Iatrogenic or recurrent bladder neck contracture treated by the Palminteri-Ferrari technique: a new way to approach a frustrating condition.

PURPOSE: Bladder neck stricture (BNS) is a bothersome disease which may affect patients after trauma or prostatic surgery. It is frustrating due to the low durable success rate of currently available surgical techniques. The aim of the study is to explore the efficacy of a novel technique. MATERIALS & METHODS: The surgical protocol was developed by two high case-volume surgeons. The technique consists of Holmium laser incisions at 3-6-9-12 o'clock. Subsequently, triamcinolone acetonide 40 mg is injected. Two months later, the BNS is endoscopically checked in operatory room and re-procedure take place, if necessary (max 3 times). Failure was defined as the need of definitive urinary diversion. Subjective satisfaction was measured through PGI-I Questionnaire. RESULTS: A total of 45 patients were enrolled. Median age was 63 (IQR 59-69) years and BNS developed by different causes. Naïve BNS procedure patients were 12 (26.7%), others 33 (73.3%) underwent median 2 (IQR 1-4) previous urethrotomies, including 16 other surgeries. Suprapubic bladder catheter was present in 34 patients (75.6%). No complications were registered. Re-procedure at control was necessary in 24 patients (53.3%) for a median of 1 (IQR 1-3) procedures. At median follow-up of 18 months, failures were 4 (8.9%) and urinary incontinence was reported in 2 patients (4.5%) who required incontinence surgery. Median PGI-I was 2. CONCLUSIONS: Our technique of BNS treatment allows good outcomes and high rate of subjective improvement amongst patients. Moreover, naïve patients seem to have better results. However, longer follow-up and higher sample size are mandatory to further assess these data.

Small intestinal submucosa graft bulbar urethroplasty is a viable technique: results compared to buccal mucosa graft urethroplasty after propensity score matching.

PURPOSE: Small intestinal submucosa (SIS) graft urethroplasty has been employed to decrease buccal mucosa morbidity and facilitate the procedure. The first published series had a short follow-up, inhomogeneous patient selection, and a lack of a control group. Our purpose is to report treatment outcomes at 13 years in a propensity score-matched cohort comparing bulbar urethroplasty with SIS (SISU) or buccal mucosa (BMU). METHODS: From our institutional database of 1132 bulbar urethroplasties, we used propensity score matching with the nearest-neighbor method without replacement to generate a study sample of 25 BMU and 25 SISU. Failure was defined as any treatment after urethroplasty. Survival analyses were used to analyze treatment failure occurrence with data censored at 156mo. RESULTS: Matching resulted in a complete correction of bias between the two samples except for the follow-up duration, which was slightly longer in the SIS group. The cumulative treatment success probability of BMU and SISU at 156mo was 83.4% and 68%, respectively. At multivariable Cox regression, SIS graft, previous urethrotomy, stricture length, and lower postoperative Qmax (within 2mo after catheter removal) were predictors of failure. Stricture length had a more remarkable effect in SISU, with estimated survival probabilities from the Cox model lower than 80% in strictures > = 3 cm. CONCLUSION: SIS has poorer outcomes compared to BM but may still be useful when BM grafting is not possible. The best candidates for SISU, with similar success to BMU, are patients with strictures shorter than 3 cm, preferably without a history of DVIU.

Two-sided urethra-sparing reconstruction combining dorsal preputial skin plus ventral buccal mucosa grafts for tight bulbar strictures.

