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Le Guévelou J, Zilli T, Ferretti L, Beuzit L, De Hertogh O, Palumbo S, Jolicoeur M, Crehange G, Derashodian T, De Crevoisier R, Chapet O, Terlizzi M, Supiot S, Salembier C, Sargos P. Urinary organs-at-risk for prostate cancer external beam radiotherapy: contouring guidelines on behalf of the Francophone Group of Urological Radiation Therapy (GFRU). Pract Radiat Oncol 2024:S1879-8500(24)00145-0. [PMID: 38986900 DOI: 10.1016/j.prro.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/09/2024] [Accepted: 05/14/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE Occurrence of genitourinary (GU) toxicity is a common adverse event observed after external beam radiotherapy (EBRT) for prostate cancer (PCa). Recent findings suggest that the dose delivered to specific urinary organs-at-risk (OARs) such as ureters, bladder trigone, and urethra is involved in the development of GU toxicity. METHODS AND MATERIALS A multidisciplinary task force including three radiation oncologists, a uroradiologist, and a urologist was created in 2022. First, OARs potentially involved in GU toxicity were identified and discussed. A literature review was performed, addressing several questions relative to urinary OARs: anatomical and radiological definition, radiation-induced injury, dose-volume parameters. Secondly, results were presented and discussed with a panel of radiation oncologists, members of the "Francophone Group of Urological Radiation Therapy" (GFRU). Thereafter, GFRU experts were asked to answer a dedicated questionnaire, including 35 questions on the controversial issues related to the delineation of urinary OARs. RESULTS The following structures were identified as critical for PCa EBRT: ureters, bladder, bladder neck, bladder trigone, urethra (intraprostatic, membranous, spongious), striated sphincter, and post-enucleation or post-transurethral resection of the prostate (TURP) cavity. A consensus was obtained for 32 out of 35 items. CONCLUSION This consensus highlights contemporary urinary structures in both upper and lower urinary tract to be considered for EBRT treatment planning of PCa. The current recommendations also propose a standardized definition of urinary OARs, for both daily practice and future clinical trials.
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Affiliation(s)
- J Le Guévelou
- Department of radiation oncology, Centre Eugène Marquis, Rennes, France.
| | - T Zilli
- Department of radiation oncology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - L Ferretti
- Department of urology, MSP Bordeaux Bagatelle, Talence, France
| | - L Beuzit
- Department of radiology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - O De Hertogh
- Department of radiation oncology, CHR Verviers East Belgium, Verviers, Belgium
| | - S Palumbo
- Department of radiation oncology, Hôpital de Jolimont, La Louvière, Belgium
| | - M Jolicoeur
- Department of radiation oncology, Charles LeMoyne Hospital, CISSS Montérégie-center, Montréal, Quebec, Canada
| | - G Crehange
- Department of radiation oncology, Institut Curie, Saint-Cloud, France
| | - T Derashodian
- Department of radiation oncology, Charles LeMoyne Hospital, CISSS Montérégie-center, Montréal, Quebec, Canada
| | - R De Crevoisier
- Department of radiation oncology, Centre Eugène Marquis, Rennes, France
| | - O Chapet
- Department of radiation oncology, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - M Terlizzi
- Department of radiation oncology, Institut Gustave Roussy, Villejuif, France
| | - S Supiot
- Department of radiation oncology, Institut de Cancérologie de l'Ouest, Nantes Saint-Herblain, France; Unité en Sciences Biologiques et Biotechnologies, University of Nantes, Nantes, France
| | - C Salembier
- Department of radiation oncology, Europe Hospitals Brussels, Brussels, Belgium
| | - P Sargos
- Department of radiation oncology, Institut Bergonié, Bordeaux, France
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Rosenbaum CM, Netsch C, Gross AJ, Becker B. [Urethral reconstruction]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:713-720. [PMID: 38833015 DOI: 10.1007/s00120-024-02369-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 06/06/2024]
Abstract
A urethral stricture is an abnormal narrowing of the urethra due to spongiofibrosis of the urethral mucosa and the underlying corpus spongiosum. The diagnostics include uroflowmetry, sonography and radiology. For penile strictures the success rate of endoscopic treatment is low. Therefore, urethroplasty should always be performed, preferably using oral mucosa. Depending on the complexity, reconstruction must be carried out in one or multiple stages. For short bulbous strictures endoscopic treatment can primarily be carried out. In the case of recurrence urethroplasty should be carried out. The indications for urethral reconstruction are primarily given for long bulbous strictures. Depending on the length and extent of the stricture, a scar resection and end-to-end anastomosis, non-transsecting end-to-end anastomosis or augmentation urethroplasty can be performed. Perineal urethrostomy (the so-called boutonnière procedure) is a treatment option for patients with complex strictures or for patients who want a straightforward solution.
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Affiliation(s)
- Clemens M Rosenbaum
- Klinik für Urologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22307, Hamburg, Deutschland.
| | - Christopher Netsch
- Klinik für Urologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22307, Hamburg, Deutschland
| | - Andreas J Gross
- Klinik für Urologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22307, Hamburg, Deutschland
| | - Benedikt Becker
- Klinik für Urologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22307, Hamburg, Deutschland
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3
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Berg C, Singh A, Hu P, Sura A, Rourke K, Myers J, Alwaal A. Current Trends in the Use of Buccal Grafts During Urethroplasty Among Society of Genitourinary Reconstructive Surgeons. Urology 2024:S0090-4295(24)00462-X. [PMID: 38925372 DOI: 10.1016/j.urology.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE To analyze current standards in urethroplasty by urologists employing buccal mucosal grafts (BMG) for treating urethral stricture disease (USD). METHODS An IRB-approved online survey was distributed to members of the Society of Genitourinary Reconstructive Surgeons (GURS) between July and October 2022 to assess BMG utilization in urethroplasty. Questions covered surgeon experience, graft harvest site, graft length, surgical technique, and perceived success rates. RESULTS Of 350 invited GURS members, 134 responded (38%). Sixty-nine percentage were GURS fellowship-trained, performing 10-30 urethroplasties annually. Ninety-five percentage harvested their own grafts, with 99% preferring buccal mucosa as the primary site. Buccal mucosa was favored over fasciocutaneous flap for penile urethroplasty, regardless of circumcision status (95% with, 84% without). For bulbar urethroplasty with BMG, dorsal graft placement was favored (66%) over ventral (34%). Most surgeons (90%) preferred multiple BMGs over combined graft/flap for panurethral strictures. When harvesting long grafts, 56% preferred using both cheeks. Anastomotic urethroplasty was preferred over buccal graft urethroplasty for short bulbomembranous stenosis post-radiotherapy (63% vs 37%). Surgeons reported a success rate of 80%-90% (53%). CONCLUSION The expanded scope of reconstructive urology has led to increased use of BMG in diverse urethral reconstructions. Buccal grafts are now preferred for penile, bulbar, and panurethral strictures, demonstrating high perceived success rates in the reconstructive community.
