Perineal Urethrostomy for Complex Urethral Strictures: Long-Term Patient-Reported Outcomes From a Reconstructive Referral Center and a Scoping Literature Review.

PURPOSE: There is a paucity of long-term objective and patient-reported outcomes after definitive perineal urethrostomy for complex urethral strictures. Our objective is to determine comprehensive long-term success of perineal urethrostomy with our 15-year experience at a reconstructive referral center. MATERIALS AND METHODS: Patients who underwent perineal urethrostomy between 2009 and 2023 were identified. A comprehensive long-term follow-up was conducted, evaluating both objective outcomes (retreatment-free survival) and subjective outcomes through the use of validated questionnaires. Additionally, to provide further context for our findings, we conducted a scoping review of all studies reporting outcomes following perineal urethrostomy. RESULTS: Among 76 patients, 55% had iatrogenic strictures, with 82% previously undergoing urethral interventions. At a median follow-up of 55 months, retreatment-free survival was 84%, with 16% of patients experiencing perineal urethrostomy recurrent stenosis. Patient-reported outcomes revealed a generally satisfactory voiding function (Urethral Stricture Surgery Patient-Reported Outcome Measure Lower Urinary Tract Symptoms score) and continence (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form), with median scores of 4 (range 0-24) and 0 (range 0-21), but with bimodal distributions of sexual function scores (median International Index of Erectile Function-Erectile Function domain: 3.5; median Male Sexual Health Questionnaire-Ejaculation Scale: 21). Treatment satisfaction was very high with a median International Consultation on Incontinence Questionnaire-Satisfaction outcome score of 21 (range 0-24). The scoping review revealed varying success rates ranging from 51% to 95%, highlighting difficulties in comparison due to variable success definitions and patient case mix. CONCLUSIONS: Perineal urethrostomy provides effective treatment for complex anterior urethral strictures, with high patient satisfaction, preserved continence function, and favorable voiding outcomes. It presents a viable option for older and comorbid patients, especially after thorough counseling on expected outcomes and potential risks.

Analysis of prognostic factors of failure in perineal urethrostomy.

PURPOSE: To identify prognostic factors of failure in patients undergoing perineal urethrostomy (PU) with Blandy technique, with inverted U-shaped perineal flap. METHODS: This is a retrospective study of PU of non-oncological causes (2001-2017). Data of age, BMI, history of diabetes mellitus, etiology of urethral stricture, type of stricture, previous surgeries, dilatation and suprapubic catheter were collected. Failure was defined as the need for any instrumentation after surgery. Variables were analyzed by Cox regression and Kaplan-Meier curves were used for survival analysis. RESULTS: A total of 115 PU were performed. Median age was 61 years (IQR 53-68) and BMI 27.9 (IQR 25-30.9). The most frequent etiologies were: lichen sclerosus (30.4%), iatrogenic (27%), and idiopathic (25.7%). 62.6% had panurethral stricture. There were no complications in 73%. Clavien I complications occurred in 25.2%, Clavien II in 0.9% and Clavien IVa in 0.9%. The overall success rate was 51.3% with a median follow-up of 71 months. In the last 8 years, it was 75%. In the multivariate analysis, we found that age (p = 0.01), BMI (p = 0.01), date of surgery (p = 0.01), and suprapubic catheter (p = 0.003) were predictive variables. The voiding satisfaction rate was 88.7%. CONCLUSIONS: PU with Blandy technique is a surgery with low morbidity. During the entire study period, it had a failure rate of 48.7% but the failure rate decreased to 25% over the last 8 years. Age, BMI, date of surgery and suprapubic catheter are the most important prognostic factor of failure.

Efficacy of urethral reconstruction for urethral stricture associated with hypospadias surgery in adults.