OBJECTIVES: To report our initial experience with urethra-sparing reconstruction combining dorsal preputial skin and ventral buccal mucosa grafts for tight bulbar urethral strictures. METHODS: Between November 2006 and September 2012, 26 patients with tight bulbar strictures underwent urethroplasty. Using a ventral urethrotomy approach, the two-sided urethral reconstruction was carried out avoiding the transection of urethra and augmenting the preserved urethral plate by dorsal preputial skin plus ventral buccal mucosa grafts. The primary outcome was the objective urinary result, defined as the absence of stricture recurrence. The outcome was considered a failure when any postoperative instrumentation was required. Postoperative sexual dysfunctions were investigated using a validated questionnaire. RESULTS: Mean follow up was 30.1 months (range 12-79 months). Mean stricture length was 3.3 cm (range 1.5-6 cm). Mean length for dorsal preputial skin and ventral buccal mucosa grafts was 3.2 cm (range 2-7 cm) and 4.9 cm (range 4-6 cm), respectively. Of 26 cases, 23 (88.5%) were successful and three (11.5%) were failures with stricture recurrence. Failures were treated with perineal urethrostomy in one case, ventral buccal graft urethroplasty in one case and internal urethrotomy in one case. Among 12 sexually active men preoperatively, none reported postoperative penile curvature/shortening, impaired erection or dissatisfaction regarding erection; sexual activity was unaltered pre- and post-surgery. CONCLUSIONS: In tight bulbar urethra strictures, the two-sided urethroplasty combining dorsal preputial skin and ventral buccal mucosa grafts provides a safe and effective semi-circumferential reconstruction by augmenting the preserved urethral plate, with no impact on sexual function.

Male genital reconstruction for the penile cancer survivor.

PURPOSE OF REVIEW: Malignant penile lesions are uncommon but represent a challenge for reconstructive surgeons because their treatment has a profound effect on appearance and quality of life of the patient. RECENT FINDINGS: Partial or total penectomy remains the gold standard in the treatment of penile carcinoma. However, less invasive options that may improve quality of life are being considered, based on stage and grade of the tumor. SUMMARY: A variety of surgical options exist for penile cancer treatment. In this article, we review various reconstructive approaches after initial surgical management of penile carcinoma. Regardless of reconstruction method, the goals remain the same: creating a functional and aesthetically acceptable phallus with the ability to void standing and to achieve sexual function.

Dorsal plus ventral oral mucosal graft bulbar urethroplasty.

Traditionally, anastomotic procedures with transection and urethral excision are suggested for short bulbar strictures, while longer strictures are treated by patch graft urethroplasty preferably using the buccal mucosa as gold-standard material due to its histological characteristics. However, anastomotic urethroplasties may cause sexual complications related to vascular damage of the spongiosum following the urethral section or to excessive urethral shortening. On the other hand, one-sided graft procedures, using either dorsal or ventral graft location, could be insufficient in providing a lumen of adequate width in strictures with a particularly narrow area. The double buccal graft urethroplasty is a new technique that aims to obtain a sufficient "two-sided" augmentation of the urethra avoiding its transection and preserving the urethral plate. In this chapter we discuss the rationale for utilizing our procedure. In addition, the surgical technique is described in detail.

Shear Wave Elastography in Assessing Spongiofibrosis of Urethral Stricture: Is It Clinically Useful?

RATIONALE AND OBJECTIVES: To compare urethral stricture shear wave elastography (SWE) with normal areas and assess its association with other explanatory variables. SUBJECTS AND METHODS: we recruited all men with urethral stricture disease referred to our center between December 2021 and July 2023. Patients underwent SWE and elasticity in the stricture area, and one and three centimeters distant from the stricture were measured. Gathered data were analyzed using Freidman and post hoc analysis, correlation methods, student t-tests, and one-way ANOVA. RESULTS: 22 patients were recruited for our study. Spongiofibrosis was significantly higher in the stricture area relative to the one-centimeter-distant adjacent area (p < .0005), in the one-centimeter-distant compared to the three-centimeter-distant area (p = .002), and in the stricture area relative to the three-centimeter-distant area (p < .0005). There was no association between elasticity ratio and patient age or stricture location. Likewise, there was no difference in elasticity ratios between bulbar and pendulous strictures (p = 0.19) or among different etiologies of urethral strictures (p = 0.76). CONCLUSION: There is a significant difference in elasticity between the urethral stricture area and other parts of the corpus spongiosum. Normal areas closer to strictures are stiffer. The elasticity ratio is unrelated to patient age or prior internal urethromies. Neither stricture locations nor distinct urethral stricture etiologies differed in elasticity ratios.

