Surgical outcomes and proposal for a treatment algorithm for urethral strictures in transgender men.

OBJECTIVES: To assess our results of surgical treatment for urethral strictures in transgender men, and to provide a surgical treatment algorithm. PATIENTS AND METHODS: A single centre, retrospective cohort study was conducted of transgender men who underwent surgical correction of their urethral stricture(s) between January 2013 and March 2020. The medical charts of 72 transgender men with 147 urethral strictures were reviewed. The primary outcomes were the success and recurrence rates after surgical treatment for urethral strictures. RESULTS: The median (interquartile range [IQR]) follow-up was 61 (25-202) months. At last follow-up, 50/72 (69%) were able to void while standing (after one [60%], two [20%], three [6%], four [8%], five [4%], or seven [2%] procedures), 10/72 (14%) await further treatment, two of the 72 (3%) sat to void despite good urodynamic function, and 10/72 (14%) had a definitive urethrostomy. Of 104 surgical treatments included in separate success rate analysis, 65 (63%) were successful (43/75 [57%] after phalloplasty, 22/29 [76%] after metoidioplasty). The highest success rates in short urethral strictures were seen after a Heineke-Mikulicz procedure (six of seven cases), and in longer or more complicated urethral strictures after two-stage with graft (four of six), two-stage without graft (10/12), pedicled flap (11/15, 73%), and single-stage graft (seven of seven) urethroplasties. Grafts used were buccal mucosa or full-thickness skin grafts. Success rates improved over time, with success rates of 38% and 36% in 2013 and 2014, to 71% and 73% in 2018 and 2019, respectively. We concluded with a surgical treatment algorithm based on previous literature, stricture characteristics, and our surgical outcomes. CONCLUSION: The highest success rates were seen after a Heineke-Mikulicz procedure in short urethral strictures; and after graft, pedicled flap, or two-stage urethroplasties in longer or more complicated urethral strictures. Finally, most of the transgender men were able to void while standing, although in some multiple surgical procedures were necessary to accomplish this.

Single-surgeon experience of excision and primary anastomosis for bulbar urethral stricture: analysis of surgical and patient-reported outcomes.

PURPOSE: To report our experience with excision and primary anastomosis (EPA) for bulbar urethral stricture. METHODS: Patients who underwent EPA for bulbar stricture between 2012 and 2019 were retrospectively analyzed (n = 308). Successful urethroplasty was defined as the absence of the need for additional treatment. For follow-up, uroflowmetry was performed and the patients completed the validated Urethral Stricture Surgery Patient-reported Outcome Measure and Sexual Health Inventory for Men (SHIM) questionnaires before (baseline) and 6 months after EPA. Overall patient satisfaction after urethroplasty was also evaluated. RESULTS: Urethroplasty was successful in 97.1% of patients (n = 299) with a median follow-up of 37 months. A total of 215 patients (69.8%) completed the questionnaires at 6 months postoperatively. The mean maximum flow rate, lower urinary tract symptom (LUTS)-total score, Peeling's picture score, LUTS-specific quality of life, and EuroQol-visual analog scale scores improved significantly from 7.7 ml/s, 11.6, 3.3, 2.4, and 58.0 at baseline to 24.1 ml/s, 2.7, 1.9, 0.4, and 82.1 postoperatively (p < 0.0001 for all comparisons). However, five-point or greater deterioration in the SHIM score was found in 41 patients (19.1%). Regarding patient satisfaction, 98.6% of patients (212/215) were "satisfied" (32.6%) or "very satisfied" (66.0%) with the outcome. A low postoperative LUTS-total score and Peeling's picture score were independent predictors of a "very satisfied" patient (p = 0.001 and p = 0.01, respectively). CONCLUSIONS: EPA had a high success rate and was associated with significant benefits in both subjective and objective outcomes. Contrarily, a high incidence of postoperative erectile dysfunction was observed.

Medical Management of Penile and Urethral Lichen Sclerosus with Topical Clobetasol Improves Long-Term Voiding Symptoms and Quality of Life.

