Intrasphincteric anastomotic urethroplasty allows preservation of continence in men with bulbomembranous urethral strictures following benign prostatic hyperplasia surgery.

PURPOSE: Injury to the external sphincter during urethroplasty at or near the membranous urethra can result in incontinence in men whose internal sphincter mechanism has been compromised by previous benign prostatic hyperplasia (BPH) surgery. We present outcomes of a novel reconstructive procedure, incorporating a recent anatomic discovery revealing a connective tissue sheath between the external sphincter and membranous urethra, which provides a surgical plane allowing for intrasphincteric bulbo-prostatic urethroplasty (ISBPA) with continence preservation. METHODS: Stricture at or near the membranous urethra after transurethral resection (TURP) or open simple prostatectomy (OSP) was reconstructed with ISBPA. The bulbomembranous junction is approached dorsally with a bulbar artery sparing approach and the external sphincter muscle is carefully reflected, exposing the wall of the membranous urethra. Gentle blunt dissection along this connective tissue plane allows separating the muscle away up to the prostatic apex, where healthy urethra is found for anastomosis. RESULTS: From January 2010 to August 2019, 40 men (18 after TURP and 22 after OSP) underwent ISBPA at a single institution. Mean age was 67 years (54-82). Mean stricture length was 2.6 cm (1-6) with obliterative stricture identified in 10 (25%). At a mean follow-up of 53 months (10-122), 36 men (90%) are free of stricture recurrence and 34 (85%) were completely dry or using one security pad. CONCLUSION: This novel intrasphincteric urethroplasty technique for stricture following BPH surgery is feasible and safe, allowing successful reconstruction with continence preservation in most patients. A larger series and reproduction in other centers is needed.

Update on female urethral reconstruction.

PURPOSE OF REVIEW: Female urethral stricture (FUS) is not frequent but can be the cause of significant morbidity. A somewhat overlooked condition for years, it has received significant attention in recent times. In this review, we update the current evidence surrounding FUS management. RECENT FINDINGS: It is estimated that FUS is present in about 1% of all women having check-ups for lower urinary tract symptoms. Etiology is considered as idiopathic in half of the cases, iatrogenic in one-third, whereas infection/inflammation and trauma account for the rest. Symptoms presented are usually nonspecific and nondiagnostic. Pelvic examination, uroflowmetry, endoscopy, and urethrography are the most frequently employed diagnostic tools. Urodynamics/video-urodynamics can be used to document obstruction and to differentiate true anatomic strictures from functional disorders. Urethral dilation (UD) is the most frequent management procedure, sometimes followed by self-dilation, but recurrence is high, at over 50%. By contrast, reconstructive surgery is far more efficient, with overall curative rates of around 90%. SUMMARY: A high index of suspicion is required to identify FUS patients. UD is advised as a first approach but after one or two failed attempts, reconstruction at a referral center should be considered.

Female urethral reconstruction: dorsal buccal mucosa graft onlay.

PURPOSE: Female urethral stricture (FUS) is an infrequent entity, but may cause significant morbidity. Despite a rising interest in recent years, there is still scarce published information. In this article, we review FUS with a special attention to the use of dorsal buccal mucosa grafts (DBMG). METHODS: A literature search was conducted summarizing information about etiology, anatomy, diagnosis, and management. A detailed description of our technique for DBMG urethroplasty is given, with a summary report of our experience and results. RESULTS: FUS accounts for about 1% of all women consulting for lower urinary tract symptoms (LUTS). Diagnosis is suspected in front of persistent LUTS suggestive of obstruction. Confirmatory tests are uroflowmetry, endoscopy, and urethrography; true anatomic strictures must be differentiated from functional or physiological obstructions. Initial management may include dilations, but recurrence is frequent. On the contrary, reconstructive surgery is highly efficient, with overall curative rates around 90%. For reconstruction, DBMG has gained popularity, because it would maintain intact the ventro-lateral urethral supporting structures, important for continence. The pathology of female strictures is unknown and neither the pre nor the intraoperative assessment allows determining the precise location and extent or the urethral damage; therefore, we advise extensive grafting of the entire urethra. Collected success of DBMG is 86% at a mean follow-up of 21 months. Morbidity is very low and de novo stress incontinence has not been reported. CONCLUSIONS: Because of its many advantages, DMBG currently represents a prime choice for FUS reconstruction.

