The impact of surgical volume on perioperative safety after urethroplasty: a population-based study.

BACKGROUND: The aim of the study was to assess whether the risk of perioperative complications after urethroplasty was affected by hospital annual surgical volume (ASV). METHODS: In the Nationwide Inpatient Sample, we searched for patients who underwent urethroplasty between 2001 and 2015. Hospitals were categorized into empirically determined tertiles, according to ASV of performed urethroplasties and divided into low (<3) (LVC), intermediate (3-19) (IVC) and high (>20) volume centers (HVC). Multivariable logistic regression (MLR) analyses examined the effect of ASV on perioperative complications and on four specific sub-types of post-operative complications. RESULTS: A weighted estimate of 39 912 patients underwent urethroplasty in the US. 34.9% were operated in HVC, while the rate of performed urethroplasties increased in LVC and decreased in HVC. Overall, 1.1%, 18.8% and 2.1% patients respectively experienced intraoperative, post-operative, and transfusions complications. At MLR, IVC and LVC were associated with higher risk of both intraoperative (IVC: OR 2.65, P=0.0008; LVC: OR 4.98, P<0.0001), post-operative (IVC: OR 1.14, P=0.01; LVC: OR 1.26, P=0.001) and transfusions complications (IVC: OR 1.85, P<0.001; LVC: OR 3.03, P=0.01). LVC was also associated with higher risk of hematuria (OR 3.77), urinary infections (OR 1.60) and sepsis (OR 2.83) complications. CONCLUSIONS: Approximately 65% of patients were operated in IVC and LVC, and patients treated in IVC or LVC had higher risk of developing both intra and post-operative complications. These data provide important indicators for policy makers to categorize institution based on urethroplasty outcomes.

Optimizing decision-making after ventral onlay buccal mucosa graft urethroplasty failure.

OBJECTIVES: To evaluate factors predicting recurrence after treatment and to assess the best rescue option for patients failing buccal mucosa graft (BMG) urethroplasty. MATERIALS AND METHODS: We evaluated the data from 575 patients treated with ventral onlay BMG urethroplasty. Multivariable Cox regression analysis was performed to identify predictors of BMG urethroplasty failure, and their effect on failure risk was estimated using the Kaplan-Meier method and compared using log-rank tests. Then, for those patients who underwent a rescue treatment, namely, direct visual internal urethrotomy (DVIU) vs open urethroplasty, we assessed the probability of success after retreatment using the Kaplan-Meier method and regression tree analyses. RESULTS: On multivariable Cox regression analysis, only stricture length ≥5 cm (hazard ratio 3.46, 95% confidence interval 1.50-7.94; P = 0.003) was a predictor of failure. A total of 103 patients had at least one re-intervention. Notably, 12-month success rates after first rescue DVIU, second rescue DVIU, third rescue DVIU, and fourth rescue DVIU were 66.3%, 62.5%, 37.5% and 25%, respectively. Conversely, for those patients who underwent open urethroplasty retreatment, success rates at 12 months were 83.3%, 79%, 92.3% and 75% after BMG ventral onlay, first rescue DVIU, second rescue DVIU and third rescue DVIU, respectively. These data were confirmed in regression tree analyses. CONCLUSION: Ventral BMG urethroplasty fails in approximately one out of five patients. Despite DVIU as a rescue treatment being a good option, its success rate becomes lower as the number of DVIU treatments performed increases. Conversely, open urethroplasty improves patient outcomes in almost three out of four patients, even in the case of previous failed DVIU treatments for stricture recurrence.

Graft Plus Fasciocutaneous Penile Flap for Nearly or Completely Obliterated Long Bulbar and Penobulbar Strictures.

