Novel strategy using a spiral embedded flap for meatal stenosis after post-penile cancer amputation surgery: a single-center experience.

This study aimed to investigate the curative effect of spiral embedded flap urethroplasty for the treatment of meatal stenosis after penile carcinoma surgery. From January 2015 to January 2021, we used our technique to treat strictures of the external urethral orifice in seven patients, including four cases of meatal stenosis after partial penile resection and three cases of meatal stenosis after perineal stoma. All patients had previously undergone repeat urethral dilatation. The patients underwent spiral embedded flap urethroplasty to enlarge the outer urethral opening. The patients' mean age at the time of surgery was 60 (range: 42-71) years, the mean operative time was 43 min, and the median follow-up period was 18 months. The patients voided well post-operatively, and urinary peak flow rates ranged from 18.3 ml s-1 to 30.4 ml s-1. All patients were successful with absence of urethral meatus stricture. The present study showed that using spiral embedded flap urethroplasty to treat meatal stenosis after penile carcinoma surgery is an effective surgical technique with good long-term outcomes.

Factors that influence the outcome of open urethroplasty for pelvis fracture urethral defect (PFUD): an observational study from a single high-volume tertiary care center.

PURPOSE: To report the clinical features of pelvic fracture urethral injury (PFUI) and assess the real effect of factors that are believed to have adverse effects on delayed urethroplasty. METHODS: An observational descriptive study in a single urological center examined 376 male patients diagnosed with PFUI who underwent open urethroplasty from 2009 to 2013. Analyzed factors included patient age at the time of injury, etiology of PFUI, type of emergency treatment, concomitant injuries, length and position of stricture, type of urethroplasty and the outcome of surgery. Univariate and multivariate logistic regression analyses were applied, together with analytical statistic methods such as t test and Chi-square test. RESULTS: The overall success rate of delayed urethroplasty was 80.6 %. Early realignment was associated with reduced stricture length and had beneficial effect on delayed surgery. Concomitant rectum rupture, strictures longer than 1.6 cm and strictures closer than 3 cm to the bladder neck were indicators of poor outcome. Age, type of injury, urethral fistula and bladder rupture were not significant predicators of surgery outcome. Failed direct vision internal urethrotomy and urethroplasty had no significant influence on salvage operation. CONCLUSIONS: The outcome of posterior urethroplasty is affected by multiple factors. Early realignment has beneficial effect; while the length and position of stricture and its distance to bladder neck plays the key role, rectum rupture at the time of injury is also an indicator of poor outcome. The effect of other factors seems insignificant.

Recurrence and complications after transperineal bulboprostatic anastomosis for posterior urethral strictures resulting from pelvic fracture: a retrospective study from a urethral referral centre.

OBJECTIVE: To describe the complications of transperineal end-to-end anastomotic urethroplasty in patients with posterior urethral strictures resulting from pelvic fracture. MATERIALS AND METHODS: A total of 573 patients, who underwent bulboprostatic anastomosis for posterior urethral strictures, were enrolled in this study. Distraction defects were measured using retrograde urethrography combined with voiding cysto-urethrography. All patients underwent perineal excision and primary anastomotic urethroplasty. The urethroplasty was considered successful if the patient was free of stricture-related obstruction and did not require any further intervention. The degree of stress incontinence was assessed daily by pad testing. The prevalence of pre- and postoperative sexual disorders was investigated using the International Index of Erectile Function-5 questionnaire. RESULTS: Of 573 bulboprostatic anastomosis procedures performed, 504 (88%) were successful and 69 (12%) were not successful. The mean (sd) maximum urinary flow rate, assessed by uroflowmetry 4 weeks after surgery, was 20.52 (5.1) mL/s. Intraoperative rectal injury was repaired primarily in 28 cases. Recurrence of urethral strictures was observed in 10 (1.7%) patients during the first 6 months after surgery, and in 45 patients from 6 months to 1 year. All of these patients underwent re-operation. Twenty-four (4.2%) patients had mild urge incontinence and 28 (4.9%) had mild stress incontinence. Erectile dysfunction (ED) was present in two (<0.1%) patients before trauma and in 487 (85%) patients after trauma. There was no statistical difference between the incidences of preoperative and postoperative ED (85 vs 86%, P > 0.05). Nine (1%) patients were found to have false passage between the posterior urethra and bladder neck. CONCLUSION: The majority of complications associated with transperineal bulboprostatic anastomosis can be avoided as long as meticulous preoperative evaluation to define the anatomy and careful intra-operative manipulation are ensured.

