Preservation of the native urethral plate and corpus spongiosum combined with buccal mucosa graft plus Orandi's penile skin flap as an alternative to staged urethroplasty for narrow penile strictures.

OBJECTIVE: In narrow anterior urethral strictures, the combined buccal mucosa graft (BMG) with pedicled penile skin flap (PSF) represents a well-known effective alternative to staged urethroplasty. We hypothesized that if the native urethral plate and adjacent corpus spongiosum were preserved, a narrower flap would be needed, and reinforced ventral stability could be achieved without compromising the surgical outcome. METHODS: Twelve patients with narrow penile urethral strictures underwent single-stage augmentation urethroplasty using a combined technique. A BMG was quilted to the corpora cavernosa in a dorsal onlay approach, and a longitudinal ventral PSF was transposed ventrally and sutured to the scarred native urethral mucosa on one side and to the BMG on the other side to form a neourethra of triangular form. The preserved corpus spongiosum was wrapped and fixed around the flap ventrally. RESULTS: The median age was 47 years (IQR 35-59), and the median stricture length was 5 cm (IQR 3, 8-7). The median surgical time was 205 min (IQR 172-236). The overall success rate (SR) was 91.7% without sacculation or diverticula formation after a median follow-up period of 38 months (IQR 33-40). Three transient fistulas healed through prolonged urinary diversion. Five patients (41.7%) reported postvoid dribbling following urethroplasty. CONCLUSION: Preservation of the native urethral plate is a valuable adjunct to the combination of graft and flap for single-stage augmentation urethroplasty for narrow urethral strictures, with satisfactory mid-term success and an acceptable complication rate.

Early safety and efficiency outcomes of a novel interdisciplinary laparoscopic resection rectopexy combined with sacrocolpopexy for women with obstructive defecation syndrome and pelvic organ prolapse: a single center study.

BACKGROUND: Obstructive defecation syndrome (ODS) defines a disturbed defecation process frequently associated with pelvic organ prolapse (POP) in women that substantially compromises quality of life. Conservative management offers limited relief and a surgical intervention may be required. This is characterized by individual approaches. AIM OF THE STUDY: This retrospective single center study evaluated the surgical and clinical short-term outcome of a novel interdisciplinary laparoscopic resection rectopexy (L-RRP) with mesh- sacrocolpopexy (L-SCP) for women suffering from ODS and POP. METHODS: The study participants underwent surgery in an interdisciplinary laparoscopic approach. Safety was the primary endpoint, assessed via postoperative morbidity classified by Clavien-Dindo scale. Secondary outcomes included evaluation of bowel function, fecal and urinary incontinence and pelvic organ prolapse status at 12 months follow-up. Additionally, a biological mesh (BM) was offered to women, who asked for an alternative to synthetic mesh material (SM). RESULTS: Of the 44 consecutive patients requiring surgery for ODS and POP, 36 patients underwent the interdisciplinary surgical approach; 28 patients with SM and 8 patients with BM. In total 5 complications occurred, four of them were classified as minor. One minor complication was observed in the BM group. One anastomotic leakage occurred in the SM group. The two ODS scores, the bowel dysfunction score, and the incontinence score improved significantly (p = 0.006, p = 0.003, p < 0.001, and p = 0.0035, respectively). Pelvic floor anatomy was fully restored (POP-Q 0) for 29 (80%) patients after surgery. 17 patients (47%) suffered from urinary incontinence before surgery, which was restored in 13 patients (76.5%). CONCLUSIONS: The interdisciplinary approach with L-RRP and L-SCP and the use of a BM in a small subgroup were technically feasible, safe, and effective in this single center setting. The study's retrospective design, the small sample size and the lack of comparators limit the generalizability of the findings requiring future randomized trials. TRIAL REGISTRATION: Retrospectively registered at clinicaltrials.gov, trial number NCT05910021, date of registration 06/10/2023.

