Female Urethroplasty: Outcomes of Different Techniques in a Single Center (original) (raw)
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Primary versus Redo Urethroplasty: Results from a Single-Center Comparative Analysis
BioMed Research International
Objectives. To explore the differences between primary and redo urethroplasty and to directly compare according stricture-free survival (SFS). Materials and Methods. Data of all male patients who underwent urethroplasty at Ghent University Hospital were collected between 2000 and 2018. Exclusion criteria for this analysis were age <18 years and follow-up <1 year. Two patient groups were created for further comparison: the primary urethroplasty (PU) group (no previous urethroplasty) and redo urethroplasty (RU) group (≥1 previous urethroplasty), irrespective of prior endoscopic treatments. A comparison between groups was performed using the Mann–Whitney U test and Fisher’s Exact test. SFS was calculated using Kaplan–Meier statistics. A functional definition of failure, being the need for further urethral manipulation, was used. Uni- and multivariate Cox regression analyses were performed on the entire patient cohort. Results. 805 patients were included. Median (IQR) follow-up of...
Urethroplasty : a review of indications , techniques and outcomes
rethral stricture is the most common cause of lower urinary tract obstruction in men aged between 20 and 40, carrying an estimated overall prevalence of 0.5% in the UK [1] and results in around 17,000 hospital admissions annually [2]. Endoscopic management, by urethral dilatation or optical urethrotomy, has traditionally been the mainstay of surgical treatment, however high recurrence and poor long-term success rates have led to the development of novel techniques. Reconstructive surgery, namely urethroplasty, is an increasingly common option in the surgical management of both primary and recurrent urethral stricture, and produces encouraging long-term results. This article will discuss the basis for urethroplasty, the techniques involved and the current evidence-base behind the trend towards this treatment, particularly in the context of stricture disease.
Reoperative urethroplasty. A systematic review
Archivos españoles de urología
Limited articles are published on reoperative urethroplasty outcomes. We sought to perform a systematic review of re-operative urethroplasty articles over the past fifteen years. A systematic review was performed on PubMed using the search terms "Urethra" AND "Surgical Procedures, Operative" OR "Urethroplasty". Five articles out of 3,541 articles identified between 1998 and 2012 specifically addressed re-operative urethroplasty patients. A total of 212 patients were included in these five studies. Re-operative urethroplasty success rates ranged from 35% to 84%. Success rates were higher in the two studies with over 40 patients and ranged from 78-84%. Limited studies address re-operative urethroplasty outcomes. Success rates for re-operation are lower than those for initial urethroplasty procedures. Overall, studies with a higher number of patients had an increased success rate.
Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques
Urethroplasty means plastic surgery of the urethra. Herein we are going to describe urethroplasty in terms of; diagnosis, indications, surgical techniques and definition of failure or success. A lot of issues related to urethroplasty remain to be defined, therefore we will clarify the debatable issues and highlight the last advances on urethroplasty. There are two main causes which mandate ur ethroplasty; the first is the congenital anomalies with hypospadias being the most common, and the acquired anomalies with urethral stricture being the most common of them. Hypospadias is found commonly in newborn boys and it seen in approximately 8.2 per 1000 births. The goal of hypospadias reconstruction are to bring the meatus close to glans to allow the child to void standing, removing the chordee to allow for normal sexual intercourse and giving the phallus appearance of a normally circumcised penis wh en observed from distance. There are more than 200 named surgical procedure to correct hypospadias. Now a days tubularized incised plate (TIP) urethroplasty described by Snodgrass in 1994 is the most common procedure used for repair of hypospadias. The advantages of this technique include its simplicity, high success rate, low rate of complication and excellent cosmetic results. A lot of modifications were introduced on the TIP urethroplasty aiming to improve the success rate and to decrease fistula formation. We were from the firsts who published such modification regarding the use of double- layer dartos flap covering for urethra instead of the classic way of utilizing dorsal dartos flap (button hole maneuver). The second cause of urethroplasty is the acquired anomalies. Strictures of urethra is of much clinical important than hypospadias, because it bothers the patients more, unfortunately the results of surgery is not promising as that of hypospadias. The term “urethral stricture” refer to anterior urethral disease or scaring pr ocess involving the spongy erectile tissue of the corpus spongiosum (spongiofibrosis). According to World Health Organization posterior urethral stricture are not included in the common definition of urethral stricture and the term stricture is limited to the anterior urethra. Urethral disruption injuries typically occur in conjunction with multisystem trauma from vehicular accident, falls, or