Transperineal bulbo-prostatic anastomosis for posterior urethral stricture associated with false passage: a single-centre experience.

OBJECTIVE: • To evaluate the management of traumatic posterior urethral stricture associated with false passage, as this remains a challenge for urologists. PATIENTS AND METHODS: • From January 2000 to February 2010, 19 patients (mean (range) age 34 [25-52] years) with traumatic posterior urethral obliteration associated with false passage were evaluated and treated at our centre. • All patients underwent perineal excision and primary anastomotic urethroplasty using cystoscopy by the suprapubic route to insert a guidewire into the original bladder neck, allowing exposure of the normal posterior urethra. • Patients underwent voiding cysto-urethrography 1 month after the procedure. When symptoms of decreased force of stream were present and uroflowmetry was <15 mL/s, urethrography and urethroscopy were repeated. • Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilatation. RESULTS: • The mean (range) follow-up was 12 (9-14) months. The overall success rate was 84%. • Three patients (16%) with persistent voiding difficulty developed a short anastomotic stricture 1-3 months after surgery. • The mean maximum urinary flow rate after surgery was 20.01 mL/s and no patient had urinary incontinence. CONCLUSION: • The preoperative use of flexible cystoscopy via the suprapubic route represented a successful key point of urethroplasty for posterior urethral stricture associated with false passage.

Surgical treatment of 31 complex traumatic posterior urethral strictures associated with urethrorectal fistulas.

BACKGROUND: Urethrorectal fistulas (URF) in patients with complex posterior urethral strictures are rare and difficult to repair surgically. There is no widely accepted standard approach described in the published literature. OBJECTIVE: The aim of this study was to describe the outcomes of various operative approaches for the repair of URFs in patients with complex posterior urethral strictures. DESIGN, SETTING, AND PARTICIPANTS: From January 1985 to December 2007, 31 patients (age: 6-61 yr; mean: 28.4) with URFs secondary to posterior urethral strictures were treated using a perineal or combined abdominal transpubic-perineal approach. INTERVENTIONS: A simple perineal approach was used in 4 patients; a transperineal inferior pubectomy approach was used in 18 patients; and a combined transpubic-perineal approach was used in 9 patients. A bulbospongiosus muscle and subcutaneous dartos pedicle flaps were interposed between the repaired rectum and urethra in 22 patients. The combined transpubic-perineal approach used either a gracilis muscle flap (one patient) or a rectus muscle flap (eight patients). MEASUREMENTS: Suprapubic catheterisation was used for bladder drainage, and a urethral silicone stent was left indwelling for 4 wk. RESULTS AND LIMITATIONS: One-stage repair was successful in 4 patients (100%) using the perineal approach, in 16 of 18 patients (88.9%) using the transperineal-inferior pubectomy approach, and in 7 of 9 patients (77.8%) using the transpubic-perineal approach. Recurrent urethral strictures developed in two cases; one patient required regular dilation, and the other patient was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent URFs developed in two additional patients. CONCLUSIONS: Surgical approaches for the treatment of URFs associated with complex urethral strictures should be based on a number of considerations including the location of the URF, its aetiology, the length of the urethral strictures, and a history of previous unsuccessful repairs. These results demonstrate that the transperineal-inferior pubic approach may be appropriate as a first-line procedure.

Transperineal bulboprostatic anastomosis in patients with simple traumatic posterior urethral strictures: a retrospective study from a referral urethral center.