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Affiliation(s)
- Courtney Berg
- Division of Urology, Department of Surgery, Rutgers New Jersey Medical School Newark NJ.
| | - Adityabikram Singh
- Division of Urology, Department of Surgery, Rutgers New Jersey Medical School Newark NJ
| | - Patrick Hu
- Division of Urology, Department of Surgery, Rutgers New Jersey Medical School Newark NJ
| | - Avi Sura
- Division of Urology, Department of Surgery, Rutgers New Jersey Medical School Newark NJ
| | - Keith Rourke
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jeremy Myers
- Department of Surgery (Urology), University of Utah School of Medicine, Salt Lake City, UT
| | - Amjad Alwaal
- Division of Urology, Department of Surgery, Rutgers New Jersey Medical School Newark NJ
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Joshi P, Albanese N, Bhadranawar S, Cattafi F, Salonia A, Montorsi F, Kulkarni S, Bandini M. Total bulbospongiosum muscle sparing for bulbar urethroplasty: beyond the one-sided dissection. BJU Int 2024. [PMID: 38923103 DOI: 10.1111/bju.16446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Affiliation(s)
- Pankaj Joshi
- Kulkarni UroSurgery Institute, Pune, Maharashtra, India
| | - Nicole Albanese
- Unit of Urology, Urological Research Institute (URI), San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Francesco Cattafi
- Unit of Urology, Urological Research Institute (URI), San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Salonia
- Unit of Urology, Urological Research Institute (URI), San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Unit of Urology, Urological Research Institute (URI), San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Marco Bandini
- Kulkarni UroSurgery Institute, Pune, Maharashtra, India
- Unit of Urology, Urological Research Institute (URI), San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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Cho MC, Lee J, Kim SW. Staged urethroplasty with groin full-thickness skin graft for managing complex anterior urethral strictures: surgical outcomes and predictive factors. World J Urol 2024; 42:342. [PMID: 38775814 PMCID: PMC11111480 DOI: 10.1007/s00345-024-05049-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE To describe outcomes of staged-urethroplasty in complex anterior urethral strictures using full-thickness-skin-graft (FTSG) harvested from the hairless groin area, and to identify factors influencing successful outcomes. METHODS Through retrospective chart review, we identified a total of 67 men who underwent the first-stage operation (grafting) using groin-FTSG for staged-urethroplasty to treat complex anterior urethral strictures unsuitable for one-stage urethroplasty. Among these, 59 underwent the second-stage operation (tubularization) at a median duration of 5.1-months after grafting. Patients were assessed for outcomes as scheduled after tubularization outcomes were analyzed only for 48 patients for whom ≥ 1-year follow-up data after tubularization were available. Their mean follow-up duration was 27.1 months. Success was defined as achieving physiologic voiding without requiring further procedures. RESULTS Median stricture-length was 5.5 cm in all 67 patients. After grafting, neourethral-opening-narrowing occurred in 18. Partial graft-loss occurred in 8, of whom only 3 underwent re-grafting. The percentage of patients who achieved successful outcomes was 81.3%. Improvements in maximum-urine-flow-rate and post-void-residual-urine-volume were maintained until the last follow-up visit. A urethrocutaneous-fistula occurred in one patient, while meatal-stenosis occurred in two. On multivariate-regression-analysis, the presence of neourethral-opening-narrowing was the only predictor of non-success after tubularization. Furthermore, the presence of hypertension, longer stricture-length, and a history of prior direct-vision-internal-urethrotomy were predictors of the occurrence of neourethral-opening-narrowing. CONCLUSION Staged-urethroplasty using groin-FTSG is well worth considering as a useful therapeutic option for complex anterior urethral strictures, with an acceptable success rate and low morbidity. The absence of neourethral-opening-narrowing after the first-stage operation leads to success.
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Affiliation(s)
- Min Chul Cho
- Department of Urology, Seoul National University College of Medicine and Seoul National University Boramae Medical Center, Seoul, 07061, Korea
| | - Jooho Lee
- Seoul National University Hospital, Seoul, 03080, Korea
| | - Soo Woong Kim
- Department of Urology, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Korea.
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Gul A, Ekici O, Zengin S, Barali D, Keskin T. Investigation of risk factors in the development of recurrent urethral stricture after internal urethrotomy. World J Clin Cases 2024; 12:2324-2331. [PMID: 38765734 PMCID: PMC11099401 DOI: 10.12998/wjcc.v12.i14.2324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/08/2024] [Accepted: 04/01/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Urethral stricture is a condition that often develops with trauma and results in narrowing of the urethral lumen. Although endoscopic methods are mostly used in its treatment, it has high recurrence rates. Therefore, open urethroplasty is recommended after unsuccessful endoscopic treatments. AIM To investigate the risk factors associated with urethral stricture recurrence. METHODS The data of male patients who underwent internal urethrotomy for urethral stricture between January 2017 and January 2023 were retrospectively analyzed. Demographic data, comorbidities, preoperative haemogram, and biochemical values obtained from peripheral blood and operative data were recorded. Patients were divided into two groups in terms of recurrence development; recurrence and non-recurrence. Initially recorded data were compared between the two groups. RESULTS A total of 303 patients were included in the study. The mean age of the patients was 66.6 ± 13.6 years. The mean duration of recurrence development was 9.63 ± 9.84 (min-max: 1-39) months in the recurrence group. Recurrence did not occur in non-recurrence group throughout the follow-up period with an average time of 44.15 ± 24.07 (min-max: 12-84) months. In the comparison of both groups, the presence of diabetes mellitus (DM), hypertension (HT), and multiple comorbidities were significantly higher in the recurrence (+) group (P = 0.038, P = 0.012, P = 0.013). Blood group, postoperative use of non-steroidal anti-inflammatory drugs, preoperative cystostomy, cause of stricture, iatrogenic cause of stricture, location and length of stricture, indwelling urinary cathater size and day of catheter removal did not differ between the two groups. No statistically significant difference was observed between the two groups in terms of age, uroflowmetric maximum flow rate value, hemogram parameters, aspartate aminotransferase (AST), alanine aminotransferase (ALT), fasting blood sugar, creatinine, glomerular filtration rate, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio, monocyte-lymphocyte ratio and AST/ALT ratios. CONCLUSION In patients with urethral stricture recurrence, only the frequency of DM and HT was high, while inflammation marker levels and stricture-related parameters were similar between the groups.
