Complicaciones en posoperatorio inmediato de cirugía uretral anterior; ¿existe relación con la recaída? / Early complications in urethral anterior surgery; is there any relationship with recurrence?

INTRODUCCIÓN/OBJETIVO: La estrechez uretral puede causar síntomas miccionales, dolor, disfunción vesical y eyaculatoria. La tasa de complicaciones en uretroplastía anterior es baja. El principal objetivo es evaluar complicaciones del posoperatorio (pop) inmediato (dentro de los 30 días pop). El objetivo secundario es valorar la relación entre complicaciones y la tasa de recaída. MATERIALES Y MÉTODO: Se realizó una revisión retrospectiva de las uretroplastías anteriores realizadas entre octubre del 2012 y junio del 2017. Se valoró: reinternación, reingreso a cirugía, infarto agudo de miocardio, tromboembolismo de pulmón, trombosis venosa profunda, óbito, infecciones, dehiscencia de herida, hematomas, sangrados, etc. Se definió recaída a la necesidad de realizar cualquier instrumentación uretral secundaria a la uretroplastía. Las variables se analizaron estadísticamente con Chi square y Mann-Whitney U test. RESULTADOS: Se incluyeron 92 pacientes, con un seguimiento mínimo de 12 meses. Las edades fueron de 18 a 88 años (mediana, 61,5 años). En 58 pacientes, se utilizaron transferencia de tejidos (27 injertos y 31 colgajos). La longitud de la estrechez fue desde 1-15 cm (media, 3,25 cm). La iatrogénica (56%) fue la etiología más frecuente. 56 pacientes (63%) tenían tratamientos previos. La tasa de complicaciones pop inmediato fue del 32%, las infecciones fueron las más frecuentes. Según Clavien, se clasificaron: I: 40%; II: 47%; III: 10%; IV: 3%. Hubo 17 recaídas (18%), 13 dentro de los primeros 6 meses del pop. De los pacientes que presentaron complicaciones, recayó el 23%; solo 16% de los que no las presentaron (p: 0,4). Aquellos pacientes con complicaciones graves presentaron mayor tasa de recaída (p: 0,2). CONCLUSIÓN: La tasa de complicaciones pop inmediata de uretroplastía anterior fue de 32%; las infecciones fueron las más frecuentes. La mayoría fue Clavien I y II. La recaída fue mayor en aquellos pacientes que sufrieron complicaciones en pop inmediato.

INTRODUCCION/OBJECTIVE: Urethral stenosis can cause mictional symptoms, pain, bladder dysfunction and ejaculatory problems. Complications rate in anterior urethroplasty is low. Main objetive is to evaluate early post operatory complications Secondary objetive is to assess the relationship between complications and recurrence rate. MATERIALS AND METHODS: We performed a restrospective review of our anterior urethroplasty database between October 2012 and June 2017. We recorded: patients readmission, return to operating room, acute myocardial infarction, pulmonary embolism, deep venous thrombosis, death, infections, wound dehiscense, hematomas, bleedings, etc. We defined recurrence as any urethral instrumentation after urethroplasty. Variables were analyzed using Chi Square and Mann Whitney U test. RESULTS: 92 patients were included in the study with at least 12 months follow up. Age range was between 18-88 years. (median 61,5 years) Substitution urethroplasty were performed in 58 patients (grafts 27 and flaps 31) Urethral stenosis lenght range was between 1 and 15 cm (mean 3,25cm) Most frequent cause of urethral stenosis was iatrogenic (56%) 56 patients underwent previous treatment (63%) Complication rate in early post operative period was 32%, most of them infections. Clavien clasiffication: I: 40%; II: 47%; III: 10%; IV: 3%. There were 17 recurrences (18%), 13 during the first 6 months after surgery. 23 % of patients with complications had recurrence and only 16% of patients without, had recurrence (p:0,4) Patients with serious complications had greater recurrence rate (p: 0,2) CONCLUSION: Recurrence rate in early complications of anterior urethroplasty was 32%, most of them infections. Clavien I and II are the most frequent. Recurrence was greater in patients who suffered early complications