OBJECTIVES: We report our experience with urethral reconstruction for hypospadias surgery-related urethral stricture in terms of surgical and patient-reported outcomes. METHODS: Twenty-nine adult males who underwent urethral reconstruction for hypospadias surgery-related urethral stricture between August 2008 and January 2022 were retrospectively reviewed. Uroflowmetry and patient-reported outcomes were evaluated at 3, 6, and 12 months, and annually thereafter. Surgical success was defined as the absence of additional procedures. Patients were asked to rate their satisfaction with urethral reconstruction as "very satisfied", "satisfied", "unsatisfied", or "very unsatisfied". RESULTS: The median patient age at referral was 43 years. The median number of previously performed hypospadias surgeries was three, and 18 patients (62.8%) had been treated with repeated transurethral procedures. The median stricture length was 54 mm (interquartile range 36-81). Performed urethral reconstruction included staged urethroplasty in 22 (75.9%), one-stage onlay augmentation in 3 (10.2%), and perineal urethrostomy in 4 (13.8%) cases. Urethral reconstruction was successful in 26 patients (89.7%) over a median postoperative period of 31 months. Patient-reported outcomes were assessed in 25 (86.2%) patients. The mean maximum flow rate, international prostate symptom score total score, international prostate symptom score quality of life score, and EuroQol-5 dimensions index significantly improved postoperatively. Twenty-three patients (92%) were "very satisfied" or "satisfied" with the outcome of their urethral reconstruction. CONCLUSIONS: Urethral reconstruction is a highly successful and patient-satisfying treatment for hypospadias surgery-related urethral stricture in adult patients. Perineal urethrostomy is a reasonable alternative for elderly patients and for patients with complicated hypospadias surgery-related urethral strictures.

[Perineal urethrostomy: results, clinical, statistical and terminological aspects].

The analysis of the results of perineal urethrostomy for urethral stricture in men for the period from 2000 to 2020 is presented in the article. We identified 29 original articles devoted to this technique, including 4 Russian and 25 foreign publications. In two studies, there were more than 100 patients, four studies included from 51 to 77 men, and in remaining studies less than 50 patients were analyzed. Complete data on all pre- and postoperative aspects of perineal urethrostomy were provided only in a few studies. In the overwhelm of cases, perineal urethrostomy was performed after one or several unsuccessful reconstructive procedures and only in few patients it was done prior to various types of urethroplasty. It was not possible to establish any association between etiological factors and localization of urethral stricture among these patients. The incidence of pan-urethral stricture ranged from 28.6% to 100%. Only in one study the average stricture length was 2 cm, while in all other studies it was 5 cm or more. Postoperative follow-up was on average 14 to 62 months. Treatment success with perineal urethrostomy ranged from 0% to 100%, but in most studies it was 75% or more. The most common perineal urethrostomy technique used included Blandy technique, and Johanson and 7-flap techniques.

Evaluation of the efficacy of perineal urethrostomy for patients with anterior urethral stricture: insights from surgical and patient-reported outcomes.

PURPOSE: To examine the efficacy of perineal urethrostomy (PU) in patients with anterior urethral stricture. METHODS: Patients who underwent PU for anterior urethral stricture between 2013 and 2020 were retrospectively reviewed (n = 56). Surgical success was defined as no need for additional intervention. Uroflowmetry and measurement of residual urine volume (PVR) were examined postoperatively, and the patients were asked to fill out sexual health inventory for men (SHIM) and the validated Urethral Stricture Surgery Patient-reported Outcome Measure questionnaires before and after PU. The overall patient satisfaction was also assessed. RESULTS: PU was successful in 92.9% of patients (n = 52), with a median follow-up of 34 months. Two of four were salvaged by re-do PU, and one was salvaged by forming a composite stoma using a penile skin graft. Thirty-nine patients (69.6%) filled out the questionnaires 6 months after surgery. The mean maximum flow rate, PVR, lower urinary tract symptoms (LUTS)-total score, LUTS-specific quality of life, and EuroQol-visual analog scale scores improved significantly from 3.8 mL/s, 77.6 mL, 12.9, 2.6, and 53.6 at baseline to 17.6 mL/s, 21.3 mL, 4.1, 0.9, and 74.9 postoperatively (p = 0.003, p = 0.004, p = 0.005, p < 0.0001, p < 0.0001, respectively). The SHIM score did not change significantly (from 2.6 at baseline to 2.3 postoperatively; p = 0.59). As for patient satisfaction, 84.6% of patients (33/39) were "satisfied" (46.1%) or "very satisfied" (38.5%) with the outcome. CONCLUSIONS: PU had a high surgical success rate, and significantly improved patients' subjective symptoms and achieved a high level of satisfaction.

