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1.
J Urol ; 204(6): 1270-1274, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32718203

RESUMO

PURPOSE: Our primary objective was to determine the incidence of extravasation on imaging at the time of catheter removal after ventral onlay buccal mucosal graft urethroplasty. MATERIALS AND METHODS: This is a single center retrospective cohort study of patients who underwent ventral onlay buccal mucosal graft bulbar urethroplasty from 2007 to 2017. Patients with imaging at the time of catheter removal were included. Urethroplasty success was defined as the ability to pass a 17Fr cystoscope at the time of followup cystoscopy. RESULTS: A total of 229 patients met the inclusion criteria, including 110 with a ventral onlay buccal mucosal graft and 119 with an augmented anastomotic urethroplasty with a mean stricture length of 4.4 cm. Imaging consisted of a voiding cystourethrogram in 210 and retrograde urethrogram in 19 patients at a median of 21.7 days after surgery. The incidence of extravasation was 3.1% (7/229). Of patients who had a documented followup cystoscopy (60%, 137/229), those with extravasation on imaging had a worse urethroplasty success rate (60%, 3/5) compared to those who did not (94%, 117/130) (p=0.047). On multivariate analysis those who had 5 or more endoscopic interventions were 9.6 times more likely to demonstrate extravasation (OR 9.6, p=0.0080). CONCLUSIONS: The incidence of radiological extravasation after ventral onlay using a single buccal mucosal graft, with or without augmented anastomotic urethroplasty, is 3.1%. Given this low rate it is reasonable to omit routine imaging at the time of Foley removal in this population. It appears that extravasation may be associated with a worse cystoscopic patency rate but does not lead to more complications.


Assuntos
Cistoscopia/efeitos adversos , Extravasamento de Materiais Terapêuticos e Diagnósticos/epidemiologia , Cuidados Pós-Operatórios/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Estreitamento Uretral/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversos , Adulto , Cistoscopia/estatística & dados numéricos , Extravasamento de Materiais Terapêuticos e Diagnósticos/diagnóstico , Extravasamento de Materiais Terapêuticos e Diagnósticos/etiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Mucosa Bucal/transplante , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento , Uretra/diagnóstico por imagem , Uretra/cirurgia , Estreitamento Uretral/patologia , Cateterismo Urinário/instrumentação , Procedimentos Cirúrgicos Urológicos Masculinos/instrumentação
2.
J Urol ; 204(6): 1290-1295, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32717158

RESUMO

PURPOSE: We evaluated the success of minimally invasive management of lichen sclerosus with topical and intraurethral clobetasol, as defined by improvement in patient reported outcome measures and nonprogression to surgery. MATERIALS AND METHODS: We conducted a review of our prospective ongoing quality improvement study to determine outcomes of our current standard practice for males with penile and urethral biopsy proven lichen sclerosus. Data were collected between 2011 and 2019, and included patient demographic information, medical and surgical histories, and location and extent of lichen sclerosus related pathology. The primary outcomes for this study were voiding function and voiding related quality of life, and were assessed using the AUASS (American Urological Association Symptom Score) and quality of life bother index, respectively. RESULTS: We identified 42 patients with biopsy proven lichen sclerosus related urethral stricture disease. Of these patients 85.7% were treated with intraurethral steroids alone and did not require surgical intervention. Median AUASS significantly improved from 12 to 8, and median quality of life bother index improved from 4 ("mostly dissatisfied") to 2 ("mostly satisfied"). Average stricture length of those with penile urethral disease and bulbar urethral disease was 4.8 cm (SD 3.0) and 16.2 cm (SD 6.5), respectively. Median followup was 8.4 months (IQR 2.6-26.4). CONCLUSIONS: Lichen sclerosus related urethral stricture disease can be effectively managed with intraurethral steroids. This minimally invasive management strategy improves patient reported voiding symptoms and voiding quality of life.


Assuntos
Clobetasol/administração & dosagem , Líquen Escleroso e Atrófico/tratamento farmacológico , Qualidade de Vida , Estreitamento Uretral/tratamento farmacológico , Micção/fisiologia , Administração Tópica , Adulto , Biópsia , Seguimentos , Humanos , Líquen Escleroso e Atrófico/complicações , Líquen Escleroso e Atrófico/patologia , Líquen Escleroso e Atrófico/fisiopatologia , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Satisfação do Paciente , Pênis/efeitos dos fármacos , Pênis/patologia , Estudos Prospectivos , Estudos Retrospectivos , Creme para a Pele/administração & dosagem , Resultado do Tratamento , Uretra/efeitos dos fármacos , Uretra/patologia , Estreitamento Uretral/etiologia , Estreitamento Uretral/patologia , Estreitamento Uretral/fisiopatologia
3.
Urology ; 137: 183-189, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31926195