Larger patients shouldnt have fewer options: urethroplasty is safe in the obese

ABSTRACT Objective To examine the impact of obesity on perioperative outcomes and urethral stricture recurrence after anterior urethroplasty. Material and Methods We reviewed our prospectively maintained single-surgeon database to identify men with anterior urethral strictures who had undergone anastomotic or augmentation urethroplasty between October 2012 and March 2018. In all, 210 patients were included for primary analysis of perioperative outcomes, while 193 patients with at least 12 months follow-up were included for secondary analysis of stricture recurrence. Patients grouped by BMI were compared using univariate and multivariate analyses for perioperative outcomes and log rank testing for recurrence-free survival. Results Overall, 41% (n=86) of patients were obese and 58.6% (n=123) had bulbar urethral strictures. Obese patients had significantly longer urethral strictures (mean=6.7cm±4.7) than nonobese patients (p <0.001). Though urethroplasty in obese patients was associated with increased estimated blood loss (EBL) relative to normal BMI patients on both univariate (p=0.003) and multivariate (p <0.001) analyses, there was no difference in operative time, length of stay, or complication rate between BMI groups. At a mean follow-up interval of 36.7 months, 15% (n=29) of patients had stricture recurrence, yet recurrence-free survival was not significantly different between groups (log rank p=0.299). Dorsal augmentation urethroplasty resulted in significantly fewer recurrences in obese patients compared to nonobese patients (p=0.036). Conclusion Despite the association with increased urethral stricture length and EBL, obesity is not predictive of adverse perioperative outcomes or stricture recurrence. Obese patients should be offered urethral reconstruction, but patient selection and preoperative counseling remain imperative.

Is neutrophil to lymphocyte ratio a predictive factor for recurrence of urethral stricture?

SUMMARY INTRODUCTION Due to spongiofibrosis and inflammatory processes underlying the pathogenesis of urethral stricture, it is possible that the neutrophil-lymphocyte ratio (NLR) may give essential information about the course of the disease and recurrence possibilities. Our study aims to evaluate the correlation between NLR and recurrence rates. METHODS A total of 512 patients who underwent direct visual internal urethrotomy (DVIU) due to urethral stricture in our clinic between February 2010 and January 2018 were evaluated retrospectively. RESULTS The median follow up for non-recurrent and recurrent groups after DVIU was 30 and 36 months, respectively. During the follow-up, 280 (54.7%) of the patients had recurrences, and 232 (45,3%) had no recurrences. The mean time for recurrence after DVIU was 6,5±1,4 months, with a range of 1-36 months. The mean NLR in the non-recurrence group was 2,02±0,87, with a median of 1.9, and 3,66±2,30, with a median of 3 in the recurrence group. A highly significant statistical difference was observed between two groups in terms of neutrophil count and NLR (p: 0.000 - both). The area under curve value for NLR was 0.767, with a standard error of 0.021 (95% CI 0.727-0.808). The cut-off value of NLR was determined as 2.25, with a 70% sensitivity and 67,7% specificity. CONCLUSION By using NLR, the inflammatory features of the urethral tissue can be predicted, and possible recurrences after surgery can be estimated. Consequently, open urethroplasty techniques can be used in cases with a significant NLR value instead of the recurrent endoscopic procedure.

RESUMO INTRODUÇÃO Devido à espongiofibrose e processos inflamatórios subjacentes à patogênese da estenose uretral, pode-se pensar que a relação de linfócitos neutrofílicos (NLR) pode fornecer informações essenciais sobre o curso da doença e as possibilidades de recorrência. O objetivo do nosso estudo é avaliar a correlação entre NLR e taxas de recorrência. MÉTODOS Quinhentos e doze pacientes submetidos à uretrotomia interna visual direta (DVIU) devido à estenose uretral em nossa clínica entre as datas de fevereiro de 2010 e janeiro de 2018 foram avaliados retrospectivamente. RESULTADOS A mediana de acompanhamento para os grupos não recorrentes e recorrentes após a DVIU foi de 30 e 36 meses, respectivamente. Durante o seguimento, 280 (54,7%) dos pacientes tiveram recidivas e 232 (45,3%) não tiveram recidivas. O tempo médio de recorrência após a DVIU foi de 6,5±1,4 mês, com variação de 1-36 meses. A média da RNL no grupo sem recorrência foi de 2,02±0,87 com mediana de 1,9 e 3,66±2,30 com mediana de 3 no grupo com recidiva. Uma diferença estatística altamente significativa foi observada entre dois grupos em termos de contagem de neutrófilos e NLR (p: 0,000 - ambos). A área sob o valor da curva para NLR foi de 0,767 com um erro padrão de 0,021 (IC 95% 0,727-0,808). Valor de corte de NLR determinado como 2,25 com uma sensibilidade de 70%, especificidade de 67,7%. CONCLUSÃO Ao utilizar a RNL, as características inflamatórias do tecido uretral podem ser previstas e possíveis recidivas após a cirurgia podem ser estimadas. Dessa forma, técnicas de uretroplastia aberta podem ser usadas em casos com valor significativo de NLR em vez de procedimento endoscópico recorrente.