Long-term follow-up of two-sided dorsal plus ventral oral graft bulbar urethroplasty: single center experience on 216 patients.

BACKGROUND: Two-sided dorsal plus ventral oral graft urethroplasty is a new urethra-sparing technique suggested in tight bulbar strictures which are too severe for a simple one-side grafting. The aim of this study was to evaluate long-term outcomes and the success predictive factors of this technique. METHODS: A descriptive retrospective study was conducted on 216 patients undergoing dorsal plus ventral graft urethroplasty for bulbar strictures between 2002 and 2018 in a single high-volume center by a single surgeon (EP). The primary outcome measure was stricture recurrence at follow-up. Surgical procedure was considered failed when any postoperative instrumentation was needed. Univariable and multivariable logistic regression analysis were performed. RESULTS: Median follow-up was 98 months (IQR: 41-131). Among the 216 patients, 188 (87%) were successful and 28 (13%) were failures. Most of the failures (78.4%) were observed during the first 7 years of follow-up, afterward failures were less frequently recorded. Stricture length <1.5 cm and the absence of previous treatments resulted as independent success predictors (respectively P=0.04, OR=0.55 (0.29-0.99) and P=0.02, OR=0.23 (0.06-0.79). Age and stricture etiology were not significant predictors of surgical outcome. The limitation of our survey is that it is a retrospective single center experience. Multicentric experiences from different centers should be performed. CONCLUSIONS: After long-term follow-up in our wide series, the two-sided dorsal plus ventral oral graft bulbar urethroplasty showed a high success rate. Stricture length <1.5 cm and the absence of previous treatments resulted as independent success predictors.

Urethral reconstruction in lichen sclerosus.

PURPOSE OF REVIEW: Lichen sclerosus is a chronic skin disease that shows a predilection for the anogenital area and may involve anterior urethra causing stenosis. Surgical options in the management of urethral strictures caused by lichen sclerosus still represent a challenging issue. RECENT FINDINGS: Depending on the length and severity of urethral involvement, surgical management of lichen sclerosus urethral strictures can range from a simple meatotomy to a single or complex staged long repair using oral mucosa. Skin grafts or flaps are not recommended because skin could be involved by the disease. Perineal urethrostomy may represent the salvage solution in severe panurethral strictures. SUMMARY: One-stage or staged repairs using oral mucosa grafts are the most recommended procedures for the treatment of lichen sclerosus urethral strictures, but derivative perineal urethrostomy may play an important role in severe situations. Patients require long-term follow-up and extensive counseling that enables them to fully grasp the chronic and progressive nature of the disease and to deal with it.

The Role of Multi-Staged Urethroplasty in Lichen Sclerosus Penile Urethral Strictures.

BACKGROUND: One-stage buccal mucosa graft urethroplasty (BMGU) is advised for non-obstructing, simple penile strictures due to lichen sclerosus (LS), while a multistage approach is preferred for most complex cases. Our study aims to evaluate long-term treatment outcomes and patient-reported outcomes (PROs) in patients undergoing multistage BMGU for LS-associated penile strictures. METHODS: This is a retrospective analysis of prospectively collected data on multistage penile BMGU from 2001. All patients underwent a 2-stage (2St) or 3-stage (3St) BMGU with the final closure of the urethral plate. PROs were collected from a pre-defined questionnaire. RESULTS: Twenty patients were successfully treated, while five experienced recurrence. If a first-stage Johanson was only performed, a 3St-BMGU was more likely, and higher treatment success was observed. A time course between the first and last stages shorter than 12 m was an independent predictor of treatment failure. Patients reported high overall satisfaction and urinary flow improvement. Sexual life was not significantly affected, while aesthetic appearance was the most affected dimension. CONCLUSIONS: Staged approaches have satisfactory treatment success rates, likely depending on the duration from the first to the last stage. PROs do not differ based on the number of stages performed, and overall satisfaction with the procedure is high.

Non-transecting dorsal mucosal anastomosis plus ventral oral graft for the treatment of urethral bulbar strictures: single surgeon experience.

