Dorsal onlay lingual mucosal graft urethroplasty for urethral strictures in women.

OBJECTIVE: To describe the technique and results of dorsal onlay lingual mucosal graft (LMG) urethroplasty for the definitive management of urethral strictures in women. PATIENTS AND METHODS: In all, 15 women (mean age 42 years) with a history suggestive of urethral stricture who had undergone multiple urethral dilatations and/or urethrotomy were selected for dorsal onlay LMG urethroplasty after thorough evaluation, from October 2006 to March 2008. After a suprameatal inverted-U incision, the dorsal aspect of the urethra was dissected and urethrotomy was done at the 12 o'clock position across the strictured segment. Tailored LMG harvested from the ventrolateral aspect of the tongue was then sutured to the urethrotomy wound over an 18 F silicone catheter. RESULTS: The preoperative mean maximum urinary flow rate of 7.2 mL/s increased to 29.87 mL/s, 26.95 mL/s and 26.86 mL/s with a 'normal' flow rate curve at 3, 6 and 12 months follow-up, respectively. One patient at the 3-month follow-up had submeatal stenosis and required urethral dilatation thrice at monthly intervals. At the 1-year follow-up, none of the present patients had any neurosensory complications, urinary incontinence, or long-term functional/aesthetic complication at the donor site. CONCLUSION: LMG urethroplasty using the dorsal onlay technique should be offered for correction of persistent female urethral stricture as it provides a simple, safe and effective approach with durable results.

Dorsal onlay lingual mucosal graft urethroplasty: Comparison of two techniques.

OBJECTIVES: To compare the results of two different techniques of dorsal onlay lingual mucosal graft (LMG) urethroplasty for anterior urethral strictures. METHODS: Thirty patients underwent dorsal onlay LMG urethroplasty by Barbagli's technique (group I) and 25 through a ventral sagittal urethrotomy approach (group II). All of the patients were followed up with a pericatheter urethrography at 3 weeks, retrograde urethrography with micturating cystourethrography and uroflowmetry at 3, 6 and 12 months. RESULTS: Mean follow up was 22 months and 13 months in group I and II, respectively. The mean peak flow rate increased from 4.2 mL/s preoperatively to 35.5, 25.06 and 25 mL/s at 3, 6, and 12 months, respectively, in group I and from 7.8 mL/s to 34.2, 28.4 and 26.2 mL/s at 3, 6 and 12 months, respectively, in group II. Five patients in group I and two patients in group II had an anastomotic stricture at 12 months. Meatal narrowing was seen in five patients in group I and three patients in group II. The overall success rate was 83.4% and 76.6% in group I and 90% and 80% in group II at 6 and 12 months, respectively. One patient had chordee in group I and no patient had chordee in group II. There was a shorter operative time and less blood loss in group II. CONCLUSIONS: Dorsal onlay LMG urethroplasty through a ventral sagittal approach is better than the Barbagli's technique in terms of results and complications.

Mid-term experience with valved bovine jugular vein conduits.

From June 1999 to January 2004, 43 children underwent implantation of a valved bovine jugular vein conduit and correction of complex congenital heart defects. Median age was 1.98 years (range, 11 days - 13.3 years). There were 7 early deaths (16.3%) unrelated to conduit failure or thrombosis. Median follow-up of 36 survivors was 24 months (range, 1-48 months, quartile range, 12-48 months), total follow-up was 78 patient-years. There were 3 late deaths (8.3%) due to infection, pulmonary thromboembolism, and sudden cardiac arrest after re-operation to repair a right ventricular outflow tract aneurysm. There were 2 conduit explantations due to dysfunction and suspected endocarditis. Three patients underwent balloon dilatation of distal stenoses. The mean peak gradient through the pulmonary anastomosis was 15 mm Hg (range, 3-42 mm Hg) among patients free from re-intervention. No severe valve regurgitation was observed. Freedom from re-intervention was 72% at 48 months. This conduit remains a good alternative to homografts. Causes of distal stenosis must be clarified, guidelines for prophylactic anticoagulation must be created, and the role of percutaneous balloon dilatation established.