RESUMO

OBJECTIVE: To characterize the bulbospongiosus muscle (BSM) in patients with bulbar urethral strictures. MATERIALS AND METHODS: We studied 21 patients divided into 2 groups: Stricture Group (n = 14; mean age = 62.00 years) with bulbar stricture submitted to open urethroplasty; and Control Group (n = 7; mean age = 60.14 years) with penile strictures (hypospadias cripples, penile cancer and/or penile infection) who were submitted to perineal urethrostomy. Samples of the BSM were dissected and histologic sections were stained by histochemical and immunohistochemical techniques. Histomorphometric analyzes were performed on photomicrographs. Means were statistically compared using the unpaired Student t test and the Mann-Whitney test (P <.05). RESULTS: The etiology of bulbar urethral stricture was idiopathic in 2 cases (14.29%), post-TURP in 6 (42.86%), post open radical prostatectomy in 5 (35.71%) and post open prostatectomy in 1 case (7.14%). The average length of the stricture was 2.08 cm. The only parameter analyzed with significant difference between the groups was the vessels (significant difference between the control group: 5.11 ± 1.98% and stricture group: 3.57 ± 1.32%, P = .0460). The quantitative analysis of collagen (Control Group: 10.63 ± 5.37% and Stricture Group: 10.83 ± 4.55%, P = .9296); diameter of BSM muscle fibers (Control Group: 41.71 ± 14.63 µm and Stricture Group: 40.11 ± 8.59 µm, P = .76 and elastic system fibers (Control Group; 3.83 ± 1.54% and Stricture Group: 5.43 ± 2.90%, P = .2601) showed no significant difference. CONCLUSIONS: Histologic analysis showed a significant decrease of the BSM vessels in urethral stricture, without changes in elastic fibers, collagen, nerves, and muscle fiber diameter. These findings show that the bulbar urethral stricture causes minimal alterations in the structure of the BSM.


Assuntos
Doenças do Pênis , Pênis , Complicações Pós-Operatórias , Uretra , Estreitamento Uretral , Procedimentos Cirúrgicos Urológicos , Pesos e Medidas Corporais/métodos , Brasil , Constrição Patológica , Correlação de Dados , Técnicas de Imagem por Elasticidade/métodos , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Doenças do Pênis/diagnóstico , Doenças do Pênis/etiologia , Pênis/patologia , Pênis/cirurgia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/patologia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Uretra/irrigação sanguínea , Uretra/inervação , Uretra/patologia , Uretra/cirurgia , Estreitamento Uretral/diagnóstico , Estreitamento Uretral/epidemiologia , Estreitamento Uretral/etiologia , Estreitamento Uretral/patologia , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Urológicos/métodos
4.
J Urol ; 203(4): 773-778, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31621469

RESUMO

PURPOSE: Urethroplasty of lichen sclerosus strictures has a significantly higher failure rate than strictures due to other causes. We sought to determine predictors of urethroplasty failure in men with lichen sclerosus urethral stricture disease by evaluating protein expression profiles. MATERIALS AND METHODS: Urethral tissue was excised from patients with lichen sclerosus who were undergoing urethroplasty of urethral stricture disease at a single institution. A tissue microarray was created with cores from each sample. Immunohistochemistry was performed to compare protein expression related to inflammation, cell cycle disruption, oxidative stress, hormone receptor status and infection. Stricture recurrence was defined by the need for a subsequent unanticipated procedure for urethral stricture disease. RESULTS: We evaluated 50 men with lichen sclerosus urethral stricture disease, including 31 with successful reconstruction and 19 with recurrent stricture. Recurrent strictures expressed lower levels of several inflammatory markers and had a lower Ki-67 mitotic index and significantly higher vascular endothelial growth factor levels than nonrecurrent strictures. CONCLUSIONS: To our knowledge this is the first study to use tissue protein expression to identify risk factors for urethroplasty failure among men with lichen sclerosus urethral stricture disease. Our findings suggest that recurrent lichen sclerosus strictures demonstrate a suppressed inflammatory response, a decreased cell turnover rate, and poor oxygenation and nutrient delivery. Prospective studies are needed to clarify the role of these pathways in the pathophysiology of lichen sclerosus urethral stricture disease, determine whether preoperative biopsy can predict urethroplasty success, help counsel patients and develop future treatments.