BACKGROUND: Graft plus flap urethroplasty is gaining momentum in patients with nearly or completely obliterated urethral strictures, in whom staged procedures or perineal urethrostomy is the only possible alternative. However, graft plus flap urethroplasty is mainly adopted for strictures involving the penile urethra. OBJECTIVE: To report our experience on graft plus flap urethroplasty for bulbar and penobulbar reconstruction. DESIGN SETTING AND PARTICIPANTS: Between January 2014 and June 2020, patients with nearly or completely obliterated long (>4 cm) bulbar or penobulbar strictures, who required graft plus flap urethroplasty, were considered for this study. SURGICAL PROCEDURE: The bulbar and the penile urethra were accessed through a perineal incision and penile invagination when required. Grafts were harvested from cheek, lingual, or preputial skin and quilted over the corpora to reconstruct the dorsal plate of the neourethra. The fasciocutaneous penile flap recreated the ventral plate of the neourethra. The corpus spongiosum was flapped over the neourethra to prevent the formation of diverticula. MEASUREMENTS: Any need for instrumentation after surgery was defined as the primary failure. Obstructive symptoms or maximum flow rate (Qmax) below 10 ml/s, with or without a need for instrumentation, was defined as a secondary failure. RESULTS AND LIMITATIONS: We identified 15 patients who met the inclusion criteria. The median stricture length was 7 cm (interquartile range [IQR] 5-8 cm). The inner cheek was the preferred site for graft harvesting (53.3%). No perioperative complication of Clavien-Dindo grade ≥III were recorded in the first 30 postoperative days. The median Qmax at catheter removal was 23 ml/min (IQR 21.5-26 ml/min). The median follow-up was 25 mo (IQR 10-30 mo). The primary success rate was 86.7% (13/15) and the secondary success rate was 73.3% (11/15). Post-traumatic strictures represent a contraindication for this technique. CONCLUSIONS: In referral centers, graft plus flap urethroplasty represents a feasible option for patients with nearly or completely obliterated long (>4 cm) strictures. Our study demonstrated that this option is also feasible for strictures involving mainly the bulbar urethra. PATIENT SUMMARY: Perineal urethrostomy should be considered as the last option in patients with a nearly or completely obliterated bulbar urethral stricture. Nowadays, graft plus fasciocutaneous penile flap augmentation enriched our armamentarium of bulbar urethra reconstruction.

Assessing in-hospital morbidity after urethroplasty using the European Association of Urology Quality Criteria for standardized reporting.

PURPOSE: To conduct a rigorous assessment of in-hospital morbidity after urethroplasty according with the European Association of Urology (EAU) guidelines for complication reporting. METHODS: We retrospectively (2015-2019) identified 469 consecutive patients receiving urethroplasty (e.g. bulbar urethroplasty with grafts, penile urethroplasty with/without grafts/flaps, Johanson, de novo or revision perineostomy, end-to-end anastomosis, meatoplasty and/or meatotomy) at our tertiary care institution. Complications were graded with Clavien-Dindo score and Comprehensive Complication Index (CCI). Complications were classified in: bleeding no gastrointestinal, cardiac, gastrointestinal, genitourinary, infectious, neurological, oral, wound, miscellaneous, and pulmonary. Logistic regression tested for predictors of in-hospital complications and prolonged hospitalization (> 75th percentile). Kaplan-Meier and Cox regression investigated the effect of complications on failure after urethroplasty. RESULTS: Overall, 161 (34.3%) patients experienced at least one complication. Of those, 47 (10%) experienced two or more complications and 59 (12.6%) experienced at least one Clavien-Dindo ≥ II complication. Only two patients had Clavien-Dindo III complications. Infectious was the most frequent complication, and de novo or revision perineostomy was associated with the highest rate of complications. The occurrence of any complications, as well as complication with Clavien-Dindo ≥ II were associated with prolonged hospitalizations, but not with higher rates of post-urethroplasty failure. CONCLUSIONS: Complications after urethroplasty were common events, but rarely with severe sequelae. Infectious were the most common complications and perineostomy was the type of urethroplasty with the highest rate of complications. The application of the EAU recommendations allowed the identifications of a higher number of complications after urethroplasty if compared with previous reports based on unsupervised chart review.

Patient-reported outcomes for typical single cheek harvesting vs atypical lingual, labial or bilateral cheeks harvesting: a single-center analysis of more than 800 patients.