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Affiliation(s)
- Abdullah Gul
- Department of Urology, University of Health Sciences, Bursa Yüksek İhtisas Education and Research Hospital, Bursa 16100, Türkiye
| | - Ozgur Ekici
- Department of Urology, University of Health Sciences, Bursa City Hospital, Bursa 16000, Türkiye
| | - Salim Zengin
- Department of Urology, University of Health Sciences, Bursa Yüksek İhtisas Education and Research Hospital, Bursa 16100, Türkiye
| | - Deniz Barali
- Department of Urology, University of Health Sciences, Bursa Yüksek İhtisas Education and Research Hospital, Bursa 16100, Türkiye
| | - Tarik Keskin
- Department of Urology, University of Health Sciences, Bursa Yüksek İhtisas Education and Research Hospital, Bursa 16100, Türkiye
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7
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Licari LC, Bologna E, Manfredi C, Franco A, Ditonno F, De Nunzio C, Antonelli A, Simone G, De Sio M, Cindolo L, Olweny EO, Cherullo EE, Leonardo C, Autorino R. Incidence and management of BPH surgery-related urethral stricture: results from a large U.S. database. Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00841-z. [PMID: 38714780 DOI: 10.1038/s41391-024-00841-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 05/10/2024]
Abstract
INTRODUCTION AND OBJECTIVES Urethral stricture (US) is a well-known complication after surgical treatment of benign prostatic hyperplasia (BPH). This study aimed to evaluate the contemporary incidence of the US after different types of BPH surgery, to identify associated risk factors and to assess its management. METHODS A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing de-identified patient records compiled between 2011 and 2022. Specific International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify population characteristics and outcomes. All the most employed surgical procedures for BPH treatment were considered. Multivariable logistic regression was employed to evaluate factors associated with diagnosis of post-operative US. RESULTS Among 274,808 patients who underwent BPH surgery, 10,918 developed post-operative US (3.97%) within 12 months. Higher incidence of US was observed following TURP (4.48%), Transurethral Incision of the Prostate (TUIP) (3.67%), Photoselective Vaporization of the Prostate (PVP) (3.92%), HoLEP/ThuLEP (3.85%), and open Simple Prostatectomy (SP) (3.21%). Lower incidence rates were observed after laparoscopic\robot-assisted SP (1.76%), Aquablation (1.59%), Prostatic Urethral Lift (PUL) (1.07%), Rezum (1.05%), and Prostatic Artery Embolization (PAE) (0.65%). Multivariable analysis showed that patients undergoing PUL, Rezum, Aquablation, PAE, and PVP were associated with a reduced likelihood of developing US compared to TURP. US required surgical treatment in 18.95% of patients, with direct visual internal urethrotomy (DVIU) and urethroplasty performed in 14.55% and 4.50% of cases, respectively. Urethral dilatation (UD) in an outpatient setting was the primary management in most cases (76.7%). CONCLUSIONS The present analysis from a contemporary large dataset suggests that the incidence of US after BPH surgery is relatively low (<5%) and varies among procedures. Around 94% of US cases following BPH surgery are managed using minimally invasive treatment approaches such as UD and DVIU.
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Affiliation(s)
- Leslie Claire Licari
- Department of Urology, Rush University, Chicago, IL, USA
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Eugenio Bologna
- Department of Urology, Rush University, Chicago, IL, USA
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Celeste Manfredi
- Department of Urology, Rush University, Chicago, IL, USA
- Unit of Urology, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Franco
- Department of Urology, Rush University, Chicago, IL, USA
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Francesco Ditonno
- Department of Urology, Rush University, Chicago, IL, USA
- Department of Urology, Azienda Ospedaliera Universitaria Integrata Verona, University of Verona, Verona, Italy
| | - Cosimo De Nunzio
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Alessandro Antonelli
- Department of Urology, Azienda Ospedaliera Universitaria Integrata Verona, University of Verona, Verona, Italy
| | - Giuseppe Simone
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Marco De Sio
- Unit of Urology, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luca Cindolo
- Department of Urology, Villa Stuart Hospital, Rome, Italy
| | | | | | - Costantino Leonardo
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
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8
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Chen C, Qin J, Wang C, Huang H, Li H, Wen Z, Liu Y, Yang X. Comparison of laser versus cold knife visual internal urethrotomy in the treatment of urethral stricture (stricture length <2 cm): A systematic review and meta-analysis. Medicine (Baltimore) 2024; 103:e37524. [PMID: 38701298 PMCID: PMC11062742 DOI: 10.1097/md.0000000000037524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/15/2024] [Indexed: 05/05/2024] Open
Abstract
PURPOSE There is still controversy regarding the safety and efficacy of cold knife visual internal urethrotomy and laser incisions for the treatment of urethral stricture. This study aims to compare the results of postoperative long-term and short-term maximum urinary flow rates (Qmax), surgical time, postoperative complications, and 1-year recurrence rates between the cold knife and laser surgery. METHODS We searched databases including Embase, PubMed, Cochrane, and Clinical Trials.gov to identify relevant literature published in English up to September 2023. We used Stata to compare various parameters. This study is registered in PROSPERO (CRD42023471634). Nine comparative experiments were conducted, involving a total of 659 participants. RESULTS The laser group showed significantly better results compared to the cold knife group in terms of postoperative 12-month maximum urinary flow rate (mean differences [MD] 2.131; 95% [1.015, 3.249], P < .0001), postoperative bleeding (RR 0.277, 95% [0.079, 0.977], P = .046), and 1-year recurrence rate (RR 0.667, 95% [0.456, 0.976], P = .037). However, there were no significant differences in postoperative 6-month and 3-month Qmax, surgical time, urethral leakage complications, overall complications, and Visual Analog Scale (VAS) scores. CONCLUSION The current study results suggest that laser urethral incision has greater advantages in the long-term (12 months), 1-year recurrence rate, and bleeding complications compared to cold knife urethral incision in the treatment of urethral stricture (<2 cm). Therefore, laser urethral incision may be a better choice for patients with urethral stricture.
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Affiliation(s)
- CaiXia Chen
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jiao Qin
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - ChongJian Wang
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - HaoTian Huang
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - HongYuan Li
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Zhi Wen
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yang Liu
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - XueSong Yang
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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Tokuc E, Eksi M, Kayar R, Demir S, Topaktas R, Bastug Y, Akyuz M, Ozturk M. Inflammation indexes and machine-learning algorithm in predicting urethroplasty success. Investig Clin Urol 2024; 65:240-247. [PMID: 38714514 PMCID: PMC11076797 DOI: 10.4111/icu.20230302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/06/2023] [Accepted: 12/29/2023] [Indexed: 05/10/2024] Open
Abstract
PURPOSE To assess the predictive capability of hematological inflammatory markers for urethral stricture recurrence after primary urethroplasty and to compare traditional statistical methods with a machine-learning-based artificial intelligence algorithm. MATERIALS AND METHODS Two hundred eighty-seven patients who underwent primary urethroplasty were scanned. Ages, smoking status, comorbidities, hematological inflammatory parameters (neutrophil-lymphocyte ratios, platelet-lymphocyte ratios [PLR], systemic immune-inflammation indexes [SII], and pan-immune-inflammation values [PIV]), stricture characteristics, history of previous direct-visual internal urethrotomy, urethroplasty techniques, and grafts/flaps placements were collected. Patients were followed up for one year for recurrence and grouped accordingly. Univariate and multivariate logistic regression analyses were conducted to create a predictive model. Additionally, a machine-learning-based logistic regression analysis was implemented to compare predictive performances. p<0.05 was considered statistically significant. RESULTS Comparative analysis between the groups revealed statistically significant differences in stricture length (p=0.003), localization (p=0.027), lymphocyte counts (p=0.008), PLR (p=0.003), SII (p=0.003), and PIV (p=0.001). In multivariate analysis, stricture length (odds ratio [OR] 1.230, 95% confidence interval [CI] 1.142-1.539, p<0.0001) and PIV (OR 1.002, 95% CI 1.000-1.003, p=0.039) were identified as significant predictors of recurrence. Classical logistic regression model exhibited a sensitivity of 0.76, specificity of 0.43 with an area under curve (AUC) of 0.65. However, the machine-learning algorithm outperformed traditional methods achieving a sensitivity of 0.80, specificity of 0.76 with a higher AUC of 0.82. CONCLUSIONS PIV and machine-learning algorithms shows promise on predicting urethroplasty outcomes, potentially leading to develop possible nomograms. Evolving machine-learning algorithms will contribute to more personalized and accurate approaches in managing urethral stricture.