Assuntos
Líquen Escleroso e Atrófico/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Uretra/patologia , Estreitamento Uretral/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Biomarcadores/análise , Biomarcadores/metabolismo , Biópsia , Feminino , Seguimentos , Perfilação da Expressão Gênica , Humanos , Imuno-Histoquímica , Líquen Escleroso e Atrófico/complicações , Líquen Escleroso e Atrófico/patologia , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Prognóstico , Estudos Prospectivos , Recidiva , Reoperação/estatística & dados numéricos , Análise Serial de Tecidos , Resultado do Tratamento , Uretra/cirurgia , Estreitamento Uretral/etiologia , Estreitamento Uretral/patologia
5.
Urology ; 135: 139-145, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31586471

RESUMO

OBJECTIVE: To examine the most cited literature in urethral reconstruction, review types of work published, and observe research trends. METHODS: The Web of Sciences Sci-Expanded Index was used to conduct a search for urethral reconstruction. References were assessed for relevance to urethral reconstruction by 2 independent reviewers and a final list of the top 100 articles ranked by citation count was obtained. For each article, citation count, publication date, corresponding author, origin institution, origin country, topic area, study design, level of evidence, and origin journal were collected. RESULTS: The mean citation count per publication was 108 (median = 94.5; range = 69-366, SD = 43) with a total of 10,874 citations for all papers since 1970. The top 100 articles were published between 1973 and 2011, came from 19 different countries and 16 different journals. Nearly half were case series and most studies were Level III evidence or lower. The United States was the largest contributor to the top 100 with 56 publications, followed by Italy (14), England (12), and Egypt (7). "Outcomes of surgical treatment for urethral stricture disease" was the most prevalent topic area comprising 55 articles in the top 100, with most articles including descriptions or outcomes of novel surgical techniques. CONCLUSION: In this study, we discovered that the most cited literature in the field of urethral reconstruction is singularly focused and lacking in high levels of evidence. The top 100 cited articles originate primarily from the United States, focus on short-term outcomes after surgical treatment for urethral stricture disease, and are predominantly case series.


Assuntos
Bibliometria , Procedimentos Cirúrgicos Reconstrutivos/métodos , Uretra/cirurgia , Estreitamento Uretral/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Humanos , Masculino , Procedimentos Cirúrgicos Reconstrutivos/estatística & dados numéricos , Uretra/patologia , Estreitamento Uretral/patologia , Procedimentos Cirúrgicos Urológicos Masculinos/estatística & dados numéricos
6.
S Afr Med J ; 109(12): 947-951, 2019 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-31865957

RESUMO

BACKGROUND: Limited data are available on outcomes of the surgical management of inflammatory urethral strictures secondary to infection, a major cause of stricture. Several shortcomings that need to be addressed have been identified in the past. OBJECTIVE: To determine the impact of stricture length, position and degree of obliterative urethral lumen on the surgical outcomes of corrective procedures for inflammatory anterior urethral strictures. METHODS: This retrospective analysis used the records of patients who presented with proven infective anterior urethral strictures at an academic hospital from 2007 to 2010. All patients were followed up after 48 months. Urethroplasty outcomes were analysed according to stricture location and length and effect of urethral obliteration. RESULTS: The median age of the 174 patients in the study was 47 (range 21 - 86) years. Anastomotic urethroplasty was successful in 59/99 (59.6%) patients. Augmented anastomotic urethroplasty was successful in 11/15 (73.3%) patients. Dorsal onlay buccal mucosa graft urethroplasty was successful in 23/32 (71.9%) patients, significantly higher than in 2/9 (22.2%) patients who underwent ventral onlay buccal mucosa graft urethroplasty (p=0.017; hazard ratio 3.4; 95% confidence interval 1.29 - 9.40). The one-stage circular pedicled penile skin-flap urethroplasty was successful in 1/12 (8.3%) patients. Two-stage urethroplasty was successful in 5/7 (71.4%) patients. A primary component analysis of the 73 failed procedures showed that stricture length was the main contributor to failure (eigenvalue 1.79; 45%). CONCLUSIONS: Urethroplasty remains a challenge in inflammatory urethral strictures, where stricture length was the main reason for treatment failure.


