Precise treatment of pelvic fracture urethral injury associated with urethrorectal fistula.

OBJECTIVE: To evaluate the effect of a new strategy of transperineal anastomotic urethroplasty (TAU) with proximal transection in treating pelvic fracture urethral injury (PFUI) associated with urethrorectal fistula (URF). PATIENTS AND METHODS: A retrospective review of all patients treated by TAU with proximal transection and fistula repair for PFUI associated with URF was performed between August 2013 and July 2022. Information on demographics, peri-operative variables, and postoperative follow-up outcomes was collected. Successful surgery was defined as restoration of a uniform urethral calibre using flexible cystoscopy (third postoperative month) without strictures or leakage, with no further interventions required. Functional outcomes, including erectile function (assessed using the five-item International Index of Erectile Function) and urinary continence, were assessed. RESULTS: Forty patients diagnosed with PFUI associated with URF and treated by TAU with proximal transection and rectal fistula repair were enrolled. Six patients (15.0%) had a history of failed urethral reconstruction. The mean stenosis length and fistula diameter were 2.9 cm and 1.2 cm, respectively. All patients underwent faecal diversion before urethroplasty. After a median (range) follow-up of 45 (3-115) months, the final success rate was 90.0% (36/40). Postoperative complications included haematoma in three patients, epididymo-orchitis in three, wound infection in one, wound bleeding in one, delayed wound healing in three, and wound numbness in three. The overall incidence of postoperative erectile dysfunction reached 75.0%, with a median (range) score of 9 (0-19). Normal continence was achieved in 31 patients (77.5%). Occasional incontinence without the need for urinal pads occurred in eight patients, whereas one patient required urinal pads. CONCLUSIONS: Transperineal anastomotic urethroplasty with proximal transection is a precise and effective surgical strategy for treating PFUI associated with URF. This strategy ensures a high success rate and improves surgical efficiency.

Modified Y-V plasty based on MRU evaluation for iatrogenic bladder outlet obliteration: a multicentre experience in China.

PURPOSE: To compare the diagnostic ability of traditional radiographic urethrography and magnetic resonance urethrography (MRU) for iatrogenic bladder outlet obliteration (BOO), and explore the efficacy and complications of laparoscopic modified Y-V plasty for patients selected based on MRU evaluation. METHODS: 31 patients with obliteration segments ≤ 2 cm and no false passages or diverticula based on MRU evaluation from eight centers in China were included. Obliteration segments were measured preoperatively by MRU and conventional RUG/VCUG and compared with intra-operative measurements. Surgical effects were evaluated by uroflow rates, urethrography, or cystoscopy at 1, 3, 6, and 12 months post-operation and then every 12 months. Postoperative urinary continence was assessed by 24-h urine leakage (g/day). RESULTS: The results showed that MRU measured the length of obliteration more accurately than RUG/VCUG (MRU 0.91 ± 0.23 cm, RUG/VCUG 1.72 ± 1.08 cm, Actual length 0.96 ± 0.36 cm, p < 0.001), and clearly detected false passages and diverticula. Laparoscopic Y-V plasty was modified by incisions at 5 and 7 o'clock positions and double-layer suture with barbed sutures. All operations were successfully completed within a median time of 75 (62-192) minutes and without any complications. Urethral patency and urinary continence rates were 90.3% (28/31) and 87.1% (27/31), respectively. Three recurrences were cured by direct visual internal urethrotomy. Four patients had stress urinary incontinence after catheter removal 14 days post-operation, with urine leakage of 80-120 g/day, not relieved during follow-up. CONCLUSIONS: Laparoscopic modified Y-V plasty based on MRU evaluation is a promising approach for iatrogenic BOO, with a high patency rate and a low incontinence rate.

Transperineal anastomotic urethroplasty for the treatment of pelvic fracture urethral distraction defects: a progressive surgical strategy.