OBJECTIVES: To evaluate the results of ancillary procedures for posterior urethroplasty and compare them with the severity of urethral stricture. METHODS: A total of 301 patients (average age: 36 years) with posterior urethral strictures due to pelvic fracture urethral distraction defects were included in the study. Delayed transperineal bulboprostatic anastomosis was performed 6-24 months (mean 10 months) after pelvic fracture urethral distraction defects. Simple perineal anastomosis: 103 (34.2%) patients (group 1); perineal anastomosis with separation of the corporeal bodies: 89 (29.6%) patients (group 2); perineal anastomosis with inferior pubectomy: 95 (31.6%) patients (group 3); perineal anastomosis with rerouting of the urethra around the corpora cavernosum: 14 (4.7%) patients (group 4). The clinical outcome was considered a failure when any postoperative instrumentation was needed. The primary outcome examined the total success rate of the procedures. The secondary outcome examined the success rate of the procedures according to the ancillary surgical steps. RESULTS: Of the 301 delayed transperineal bulboprostatic anastomosis procedures, 263 (87.4%) were successful and 38 (12.6%) were unsuccessful. Simple perineal anastomosis without ancillary procedures reflected an 89.3% success rate, perineal anastomosis with separation of the corporeal body had an 86.5% success rate, perineal anastomosis with inferior pubectomy had an 84.2% success rate, and perineal anastomosis with urethral rerouting had an 85.7% success rate. CONCLUSIONS: Corporal splitting, inferior pubectomy, and urethral rerouting are beneficial and useful ancillary procedures in transperineal posterior urethroplasty to achieve tension-free anastomosis.

Use of anastomotic urethroplasty with partial pubectomy for posterior urethral obliteration injuries: 10 years experience.

PURPOSE: Management of pelvic trauma-induced posterior urethral disruption due can be quite controversial and challenging. METHODS: Posterior urethral obliteration cases at the membranous urethra (n = 154) were analyzed from January 1997 to December 2006. The mean length of the urethral obliteration was 4.82 +/- 1.1 cm (range 3.5-6 cm). All patients underwent excision and primary bulboprostatic anastomosis with a perineal approach partial pubectomy. RESULTS: The percentage of overall successful surgeries (defined by Qmax values > 15 ml/s) was 85.1%, and the mean Qmax value was 22.94 +/- 5.7 cm/s without post-operative incontinence. Short anastomotic strictures developed 1-3 months post-operatively in 23 cases with persistent voiding difficulties. CONCLUSIONS: Partial pubectomy is a feasible therapeutic option in patients with long urethral obliteration and may provide effective surgical results for post-traumatic posterior urethral strictures.

Transpubic access using pedicle tubularized labial urethroplasty for the treatment of female urethral strictures associated with urethrovaginal fistulas secondary to pelvic fracture.

BACKGROUND: Female urethral injury is rare, and there is no accepted standard approach for the repair of urethral strictures. OBJECTIVE: To evaluate the efficacy of transpubic access using pedicle tubularized labial urethroplasty for urethral reconstruction in female patients with urethral obliterative strictures and urethrovaginal fistulas. DESIGN, SETTING, AND PARTICIPANTS: Between January 1996 and December 2006, eight cases of female urethral strictures associated with urethrovaginal fistulas were treated using pedicle labial skin flaps. INTERVENTIONS: A flap of approximately 3x3.5x3cm of the labia minora or majora with its vascular pedicle was tubularized over an 18-22 Fr fenestrated silicone stent to create a neourethra. This technique was used in five women. Two flaps, approximately 1.5-3.5 cm, were taken from bilateral labia minora or majora and were pieced together to create a neourethra. This technique was used in three patients. MEASUREMENTS: We performed voiding cystourethrography and uroflowmetry to assess postoperative results. RESULTS AND LIMITATIONS: The patients were followed up for 10-118 mo (mean 48.25 mo) after the procedure. There were no postoperative complications. Two patients complained of dysuria, which resolved spontaneously after 2 wk. One patient experienced stress incontinence that resolved after 4 wk. At 3-mo follow-up, one patient complained of difficulty voiding; the urinary peak flow was 13 ml/s, and the patient was treated successfully with urethral dilation. All other patients had normal micturition following catheter removal. CONCLUSIONS: Pedicle labial urethroplasty is a reliable technique for the repair of extensive urethral damage, and a transpubic surgical approach provides wide and excellent exposure for the management of complex obliterative urethral strictures and urethrovaginal fistulas secondary to pelvic fracture.