Assuntos
Procedimentos Cirúrgicos Reconstrutivos/métodos , Uretra/patologia , Uretra/cirurgia , Estreitamento Uretral/patologia , Estreitamento Uretral/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Seguimentos , Humanos , Inflamação/microbiologia , Masculino , Pessoa de Meia-Idade , Mucosa Bucal/transplante , Estudos Retrospectivos , Fatores de Risco , Retalhos Cirúrgicos , Falha de Tratamento , Estreitamento Uretral/microbiologia , Infecções Urinárias/complicações , Adulto Jovem
7.
Prensa méd. argent ; 105(11): 852-860, dic2019. fig, tab
Artigo em Inglês | LILACS, BINACIS | ID: biblio-1050073

RESUMO

Background: The Tubularized Incised Urethral Plate (TIP) urethroplasty is a widely accepted technique among urologists and heavily used in their centers. This technique was developed by Snodgrass in 1994 for repairing varied degrees of hypospadias. Aim: This paper aims at analyzing and evaluating our early experience and the outcomes of using TIP urethroplasty technique. Therefore, the results have to be assessed in a large series. Methods: In this prospective study, 95 patients with varying hypospadiac meatus levels who experienced the procedure of TIP. During the entire sampling period, patients had varying degrees of hypospadias ranging from glanular to penoscrotal (glanular 2, coronal/subcoronal 37, distal shaft 30, mid-shaft 10, proximal shaft 5 and penoscrotal 11). Results: The overall success rate of TIP procedure repair of hypospadias was 87.4%; whereas the overall reoperation rate was 12.6%. The highest percentage was for those with failed previous repair (secondary). The average duration of the procedure was 58.6±18.4 minutes. Nearly a third of the patients developed one or more postoperative major complication. The total rate of fistula was 12.6%, with "10.6% in primary distal, 15.9% in primary proximal and 20% in secondary repair". Sixteen cases had a mild degree of "meatal stenosis" (16.8%), but all were managed by simple dilatation at the office or at home using 8 F feedingtube. Conclusion: The outcomes demonstrated that the TIP procedure is a quick, safe and reliable technique. Additionally, it can provide excellent cosmoses and function with few complications and acceptable reoperation rate.


Assuntos
Humanos , Masculino , Uretra/cirurgia , Estreitamento Uretral/patologia , Estudos Prospectivos , Hipospadia/cirurgia , Reoperação/estatística & dados numéricos
8.
BJU Int ; 124 Suppl 1: 37-41, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31638318

RESUMO

OBJECTIVES: To identify trends in the management of urethral stricture disease in Australia, assess changes in the standard of care, and examine the availability of genitourinary reconstructive surgery. METHODS: Data on eight stricture management procedures were collected online via Medicare Item Reports from the Australian Government Department of Human Services, and then matched to population data from the Australian Bureau of Statistics. A survey was disseminated via the Urological Society of Australia and New Zealand (USANZ) asking whether active members performed urethroplasty and whether this was done in a rural, regional or metropolitan setting. RESULTS: Over a 22-year period, there were 140 540 endoscopic procedures and 5136 urethroplasties, with 27.4 endoscopic procedures per urethroplasty. From 1994 to 2016, the per capita number of passage of sounds and dilatation procedures decreased by 74% and 75%, respectively, with increases in use of optical urethrotomy of 70% and in single-stage urethroplasty of 144%. Overall, the ratio of all endoscopic procedures vs urethroplasty decreased from 58.9 to 16.8. There were as few as 16 surgeons in the USANZ performing urethroplasty, with seven providing this service in regional areas. Seven had formal fellowship training. CONCLUSION: There has been a clear shift from repetitive endoscopic procedures towards urethroplasty, but the former still make up the majority of interventions. This may be explained by patients not being referred for urethroplasty earlier in the course of disease and there appears to be a gap in genitourinary reconstructive expertise in regional and rural areas.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Estreitamento Uretral/cirurgia , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos , Adulto , Austrália/epidemiologia , Dilatação/métodos , Dilatação/estatística & dados numéricos , Endoscopia/estatística & dados numéricos , Acesso aos Serviços de Saúde/tendências , Pesquisa sobre Serviços de Saúde , Humanos , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Recuperação de Função Fisiológica , Recidiva , Estudos Retrospectivos , Estados Unidos , Estreitamento Uretral/epidemiologia , Estreitamento Uretral/patologia , Procedimentos Cirúrgicos Urológicos/tendências
10.
Cell Transplant ; 28(9-10): 1106-1115, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31237144

RESUMO

The urethra is part of the lower urinary tract and its main role is urine voiding. Its complex histological structure makes urethral tissue prone to various injuries with complicated healing processes that often lead to scar formation. Urethral stricture disease can affect both men and women. The occurrence of this pathology is more common in men and thus are previous research has been mainly oriented on male urethra reconstruction. However, commonly used surgical techniques show unsatisfactory results because of complications. The new and progressively developing field of tissue engineering offers promising solutions, which could be applied in the urethral regeneration of both men´s and women´s urethras. The presented systematic review article offers an overview of the cells that have been used in urethral tissue engineering so far. Urine-derived stem cells show a great perspective in respect to urethral tissue engineering. They can be easily harvested and are a promising autologous cell source for the needs of tissue engineering techniques. The presented review also shows the importance of mechanical stimuli application on maturating tissue. Sufficient vascularization and elimination of stricture formation present the biggest challenges not only in customary surgical management but also in tissue-engineering approaches.