Penile skin flap: a versatile substitute for anterior urethral stricture

ABSTRACT Purpose Penile skin flap uretroplasty is a useful technique for a long urethral stricture due to the ample length and surgical handling characteristics. We investigated the surgical technique and initial results of uretroplasty for anterior urethral strictures using a dorsal penile skin flap. Patients and methods From January 2003 to January 2018, a total of 77 patients underwent substitution urethroplasty using dorsal penile skin flap for bulbar urethral strictures in our institution. All patients were assessed preoperatively, and followed postoperatively by physical examination, urinalysis, retrograde and voiding urethrography, uroflowmetry and post-void residual urine measurement. Success was defined as no requirement of additional urethral instrumentation. Results The mean age was 45 years (10-87). The mean stricture length was 5cm (3-10cm). The mean flap length was 6cm. Urinary fistula was the most common postoperative complication. The mean follow-up was 60 months (6-120). The overall success rate was 88%. Recurrent strictures were found in 4 patients (5%) at 1 year. At 3 year follow-up, 5 (7%) more patients had recurrences. All recurrences were managed by internal urethrotomy. Conclusions Substitution urethroplasty using penile skin flap appear to be a safe and efficient technique for the treatment of a long and complex anterior urethral stricture. It provides encouraging cosmetic and functional results.

Assessment of long term outcomes after buccal mucosal graft urethroplasty: the impact of chronic kidney disease

ABSTRACT Objectives To compare and assess various outcomes and success of buccal mucosal graft urethroplasty (BMGU) in patients with CKD versus patients having normal renal function. Material and Methods This was a retrospective, single centre study, during period 2013 to 2017. Patients were grouped into two groups. Group 1 had patients with estimated Glomerular Filtration Rate (eGFR)>60mL/min/1.73m2 while group 2 had patients with eGFR <60mL/min/1.73m2. eGFR was calculated according to the MDRD equation. The two groups were compared with regard to various outcomes like length, location of stricture, technique of graft placement, intra-operative blood loss (haemoglobin drop), duration of hospital stay, post-operative complications and recurrence. Results A total of 223 patients were included in study with group 1 had 130 patients and group 2 had 93 patients. Mean age of patients with CKD were higher (47.49 years versus 29.13 years). The mean follow-up period was comparable between both groups (23.29 months and 22.54 months respectively). Patients with CKD had more post-operative Clavien Grade 2 or higher complications (p=0.01) and a greater recurrence rates (p<0.001) than in non-CKD patients. On multivariate analysis, age and CKD status was significant predictor of urethroplasty success (p=0.004) (OR= 14.98 (1.952-114.94, 95% CI). Conclusions CKD patients are more prone to post-operative complications in terms of wound infection, graft uptake and graft failure and higher recurrence rates following BMGU.

Tratamiento Quirúrgico de la estenosis bulbomembranosa secundaria a fractura pelviana: resultados funcionales / Bulbomenbranous Urethral Stricture After Pelvic Fracture: Surgical Managment and Functional Outcomes