Versatile algorithmic midline approach to perineal urethrostomy for complex urethral strictures.

PURPOSE: To present results of an algorithmic approach to perineal urethrostomy (PU) based on a midline perineal incision among men with complex urethral strictures. METHODS: A single surgeon retrospective review of consecutive patients who underwent PU between 2008 and 2017 was performed. Patient demographics and outcomes were collected via medical record review. After a midline perineal incision, the PU was matured either by (a) mobilization of the urethral plate (loop) alone in cases with distal strictures or low body mass index (BMI), or (b) with creation of a lateral perineal skin flap (7-flap) for those with longer urethra-to-skin distances. Success was defined as functional voiding without the need for further procedures. Patients were contacted by phone and administered validated questionnaires. RESULTS: Of 62 PU patients, 20 (32.3%) underwent the loop technique, and 42 (67.7%) had the 7-flap procedure, 7 of which were reoperative for prior failed PU. Median age was 61.9 years (range 23-85) and the median stricture length was 8.0 cm (range 2.5-18 cm). Mean BMI was greater among 7-flap compared to loop patients (34.9 vs. 30.0 kg/m2, p = 0.01). Success rates were 92.9% (39/42) in the 7-flap group and 100% (20/20) in the loop PU cohort during a median follow-up of 30.7 months. Among 62 PU patients, 19 (30.6%) responded to the survey-median PGI-I score was 1.0 (range 1-2) indicating that symptoms were "very much improved". CONCLUSIONS: The algorithmic midline approach to PU offers a standardized, versatile solution with excellent surgical outcomes and high patient satisfaction, even in obese or refractory stricture patients.

Augmented perineal urethrostomy using a dorsal buccal mucosal graft, bi-institutional study.

PURPOSE: To present our technique and outcomes for perineal urethrostomy augmented with a dorsal onlay buccal mucosa graft (BMG). Results from initial series and collaboration from an international center are included. METHODS: A retrospective chart review of all adult patients who underwent urethral reconstruction with perineal urethrostomy utilizing a buccal mucosal graft between January 1, 2002 and January 1, 2013 was performed. All surgeries were performed by three surgeons using the same technique (GHJ, KAM, and RV). Success was defined as no need for additional treatment following definitive surgery. RESULTS: A total of 44 patients met inclusion criteria. Mean patient age was 60 (range 44-81) years. All strictures were pananterior. Etiologies included unknown in 16 (36%), failed hypospadias repair in six (14%), lichen sclerosus in ten (23%), iatrogenic in seven (16%), Fournier's in three (7%), urethral cancer in one (2%) and penile cancer in one (2%). Mean follow-up was 45 (range 6-136) months. Overall success was 80%. Nine patients recurred, of which four had a successful revision, two are awaiting potential revision, and three are being managed with periodic dilations. CONCLUSIONS: BMG perineal urethrostomy is a valid alternative for complex urethral strictures due to lichen sclerosus, previous failed reconstructions or hypospadias cripples. Midterm results are encouraging for this novel technique.

Proximal Urethrostomy Versus Urethroplasty for Complex Urethral Strictures.