Comparison of oral morbidity and mid-term efficacy of anterior urethroplasty using an autologous tissue-engineered graft (MukoCell®) versus native oral mucosa graft.

OBJECTIVE: Our study aimed to compare surgical success rate (SR) and oral morbidity of augmentation urethroplasty for anterior urethral strictures using autologous tissue-engineered oral mucosa graft (TEOMG) named MukoCell® versus native oral mucosa graft (NOMG). METHODS: We conducted a single-institution observational study on patients undergoing TEOMG and NOMG urethroplasty for anterior urethral strictures >2 cm in length from January 2016 to July 2020. SR, oral morbidity, and potential risk factors of recurrence were compared between groups were analyzed. A decrease of maximum uroflow rate < 15 mL/s or further instrumentation was considered a failure. RESULTS: Overall, TEOMG (n = 77) and NOMG (n = 76) groups had comparable SR (68.8% vs. 78.9%, p = 0.155) after a median follow-up of 52 (interquartile range [IQR] 45-60) months for TEOMG and 53.5 (IQR 43-58) months for NOMG. Subgroup analysis revealed comparable SR according to surgical technique, stricture localization, and length. Only following repetitive urethral dilatations, TEOMG achieved lower SR (31.3% vs. 81.3%, p = 0.003). Surgical time was significantly shorter by TEOMG use (median 104 vs. 182 min, p < 0.001). Oral morbidity and the associated "burden" in patients' quality of life were significantly less at 3 weeks following the biopsy required for TEOMG manufacture, compared to NOMG harvesting and totally absent at 6 and 12 months postoperatively. CONCLUSIONS: The SR of TEOMG urethroplasty appeared to be comparable to NOMG at a mid-term follow-up but taking into account the uneven distribution of stricture site and the surgical techniques used in both groups. Surgical time was significantly shortened, since no intraoperative mucosa harvesting was required, and oral complications were diminished through the preoperative biopsy for MukoCell® manufacture.

Bilateral T-shaped Scrotoplasty as an Ancillary Technique of Staged Anterior Urethroplasty: The End Justifies the Means.

Staged urethroplasty is performed to treat long-segment obliterating anterior urethral strictures. The technique is particularly challenging when the penobulbar junction is involved, as it requires the transection of the scrotum and the formation of lateral testicular fans. To date, there is no established surgical protocol for this ancillary technique in large volume scrotums with excess skin. We report a case of staged urethroplasty with the necessity of performing T-scrotoplasty due to bulky scrotum. After six months, the T-plasty was successfully resolved, and a new scrotum was formed from the two hemiscrota. In conclusion, scrotoplasty using a bilateral T-plasty is an excellent technique to overcome the necessity of splitting the scrotum by externalizing the urethra to allow for excellent buccal mucosal graft healing over a period of six months. The two separate testicular fans can be reapproximated along the raphe after re-tubularizing the urethra in the 2nd stage, shaping a new scrotum with satisfactory cosmetic results.

Tacks vs. sutures: a biomechanical analysis of sacral bony fixation methods for laparoscopic apical fixations in the porcine model.

PURPOSE: There is a novel surgical procedure, called cervicosacropexy (CESA) and vaginosacropexy (VASA) to treat pelvic organ prolapse and a concomitant urgency and mixed urinary incontinence. As there is little experience with the tapes so far and literature is scanty, the aim of this study was to investigate biomechanical properties for the fixation of the PVDF-tapes with three different fixation methods in context of apical fixations. METHODS: Evaluation was performed on porcine, fresh cadaver sacral spines. A total of 40 trials, divided into 4 subgroups, was performed on the anterior longitudinal ligament. Recorded biomechanical properties were displacement at failure, maximum load and stiffness in terms of the primary endpoints. The failure mode was a secondary endpoint. Group 4 was a reference group to compare single sutures on porcine tissue with those on human tissue. Biomechanical parameters for single sutures on the human anterior longitudinal ligament were evaluated in a previous work by Hachenberg et al. RESULTS: The maximum load for group 1 (two single sutures) was 65 ± 12 N, for group 2 (three titanium tacks arranged in a row) it was 25 ± 10 N and for group 3 (three titanium tacks arranged in a triangle) it was 38 ± 12 N. There was a significant difference between all three groups. The most common failure mode was a "mesh failure" in 9/10 trials for groups 1-3. CONCLUSION: The PVDF-tape fixation with two single sutures endures 2.6 times more load than titanium tacks arranged in a row and 1.7 times more load than titanium tacks arranged in a triangle. The presacral fixation with titanium tacks reduced surgical time compared to the fixation with sutures, nevertheless sutures represent the significantly stronger and cheaper fixation method.