Objetivos: La incidencia de lesión uretral bulboprostática secundaria a fractura pelviana es del 5-10%. Una uretroplastia exitosa garantiza el comienzo de la rehabilitación de los pacientes. Presentamos nuestra experiencia en el manejo quirúrgico de la estenosis uretral secundaria a fractura pelviana y resultados funcionales: tasa de éxito, reestenosis, disfunción eréctil e incontinencia urinaria. Evaluamos si existe asociación entre la falta de erecciones postrauma y la reestenosis. Materiales y métodos: Cincuenta y tres pacientes fueron operados durante el período comprendido entre 2001 y 2015. Todos fueron estudiados con cistoscopia flexible, cistouretrografía retrógrada y miccional. La técnica quirúrgica empleada fue la resección y anastomosis primaria. Se utilizó siempre la sistemática del abordaje perineal progresivo para lograr una anastomosis sin tensión. Interrogamos sobre la calidad de las erecciones posterior al trauma y después de la cirugía, y su estado de continencia urinaria. Se realizó un análisis estadístico donde se evaluó si la falta de erecciones era un factor de riesgo para recaída. Resultados: La edad promedio de los pacientes fue de 34,5 (r=17-67) años. La longitud promedio de la estenosis fue de 2,28 cm, siendo la uretra bulbomembranosa la más afectada (89%). La tasa de éxito fue del 86% (46/53), que asciende al 94% (50/53) al asociar un procedimiento endoscópico. Un solo paciente refirió disfunción eréctil postcirugía (1/19; 5,3%). Dos (3,7%) pacientes evolucionaron con incontinencia de orina de esfuerzo. No se hallaron diferencias estadísticamente significativas entre el grupo de pacientes con erecciones y aquellos sin erecciones en cuanto a la posibilidad de reestenosis. Conclusiones: La anastomosis bulbomembranosa por vía perineal es el tratamiento de elección de la estenosis uretral postfractura pelviana. Los índices de incontinencia de orina y disfunción eréctil no aumentan significativamente luego de la uretroplastia. En nuestra experiencia, la falta de erecciones preoperatoria no predice mayor índice de recaídas(AU)

Objectives: Bulboprostatic urethral stricture after pelvic fracture occurs in about 5-10%. A successful urethroplasty guarantees the beginning of patient recovery. We present our experience in the surgical management of posterior urethral stricture after pelvic fracture and functional outcomes (success and failure rates, erectile dysfunction and urinary incontinence). The association between the lack of erections post-trauma and the incidence of restenosis was also evaluated. Materials and methods: 53 patients were operated between 2001- 2015. Preop workout included a flexible cystoscopy and a combination of retrograde and voiding cystourethrogram to define the site and length of urethral stricture. Resection and primary anastomosis was the technique always employed. In all cases the progressive perineal approach was followed in order to achieve a tension free anastomosis. Erectile function and urinary continence were evaluated before and after surgery. Statistical analysis was performed to evaluate if lack of erections was a failure predictor. Results: Median age was 34.5 (r=17-67) years. Median urethral stricture length was 2.28 cm. Bulbomembranous junction was the most affected portion (89%). Success rate was 86% (46/53) ascending to 94% (50/53) when an endoscopic procedure was associated. One patient referred erectile dysfunction after surgery (1/19; 5.3%). Two patients (3.7%) developed stress urinary incontinence. The restenosis rate did not show statiscally differences between the erectile dysfunction and non-erectile dysfunction group. Conclusions: Perineal bulbomembranous anastomosis is the elected procedure for urethral stricture after pelvic fracture. Incidence of urinary incontinence and erectile dysfunction are not significantly elevated after urethroplasty. In our experience, lack of erections before surgery does not predict a higher rate of restenosis(AU)

Assessment of satisfaction and Quality of Life using self - reported questionnaires after urethroplasty: a prospective analysis

ABSTRACT Objectives To assess patient satisfaction and quality of life after urethroplasty using two different self-reported outcome measures and to compare it with objective clinical data. Materials and Methods We prospectively collected data from 35 consecutive patients who underwent urethroplasty from January 2013 to September 2014. Patient demographics, International Prostate Symptom Score (IPSS), quality of life score, urethral stricture surgery patient-reported outcome measure (USS-PROM), maximum flow rate (Qmax) and post-void residual urine were collected before, two and eight months after surgery. Failure occurred when any postoperative instrumentation was performed. General estimation equation was used to compare the results and linear regression analysis to correlate both questionnaires with objective data. Results Mean age was 61 years. Urethroplasties were equally divided between anastomotic and buccal mucosa grafts and 19 patients (59.3%) had a previous urethral procedure. Overall success rate was 87.5%. IPSS improved from a mean 19 at baseline to 5.32 at 8 months (p <0.001). The mean USS-PROM score also improved from 13.21 preoperatively to 3.36 after surgery (p <0.001) and 84.3% of patients were satisfied or very satisfied with surgical results. Mean Qmax increased from 4.64mL/s to 11mL/s (p <0.001). Strong negative correlation was found respectively between flow rate and USS-PROM (r=-0.531, p <0.001) and with IPSS (r=-0.512, p <0.001). Conclusions Significant improvements in urinary symptoms and in quality of life are expected after urethroplasty and they are correlated with objective measures.