PURPOSE: To report our experience with the non-transecting dorsal mucosal anastomosis plus ventral oral graft urethroplasty (NTAVOG) for the repair of tight bulbar urethral strictures. METHODS: Data of 68 men with tight bulbar strictures underwent NTAVOG urethroplasty between 2012 and 2019 were retrospectively revised. The urethra was opened ventrally; the dorsal scarred mucosa was excised preserving the spongiosum; the mobilized mucosal edges were anastomosed to recreate the dorsal urethral plate; the repaired urethral plate was augmented by the ventral oral graft and the spongiosum was closed over it. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Sexual function was investigated using a validated questionnaire. RESULTS: Median follow-up was 58 months (IQR 38-63) and mean stricture length was 1 cm (IQR 1-1.5). Of 68 cases, 56 (82.4%) were successful and 12 (17.6%) were failures requiring re-treatment. At multivariable analysis, no preoperative factor was significantly associated with recurrence. None of the preoperatively sexually active 53 patients reported postoperative erectile impairment and all were satisfied with their sexual life. The main limitation is the retrospective design. CONCLUSIONS: In cases of tight bulbar stricture, the NTAVOG urethroplasty provides adequate urethral augmentation by preserving the spongiosum and avoiding postoperative sexual complications. We presented a series of patients undergone non-transecting dorsal anastomosis plus ventral oral graft urethroplasty for tight bulbar stricture. This treatment seems to be safe and with limited postoperative complications thanks to the preservation of the corpus spongiosum.

Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique.

PURPOSE: Repair of bulbar strictures using anastomotic techniques may cause sexual complications, while 1-side graft urethroplasties may not be sufficient to provide an adequate lumen in narrow strictures. We evaluated the urinary and sexual results of a 2-sided dorsal plus ventral graft urethroplasty by preserving the narrow urethral plate in tight strictures. MATERIALS AND METHODS: Between 2002 and 2010, 105 men with bulbar strictures underwent dorsal plus ventral graft urethroplasty. The results are reported in a homogeneous group of 73 of 105 cases in which buccal mucosa was used as a graft with findings after 1 year or more of followup. The urethra was opened ventrally, and the exposed dorsal urethra was incised in the midline to create a raw area over the tunica albuginea where the first graft was placed dorsal-inlay. Thereafter the urethra was augmented by the ventral-onlay second graft and the spongiosum was closed over itself. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Postoperative sexual dysfunction was investigated using a validated questionnaire. RESULTS: Mean followup was 48.9 months and mean stricture length was 3.3 cm. Of these 73 cases 64 (88%) were successful and 9 (12%) were treatment failures with re-stricture. Furthermore, of 49 of 73 cases who were preoperatively sexually active, none reported postoperative erectile impairment and all were satisfied with their sexual life. CONCLUSIONS: In cases of tight bulbar stricture the dorsal plus ventral buccal mucosa graft provides adequate urethral augmentation by preserving the urethral plate and avoiding postoperative sexual complications.

Primary versus Redo Urethroplasty: Results from a Single-Center Comparative Analysis.

OBJECTIVES: To explore the differences between primary and redo urethroplasty and to directly compare according stricture-free survival (SFS). Materials and Methods. Data of all male patients who underwent urethroplasty at Ghent University Hospital were collected between 2000 and 2018. Exclusion criteria for this analysis were age <18 years and follow-up <1 year. Two patient groups were created for further comparison: the primary urethroplasty (PU) group (no previous urethroplasty) and redo urethroplasty (RU) group (≥1 previous urethroplasty), irrespective of prior endoscopic treatments. A comparison between groups was performed using the Mann-Whitney U test and Fisher's Exact test. SFS was calculated using Kaplan-Meier statistics. A functional definition of failure, being the need for further urethral manipulation, was used. Uni- and multivariate Cox regression analyses were performed on the entire patient cohort. RESULTS: 805 patients were included. Median (IQR) follow-up of the PU (n = 556) and RU (n = 556) and RU (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (. CONCLUSIONS: Several differences between primary and redo urethroplasties exist. Redo urethroplasty entails a distinct patient population to treat and is, in general, associated with lower stricture-free survival than primary urethroplasty, although more homogeneous series are required to corroborate these results. Prior urethroplasty and diabetes are independent risk factors for urethroplasty failure.