Assuntos
Células-Tronco/metabolismo , Engenharia Tecidual , Uretra/metabolismo , Estreitamento Uretral/terapia , Estreitamento Uretral/urina , Animais , Feminino , Humanos , Masculino , Células-Tronco/patologia , Uretra/patologia , Estreitamento Uretral/patologia
11.
J Cell Physiol ; 234(12): 23243-23255, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31144307

RESUMO

The effective treatment of urethral stricture remains a medical problem. The use of proinflammatory cytokines as stimuli to improve the reparative efficacy of mesenchymal stem cells (MSCs) towards damaged tissues represents an evolving field of investigation. However, the therapeutic benefits of this strategy in the treatment of urethral stricture remain unknown. Here, we enriched exosomes derived from human umbilical cord-derived MSCs pretreated with or without tumor necrosis factor alpha (TNF-α) to evaluate their therapeutic effects in an in vivo model of TGFß1-induced urethral stricture. Male Sprague-Dawley rats received sham (saline) or TGFß1 injections to urethral tissues followed by incisions in the urethra. Animals in the TGFß1 injection (urethral fibrosis) cohort were subsequently injected with vehicle control, or with exosomes derived from MSCs cultured with or without TNF-α. After 4 weeks, rats underwent ultrasound evaluation and, following euthanasia, urethral tissues were harvested for histological and molecular analysis. In vitro, the effects of MSC-derived exosomes on fibroblast secretion of collagen and cytokines were studied by enzyme-linked immunosorbent assay (ELISA), quantitative real-time polymerase chain reaction (qRT-PCR), and western blot analysis. Exosomes derived from MSCs pretreated with TNF-α were more effective in suppressing urethral fibrosis and stricture than exosomes from untreated MSCs. We found that miR-146a, an anti-inflammatory miRNA, was strongly upregulated in TNF-α-stimulated MSCs and was selectively packaged into exosomes. Moreover, miR-146a-containing exosomes were taken up by fibroblasts and inhibited fibroblast activation and associated inflammatory responses, a finding that may underlie the therapeutic mechanism for suppression of urethral stricture. Inhibition of miR-146a in TNF-α-treated MSCs partially reduced antifibrotic effects and increased the release of proinflammatory factors of exosomes derived from these cells. Together these findings demonstrate that exosomes derived from TNF-α-treated MSCs are of therapeutic benefit in urethral fibrosis, suggesting that this strategy may have utility as an adjuvant therapy in the treatment of urethral stricture diseases.


Assuntos
Exossomos/transplante , MicroRNAs/metabolismo , Fator de Necrose Tumoral alfa/metabolismo , Estreitamento Uretral/patologia , Animais , Exossomos/metabolismo , Fibroblastos/metabolismo , Fibrose , Humanos , Masculino , Células-Tronco Mesenquimais/metabolismo , Ratos , Ratos Sprague-Dawley
12.
Biomed Res Int ; 2019: 9046430, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31139658

RESUMO

To date, urethral stricture disease in men, though relatively common, represents an often poorly managed condition. Therefore, this article is dedicated to encompassing the currently existing data upon anatomy, etiology, symptoms, diagnosis, and treatment of the disease, based on more than 40 years of experience at a tertiary referral center and a PubMed literature review enclosing publications until September 2018.


Assuntos
Estreitamento Uretral/etiologia , Estreitamento Uretral/patologia , Humanos , Masculino , Retalhos Cirúrgicos , Ultrassonografia , Estreitamento Uretral/diagnóstico , Estreitamento Uretral/terapia
13.
J Urol ; 202(4): 748-756, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31091176

RESUMO

PURPOSE: Histopathology can provide insights into disease mechanisms but to date it has been poorly described for urethral stricture. The purpose of this study was to comprehensively describe histopathological findings of stricture specimens obtained at the time of anterior urethroplasty. MATERIALS AND METHODS: All pathological specimens of men who underwent anterior urethroplasty of urethral stricture disease from 2010 to 2017 at a single institution were rereviewed by a single blinded pathologist directed to rule out lichen sclerosus and then describe inflammatory cell type and severity when present. Cohorts comprising strictures with no inflammation, minimal to mild inflammation or moderate to severe inflammation were developed and stricture, patient and surgical outcome characteristics were compared. RESULTS: Histopathology slides from 100 anterior urethroplasty cases were reviewed. Two or more lichen sclerosus characteristics were present in 21% of specimens and 44% of specimens showed chronic inflammation, which was minimal in 20%, mild in 39%, moderate in 39% and severe in 2%. Lymphocytes in 86% of specimens and plasma cells in 12% were the predominant cell types. Patients with inflammatory stricture reported worse overall health. Inflammation was largely absent from isolated bulbomembranous strictures (9%) and more common in lichen sclerosus strictures (100%). The 11% overall failure rate was not affected by the presence (7%) or absence (14%) of inflammation. CONCLUSIONS: Chronic inflammation is prevalent in a significant percent of urethral stricture disease specimens. Associations with worse overall health suggest systemic mediators. Absent inflammation in bulbomembranous strictures suggests a unique pathophysiology in this region. The presence of inflammation did not affect surgical outcomes at mid-term followup.