The long-term results of temporary urethral stent placement for the treatment of recurrent bulbar urethral stricture disease

ABSTRACT Aim: To evaluate the long term outcomes of temporary urethral stent placement for the treatment of recurrent bulbar urethral stricture. Materials and Methods: Twenty-eight patients who underwent temporary polymer coated urethral stent placement due to recurrent bulbar urethral stricture between 2010 and 2014 were enrolled in the study. The long term outcomes of the patients were analyzed. Results: The mean age of the patients was 62.3±6.4 (44–81). The overall clinical success was achieved in 18 (64.2%) of the 28 patients at a median (range) follow-up of 29 (7–46) months. No patient reported discomfort at the stent site. Stone formation was observed at the urethral stent implantation area only in one patient. Stenosis occurred in the distal end of the stents in two patients and took place in bulbar urethra in seven patients after removed the stents. The mean maximum urine flow rates were 6.24±2.81mL/sec and 19.12±4.31mL/sec before and at 3 months after the procedure, respectively. Conclusion: In this study, the success rate of temporary urethral stent placement has remained at 64.2% at a median follow-up of 29 months. Therefore, our outcomes have not achieved desired success rate for the standard treatment of recurrent bulbar urethral stricture.

Bipolar plasma vaporization using plasma-cutting and plasma-loop electrodes versus cold-knife transurethral incision for the treatment of posterior urethral stricture: a prospective, randomized study

OBJECTIVE: Evaluate the efficiency and safety of bipolar plasma vaporization using plasma-cutting and plasma-loop electrodes for the treatment of posterior urethral stricture. Compare the outcomes following bipolar plasma vaporization with conventional cold-knife urethrotomy. METHODS: A randomized trial was performed to compare patient outcomes from the bipolar and cold-knife groups. All patients were assessed at 6 and 12 months postoperatively via urethrography and uroflowmetry. At the end of the first postoperative year, ureteroscopy was performed to evaluate the efficacy of the procedure. The mean follow-up time was 13.9 months (range: 12 to 21 months). If re-stenosis was not identified by both urethrography and ureteroscopy, the procedure was considered “successful”. RESULTS: Fifty-three male patients with posterior urethral strictures were selected and randomly divided into two groups: bipolar group (n=27) or cold-knife group (n=26). Patients in the bipolar group experienced a shorter operative time compared to the cold-knife group (23.45±7.64 hours vs 33.45±5.45 hours, respectively). The 12-month postoperative Qmax was faster in the bipolar group than in the cold-knife group (15.54±2.78 ml/sec vs 18.25±2.12 ml/sec, respectively). In the bipolar group, the recurrence-free rate was 81.5% at a mean follow-up time of 13.9 months. In the cold-knife group, the recurrence-free rate was 53.8%. CONCLUSIONS: The application of bipolar plasma-cutting and plasma-loop electrodes for the management of urethral stricture disease is a safe and reliable method that minimizes the morbidity of urethral stricture resection. The advantages include a lower recurrence rate and shorter operative time compared to the cold-knife technique.

Perineostomy: the last oportunity

Objective To review the technique and outcome of perineal urethrostomy or urethral perineostomy and to identify factors related to the procedure failure. Material and methods We studied 17 patients who underwent perineal urethrostomy between 2009-2013 in a single hospital. Success was defined as no need for additional surgical treatment or urethral dilatation. We reviewed the clinical data related to age, weight, previous urethral surgery, diabetes, hypertension, ischemic cardiopathy, lichen sclerosus and other causes and studied their association with the procedure failure (univariate analysis). We completed the analysis with a multivariate test based on binary regression. Results The average follow-up was 39.41 months. From all the causes, we found Lichen Sclerosus in 35%, idiopathic etiology in 29% and prior hypospadia repair in 18%. Postoperative failure occurred in 3 patients, with a final success of 82.4%. The binary regression model showed as independent risk factors ischemic cardiopathy (OR: 2.34), and the presence of Lichen Sclerosis (OR: 3.21). Conclusions The success rate with the perineal urethrostomy technique shows it to be a valid option above all when we preserve the urethral blood supply and plate. Lichen sclerosus and ischemic vascular problems are risk factors to re-stenosis. .