[Tree analysis pattern of mass spectral urine profiles in differential diagnosis of bladder transitional cell carcinoma].

OBJECTIVE: To develope a tree analysis pattern of mass spectral urine profiles to discriminate bladder transitional cell carcinoma (TCC) from non-cancer lesions using surface-enhanced laser desorption and ionization time-of-flight mass spectrometry (SELDI-TOF-MS) technology. METHODS: Urine samples from 61 bladder transitional cell carcinoma (TCCs) patients, 53 healthy volunteers and 42 patients with other urogenital diseases were analyzed using IMAC-Cu-3 ProteinChip. Proteomic spectra were generated by SELDI-TOF- MS. A preliminary "training" set of spectra derived from analysis of urine from 46 TCC patients, 32 patients with benign urogenital diseases (BUD), and 40 age-matched unaffected healthy men were used to train and develop a decision tree classification algorithm which identified a fine-protein mass pattern that discriminated cancers from non-cancers effectively. A blinded test set including 38 cases was used to determine the sensitivity and specificity of the classification system. RESULTS: The algorithm identified a cluster pattern that, in the training set, segregated cancer from non-cancer with a sensitivity of 84.8% and specificity of 91.7%. The discriminatory pattern was correctly identified. A sensitivity of 93.3% and a specificity of 87% for the blinded test were obtained when compared the TCC versus non-cancers. CONCLUSION: SELDI-TOF-MS technology is a rapid, convenient and high-throughput analyzing method. The urine tree analysis proteomic pattern as a screening tool is effective for differential diagnosis of bladder cancer. More detailed studies are needed to further evaluate the clinical value of this pattern.

Staged pendulous-prostatic anastomotic urethroplasty followed by reconstruction of the anterior urethra: an effective treatment for long-segment bulbar and membranous urethral stricture.

OBJECTIVES: To describe a novel surgical technique for male long-segment urethral stricture after pelvic trauma using the intact and pedicled pendulous urethra to replace the bulbar and membranous urethra, followed by reconstruction of the anterior urethra. METHODS: Two patients with long-segment post-traumatic bulbar and membranous urethral strictures with short left pendulous urethras who had undergone several failed previous surgeries were treated with staged pendulous-prostatic anastomotic urethroplasty followed by reconstruction of the anterior urethra. This procedure was divided into three stages. First-stage surgery was mobilization of the anterior urethra down to the coronary sulcus and then rerouted to the prostatic urethra followed by pendulous-prostatic anastomotic urethroplasty with transposition of the penis to the perineum. Second-stage surgery was transecting the anterior urethra at the revascularised coronary sulcus 6 mo later, followed by straightening of the penis and urethroperineostomy. Third-stage surgery was reconstruction of the anterior urethra 6 mo later. RESULTS: Postoperatively, the two patients reported satisfactory voiding. For patient 1, retrograde urethrography showed that the urethra was patent, and that the mean maximal flow rate (MFR) was 18.4 ml/s with no postvoiding residual urine after the third-stage surgery and at 3-yr follow-up. For patient 2, a 22F urethral catheter could pass smoothly through the urethra, and the MFR was 19.5 ml/s with no postvoiding residual urine at 2-yr follow-up. CONCLUSIONS: This procedure was an effective surgical option for men with complex long-segment post-traumatic bulbar and membranous urethral strictures, especially for those who had undergone failed previous surgical treatments.

[Clinical analysis of operative treatment of 191 patients with posterior urethral strictures].