Reconstruction of Membranous Urethral Strictures.

PURPOSE OF REVIEW: Due to the proximity of the rhabdosphincter and cavernous nerves to the membranous urethra, reconstruction of membranous urethral stricture implies a risk of urinary incontinence and erectile dysfunction. To avoid these complications, endoscopic management of membranous urethral strictures is traditionally favored, and bulboprostatic anastomosis is reserved as the main classical approach for open reconstruction of recalcitrant membranous urethral stricture. The preference for the anastomotic urethroplasty among reconstructive urologists is likely influenced by the familiarity and experience with trauma-related injuries. We review the literature focusing on the anatomy of membranous urethra and on the evolution of treatments for membranous urethral strictures. RECENT FINDINGS: Non-traumatic strictures affecting bulbomembranous urethra are typically sequelae of instrumentation, transurethral resection of the prostate, prostate cancer treatment, and pelvic irradiation. Being a different entity from trauma-related injuries where urethra is not in continuity, a new understanding of membranous urethral anatomy is necessary for the development of novel reconstruction techniques. Although efficacious and durable to achieve urethral patency, classical bulboprostatic anastomosis carries a risk of de-novo incontinence and impotence. Newer and relatively less invasive reconstructive alternatives include bulbar vessel-sparing intra-sphincteric bulboprostatic anastomosis and buccal mucosa graft augmented membranous urethroplasty techniques. The accumulated experience with these techniques is relatively scarce, but several published series present promising results. These approaches are especially indicated in patients with previous transurethral resection of the prostate in which sparing of rhabdosphincter and the cavernous nerves is important in attempt to preserve continence and potency. Additionally, introduction of buccal mucosa onlay grafts could be especially beneficial in radiation-induced strictures to avoid transection of the sphincter in continent patients, and to preserve the blood supply to the urethra for incontinent patients who will require artificial urinary sphincter placement. The evidence regarding erectile functional outcomes is less solid and this item should be furtherly investigated.

Modified transurethral resection of the prostate for the management of BPH-related refractory lower urinary tract symptoms in patients with a history of pelvic fracture urethral injury reconstruction.

INTRODUCTION: To evaluate the impact of a modified transurethral resection of prostate (mTURP) in patients with a history of pelvic fracture urethral injury (PFUI) status post-urethroplasty, and subsequent lower urinary tract symptoms (LUTS) refractory to medical therapy caused by benign prostatic hyperplasia (BPH). METHODS: Five patients were identified with a history of PFUI and a successful reconstruction of the urethra, who developed severe LUTS. After maximal medical therapy failed, these patients underwent a mTURP. Their continence status and voiding parameters were recorded before and after surgery. RESULTS: Significant improvements in both post-void residual (172 ± 137.36 mL vs. 26.6 ± 24.44 mL), p = 0.026, and International Prostatic Symptom Score (23.6 ± 4.82 vs. 7.6 ± 4.30), p = 0.002 were observed in the study. Although maximum flow rate was not statistically significant, there was an overall improvement in Qmax in all patients (8.92 ± 3.71 vs. 16.78 ± 6.44 mL/sec). Furthermore, all patients remained continent after this modified intervention. CONCLUSION: Our modified TURP provides an adjunctive option in the management of severe LUTS secondary to BPH in patients with a history of PFUI urethroplasty who are refractory to medical management. In our experience, the patients experienced a lasting response with no incontinence.

Delayed Posterior Urethroplasty Following Pelvic Fracture Urethral Injury: Do We Have to Wait 3 Months?