Assuntos
Líquen Escleroso e Atrófico/epidemiologia , Uretra/patologia , Estreitamento Uretral/etiologia , Uretrite/epidemiologia , Adulto , Seguimentos , Humanos , Líquen Escleroso e Atrófico/complicações , Líquen Escleroso e Atrófico/patologia , Masculino , Pessoa de Meia-Idade , Prevalência , Procedimentos Cirúrgicos Reconstrutivos , Estudos Retrospectivos , Resultado do Tratamento , Uretra/cirurgia , Estreitamento Uretral/patologia , Estreitamento Uretral/cirurgia , Uretrite/complicações , Uretrite/patologia , Procedimentos Cirúrgicos Urológicos Masculinos
14.
J Urol ; 201(6): 1158-1163, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30835614

RESUMO

PURPOSE: We evaluated the pathophysiology of lichen sclerosus and nonlichen sclerosus urethral stricture disease by comparing protein expression related to inflammation, cell cycle disruption, oxidative stress, hormone receptor status and infection. MATERIALS AND METHODS: Tissue samples were collected from the urethral strictures of 81 patients undergoing urethroplasty. Clinical and demographic data were obtained by chart review. After identifying areas pathognomonic for lichen sclerosus a tissue microarray was created with cores from each sample and immunohistochemistry was performed. RESULTS: Patients had similar baseline demographics and comorbidities. Of the 81 strictures 58 were and 23 were not due to lichen sclerosus. Lichen sclerosus strictures were significantly longer and showed higher levels of inflammation. The proportion of T cells which stained positive for CD8 was significantly higher in strictures due to lichen sclerosus (50% vs 13%, p = 0.004). CCL-4 was expressed significantly more in strictures due to lichen sclerosus (76% vs 42%, p = 0.01). Several other inflammatory markers were only found in strictures due to lichen sclerosus. Block-like p16, a surrogate for high risk human papillomavirus infection, and varicella zoster virus were found only in lichen sclerosus urethral stricture disease samples, although both were rare. Epstein-Barr virus RNA was found in significantly more lichen sclerosus samples (37% vs 10%, p = 0.024). CONCLUSIONS: To our knowledge this is the first study to evaluate protein expression in lichen sclerosus urethral stricture disease. These strictures demonstrate increased inflammation compared to nonlichen sclerosus urethral strictures. Markers of oxidative stress, cell cycle dysregulation and the androgen receptor do not appear to be uniquely associated with lichen sclerosus urethral stricture disease. Positive staining for several viruses in samples of lichen sclerosus urethral stricture disease suggests a possible infectious etiology.


Assuntos
Estreitamento Uretral/patologia , Estreitamento Uretral/fisiopatologia , Biomarcadores/análise , Feminino , Humanos , Líquen Escleroso e Atrófico/complicações , Líquen Escleroso e Atrófico/metabolismo , Masculino , Pessoa de Meia-Idade , Biossíntese de Proteínas , Estreitamento Uretral/etiologia , Estreitamento Uretral/metabolismo
16.
Urology ; 130: 167-174, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30880075

RESUMO

OBJECTIVE: To analyze contemporary urethroplasty trends and urethral stricture etiologies over a 7-year study period among urologists from a large multi-institutional surgical outcomes group. METHODS: Review of a multi-institutional, prospectively maintained urethroplasty database was performed on 2098 anterior urethroplasties done between 2010 and 2017 by 10 surgeons. Stricture characteristics, including etiology, length, and anatomic location were analyzed and compared to urethroplasty type over the study period using chi-squared analysis to assess for linear trends within the group and by surgeon. RESULTS: Average stricture lengths for bulbar (2.8 ± 1.8 cm), penile (3.6 ± 2.6 cm), and penile-bulbar strictures (8.7 ± 5.0) remained stable. The most common stricture etiology was idiopathic/unknown in all study years (63%). In the bulbar urethra, the group performed significantly (1) fewer excisional repairs (-31%) and more substitutional repairs (+78%); (2) of substitutional repairs, more grafts are being placed dorsally (+95%) vs ventrally (-75%) (3) of the bulbar excisional repairs, more are being performed without transection of the bulbar urethra (+430%); and in the penile urethra (4) the fasciocutaneous flap is in decline (-86%), while single-stage dorsal repairs are increasing (+280%). CONCLUSION: Anterior urethroplasty techniques continue to evolve in the absence of robust clinical data or randomized controlled trials, with a general movement in this cohort toward an initial dorsal approach for most strictures. Inter- and intrasurgeon variability in the surgical management of similar strictures was noted, and the feasibility of any future randomized controlled trials, without apparent surgical equipoise, must be questioned.