OBJECTIVE: To evaluate the various operative details of strictures of the posterior urethra that are essential for a successful result. METHODS: The clinical data of 191 patients with posterior urethral strictures or distraction defects from January 1990 to January 2006 were analyzed retrospectively. All patients underwent a retrograde and voiding urethrogram, 62 patients had urethral ultrasonography, 48 patients had urethroscopy, 3 patients had MRI. Repair was performed with a simple anastomosis after urethral mobilization in 66 patients, separation of the corporeal bodies in 48 patients, separation of the corporeal bodies and inferior pubectomy in 30 patients, transpubic anastomosis in 18 patients, pull-through operation in 3 patients, and optical urethrotomy in 26 patients. Followup ranged from 6 to 48 months. RESULTS: The mean stricture length was 3.6 cm (range from 1.5 to 8.0 cm). Posterior urethral strictures is in 31 (16%), posterior distraction defects is in 160 (84%), of which the length of the distraction defects < 3 cm is in 102 (53.4%), and the the length of the distraction defects > 3 cm is in 58 (30.6%). The overall successful results (Qmax > 15 ml/s) after operation was 84.3%. Optical urethrotomy was 69%, the successful results with anastomotic urethroplasty were 97% with a simple anastomosis; 79% with separation of the corporeal bodies; 80% with separation of the corporeal bodies and inferior pubectomy; 83% with transpubic anastomosis; and 67% with pull-through operation. CONCLUSIONS: The anastomotic urethroplasty is better than the optical urethrotomy, the length of the strictures or distraction defect which is lower than 3 cm is much more successfully corrected.

[The treatment of complex urethral stricture greater than 8 cm long].

OBJECTIVE: To evaluate the selection of different procedures and the feasibility for the treatment of long segment urethral stricture. METHODS: Seventy-six patients with complex urethral stricture greater than 8 cm long underwent different procedures of urethroplasty. Of them various mucosa grafts urethral reconstruction were adopted in 42 cases (colonic mucosal graft, n = 26; buccal mucosal graft, n = 10; bladder mucosal graft, n = 6); One-stage pedicle flaps urethroplasty in 20; two-stage urethroplasty of Johanson procedure in 12; and penile urethra-prostatic urethra anastomosis, three-stage urethroplasty in 2. RESULTS: In early followed up (within 6 months postoperatively), 67 patients (88%) voided well and complications developed in 10. Among the 70 patients who lasted more than 1 year after operation, 51 cases were followed up. Forty-four patients voided well, and complications developed in 8. Of the 8 cases urethral restructure developed in 2 (18%) for pedicle flaps urethroplasty, 2 for colonic mucosal urethroplasty (9%), 1 for buccal mucosal graft (1/7), 1 for bladder mucosal graft (1/3); penile chordee in 2 (2/5), and one of them was accompanied by hair bearing neourethra for two-stage urethroplasty of Johanson procedure. CONCLUSIONS: Colonic mucosal and buccal mucosal grafts urethroplasty are feasible procedures for the treatment of long segment urethral stricture, and Colonic mucosal graft urethroplasty may be considered when more conventional procedures fail or complicated urethral strictures greater than 10 cm long.

An evaluation of surgical approaches for posterior urethral distraction defects in boys.

PURPOSE: We present our preliminary experience with operative approaches in the treatment of complex posterior urethral distraction defects in children. MATERIALS AND METHODS: A total of 24 boys 7 to 14 years old with obliterative complex posterior urethral distraction defects were treated with 1 of 3 surgical approaches between January 1998 and December 2002. A perineal approach was used in 5 cases, a transperineal-inferior pubic approach including distal urethral mobilization, corporeal body separation and inferior pubectomy in 10, and a combined transpubic-perineal approach in 9. RESULTS: Patients were followed 1 to 5 years postoperatively. A successful result of no recurrence of stricture was achieved in 19 of 24 patients (79.2%), including 3 of 5 (60%) treated with a perineal approach, 9 of 10 (90%) with a transperineal-inferior pubic approach and 7 of 9 (77.8%) with a transpubic-perineal approach. Complications included 1 combined false passage, which was resolved using a transperineal-inferior pubic approach, 2 urethrocutaneous fistulas, which were resolved using a perineal approach in 1 and a transpubic-perineal approach in 1, and 3 rectourethral fistulas, which were resolved using a transpubic-perineal approach in 1 and a transperineal-inferior pubic approach in 1. Of the 9 patients treated with the transpubic-perineal approach 3 walked with an abnormal gait postoperatively. CONCLUSIONS: The transperineal-inferior pubic approach fully exposes the space behind the pubis, does not damage pelvic stability and yields better results compared to the perineal and transpubic-perineal approaches. We recommend it as first line operative treatment for complex posterior urethral distraction defects in boys.