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Affiliation(s)
- Emre Tokuc
- Urology Clinic, Haydarpasa Numune SUAM, University of Health Sciences, Istanbul, Türkiye.
| | - Mithat Eksi
- Urology Clinic, Bakırkoy Dr. Sadi Konuk SUAM, University of Health Sciences, Istanbul, Türkiye
| | - Ridvan Kayar
- Urology Clinic, Haydarpasa Numune SUAM, University of Health Sciences, Istanbul, Türkiye
| | - Samet Demir
- Urology Clinic, Haydarpasa Numune SUAM, University of Health Sciences, Istanbul, Türkiye
| | - Ramazan Topaktas
- Urology Clinic, Haydarpasa Numune SUAM, University of Health Sciences, Istanbul, Türkiye
| | - Yavuz Bastug
- Urology Clinic, Haydarpasa Numune SUAM, University of Health Sciences, Istanbul, Türkiye
| | - Mehmet Akyuz
- Urology Clinic, Haydarpasa Numune SUAM, University of Health Sciences, Istanbul, Türkiye
| | - Metin Ozturk
- Urology Clinic, Haydarpasa Numune SUAM, University of Health Sciences, Istanbul, Türkiye
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10
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Calvo CI, Rourke KF. Routine Imaging After Bulbar Urethral Reconstruction Does Not Impact Surgical Outcomes and May Not Be Necessary. Urology 2024; 186:41-47. [PMID: 38417467 DOI: 10.1016/j.urology.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/02/2024] [Accepted: 02/21/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE To assess whether omitting routine post-operative imaging adversely impacts clinical outcomes after bulbar urethroplasty. Contrast imaging is commonly performed prior to catheter removal after urethroplasty but the clinical need for this is unclear. METHODS This was a matched, case-control analysis comparing patients undergoing routine voiding cystourethrogram (VCUG) prior to catheter removal after bulbar urethroplasty to patients without imaging. Patients were matched with respect to age, stricture etiology, length, and urethroplasty technique. Follow-up consisted of clinical assessment 3 weeks post-operatively for VCUG/catheter removal, cystoscopy at 3-4 months with clinical assessment annually. Outcome measures were 90-day complications (Clavien ≥2) and stricture recurrence (failure to pass a 16-Fr flexible cystoscope on follow-up). Chi-square and Kaplan-Meier analysis were conducted where appropriate. RESULTS Hundred patients undergoing bulbar urethroplasty with VCUG prior to catheter removal were compared to 100 matched case controls without imaging. Groups did not differ with respect to failed endoscopic treatment (P = .82), prior urethroplasty (P = .09), comorbidities (P = .54), smoking (P = .42), or pre-operative bacteriuria (P = 1.00). The incidence of extravasation in the VCUG group was 2%. Overall 90-day complications were 9.5% and 15 patients developed recurrence with a median follow-up of 174 months. On chi-square analysis, 90-day complications did not differ between patients undergoing VCUG and those without (12% vs 7.0%; P = .34). On log-rank analysis, stricture recurrence did not differ between groups (P = .44). CONCLUSION Routine imaging with VCUG after bulbar urethroplasty does not influence the risk of post-operative complications or stricture recurrence. Surgeons should consider avoiding this potentially unnecessary examination in routine clinical practice.
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Affiliation(s)
- Carlos I Calvo
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Departamento de Urología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Keith F Rourke
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
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11
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Mousa A, Eissa A, Rawal AY, Zoeir A. Outcomes of Ventral Onlay Buccal Mucosal Graft Urethroplasty in Bulbomembranous Urethral Strictures Post-transurethral Resection of the Prostate. Urology 2024; 186:9-14. [PMID: 38403138 DOI: 10.1016/j.urology.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/26/2023] [Accepted: 01/04/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE To evaluate the outcomes of ventral onlay buccal mucosal graft urethroplasty (VOBMGU) in bulbomembranous urethral strictures after transurethral resection of the prostate. METHODS After approval of the institutional ethical committee, we retrospectively examined the database of patients diagnosed with post-TURP urethral stricture (PTS) and treated by VOBMGU from January 2020 to January 2022. The patients were evaluated by retrograde urethrogram and voiding cystourethrogram. Follow-up evaluation included assessment of lower urinary tract symptoms, physical examination, uroflowmetry (Q-max and International Prostate Symptom Score) 3, 6, and 12months of follow-up. RESULTS A total of 30 patients underwent VOBMGU for bulbomembranous PTS were included. The median age of the patients was 63.5 (11.25). The median stricture length was 3.5 (1.5) cm. During follow-up, the mean Q-max significantly increased to 21.1 ± 5.5 mL/s (P < .0001), 20.1 ± 5.4 mL/s (P < .001), and 19.1 ± 5.3 mL/s (P < .003) at 3, 6, and 12months, respectively. IPSS significantly decreased to 8.93 ± 6.37 at the 12-month follow-up mark (P < .0001). Three patients developed stricture recurrence and two patients developed postoperative urinary incontinence. CONCLUSION VOBMGU in cases of bulbomembranous urethral PTS offered excellent functional outcomes with low stricture recurrence and minimal risk of incontinence. Further prospective studies are warranted to confirm the results.
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Affiliation(s)
- Ayman Mousa
- Department of Urology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed Eissa
- Department of Urology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amar Y Rawal
- Department of Urology, Heartland Regional Hospital, Marion, IL
| | - Ahmed Zoeir
- Department of Urology, Faculty of Medicine, Tanta University, Tanta, Egypt.
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12
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Leng W, Li X, Dong L, Guo Z, Ji X, Cai T, Xu C, Zhu Z, Lin J. The Regenerative Microenvironment of the Tissue Engineering for Urethral Strictures. Stem Cell Rev Rep 2024; 20:672-687. [PMID: 38305981 DOI: 10.1007/s12015-024-10686-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2024] [Indexed: 02/03/2024]
Abstract
Urethral stricture caused by various reasons has threatened the quality of life of patients for decades. Traditional reconstruction methods, especially for long-segment injuries, have shown poor outcomes in treating urethral strictures. Tissue engineering for urethral regeneration is an emerging concept in which special designed scaffolds and seed cells are used to promote local urethral regeneration. The scaffolds, seed cells, various factors and the host interact with each other and form the regenerative microenvironment. Among the various interactions involved, vascularization and fibrosis are the most important biological processes during urethral regeneration. Mesenchymal stem cells and induced pluripotent stem cells play special roles in stricture repair and facilitate long-segment urethral regeneration, but they may also induce carcinogenesis and genomic instability during reconstruction. Nevertheless, current technologies, such as genetic engineering, molecular imaging, and exosome extraction, provide us with opportunities to manage seed cell-related regenerative risks. In this review, we described the interactions among seed cells, scaffolds, factors and the host within the regenerative microenvironment, which may help in determining the exact molecular mechanisms involved in urethral stricture regeneration and promoting clinical trials and the application of urethral tissue engineering in patients suffering from urethral stricture.