A biomechanical analysis of different meshes for reconstructions of the pelvic floor in the porcine model.

PURPOSE: Many different surgical approaches have been established for the repair of a pelvic organ prolapse. Especially in laparoscopic surgery, it is important to generate easy surgical techniques with similar stability. This study shall simplify the choice of mesh by evaluating three polypropylene meshes regarding their biomechanical properties. METHODS: Biomechanical testing was performed in the porcine model. The meshes are fixated on porcine fresh cadaver cervices after subtotal hysterectomy. The apical part of the mesh is fixated with parallel screw clamps at the testing frame. Forty-one trials were performed overall, subdivided into four subgroups. The groups differ in mesh type and fixation method. Maximum load, displacement at failure and stiffness parameters were evaluated with an Instron 5565® test frame. RESULTS: SERATEX® E11 PA (E11) showed the highest values for maximum load (199 ± 29N), failure displacement (71 ± 12 mm) and stiffness (3.93 ± 0.59 N/mm). There was no significant difference in all three evaluated parameters between SERATEX® B3 PA (B3) and SERATEX® SlimSling® with bilateral fixation (SSB). SERATEX® SlimSling® with unilateral fixation (SSU) had the lowest stiffness (0.91 ± 0.19 N/mm) and maximum load (30 ± 2 N) but no significant difference in displacement at failure. CONCLUSION: All meshes achieved a good tensile strength, but the results of maximum load show that the E11 is superior to the other meshes. Through a bilateral fixation of SERATEX® SlimSling®, a simple operating method is generated without a loss of stability.

Safety and mid-term surgical results of anterior urethroplasty with the tissue-engineered oral mucosa graft MukoCell® : A single-center experience.

OBJECTIVE: To assess the mid-term efficacy and safety of anterior urethroplasty using an autologous tissue-engineered oral mucosa graft (MukoCell® ). METHODS: The data of 77 patients with anterior urethral strictures undergoing treatment with MukoCell® at a tertiary center from June 2016 to May 2019 were analyzed. Patients' characteristics, pre- and postoperative diagnostics, perioperative complications, and follow-up data were obtained. The overall stricture-free survival, outcomes of the different surgical techniques, stricture localizations, stricture length, early complications of the procedure and risk factors of recurrence were assessed. RESULTS: The median follow-up period was 38 months (interquartile range 31-46). The overall recurrence-free rate of anterior urethroplasty using MukoCell® was 68.8%, 24 patients (31.2%) developed a recurrence of the stricture. The stricture recurrences were observed at a median of 7 months (interquartile range 3-13) only in patients with at least one previous surgery or repeated dilatations in their medical history. No oral-urethral adverse events related to the use of MukoCell® were observed, except for a urethrocutaneous fistula (1.3%) requiring reoperation. CONCLUSIONS: Anterior one-stage urethroplasty using MukoCell® showed in our hands a mid-term success rate of up to 68.8% without significant adverse events after a median follow-up period of 38 months. This procedure might be an alternative option for long-segment urethral reconstruction.

Radiation exposure during retrograde intrarenal surgery (RIRS): a prospective multicenter evaluation.