PURPOSE: We evaluated the success of minimally invasive management of lichen sclerosus with topical and intraurethral clobetasol, as defined by improvement in patient reported outcome measures and nonprogression to surgery. MATERIALS AND METHODS: We conducted a review of our prospective ongoing quality improvement study to determine outcomes of our current standard practice for males with penile and urethral biopsy proven lichen sclerosus. Data were collected between 2011 and 2019, and included patient demographic information, medical and surgical histories, and location and extent of lichen sclerosus related pathology. The primary outcomes for this study were voiding function and voiding related quality of life, and were assessed using the AUASS (American Urological Association Symptom Score) and quality of life bother index, respectively. RESULTS: We identified 42 patients with biopsy proven lichen sclerosus related urethral stricture disease. Of these patients 85.7% were treated with intraurethral steroids alone and did not require surgical intervention. Median AUASS significantly improved from 12 to 8, and median quality of life bother index improved from 4 ("mostly dissatisfied") to 2 ("mostly satisfied"). Average stricture length of those with penile urethral disease and bulbar urethral disease was 4.8 cm (SD 3.0) and 16.2 cm (SD 6.5), respectively. Median followup was 8.4 months (IQR 2.6-26.4). CONCLUSIONS: Lichen sclerosus related urethral stricture disease can be effectively managed with intraurethral steroids. This minimally invasive management strategy improves patient reported voiding symptoms and voiding quality of life.

Treatment validation of the Solomon-Greenwell nomogram for female bladder outlet obstruction.

AIM: Bladder outflow in women (bladder outlet obstruction [BOO]) has no well-accepted defining diagnostic criteria. Various nomograms exist based on flow rates, pressure-flow data, and fluoroscopy. We have prospectively evaluated the Solomon-Greenwell bladder outflow obstruction nomogram (SG BOO nomogram) as a measurement of BOO resolution following targeted surgical intervention. METHODS: The routine posttreatment urodynamics of 21 unselected women with an original urodynamic diagnosis of BOO on fluoroscopy and the SG BOO nomogram (BOO boundary defined as Qmax > 2.2 Pdet.Qmax + 5) were reviewed. All women had symptomatic BOO secondary to anterior pelvic organ prolapse (aPOP), urethrovaginal fistula (UVF), previous stress urinary incontinence (SUI) surgery, urethral stricture (US), or urethral diverticulum (U Div). Following treatment, all presenting symptoms resolved and simple urodynamics were performed as part of routine follow-up. RESULTS: The urodynamic findings preoperatively and postoperatively showed statistically significant changes posttreatment in mean flow rate which increased from 9.38 to 14.71 mL/s, mean Pdet.Qmax which decreased from 38 to 18.38 cmH2 O, and mean SG BOO nomogram probability (PBOO) which reduced from PBOO = 0.68 to 0.08. Mean SG BOO nomogram PBOO was significantly reduced posttreatment in all individual categories except UVF where a nonsignificant reduction from PBOO = 0.55 to 0.05 occurred. CONCLUSIONS: All urodynamic parameters significantly improve in women who become asymptomatic following surgical treatment of BOO. This improvement is best demonstrated by the change in probability of BOO according to the Solomon-Greenwell nomogram. These findings underline the validity of the Solomon-Greenwell female BOO nomogram for diagnosing and monitoring BOO in women.

Computational Fluid Dynamic Modeling of Urethral Strictures.

PURPOSE: Computational fluid dynamics have paradigm shifting potential in understanding the physiological flow of fluids in the human body. This translational branch of engineering has already made an important clinical impact on the study of cardiovascular disease. We evaluated the feasibility and applicability of computational fluid dynamics to model urine flow. MATERIALS AND METHODS: We prepared a computational fluid dynamics model using an idealized male genitourinary system. We created 16 hypothetical urethral stricture scenarios as a test bed. Standard parameters of urine such as pressure, temperature and viscosity were applied as well as typical assumptions germane to fluid dynamic modeling. We used ABAQUS/CAE 6.14 (Dassault Systèmes®) with a direct unsymmetrical solver with standard (FC3D8) 3D brick 8Node elements for model generation. RESULTS: The average flow rate in urethral stricture disease as measured by our model was 5.97 ml per second (IQR 2.2-10.9). The model predicted a flow rate of 2.88 ml per second for a single 5Fr stricture in the mid bulbar urethra when assuming all other variables constant. The model demonstrated that increasing stricture diameter and bladder pressure strongly impacted urine flow while stricture location and length, and the sequence of multiple strictures had a weaker impact. CONCLUSIONS: We successfully created a computational fluid dynamics model of an idealized male urethra with varied types of urethral strictures. The resultant flow rates were consistent with the literature. The accuracy of modeling increasing bladder pressure should be improved by future iterations. This technology has vast research and clinical potential.