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Affiliation(s)
- Wenyuan Leng
- Department of Urology, Peking University First Hospital, Beijing, 100034, China
- Institute of Urology, Peking University, Beijing, 100034, China
- National Urological Cancer Center, No. 8, Street Xishiku, District Xicheng, Beijing, 100034, China
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China
| | - Xiaoyu Li
- Department of Urology, Peking University First Hospital, Beijing, 100034, China
- Institute of Urology, Peking University, Beijing, 100034, China
- National Urological Cancer Center, No. 8, Street Xishiku, District Xicheng, Beijing, 100034, China
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China
| | - Lei Dong
- Department of Urology, Peking University First Hospital, Beijing, 100034, China
- Institute of Urology, Peking University, Beijing, 100034, China
- National Urological Cancer Center, No. 8, Street Xishiku, District Xicheng, Beijing, 100034, China
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China
| | - Zhenke Guo
- Department of Urology, Peking University First Hospital, Beijing, 100034, China
- Institute of Urology, Peking University, Beijing, 100034, China
- National Urological Cancer Center, No. 8, Street Xishiku, District Xicheng, Beijing, 100034, China
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China
| | - Xing Ji
- Department of Urology, Peking University First Hospital, Beijing, 100034, China
- Institute of Urology, Peking University, Beijing, 100034, China
- National Urological Cancer Center, No. 8, Street Xishiku, District Xicheng, Beijing, 100034, China
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China
| | - Tianyu Cai
- Department of Urology, Peking University First Hospital, Beijing, 100034, China
- Institute of Urology, Peking University, Beijing, 100034, China
- National Urological Cancer Center, No. 8, Street Xishiku, District Xicheng, Beijing, 100034, China
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China
| | - Chunru Xu
- Department of Urology, Peking University First Hospital, Beijing, 100034, China
- Institute of Urology, Peking University, Beijing, 100034, China
- National Urological Cancer Center, No. 8, Street Xishiku, District Xicheng, Beijing, 100034, China
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China
| | - Zhenpeng Zhu
- Department of Urology, Peking University First Hospital, Beijing, 100034, China
- Institute of Urology, Peking University, Beijing, 100034, China
- National Urological Cancer Center, No. 8, Street Xishiku, District Xicheng, Beijing, 100034, China
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China
| | - Jian Lin
- Department of Urology, Peking University First Hospital, Beijing, 100034, China.
- Institute of Urology, Peking University, Beijing, 100034, China.
- National Urological Cancer Center, No. 8, Street Xishiku, District Xicheng, Beijing, 100034, China.
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China.
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Calvo CI, Hoy N, Rourke KF. Refining Bacteriuria as a Risk Factor for Complications After Urethroplasty: Identifying the Culprit. Urology 2024; 186:1-6. [PMID: 38354912 DOI: 10.1016/j.urology.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVE To determine which bacteria are associated with an increased risk of 90-day complications after urethroplasty. Preoperative bacteriuria is associated with an increased risk of complications after urethroplasty. However, it remains unclear which specific micro-organisms are the primary drivers of this morbidity. METHODS A single-institution, 2-surgeon retrospective review was performed on patients undergoing urethroplasty from 08/2003 to 06/2021. Preoperative bacteriuria was considered significant when the patient had a mixed culture with ≥108 CFU/L or an identifiable micro-organism with ≥106 CFU/L. Descriptive statistics were used to summarize the results and chi-square was used to determine the association between 90-day complications (Clavien ≥2) and clinical characteristics/bacteria. RESULTS Out of 1611 patients, 23.2% (373) had significant preoperative bacteriuria. The most common pathogens included coagulase-negative staphylococcus 18.5% (69), mixed growth 15.8% (59), Escherichia coli 10.7% (40), and Enterococcus 14.2% (53). 7.9% (128/1611) experienced a significant 90-day complication (Clavien-Dindo ≥2). Gram-negative bacilli including E coli, Pseudomonas sp, Klebsiella sp, Serratia sp, Citrobacter sp, Achromobacter sp, Stenotrophomonas sp, and Morganella sp were associated with higher rates of postoperative complications (14.2%; P = .01) as well as Enterococcus sp (15.1%; P = .03). However, gram-positive cocci (7.9%; P = .97), gram-positive bacilli (11.8%; P = .47), mixed growth (5.1%; P = .54) and Candida (16.7%; P = .27) were not. Neither escalating concentrations of bacteria (P = .44) or number of strains (P = .08) were associated with increased risk of complications. CONCLUSION The main driver of bacteriuria-related complications after urethroplasty are gram-negative bacilli and Enterococcus sp. Patients with bacteriuria related to other micro-organisms can likely proceed with urethroplasty without increased risk of postoperative complications.
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Affiliation(s)
- Carlos I Calvo
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Departamento de Urología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nathan Hoy
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Keith F Rourke
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
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14
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Marks P, Dahlem R, Fisch M, Vetterlein MW. Controversies of mucosa and spongiosum preservation in non-transecting augmented anastomotic repair. BJU Int 2024; 133:351-352. [PMID: 38098367 DOI: 10.1111/bju.16264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Affiliation(s)
- Phillip Marks
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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15
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Delchet O, Nourredine M, González Serrano A, Morel-Journel N, Carnicelli D, Ruffion A, Neuville P. Post-prostatectomy anastomotic stenosis: systematic review and meta-analysis of endoscopic treatment. BJU Int 2024; 133:237-245. [PMID: 37501631 DOI: 10.1111/bju.16141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis of endoscopic procedures for treating vesico-urethral anastomotic stenosis (VUAS) after prostatectomy, as initial VUAS management remains unclear. METHODS A search of the MEDLINE database, the Cochrane database, and clinicaltrials.gov was performed (last search February 2023) using the following query: (['bladder neck' OR 'vesicourethral anastomotic' OR 'anastomotic'] AND ['stricture' OR 'stenosis' OR 'contracture'] AND 'prostatectomy'). The primary outcome was the success rate of VUAS treatment, defined by the proportion (%) of patients without VUAS recurrence at the end of follow-up. RESULTS The literature search identified 420 studies. After the screening, 78 reports were assessed for eligibility, and 40 studies were included in the review. The pooled characteristics of the 40 studies provided a total of 1452 patients, with a median (interquartile range [IQR]) follow-up of 23.7 (13-32) months and age of 66 (64-68) years. The overall success rate (95% confidence interval [CI]) of all endoscopic procedures for VUAS treatment was 72.8% (64.4%-79.9%). Meta-regression models showed a negative influence of radiotherapy on the overall success rate (P = 0.012). After trim-and-fill (addition of 10 studies), the corrected overall success rate (95% CI) was 62.9% (53.6%-71.4%). CONCLUSION This first meta-analysis of endoscopic treatment success rate after VUAS reported an overall success rate of 72.8%, lowered to 62.9% after correcting for significant publication bias. This study also highlighted the need for a more thorough reporting of post-prostatectomy VUAS data to understand the treatment pathway and provide higher-quality evidence-based care.