PURPOSE: The optimal harvesting site for oral grafting in patients with urethral strictures remain controversial, with no study investigating morbidity on large scale. We aimed to compare typical single cheek harvesting vs atypical lingual, labial or bilateral cheeks harvesting in terms of complications and patient-reported outcomes. METHODS: Within 827 patients treated at our referral center with oral graft urethroplasty, we compared typical vs atypical harvesting techniques. A self-administered, semiquantitative, non-validated questionnaire assessed early (10 days) and late (4 months) postoperative complications and patient-reported outcomes. A semiquantitative score was calculated according to patient responses, and it was used to assess early (6 questions) and late (13 questions) patient dissatisfaction status. Patients were defined early and/or late dissatisfied when they scored ≥ 7 and ≥ 10 at the early or late questionnaires, respectively. RESULTS: Between 1998 and 2019, our patients predominantly received typical single cheek harvesting (89% vs 11%), with + 1.5% increase rate per year (p < 0.001). Early and late dissatisfied patients were, respectively, 170 (23%) vs 39 (44%) and 59 (8%) vs 16 (18%) in the typical vs atypical groups. Atypical harvesting was associated with higher rates of early (Odds ratio [OR]: 2.34; 95% Confidence interval [CI] 1.44-3.75; p = 0.001) and late (OR: 2.37; 95%CI 1.22-4.42; p = 0.008) postoperative dissatisfaction. CONCLUSIONS: Typical single cheek harvesting was the preferred surgical option at our center and it was associated with negligible early and late rates of complications and patient's dissatisfaction. Conversely, atypical lingual, labial or bilateral cheeks harvesting was associated with higher complications and frequent patient dissatisfaction.

Risk calculator for prediction of treatment-related urethroplasty failure in patients with penile urethral strictures.

PURPOSE: To design a dedicated risk calculator for patients with penile urethra stricture who are scheduled to urethroplasty that might be used to counsel patients according to their pre-operative risk of failure. METHODS: Patients treated with penile urethroplasty at our center (1994-2018) were included in the study. Patients received 1-stage or staged penile urethroplasty. Patients with failed hypospadias repair, lichen sclerosus or incomplete clinical records were excluded. Treatment failure was defined as any required postoperative instrumentation, including dilation. Univariable Cox regression identified predictors of post-operative treatment failure and Kaplan-Meier analysis plotted the failure-free survival rates according to such predictors. Multivariable Cox regression-based risk calculator was generated to predict the risk of treatment failure at 10 years after surgery. RESULTS: 261 patients met the inclusion criteria. Median follow-up was 113 months. Out of 216 patients, 201 (77%) were classified as success and 60 (23%) failures. Former smoker (hazard ratio [HR] 2.12, p = 0.025), instrumentation-derived stricture (HR 2.55, p = 0.006), and use of grafts (HR 1.83, p = 0.037) were predictors of treatment failure. Model-derived probabilities showed that the 10-year risk of treatment failure varied from 5.8 to 41.1% according to patient's characteristics. CONCLUSIONS: Long-term prognosis in patients who underwent penile urethroplasty is uncertain. To date, our risk-calculator represents the first tool that might help physicians to predict the risk of treatment failure at 10 years. According to our model, such risk is largely influenced by the etiology of the stricture, the use of graft, and patient's smoking habits.

Surgical treatment of bulbar urethral strictures: tips and tricks.

The surgical treatment of bulbar urethral strictures is still one of the most challenging reconstructive surgery problems. Bulbar urethral strictures are usually categorized as traumatic and non-traumatic strictures depending on the aetiology. The traumatic strictures are caused by trauma and they determine disruption of the urethra with obliteration of the urethral lumen, ending with fibrotic gaps between the urethral ends. Differently, the non-traumatic urethral strictures are mainly caused by catheterization, instrumentation, and infection, or they can also be idiopathic. They are usually asso-ciated with spongiofibrosis of the segment of the urethra that has been involved. Worldwide, two different surgical approaches are currently adopted for bulbar urethral repair: transecting techniques with end-to-end anastomosis and non-transecting techniques followed by grafting. Traumatic obliterated strictures require transection of the urethra allowing complete removal of the fibrotic tissue that involves the urethral ends. Conversely, non-traumatic, non-obliterated urethral strictures require augmentation of the urethral plate using oral mucosa grafts. Nowadays, it is still difficult to choose the correct surgical management for non-obliterated bulbar stricture repair. Indeed, different surgical techniques have been proposed (pedicled flap vs free graft, dorsal vs ventral placement of the graft, non-transecting technique using or non-using free graft, etc.) but none emerged as the best solution since all techniques have showed similar success and complication rates. Consequently, the final choice is still based on surgeon's preferences and patient's characteristics. Within the current manuscript, we like to present some of our tips and tricks that we developed along our prolonged surgical experience on the treatment of bulbar urethral strictures. These might be of interest for surgeons that approach this complex surgery. Moreover, our suggestions want to be useful regardless the type of chosen technique being adaptable for different scenario.

