boys and 97% in secondary repairs.

CONCLUSIONS

The overall success of our progressive 1-stage perineal anastomotic repair of pelvic fracture urethral distraction defect continues to be excellent with the majority of failures occurring in prepubescent boys and secondary repairs.

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.

Dartos flap interposition in the surgical repair of rectourethral fistulas

BACKGROUND

Multilayer closures are important techniques in urethral fistula repair. We report our experience with dartos flap interposition in the repair of rectourethral fistula.

METHODS/RESULTS

A tip of a V-shaped scrotal skin flap is mobilized and de-epithelialized to develop a dartos flap. Two patients with a rectourethral fistula underwent fistula closure covered with this dartos flap. The surgical repair was successful in both cases and neither patient showed any late complication.

CONCLUSIONS

A scrotal dartos flap is well vascularized and easy to mobilize. We believe this technique is helpful in preventing postoperative complications following complex posterior urethral surgery.

Symptomatic urethral hair ball and diverticulum complicating island flap urethroplasty

A 29-year-old man underwent a one-stage island flap urethroplasty, using perineal skin, to treat a urethral stricture. Four years following surgery he represented with symptoms from a urethral diverticulum containing a hair ball. This was at the site of the previous urethroplasty and was treated by excision.

The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years

We reviewed our experience with 145 posterior urethral strictures and disruptions complicating pelvic fracture urethral injury during 17 years. Stricture was corrected by optical urethrotomy in 12 cases, urethroscrotal inlay in 23, perineal anastomotic urethroplasty in 78 and transpubic urethroplasty in 32. Results were almost always successful after anastomotic urethroplasty, whether performed by the perineal (95%) or transpubic (97%) route. Therefore, this procedure deserves to be regarded as the gold standard for the treatment of posttraumatic posterior urethral strictures and disruptions. Urethral anastomosis should be attempted first through the perineum in every case, with the transpubic procedure done only when a tension-free bulbo-prostatic anastomosis could not be accomplished from below the stricture. Optical urethrotomy was successful (58%) in patients with mild strictures and a persistent opening between the bulbar and prostatic areas of the intact urethra. Therefore, this procedure should be reserved for such cases. Repeated urethrotomy of a long fibrous segment between a widely distracted prostatic and bulbar urethra would not only have a poor result but, by jeopardizing the elasticity of the anterior urethra, it also may undermine the chance for subsequent anastomotic urethroplasty. A urethroscrotal inlay procedure is doomed to failure in 57% of the cases and (with other substitution procedures) it should be restricted to strictures involving extensive segments of the posterior and/or anterior urethra. Sexual impotence usually (15%) resulted from the original pelvic fracture urethral injury and rarely (2.5%) from the urethroplasty itself.

Long-term results of treatment of urethral injuries in males caused by external trauma

Of 134 males with traumatic rupture of the urethra seen between 1967 and 1989, 10 have been lost to follow-up and 124 have been followed up for 1 to 22 years (mean 8); 100 patients had a pelvic fracture (3 with associated rectal injury) and 24 had perineal injuries. Prior to referral 31 patients (25%) had undergone treatment in addition to suprapubic cystostomy. Wherever possible, strictures were managed by optical urethrotomy (33) or intermittent dilatation (4). In 2 patients only a suprapubic cystostomy was possible. Skin inlay urethroplasty in 1 or 2 stages was performed in 75 cases, an end-to-end anastomosis with or without resection of the symphysis pubis in 7 and a scrotal tube pull-through in 3. The immediate and long-term results depended on the severity of the original injury. With minimal displacement the management was simple and the long-term prognosis good, a single urethrotomy being sufficient in 22 patients. Where there was considerable displacement the initial management was more difficult and there was a high incidence of long-term complications: of 73 patients treated by urethroplasty or end-to-end anastomosis, significant post-operative infection occurred in 11 (15%) and restenosis in 15 (20%), of whom 7 required a revision urethroplasty. Data in respect of potency were recorded in 80 patients: 28 of these were impotent, 20 of the 28 having sustained an injury with considerable displacement.

Long-term results of one-stage scrotal patch urethroplasty

Of 211 patients with urethral strictures undergoing one-stage dartos pedicled island patch urethroplasty between 1970 and 1987, 194 have been followed up from 3 to 20 years. There was 1 post-operative death (from hepatitis). During the period of follow-up, strictures recurred in 14 patients (7%), some of them as late as 15 years after an apparently successful urethroplasty. Calculi forming on hairs required treatment in 6 patients (3%) and it was necessary to revise a redundant skin pouch in 6.

Posterior urethroplasty with tubularized bladder mucosal graft

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

Autologous everted vein graft for repairing long-section urethral defects

In 21 male dogs a 4- to 10-cm sections of the urethra was replaced by an autologous vein graft. After an observation period of 21-380 days (mean 118), the results of radiological, endoscopic, macroscopic and histological examination were evaluated for 19 animals; 2 of the animals died perioperatively. Micturition was normal in 18 of 19 animals until they were killed. One animal died on the 30th day due to a high-grade meatal stenosis with a subsequent episode of urine retention and ascending urinary infection. Gross examination of the graft in this animal, however, revealed a good result. The local surrounding tissue was found to be ideal in 11 animals, and 5 showed satisfactory results. Three times we observed a pronounced stenosis, so that in these cases results were judged to be unsatisfactory. Postmortem examinations showed the neo-urethra to be a tube made up of connective tissue completely lined by urothelium. In our opinion the results of these animal experiments could at least be equalled in clinical application.

Scrotal island flap urethroplasty in the management of bulbar urethral strictures

We describe our experience with 20 patients undergoing 1-stage scrotal island flap urethroplasty for severe bulbomembranous stricture disease. While 16 patients achieved satisfactory results, 4 required revision for recurrent stricture, diverticulum or fistula. Use of hairless skin and aggressive tailoring of the flap are stressed to avoid the common complications of diverticulum, hair ball and stone formation. This highly vascularized pedicle represents a reasonable alternative to staged repair when local tissue scarring is great and free full thickness skin graft viability is questionable.

Mesh graft urethroplasty using split thickness skin graft or foreskin

Long urethral strictures remain one of the hazards of modern urology. Reconstructive operations with scrotal skin suffer a high rate of recurrent stricture. To avoid complications, meshed split thickness skin graft or foreskin was used to construct a neourethra. In stage 1 split thickness skin graft is harvested and transplanted along the opened urethra. In stage 2 the neourethra is formed 8 to 12 weeks later. Since 1977 mesh graft urethroplasty has been performed in 96 patients using meshed foreskin (76) or split thickness skin grafts (23). In all but 1 patient excellent anatomical and functional results were achieved regardless of which type of graft was used. This technique was most useful in exceedingly long or problematic strictures, for example in spinal cord injury patients.