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Affiliation(s)
- Ophélie Delchet
- Service d'Urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
| | - Mikaïl Nourredine
- Service de Biostatistiques, Hospices Civils de Lyon, Lyon, France
- UMR CNRS 558, Laboratoire de Biométrie et Biologie Évolutive, Lyon, France
| | | | | | - Damien Carnicelli
- Service d'Urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
| | - Alain Ruffion
- Service d'Urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
- Claude Bernard University Lyon 1, Lyon, France
| | - Paul Neuville
- Service d'Urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
- Claude Bernard University Lyon 1, Lyon, France
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16
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Li X, Xu C, Ji X, Zhu Z, Cai T, Guo Z, Lin J. Balloon dilation for the treatment of male urethral strictures: a systematic review and meta-analysis. BMJ Open 2024; 14:e071923. [PMID: 38320837 PMCID: PMC10860052 DOI: 10.1136/bmjopen-2023-071923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/22/2024] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE The use of minimally invasive endoluminal treatment for urethral strictures has been a subject for debate for several decades. The aim of this study was to review and discuss the safety, efficacy and factors influencing the clinical application of balloon dilation for the treatment of male urethral strictures. DESIGN Systematic review and meta-analysis. DATA SOURCES Embase, Medline, Web of Science, Cochrane Library and Scopus were searched for publications published before 17 July 2022. STUDY SELECTION Two independent researchers screened and assessed the results, and all clinical studies on balloon dilation for the treatment of urethral strictures in men were included. DATA EXTRACTION AND SYNTHESIS The success rate, rate of adverse events, International Prostate Symptom Scores, maximum uroflow (Qmax) and postvoid residual urine volume were the main outcomes. Stata V.14.0 was used for statistical analysis. RESULTS Fifteen studies with 715 patients were ultimately included in this systematic review. The pooled results of eight studies showed that the reported success rate of simple balloon dilation for male urethral strictures was 67.07% (95% confidence interval [CI]: 55.92% to 77.36%). The maximum urinary flow rate at 3 months (risk ratio [RR]= 2.6510, 95% CI: 1.0681 to 4.2338, p<0.01) and the maximum urinary flow rate at 1 year (RR= 1.6637, 95% CI: 1.1837 to 2.1437, p<0.05) were significantly different after dilation. There is insufficient evidence to suggest that balloon dilation is superior to optical internal urethrotomy or direct visual internal urethrotomy (DVIU) (RR= 1.4754, 95% CI: 0.7306 to 2.9793, p=0.278). CONCLUSION Balloon dilation may be an intermediate step before urethroplasty and is a promising alternative therapy to simple dilation and DVIU. The balloon is a promising drug delivery tool, and paclitaxel drug-coated balloon dilation is effective in reducing retreatment rates in patients with recurrent anterior urethral strictures. The aetiology, location, length, previous treatment of urethral stricture may be associated with the efficacy of balloon dilation. PROSPERO REGISTRATION NUMBER CRD42022334403.
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Affiliation(s)
- Xiaoyu Li
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Chunru Xu
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Xing Ji
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Zhenpeng Zhu
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Tianyu Cai
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Zhenke Guo
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Jian Lin
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
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Wang M, Zhou L, Liao B, Ye D, Ma Y, Jian Z, Yuan C, Jin X, Li H, Wang K. Transperineal anastomotic posterior urethroplasty with bulbocavernosus flap and fibrin sealant in the complicated posterior urethral stricture reconstruction: a retrospective cohort study. Int J Surg 2024; 110:668-674. [PMID: 37983809 PMCID: PMC10871590 DOI: 10.1097/js9.0000000000000890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/26/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Management of complicated posterior urethral stricture is challenging. Modified transperineal anastomotic urethroplasty (TAU) with bulbocavernosus flap interposition and human fibrin sealant provides another treatment option. The authors aimed to evaluate whether this technique could improve the success rate in the complicated posterior urethral stricture reconstruction in this study. MATERIALS AND METHODS Between 2016 and 2019, 48 patients underwent either conventional or modified TAU. The criteria for success included both the absence of clinical symptoms and no need for further surgical intervention during follow-up. RESULTS Twelve patients underwent the modified TAU (group A) using bulbocavernosus flap interposition and human fibrin sealant. Thirty-six patients underwent the traditional end-to-end anastomotic urethroplasty (group B). Follow-up was 24.3-57.2 months. The patients in group A had a higher surgery success rate compared to the patients in group B (91.7 vs. 63.9%, P =0.067), with a quasi-significant result. Besides, no postoperative complications were observed in group A, while two individuals in group B had urinary incontinence, but the difference was not significant (0 vs. 5.6%, P =0.404). CONCLUSION Based on the preliminary results, modified TAU with bulbocavernosus flap interposition and human fibrin sealant is a safe and feasible technique for complicated posterior urethral stricture reconstruction.
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Affiliation(s)
- Menghua Wang
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital
| | - Liang Zhou
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital
| | - Banghua Liao
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital
| | - Donghui Ye
- Department of Urology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Yucheng Ma
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital
| | - Zhongyu Jian
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital
- West China Biomedical Big Data Center, Sichuan University, Chengdu, Sichuan
| | - Chi Yuan
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital
| | - Xi Jin
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital
| | - Hong Li
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital
| | - Kunjie Wang
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital
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18
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Marks P, Dahlem R, Daniels P, Klemm J, Kühnke L, Kranzbühler B, König F, Ding L, Engel O, Soave A, Fisch M, Vetterlein MW. Advancing Intraoperative Assessment of Urethral Stricture Anatomic Variation: A Prospective Proof-of-Concept Study. Urol Int 2024; 108:254-258. [PMID: 38295776 DOI: 10.1159/000536565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/27/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Urethral strictures, particularly those refractory to endoscopic interventions, are commonly treated through open urethroplasty. However, predicting recurrence in homogeneous patient populations remains challenging. METHODS To address this, we developed an intraoperative urethral stricture assessment tool aiming to identify comprehensive risk predictors. The assessment includes detailed parameters on stricture location, length, urethral bed width, spongiosum thickness, obliteration grade, and spongiofibrosis extension. The tool was prospectively implemented in 106 men with anterior one-stage augmentation urethroplasty from April 2020 to October 2021. RESULTS An intraoperative granular assessment of intricate stricture characteristics is feasible. Comparative analyses revealed significant differences between bulbar and penile strictures. Bulbar strictures exhibited wider urethral beds and thicker spongiosum compared to penile strictures (all p < 0.001). The assessment showed marked variations in the degree of obliteration and spongiofibrosis extension. CONCLUSION Our tool aligns with efforts to standardize urethral surgery, providing insights into subtle disease intricacies and enabling comparisons between institutions. Notably, intraoperative assessment may surpass the limitations of preoperative imaging, emphasizing the necessity of intraoperative evaluation. While limitations include a single-institution study and limited sample size, future research aims to refine this tool and determine its impact on treatment strategies, potentially improving long-term outcomes for urethral strictures.
