Reconstruction of urethral strictures in patients with a long history of blind urethral dilatation (original) (raw)
Related papers
Characteristics of the urethroplasty and our approach-Experience in patients with urethral stricture
Türk Üroloji Dergisi/Turkish Journal of Urology, 2018
Objective: Urethral stricture is a common pathology with different etiologic factors in different age groups and societies. In our research, patients who underwent urethroplasty because of urethral stricture were evaluated in terms of etiology, localization, surgical technique and demographic characteristics. Material and methods: One hundred and sixty-three patients with a mean age of 53.43±16.5 years, operated between January 2008 and May 2016 because of urethral stricture were retrospectively included in the study. Diagnosis of the urethral stricture was established based on the complaints of the patient, results of urinalysis, urine culture, uroflowmetry, retrograde urethrography and/or voiding urethrography, and urethroscopy in case of need. Postoperative success for the patients was determined based on urinary flow rate and maximum flow rate of over 15 mL/sec were evaluated as success. Results: Etiologic factors for urethral stricture included trauma in 40 (24.5%), urethral catheterization in 45 (27.6%), endoscopic procedure in 59 (36.2%), infection in 10 (6.2%), idiopathic etiologies in 9 (5.5%) out of 163 patients. Mean length of the stricture was 3.6±1.7 cm. While the indicated number of patients had buccal mucosa graft (n=73, 44.7%), penile skin flap (n=21, 12.8%), Heineke-Mikulicz repair (n=5, 3.0%), and end-to-end anastomosis (n=64, 39.1%). Mean follow-up period was 43.2±33.7 months. Buccal mucosa graft was applied as ventral (n=32, 43.8%), dorsal (n=22, 30.2%), and dorsolateral (n=14, 19.2%) onlay, and transventrally dorsal inlay (n=5, 6.8%) grafts. Average success rates were 83.5% (n=61/73) in buccal mucosa, 76.2% (n=16/21) in penile skin grafts; 85.9% (n=55/64) in end-to-end anastomosis and 80.0% (n=4/5) in Heineke-Mikulicz repair. Conclusion: Our assumption is that urethroplasty procedures have satisfactory long-term results, regardless of the location and size of the stenosis. According to our clinical experience, deciding on the most appropriate surgical technique by assessing each patient individually in experienced centers will increase success rates.
To assess the impact of prior urethral dilatation or DVIU on the outcome of anterior urethroplasty
International Journal of Endorsing Health Science Research
Background: Male urethral stricture has remained the major problem in urologic practice. Patients presenting with urethral stricture disease are commonly managed by dilatation, DVIU, and urethroplasty. Methodology: This is a descriptive study of male patients who underwent anterior urethroplasty at our setup from 5th August 2021 to 25th February 2022. We analyzed the age, duration, type, length, and location of the stricture and the surgical treatment outcome after urethroplasty. The post-operative catheter was removed after 3 weeks, and UFM is advised. Qmax (max flow rate) > 15 ml/sec was measured on UFM (uroflowmetry) on the 1st week, 6 weeks, and followed on 3 months. Final outcome in terms of success was assessed by uroflowmetry. A maximum urine flow greater than 15mL/s after 3 months’ treatment assessed by uroflowmetry was considered as success. Results: In our study, the blood loss in group A and group B patients, those patients who had DVIU or dilation in the past, had mor...
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.
Repeat Urethroplasty After Failed Urethral Reconstruction: Outcome Analysis of 130 Patients
Journal of Urology, 2012
Male urethral stricture disease accounts for a significant number of hospital admissions and health care expenditures. Although much research has been completed on treatment for urethral strictures, fewer studies have addressed the treatment of strictures in men with recurrent stricture disease after failed prior urethroplasty. We examined outcome results for repeat urethroplasty. Materials and Methods: A prospectively collected, single surgeon urethroplasty database was queried from 1977 to 2011 for patients treated with repeat urethroplasty after failed prior urethral reconstruction. Stricture length and location, and repeat urethroplasty intervention and failure were evaluated with descriptive statistics, and univariate and multivariate logistic regression. Results: Of 1,156 cases 168 patients underwent repeat urethroplasty after at least 1 failed prior urethroplasty. Of these patients 130 had a followup of 6 months or more and were included in analysis. Median patient age was 44 years (range 11 to 75). Median followup was 55 months (range 6 months to 20.75 years). Overall, 102 of 130 patients (78%) were successfully treated. For patients with failure median time to failure was 17 months (range 7 months to 16.8 years). Two or more failed prior urethroplasties and comorbidities associated with urethral stricture disease were associated with an increased risk of repeat urethroplasty failure. Conclusions: Repeat urethroplasty is a successful treatment option. Patients in whom treatment failed had longer strictures and more complex repairs.
