Urethroplasty for urethral injuries and trauma-related strictures in children and adolescents: a single-institution experience.

INTRODUCTION: Urethral injuries and trauma-related strictures (UITSs) in children are rare. The treatment is challenging but crucial to avoid life-long urinary complications such as recurrent stricture formation, urinary incontinence, and impotence. OBJECTIVE: The aim was to report on the surgical and functional outcome of urethroplasty for UITSs and to provide data on patient-reported outcome measures (PROMs). MATERIAL AND METHODS: Between November 2001 and October 2017, 18 male children (≤18 years; median: 13 years) underwent urethroplasty for UITSs at a single tertiary referral center. Etiology was iatrogenic in five (27.8%), perineal straddle injury in six (33.3%) and pelvic fracture urethral injury (PFUI) in seven (38.8%) patients. PFUIs and short (≤3 cm) bulbar strictures were treated by transperineal anastomotic repair (n = 15; 83.3%), whereas a long bulbar stricture and a penile stricture were treated by, respectively, a preputial skin graft and flap urethroplasty. A penetrating penile urethral injury during circumcision underwent early exploration with primary repair of the laceration. Failure was defined as need for additional urethral instrumentation. PROMs were sent to patients ≥16 years at the latest evaluation. RESULTS: Median follow-up was 57 (range: 8-198) months. No complications and grade 1, 2, and 3 were present in, respectively, 13 (72.2%), two (11.1%), one (5.6%), and two (11.1%) patients. The success rate in a tertiary referral center was 94.4%. An immediate failure was observed in a patient with a PFUI and concomitant bladder neck injury. PROMs were available in 12 patients. Four patients (33.3%) reported erectile dysfunction. Post-void dribbling (25%) and urgency (50%) were the most frequently reported complaints. All patients were satisfied after urethroplasty and stated that they would undergo the surgery again. DISCUSSION: This series corroborates the recent trend in favor of transperineal anastomotic repair for PFUI, with combined abdominoperineal approach reserved for complex situations (e.g. bladder neck injury). For anterior UITSs, adaption of the technique to the characteristics of UITSs (etiology, location, length, and quality of graft bed) yielded excellent outcomes. Future systematic use of PROMs is also needed in children to elucidate the impact of urethroplasty on the urinary and sexual function. CONCLUSION: External trauma is the most important etiology of UITSs, but iatrogenic causes should not be neglected. Urethroplasty, mainly by anastomotic repair (AR) but with the technique adapted to local stricture characteristics if necessary, has an excellent long-term success rate in experienced hands. Functional disturbances are frequent, but despite this, patient satisfaction is high after urethroplasty.

Excision and Primary Anastomosis for Short Bulbar Strictures: Is It Safe to Change from the Transecting towards the Nontransecting Technique?

OBJECTIVE: To explore whether it is safe to change from transecting excision and primary anastomosis (tEPA) towards nontransecting excision and primary anastomosis (ntEPA) in the treatment of short bulbar urethral strictures and to evaluate whether surgical outcomes are not negatively affected after introduction of ntEPA. MATERIALS AND METHODS: Two-hundred patients with short bulbar strictures were treated by tEPA (n=112) or ntEPA (n=88) between 2001 and 2017 in a single institution. Failure rate and other surgical outcomes (complications, operation time, hospital stay, catheterization time, and extravasation at first cystography) were calculated for both groups. Potentially predictive factors for failure (including ntEPA) were analyzed using Cox regression analysis. RESULTS: Median follow-up for the entire cohort was 76 months, 118 months, and 32 months for, respectively, tEPA and ntEPA (p<0.001). Nineteen (9.5%) patients suffered a failure, 13 (11.6%) with tEPA and 6 (6.8%) with ntEPA (p=0.333). High-grade (grade ≥3) complication rate was low (1%) and not higher with ntEPA. Median operation time, hospital stay, and catheterization time with tEPA and ntEPA were, respectively, 98 and 87 minutes, 3 and 2 days, and 14 and 9 days. None of these outcomes were negatively affected by the use of ntEPA. Diabetes and previous urethroplasty were significant predictors for failure (Hazard ratio resp. 0.165 and 0.355), whereas ntEPA was not. CONCLUSIONS: Introduction of ntEPA did not negatively affect short-term failure rate, high-grade complication rate, operation time, catheterization time, and hospital stay in the treatment of short bulbar strictures. Diabetes and previous urethroplasty are predictive factors for failure.