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Affiliation(s)
- Phillip Marks
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peer Daniels
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Klemm
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lennart Kühnke
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt Kranzbühler
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, University Medical Center Zurich, Zurich, Switzerland
| | - Frederik König
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Liucheng Ding
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Oliver Engel
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, Asklepios Hospital Harburg, Hamburg, Germany
| | - Armin Soave
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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19
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Klemm J, Dahlem R, Kluth LA, Rosenbaum CM, Shariat SF, Fisch M, Vetterlein MW. [Evaluation and management of urethral strictures-guideline summary 2024 : Part 2-posterior urethra]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:15-24. [PMID: 38057615 DOI: 10.1007/s00120-023-02241-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 12/08/2023]
Abstract
In light of recently published international guidelines concerning the diagnosis, treatment, and aftercare of urethral strictures and stenoses, the objective of this study was to synthesize an overview of guideline recommendations provided by the American Urological Association (AUA, 2023), the Société Internationale d'Urologie (SIU, 2010), and the European Association of Urology (EAU, 2023). The recommendations offered by these three associations, as well as the guidelines addressing urethral trauma from the EAU, AUA, and the Urological Society of India (USI), were assessed in terms of their guidance on posterior urethral stenosis. On the whole, the recommendations from the various guidelines exhibit considerable alignment. However, SIU and EAU place a stronger emphasis on the role of repeated endoscopic treatment compared to AUA. The preferred approach for managing radiation-induced bulbomembranous stenosis remains a subject of debate. Furthermore, endoscopic treatments enhanced with intralesional therapies may potentially serve as a significant treatment modality for addressing even fully obliterated stenoses.
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Affiliation(s)
- Jakob Klemm
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Comprehensive Cancer Center, Medizinische Universität Wien, Universitätsklinik für Urologie, Wien, Österreich
| | - Roland Dahlem
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Luis A Kluth
- Klinik für Urologie, Universitätsklinikum Frankfurt am Main, Frankfurt am Main, Deutschland
| | | | - Shahrokh F Shariat
- Comprehensive Cancer Center, Medizinische Universität Wien, Universitätsklinik für Urologie, Wien, Österreich
- Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordanien
- Karl Landsteiner Institut für Urologie und Andrologie, Wien, Österreich
- Department of Urology, Weill Cornell Medical College, New York, NY, USA
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
- Department of Urology, Second Faculty of Medicine, Charles University, Prag, Tschechien
| | - Margit Fisch
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Malte W Vetterlein
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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Klemm J, Dahlem R, Kluth LA, Rosenbaum CM, Shariat SF, Fisch M, Vetterlein MW. [Evaluation and management of urethral strictures-guideline summary 2024 : part 1-anterior urethra]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:3-14. [PMID: 38153427 DOI: 10.1007/s00120-023-02240-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 12/29/2023]
Abstract
In recent years, several international urological societies have published guidelines on the diagnosis, treatment, and follow-up of urethral strictures, but a guideline for the German-speaking region has not been available to date. This summary provides a detailed comparison of the guidelines of the European Association of Urology (EAU), American Urological Association (AUA) and the Société Internationale d'Urologie (SIU) with regard to the treatment of anterior urethral strictures, i.e. from the bulbar urethra to the meatus. In the following work, differences and specific recommendations in the guidelines are highlighted. In particular, the three guidelines largely agree with regard to diagnostic workup and follow-up. However, divergences exist in the management of anterior urethral strictures, particularly with regard to the use of endoscopic therapeutic approaches and the use of urethral stents. In addition, the EAU provides more comprehensive and detailed recommendations on urethroplasty techniques and specific patient follow-up. The EAU guidelines are the most current and were the first to include instructions for urethral strictures in women and individuals with gender incongruence after genital approximation surgery. Reconstructive urology is a rapidly evolving specialty and, thus, the clinical approach has been changing accordingly. Although guideline recommendations have become more inclusive and comprehensive, more high-quality data are needed to further improve the level of evidence.
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Affiliation(s)
- Jakob Klemm
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Universitätsklinik für Urologie, Comprehensive Cancer Center, Medizinische Universität Wien, Wien, Österreich
| | - Roland Dahlem
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Luis A Kluth
- Klinik für Urologie, Universitätsklinikum Frankfurt am Main, Frankfurt am Main, Deutschland
| | | | - Shahrokh F Shariat
- Universitätsklinik für Urologie, Comprehensive Cancer Center, Medizinische Universität Wien, Wien, Österreich
- Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordanien
- Karl Landsteiner Institut für Urologie und Andrologie, Wien, Österreich
- Department of Urology, Weill Cornell Medical College, New York, NY, USA
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
- Department of Urology, Second Faculty of Medicine, Charles University, Prag, Tschechien
| | - Margit Fisch
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Malte W Vetterlein
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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Zhao X, Xing Y, Zhang X, Guo Q, Li C, Guo C, Wang J, Hao C. Low risk of erectile dysfunction after nontransecting bulbar urethroplasty for urethral stricture: a systematic review and meta-analysis. J Sex Med 2023; 21:11-19. [PMID: 37973403 DOI: 10.1093/jsxmed/qdad141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/16/2023] [Accepted: 09/20/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Sexual function after urethroplasty may be a concern for patients, but there are still some controversies regarding the consequences of nontransecting bulbar urethroplasty (ntBU) in terms of erectile dysfunction (ED). AIM This meta-analysis aimed to compare the efficacy and safety of ntBU with that of transecting bulbar urethroplasty (tBU). METHODS The PubMed, Web of Science, Cochrane, and Embase databases were searched and reviewed up to October 31, 2022. Quality evaluation was performed using the Newcastle-Ottawa scale system and Cochrane tools for the nonrandomized and randomized studies, respectively. Baseline characteristics, preoperative information, and postoperative outcomes were collected. OUTCOMES Outcomes included success rate, ED, overall complication, and maximum urinary flow. RESULTS Thirteen studies comprising 1683 patients met the inclusion criteria, with 596 and 1087 patients undergoing ntBU and tBU, respectively. The results revealed that compared with the tBU group, the patients who underwent ntBU had a significantly lower incidence of ED, while there were no significant differences in the other perioperative outcomes. In subgroup analysis, the nontransecting anastomotic urethroplasty group had a lower incidence of ED than excision and primary anastomosis, and other perioperative outcomes were similar between the 2 groups. CLINICAL IMPLICATIONS The results of the study may help clinicians choose procedures that protect sexual function in the treatment of urethral stricture. STRENGTHS AND LIMITATIONS The strength of this study is that it is, to our knowledge, the first meta-analysis to evaluate the efficacy and safety of ntBU. A limitation is that most of the included studies were retrospective cohort studies. CONCLUSION ntBU preserves the high efficacy of its transecting counterpart while reducing postoperative ED.