Insights into the Pathophysiology of Urethral Stricture Disease due to Lichen Sclerosus: Comparison of Pathological Markers in Lichen Sclerosus Induced Strictures vs Nonlichen Sclerosus Induced Strictures.

PURPOSE: We evaluated the pathophysiology of lichen sclerosus and nonlichen sclerosus urethral stricture disease by comparing protein expression related to inflammation, cell cycle disruption, oxidative stress, hormone receptor status and infection. MATERIALS AND METHODS: Tissue samples were collected from the urethral strictures of 81 patients undergoing urethroplasty. Clinical and demographic data were obtained by chart review. After identifying areas pathognomonic for lichen sclerosus a tissue microarray was created with cores from each sample and immunohistochemistry was performed. RESULTS: Patients had similar baseline demographics and comorbidities. Of the 81 strictures 58 were and 23 were not due to lichen sclerosus. Lichen sclerosus strictures were significantly longer and showed higher levels of inflammation. The proportion of T cells which stained positive for CD8 was significantly higher in strictures due to lichen sclerosus (50% vs 13%, p = 0.004). CCL-4 was expressed significantly more in strictures due to lichen sclerosus (76% vs 42%, p = 0.01). Several other inflammatory markers were only found in strictures due to lichen sclerosus. Block-like p16, a surrogate for high risk human papillomavirus infection, and varicella zoster virus were found only in lichen sclerosus urethral stricture disease samples, although both were rare. Epstein-Barr virus RNA was found in significantly more lichen sclerosus samples (37% vs 10%, p = 0.024). CONCLUSIONS: To our knowledge this is the first study to evaluate protein expression in lichen sclerosus urethral stricture disease. These strictures demonstrate increased inflammation compared to nonlichen sclerosus urethral strictures. Markers of oxidative stress, cell cycle dysregulation and the androgen receptor do not appear to be uniquely associated with lichen sclerosus urethral stricture disease. Positive staining for several viruses in samples of lichen sclerosus urethral stricture disease suggests a possible infectious etiology.

Effect of Urethroplasty on Anxiety and Depression.

PURPOSE: To our knowledge anxiety and depression in patients with urethral stricture disease and the impact of urethroplasty on mental health has never been explored. We hypothesized that patients with urethral stricture disease would have higher than normal anxiety and depression levels, and urethroplasty would improve mental health. MATERIALS AND METHODS: We retrospectively reviewed the records of patients in a multi-institutional reconstructive urology database who underwent anterior urethroplasty. Preoperative and postoperative evaluation of anxiety and depression, and overall health was recorded using the validated EQ-5D™-3L Questionnaire. Sexual function was evaluated with the IIEF (International Index of Erectile Function) and the Men's Sexual Health Questionnaire. Stricture recurrence was defined as the need for a subsequent procedure. RESULTS: Median followup in the 298 patients who met study inclusion criteria was 4.2 months. Preoperative anxiety and depression was reported by 86 patients (29%). Those with anxiety and depression reported higher rates of marijuana use, a worse preoperative IIEF score (17.5 vs 19.6, p = 0.01) and a lower image of overall health (66 vs 79, p ≤0.001). Improvement or resolution of anxiety and depression was experienced by 56% of patients treated with urethroplasty while de novo postoperative anxiety and depression were reported by 10%. These men reported a decreased flow rate (16 vs 25 ml per second, p = 0.01). Clinical failure in 8 patients (2.7%) had no effect on the development, improvement or resolution of anxiety and depression. CONCLUSIONS: Of patients with preoperative anxiety and depression 56% reported improvement or resolution after urethroplasty. Although new onset anxiety and depression was rare, these patients had a significantly lower postoperative maximum flow rate, possibly representing a group with a perceived suboptimal surgical outcome. A urethral stricture disease specific questionnaire is needed to further elucidate the interplay of urethral stricture disease with anxiety and depression.

Cycling, and Male Sexual and Urinary Function: Results from a Large, Multinational, Cross-Sectional Study.