Urothelial or oral mucosa cells for tissue-engineered urethroplasty: A critical revision of the clinical outcome.

OBJECTIVE: To report the clinical outcome of urethral reconstruction by cultured urothelial or oral mucosa cells for tissue-engineered urethroplasty. METHODS: We systematically searched for studies reporting the use of tissue-engineered techniques for hypospadias and urethral stricture repair in humans in PubMed and Embase (OvidSP) through January, 1990 to June, 2018. We excluded studies based on titles that clearly were not related to the subject, studies in which tissue-engineered biomaterial were used only in laboratory or experimental animals, and in the absence of autologous cultured epithelial cells. Studies were also excluded if they were not published in English, had no disease background and adequate follow-up. Finally, we search all relevant abstract presented at two of the main urological meetings in the last 10 years: European Association of Urology (EAU) and American Urological Association (AUA). RESULTS: A total of six articles, reporting the clinical use of tissue-engineered techniques in humans, were fully reviewed in our review. The epithelial cells were harvested from the urethra (10 patients), the bladder (11 patients) and the mouth (104 patients). The tissue-engineered grafts were used in children for primary hypospadias repair in 16 cases, and in adults for posterior and anterior urethral strictures repair in 109 cases. Tissue-engineered grafts were showed working better in children for primary hypospadias repair than in adults for urethral strictures repair. CONCLUSION: One hundred and twenty-five patients received tissue-engineered urethroplasty using cultured epithelial cells for primary hypospadias or urethral strictures repair. The studies demonstrate a high degree of heterogeneity respect to epithelial cells (from urethra, bladder, and mouth), type of scaffold, etiology, site of urethral stricture, number of patients, follow-up and outcomes.

Focus on Internal Urethrotomy as Primary Treatment for Untreated Bulbar Urethral Strictures: Results from a Multivariable Analysis.

BACKGROUND: The use of internal urethrotomy for treatment of urethral stricture remains a controversial topic in urology. OBJECTIVE: To investigate outcomes and predictors of failure for internal urethrotomy as primary treatment for untreated bulbar urethral strictures. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective analysis of patients who underwent internal urethrotomy. Patients with bulbar urethral stricture who did not receive any previous treatment were included. Patients with traumatic, penile or posterior urethral strictures, lichen sclerosus, failed hypospadias repair, or stricture length >4cm were excluded. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was treatment failure. Kaplan-Meyer plots were used to depict treatment failure-free survival. Univariate and multivariable Cox regression analyses were used to test the association between predictors (age, body mass index, diabetes, history of smoking, etiology, stenosis type and length, preoperative maximum flow [pQmax]) and treatment failure. RESULTS AND LIMITATIONS: Overall, 136 patients were included. The median stricture length was 2cm. Median follow-up was 55 mo. At 5-yr follow-up the failure-free survival rate was 57%. On univariate analysis, diabetes, nonidiopathic etiology, stricture length of 3-4cm, and pQmax were significantly associated with treatment failure. These predictors were included in a multivariable analysis, in which pQmax was the only significant predictor of treatment failure. CONCLUSIONS: Failure of internal urethrotomy for untreated bulbar urethral strictures greatly depends on pQmax flow at uroflowmetry. Patients with pQmax >8ml/s have a high probability of success, while patients with pQmax <5ml/s have a low probability of success. PATIENT SUMMARY: The use of internal urethrotomy in patients with an untreated bulbar urethral stricture should only be considered in selected cases.

Development and content validation of the Urethroplasty Training and Assessment Tool (UTAT) for dorsal onlay buccal mucosa graft urethroplasty.