Background: The optimal treatment for complex urethral stricture (CUS) is yet to be determined. Comparisons of methods based on validated questionnaires or objective outcome measures are lacking. Objective: To compare proximal urethrostomy and urethroplasty for CUS using objective measures and validated questionnaires, and to evaluate trends in subgroups of patients who underwent proximal urethrostomy as the intended definitive treatment versus first-stage urethroplasty. Design setting and participants: We identified all patients who underwent proximal urethrostomy at our center from 2004 to 2021. The control group comprised patients who underwent urethroplasty for CUS (strictures >6 cm, recurrent posturethroplasty strictures, or CUS due to lichen sclerosus or past hypospadias surgery). Outcome measurements and statistical analysis: The primary outcome was a recurrent stricture at a minimal follow-up of 1 yr. The secondary outcomes included validated questionnaires, uroflowmetry, and residual urine volume. Survival was compared by a Kaplan-Meier analysis. Results and limitations: The study included 57 proximal urethrostomy and 75 urethroplasty patients. Results for these two groups were as follows: the cumulative incidence of stricture recurrence over a median follow-up of 46 mo was 22.6% for proximal urethrostomy versus 36.2% for urethroplasty (p = 0.106); no statistically significant differences were observed between groups in terms of postoperative quality of urination or life, satisfaction with outcome, and erectile function. Both groups had a significant improvement in urinary flow after surgery (19.65 vs 20.29 ml/s), with no difference between the groups (p = 0.796); the proximal urethrostomy group had a significant improvement in postvoid residual after surgery, but there was no difference between the groups in the last follow-up visit (79.16 vs 52.03 ml; p = 0.245). A subgroup analysis of the proximal urethrostomy group showed no significant differences in cumulative primary or secondary outcomes. Limitations included the retrospective design and the relatively small study population. Conclusions: Comparisons of the two groups revealed no significant differences in stricture recurrence, results of validated questionnaires, or objective measures of urination. Patient summary: Proximal urethrostomy is equivalent to urethral reconstruction, and it should be offered as a viable solution for complex urethral stricture.

Description of Transperineostomal Resection of the Prostate: A Case Report.

We report a case of transperineostomal bipolar resection of the prostate (TPR-P) for lower urinary tract symptoms (LUTS). To our knowledge, this is the first description in the scientific literature. A 67-year-old man with a medical history of multiple penile debridements and formation of a perineostomy due to an episode of severe Fournier's gangrene in 2015, was admitted to the emergency room with acute urinary retention. Consecutively, a suprapubic catheter was inserted. Attempts of catheterization failed due to bulbar stenosis and an obstructive prostatic urethra. After the resolution by dilatation of the bulbar stenosis, post-voiding residual volume persisted at up to 150 ml. The intra- and postoperative course after TPR-P was uneventful. No adverse events occurred. The assessment after six weeks revealed an International Prostate Symptom Score (IPSS) improvement of nearly 50% for the symptoms and >60% for overall satisfaction (preoperative: IPSS: S=24, L=6; postoperative IPSS: S=13, L=2). The average post-voiding residual volume decreased from 150 ml preoperatively to 15 ml (range 0-30 ml) postoperatively. Due to the missing full length of the urethra, the augmented range of motion seemed almost too loose for classic resection techniques in our hands. Therefore, we believe that in such cases it might be advantageous to use enucleation techniques. However, in our case, TPR-P was feasible and safe with a good functional outcome.

Y-type urethral duplication in children: Management strategy at our center.

AIMS: Report of seven children with Y-type urethral duplication (YUD). MATERIALS AND METHODS: (A) Four staged operations were performed in patients having extensive perineal dissection (for rectourinary fistula separation and anterior mobilization of ventral urethra (VU)), tension rectocutaneous anastomosis, and children who were not toilet trained). These stages are (1) diversion sigmoid colostomy with anterior mobilization of VU as perineal urethrostomy via anterior sagittal approach; (2) Orthotopic urethral (OU) reconstruction; (3) anastomosis of OU and perineal urethra; (4) colostomy closure with management of complications. (B) The patients having VU onto the perineum underwent single stage urethral reconstruction. RESULTS: The VU was urethrorectal/urethroanal in five and urethroperineal in two. Low anorectal malformation and upper urinary tract anomalies were present in 57.1% (4/7) and 14.7% (1/7) patients, respectively. Buccal mucosa free graft, transverse inner preputial flap, and perineal skin were tubularized for OU reconstruction. Mean age at 1(st) , 2(nd) , 3(rd) , and 4(th) surgery was 5 ± 0.78, 28 ± 0.78, 36 ± 0.78, 49 ± 0.78 months respectively. Three patients needed surgery for complications (urethrocutaneous fistula in two and urethral diverticulum in one) in a mean 3.12 ± 0.34 years of follow-up. Final uroflowmetry and fecal continence were good in all patients. CONCLUSIONS: The YUD is a difficult entity to manage. Although, staged procedure appears to be time consuming, but good and promising results can be achieved by staging the procedure.