PURPOSE: The aim was to reduce the difficulty of transperineal anastomotic urethroplasty for pelvic fracture urethral distraction defect (PFUDD) and make it easy to master through an effective strategy. PATIENTS AND METHODS: Between January 2010 and December 2019, 1637 patients with PFUDDs were treated by transperineal anastomotic urethroplasty. The surgical strategy we used was the progressive transperineal anastomotic urethroplasty. First, after full mobilization of the distal bulbomembranous urethra, the stenotic urethra was transected directly at the proximal margin of the stenotic urethra to expose the proximal disrupted urethral end. Second, if the urethral stenosis location of some complicated cases was too deep to fully mobilize, the position of urethral transection was selected at the distal margin of the stenotic urethra. Then, the distal and proximal disrupted urethras were then trimmed and anastomosed without tension. A successful urethroplasty was defined as reestablishment of a uniform urethral caliber and no further interventions were needed. RESULTS: Follow-up was obtained in 1475 patients. The success rate was 92.4% (1363/1475). Among the 112 failed patients, 10 patients received endoscopic urethrotomy, 99 underwent a secondary or third anastomotic urethroplasty and 3 successfully treated with perineal skin flap urethroplasty. After final successful urethroplasty, 125 patients (8.5%) had different degrees of urinary incontinence and 15 (1.6%) developed de novo erectile dysfunction (1.6%). CONCLUSION: The progressive transperineal anastomotic urethroplasty strategy was effective for treating PFUDD cases, improving surgical efficacy and reducing complications. It may contribute to standardizing the transperineal anastomotic urethroplasty and making it easy to master.

[Modified urethral reconstruction with lingual mucosa for complicated anterior urethral stricture].

OBJECTIVE: To investigate the efficiency and complications of modified urethral reconstruction with lingual mucosa in the treatment of complicated anterior urethral stricture (CAUS). METHODS: We retrospectively studied the clinical data on 10 cases of CAUS treated by modified urethral reconstruction with lingual mucosa from December 2017 to June 2019 concerning the age of the patients and the causes, location and length of urethral stricture. We statistically analyzed the pre- and post-operative maximum urine flow rate (Qmax), scores on Mental Status Scale in Non-psychiatric Settings (MSSNS) and quality of life (QOL) scores and observed post-operative complications such as abnormal taste, tongue numbness, urinary tract infection, urethral diverticulum, and urethral stricture. RESULTS: Compared with the baseline, Qmax was significantly improved and the MSSNS and QOL scores dramatically decreased at 3, 6 and 12 months after surgery (P < 0.01). Paraurethral infection developed in 1 case postoperatively, which was cured after dressing change, external urethral orifice stenosis occurred in another, which was improved after regular urethral orifice expansion, and mild tongue numbness was found in 2 cases at 1 month but gradually restored to abnormal. Urethrography showed no urethral diverticulum before catheter removal. CONCLUSIONS: Lingual mucosa is an ideal alternative material for urethral reconstruction in the treatment of CAUS, and lateral lingual mucosa can be easily obtained. Modified urethral reconstruction by embedding lingual mucosa in the dorsal base of the urethra, with the advantages of definite effectiveness and few postoperative complications, is worthy of clinical application.

Bladder neck reconstruction in girls' pelvic fracture bladder neck avulsion and urethral rupture.

BACKGROUND: Girls' pelvic fracture bladder neck avulsion and urethral rupture is rare however it causes great morbidity. The management is complex and not standard yet. We report our experience and a technique of bladder neck reconstruction with anterior bladder wall flap. METHODS: We retrospectively analysed data of 5 girls with pelvic fracture bladder neck avulsion and urethral rupture admitted to our institution from July 2017 to October 2019. They all came to our institution with a suprapubic tube. Patients' trauma was all initially treated at other hospitals, 4 had suprapubic cystotomy and 1 had urethral realignment. One girl also had three other urethroplasties at other hospitals. We took pubectomy, posterior ureth roplasty and bladder neck reconstruction with anterior bladder wall flap in these 5 girls. Post-operative assessments included voiding cystourethrography, uroflowmetry and urethroscopy after urethral catheter removal. Verbal consent to participate was obtained from the parent or legal guardian of the children. RESULTS: Operation time ranged from 120 to 180 min. Follow-up time is 12 to 27 months. Uroflowmetry showed that maximum urine flow rate improved significantly. Cystourethrography indicated good continuity of the urethra. Two girls had urinary incontinence postoperatively but were continent 3 months later. One patient developed vesical-abdominal fistula and got repaired by surgery 6 months later. She was continent ever since. Other complications were not observed during the follow-up period. CONCLUSIONS: Our method of bladder neck reconstruction using bladder flap as a patch is feasible and provides good continence, especially for those with serious bladder neck avulsion and urethral rupture caused by extensive trauma and those who had posttraumatic urethral distraction needed second repair.