PURPOSE: We explored the relation of cycling to urinary and sexual function in a large multinational sample of men. MATERIALS AND METHODS: Cyclists were recruited to complete a survey through Facebook® advertisements and outreach to sporting clubs. Swimmers and runners were recruited as a comparison group. Cyclists were categorized into low and high intensity cyclists. Participants were queried using validated questionnaires, including SHIM (Sexual Health Inventory for Men), I-PSS (International Prostate Symptom Score) and NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index), in addition to questions about urinary tract infections, urethral stricture, genital numbness and saddle sores. RESULTS: Of 5,488 complete survey responses 3,932 (72%) were included in our analysis. On multivariate analysis swimmers/runners had a lower mean SHIM score than low and high intensity cyclists (19.5 vs 19.9 and 20.7, p = 0.02 and <0.001, respectively). No significant differences were found in I-PSS or NIH-CPSI scores, or urinary tract infection history. Cyclists had statistically higher odds of urethral stricture compared to swimmers/runners (OR 2.5, p = 0.042). Standing more than 20% of the time while cycling significantly reduced the odds of genital numbness (OR 0.4, p = 0.006). Adjusting the handlebar higher or even with the saddle had lower odds of genital numbness and saddle sores (OR 0.8, p = 0.005 and 0.6, p <0.001, respectively). CONCLUSIONS: Cyclists had no worse sexual or urinary functions than swimmers or runners but cyclists were more prone to urethral stricture. Increased time standing while cycling and a higher handlebar height were associated with lower odds of genital sores and numbness.

Contemporary outcomes of hypospadias retrieval surgery in adults.

OBJECTIVE: To describe the surgical approach and outcomes in the treatment of adult patients with complications of childhood hypospadias surgery, as such patients present a significant reconstructive challenge due to the combination of anatomical and cosmetic deformity, which often results in major functional and psychosexual sequelae. PATIENTS AND METHODS: We analysed prospectively collected data on 79 adults with complications of childhood hypospadias surgery, who were operated on between 2004 and 2016. Of the 79 patients, 48 underwent a two-stage urethroplasty using a buccal mucosa graft, and 31 underwent a one-stage distal urethroplasty. RESULTS: Patients were followed up using flexible cystoscopy (every 6-9 months). The mean (range) follow-up was 48 (12-96) months. Of the 48 patients who underwent a two-stage repair, eight (16%) needed a revision of the first-stage graft. In total, nine of the 48 patients (16%) developed fistula requiring closure after the second stage; all but one was closed successfully on the first attempt, whilst one required two attempts before closure. Only two of the 48 patients that underwent a two-stage procedure required a re-do urethroplasty within 3 years. Of the 31 patients who underwent a one-stage repair, six (19%) needed fistula closure, all of which were successful. No patient required a further urethroplasty during follow-up. CONCLUSIONS: Despite the significant surgical challenges found in this patient group, excellent long-term functional outcomes can be achieved. As expected there is a need for additional intervention, either for revision of the first stage or to close fistulae and less commonly for further reconstruction for stricture recurrence.

Ejaculatory Disorders in Men With Urethral Stricture and Impact of Urethroplasty on the Ejaculatory Function: A Systematic Review.

BACKGROUND: Urethral stricture may disturb both micturition and semen emission. Urethroplasty, despite the restoration of a proper urethral patency, may not eliminate the accompanying ejaculatory dysfunction (EjD). AIM: To investigate the relationship among urethral stricture, urethroplasty, and ejaculatory function. METHODS: For the systematic review, the authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Internet-based bibliographic databases (PubMed and Scopus) were searched to access studies that examined the influence of urethral stricture and urethroplasty on ejaculatory function. OUTCOMES: EjD accompanying urethral stricture, before and after urethroplasty, was evaluated. RESULTS: 20 Studies were included in the final analysis. In total, these studies comprised a population of 1,913 patients, aged between 11-86 years, 1,823 with an anterior urethral stricture and 90 with a posterior one. No randomized trials regarding the topic were found. Patients with urethral stricture typically report poor force of ejaculation, reduced ejaculatory volume, reduced pleasure, or complete failure to ejaculate. The prevalence of pre-operative disorders depends on patients' age and is more severe in the older population. The pre-operative stricture length, location, and type of surgery have no statistically significant influence on post-operative EjD. In some patients, despite a successful urethral reconstruction, problems with ejaculation persist. The improvement in ejaculation after urethroplasty is observed only in younger men. The available data are inconclusive whether the separation of the bulbospongiosus muscle during urethroplasty impairs its later functionality. CLINICAL IMPLICATIONS: Analyzing the available literature on the subject, this review provides knowledge about the possible influence of urethroplasty on ejaculatory function, which may be useful both in the pre-operative patient consultation and in the choice of treatment method. STRENGTHS & LIMITATIONS: The evidence is sufficient to determine effects on health outcomes. However, the strength of evidence is limited by the lack of randomized trials and differences in terms of methodology and analyzed populations, preclusive of conducting the meta-analysis. CONCLUSION: It has not been unequivocally determined which factors related to the stricture or surgery are decisive for post-operative ejaculatory function. The improvement in ejaculation after urethroplasty is observed only in younger men. Kaluzny A, Gibas A, Matuszewski M. Ejaculatory Disorders in Men With Urethral Stricture and Impact of Urethroplasty on the Ejaculatory Function: A Systematic Review. J Sex Med 2018;15:974-981.