Buccal Versus Lingual Mucosa Graft in Anterior Urethroplasty: A Prospective Comparison of Surgical Outcome and Donor Site Morbidity.

PURPOSE: We prospectively compared buccal mucosa graft and lingual mucosa graft urethroplasty with respect to donor site morbidity and urethroplasty outcome. MATERIALS AND METHODS: Patients treated with buccal mucosa graft (29) or lingual mucosa graft (29) urethroplasty were included in the study. Oral pain and morbidity were assessed using the numeric rating scale (scale 0 to 10) as well as an in-home questionnaire administered 3 days, 2 weeks and 6 months postoperatively. RESULTS: After a mean (± SD) followup of 30 (± 13) months successful urethroplasty was achieved in 24 (82.8%) and 26 (89.7%) patients treated with buccal mucosa graft and lingual mucosa graft, respectively (p = 0.306). Median numeric rating scale after 3 days, 2 weeks and 6 months was 4, 2 and 0 for buccal mucosa graft and 6, 3 and 0 for lingual mucosa graft, respectively, with no statistical differences between the groups. At day 3 significantly more patients in the lingual mucosa graft group had severe difficulties with eating and drinking (62.1% vs 24.1%, p = 0.004) and speaking (93.1% vs 55.2%, p = 0.001), and had dysgeusia (48.3% vs 13.8%, p = 0.01). Two weeks postoperatively speech impairment was still more frequent with lingual mucosa graft (55.2% vs 13.8%, p = 0.002), whereas oral tightness was more frequent with buccal mucosa graft (41.4% vs 6.9%, p = 0.005). After 6 months 44.8% and 31% of patients treated with buccal mucosa graft and lingual mucosa graft, respectively, still reported sensitivity disorders (p = 0.279). CONCLUSIONS: The success of urethroplasty with lingual and buccal mucosa grafts was similar. Oral pain was not different after both grafts. In the early postoperative period there were differences in oral morbidity between buccal and lingual mucosa grafts. Long-term oral morbidity was not infrequent with both grafts.

Revision of perineal urethrostomy using a meshed split-thickness skin graft.

Perineal urethrostomy is considered to be the last option to restore voiding in complex/recurrent urethral stricture disease. It is also a necessary procedure after penectomy or urethrectomy. Stenosis of the perineal urethrostomy has been reported in up to 30% of cases. There is no consensus on how to treat a stenotic perineal urethrostomy, but, in general, a form of urinary diversion is offered to the patient. We present the case of a young male who underwent perineal urethrostomy after urethrectomy for urethral cancer. The postoperative period was complicated by wound dehiscence with subsequent complete obliteration of the perineal urethrostomy. Revision surgery was performed with reopening of the obliterated urethral stump and coverage of the skin defect between the urethra and the perineal/scrotal skin with a meshed split-thickness skin graft. To date, this patient is voiding well and satisfied with the offered solution.

Screening and early diagnosis of prostate cancer: an update.

Screening for prostate cancer has become a main controversial topic. First the currently used screening tools, PSA (Prostate Specific Antigen) and DRE (Digital Rectal Examination) have a low accuracy in the prediction of prostate cancer. Second, the benefit of screening in reducing the prostate cancer related mortality was not uniformly shown in older screening studies and there was concern about the risk of overdiagnosis and over-treatment of insignificant prostate cancers. Very recently, 3 major prospective, randomized screening studies have been published. This paper aims to provide an overview how the performance of the current screening tools can be ameliorated and evaluates the recently published screening studies with practical considerations for future screening protocols.

Urethral reconstruction using buccal mucosa or penile skin grafts: systematic review and meta-analysis.