OBJECTIVES: To develop and validate the Urethroplasty Training and Assessment Tool (UTAT) using Healthcare Failure Mode and Effect Analysis (HFMEA) for training and assessment of urology trainees learning this urethral reconstruction technique, as urethroplasty is the 'gold standard' treatment for long and recurrent urethral strictures and with a variety of techniques and a lack of standardised reconstructive curricula, there is a need for procedure-specific training tools to improve surgeon training and patient safety. MATERIALS AND METHODS: This international observational study was performed over an 11-month period. The HFMEA was used to identify and evaluate hazardous stages of urethroplasty to develop the UTAT. Hazard scores were calculated for the included steps of urethroplasty. Content validation was performed by 12 expert surgeons and multidisciplinary teams from international tertiary centres. RESULTS: The HFMEA process resulted in an internationally validated UTAT. Hazard scores ≥4 and single point weaknesses were included to implement actions and outcome measures. Content validation was achieved by circulating the process map, hazard analysis table, and developed tools. Changes were implemented based on the feedback received from expert surgeons. The content validated dorsal onlay buccal mucosa graft bulbar UTAT contained five phases, 10 processes and 23 sub-processes. CONCLUSIONS: The modular UTAT offers a comprehensive validated training tool developed via a detailed HFMEA protocol. This may be utilised to standardise the training and assessment of urology trainees.

Surgical treatment of bulbar urethral strictures: tips and tricks

ABSTRACT The surgical treatment of bulbar urethral strictures is still one of the most challenging reconstructive-surgery problems. Bulbar urethral strictures are usually categorized as traumatic and non-traumatic strictures depending on the aetiology. The traumatic strictures are caused by trauma and they determine disruption of the urethra with obliteration of the urethral lumen, ending with fibrotic gaps between the urethral ends. Differently, the non-traumatic urethral strictures are mainly caused by catheterization, instrumentation, and infection, or they can also be idiopathic. They are usually associated with spongiofibrosis of the segment of the urethra that has been involved. Worldwide, two different surgical approaches are currently adopted for bulbar urethral repair: transecting techniques with end-to-end anastomosis and non-transecting techniques followed by grafting. Traumatic obliterated strictures require transection of the urethra allowing complete removal of the fibrotic tissue that involves the urethral ends. Conversely, non-traumatic, non-obliterated urethral strictures require augmentation of the urethral plate using oral mucosa grafts. Nowadays, it is still difficult to choose the correct surgical management for non-obliterated bulbar stricture repair. Indeed, different surgical techniques have been proposed (pedicled flap vs free graft, dorsal vs ventral placement of the graft, non-transecting technique using or non-using free graft, etc.) but none emerged as the best solution since all techniques have showed similar success and complication rates. Consequently, the final choice is still based on surgeon's preferences and patient's characteristics. Within the current manuscript, we like to present some of our tips and tricks that we developed along our prolonged surgical experience on the treatment of bulbar urethral strictures. These might be of interest for surgeons that approach this complex surgery. Moreover, our suggestions want to be useful regardless the type of chosen technique being adaptable for different scenario.

Penile urethroplasty using Orandi's dorsal skin flap: a new technique.

OBJECTIVES: To describe, step by step, a new one-stage dorsal skin flap urethroplasty for penile stricture repair. MATERIALS AND METHODS: The surgery was accomplished through a midline incision on the ventral penile surface, the urethra was fully dissected from the corpora cavernosa and longitudinally opened along its dorsal surface. A penile skin island, based on the dartos fascia flap, was dissected and moved over the corpora cavernosa, and the urethra was moved and sutured over the penile skin flap. RESULTS: Out of the 12 cases, 10 were classified successful and there were two failures. The operating time was 60 min. There was no postoperative fistula or urethral diverticulum. CONCLUSION: Our modified Orandi's technique was easy and feasible, and avoided fistula and diverticulum formation after repair.

Repair of sphincter urethral strictures preserving urinary continence: surgical technique and outcomes.