Optimisation of sonourethrography: the clamp method.

PURPOSE: To describe the clamp method for performing retrograde sonourethrography (RSUG) and contrast-enhanced voiding sonourethrography (CE-VSUG) via the transperineal approach in male adults. MATERIALS AND METHODS: Prospective study of 113 males (14-86 years) with urethral strictures confirmed by urethrography who received sonourethrography via the clamp method between 2011 and 2015. The characteristic parameters of the quantitative variables were calculated and a comparative analysis of the qualitative variables was conducted using the McNemar test. RESULTS: RSUG was performed successfully in all the cases (n = 113) and detected 49 cases with anterior urethral strictures; the strictures in the proximal bulbar cone in five of them (10.2%) were not visualised on retrograde urethrography (RUG) (p < 0.05). CE-VSUG was performed successfully in 97 cases and observed posterior urethral strictures in 82; the bladder neck strictures in 6 of them (7.3%) were not observed on voiding cystourethrography (VCUG) (p < 0.05). Retrograde bladder filling was achieved in approximately 6 min. CONCLUSION: The clamp method enables RSUG and CE-VSUG to be performed simply, effectively and painlessly by a single operator. It also allows the evaluation of cases with urethromeatal alterations (stricture, hypospadias and meatotomy). KEY POINTS: • The clamp method enables RSUG to be performed simply and painlessly. • The clamp method requires only one operator and allows assessing urethromeatal alterations. • RSUG shows greater capacity for detecting anterior urethral strictures than RUG. • The clamp method achieves retrograde bladder filling in approximately 6 min. • CE-VSUG shows greater capacity for detecting strictures than VCUG.

Suture causing urethral meatus stricture: A novel animal model of partial bladder outlet obstruction.

AIMS: Open surgery is the most commonly used methodological approach for generating a partial bladder outlet obstruction (pBOO) animal model. Surgical suturing closing a part of the urethral meatus induces comparable pathophysiological changes in bladder and renal functions, but the optimum degree of obstruction that closely mimics the clinical pathology of pBOO has not been elucidated. We investigated the optimum obstruction level by performing a comprehensive time-dependent analysis of the stability and reliability of this novel animal model. METHODS: Six- to eight-week-old female BALB/c mice were divided into three groups according to the degree of urethral meatus stricture (UMS). Non-operated mice served as controls, and a pBOO model generated using the traditional method served as a positive control. A cystometric evaluation and long-term studies were performed to evaluate the validity and reliability of this novel animal model. An additional 35 mice were used to investigate the protein expression levels and histopathological features 24 h and 14 days postoperatively, respectively. RESULTS: The characteristic cystometry features in the UMS group revealed increased changes in pressure-related parameters compared with the control. The 1/3 UMS model is an optional pBOO animal model because the cystometric evaluation and histopathological studies revealed a striking resemblance between the 1/3 UMS model and the model generated using the traditional open-surgery method. CONCLUSIONS: The minimally invasive UMS model required less time and produced minimal alterations in pathophysiologically relevant processes compared with the traditional surgery model. Suturing to cause UMS produced effective and repeatable patterns in bladder function investigations in mice.

Male Urethral Stricture: American Urological Association Guideline.