PURPOSE: Retrograde intrarenal surgery (RIRS) may require extensive X-ray usage. We evaluated the impact of preoperative surgeon briefing regarding the inclusion and evaluation of fluoroscopy time (FT) and dose area product (DAP) in a multicenter study on the applied X-ray usage. METHODS: A prospective multicenter study of 6 tertiary centers was performed. Each center recruited up to 25 prospective patients with renal stones of any size for RIRS. Prior to study´s onset, all surgeons were briefed about hazards of radiation and on strategies to avoid high doses in RIRS. Prospective procedures were compared to past procedures, as baseline data. FT was defined as the primary outcome. Secondary parameters were stone-free rate (SFR), complications according to the Clavien, SATAVA and postureteroscopic lesion scale. Results were analyzed using T test, chi-squared test, univariate analysis and confirmed in a multivariate regression model. RESULTS: 303 patients were included (145 retro- and 158 prospective). Mean FT and DAP were reduced from 130.8 s/565.8 to 77.4 s/357.8 (p < 0.05). SFR was improved from 85.5% to 93% (p < 0.05). Complications did not vary significantly. Neither stone position (p = 0.569), prestenting (p = 0.419), nor surgeons' experience (> 100 RIRS) had a significant impact on FT. Significant univariate parameters were confirmed in a multivariate model, revealing X-ray training to be radiation protective (OR - 44, p = 0.001). CONCLUSIONS: Increased surgeon awareness of X-ray exposure risks has a significant impact on FT and DAP. This "awareness effect" is a simple method to reduce radiation exposure for the patient and OR staff without the procedures´ outcome and safety being affected.

A rare case of tined lead migration of InterStim device into the rectum with subsequent novel combined surgical-endoscopic removal technique.

After the introduction of self-anchoring tined leads in 2002, lead migration after sacral neuromodulation (SNM) in the form of InterStimTM (Medtronic, Minneapolis, MN) has been reduced; however, it remains a considerable complication of this otherwise low-risk procedure. As intestinal perforation through lead migration or primary incorrect positioning portrays a rarity and has been scarcely reported in the literature, no algorithm for explantation in such cases has been determined. We present a case of a young man with an SNM device implant (InterStim II®) because of neurogenic urinary retention, who was admitted with inflammation, localized at the sacral lead insertion site. Our diagnostic algorithm revealed a tined lead electrode protruding into the rectum without concomitant abscess. We performed an interdisciplinary surgical approach combining regular incisions over the sacrum and buttocks for dissection of the lead and the implanted pulse generator, respectively, with an endoscopic transanal lead extraction. This method prevented further bacterial seeding in the surrounding tissues of the colon and, therefore, presacral abscess formation or sacral osteomyelitis. Combined surgical-endoscopic removal of the InterStim device is an effective and safe procedure that should be included in the armamentarium of urologists performing neuromodulation surgery in cases of intestinal perforation.

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.

[Surgical treatment of pelvic organ prolapse]. / Chirurgische Therapie des urogenitalen Deszensus.

Female pelvic organ prolapse is a widely prevalent condition and is associated with variable morbidity. It encompasses a number of clinical conditions, including subvesical obstruction, overactive bladder symptoms, sexual dysfunction and urinary und fecal incontinence. The prevalence of pelvic insufficiency is estimated to be between 30 and 50 %. As life expectancy is increasing and the elderly population is growing, there will be an increased incidence of the condition and growing demand for pelvic floor treatment in the future. The incidence of recurrent pelvic floor prolapse is also growing. The goal of surgical management is the restoration of pelvic anatomy and bladder, vaginal and bowel function, resolution of patient symptoms and improvement in quality of life. The objective of this review is to present the main surgical procedures for different subtypes of genital prolapse and to evaluate their outcomes and complications. During the last ten years, technologies for the minimally invasive approach have advanced and robotic assisted sacrocolpopexy is now equivalent to classical vaginal and transabdominal procedures.