INTRODUCTION: Different types of grafts have been described in urethral reconstruction (UR), with penile skin graft (PSG) and buccal mucosa graft (BMG) as the most frequently used ones. It still remains unclear whether one graft is superior in terms of success when compared to the other. MATERIAL AND METHODS: A systematic review of the literature was performed searching the MEDLINE database with the following search strategy: 'urethroplasty' AND 'penile skin'/ 'urethroplasty' AND 'buccal mucosa'. 266 and 144 records were retrieved for urethroplasty with PSG and BMG, respectively. These records were reviewed to identify papers where PSG and BMG were used in UR and where individualized data on success were available within the same series. RESULTS: 18 papers were found eligible for further analysis. In total, 428 and 483 patients were respectively treated with PSG or BMG. If available, follow-up duration was 64.1 versus 42.1 months (p < 0.0001) and stricture length 6.2 versus 4.6 cm (p < 0.0001) for PSG and BMG, respectively. Success of UR with PSG was 81.8 versus 85.9% with BMG (p = 0.01). CONCLUSIONS: Success of UR using BMG is significantly better compared to PSG. Results might be seriously biased by a longer follow-up duration and stricture length for PSG compared to BMG.

[EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder, the 2011 update]. / Guía clínica del carcinoma urotelial de vejiga no músculo-invasivo de la Asociación Europea de Urología. Actualización de 2011.

CONTEXT AND OBJECTIVE: To present the 2011 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer (NMIBC). EVIDENCE ACQUISITION: Literature published between 2004 and 2010 on the diagnosis and treatment of NMIBC was systematically reviewed. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned. EVIDENCE SYNTHESIS: Tumours staged as Ta, T1, or carcinoma in situ (CIS) are grouped as NMIBC. Diagnosis depends on cystoscopy and histologic evaluation of the tissue obtained by transurethral resection (TUR) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TUR is essential for the patient's prognosis. Where the initial resection is incomplete or where a high-grade or T1 tumour is detected, a second TUR should be performed within 2-6 wk. In papillary tumours, the risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients into low-, intermediate-, and high-risk groups (separately for recurrence and progression) is pivotal to recommending adjuvant treatment. For patients with a low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is recommended. Patients with an intermediate or high risk of recurrence and an intermediate risk of progression should receive one immediate instillation of chemotherapy followed by a minimum of 1 yr of bacillus Calmette-Guérin (BCG) intravesical immunotherapy or further instillations of chemotherapy. Papillary tumours with a high risk of progression and CIS should receive intravesical BCG for 1 yr. Cystectomy may be offered to the highest risk patients, and it is at least recommended in BCG failure patients. CONCLUSIONS: These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice.

[European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. European Association of Urology Guideline Group for urothelial cell carcinoma of the upper urinary tract]. / Guía clínica para el diagnóstico y tratamiento de los carcinomas de las células uroteliales de las vías urinarias superiores: actualización de 2011.

CONTEXT: The European Association of Urology (EAU) Guideline Group for urothelial cell carcinoma of the upper urinary tract (UUT-UCC) has prepared new guidelines to aid clinicians in assessing the current evidence-based management of UUT-UCC and to incorporate present recommendations into daily clinical practice. OBJECTIVE: This paper provides a brief overview of the EAU guidelines on UUT-UCC as an aid to clinicians in their daily practice. EVIDENCE ACQUISITION: The recommendations provided in the current guidelines are based on a thorough review of available UUT-UCC guidelines and papers identified using a systematic search of Medline. Data on urothelial malignancies and UUT-UCCs in the literature were searched using Medline with the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract, carcinoma, transitional cell, renal pelvis, ureter, bladder cancer, chemotherapy, nephroureterectomy, adjuvant treatment, neoadjuvant treatment, recurrence, risk factors, and survival. A panel of experts weighted the references. EVIDENCE SYNTHESIS: There is a lack of data in the current literature to provide strong recommendations due to the rarity of the disease. A number of recent multicentre studies are now available, whereas earlier publications were based only on limited populations. However, most of these studies have been retrospective analyses. The TNM classification 2009 is recommended. Recommendations are given for diagnosis as well as for radical and conservative treatment; prognostic factors are also discussed. Recommendations are provided for patient follow-up after different therapeutic options. CONCLUSIONS: These guidelines contain information for the diagnosis and treatment of individual patients according to a current standardised approach. When determining the optimal treatment regimen, physicians must take into account each individual patient's specific clinical characteristics with regard to renal function including medical comorbidities; tumour location, grade and stage; and molecular marker status.