Aortoventriculoplasty and left ventricle function: long-term follow-up.

OBJECTIVE: Depressed cardiac function after aortoventriculoplasty is well known during the postoperative period. Little data exist concerning the long-term follow-up. The aim of this study is to determine whether septal incision has any permanent effect on the left ventricle function. METHODS: From 1988 to 2002, 45 patients received aortic mechanical prosthesis. These patients were divided into two groups. Group A consisted of 26 patients 5-18 years old, who underwent simple aortic valve replacement. Group B consisted of 19 patients 4-20 years old, who underwent the Konno procedure. Systolic and diastolic functions of the left ventricle were analyzed using echocardiography. For the systolic function, the following parameters were assessed: pressure gradient between left ventricle and ascending aorta, shortening and ejection fraction of the left ventricle. For the diastolic function, left ventricle-filling parameters were assessed: ratio of early to late filling velocity, deceleration slope of the early filling velocity and left ventricular isovolumetric relaxation time. Furthermore the percentage fraction of the aortic valve index (AOVI%) was calculated and compared between these two groups. RESULTS: After the surgery in group A, AOVI% dropped from 110+/-21 to 98+/-11%, while in group B it increased from 82+/-16 to 114+/-11%. As a result a higher residual pressure gradient across the aortic valve was noted in group A: 21.26+/-15 as compared to 11.17+/-5 mmHg in group B. A mean pressure above 30 mmHg appeared in group A 2 years after the surgery, while in group B this was obtained after 6 years. As for the diastolic function no significant difference was noted between these two groups. Overall there was one late death in group A, and in group B two early deaths, two reoperations because of excessive drainage and in two patients permanent pacemakers had to be implanted. CONCLUSIONS: Improvement of the systolic function after the surgery was noted in both groups. In patients with low AOVI%, postsurgical pressure gradient, either residual or recurrent, appeared during the follow-up. As for the septal incision, it may have some transient effects on the left ventricle function in the postoperative period, but no permanent sequelae were observed in the long-term follow-up.

Polyscope: a new era in flexible ureterorenoscopy.

INTRODUCTION: Despite improvements in instrumentation and technology in flexible ureteroscopy, the issue of procedural and off-procedural damage remains a problem. The aim of our study was to highlight our initial experience in flexible ureteroscopy using polyscope, a new advancement in the era of flexible ureterorenoscopy. MATERIALS AND METHODS: In this study, we used an 8F modular flexible, steerable polyscope for diagnostic purposes and Dormia basket removal for small renal stones. Three outer disposable catheters were used with proper sterilization in 22 cases. RESULTS: The polyscope was used in six cases of undiagnosed hematuria, and biopsy was taken from pelvic growth in one patient, which turned out to be transitional-cell carcinoma. Polyscope was used for removal of residual stones or small stones (< 1 cm) using Dormia basket in 16 cases (from August 2008 to July 2009). The mean stone size was 7.5 mm. The vision achieved was excellent in all the cases. CONCLUSIONS: Minimally invasive techniques are preferred for treatment of renal stones. The problem of lower caliceal stone access has been solved with the primary and secondary deflection of modern flexible ureteroscopes. The modular design of polyscope makes it a more cost-effective option. Relatively cheap and disposable multilumen catheters preclude the need for sterilization of optic cable, thus decreasing the chances of handling-related damages. The chance of instrument-related infection is minimal. Besides, it can be used as a semirigid ureteroscope should the need arises.

Management of superficial bladder carcinoma: time to rethink the treatment strategies in the era of orthotopic neo-bladder.