OBJECTIVE: To compare outcomes with early vs delayed reconstruction following pelvic fracture urethral injury (PFUI) to determine if a traditional 3-month delay is necessary. This delay has been advocated to allow resolution of traumatic inflammation and hematoma but has never been validated. We proceed to reconstruction at 3-6 weeks if the associated injuries are stable, the perineum is soft on rectal palpation, and the fracture is stable for lithotomy positioning. METHODS: PFUI patients treated with a suprapubic tube and delayed urethroplasty from October 1991 to August 2016 were included. Patients with initial catheter realignment were excluded. We compared reconstruction failure, incontinence, and erectile dysfunction rates in patients reconstructed within 6 weeks after injury with those reconstructed after the traditional ≥12 weeks. RESULTS: Thirty-nine patients were identified with a median age of 32 years (17 to 69). Overall, the median urethral gap was 2 cm (1-4.5) and median follow-up was 64 months (12-277). Stricture failure occurrence was 5.1%, incontinence rate was 7.7%, and erectile dysfunction rate was 56.4%. The 22 patients with urethroplasty ≤6 weeks post-injury were no more likely to experience erectile dysfunction (13 vs 9, P = .70), urinary incontinence (1 vs 2, P = .40) or reconstruction failure (2 vs 0, P = .20) than the 17 patients delayed ≥12 weeks. CONCLUSION: We report similar outcomes following urethral reconstruction for PFUI patients repaired ≤6 weeks after injury compared with those delayed ≥12 weeks. This suggests that in selected cases reconstruction at 3-6 weeks is feasible, minimizing the morbidity of a suprapubic tube.

Anatomy and techniques in posterior urethroplasty.

Given its complex anatomy, injury to the posterior urethra may result in a number of reconstructive challenges. With the appropriate operative planning and experience, surgical repair can be very successful. This review discusses the applicable techniques for the perineal approach to posterior urethral stenosis, including bulbomembranous anastomosis for pelvic fracture urethral injury and repair of vesicourethral anastomotic stenosis (VUAS) following prostate surgery. The advanced techniques reviewed include an adaptation allowing a bulbar artery sparing approach to posterior urethroplasty and an intrasphincteric urethroplasty procedure which may allow continence preservation in patients with membranous urethral stenosis.

Reconstruction of Pelvic Fracture Urethral Injuries With Sparing of the Bulbar Arteries.

OBJECTIVE: To present a novel reconstruction technique for patients with pelvic fracture urethral injuries (PFUI) with bulbar artery sparing. MATERIALS AND METHODS: We modified the traditional technique for PFUI reconstruction to preserve the proximal arterial inflow to the bulb. Since 2008, 26 consecutive patients have undergone this technique at our institution. The bulbar arteries are located using a Doppler ultrasound stethoscope and then the bulb is mobilized from one side only, without detachment from the perineum. The artery from that side is sacrificed to preserve the contralateral one; sometimes both arteries can be spared. Removal of the scar and end-to-end anastomosis is performed as usual. Successful arterial preservation was verified by postanastomosis Doppler auscultation. RESULTS: Mean age was 37 years (15 to 70). Median time from trauma to urethral reconstruction was 11 weeks and mean stenosis length was 2.3 cm (1 to 4.5 cm). The left bulbar artery was preserved in 14 cases, the right in 4, and both arteries were spared in seven; an accidental injury of the artery to be preserved occurred in the remaining case. At a mean follow-up of 20 months (2-69), all patients are voiding normally stricture free. CONCLUSION: Preservation of proximal arterial blood supply to the bulb during PFUI reconstruction is feasible and safe. A well-perfused reconstruction should heal better and theoretically our technique may avoid ischemic failure of the urethroplasty. A larger series and replication of our results in other centers are necessary to validate our technique's potential benefits.

A Multi-institutional Evaluation of the Management and Outcomes of Long-segment Urethral Strictures.