Assessment of the short-term functional outcome after urethroplasty: a prospective analysis

OBJECTIVES: To assess the short-term functional outcomes on urinary symptoms, erectile function, urinary continence and patient's satisfaction after urethroplasty. MATERIALS AND METHODS: A prospective analysis was done in 21 patients who underwent urethroplasty. An assessment of the urinary flow, urinary symptoms (International Prostate Symptome Score

Response of mouse brain perfusion to hypo- and hyperventilation measured by arterial spin labeling.

We aimed to setup a noninvasive and well-controlled methodology for evaluation of the cerebrovascular response in mice (C57BL/6J; 12 weeks). Therefore we applied a normo-, hypo-, and hyperventilation paradigm combined with arterial spin labeling and monitoring of the expired CO(2) (expCO(2)) (n=7) or arterial pCO(2) (apCO(2)) (n=12). Reducing the tidal volume by 25% and the respiratory rate by 20% resulted in hypercapnia (apCO(2) from 33 ± 6 mmHg to 64 ± 16 mmHg). Increasing the respiratory rate by 25% and the tidal volume by 20% decreased apCO(2) to 22 ± 5 mmHg. Cerebral blood flow (CBF) was 82 ± 21, 163 ± 41 and 64 ± 18 mL/100 g/min during normo, hypo-, and hyperventilation, respectively (midbrain). The correlation of apCO(2) and CBF levels resulted in a cerebrovascular response of 2.7 ± 0.3, 2.1 ± 0.3, 2.1 ± 0.3, and 3.7 ± 0.5 mL/100 g/min/mmHg for midbrain, cortex, hippocampus and thalamus, respectively. As expCO(2) levels were correlated with apCO(2) (r(2)=0.86; n=4) and CBF (r(2)=0.67) a cerebrovascular response based on simultaneously recorded CBF and expCO(2) levels could be derived (3.3 ± 0.5, 2.5 ± 0.4, 3.0 ± 0.4, and 4.5 ± 0.6 mL/100 g/min/mmHg; order as above). A cross-over experiment resulted in similar responses. In conclusion, this protocol allows evaluating basal CBF and cerebrovascular response in mice under well-controlled conditions by simply changing ventilator settings and correlating CBF with apCO(2) and/or simultaneously obtained expCO(2).

Assessment of the short-term functional outcome after urethroplasty: a prospective analysis.

OBJECTIVES: To assess the short-term functional outcomes on urinary symptoms, erectile function, urinary continence and patient's satisfaction after urethroplasty. MATERIALS AND METHODS: A prospective analysis was done in 21 patients who underwent urethroplasty. An assessment of the urinary flow, urinary symptoms (International Prostate Symptoms Score ), erectile function (International Index of Erectile Function-5 ) and urinary continence International Consultation Committee on Incontinence Questionnaire male Short Form ) was done before urethroplasty and 6 weeks and 6 months after urethroplasty. Patients were also asked to score their satisfaction with the urethroplasty after 6 weeks and 6 months. RESULTS: Mean patient's age was 48 years range: 26-80 years). Mean stricture length was 4.2 cm (range: 1-12 cm). Three patients suffered a stricture recurrence. Mean maximum urinary flow increased from 5.83 mL/s to 24.92 mL/s (p < 0.001). Mean IPSS preoperative, 6 weeks and 6 months postoperative was respectively 15.86, 4.60 and 6.41(p < 0.001). The mean IIEF-5 score preoperative, 6 weeks and 6 months postoperative was respectively 15, 12.13 and 11.62 (not significant). The mean ICI-Q-SF score preoperative, 6 weeks and 6 months postoperative was respectively 10.47, 8.33 (p = 0.04) and 9.47 (p = 0.31). Patient's satisfaction 6 weeks and 6 months postoperative was respectively 17.14/20 and 17.12/20. CONCLUSIONS: Urethroplasty leads to a significant improvement in urinary flow and IPSS and urinary continence is tending to improve. Although not significant, erectile function was slightly diminished after urethroplasty. Functional outcome should be assessed when urethroplasty is performed.