Long-term results of permanent memotherm urethral stent in the treatment of recurrent bulbar urethral strictures

Purpose: To evaluate the long term outcomes of permanent Memotherm urethral stent in the treatment of recurrent bulbar urethral stricture. Materials and Methods: Twenty patients who underwent permanent Memotherm urethral stent implantation due to recurrent bulbar urethral stricture following previous unsuccessful surgical procedure from 1996 to 2002 were included in the study. Long-term outcomes of the patients were evaluated. Results: The overall success rate was 87.5% at the end of the tenth year. There was discomfort in implantation area in eight patients about 1 month following the procedure. These patients were treated with alpha-blocker and anti-inflammatory drugs. Stone formation was observed at the urethral stent implantation area in two patients. Post-void dripping has been observed in 15 patients up to the postoperative 3rd month. Stress urinary incontinence was observed in a patient with a 1-year follow-up. Partial stent migration was observed in two patients. None of the patients experienced pain during erection. Conclusion: Memotherm urethral stent is a minimal invasive surgical procedure which can be safely and effectively used in patients with recurrent urethral stricture. .

Initial Experience of Transurethral Resection with Pediatric Resectoscope for Incomplete Anterior Urethral Stricture

Purpose Endoscopic urethrotomy is an alternative method in treatment of urethral stricture. However, it have high recurrence rate because of the remained fibrotic tissue. Removal of the fibrotic tissue can maintain the patency of the urethral lumen after the procedure. We report the therapeutic efficacy of our initial experience using pediatric resectoscope for treating anterior urethral stricture in 16 cases. Materials and Methods From January 2009 to April 2011, transurethral resection with pediatric resectoscope was primarily performed on 16 patients with anterior urethral stricture. Retrograde urethrography, uroflowmetry, postvoid residual volume, IPSS score and QoL score were performed preoperatively. We used 11.5Fr pediatric resectoscope (Wolf) and monopolar electrosurgical generator. The stricture was incised under vision at the 12 o'clock location or the site of maximum scar tissue or narrowing in asymmetric strictures for working space. After incision, transurethral resection with pediatric resectoscope was performed to all scar tissues. Monopolar cutting current was set on 45 watt and coagulation current was set on 30 watt, fulgurate mode. Postoperatively, drainage of the bladder was performed for 7 days using an 18F latex catheter. Patients were followed up by IPSS score, QoL score, uroflowmetry and postvoid residual volume. Results Successful results without recurrence were achieved in 11 of 16patients. Postoperative urethral dilation had been performed average 2.4 times (0∼6 times). When we classified the results by etiology, the number of successful results in strictures with a trauma, iatrogenic, or unknown cause was 5 (7/11), 3 (3/4) and 1 (1/1), respectively. In 5 patients who failed treatment, we repeated transurethral resection with pediatric resectoscope in 1 patient, and periodic urethral dilation in 4 patients. No operative complications occurred in any patients. Conclusions Transurethral resection with ...

Monti's procedure as an alternative technique in complex urethral distraction defect