Comparison of urethral length and orifice diameter in cats undergoing transpelvic or subpubic urethrostomy for perineal urethrostomy revision (cadaveric study).

OBJECTIVES: Stenosis is a postoperative complication reported in 12-17% of male cats that undergo perineal urethrostomy (PU). This study compared two different revision techniques for failed perineal urethrostomies. The first objective was to evaluate the feasibility of performing a transpelvic urethrostomy (TPU) after a previous, correctly performed PU in male cats. The second objective was to determine the residual urethral length, orifice diameter, and the position of the orifice relative to the pubic brim and anus after PU, TPU and subpubic urethrostomy (SPU). METHODS: Twenty male cat cadavers were randomly divided into two groups: TPU and SPU. In group TPU, PU was followed by TPU; in group SPU, PU was followed by SPU. After each procedure, the urethral orifice cross-section size was estimated by inserting the largest possible urinary catheter without resistance. Residual urethral length was measured both on contrast radiographs and after anatomical dissection. RESULTS: In all cats, TPU could be performed following a technically correct PU. The TPU resulted in a 1.5-times longer residual urethral length than SPU, based on contrast radiographs (P = 0.001) and confirmed by anatomical dissection (P <0.001). Relative to the initial urethral length, PU, TPU and SPU resulted in a reduction of 24%, 36% and 56%, respectively. The urethral orifice diameter after TPU did not differ from SPU (P = 1.000), and it was not statistically significantly different between TPU and PU (P = 0.317) or between SPU and PU (P = 0.655). The urethral orifice was located further away from the pubis (P <0.001) and closer to the anus (P <0.001) after TPU than after SPU. CONCLUSIONS AND RELEVANCE: Both TPU and SPU are possible revision surgeries following PU. As TPU preserves a significantly longer urethral length and requires less tissue dissection, the risk of urinary tract infections, urinary dermatitis and urinary incontinence might be less following TPU than SPU.

Surgical management of stricture urethra in patients with chronic renal failure: Ten years' experience at a tertiary center.

Introduction: Patients suffering from stricture urethra and deranged renal function have poor quality of life. The incidence of urethral stricture co-existing with renal failure is comparatively small and cause may be multifactorial. There is paucity of literature on management of urethral stricture associated with deranged renal function. We present our experience of managing stricture urethra associated with chronic renal failure. Materials and Methods: This was a retrospective study conducted from 2010 to 2019. Patients with stricture urethra and deranged renal function (serum creatinine >1.5 mg/dl) who underwent urethroplasty or perineal urethrostomy were included in our study. A total of 47 patients met the inclusion criteria and were included in this study. Patients were followed every 3 months in their 1st year of surgery and 6 monthly thereafter. Statistical analysis was done using SPSS version 16. Results: There was a significant increase in the mean postopérative maximum and average urinary flow rates when compared to the preoperative values. The overall success rate was 76.59%. Out of 47 patients, 10 had wound infection and delayed wound healing, 2 patients developed ventricular arrhythmias, 6 patients developed fluid and electrolyte imbalance, 2 patients developed seizures, and 1 patient developed septicemia in the postoperative period. Conclusion: Prevalence of patients with chronic renal failure associated with stricture urethra was 4.58% and features suggestive of deranged renal function at presentation were present in 1.81% patients. In the present study, complications related with chronic renal failure occurred in 17 (36.17%) patients. Multidisciplinary care of the patient along with appropriate surgical management is a viable option in this sub-group of patients.

Successful management of pelvic urethral strictures with balloon dilation in 3 cats.