Clinical and imaging tools in the early diagnosis of prostate cancer, a review.

Measurement of serum Prostate Specific Antigen (PSA) level is useful to detect early prostate cancer. PSA-screening may reduce the mortality rate from prostate cancer, but this is associated with a high rate of overdiagnosis and overtreatment. To improve the detection of clinically significant cancers, several auxiliary clinical and imaging tools can be used. The absolute PSA value can be complemented with parameters such as PSA velocity, PSA density and free/total PSA. Transrectal Ultrasound (TRUS) has only moderate accuracy in the detection of prostate carcinoma, but is very useful in the estimation of prostate volume and thus calculation of PSA-density. The role of Magnetic Resonance Imaging (MRI) in diagnosis and staging of prostate carcinoma is rapidly increasing. Morphologic T2-weighted MR images (T2-WI), preferably with an endorectal coil, depict the prostatic anatomy with high resolution and can detect tumoral areas within the peripheral zone of the prostate. Addition of MR spectroscopic imaging (MRSI), dynamic contrast enhanced MRI (DCE-MRI) and/or diffusion weighted imaging (DWI) further increase the diagnostic performance of MRI. The gold standard for diagnosis of prostate carcinoma is histological assessment obtained by transrectal ultrasound-guided systematic core needle biopsy. In the future, imaging-based targeted biopsies may improve the biopsy yield and decrease the number of biopsy cores. Computed Tomography (CT) and positron emission tomography (PET) have no value in early prostate cancer detection and the indications are limited to lymph node staging and detection of distant metastases.

[Surgical treatment of urethral stenoses: technical aspects]. / Traitement chirurgical des sténoses de l'urètre: aspects techniques.

This article is an extensive review on open surgery techniques for urethral strictures from the membranous urethra after pelvic fracture up to the meatus urethrae. It is based on more than 10 year personal experience with nearly all mentioned techniques and a PubMed review on the subject from 1992 to 2005. Most of the studies published are descriptive and retrospective and deliver only a level 3 of evidence. General principles applicable to urethral surgery and tissue transfer are discussed. The different techniques are described in detail. Their indications, Limitations, advantages, disadvantages and results are discussed. Especially re-interventions need experience to make the best choice among the different techniques.

All-Optical flip-flop operation using a SOA and DFB laser diode optical feedback combination.

We report on the switching of an all-optical flip-flop consisting of a semiconductor optical amplifier (SOA) and a distributed feedback laser diode (DFB), bidirectionally coupled to each other. Both simulation and experimental results are presented. Switching times as low as 50ps, minimal required switch pulse energies below 1pJ and a repetition rate of 1.25GHz have been measured. Contrast ratios over 25dB have been obtained. The dependence on the pulse length and CW input power of the minimal required switch energy is investigated.

[Endoscopic treatment of urethral strictures]. / Traitement endoscopique des sténoses de l'urètre.

The present article reviews the literature regarding the endoscopic treatment of urethral strictures. Only few prospective randomised clinical trials with sufficient power have been performed and most of the literature provides evidence of only level 3 and 4. Since length, location, extent and calibre of the urethral stricture have an important impact on prognosis, diagnosis and the role of ultrasonography are discussed. Pathophysiology of wound healing is discussed in relation to urethrotomy, as it explains the outcomes of the procedure. Operative techniques using cold knife and laser, use of endoprostheses, indications, complications, results and postoperative management are described. The possible role of urethral catheters, hydraulic dilatations and corticosteroid applications are discussed.

EAU guidelines on diagnosis and treatment of upper urinary tract transitional cell carcinoma.

OBJECTIVES: On behalf of the European Association of Urology (EAU) guidelines for diagnosis, therapy and follow-up of upper urinary tract transitional cell carcinoma (UUTT) patients were established. Criteria for recommendations are based of level 2 only, as large randomised clinical trials have not been performed in this type of disease. METHOD: A systematic literature research using Medline Services was conducted. References were weighted by a panel of experts. RESULTS: TNM classification 2002 is recommended. Recommendations are developed for diagnosis, radical and conservative treatment and for local chemo-immunotherapy. Prognostic factors are defined. Recommendations for follow-up after different types of treatment are given.