INTRODUCTION: Repair of post-TURP sphincter urethral strictures represents challenging problem, due to the risk of urinary incontinence after the repair. We described a surgical technique we use to repair these strictures preserving urinary continence in patients with incompetent bladder neck. MATERIALS AND METHODS: An observational, retrospective, study was conducted to include patients with post-TURP urethral strictures in the area of distal sphincter. We included only patients with complete clinical data and follow-up who previously underwent TURP or HOLEP or TUIP, and subsequently developed proximal bulbar urethral strictures close to the membranous urethra and the related distal urethral sphincter. Patients were included, if they were fully continent after TURP or other procedures to treat BPH. The primary outcome of the study was treatment failure, defined as the need for any post-operative instrumentation. Secondary outcome was post-urethroplasty urinary continence. Patients showing stricture recurrence or post-operative incontinence were classified as failure. RESULTS: Overall, 69 patients were included in the study. Median patient's age was 67 years; median stricture length was 4 cm. Thirty-tree patients (47.8%) underwent previous urethrotomy. Median follow-up was 52 months. Out of 69 patients, 55 (79.7%) were classified as success and 14 (20.3%) as failure. Out of the whole cohort, thus, 11/69 (16%) have a risk of recurrent strictures and 3/69 (4.3%) have incontinence. CONCLUSIONS: The use of modified ventral onlay graft urethroplasty, using particular non-aggressive steps, is a suitable surgical technique for repair of sphincter urethral stricture in patients who underwent BPH transurethral surgery, using different procedures (TURP, HOLEP, TUIP).

Treatments of 1242 bulbar urethral strictures: multivariable statistical analysis of results.

PURPOSE: We investigated the success rate of different surgical techniques for bulbar stricture repair. METHODS: Retrospective study of patients with bulbar urethral strictures treated using different techniques. The primary outcome of the study was to evaluate the overall results of treatment (success vs. failure); the secondary outcome was to evaluate the outcome according to any surgical technique. Cysto-urethrography was performed 1 month following surgery. Patients underwent clinical evaluation, uroflowmetry and residual urine measurement every 6 months for 2 years after surgery and later once on year. When patient showed obstructive symptoms, Qmax < 12 ml/s, the urethrography was repeated. Patients who underwent further treatment for recurrent stricture were classified as failures. A bivariable and multivariable statistical analysis was performed. RESULTS: Overall, 1242 patients were included in the study with mean age 40 years (range 12-84). Median stricture length was 4 cm (range 1-8). The median follow-up was 103 months (range 12-362). Over 1242 patients, 916 (73.8%) were success and 326 (26.2%) failures. Fourteen different surgical techniques showed a success rate ranging from 87.5 to 14.3%. The multivariable analysis showed that stricture length was an independent predictor factors for failure: p < 0.0001 CI 1146-1509. End-end anastomosis and oral mucosa graft urethroplasty are independent predictor factor of success after internal urethrotomy failure. CONCLUSIONS: Our results showed that treatment of bulbar urethral stricture is satisfactory on 73.8% of patients, but with a wide range of success rate (from 14.3 to 87.5%) using different techniques. Oral mucosa is greatly superior to the skin as substitute material.

Risk factors for urethral stricture and/or bladder neck contracture after monopolar transurethral resection of the prostate for benign prostatic hyperplasia.

OBJECTIVE:: To identify risk factors for urethral stricture and/or bladder neck contracture after transurethral resection of benign prostatic hyperplasia. MATERIALS AND METHODS:: We performed a retrospective analysis of 402 patients, which underwent a monopolar transurethral resection of the prostate in the urology clinic of Sechenov First Moscow State Medical University for prostatic hyperplasia during the period 2011-2014. Urethral stricture and (or) bladder neck contracture in the postoperative period were diagnosed in 61 (15.27%) patients; 34 patients (8.6%) had urethral stricture, 20 (4.97%) bladder neck contracture, and 7 (1.7%) had a combination of urethral stricture and bladder neck contracture. In 341 of cases (84.73%), no late postoperative complications were observed. A total of 106 of the 341 patients met the inclusion criteria, hence, containing all the information necessary for analysis such as the volume of the prostate, the duration of the surgery, the size of the endoscope, data on concomitant diseases, analysis prostatic secretion, and so on. Thus, two groups were formed. Group 1 (106 patients) is the control group in which urethral strictures and/or bladder neck contractures did not occur in the long-term postoperative period and group 2 (61 patients), in which was observed the formation of these complications. To calculate the statistical significance of the differences for categorical data, Fisher criterion was used. For quantitative variables, in the case of normal data distribution, an unpaired t-test or one-way analysis of variance was used; for data having a distribution different from normal, a Mann-Whitney rank test was used. RESULTS:: Regression analysis established the significance of the influence of four factors on the development of scar-sclerotic changes of urethra and bladder neck: the tool diameter 27 Fr ( p < 0.0001), presence of prostatitis in past medical history ( p < 0.0001), prostate volume ( p = 0.003), and redraining of the bladder ( p = 0.0162). CONCLUSION:: The relationship between the diameter of the instrument, presence of chronic prostatitis in anamnesis, increased volume of the prostate, and repeated drainage of the bladder using the urethral catheter with the risk of developing scar-sclerotic changes in the urethra and/or bladder neck are statistically reliable and confirmed as a result of regression analysis.

