Yue-Min Xu

Urethral reconstruction using colonic mucosa graft for complex strictures.

PURPOSE We investigated the long-term outcome of urethral reconstruction using colonic mucosa grafts for long segment, complex urethral strictures. Another aim was to identify clinical factors impacting long-term outcomes. MATERIALS AND METHODS We retrospectively reviewed the records of 36 consecutive patients with a mean age of 39.8 years (range 17 to 70) who underwent colonic mucosal graft urethroplasty for long segment, complex urethral stricture from October 2000 to November 2006. Patients were evaluated postoperatively at scheduled office visits at our institution and/or by telephone interview. Successful repair was defined as normal voiding without any postoperative procedure such as dilation. RESULTS Urethral reconstruction with done with colonic mucosa grafts 10 to 20 cm long (mean 15.1). One patient was lost to followup. Mean followup in the remaining cases was 53.6 months (range 26 to 94). Outcomes were successful in 30 of 35 patients (85.7%). Complications, specifically meatal stenosis, bulbar or bulbomembranous urethral stenosis and proximal anastomotic site stricture, developed in 5 patients (13.3%). CONCLUSIONS Colonic mucosa graft urethroplasty is a feasible procedure for complex urethral strictures. The most common complications are meatal stenosis and stenosis at the anastomosis.

Surgical Treatment of 31 Complex Traumatic Posterior Urethral Strictures Associated with Urethrorectal Fistulas

BACKGROUND Urethrorectal fistulas (URF) in patients with complex posterior urethral strictures are rare and difficult to repair surgically. There is no widely accepted standard approach described in the published literature. OBJECTIVE The aim of this study was to describe the outcomes of various operative approaches for the repair of URFs in patients with complex posterior urethral strictures. DESIGN, SETTING, AND PARTICIPANTS From January 1985 to December 2007, 31 patients (age: 6-61 yr; mean: 28.4) with URFs secondary to posterior urethral strictures were treated using a perineal or combined abdominal transpubic-perineal approach. INTERVENTIONS A simple perineal approach was used in 4 patients; a transperineal inferior pubectomy approach was used in 18 patients; and a combined transpubic-perineal approach was used in 9 patients. A bulbospongiosus muscle and subcutaneous dartos pedicle flaps were interposed between the repaired rectum and urethra in 22 patients. The combined transpubic-perineal approach used either a gracilis muscle flap (one patient) or a rectus muscle flap (eight patients). MEASUREMENTS Suprapubic catheterisation was used for bladder drainage, and a urethral silicone stent was left indwelling for 4 wk. RESULTS AND LIMITATIONS One-stage repair was successful in 4 patients (100%) using the perineal approach, in 16 of 18 patients (88.9%) using the transperineal-inferior pubectomy approach, and in 7 of 9 patients (77.8%) using the transpubic-perineal approach. Recurrent urethral strictures developed in two cases; one patient required regular dilation, and the other patient was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent URFs developed in two additional patients. CONCLUSIONS Surgical approaches for the treatment of URFs associated with complex urethral strictures should be based on a number of considerations including the location of the URF, its aetiology, the length of the urethral strictures, and a history of previous unsuccessful repairs. These results demonstrate that the transperineal-inferior pubic approach may be appropriate as a first-line procedure.

Transpubic Access Using Pedicle Tubularized Labial Urethroplasty for the Treatment of Female Urethral Strictures Associated with Urethrovaginal Fistulas Secondary to Pelvic Fracture

BACKGROUND Female urethral injury is rare, and there is no accepted standard approach for the repair of urethral strictures. OBJECTIVE To evaluate the efficacy of transpubic access using pedicle tubularized labial urethroplasty for urethral reconstruction in female patients with urethral obliterative strictures and urethrovaginal fistulas. DESIGN, SETTING, AND PARTICIPANTS Between January 1996 and December 2006, eight cases of female urethral strictures associated with urethrovaginal fistulas were treated using pedicle labial skin flaps. INTERVENTIONS A flap of approximately 3x3.5x3cm of the labia minora or majora with its vascular pedicle was tubularized over an 18-22 Fr fenestrated silicone stent to create a neourethra. This technique was used in five women. Two flaps, approximately 1.5-3.5 cm, were taken from bilateral labia minora or majora and were pieced together to create a neourethra. This technique was used in three patients. MEASUREMENTS We performed voiding cystourethrography and uroflowmetry to assess postoperative results. RESULTS AND LIMITATIONS The patients were followed up for 10-118 mo (mean 48.25 mo) after the procedure. There were no postoperative complications. Two patients complained of dysuria, which resolved spontaneously after 2 wk. One patient experienced stress incontinence that resolved after 4 wk. At 3-mo follow-up, one patient complained of difficulty voiding; the urinary peak flow was 13 ml/s, and the patient was treated successfully with urethral dilation. All other patients had normal micturition following catheter removal. CONCLUSIONS Pedicle labial urethroplasty is a reliable technique for the repair of extensive urethral damage, and a transpubic surgical approach provides wide and excellent exposure for the management of complex obliterative urethral strictures and urethrovaginal fistulas secondary to pelvic fracture.

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

To investigate the feasibility of small intestinal submucosa graft for the repair of selected anterior urethral strictures.

EFFERENT TUBE SUSPENSION AS A CONTINENT DIVERSION MECHANISM: A PRELIMINARY REPORT OF A CLINICAL STUDY

PURPOSE We constructed a reliable continent tube that is surgically simple. MATERIALS AND METHODS In 12 patients with malignant bladder tumor we performed radical cystectomy with isolation of a 50 cm. ileal loop with pedicle. The proximal segment (8 to 10 cm.) was tapered over a 16Fr catheter as an efferent tube, the remaining segment was detubularized to create a W-shape pouch and the tapered ileum was fixed to the back surface of the rectus muscle with 2 polyester tapers 1 cm. wide with a suspension tension of 500 g. The external orifice of the tapered ileum was anastomosed to the umbilicus. In 2 patients with neuropathic bladder a 15 cm. ileal loop with pedicle was isolated, the proximal segment (8 cm.) was tapered as an efferent tube with 500 g. suspension tension, and the remaining segment was detubularized and anastomosed to the bladder. RESULTS The patients were followed for 6 to 17 months (mean 11.4) and were completely continent day and night. The stoma was easily catheterized with a 16Fr catheter in all cases. Urodynamic study of the efferent tubes revealed maximum pressure of 84 to 159 cm. water (mean 114). Retrograde radiography of the efferent tubes demonstrated perfect canalization without stenosis. CONCLUSIONS This study suggests that the continent mechanism of the tapered ileum can be greatly enhanced by a suspension technique. This maneuver also provides easy catheterization and surgical simplicity.

Ileal ureteric replacement with an ileo-psoas muscle tunnel antirefluxing technique for the treatment of long segment ureteric strictures

To develop and report our initial experience with a novel antirefluxing technique for segmental ileal ureteric replacement for the treatment of long ureteric strictures.