PURPOSE: Pelvic fracture urethral distraction defect is usually managed by the end to end anastomotic urethroplasty. Surgical repair of those patients with post-traumatic complex posterior urethral defects, who have undergone failed previous surgical treatments, remains one of the most challenging problems in urology. Appendix urinary diversion could be used in such cases. However, the appendix tissue is not always usable. We report our experience on management of patients with long urethral defect with history of one or more failed urethroplasties by Monti channel urinary diversion. MATERIALS AND METHODS: From 2001 to 2007, we evaluated data from 8 male patients aged 28 to 76 years (mean age 42.5) in whom the Monti technique was performed. All cases had history of posterior urethral defect with one or more failed procedures for urethral reconstruction including urethroplasty. A 2 to 2.5 cm segment of ileum, which had a suitable blood supply, was cut. After the re-anastomosis of the ileum, we closed the opened ileum transversely surrounding a 14-16 Fr urethral catheter using running Vicryl sutures. The newly built tube was used as an appendix during diversion. RESULTS: All patients performed catheterization through the conduit without difficulty and stomal stenosis. Mild stomal incontinence occurred in one patient in the supine position who became continent after adjustment of the catheterization intervals. There was no dehiscence, necrosis or perforation of the tube. CONCLUSION: Based on our data, Monti's procedure seems to be a valuable technique in patients with very long complicated urethral defect who cannot be managed with routine urethroplastic techniques.

Challenging non-traumatic posterior urethral strictures treated with urethroplasty: a preliminary report

Introduction: Posterior urethral strictures after prostatic radiotherapy or surgery for benign prostatic hyperplasia (BPH) refractory to minimal invasive procedures (dilation and/or endoscopic urethrotomy) are challenging to treat. Published reports of alternative curative management are extremely rare. This is a preliminary report on the treatment of these difficult strictures by urethroplasty. Materials and Methods: Seven cases were treated: 4 cases occurred after open prostatectomy or transurethral resection of the prostate for BPH, one case after external beam irradiation and 2 after brachytherapy. The 4 cases after BPH-related surgery were in fact complete obstructions at the bladder neck and the membranous urethra with the prostatic urethra still partially patent. Anastomotic repair by perineal route was done in all cases with bladder neck incision in the BPH-cases and prostatic apex resection in the radiotherapy cases. Results: Mean follow-up was 31 months (range: 12-72 months). The operation was successful, with preserved continence, in 3 of the 4 BPH-cases and in 2 of the 3 radiotherapy cases. An endoscopic incision was able to treat a short re-stricture in the BPH-patient and a longer stricture at the bulbar urethra could be managed with a perineostomy in the radiotherapy-patient. Conclusion: Posterior non-traumatic strictures refractory to minimal invasive procedures (dilation/endoscopic urethrotomy) can be treated by urethroplasty using an anastomotic repair with a bladder neck incision if necessary.

Can bipolar vaporization be considered an alternative energy source in the endoscopic treatment of urethral strictures and bladder neck contracture?

OBJECTIVE: We evaluated the outcome of bipolar energy by using PlasmaKinetic™ cystoscope instruments in the treatment of urethral stricture and bladder neck contracture. MATERIALS AND METHODS: Twenty-two male patients with urethral stricture and five with bladder neck contracture were treated by endoscopic bipolar vaporization. The most common etiology for stricture formation was iatrogenic (85.2 percent) and the mean stricture length was 12.2 mm. All patients were evaluated with urethrography and uroflowmetry one month and 3 months after surgery. Urethroscopy was routinely performed at the end of the first year. Preoperative mean maximum flow rate (Q max) was 4.9 mL/s for urethral stricture and mean Q max was 3.4 mL/s for bladder neck contracture. The results were considered as "successful” in patients where re-stenosis was not identified with both urethrography and urethroscopy. Minimum follow-up was 13.8 months (range 12 to 20). RESULTS: Tissue removal was rapid, bleeding was negligible and excellent visualization was maintained throughout the vaporization of the fibrotic tissue. Postoperative mean Q max was 14.9 mL/s and the success rate was 77.3 percent for urethral stricture at mean follow-up time of 14.2 months. The success rate was 60 percent with a mean follow-up time of 12.2 months for bladder neck contracture and the mean Q max was 16.2 mL/s, postoperatively. CONCLUSIONS: The study suggests that bipolar vaporization is a safe, inexpensive and reliable procedure with good results, minimal surgical morbidity, negligible blood loss, and thus, it could be considered as a new therapeutic option for the endoscopic treatment of urethral stricture and bladder neck contracture.

Full-thickness abdominal skin graft for long-segment urethral stricture reconstruction

Multiple tissue sources have been used for urethral reconstruction in adults. Patients with lichen sclerosis (LS), long segment strictures, or prior oral graft use have less available tissue for urethroplasty. We describe a technique for the use of a full-thickness skin graft of hairless abdominal skin for long segment urethroplasty.