Experience with 32 Pelvic Fracture Urethral Defects Associated with Urethrorectal Fistulas: Transperineal Urethroplasty with Gracilis Muscle Interposition.

PURPOSE: Pelvic fracture urethral defects associated with urethrorectal fistulas are rare and difficult to repair. The aim of this study was to evaluate the efficacy of transperineal urethroplasty with gracilis muscle interposition for the repair of pelvic fracture urethral defects associated with urethrorectal fistulas. MATERIALS AND METHODS: We identified 32 patients who underwent transperineal urethroplasty with gracilis muscle interposition to repair pelvic fracture urethral defects associated with urethrorectal fistulas. Patient demographics as well as preoperative, operative and postoperative data were obtained. RESULTS: Mean followup was 33 months (range 6 to 64). The overall success rate was 91% (29 of 32 cases). One-stage repair was successful in 17 of 18 patients (94%) using perineal anastomosis with separation of the corporeal body and in 12 of 14 (86%) using perineal anastomosis with inferior pubectomy and separation of the corporeal body. All 22 patients (100%) without a previous history of repair were successfully treated. However, only 7 of 10 patients (70%) with a previous history of failed urethroplasty and urethrorectal fistula repair were cured. Recurrent urethral strictures developed in 2 cases. One patient was treated successfully with optical internal urethrotomy and the other was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent urethrorectal fistulas associated with urethral strictures developed in an additional patient. CONCLUSIONS: Transperineal urethroplasty with gracilis muscle interposition is a safe and effective surgical procedure for most pelvic fracture urethral defects associated with urethrorectal fistulas. Several other factors may affect its postoperative efficiency.

Intermediate-Term Outcomes and Complications of Long Segment Urethroplasty with Lingual Mucosa Grafts.

PURPOSE: We evaluated outcomes and donor site complications in male patients with complex urethral strictures who underwent urethroplasty using with long strip oral mucosal grafts. We also analyzed whether a lingual mucosa graft is a good substitute for repairing long segment urethral strictures. MATERIALS AND METHODS: This retrospective study was done in 81 male patients with complex urethral strictures who underwent oral mucosal graft urethroplasty. Patients with long segment (8 cm or greater) anterior urethral strictures who were considered candidates for long strip lingual mucosa graft urethroplasty were included in study. RESULTS: Oral mucosal graft urethroplasty was performed in 81 patients with complex urethral strictures between August 2006 and December 2014. Mean urethral stricture length was 12.1 cm (range 8 to 20). A single 9 to 12 cm long strip lingual mucosa graft was used in 52 patients, a lingual mucosa graft greater than 12 cm was placed in 17 and a lingual mucosa graft combined with a buccal mucosal graft was used in 12. Mean followup was 41 months (range 15 to 86) postoperatively. The overall urethroplasty success rate was 82.7%. Urethral complications developed in 14 patients (17.3%), including urethral strictures in 10 and urethrocutaneous fistulas in 4. At 12 months 5 patients (6.2%) reported minimal difficulty with fine motor movement of the tongue. CONCLUSIONS: Lingual mucosa harvested from the ventrolateral surface of the tongue can provide a wide and long graft that is an excellent urethral substitute. Donor site complications are primarily limited to postoperative year 1. Our study confirms that the lingual mucosa graft is a good substitute for urethral reconstruction and lingual mucosa graft urethroplasty is a valuable procedure to treat long anterior urethral strictures.

