Jiong Zhang

Transperineal bulboprostatic anastomosis in patients with simple traumatic posterior urethral strictures: a retrospective study from a referral urethral center.

OBJECTIVES To evaluate the results of ancillary procedures for posterior urethroplasty and compare them with the severity of urethral stricture. METHODS A total of 301 patients (average age: 36 years) with posterior urethral strictures due to pelvic fracture urethral distraction defects were included in the study. Delayed transperineal bulboprostatic anastomosis was performed 6-24 months (mean 10 months) after pelvic fracture urethral distraction defects. Simple perineal anastomosis: 103 (34.2%) patients (group 1); perineal anastomosis with separation of the corporeal bodies: 89 (29.6%) patients (group 2); perineal anastomosis with inferior pubectomy: 95 (31.6%) patients (group 3); perineal anastomosis with rerouting of the urethra around the corpora cavernosum: 14 (4.7%) patients (group 4). The clinical outcome was considered a failure when any postoperative instrumentation was needed. The primary outcome examined the total success rate of the procedures. The secondary outcome examined the success rate of the procedures according to the ancillary surgical steps. RESULTS Of the 301 delayed transperineal bulboprostatic anastomosis procedures, 263 (87.4%) were successful and 38 (12.6%) were unsuccessful. Simple perineal anastomosis without ancillary procedures reflected an 89.3% success rate, perineal anastomosis with separation of the corporeal body had an 86.5% success rate, perineal anastomosis with inferior pubectomy had an 84.2% success rate, and perineal anastomosis with urethral rerouting had an 85.7% success rate. CONCLUSIONS Corporal splitting, inferior pubectomy, and urethral rerouting are beneficial and useful ancillary procedures in transperineal posterior urethroplasty to achieve tension-free anastomosis.

An Evaluation of Surgical Approaches for Posterior Urethral Distraction Defects in Boys

PURPOSE We present our preliminary experience with operative approaches in the treatment of complex posterior urethral distraction defects in children. MATERIALS AND METHODS A total of 24 boys 7 to 14 years old with obliterative complex posterior urethral distraction defects were treated with 1 of 3 surgical approaches between January 1998 and December 2002. A perineal approach was used in 5 cases, a transperineal-inferior pubic approach including distal urethral mobilization, corporeal body separation and inferior pubectomy in 10, and a combined transpubic-perineal approach in 9. RESULTS Patients were followed 1 to 5 years postoperatively. A successful result of no recurrence of stricture was achieved in 19 of 24 patients (79.2%), including 3 of 5 (60%) treated with a perineal approach, 9 of 10 (90%) with a transperineal-inferior pubic approach and 7 of 9 (77.8%) with a transpubic-perineal approach. Complications included 1 combined false passage, which was resolved using a transperineal-inferior pubic approach, 2 urethrocutaneous fistulas, which were resolved using a perineal approach in 1 and a transpubic-perineal approach in 1, and 3 rectourethral fistulas, which were resolved using a transpubic-perineal approach in 1 and a transperineal-inferior pubic approach in 1. Of the 9 patients treated with the transpubic-perineal approach 3 walked with an abnormal gait postoperatively. CONCLUSIONS The transperineal-inferior pubic approach fully exposes the space behind the pubis, does not damage pelvic stability and yields better results compared to the perineal and transpubic-perineal approaches. We recommend it as first line operative treatment for complex posterior urethral distraction defects in boys.