PURPOSE: The purpose of this Guideline is to provide a clinical framework for the diagnosis and treatment of male urethral stricture. MATERIALS AND METHODS: A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional guidance is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. RESULTS: The Panel identified the most common scenarios seen in clinical practice related to the treatment of urethral strictures. Guideline statements were developed to aid the clinician in optimal evaluation, treatment, and follow-up of patients presenting with urethral strictures. CONCLUSIONS: Successful treatment of male urethral stricture requires selection of the appropriate endoscopic or surgical procedure based on anatomic location, length of stricture, and prior interventions. Routine use of imaging to assess stricture characteristics will be required to apply evidence based recommendations, which must be applied with consideration of patient preferences and personal goals. As scientific knowledge relevant to urethral stricture evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Turkish validation of the urethral stricture surgery specific patient-reported outcome measure (USS-PROM) with supplemental assessment of erectile function and morbidity due to oral graft harvesting.

AIMS: We validated a Turkish language version of the urethral stricture surgery specific patient-reported outcome measure (USS-PROM) in men undergoing anterior urethroplasty. We also investigated changes in erectile function (EF) and quality of life (QoL) due to oral mucosa graft (OMG) harvesting. METHODS: The USS-PROM captures lower urinary tract symptoms (LUTS), health related QoL (HRQoL) with EQ-5D visual analogue scale (EQ-VAS). To evaluate EF and OMG morbidity, we used International Index of Erectile Function (IIEF-5) and a self-completed questionnaire, respectively. Psychometric assessment of USS-PROM included test-retest reliability, internal consistency, criterion validity, and responsiveness. Objective evidence for urethroplasty success was demonstrated with fluoroscopic imaging and urethral calibration at post-operative six months. RESULTS: Among the 101 men included during study period, 42 had complete pre- and postoperative 6th month data for analysis. The test-retest intraclass correlation was 0.79. Cronbach's α for internal consistency of the LUTS construct was 0.79. There was a significant negative correlation between total LUTS scores and peak flow rates, both preoperatively (r = -0.478) and postoperatively (r = -0.508). Mean baseline EQ-VAS increased from 70 to 84 postoperatively (P < 0.001), indicating improved HRQoL. IIEF scores did not change significantly after urethroplasty. Early and late-term QoL impairment rates due to OMG harvesting were 28.9 and 13.1%, respectively. Three (7.1%) men required endoscopic intervention for recurrence within 6 months. CONCLUSIONS: Turkish version of USS-PROM showed comparable psychometric properties with the original version. Complementation of this instrument with additional measures that address sexual function and OMG morbidity provides better QoL assessment for urethral reconstruction.

Urethroplasty and Quality of Life: Psychometric Validation of a Dutch Version of the Urethral Stricture Surgery Patient Reported Outcome Measures.

PURPOSE: The study aimed to translate the Urethral Stricture Surgery Patient Reported Outcome Measures (USS-PROM) questionnaire in Dutch. To validate this translated questionnaire, the study evaluates its psychometric properties in a different population, a different environment, and a different health care system. Questions about urinary incontinence and sexual functioning were added. MATERIALS AND METHODS: Between December 2014 and January 2017, Dutch-speaking adult men scheduled for urethroplasty at Ghent University Hospital were prospectively enrolled in this study. Patients completed the USS-PROM before surgery, 3-6 months after surgery, and 1 year after surgery. Psychometric criteria included content validity, criterion validity, internal consistency, reproducibility, responsiveness, and floor and ceiling effects. (EC/2014/0438). RESULTS: A total of 100 patients were included, 39 patients completed both the preoperative and the postoperative questionnaire, and 30 patients completed the USS-PROM twice within a short period of time in order to evaluate test-retest reliability. Pearson correlation coefficients showed no statistical significant correlation between lower urinary tract symptoms (LUTS) scores and maximum flow rates. Cronbach's α was 0.81 and 0.89, respectively, for the LUTS score and the summative Male Sexual Health Questionnaire Ejaculatory Dysfunction short form (MSHQ-EjD short form) score. The intraclass correlation coefficients ranged from 0.72 to 0.94. Significant changes were observed in all items except the MSHQ-EjD short form scores. All values exceeded the predefined thresholds. CONCLUSIONS: The Dutch version of the USS-PROM has adequate psychometric properties and is a valid instrument to assess patient-reported outcome measures in men undergoing urethroplasty.