Urethral Reconstruction with Small Intestinal Submucosa Seeded with Oral Keratinocytes and TIMP-1 siRNA Transfected Fibroblasts in a Rabbit Model.

BACKGROUND: To evaluate the effect of tissue inhibitor of metalloproteinase-1 small interfering RNA (TIMP-1 siRNA) transfected fibroblasts (FB) for urethral reconstruction. MATERIALS AND METHODS: A ventral urethral mucosal defect was created. Substitution urethroplasty was performed with small intestinal submucosa (SIS) alone (8 rabbits, group 1), autogenic oral keratinocytes (OK)-seeded SIS (8 rabbits, group 2) or autogenic OK and TIMP-1 siRNA transfected FB-seeded SIS (8 rabbits, group 3). At 1 and 6 months after surgery (4 rabbits at each time point), retrograde urethrogram and histologic analysis were performed to evaluate the outcomes of urethroplasty. RESULTS: TIMP-1 siRNA transfected FB decreased the secretion of type I collagen. Under retrograde urethrography, 5 rabbits in group 1, 6 in group 2 and 7 in group 3 maintained a wide urethral caliber. Histologically, inflammation and fibrosis were observed at 6 months in group 1. The speed of urothelium, smooth muscle and vessel regeneration in group 3 was faster than that in group 2. Comparison of smooth muscle-to-collagen ratio, epithelial layers, smooth muscle content and microvessel density among three groups revealed a significant increase (p < 0.05). CONCLUSIONS: TIMP-1 siRNA transfected FB could be used as a source of seed cell for urethral tissue engineering and could prevent the proliferation of urethral scar tissue.

Etiology and Management of Male Iatrogenic Urethral Stricture: Retrospective Analysis of 172 Cases in a Single Medical Center.

PURPOSE: To investigate the etiology and management of male iatrogenic urethral stricture in China. METHODS: The data of 172 patients with iatrogenic urethral stricture who underwent treatment at a high volume reference center in China from January 2008 to February 2014 were analyzed retrospectively. Databases were analyzed to understand the impact of different types of iatrogenic injury on stricture location, length and treatment of urethral strictures, as well as success rates. RESULTS: The most common type of iatrogenic stricture was urethral instrumentations in 80 patients (46.51%). Mean stricture length was 3.3 ± 2.54 cm and the longest strictures were those caused by intravesical instillation. Substitution urethroplasty was the most common intervention and was performed in 60.47% (104/172) of patients. The overall success rate was 85.00% (136/160). Univariable analyses revealed that the type of iatrogenic injury was significantly related to restenosis (p = 0.036), and it is more apt to postoperative restenosis in the type of intravesical instillation than others. CONCLUSION: Our results showed that urethral instrumentation is the most common etiology of iatrogenic urethral stricture, and most iatrogenic urethral strictures involve the anterior urethra. The different etiologies are closely associated with stricture location, length and the overall prognosis of urethral strictures.

TIMP-1 Induces α-Smooth Muscle Actin in Fibroblasts to Promote Urethral Scar Formation.

BACKGROUND/AIMS: Tissue inhibitor of metalloproteinases-1 (TIMP-1) has been reported to upregulate in urethral scar. However, the underlying molecular mechanisms remain undefined. METHODS: Here, we studied levels of TIMP-1 and α-smooth muscle actin (α-SMA) in the fibroblasts isolated from urethral scar tissues, compared to the fibroblasts isolated from normal urethra. Then we either overexpressed TIMP-1, or inhibited TIMP-1 by lentiviruses carrying a transgene or a short hairpin small interfering RNA for TIMP-1 in human fibroblasts. We examined the effects of modulation of TIMP-1 on α-SMA, and on epithelial-mesenchymal transition (EMT)-related genes. We also studied the underlying mechanisms. RESULTS: We detected significantly higher levels of TIMP-1 and α-smooth muscle actin (α-SMA) in the fibroblasts isolated from urethral scar tissues, compared to the fibroblasts isolated from normal urethra. Moreover, the levels of TIMP-1 and α-SMA strongly correlated. Moreover, we found that TIMP-1 significantly increased levels of α-SMA, transforming growth factor ß 1 (TGFß1), Collagen I and some other key factors related to an enhanced EMT, suggesting that TIMP-1 may induce transformation of fibroblasts into myofibroblasts to promote tissue EMT to enhance the formation of urethral scar. Moreover, increases in TIMP-1 also induced an increase in fibroblast cell growth and cell invasion, in an ERK/MAPK-signaling-dependent manner. CONCLUSION: Our study thus highlights a pivotal role of TIMP-1 in urethral scar formation.