Redo-urethroplasty for the management of recurrent urethral strictures in males: a systematic review
World Journal of Urology
Purpose Redo-urethroplasty is a challenge for any genitourethral surgeon, with a number of techniques previously described. This systematic review aims to identify the surgical techniques described in the literature and evaluate the evidence for their effectiveness in managing recurrent urethral strictures. Materials and methods A systematic review of the MEDLINE and EMBASE databases from 1945 to July 2018 was performed and the urethroplasty procedures were classified according to the site and surgical technique. Primary outcomes included success rates measured via re-stricture rates and the post-op maximum urinary flow rate. Secondary outcomes included complication rates and patient-reported quality of life. Results A total of 39 identified studies met the inclusion criteria. Twenty-two studies described the use of excision and primary anastomotic urethroplasty with success rates showing wide variability (58-100%). Success rates reported according to the site of the stricture also varied: bulbar (58-100%) and posterior (69-100%) recurrent strictures. One-stage substitution urethroplasty was described in 25 studies with success rates of 18-100%, with the best outcomes reported for bulbar (58-100%) and hypospadias-related (78.6-82%) strictures. Two-stage substitution urethroplasty was described in 12 studies with the success rates of 20-100%, with the best evidence related to hypospadias-related and posterior urethral strictures. The buccal mucosa graft was the graft source with the best evidence for substitution urethroplasty (18-100%). Conclusions Trends of effectiveness were identified for redo-urethroplasty modalities in different locations. However, the current levels of evidence are limited to small observational studies, highlighting the need for further larger prospective data to evaluate different techniques used for recurrent urethral strictures.
Journal of Pediatric Urology, 2011
Objective: Urethral strictures are among the most common complications after hypospadias repair. We report our 10-year experience with endoscopic incision or dilation of urethral strictures after hypospadias repair, to determine the best management technique. Methods: All cases of urethral strictures after hypospadias repair treated with direct vision internal urethrotomy (DVIU), dilation or urethroplasty at our institution from 1997 to 2007 were included. Records were reviewed and clinical parameters analyzed. Data were statistically analyzed to identify risk factors for stricture recurrence after initial or subsequent treatment(s). Results: Of 2273 patients, 73 were treated for a postoperative urethral stricture and 15 others were referred for stricture treatment. Of these 88 patients, 39 were treated with initial dilation or DVIU and 49 underwent urethroplasty or reoperative hypospadias repair. Fifteen (38%) of the patients treated with initial DVIU or dilation showed no recurrence. Of the patients that did have a recurrence, a repeat DVIU or dilation had a success rate of 17% with no difference in success between these two groups. Choice of therapy between repeat dilation/DVIU and urethroplasty at the second procedure showed a statistically significant higher success rate in the urethroplasty group (67% vs 17%, P Z 0.03). Conclusion: Although numbers are small, our data suggest that if there is recurrent stricture after initial DVIU/dilation then a formal urethroplasty has a significantly higher success rate than repeat DVIU/dilation.
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.
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.
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.
Journal of Urology, 2009
INTRODUCTION AND OBJECTIVE: To report the results of reconstruction of extended recurrent urethral strictures with buccal mucosal graft after follow up of at least 60 months. METHODS: From 04/1994 and 10/2008 425 Patients with extended urethral strictures were operated in our centre. 132 out of 425 consecutive patients from 04/1994 and 03/2003 have now a minimum follow up of 60 months. Buccal mucosal graft was used for reconstruction. 17 out of 132 Patients were lost to follow up. In all patients the graft was placed ventrally in onlay technique. Mean stricture length ranged from 1-25 (mean 9,0) cm and the number of operative treatments before was 1-17 (mean 4.2). Patient's age was 5-80 (mean 49) years. The data's were prospectively recorded by patients reported questionnaires evaluating uroflow and residual urine every 3-month in the first year and 6 monthly thereafter. In case of uroflow less than 20ml or residual urine more than 50 ml or UTI´s we performed urethroscopy and or urethrography. Mean follow up was over 91 (80-174) months. Minimum follow up in all cases was 60 months. RESULTS: 88% Patients (n=100) out of 115 are recurrence free till date at a mean follow up of 91 months. Recurrence occurred in 15 of these Patients. 4 patients were treated with visual urethrotomy, 4 received a urethral dilatation and in 3 patients urethra was once more reconstructed with buccal mucosa. 5 out of 15 (2x visual urethrotomy, 1x reconstruction with buccal mucosa, 2x single urethral dilatation) Patients after a second intervention are recurrence free till date. 10 Patients are not fully satisfied with micturition and considered as failure. Thus there are totally 92 % (105 out of 115) patients who are now recurrence free and satisfied. CONCLUSIONS: Buccal mucosal graft implanted in onlay technique on the ventral aspect of the urethra is an excellent material for reconstruction of extended recurrent urethral strictures. The results and patient satisfaction in long term are very encouraging.