Guidelines on diagnosis and treatment of superficial bladder cancer.

This manuscript reviews the guidelines of the European Association of Urology (EAU) on superficial bladder tumors and adds new data which has come available since 2001. It emphasises the data which are evidenced based and clearly explained where still insufficient research is available to make clear recommendations. Intravenous urethrography (IVU) is only necessary in grade 3 tumors. A good transurethral resection (TUR), with muscle in the specimen is essential. Random biopsies are only necessary when there is positive urinary cytology or when tumor in situ (TIS) is suspected. The variability in pathology interpretation remains a problem which seems not to have been solved by the new WHO 1998 classification. A review of pathology seems indicated when aggressive therapy is planned or there is a discrepancy between the visual findings and pathology. The visual judgement of urologists in superficial bladder tumors is very good. Second resection is indicated whenever insufficient material is delivered and in any T1 G3 tumor. In the last infiltrative tumors are regularly found. The treatment largely depends on prognostic parameters. For recurrence rate multiplicity of the tumor is most important, followed by recurrence rate, volume of the tumor, grade and T category. For progression the most important tumor is the anaplasia grade and the T category. Up to 50% of T1 G3 tumors and TIS evaluate to invasive tumors. Even low risk tumors still have an important recurrence rate of at least 20%/year in the first years after diagnosis. One chemo instillation immediately after TUR is indicated in low and intermediate risk superficial bladder tumors. Intravesical chemotherapy prevents recurrence but not progression. Ideal dosage and schedule of instillation is not clearly defined. Longterm therapy is not worthwhile. Bacille Calmette-Guerin (BCG) therapy is indicated in all tumors at high risk for progression. In tumors at high risk for recurrence it is also superior to intravesical chemotherapy, but its side-effects are more pronounced. Local or systemic side-effects are not related to efficacy and side-effects do not increase over time. The ideal schedule for BCG has not yet been found. It is however clear that some kind of maintenance therapy is necessary to obtain good results. BCG failure is probably any tumor which recurs at 3 and 6 months under BCG therapy. One third dose seems as sufficient as a full dose BCG. That BCG can spare the bladder in T1g3 tumors is largely documented but the chance to save the bladder when the tumor is still present after 2 cycles of BCG is very low. Cystectomy is indicated in these BCG failures. Vitamin E, A, and Lactobacillus Casei are probably effective in the prevention of the disease. Stopping smoking is advocated. Cystoscopy is still the gold standard in follow-up. It is advocated at 3 months and thereafter according to the prognostic parameters. High grade tumors are at risk life long. Follow-up of 5 years for low risk tumors seems reasonable.

A prospective randomized trial comparing the 1-stage with the 2-stage implantation of a pulse generator in patients with pelvic floor dysfunction selected for sacral nerve stimulation.

OBJECTIVE: The aim of this study was to evaluate in a prospective, randomized setting if the 2-stage implant, compared to a 1-stage implant, leads to a superior subjective or objective outcome of sacral nerve stimulation after implantation of the pulse generator in patients with lower urinary tract symptoms. PATIENTS AND METHODS: We implanted a sacral (S3) foramen lead and a pulse generator (model 3023, Medtronic Inc, Minneapolis, MN, USA) in 42 patients. They were randomized in a 1-stage or a 2-stage implant if a more than 50% improvement in voided volume or reduction of residual urine was seen during the test stimulation phase as compared to baseline. RESULTS: At 24 months follow-up, subjective (visual analogue scale) and objective (voided volume or residual urine) assessment were significantly better in the 2-stage group. Ten patients (24%) failed therapy, 7 in the 1-stage implant and 3 in the 2-stage group. Two patients were lost to follow-up. Logistic regression analysis revealed that failure was positively related to the 1-stage implant and negatively to the age of the patients. 76% of the treated patients had sustained clinical benefit with 23 revisions performed. The mean cost is respectively for the PNE (2006 Euro), for the 2-stage implant (10826 Euro) and for the 1 stage implant (8505 Euro). CONCLUSION: With this study, we demonstrated that the 2-stage implantation technique of the sacral neuromodulation therapy performed as a longer test stimulation phase has a higher success rate.