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

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

Crosstalk between TGF-ß1 and CXCR3 signaling during urethral fibrosis.

Urethral fibrosis is an important pathological feature of urethral stricture. TGF-ß1 and CXC chemokine receptor 3 (CXCR3) signaling have been reported as the critical pathways involved in the pathology of fibrosis. Here, we collected the urine samples from the patients with recurring urethral stricture, recurring stricture treated by cystostomy, and age- and gender-matched healthy people. ELISA detection revealed that TGF-ß1 level was significantly up-regulated for the urethral stricture patients. By contrast, flow cytometry, real-time PCR detection, and immunofluoresecent staining showed that urethral stricture resulted in decreased expression of CXCR3. TGF-ß1 treatment could increase cell proliferation and migration ability of urethra fibroblasts, whereas IP-10/CXCR3 signaling showed the opposite effect. Further, we found a crosstalk between TGF-ß1 and CXCR3 signaling in the regulation of urethral fibrosis. Thus, pharmacological intervention of TGF-ß1 or CXCR3 signaling has a potential as the therapeutic target for the prevention of urethral fibrosis.

Complete androgen insensitivity syndrome in juveniles and adults with female phenotypes.

AIM: To report on six cases of the diagnosis and treatment of patients with complete androgen insensitivity syndrome (CAIS) and a review of the relevant published work. METHODS: A retrospective analysis was performed on the clinical features, diagnosis and treatment of a total of six patients with CAIS who were admitted to our hospital between September 1985 and June 2012. All surgical patients were examined for sex chromosomes and sex hormone levels pre- and postoperatively, respectively, and underwent lower abdominal B ultrasounds and pathological examinations among other tests. RESULTS: Five of the patients were treated with castration, one patient aged 5 years was treated conservatively Tissue from surgical resections showed normal testicular tissue that comprised Leydig cells and Sertoli cells, and pathological examinations showed no sign of testicular cancer. Following corrective operations, postoperative complications, such as female secondary sexual characteristics, stagnation and osteoporosis, have not developed. Sex hormone level ratio changed significantly after being treated with castration compared with preoperative levels; mainly testosterone and estrogen decreased significantly (P < 0.05), while luteinizing hormone and follicle-stimulating hormone significantly increased (P < 0.05). However, prolactin did not change significantly (P > 0.05). CONCLUSION: The study show that removal of the testes in CAIS patients after puberty is safe and reliable. Meanwhile, it is essential to provide a hormone drug after being treated with castration. Further studies are needed to evaluate the safety and the quality of life for CAIS patients.

Optimizing anterior urethral stricture assessment: leveraging AI-assisted three-dimensional sonourethrography in clinical practice.

PURPOSE: This investigation sought to validate the clinical precision and practical applicability of AI-enhanced three-dimensional sonographic imaging for the identification of anterior urethral stricture. METHODS: The study enrolled 63 male patients with diagnosed anterior urethral strictures alongside 10 healthy volunteers to serve as controls. The imaging protocol utilized a high-frequency 3D ultrasound system combined with a linear stepper motor, which enabled precise and rapid image acquisition. For image analysis, an advanced AI-based segmentation process using a modified U-net algorithm was implemented to perform real-time, high-resolution segmentation and three-dimensional reconstruction of the urethra. A comparative analysis was performed against the surgically measured stricture lengths. Spearman's correlation analysis was executed to assess the findings. RESULTS: The AI model completed the entire processing sequence, encompassing recognition, segmentation, and reconstruction, within approximately 5 min. The mean intraoperative length of urethral stricture was determined to be 14.4 ± 8.4 mm. Notably, the mean lengths of the urethral strictures reconstructed by manual and AI models were 13.1 ± 7.5 mm and 13.4 ± 7.2 mm, respectively. Interestingly, no statistically significant disparity in urethral stricture length between manually reconstructed and AI-reconstructed images was observed. Spearman's correlation analysis underscored a more robust association of AI-reconstructed images with intraoperative urethral stricture length than manually reconstructed 3D images (0.870 vs. 0.820). Furthermore, AI-reconstructed images provided detailed views of the corpus spongiosum fibrosis from multiple perspectives. CONCLUSIONS: The research heralds the inception of an innovative, efficient AI-driven sonographic approach for three-dimensional visualization of urethral strictures, substantiating its viability and superiority in clinical application.