Justification For Re-Look Cystoscopy After Posterior Urethral Valve Fulguration.

BACKGROUND: Posterior urethral valve (PUV) is life-threatening congenital anomaly of the urinary tract that results in vesicoureteric reflux, recurrent UTI, voiding dysfunction and renal insufficiency if not treat timely. Endoscopic ablation of posterior urethral valves using cold knife or laser is the current gold standard therapy. Many urologists go for repeat cystoscopy to see residual valve or stricture while others repeat VCUG to measure the posterior to anterior urethral ratio for residual obstruction. In this study, we have standardized by regularly doing re-look cystoscopy at 3 months whether the child is symptomatic or not to see justification for re-look cystoscopy after PUV ablation. METHODS: In this prospective study, first 50 cases that underwent posterior urethral valve fulguration were included. Diagnosis of posterior urethral valve was made by voiding symptoms, ultrasonography and confirmed by voiding cysto-urethrogram (VCUG). All children were treated by endoscopic fulguration of posterior urethral valves (PUV) using cold knife as urethral valvotome and were followed clinically for voiding symptoms and with ultrasonography and laboratory test at 3 and 6 months. All patients underwent re-look cystoscopy at three months to see residual valves irrespective of their clinical improvement. RESULTS: Mean age at presentation was 4.9±3.2 years. The most common symptoms were poor stream (76%), straining at voiding (72%), dribbling of urine (54%), fever (42%) and urinary retention (14%). Residual valves on re-look cystoscopy were seen in 78%. Four (8%) patients had urethral stricture on re-look cystoscopy. CONCLUSIONS: We suggest routine re-look cystoscopy after primary fulguration of PUV to pick more residual obstructive valves.

Dorsal Onlay Urethroplasty for Membranous Urethral Strictures: Urinary and Erectile Functional Outcomes.

PURPOSE: We evaluated urinary and erectile functional outcomes after dorsal onlay urethroplasty for bulbomembranous urethral strictures. Our aim was to understand the functional implications of dissection of the posterior urethra. MATERIALS AND METHODS: We report on men who underwent membranous urethral stricture repair by buccal mucosal graft dorsal onlay substitution urethroplasty. Continence and erectile function were assessed preoperatively and postoperatively. Tissue routinely excised from the intercrural space during dissection of the dorsal aspect of the membranous urethra was evaluated for scar, striated muscle and nerves. RESULTS: A total of 16 consecutive men with a mean age of 48.3 years (range 26 to 72) who had strictures with a mean length of 56 mm (range 15 to 170) involving the membranous urethra were included in analysis. Of the 16 men 15 were continent preoperatively and remained continent postoperatively. Three of 10 men (30%) with a preoperative SHIM (Sexual Health Inventory for Men) score of 17 to 25 had a decrease after urethroplasty. All 16 men had an improved maximum urinary flow rate with a mean improvement of 22 ml per second. I-PSS (International Prostate Symptom Score) improved from a median of 23 to 4 postoperatively with a median bother score improvement of 5 to 0. Histopathological assessment identified striated muscle and nerves in 6 (46%) and 9 (69%) of 13 specimens. Overall nerves and muscle comprised an average of less than 15% of the specimen. CONCLUSIONS: The dorsal onlay technique with a buccal mucosal graft for membranous urethral stricture repair does not compromise continence or erectile function in most patients. Dissection at the level of the membranous urethra should be limited because striated muscle and cavernous nerves are present.

Single-Staged Improved Tubularized Preputial/Penile Skin Flap Urethroplasty for Obliterated Anterior Urethral Stricture: Long-Term Results.