Anterior Urethroplasty Using a New Tissue Engineered Oral Mucosa Graft: Surgical Techniques and Outcomes.

PURPOSE: We investigated whether tissue engineered material may be adopted using standard techniques for anterior urethroplasty. MATERIALS AND METHODS: We performed a retrospective multicenter study in patients with recurrent strictures, excluding those with failed hypospadias, lichen sclerosus, traumatic and posterior strictures. A 0.5 cm2 oral mucosa biopsy was taken from the patient cheek and sent to the laboratory to manufacture the graft. After 3 weeks the tissue engineered oral mucosal MukoCell® graft was sent to the hospital for urethroplasty. Four techniques were used, including ventral onlay, dorsal onlay, dorsal inlay and a combined technique. Cystourethrography was performed 1 month postoperatively. Patients underwent clinical evaluation, uroflowmetry and post-void residual urine measurement every 6 months. When the patient showed obstructive symptoms, defined as maximum urine flow less than 12 ml per second, the urethrography was repeated. Patients who underwent further treatment for recurrent stricture were classified as having treatment failure. RESULTS: Of the 38 patients with a median age of 57 years who were included in study the strictures were penile in 3 (7.9%), bulbar in 29 (76.3%) and penobulbar in 6 (15.8%). Median stricture length was 5 cm and median followup was 55 months. Treatment succeeded in 32 of the 38 patients (84.2%) and failed in 15.8%. Success was achieved in 85.7% of ventral onlay, 83.3% of dorsal onlay, 80% of dorsal inlay and 100% of combined technique cases. No local or systemic adverse reactions due to the engineered material were noted. CONCLUSIONS: Our findings show that a tissue engineered oral mucosa graft can be implanted using the same techniques suggested for anterior urethroplasty and native oral mucosa, and guaranteeing a similar success rate.

Three-Dimensional Computerized Model Based on the Sonourethrogram: A Novel Technique to Evaluate Anterior Urethral Stricture.

PURPOSE: The sonourethrogram is a useful alternative to the traditional retrograde urethrogram to evaluate anterior urethral strictures. With the development of 3-dimensional reconstructive techniques 3-dimensional urethral imaging can provide more accurate and useful information to enable the surgeon to make the best surgical decisions. We evaluated the accuracy and efficacy of a 3-dimensional reconstructed digital model of the urethra based on the sonourethrogram to assess anterior urethral disease. MATERIALS AND METHODS: A total of 50 patients with an anterior urethral stricture and 10 healthy volunteers were enrolled in this study from April 2014 to January 2017. All patients and volunteers underwent sonourethrogram and retrograde urethrogram. Three-dimensional urethral models were reconstructed based on the sonourethrogram. Stricture length and location on retrograde urethrogram or sonourethrogram based images were compared with those found at operation. RESULTS: The 3-dimensional digital model revealed the entire anterior urethra, including the navicular fossa, and the penile and bulbar parts. The semitransparent model clearly demonstrated the structure of the corpus spongiosum and inside the urethral lumen. Further information on spongiofibrosis could also be seen in the 3-dimensional digital model. There was no significant difference in stricture length or location in the 3-dimensional model compared with retrograde urethrogram imaging and actual surgical findings. However, the latest technique could only reconstruct the short segment of the anterior urethra due to the probe width limitation. CONCLUSIONS: The 3-dimensional computerized model based on the sonourethrogram is a novel and effective technique of evaluating anterior urethral strictures.