industrial accident. Because the posterior urethra is fixe d at both the urogenital diaphragm and the puboprostatic ligaments, the bulbomembranous junction is more vulnerable to injury during pelvic fractures. When the fracture occur the two separa ted ends fill with scar tissue, resulting in a complete lack of urethral continuity. The location of urethral strictures was classified as penile(including navicularis fossa) , bulbar or posterior (excluding bladder neck contractures).While posterior urethral strictures were commonly caused by traumatic disruption distinctly different from etiology compared to that of anterior strictures disease, recurrence was monitored with the same procedure used for surveillance of anterior urethral reconstruction. The Urethral disruption is heralded by the tria d of blood at the meatus, inability to urinate, and palpably full bladder. When blood at the urethral meatus is discovered, an immediate retrograde urethrogram should be performed to rule out urethral injury.When urethral stricture is diagnosed immediate suprapubic tube placement remains the standard of care. While the diagnosis of hypospadias needs no radiologic tests, diagnosis of urethral stricture is a matter of discussion. The most common primary diagnostic tests are uroflowmetry (56%), urethrography (51%) and cystourethro scopy (21%). Definition of recurrence of stricture or failure of surgery is also a questionable issue. In 75% of papers regarding urethroplasty, recurrence was defined as the n eed for additional surgical procedure and in 52% as the need for additional urethral dilation. The treatment of urethral strictures is divide d in two groups; endoscopic and open surgery. The endoscopic treatment such as direct-visio n internal urethrotomy are the best reserved for selected short urethral stricture. However wh en the defects are 1 cm or longer or when a significant corpus spongiofibrosis is present , endoscopic procedure such as cutting through the pelvic scare”cut-to-light” are ineffective. Despite the popularity of this procedure the failure rate after initial urethrotomy is reported to be at least 50%. The failure rate after the second urethrotomy is considered much higher and can be as high as 100%. Therefore there has been continuing discussion about the most appropriate use of urethrotomy, dilation, stenting, and intermittent self dilation. Question have also su rfaced about the best technique for urethrotomy. There is no compelling evidence in the literature that any particular form of urethrotomy is more effective than anothe r, whether using a cold knife or laser. The second treatment option is open surgical reconstruction. There are two kinds of open surgical techniques used for urethroplasty; anastomotic urethroplasty and substitution urethroplasty. Anastomotic urethroplasty involves excision of the strictures and primary anastomosis of urethral ends. Open posterior urethroplasty through a perineal anastomotic approach is the treatment of choice for the most urethral distraction injuries because it definitely cure the patient without the need for multiple procedure. Care must be taken to carefully and meticulously excise all fibrotic tissue from the proximal urethra margin until at least a 28 french bougie passes without resistance. Free tension end to end anastomosis is the procedure of choice when the scar is 1.5-2 cm long and this is highly successful procedure in more than 95% of cases. Urethroplasty remains the gold standard for the management of urethral stricture offering the lowest rate of stricture recurrence and in some circumstance the most cost-effective compared to repeat dilation or endoscopic incision. The limiting factors with anastomotic urethroplasty is the strictures length, in particular the length of component distal to bulbopenile ju nction. Anastomatic procedure in the bulbar urethra resulted in a significant impairment of erectile function initially which improved in the majority of cases with a low of long term erectile dysfunction. The second kind of urethroplasty is substitution urethroplasty. Recent advances in tissue graft sources and the introduction of tissue sealants improve surgical outcomes and minimize patients morbidity by decreasing the number of surgical procedures and the potential disfigurement related to graft site morbidity. Substitution urethroplasty can be performed as a one-stage procedure via an augmented anastomotic procedure, patch substitution (onlay procedure) or a circumfe rential patch, or two-stage procedure which involves the formation of a roof strip followed be second stage tubularization. It has been shown that the efficacy of both grafts and fl aps was identical , but there was a much higher morbidity with penile skin flaps which were also more complex with higher morbidity. The graft which has been used included scrotal skin, oral mucosa, extrag enital skin, bladder mucosa, and colonic mucosa. The success rate at average follow-up of 53 months was reported to be 60% for augmented anastomo tic repair and 80% for onlay procedure. In conclusion urethroplasty especially in patients with urethral stricture required the urologist to be aware of the techniques which offer the patient the best success. Therefore different considerations have to be taken in to account like length , location, anatomy and etiology of stricture. In comparison to reconstruction of urethral stricture, urethroplasty done due to hypospadias seems to be less complicated with high success rate at long term follow-up.