[Ultrasonographic assessment of urethral condyloma acuminatum in men].

OBJECTIVE: To evaluate the value of ultrasonography in diagnosing urethral condyloma acuminatum (CA) in men. METHODS: Twenty-two male patients, aged 36 +/- 19, diagnosed as with urethral CA based on history and clinical symptoms underwent ultrasonography and urethroscopy. The patients were asked to micturate to distend the urethra. The posterior urethra was detected by transrectum approach. Transperineal scans were performed to image the bulbar urethra, scrotal urethra and penile urethra. The sonographically positive results were compared with the pathological results. RESULTS: Eighty-three vegetations were found in the anterior urethra of seventeen patients, and eighty-one vegetations were diagnosed as CA by pathology, of which 1.2% were polyp shape, 38.3% papillary shape, and 60.5% cauliflower mass. Sonourethrography was an accurate predictor of papillary shape and cauliflower mass; however, it was difficult to differentiate between polyp shape vegetation and crystal. CONCLUSION: Sonourethrography is a sensitive and accurate tool not only for primary diagnosis of but also for follow-up of urethral CA in men.

[Screening urine markers of renal cell carcinoma using SELDI-TOF-MS].

OBJECTIVE: To screen relatively specifical markers in urines from renal cell carcinoma patients using surface-enhanced laser desorption and ionization time of flight mass spectrometry (SELDI-TOF-MS) ProteinChip technology. METHODS: Urine samples from 40 renal cell carcinoma (RCC) patients, 40 healthy volunteers and 40 patients with other urogenital diseases were analyzed using IMAC-Cu-3 PoteinChip, which can specifically bind the metal-combining-proteins. Proteomic spectra were generated by mass spectrometry. RESULTS: Four differentially expressed potentially biomarkers were identified with the relative molecular weights of 4020, 4637, 5070, and 5500. The sensitivity for diagnosing RCC was 57.5%, 66.7%, 63.7%, 65%, and specificity was 86.2%, 95%, 82.5% and 75% when the critical points were 2.0, 5.0, 5.0 and 5.0 respectively. CONCLUSIONS: SELDI-TOF-MS ProteinChip technology is a quickly, easy and convenient, and high-throughput analyzing method capable of screening several relatively specific, potential biomarkers from the urines of RCC patients and had better clinical value.

Efferent tube suspension as a continent diversion mechanism: a preliminary report of a clinical study.

PURPOSE: We constructed a reliable continent tube that is surgically simple. MATERIALS AND METHODS: In 12 patients with malignant bladder tumor we performed radical cystectomy with isolation of a 50 cm. ileal loop with pedicle. The proximal segment (8 to 10 cm.) was tapered over a 16Fr catheter as an efferent tube, the remaining segment was detubularized to create a W-shape pouch and the tapered ileum was fixed to the back surface of the rectus muscle with 2 polyester tapers 1 cm. wide with a suspension tension of 500 g. The external orifice of the tapered ileum was anastomosed to the umbilicus. In 2 patients with neuropathic bladder a 15 cm. ileal loop with pedicle was isolated, the proximal segment (8 cm.) was tapered as an efferent tube with 500 g. suspension tension, and the remaining segment was detubularized and anastomosed to the bladder. RESULTS: The patients were followed for 6 to 17 months (mean 11.4) and were completely continent day and night. The stoma was easily catheterized with a 16Fr catheter in all cases. Urodynamic study of the efferent tubes revealed maximum pressure of 84 to 159 cm. water (mean 114). Retrograde radiography of the efferent tubes demonstrated perfect canalization without stenosis. CONCLUSIONS: This study suggests that the continent mechanism of the tapered ileum can be greatly enhanced by a suspension technique. This maneuver also provides easy catheterization and surgical simplicity.