Redo inferior pubectomy for failed anastomotic urethroplasty in pelvic fracture urethral injury.

Objectives: To assess the effect of redo inferior pubectomy on the management of complicated pelvic fracture urethral injury (PFUI) in patients with a history of failed anastomotic urethroplasty. Materials and methods: We retrospectively reviewed all patients receiving redo anastomotic urethroplasty with redo inferior pubectomy for failed PFUI between January 2010 and December 2021. Patients with incomplete data and those who were lost to follow-up were excluded. Successful urethroplasty was defined as the restoration of a uniform urethral caliber without stenosis or leakage and further intervention. Functional results, including erectile function and urinary continence, were evaluated. Descriptive statistical analyses were then performed. Results: Thirty-one patients were included in this study. Among them, concomitant urethrorectal fistula occurred in 2 patients, and concomitant enlarged bladder neck occurred in 1. The stenosis site was the bulbomembranous urethra in 2 patients and the prostatomembranous urethra in 29. The mean length of urethral stenosis in all patients was 3.1 cm (range, 2.0-5.0 cm). After a mean follow-up of 34.6 months, the final success rate was 96.8%. The incidence of erectile dysfunction reached 77.4% (24/31). Normal continence was achieved in 27 (87.1%) patients. One patient developed urinary incontinence of grade II requiring urinary pads because of an enlarged bladder neck. According to the Clavien-Dindo classification, postoperative complications of grade I occurred in 7 patients and grade II in 4. Conclusions: Repeat anastomotic urethroplasty with repeat inferior pubectomy provides reliable success rates for failed PFUI. In complicated cases, it should be known and mastered.

A rationale for procedure selection to repair female urethral stricture associated with urethrovaginal fistulas.

PURPOSE: We investigated a rationale for procedure selection to repair female urethral stricture associated with urethrovaginal fistula. We compared the outcomes of the 5 techniques used. MATERIALS AND METHODS: Between January 1999 and October 2011, 44 female patients with urethral stricture associated with urethrovaginal fistula were treated using a total of 5 techniques. The surgical techniques were labial pedicle flap urethroplasty in 24 patients, vulvar flap urethroplasty in 3, anterior vaginal flap urethroplasty in 11, end-to-end anastomosis in 4 and bladder flap urethroplasty in 2. Supplementary procedures were performed in some patients during urethroplasty, including bladder neck reshaping for incontinence in 5, intestinal-vaginal fistula repair in 3, colpoplasty for island vulvar skin flaps in 3, middle vaginal stricture vaginoplasty in 2 and enlargement of the vaginal introitus in 1. RESULTS: Average postoperative followup was 42.3 months (range 6 to 140). Urethrovaginal fistula recurred in 2 patients because of infection, urethral stricture developed in 1 and stress incontinence appeared in 1. The other patients voided normally with an average maximum urine flow greater than 15 ml per second (range 16.7 to 46). The overall anatomical success rate was 93.18% (41 of 44 cases) and the functional success rate was 90.91% (40 of 44). CONCLUSIONS: Surgical procedures for treating female urethral strictures with urethrovaginal fistulas should be based on fistula location, stricture length and vaginal anatomy. A transvaginal approach might be optimal if the vagina is wide and easily dilated. Pedicle labial flap urethroplasty was a reliable technique for complex strictures.