One-stage urethroplasty for strictures at a rural hospital
Annals of African Surgery, 2019
Introduction: St Mary's Mission Hospital manages many inflammatory and traumatic urethral strictures. Previously, we treated strictures with dilatation, but high recurrence and poor patient satisfaction necessitated adoption of reconstructive procedures since 2017. Objective: To review the scope, outcome and complications of urethroplasties using data collected prospectively. Methods: All cases of one-stage urethroplasty were included. Patient biodata and pre-operative adverse factors were collected and analyzed. Results: 23 male patients ranging in age from 24 to 74 years were studied: 9 strictures were inflammatory (40%), 9 were traumatic (40%), 3 (20%) were recurrent. Nineteen strictures were in the bulbar urethra (83%), 2 were cases of penile strictures and 1 case each of pan-urethral stricture and pelvic floor urethral distraction defect. Of the 23 procedures, 13 were simple anastomosis (57%), 5 were dorsal buccal mucosa graft (BMG) urethroplasty (22%), 2 were cases of non-transecting anastomotic urethroplasty, and 1 case each of ventral BMG urethroplasty and Johansson's and Kulkarni's panurethroplasty. The overall complication rate was 40% (9 patients). Four patients (17%) had recurrence; 2 had fistula and 1 case each of persistent UTI, erectile dysfunction and periurethral abscess. Three of the four recurrences had undergone BMG urethroplasty. All cases of simple anastomosis had no recurrence. Conclusion: Our centre has embraced diverse urethroplasties for a wide scope of patients. This study found a significant complication rate for substitution urethroplasties, suggesting a need for careful patient selection and an improvement in technique.
Neurourology and Urodynamics, 2020
Objective: To evaluate the management methods of female urethral stricture (FUS) and analyze the outcomes of surgical treatments. A meta-analysis was done in an attempt to identify the best approach of urethroplasty and the graft-of-choice. Materials and Methods: A systematic search of Pubmed/Medline and Embase databases was performed according to the Preferred Reporting Items For Systematic Review And Meta-Analysis statement, for articles reporting on FUS management in the last decade. The Newcastle-Ottawa scale was used to assess the quality of 28 included non-randomized studies. The data on FUS management was summarized and pooled success rates (taken as symptom improvement and no need for further instrumentation) were compared. The secondary outcome was to establish a diagnostic modality of choice and define a "successful-outcome" of repair. Results: The outcome was separately reported for 554 women undergoing surgical intervention for FUS in the literature. The criteria defining FUS were varied. A combination of tests was used for diagnosis as none was singularly conclusive. A total of 301 patients had previous urethral instrumentations. The pooled success rate of urethral dilatation (234 women) was 49% at a mean follow-up of 32 months; flap urethroplasty (108 cases) was 92% at a mean followup of 42 months; buccal mucosal graft (BMG) urethroplasty (133 cases) was 89% at a mean follow-up of 19 months; vaginal graft augmentation (44 cases) was 87% at a mean follow-up of 15 months; and labial graft reconstruction (19 cases) was 89% at a mean follow-up of 18.4 months. The dorsal approach of graft augmentation met with 88% (95% confidence interval [CI] 0.79-0.95) success compared with 95% (95% CI 0.86-1) for the ventral approach. Conclusion: FUS is a rare condition requiring a meticulous diagnostic workup using multiple tests. All urethroplasties have shown better pooled success rates (86%-93%) compared with dilatation (49%). BMG is equally effective as vaginal graft urethroplasty.
Female urethral stricture: techniques for reconstruction
Plastic and Aesthetic Research, 2022
Female urethral stricture (FUS) is a rare condition. It was not studied robustly for many years, but interest has grown recently in the reconstructive urology community, leading to an increase in publications. In this review, we gather the latest data regarding FUS and its different therapeutic options. Studies are summarized, split by technique. We also review the recently published European Guidelines. In addition, we share our preferred surgical technique and our views on future options. Diagnosing FUS can often be challenging and requires a high index of clinical suspicion. Its vague clinical symptoms and empiric initial treatments combine to make FUS an underdiagnosed condition. The lack of consensus on how to define FUS also compounds the problem. Appropriate diagnosis requires thorough investigation, and ancillary studies such as video urodynamics, cystoscopy, and voiding cystourethrogram may be useful. Treatment options range from conservative management to definitive procedures, although studies have shown that conservative measures such as urethral dilation have a low success rate overall. Within definitive management, augmented urethroplasty - using either flaps or grafts, has proven to be the gold standard. Both have shown excellent results over time; however, there is insufficient data available to recommend one over the other. Contemporary data has an overall poor level of evidence. Although challenging due to the rarity of the problem, a proper randomized controlled clinical trial comparing the principal surgical options and their outcomes would be beneficial and would allow for more informed decision making when considering options for women with urethral stricture.
Urethroplasty: current techniques and management of complications
Plastic and Aesthetic Research, 2023
Urethroplasty has always been a challenge in genitourinary surgery; urethral reconstruction (primary or redo) is one of the most critical functional requests. In recent decades, many urethroplasty techniques and their modifications have been published. Primary repair is indicated for congenital abnormalities of the urethra, such as hypospadias or epispadias, the most frequent anomalies with urethral defects. One of the essential aspects of urethroplasty is urethral stricture disease, and there is much discussion about the etiology, location, length, and management. Despite recent improvements, the management of urethral stricture disease remains a challenging problem. Successful management is based on detailed knowledge of the anatomy, pathophysiology, and proper procedure selection tailored for each case.