Assuntos
Uretra/cirurgia , Estreitamento Uretral/etiologia , Estreitamento Uretral/cirurgia , Adulto , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Fatores de Tempo , Estreitamento Uretral/patologia , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Procedimentos Cirúrgicos Urológicos Masculinos/tendências
17.
Int J Radiat Oncol Biol Phys ; 104(1): 42-49, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30611838

RESUMO

PURPOSE: To report toxicity outcomes, prostate-specific antigen (PSA) relapse, and cumulative incidence posttreatment biopsy results among patients treated on a prospective dose escalation study using ultra-hypofractionated stereotactic body radiation therapy (SBRT) for patients with low- and intermediate-risk prostate cancer. METHODS AND MATERIALS: A total of 136 patients were enrolled in a phase 1 dose-escalation study to determine the tolerance of escalating radiation dose levels of SBRT for the treatment of localized prostate cancer. The initial dose level was 32.5 Gy in 5 fractions, and doses were then sequentially escalated to 35 Gy, 37.5 Gy, and 40 Gy. Eligibility criteria included only patients with low and intermediate risk, and the maximum prostate volume was 60 cm3. Patients treated with neoadjuvant androgen deprivation were excluded. The median follow-up in survivors for the 4 dose levels was 5.9, 5.4, 4.1, and 3.5 years, respectively. RESULTS: The incidence of acute grade 2 rectal toxicities for dose levels 1 to 4 were 0%, 2.9%, 2.8%, and 11.4% respectively. No grade 3 or 4 acute rectal toxicities were observed. The incidence of acute grade 2 urinary toxicities for dose levels 1 to 4 were 16.7%, 22.9%, 8.3%, and 17.1%, respectively. No grade 3 or 4 acute urinary toxicities were observed. No grade 2 or higher rectal toxicities were observed. The incidence of late grade 2 urinary toxicities for dose levels 1 to 4 was 23.3%, 25.7%, 27.8%, and 31.4%, respectively. Only 1 late grade 3 urinary toxicity (urethral stricture) developed in the 40-Gy dose arm; the stricture was corrected with transurethral resection. No grade 4 late urinary toxicity was observed. The 5-year cumulative incidence of prostate-specific antigen failure for dose levels 1 to 4 was 15%, 6%, 0%, and 0%. The incidence of a 2-year positive posttreatment biopsy was 47.6%, 19.2%, 16.7%, and 7.7%, respectively for the 4 dose arms (P = .013). CONCLUSIONS: SBRT doses ranging from 32.5 to 40 Gy in 5 fractions were well tolerated without severe urinary or rectal toxicities. Biopsy outcomes suggest improved rates of tumor clearance observed with higher doses.


Assuntos
Neoplasias da Próstata/radioterapia , Lesões por Radiação , Radiocirurgia/métodos , Idoso , Idoso de 80 Anos ou mais , Biópsia , Fracionamento da Dose de Radiação , Marcadores Fiduciais , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estudos Prospectivos , Próstata/patologia , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Neoplasias da Próstata/patologia , Lesões por Radiação/epidemiologia , Lesões por Radiação/patologia , Radiocirurgia/efeitos adversos , Reto/efeitos da radiação , Risco , Fatores de Tempo , Resultado do Tratamento , Estreitamento Uretral/etiologia , Estreitamento Uretral/patologia , Bexiga Urinária/efeitos da radiação
18.
Int J Urol ; 26(2): 253-257, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30468021

RESUMO

OBJECTIVES: To describe the feasibility of a novel cell-based endoscopic technique using buccal epithelium, expanded and encapsulated in a thermoreversible gelation polymer scaffold for the treatment of urethral stricture. METHODS: Six male patients with bulbar urethral stricture ranging from 2.0 to 3.5 cm in length were included in this pilot study. Autologous buccal epithelial cells from a small buccal mucosal biopsy were isolated, cultured and encapsulated in thermoreversible gelation polymer scaffold, and were implanted at the stricture site after a wide endoscopic urethrotomy. RESULTS: All the patients voided well, with a mean peak flow rate of 24 mL/s. Urethroscopy carried out at 6 months showed healthy mucosa at the urethrotomy site. However, two of the six patients had recurrence at 18 and 24 months, respectively. CONCLUSIONS: This endoscopic-based Buccal epithelium Expanded and Encapsulated in Scaffold-Hybrid Approach to Urethral Stricture (BEES-HAUS) technique is a promising alternative for the open substitution buccal graft urethroplasty. It is possible to achieve the benefits of open substitution buccal urethroplasty with this endoscopic technique.