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

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

The relationship between erectile dysfunction and open urethroplasty: a systematic review and meta-analysis.

INTRODUCTION: Various urethroplasty techniques have been used to treat urethral stricture. Whether the patient erectile function is affected by this open surgery is still controversial. AIM: The aim of this study is to determine the relationship between erectile function and open urethroplasty. METHODS: A systematic review of the literature was performed using Medline, Embase, the Web of Science, and the Cochrane Library databases through October 2012 to identify articles published in any language that examined the effect of open urethroplasty on the risk of erectile dysfunction (ED). This meta-analysis was conducted according to the guidelines for the meta-analysis of observational studies in epidemiology. MAIN OUTCOME MEASURES: The incidence of ED after urethroplasty. RESULTS: This meta-analysis consisted of 23 cohort studies, which included 1,729 cases. No significant difference was noticed in patients with anterior urethral stricture before or after intervention (odds ratio [OR] = 0.86; 95% confidence interval [CI]: 0.52-1.40; P = 0.53). While statistical difference in the incidence of ED was revealed in patients before and after intervention for a posterior urethral (OR = 2.51; 95% CI: 1.82-3.45; P < 0.001), further comparisons demonstrated that most anterior urethroplasties did not have an obvious effect on patient erectile function. However, it seems that the incidence of ED was higher in the bulbar anastomosis group than in the oral graft urethroplasty group (OR = 0.32 95% CI: 0.11-0.93; P = 0.04). For the posterior urethroplasty, previous operative history did not show a strong relationship with ED. No statistically significant difference in the risk of ED was demonstrated comparing the posterior urethral reconstructive techniques included in this analysis. CONCLUSION: The adverse effect of urethroplasty itself on erectile function is limited, as more patients recover erectile function after urethral reconstruction. For anterior urethroplasty, bulbar anastomosis might cause a slightly higher incidence of ED than other operations. For posterior urethroplasty, trauma might be the main cause of ED.

Traumatic urethral diverticula: a rare malformation of the male urethra.

Urethral diverticula are pouches opening into the urethral canal that may be either acquired or congenital. Diverticula of the female urethra are fairly common. However, diverticula of the male urethra are relatively uncommon abnormalities. Clinical manifestation is frequently described with irritative and/or obstructive voiding symptoms or ventral bulging, but manifestation as a scrotal mass is extremely rare. We report a giant urethral diverticulum presenting as a scrotal mass in an adult male.

Outcome of small intestinal submucosa graft for repair of anterior urethral strictures.

OBJECTIVES: To investigate the feasibility of small intestinal submucosa graft for the repair of selected anterior urethral strictures. METHODS: From June 2009 to May 2011, 28 men (mean age 39 years) with anterior urethral strictures underwent urethroplasty using a four-layer small intestinal submucosa patch graft in an onlay or inlay fashion. The stricture was localized to the bulbar urethra in eight patients, the bulbopenile area in nine patients and the distal penile urethra in 10 patients. Failed hypospadias was observed in one patient. The mean stricture length was 4.6 cm (range 3.5-7.0 cm). RESULTS: The mean follow-up period was 24.8 months (range 12-30 months). No postoperative complications, such as infection or rejection, were related to the use of heterologous graft material. The patients voided well postoperatively, with peak flows between 16 and 44 mL/s (mean 25.4 mL/s) in 26 patients. Two patients (7.1%) developed a urethral narrowing; this occurred at 5 months in one patient and 6 months in the other, and cystoscopy, which was carried out at 20 and 24 weeks, respectively, showed clear cicatricial tissue at the proximal anastomotic site. Dilation was carried out once every 4-6 months for recurrent stricture in one patient and lingual mucosal graft urethroplasty was carried out in the other patient at 18 months postoperatively. Biopsies were obtained in four patients at 18, 24, 36 and 42 weeks, respectively. Squamous epithelium with or without hyperkeratosis was observed on histological examination of the small intestinal submucosa-grafted areas. CONCLUSIONS: The small intestinal submucosa matrix appears to be a safe and effective reconstructive material for selective use in urethral reconstructive surgery.