OBJECTIVE: To describe the successful management of pelvic urethral strictures in 3 young cats (1 after perineal urethrostomy, 1 after a third-time urethral obstruction, and 1 with prolonged lower urinary tract signs post-urethral obstruction) using balloon dilation and a short-term, indwelling urethral catheter. CASE SUMMARIES: A 9-month-old neutered male domestic longhair cat with a urethral obstruction and a suspected congenitally narrowed urethra was treated via perineal urethrostomy. The cat later developed acute kidney injury, multidrug-resistant urinary tract infections, and a pelvic urethral stricture. A second case, a 2.3-year-old neutered male domestic shorthair cat, developed a stricture of the pelvic urethra after multiple obstructions and catheterizations. A third case, a 1.2-year-old neutered male domestic shorthair cat, had persistent and prolonged lower urinary tract signs after treatment for a urinary obstruction. The cat also had an abnormally small urethral opening and was ultimately found to have a proximal urethral stricture. The strictures in all 3 cases were successfully treated with a combination of fluoroscopic-guided balloon dilation and short-term indwelling urethral catheterization while managing any present infection. NEW OR UNIQUE INFORMATION PROVIDED: To the authors' knowledge, this is the first published case series of successful balloon dilations paired with the use of a short-term indwelling urethral catheter in cats that developed urethral strictures after catheterization due to urinary obstructions. This procedure appears safe and well tolerated and appears to offer a long-term, cost-effective solution to urethral strictures at the level of the pelvis.

Comparison of perineal urethrostomy versus augmentation urethroplasty in anterior urethral stricture disease.

PURPOSE: Perineal urethrostomy and urethroplasty are very good options for complex and long anterior urethral strictures. A perineal urethroplasty is usually a neglected option. To our knowledge, a comparative study between augmentation urethroplasty and perineal urethrostomy has been not conducted regarding subjective and patient reported outcome measures. We compared both these groups in a high volume tertiary care hospital. MATERIALS AND METHODS: A prospective comparative study of augmentation urethroplasty and perineal urethroplasty for long anterior urethral stricture. it was defined by strictures of more than 3 cm. We compared demographic data, urinary and sexual function; and quality of life using validated PROMs (patient-reported outcome measures) between both above groups. RESULTS: Both groups had 40 patients each. IPSS score improvement for PU and AUP were 20 and 19.6, respectively(p = 0.1223); IIEF-5 score improvement for PU and AUP at baseline and after 6 months were 14.3 and 16.7, respectively(p = 0.1433); QOL score improvement for PU and AUP were 3.45 and 3.05, respectively; which was statistically significant (p ⩽ 0.001). CONCLUSIONS: Perineal urethrostomy is a good but neglected option for complex and long anterior urethral strictures and it should be considered one of the reliable treatment option for patients with long-segment urethral strictures.

Perineal urethrostomy with combined buccal mucosal graft and skin flap after complete loss of anterior urethra.

INTRODUCTION: We report a novel perineal urethrostomy procedure for complete loss of anterior urethral tissue. CASE PRESENTATION: A 74-year-old man had complete necrosis of the corpus spongiosum and corpora cavernosa after repeated transurethral surgical procedures. He had been managed with a suprapubic cystostomy tube for 10 years. A perineal urethrostomy was performed, and a posterior wall with an inverted U-shaped perineal skin flap and an anterior wall with a buccal mucosal graft were created. Five months later, an internal urethrotomy was required for mild anastomotic stenosis. Thereafter, an indwelling Foley catheter was used for urine drainage at night to prevent restenosis of the neourethra and avoid excessive nocturia due to low capacity of the long-time disused bladder, and the patient became catheter-free during the daytime. CONCLUSION: The method presented here is a reasonable option for patients lacking whole anterior urethral tissue.

Perineal urethrostomy: A single-stage viable option for complex anterior urethral strictures.