Assuntos
Terapia Baseada em Transplante de Células e Tecidos/métodos , Endoscopia/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Estreitamento Uretral/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Adulto , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Mucosa Bucal/transplante , Projetos Piloto , Recidiva , Tecidos Suporte , Resultado do Tratamento , Uretra/diagnóstico por imagem , Uretra/patologia , Uretra/cirurgia , Estreitamento Uretral/diagnóstico por imagem , Estreitamento Uretral/patologia
19.
Can J Urol ; 25(6): 9591-9595, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30553284

RESUMO

INTRODUCTION: There is no standardized treatment algorithm for isolated fossa navicularis strictures and treatment modality often falls to surgeon preference. We evaluated the outcomes of a standardized algorithm for fossa navicularis strictures based on stricture etiology, lumen size, and glans size to minimize the number of patients requiring a two-stage urethral reconstruction. MATERIALS AND METHODS: We retrospectively reviewed a prospectively maintained urethral reconstruction database by a single surgeon from 2011-2018. A treatment algorithm was applied and patients underwent one of three treatment modalities: a two-stage buccal mucosa graft (BMG), a single-stage dorsal inlay BMG, or a single-stage dorsal inlay BMG and ventral fasciocutaneous flap repair. Stricture recurrence was measured by inability to pass 17 Fr flexible cystoscope. Patient sexual function and satisfaction were evaluated by the International Index of Erectile Function (IIEF) and a patient perception questionnaire. RESULTS: Forty-two patients met inclusion criteria with a mean follow up of 12.3 months. Urethroplasty success rate was 92%. There was no change in IIEF scores pre and postoperatively between single stage BMG, two-stage BMG, and combined BMG and flap repairs (+ 0.4; p = 0.88, 0.0; p = 1.00, and -0.3; p = 0.74). Ninety-four percent of patients reported being very satisfied or satisfied with their reconstruction. CONCLUSION: An algorithmic approach to the treatment of fossa navicularis strictures is an appropriate method for reconstructive intervention with a high rate of success and patient satisfaction with no significant impact on erectile function.


Assuntos
Algoritmos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Estreitamento Uretral/patologia , Estreitamento Uretral/cirurgia , Adulto , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Mucosa Bucal/transplante , Satisfação do Paciente , Recidiva , Estudos Retrospectivos , Comportamento Sexual , Retalhos Cirúrgicos , Estreitamento Uretral/etiologia
20.
Scand J Urol ; 52(4): 302-308, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30382795

RESUMO

OBJECTIVE: The aim of this study was to assess whether sclerosis in histology following bulbar urethroplasty is a predictive factor for failure of surgery. MATERIALS AND METHODS: Resected stricture specimens from 45 patients undergoing open urethroplasty with excision and anastomosis were collected prospectively during 2011-2014. Histopathological characteristics, including fibrosis (grade I-III), inflammation and sclerosis, were evaluated using different routine staining. These specimens were compared to normal urethral resection specimens from patients undergoing sex-correction surgery. The uropathologist who conducted the analyses was blinded to the study design. RESULTS: The outcomes of the histological classifications were as follows: 19 patients had grade I fibrosis, of whom three had failures; 13 patients had grade II fibrosis, without any failures; and the most severe fibrosis, grade III, including sclerosis, was found in 13 patients (11 with sclerosis), with failure in eight. Sclerosis was a significant risk factor for restricture when comparing patients with sclerosis and those without sclerosis, and likewise when adjusting for age, inflammation and stricture length. CONCLUSION: Histological findings of sclerosis in the resected urethral stricture specimen indicate a significantly higher risk for restricture after urethroplasty surgery.


Assuntos
Uretra/patologia , Estreitamento Uretral/cirurgia , Adolescente , Adulto , Idoso , Fibrose , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Procedimentos Cirúrgicos Reconstrutivos , Recidiva , Esclerose , Índice de Gravidade de Doença , Falha de Tratamento , Uretra/cirurgia , Estreitamento Uretral/patologia , Adulto Jovem
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