[Surgical management of female stress urinary incontinence]. / Operative Therapie der weiblichen Inkontinenz.

Stress urinary incontinence in women is a common problem in Germany, with approx. 5 million women suffering from incontinence symptoms. These numbers are increasing, due to demographic changes; the suspected numbers are even higher. Prior to treatment, an extended diagnostic approach - including urodynamics and cystoscopy when necessary - is essential for optimal treatment selection.Primary treatment should be conservative, with pelvic floor training as an essential part of a multi-modal treatment concept. If conservative treatment fails, surgery is necessary and an increasing number of women are being treated with sub-urethral slings. The use of classical and well-known reconstructive surgeries - such as colposuspensions - is decreasing. An artificial urinary sphincter is a seldom indication in women, but a feasible option if the patient is physically and manually fit enough. The following article will summarise current diagnostic approaches and treatment options.

[Vesicouterine fistula after caesarean section]. / Vesicouterine Fistel nach Sectio caesarea.

Vesicouterine fistulas (VUFs) are a pathological communication between uterus and urinary bladder, which are mainly related to iatrogenic lesions during caesarean sections or occur during vaginal deliveries after a previous caesarean section. The main symptoms are menstruation through the bladder (menouria), amenorrhea and urinary incontinence. Treatment can be conservative, hormonal or surgical; however, a spontaneous closure of the fistula is rare (5 %). We report a case of a female VUF with menouria after caesarean section with a successful surgical fistula excision. Based on this case report, we analyse the causes, symptoms, diagnostics and treatment of VUF as reported in the literature.

[Reconstructive urethral surgery]. / Rekonstruktive Chirurgie der Harnröhre.

Urethral strictures are independent of a patient's age and can happen in every life period. They are often iatrogenic, resulting from a transurethral surgical procedure or traumatic catheterisation. Endoscopic slotting is the surgery of choice; although this method is frequently associated with recurrence. Retrograde urethrography or cystourethrography continue to play a central role in diagnostic evaluation and treatment. There is no standardised procedure regarding the surgical technique, perioperative management, and postoperative follow-up. Evidence-based recommendations or guidelines do not exist. For a successful surgical treatment of the urethra it is important to have an excellent knowledge of the urethral and urogenital anatomy. The permanent removal of urethral strictures can only be achieved by open reconstructive surgery. Direct end-to-end urethroplasty is used, in general, for short bulbar urethral strictures, while urethroplasty with oral mucosa is used for longer bulbar and penile strictures. Urethral reconstruction using a patient-specific autologous cell transplant with MukoCell® is an alternative to the conventional transplantation with native oral mucosa. Urethral reconstruction should be performed in specialised centres with appropriate expertise.

[Female urethral diverticulum with calculus formation imitating stress incontinence]. / Weibliches urethrales Divertikel mit Steinbildung imitierend eine Belastungsinkontinenz.

A female urethral diverticulum (UD) is a rare condition with a prevalence of 0.6 - 4.7 %. Possible aetiologies include chronic infection of the periurethral glands, childbirth trauma, and iatrogenic lesions after urethral manipulation. The main symptoms are recurrent urinary tract infections, post-void dribbling and leakage of urine or purulent discharge by movement, which is caused by the emptying of the diverticular lumen (paradoxical incontinence). As this may imitate stress urinary incontinence, the final diagnosis is a challenge for urologists. We report the case of a female UD containing multiple calculi, which were diagnosed during diagnostic work-up of incontinence. Based on this case report, we want to present and analyse the symptoms as well as the diagnostic evaluation and treatment of UD as reported in the literature. Also we wish to emphasise that the differential diagnosis between a complicated diverticulum and stress urinary incontinence requires a precise knowledge of the symptoms and the diagnostic algorithm for the detection of a DU because the symptoms of these two conditions are similar.