The objective of this study was to evaluate the recurrence and progression, on long-term follow-up, of patients with superficial bladder cancer managed with bladder sparing approach. A total of 48 patients with superficial bladder cancer, initially treated with bladder sparing approach between 1990 and 1992, were available for long-term follow-up ranging between 10 and 15 years; the remaining patients were lost to follow-up. All patients had undergone transurethral resection and adjuvant intravesical therapy. Recurrence was treated with resection and adjuvant therapy or radical cystectomy in cases of progression. Out of 48 study subjects, 11 had T1G1, 23 had T1G2 and 14 had T1G3 tumor. In the T1G1 group, 45.5% had recurrence. Four had single recurrence managed successfully with TURBT and intravesical therapy. One had multiple recurrences and underwent radiotherapy after the fifth recurrence. In the T1G2 group, 82.6% had recurrence and majority (60.8%) had multiple recurrences. Out of 14 cases with multiple recurrences, eight patients ultimately progressed to invasive bladder carcinoma and underwent radical cystectomy. Majority of these underwent ileal conduit because ileal neobladder could not be created due to severe fibrosis. All 14 patients with T1G3 had recurrence, of whom three (21.4%) had single recurrence. Out of the 11 other patients (78.6%) who had multiple recurrences, nine developed invasive bladder carcinoma and underwent radical cystectomy. Orthotopic neo-bladder could be performed only in one patient and the remaining had ileal conduit or Mainz pouch. We conclude that in the era of orthotopic neo-bladder offering good quality of life, radical cystectomy should be considered at the earliest opportunity in patients with aggressive superficial bladder cancer.

Lingual mucosal graft urethroplasty for anterior urethral strictures.

OBJECTIVE: To evaluate the effectiveness of a lingual mucosal graft (LMG) urethroplasty for anterior urethral strictures and the donor site complications. METHODS: A total of 30 patients underwent urethroplasty for anterior urethral strictures using dorsal on-lay of a LMG from March 2006 to December 2006. Most patients had balanitis xerotica obliterans as the etiology. The mean stricture length was 10.2 cm (range 3.7-16.5). Postoperatively, all patients underwent pericatheter urethrography at 3 weeks, followed by retrograde urethrography with micturating cystourethrography, and uroflowmetry at 3 and 6 months. Repeat uroflowmetry was done as, and when, required. RESULTS: The mean period of follow-up was 9 months (range 4-12). The overall success rate was 83.3%. The mean peak flow rate increased postoperatively from 4.36 mL/s to 35.5 mL/s at 3 months and 25.06 mL/s at 6 months of follow-up. One patient developed repeat stricture at the anastomotic site, and 4 patients developed recurrent meatal stenosis. CONCLUSIONS: The results of LMG urethroplasty were comparable to that of buccal mucosal graft urethroplasty. LMG is easy to harvest. Most importantly, the donor site complications were minimal without any functional or esthetic deficiency.

Lingual mucosal graft substitution urethroplasty for anterior urethral strictures: our technique of graft harvesting.

OBJECTIVE: To describe our technique of lingual mucosal graft harvesting for substitution urethroplasty and the complications encountered at the donor site. METHODS: Twenty-eight patients who underwent lingual mucosal graft urethroplasty between May 2006 and March 2007 were included in this study. TECHNIQUE: The site of the graft harvest is the lateral mucosal lining of the tongue. Graft harvesting is started from the posterior landmark of the graft on the left side of the tongue. It is continued across the tip of the tongue to the other side if lengthier graft is required. The graft harvesting site is simultaneously closed with continuous running suture using 4-0 polyglactin suture to achieve immediate and good homeostasis. RESULTS: Mean duration of follow up was 4.2 months. Average length of harvested graft was 6.5 cm. Mean harvesting time was 18 min. At the first postoperative day, 92% patients experienced pain at donor site and 24% had slurring of speech. By third postoperative day, >70% were free of pain and four had slurring of speech. By sixth postoperative day, none of the patient suffered pain. All the patients were able to resume oral fluid within 24 h, eat soft solid diet in 48-72 h and return to normal diet after 4-5 days of surgery. No patient suffered from difficulty in opening the mouth, salivation disturbances, peri-oral numbness or difficulty in protrusion of tongue. CONCLUSION: Lingual mucosal graft harvesting is a simple procedure, provides lengthy graft and is associated with minimal donor site complications.