Anterior Urethra Reconstruction With Lateral Lingual Mucosa Harvesting Technique

OBJECTIVE To describe a new technique for harvesting the long lingual mucosal graft (LMG) to repair the long-segment urethral strictures. METHODS We performed a retrospective observational study of patients from whom LMGs were harvested from the lateral lining of the tongue for the long-segment anterior urethral strictures repair from 2012 to 2014 at the Shanghai Sixth Peoples Hospital. Patients who had 12 months minimum follow-up were included. Patients with incomplete clinical records were excluded. The LMG was applied on the urethra according to the dorsal onlay technique. RESULTS The primary outcome of the study was the postoperative failure-free survival rate. The secondary outcome was the rate of early and late complications at the harvesting site. Success was defined as Qmax >12 ml/s and no postoperative procedures. One hundred and one patients were included. Median stricture length was 7.1 ± 3.6 cm; median LMG length was 7.2 ± 3.6 cm. The success rate was 81.2% with a median follow-up of 23 months. Complications at the donor site had occurred in 41 patients at 6-months follow-up, and persisted in 18 patients at the 12-months follow-up. A bilateral harvest and harvest length were the main factors influencing complication rate (P = .0038 for 6 months and P = .1112 for 12 months). Almost half of donor site complications subsided within 12 months (P = .0018). CONCLUSION In patients requiring long oral grafts >7 cm to repair anterior strictures, a valid option is to harvest the graft from the lateral lining of the tongue.

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.

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.

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.

One-stage dorsal lingual mucosal graft urethroplasty for the treatment of failed hypospadias repair.

The aim of this study was to retrospectively investigate the outcomes of patients who underwent one-stage onlay or inlay urethroplasty using a lingual mucosal graft (LMG) after failed hypospadias repairs. Inclusion criteria included a history of failed hypospadias repair, insufficiency of the local skin that made a reoperation with skin flaps difficult, and necessity of an oral mucosal graft urethroplasty. Patients were excluded if they had undergone a failed hypospadias repair using the foreskin or a multistage repair urethroplasty. Between January 2008 and December 2012, 110 patients with failed hypospadias repairs were treated in our center. Of these patients, 56 underwent a one-stage onlay or inlay urethroplasty using LMG. The median age was 21.8 years (range: 4-45 years). Of the 56 patients, one-stage onlay LMG urethroplasty was performed in 42 patients (group 1), and a modified Snodgrass technique using one-stage inlay LMG urethroplasty was performed in 14 (group 2). The median LMG urethroplasty length was 5.6 ± 1.6 cm (range: 4-13 cm). The mean follow-up was 34.7 months (range: 10-58 months), and complications developed in 12 of 56 patients (21.4%), including urethrocutaneous fistulas in 7 (6 in group 1, 1 in group 2) and neourethral strictures in 5 (4 in group 1, 1 in group 2). The total success rate was 78.6%. Our survey suggests that one-stage onlay or inlay urethroplasty with LMG may be an effective option to treat the patients with less available skin after failed hypospadias repairs; LMG harvesting is easy and safe, irrespective of the patient′s age.

Complete androgen insensitivity syndrome in juveniles and adults with female phenotypes

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.

Substitution urethroplasty for anterior urethral stricture repair: comparison between lingual mucosa graft and pedicled skin flap

Abstract Objectives: The aim of this study was to compare the effectiveness and outcomes of lingual mucosa graft (LMG) urethroplasty versus pedicled skin flap (PSF) urethroplasty in the repair of anterior urethral strictures. Materials and methods: A retrospective study in one urological center examined 293 male patients with anterior urethral strictures who received substitution urethroplasty from 2006 to 2015. Of these, 199 patients received PSF urethroplasty and 94 received LMG urethroplasty. The causes of stricture included catheter damage, transurethral instrumentation, trauma, infection, tumor and radiotherapy. Strictures caused by lichen sclerosus, hypospadias repair or failed urethroplasty were excluded. The success rate of PSF versus LMG in different urethra positions was analyzed. Results: Overall, PSF and LMG had similar success rates (83.4% vs 85.1%, p = 0.713). In distal penile urethra, penile skin flaps and LMG achieved similar success rates (87.7% vs 82.1%, p = 0.297), but in proximal penile urethra, scrotal flaps had relatively low success rates (69.0% vs LMG 83.3%, p = 0.345) and in bulbar urethra, perineal skin flaps had significantly lower success rates than LMG (66.7% vs 92.3%, p = 0.036). Conclusion: Lingual mucosa is a good material for the repair of urethral defects and achieves results similar to or even better than those of PSF. Scrotal skin and perineal skin had lower success rates.