INTRODUCTION: Perineal urethrostomy (PU) is a valid single stage option with maximum success to manage complex anterior urethral strictures. AIMS: To evaluate the functional outcome of permanent PU using the Blandy technique in older patients or PU with staged reconstruction in young patients with severely diseased distal urethra. MATERIALS AND METHODS: This is a retrospective analysis of 124 patients. They underwent Blandy's PU with or without Johanson stage 1. Exclusion criteria included patients with posterior urethral strictures or bladder neck contractures. RESULTS: Mean age of patients was 54 years. Strictures due to catheterisation or instrumentation were most common - 85 (68.54%). Out of 124 patients, 71(57.3%) of them were posted for PU with Johanson stage 1 and 53 for PU only (42.7%) according to patients' choice. In patients age below 50 years, PU (N=10), PU with Johanson stage 1 (N=40) and Johanson stage 2 (N= 8) patients had mean Qmax of 20.2ml/s (17-24), 20.7ml/s (16-26), 16.375ml/s (14-18) respectively. In patients age> 50 years, PU (N=43), PU with Johanson stage 1 (N=31) and Johanson stage 2 (N= 4) patients had mean Qmax of 16.41ml/s (11-24), 17.25ml/s (11-25) and14.75 ml/s (12-17) respectively.For patients with only PU, 8/53 patients (15.09%) required secondary intervention (stomal dilatation N=6 and TURP N=2) while in PU with Johanson stage 1 patients, 10/71(14.08%) required secondary intervention (Stomal dilatation N=6, 8.45% and TURP N= 4, 5.6%). 112/124 (90.32%) were considered successful. CONCLUSION: Since most of patients have suffered for years, PU provides results in one stage.

Outcomes of perineal urethrostomy for penile cancer: A 20-year international multicenter experience.

PURPOSE: Perineal urethrostomy (PU) is often the definitive form of urinary diversion in patients with locally-advanced or anatomically unfavorable penile cancer (PC) requiring total penectomy. Here, we report post-operative PU-related complications and PU stenosis rates after total penectomy with PU in a large multicenter cohort of PC patients. METHODS: We retrospectively reviewed the medical records of 299 patients who underwent PU as a means of urinary diversion for primary PC across seven international centers from 2000 to 2020. The Clavien-Dindo grading system was used to record 30-day post-operative complications. Cumulative incidence of stenosis was evaluated using the Kaplan-Meier method. RESULTS: Median patient age was 67 years (interquartile range (IQR) 58-74), and median follow-up was 19 months (IQR 7.2-57). A total of 58 patients (19%) developed a 30-day post-operative complication, of which 45 (79%) were deemed minor (CD Grade I and II). Wound infection (11%; CD grade I-III) and dehiscence (4.0%; CD grade I-III) were the more common complications. The overall incidence of stenosis was 12% (35/299 patients), of which 26 (74%) needed surgical revision (probability of stenosis revision at one year of 9.3%, median time until the revision: 6.1 months (IQR 3.0-13)). Only two stenoses were seen after two years of follow-up. CONCLUSION: We present the most extensive series of PU in the management of PC to date. Wound infections of the primary surgical site were the most common complication. Stenosis occurred mostly within one and a half years after treatment.

Impact of radiation therapy on perineal urethrostomy for penile cancer.

OBJECTIVE: A lack of demonstrated clinical benefit precludes radiotherapy (RT) from being recommended for pN1/pN2 penile cancer (PeCa) lesions; but it may be recommended in case of extranodal (pN3) disease or for positive resection margins. Perineal urethrostomy (PU) is a technique of urinary diversion in patients with PeCa requiring total or subtotal penectomy as primary therapy. Prior studies suggest PU failure rates of up to 30%, without specific mention of the potential role of RT. When RT is delivered for PeCa it is usually to the pre-pubic fat, groin and lateral pelvis, and not to the region of the PU. Here we describe the role of perioperative RT in a large, multi-institutional registry of PU for PeCa. METHODS: In our cohort, 299 patients from seven international, high-volume centers in Belgium, Brazil, China, Netherlands, United Kingdom and the United States underwent PU as urinary diversion for PeCa between 2000 and 2020. Demographic and clinicopathologic characteristics were reviewed. RESULTS: Median patient age was 67 years and median follow-up was 19 months. Seven patients (2.3%) received pre-operative RT; six of them with chemotherapy. 37 received RT post-operatively, 21 (57%) with chemotherapy. Stenosis of the PU occurred in 35 (12%) of the total population. The majority of these patients (74%) required surgical revision at a median of 6.1 months post-operatively. RT delivery was neither significantly related to PU stenosis (p = 0.16) or to subsequent revision (p = 0.75). CONCLUSION: Receipt of RT was not significantly associated with increased stenosis risk in PeCa patients who underwent PU.