Kulkarni Dorsolateral Graft Urethroplasty Using Penile Skin.

OBJECTIVES: To investigate the safety, efficacy, and versatility of dorsolateral graft urethroplasty using penile skin. MATERIALS AND METHODS: Between 2010 and 2013, 37 men with anterior urethral strictures underwent dorsolateral graft urethroplasty using penile skin by a single surgeon (EP). Inclusion criterion was patients with anterior urethral strictures. Exclusion criteria were lichen sclerosus-related strictures, absence of available penile skin because of previous surgery, and obliterative urethral strictures. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilatation. RESULTS: Mean (± standard deviation) patients age was 51 (±15.4) years. Stricture etiology was iatrogenic in 25 cases (67%), unknown in 10 (27%), trauma in 2 (6%). Stricture site was penile in 21 (57%) and peno-bulbar in 16 (43%). Median (range) stricture length was 5 cm (1-15). Of 37 patients, 30 (81%) had received previous treatments. Median (range) follow-up was 21 months (12-47). Of 37 patients, 34 (92%) had successful treatment and 3 (8%) had failed treatment. The 3 patients with failed treatment were treated with urethrostomy and are awaiting further reconstruction. Study limitations include the small sample size and the limited follow-up. CONCLUSION: With a mid-term follow-up time, the dorsolateral graft urethroplasty using penile skin is shown to be a safe, efficient, and versatile technique for the repair of short-mid-long anterior urethral strictures.

The new transperineal-prerectal approach in posterior urethroplasty.

OBJECTIVE: A new posterior urethroplasty is suggested for patients with pelvic fracture urethral distraction defect (PFUDD). METHODS: 12 men, with PFUDD were treated with an anastomotic urethroplasty, using a transperineal-prerectal approach. All patients had a suprapubic tube in place and were impotent after pelvic trauma. The goal of this approach was to facilitate an extensive removal of the scar tissues around the prostatic apex to promote successful bulbo-prostatic anastomosis. RESULTS: No patients had intraoperative, perioperative or postoperative complications. Urinary incontinence or rectourethral fistula was never observed. In 11 patients the postoperative mean peak flow was 20 ml/sec. The recurrence of the stricture occurred in 1 patient. CONCLUSIONS: The transperineal-prerectal approach to the posterior urethra facilitated a free tension posterior end-to-end anastomosis, as an alternative to the transpubic anastomotic procedure.

Two-sided dorsal plus ventral oral graft bulbar urethroplasty: long-term results and predictive factors.

OBJECTIVE: To evaluate long-term outcomes of the 2-sided dorsal plus ventral oral graft (DVOG) urethroplasty by preserving the narrow urethral plate in tight bulbar strictures and investigate which factors might influence long-term outcomes. METHODS: This is a single-center retrospective study of 166 patients who underwent DVOG urethroplasty for tight bulbar strictures by a single surgeon (E.P.) between 2002 and 2013. The strictured urethra was opened ventrally; the exposed urethral plate was incised in the midline and augmented dorsally and ventrally using 2 oral grafts. Outcome was considered a failure when any postoperative instrumentation was needed. According to stricture length, patients were classified in 3 groups as follows: ≤1.5 cm (group 1), >1.5 and ≤3.9 cm (group 2), and ≥4 cm (group 3). Time to failure was analyzed using Kaplan-Meier estimates and Cox regression. RESULTS: Median follow-up was 47 months (interquartile range, 33-95.5 months). Of the 166 patients, 149 (89.8%) were successful and 17 (10.2%) were failures. Most of the failures (90%) were observed during the first 5 years of follow-up; afterward, the success rate remained stable. The stricture length was a significant predictor of surgical outcome (odds ratio, 1.743 per cm; confidence interval, 1.2-2.5; P <.001); patients with a urethral stricture ≥4 cm presented a higher risk of late failure. Age, stricture etiology, and previous treatment were not significant predictors of surgical outcome. CONCLUSION: With long-term follow-up, the treatment of tight bulbar strictures using a 2-sided DVOG urethroplasty showed a high success rate. The stricture length is an independent predictor of failure.