OBJECTIVE: To evaluate the treatment options and surgical outcomes of long-segment urethral strictures-a review of the largest, international, multi-institutional series. METHODS: A retrospective review was performed of patients treated with strictures ≥8 cm at 8 international centers. Endpoints analyzed included surgical complications and recurrence. RESULTS: Four hundred sixty-six patients were identified. Treatment intervals ranged from December 27, 1984 to November 9, 2013. Dorsal onlay buccal mucosal graft (BMG) was the most common procedure (223, 47.9%); others included first- and second-stage Johanson urethroplasty (162 [34.8%] and 56 [12%], respectively), fasciocutaneous (FC) flaps (8, 1.7%), and a combination flap and graft (17, 3.6%). Overall success was achieved in 361 patients (77.5%) with a mean follow-up of 20 months. Second-stage Johanson urethroplasty was found to have a higher recurrence rate compared with that of 1-stage BMG urethroplasty (35.7% vs 17.5%, respectively; P <.01). This was also true in cases of lichen sclerosus (14.0% vs 47.8%, respectively; P <.01). Otherwise, success rates were similar. Urethroplasties performed with FC flaps had a higher complication rate compared with those without (32% vs 14%, respectively; P = .02). Prior dilation or urethrotomy, higher number of prior dilations or urethrotomies, abnormal voiding cystourethrogram, and skin grafts all portend a higher recurrence rate. On logistic regression analysis, only second-stage Johanson had an increased odds ratio of recurrence compared with that of BMG (2.82 [1.41-5.86]). CONCLUSION: Long-segment strictures can be treated with high success rates in experienced hands. BMG was more successful than second-stage Johanson urethroplasty. FC flaps, although successful, had high complication rates.

Traumatic testicular dislocation.

INTRODUCTION: Traumatic testicular dislocation is a rare entity. It occurs after a direct blunt scrotal trauma causing the testicle to migrate outside the scrotum, most frequently to the superficial inguinal region. MATERIALS AND METHODS: A review of the diagnostic database of our two institutions was performed searching for complex genital trauma between 1990 and 2012. RESULTS: Seven cases of traumatic testicular dislocation were identified (four on the left side; one on the right side and two bilateral) for a total of nine testicles. Six were motorcycle accidents, and the other case suffered a pelvic crush injury. All victims had significant associated injuries, one case had an open dislocation and two were killed by the accident. The testicle was located at the inguinal region in four cases at the suprapubic area in four, and the other was an open dislocation. Diagnosis was suspected with the physical examination and confirmed by Doppler ultrasound; however, in one case, the diagnosis was missed during several weeks. In one case, the testicle was reduced into the scrotum immediately at the emergency department. Two cases were operated shortly after admission, performing testicular reduction into the scrotum and standard orchidopexy. Two other cases underwent delayed intervention, and both needed release of peri-testicular adhesions. Two cases (both bilateral) died at the accident site and were diagnosed by autopsy. In all surviving cases, it was possible to obtain a satisfactory orchidopexy with gonadal preservation. CONCLUSIONS: Traumatic testicular dislocation is rare and diagnosis can be elusive. It should be suspected in motorcycle and high-energy accidents around the groin area and depends on a careful physical examination. With proper management, prognosis is excellent.

SIU/ICUD Consultation on Urethral Strictures: Pelvic fracture urethral injuries.

The posterior urethra pierces the perineal diaphragm in close relationship to the pubic arc elements of the bony pelvis to which it is tethered by attachments to the puboprostatic ligaments and the perineal membrane. Because of these relationships, it is not surprising that fracture disruptions of the pelvic ring can be associated with injuries to the urethra at this level. Although the relationship between pelvic fracture and posterior urethral injury has been recognized for >1 century, considerable controversy exists on almost any aspect of these injuries, from the anatomy and classification of the injuries to the strategies for acute management, reconstruction, and treatment of complications, to mention just a few. What it is not controversial and well known is that these injuries can result in significant morbidity in the long run--mainly strictures, erectile dysfunction, and urinary incontinence--which can cause lifelong disability. It also well known that, just as in many other areas of trauma, the severity and duration of the complications can be reduced considerably if the injury is diagnosed and treated promptly and efficiently. This chapter summarizes the most relevant published evidence about the management of pelvic fracture urethral injuries. This comprehensive review, performed by an international panel of experts, will provide valuable information and recommendations to help urologists worldwide improve the treatment and outcomes of their injured patients.