INTRODUCTION: To present an improved tubularized flap (ITF) technique and report the outcome of single-stage urethroplasty using preputial/penile skin flaps (PSFs) for the treatment of obliterative anterior urethral strictures (AUSs). MATERIALS AND METHODS: From January 2000 to June 2012, 42 cases of obliterative AUS (3-14 cm, mean 6.38 cm) with urethral plate unsalvageable were treated using PSF-ITF urethroplasty including longitudinal skin flap, circular island flap, L-flap, Q-flap. Patients were divided into 3 groups: pendulous urethral stricture (Group A), bulbar urethral stricture (Group B) and panurethral strictures (Group C). Patients were followed up by uroflowmetry, urethrography and ureteroscope when necessary. RESULTS: The mean follow-up in these patients was 65 months (range 36 months-15 years). The primary success rates at 3-year follow-up were 75, 75 and 60% for Groups A, B and C, respectively. The overall success rates were 85, 83 and 70% with the remedial measure of a single visual internal urethrotomy at 3-year follow-up. A total 60% of the patients in the study completed more than 5 years of follow-up with no additional recurrence. CONCLUSIONS: Improved tubularized preputial/PSF urethroplasty with relatively high overall satisfaction is a novel technique for treatment of AUS when there is inadequate urethral plate or obliterative defects.

Microsurgical Urethroplasty for Complex Bulbar Urethral Strictures Using the Radial Forearm Free Flap Prelaminated with Buccal Mucosa.

Background Complex bulbar urethral strictures are a heterogeneous group, including those secondary to radiotherapy, failed previous open urethroplasty, and total bulbar necrosis following pelvic trauma. Traditional urethroplasty techniques in this group are unpredictable. We describe a novel technique of a buccal mucosa-prelaminated radial forearm free flap urethroplasty, which seeks to improve the quality of life for this group of patients. Methods Known, reliable techniques from two surgical specialties were combined to create a novel surgical solution, consisting of a radial forearm free flap prelaminated with buccal mucosa. Prospective data were collected on patient and stricture characteristics, complications, and results, including voiding flow rates, urethrography, and cystourethroscopy. Success was defined as the ability to void per urethra. The procedure was performed in four patients, previously considered unreconstructable and who were suprapubic catheter dependent. Results Microsurgical transfer was successful in all four cases. All patients were voiding per urethra and remained catheter free at a minimum of 12-month follow-up. There was no significant donor morbidity and all patients were able to return to their usual occupation. Mean voiding flow rates were 17.3 mL/s. Flexible cystoscopy revealed well-vascularized, patent neomucosa. Conclusions We demonstrate proof of concept for a novel technique of microsurgical urethroplasty. We believe this technique may have widespread application in the treatment of radiation-induced and other complex urethral strictures where traditional urethroplasty has limited success.

[IPSS-QOL questionnaire in assessing symptoms and quality of life in patients with anterior urethral stricture].

RELEVANCE: The IPSS-QOL questionnaire is frequently used to assess symptoms and quality of life of men with urethral strictures. However, the psychometric properties of the questionnaire in assessing these patients have not been evaluated. AIM: To test the psychometric properties of the IPSS-QoL questionnaire in assessing patients with anterior urethral strictures. MATERIAL AND METHODS: Thirty five men with anterior urethral strictures self-completed the IPSS-QoL questionnaire. The reliability of the questionnaire was estimated by computing Cronbachs coefficient and the "point-scale" correlation coefficients. Validity was assessed by the "external criteria" - the correlations between the questionnaire scores and objective indicators - maximum urinary flow rate (Qmax) and residual urine volume (Ures), between QoL scores and index values and EQ-5D scores using a VAS rating scale. RESULTS: The content validity of the IPSS-QoL was assessed by experts and patients: the storage symptoms were found insignificant for patients with anterior urethral stricture, while the symptoms of primary importance (post-micturition dribbling) were not covered. Cronbachs coefficient of reliability was 0.65 (0.55-0.69 with one of the questions removed), i.e. it was below the generally accepted threshold of 0.7. The "point-scale" correlation coefficients ranged from 0.146 to 0.585; for 2 of the 7 questions they were lower, than the conventional threshold of 0.2, showing the internal inconsistencies of the questionnaire. The construct validity assessment showed no correlation between the questionnaire scores and objective indicators Qmax (R=0.178, p=0.306), Ures (R=-0.074, p=0.673). Correlations between QoL scores and index values and EQ-5D scores on the VAS were weak and statistically insignificant: R=-0.26, p=0.18 and R=-0.21, p=0.27, respectively. CONCLUSION: IPSS-QoL questionnaire in assessing men with anterior urethral stricture does not have sufficient reliability and validity. Its design does not allow for adequate assessment of all the symptoms, reliability indices are unsatisfactory, the questionnaire scores do not correlate with objective indicators. This questionnaire cannot be recommended for evaluating health status and quality of life of this category of patients.