Anastomotic Repair versus Free Graft Urethroplasty for Bulbar Strictures: A Focus on the Impact on Sexual Function.

Objectives. To evaluate alterations in sexual function and genital sensitivity after anastomotic repair (AR) and free graft urethroplasty (FGU) for bulbar urethral strictures. Methods. Patients treated with AR (n = 31) or FGU (n = 16) were prospectively evaluated before, 6 weeks and 6 months after urethroplasty. Evaluation included International Prostate Symptom Score (IPSS), 5-Item International Index of Erectile Function (IIEF-5), Ejaculation/Orgasm Score (EOS), and 3 questions on genital sensitivity. Results. At 6 weeks, there was a significant decline of IIEF-5 for AR (-4.8; p = 0.005), whereas there was no significant change for FGU (+0.9; p = 0.115). After 6 months, differences with baseline were not significant overall and among subgroups. At 6 weeks, there was a significant decline in EOS for AR (-1.4; p = 0.022). In the FGU group there was no significant change (+0.6; p = 0.12). Overall and among subgroups, EOS normalized at 6 months. After 6 weeks and 6 months, respectively, 62.2 and 52% of patients reported alterations in penile sensitivity with no significant differences among subgroups. Conclusions. AR is associated with a transient decline in erectile and ejaculatory function. This was not observed with FGU. Bulbar AR and FGU are likely to alter genital sensitivity.

Tachykinin NK1 and NK2 receptors mediate inhibitory vs excitatory motor responses in human isolated corpus cavernosum and spongiosum.

Motor effects produced by tachykinins were studied in human isolated corpus spongiosum and cavernosum. In quiescent preparations neurokinin A caused potent contractions (pD(2)=8.3 - 7.9 respectively) prevented by the NK(2) receptor-selective antagonist nepadutant, whereas [Sar(9)]SP sulfone and senktide (NK(1) and NK(3) receptor-selective agonists) produced no effect or spare contractions. In KCl-precontracted corpus spongiosum septide (pD(2)=7.1) and [Sar(9)]SP sulfone (pD(2)=7.7) produced tetrodotoxin-resistant relaxations, abolished by the tachykinin NK(1) receptor-selective antagonist SR 140333. [Sar(9)]SP sulfone (1 microM) produced similar relaxations in precontracted corpus cavernosum. Electrical field stimulation (EFS) elicited tetrodotoxin-sensitive relaxations, which were additive to those produced by [Sar(9)]SP sulfone. N(omega)-nitro-L-arginine (L-NOARG) totally prevented both [Sar(9)]SP sulfone- and EFS-induced relaxations. These results show that tachykinin NK(1) and NK(2) receptors mediate opposite motor effects in human penile tissues, suggesting a possible modulatory role of tachykinins on smooth muscle tone in these organs.

Dorsal onlay techniques for urethroplasty.

Dorsal onlay graft urethroplasty is a versatile procedure which may be combined with various substitute materials such as preputial skin, buccal mucosa grafts or pedicled flaps. Others substitute materials such as human urethral mucosa from corpses or collagen matrix will be possible in future. The long-term results of a wide series of patients showed a final success rate from 92% to 97%. Any kind of substitution urethroplasty deteriorate over time, and in our series of patients with an extended follow-up from 21.5 to 43 months the success rate of dorsal onlay graft urethroplasty decreased from 92% to 85%. With regard to substitute material concerns (buccal mucosa versus preputial skin) a long-term follow-up is mandatory to establish if buccal mucosa is superior to foreskin as urethral substitute material. At present, the authors currently use both according to patient preference, status of the genital tissues or strictures characteristics.