Daniela E. Andrich

SUBSTITUTION URETHROPLASTY WITH BUCCAL MUCOSAL-FREE GRAFTS

PURPOSE Buccal mucosal grafts and the Barbagli technique are recent developments in the treatment of urethral strictures. MATERIALS AND METHODS We reviewed the results of and experience with urethroplasty using buccal mucosal graft in 128 patients. RESULTS The re-stricture rate was 11% for patch grafts and 45% for tube grafts. There were no other complications. CONCLUSIONS Buccal mucosal graft is at least as good as any other material for substitution urethroplasty with fewer complications. The 2-stage is more reliable than the stage 1 approach for circumferential reconstruction of the urethra.

The Barbagli procedure gives the best results for patch urethroplasty of the bulbar urethra.

Objective To compare the surgical outcome using buccal mucosal free grafts in the Barbagli procedure (dorsal stricturotomy and patch technique) with the traditional ventral approach, for long bulbar urethral strictures.

Urethral strictures: URETHRAL STRICTURES

What’s known on the subject? and What does the study add?

Defining a Patient-Reported Outcome Measure for Urethral Stricture Surgery

BACKGROUND A systematic literature review did not identify a formally validated patient-reported outcome measure (PROM) for urethral stricture surgery. OBJECTIVE Devise a PROM for urethral stricture surgery and evaluate its psychometric properties in a pilot study to determine suitability for wider implementation. DESIGN, SETTING, AND PARTICIPANTS Constructs were identified from existing condition-specific and health-related quality of life (HRQoL) instruments. Men scheduled for urethroplasty were prospectively enrolled at five centres. INTERVENTION Participants self-completed the draft PROM before and 6 mo after surgery. MEASUREMENTS Question sets underwent psychometric assessment targeting criterion and content validity, test-retest reliability, internal consistency, acceptability, and responsiveness. RESULTS AND LIMITATIONS A total of 85 men completed the preoperative PROM, with 49 also completing the postoperative PROM at a median of 146 d; and 31 the preoperative PROM twice at a median interval of 22 d for test-retest analysis. Expert opinion and patient feedback supported content validity. Excellent correlation between voiding symptom scores and maximum flow rate (r = -0.75), supported by parallel improvements in EQ-5D visual analogue and time trade-off scores, established criterion validity. Test-retest intraclass correlation coefficients ranged from 0.83 to 0.91 for the total voiding score and 0.93 for the construct overall; Cronbachs α was 0.80, ranging from 0.76 to 0.80 with any one item deleted. Item-total correlations ranged from 0.44 to 0.63. These values surpassed our predefined thresholds for item inclusion. Significant improvements in condition-specific and HRQoL components following urethroplasty demonstrated responsiveness to change (p < 0.0001). Wider implementation and review of the PROM will be required to establish generalisability across different disease states and for more complex interventions. CONCLUSIONS This pilot study has defined a succinct, practical, and psychometrically robust PROM designed specifically to quantify changes in voiding symptoms and HRQoL following urethral stricture surgery.

Urethral strictures and their surgical treatment.

In most instances a urethral stricture is a narrowing of the calibre of the urethra caused by the presence of a scar consequent on infection or injury. However, not all strictures are caused by scarring, if a scar is taken to mean only ®brosis. So-called congenital strictures of the bulbar urethra have a substantial smooth muscle content [1] and are thought to arise from failure of normal canalization rather than ®brotic restriction of a normal-calibre urethra [2]. There is also a difference between a partial constriction of the urethra caused by, e.g. in ̄ammation (in which the epithelial lining is retained) and a ®brotic obliteration between the distracted ends of a ruptured urethra. Thus not all strictures are the same.

Posterior urethral complications of the treatment of prostate cancer

Whats known on the subject? and What does the study add?

Proposed mechanisms of lower urinary tract injury in fractures of the pelvic ring.

Authors from the UK review their experience of lower urinary tract injuries in association with fractures of the pelvic ring. They found that the pattern of pelvic fracture did not help with the prediction of the presence of lower urinary injury, but that the type of injury was related to the fracture mechanism. This study represents a large review of such injuries in both men and women, and the authors present their own theories on mechanisms of injury.

URETHROPLASTY FOR REFRACTORY ANTERIOR URETHRAL STRICTURE

PURPOSE We present our results managing anterior urethral strictures previously treated with urethroplasty and/or urethrotomy. MATERIALS AND METHODS During a 32-month period 69 males 10 to 76 years old (mean age 36) underwent treatment for anterior urethral stricture, including 32 (46%) and 26 (38%) previously treated with urethroplasty and urethrotomy, respectively. In 11 patients (16%) no previous procedures had been done. Anastomotic and dorsal patch urethroplasty was performed for bulbar stricture in 13 and 14 cases, respectively, while in 4 a penile skin flap was placed for penile stricture and in 38 a 2-stage procedure was done with urethral substitution using buccal mucosa or post-auricular skin grafts. Patients were followed with ascending urethrography at 3 weeks, and 12 and 18 months as well as with uroflowmetry. Symptoms were assessed for 6 months to 4 years. RESULTS Only 1 stricture recurred in patients treated with anastomotic or patch urethroplasty, or a skin flap. Of the patients scheduled for a 2-stage procedure stage 1 revision was required due to graft scarring or stenosis at the urethrostomy site in 21% and stage 2 revision was required in 23%. Other complications in this series included fistula in 3% of cases, wound infection in 3% and post-void dribbling in 12%. CONCLUSIONS Overall early results are good in our urethroplasty series in patients with a previously instrumented urethra. Patients should be advised of the possible need for multiple revisions of planned staged procedures. The increased rate of revision in these staged procedures compared with the excellent outcome of 1-stage procedures appears to be inherent in this operation in patients with multiple previous procedures rather than due to surgeon experience.

THE NATURE OF URETHRAL INJURY IN CASES OF PELVIC FRACTURE URETHRAL TRAUMA

PURPOSE We examine the urethral injury associated with pelvic fracture that is said to be due to a shearing force through the membranous urethra which inevitably destroys the urethral sphincter mechanism. MATERIALS AND METHODS A total of 20 asymptomatic cases were prospectively studied, including symptomatically, radiologically, endoscopically and urodynamically, 1 to 4 years after an apparently successful anastomotic repair of a pelvic fracture urethral distraction defect. RESULTS There was evidence of urethral sphincter function, including urodynamically in 11 (55%), endoscopically in 13 (65%) and functionally in 17 (85%) patients. CONCLUSIONS These findings, coupled with surgical observation, suggest that the urethral injury associated with pelvic fracture is avulsion of the membranous urethra from the bulbar urethra rather than a shearing through the membranous urethra, and that some degree of urethral sphincter function is preserved in a significant percentage of patients.

Non-transecting anastomotic bulbar urethroplasty: a preliminary report.

Study Type – Therapy (case series)