Welfare of cats 5-29 months after perineal urethrostomy: 74 cases (2015-2017).

OBJECTIVES: The objective of this study was to evaluate the long-term quality of life in cats following perineal urethrostomy. METHODS: This study comprised a retrospective case series of 74 cats with urinary obstructions that received perineal urethrostomies at the American Society for the Prevention of Cruelty to Animals (ASPCA) Animal Hospital between September 2015 and July 2017. Medical records were reviewed for information on the number of obstructions prior to surgery, urinary tract problems at the time of surgery and other potential factors influencing long-term welfare. Owners were surveyed by telephone and text 5-29 months after their cat's surgery. Responses were compiled and analyzed to determine owner perception of welfare postsurgery, and to identify patterns in medical history and welfare outcomes. RESULTS: In total, 105 cat owners were eligible for the survey; 74 responded. Altogether, 100% of responding individuals reported at least the same quality of life postsurgery compared with the cat's quality of life before demonstrating urinary problems (48% reported better). On a quality-of-life scale of 1-10 (10 = excellent), 100% of responding cat owners reported at least 7; 75% reported 10. CONCLUSIONS AND RELEVANCE: Quality-of-life outcomes for cats 5-29 months after receiving perineal urethrostomy surgery were reported to be very good. Given this finding, and that perineal urethrostomy surgery should mitigate future blockages, we suggest considering perineal urethrostomy surgery as a standard tool to manage urinary obstructions in cats. The needs of the specific client and patient, including risks, costs and welfare of the cats, should drive the options for management of urinary obstructions in male cats.

[A CASE OF NEO-MEATAL STENOSIS AFTER PENECTOMY FOR PENILE CANCER, REPAIRED BY BLANDY PERINEAL URETHROSTOMY].

Surgical resection is the standard treatment for the management of localized penile cancer and a neo-urethral meatus is generally created on the penile stump or perineum. Neo-urethral meatus is often stenosed and requires repeated transurethral manipulations such as dilation and urethrotomy. These procedures are generally futile and are associated with poor quality of life. Here, we report a case of penile cancer that developed a neo-meatal stenosis after total penectomy, which was subsequently salvaged by perineal urethrostomy using Blandy technique. A 72-year-old male who was diagnosed with localized penile cancer, underwent total penectomy and creation of neo-meatus on the perineum. Neo-meatus stenosis had developed in the patient and he received repeated urethral dilations without any success. Finally, when the patient was unable to void, he was referred to us for the amelioration of meatal stenosis through the placement of a suprapubic catheter. Because the condition of the residual bulbar urethra was adequate and its length was enough, we planned to create a non-transecting perineal urethrostomy by Blandy technique. An inverted U-shaped perineal incision was made, and a skin flap was created. The scarred neo-meatus and spongiofibrosis at the distal bulbar urethra were completely excised. The residual bulbar urethra was exposed, and a longitudinal ventral incision of 4 cm was made. The edge of the bare urethral mucosa and tunica albuginea of the corpus spongiosum were sutured by 4-0 PDS for hemostasis. The apex of the U-shaped skin flap was brought to the proximal margin of the urethrotomy and a tension-free anastomosis was created between the skin flap and the urethral plate. Thereafter, the skin of the perineum was sutured to the open longitudinal urethrotomy. The patient started to void on the 5th day post-surgery. The subject could void without the help of any intervention and did not require any instrument, sixteen weeks after the surgery.