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Affiliation(s)
- Xingming Zhao
- Department of Urology, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, China
- Department of Clinical Medicine, The Second School of Clinical Medicine, Shanxi Medical University, Taiyuan, 030001, China
| | - Yanbo Xing
- Department of Urology, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, China
| | - Xi Zhang
- Department of Urology, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, China
| | - Qiang Guo
- Department of Urology, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, China
| | - Chengyong Li
- Department of Urology, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, China
| | - Chao Guo
- Department of Urology, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, China
| | - Jingqi Wang
- Department of Urology, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, China
| | - Chuan Hao
- Department of Urology, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, China
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Karapanos L, Knorr V, Halbe L, Schmautz M, Ergashev B, Heidenreich A. Comparison of oral morbidity and mid-term efficacy of anterior urethroplasty using an autologous tissue-engineered graft (MukoCell®) versus native oral mucosa graft. Int J Urol 2023; 30:1000-1007. [PMID: 37435860 DOI: 10.1111/iju.15247] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 06/27/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE Our study aimed to compare surgical success rate (SR) and oral morbidity of augmentation urethroplasty for anterior urethral strictures using autologous tissue-engineered oral mucosa graft (TEOMG) named MukoCell® versus native oral mucosa graft (NOMG). METHODS We conducted a single-institution observational study on patients undergoing TEOMG and NOMG urethroplasty for anterior urethral strictures >2 cm in length from January 2016 to July 2020. SR, oral morbidity, and potential risk factors of recurrence were compared between groups were analyzed. A decrease of maximum uroflow rate < 15 mL/s or further instrumentation was considered a failure. RESULTS Overall, TEOMG (n = 77) and NOMG (n = 76) groups had comparable SR (68.8% vs. 78.9%, p = 0.155) after a median follow-up of 52 (interquartile range [IQR] 45-60) months for TEOMG and 53.5 (IQR 43-58) months for NOMG. Subgroup analysis revealed comparable SR according to surgical technique, stricture localization, and length. Only following repetitive urethral dilatations, TEOMG achieved lower SR (31.3% vs. 81.3%, p = 0.003). Surgical time was significantly shorter by TEOMG use (median 104 vs. 182 min, p < 0.001). Oral morbidity and the associated "burden" in patients' quality of life were significantly less at 3 weeks following the biopsy required for TEOMG manufacture, compared to NOMG harvesting and totally absent at 6 and 12 months postoperatively. CONCLUSIONS The SR of TEOMG urethroplasty appeared to be comparable to NOMG at a mid-term follow-up but taking into account the uneven distribution of stricture site and the surgical techniques used in both groups. Surgical time was significantly shortened, since no intraoperative mucosa harvesting was required, and oral complications were diminished through the preoperative biopsy for MukoCell® manufacture.
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Affiliation(s)
- Leonidas Karapanos
- Department of Urology, Uro-Oncology, Robot-Assisted and Reconstructive Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Vincent Knorr
- Department of Urology, Staedtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Luisa Halbe
- Department of Urology, Uro-Oncology, Robot-Assisted and Reconstructive Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Maximilian Schmautz
- Department of Urology, Uro-Oncology, Robot-Assisted and Reconstructive Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Bobirjon Ergashev
- Department of Urology, Andijan State Medical Institute, Andijan, Uzbekistan
| | - Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot-Assisted and Reconstructive Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Marks P, Dahlem R, Janisch F, Klemm J, Kühnke L, König F, Ding L, Riechardt S, Fisch M, Vetterlein MW. Mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty: a ventral modification for obliterative strictures. BJU Int 2023; 132:444-451. [PMID: 37409824 DOI: 10.1111/bju.16112] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
OBJECTIVES To present a surgical modification for the repair of bulbar urethral strictures containing short, highly obliterative segments and report on long-term objective and patient-reported outcomes. PATIENTS AND METHODS We considered patients undergoing bulbar buccal mucosal graft urethroplasty (BMGU) between July 2016 and December 2019. Eligibility criteria for mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty were strictures of ≥2 cm with an obliterative segment of ≤1.5 cm. The stricture is approached ventrally to avoid extensive dissection and mobilisation. Dorsally, the scar is superficially excised and the spongiosum is left intact. Dorsal mucomucosal anastomosis is complemented by ventral onlay graft. Perioperative characteristics were prospectively collected including uroflowmetry data and validated patient-reported outcome measures on voiding, erectile, and continence function. We evaluated functional follow-up, incorporating patient-reported (lower urinary tract symptoms [LUTS] score) and functional success. Recurrence was defined as need of re-treatment. RESULTS Of 641 men treated with anterior BMGU, 54 (8.4%) underwent MANTA urethroplasty. Overall, 26 (48%) and 45 (83%) had a history of dilatation and urethrotomy, respectively, and 14 (26%) were redo cases. Location was bulbar in 38 (70%) and penobulbar in 16 patients (30%), and the mean (SD) graft length was 4.5 (1.4) cm. At a median (interquartile range) follow-up of 41 (27-53) months, the functional success rate was 93%. Whereas the median LUTS score significantly improved from baseline to postoperatively (13 vs 3.5; P < 0.001), there was no change in erectile function (median International Index of Erectile Function - erectile function domain score 27 vs 24) or urinary continence (median International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form sum score 0 vs 0; all P ≥ 0.4). All patients were 'satisfied' (27%) or 'very satisfied' (73%) with the outcome of their operation. CONCLUSION With excellent long-term objective and patient-reported outcomes, MANTA urethroplasty adds to the armamentarium for long bulbar strictures with a short obliterative segment.
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Affiliation(s)
- Phillip Marks
- Department of Urology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Florian Janisch
- Department of Urology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Jakob Klemm
- Department of Urology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Lennart Kühnke
- Department of Urology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Frederik König
- Department of Urology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Liucheng Ding
- Department of Urology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- Department of Urology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Silke Riechardt
- Department of Urology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- Department of Urology, Medical Center Itzehoe, Itzehoe, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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Białek Ł, Rydzińska M, Vetterlein MW, Dobruch J, Skrzypczyk MA. A Systematic Review on Postoperative Antibiotic Prophylaxis after Pediatric and Adult Male Urethral Reconstruction. J Clin Med 2023; 12:6162. [PMID: 37834807 PMCID: PMC10573465 DOI: 10.3390/jcm12196162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/17/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
In the era of antibiotic overuse and increasing antibiotic resistance, there is a gap in evidence regarding antibiotic stewardship, and in particular, perioperative antibiotic prophylaxis after urethral reconstruction. The aim of this systematic review was to evaluate the effectiveness and relevance of postoperative antibiotic prophylaxis after male pediatric and adult urethral reconstruction. An online search of MEDLINE database via PubMed was performed. The systematic review was registered in PROSPERO (CRD42022348555) and was conducted according to the PRISMA guidelines and AMSTAR 2 checklist. A narrative synthesis of included studies was performed. After the screening of 1176 publications, six studies regarding antibiotic prophylaxis after hypospadias reconstruction and two studies regarding antibiotic prophylaxis after urethroplasty in adults were eligible to be included in the systematic review. All but one of the studies on hypospadias repair showed no benefit from postoperative antibiotic prophylaxis. The level of evidence on postoperative antibiotic prophylaxis after urethroplasty in adults is low. Neither of the two studies included in the review showed a benefit from antibiotic use. Postoperative prophylaxis after hypospadias repair is not effective in preventing urinary tract infections and wound infections. It seems that the use of postoperative prophylaxis after urethroplasty in adults is also not beneficial, but there is a high need for high-quality scientific data.
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Affiliation(s)
- Łukasz Białek
- Department of Urology, Centre for Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Marta Rydzińska
- Department of Urology, Centre for Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Malte W. Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Jakub Dobruch
- Department of Urology, Centre for Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Michał A. Skrzypczyk
- Department of Urology, Centre for Postgraduate Medical Education, 01-813 Warsaw, Poland
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Kulkarni SB, Joshi PM, Basile G, Bandini M. Novel single-stage preputial spiral graft for panurethral stricture: a step-by-step description of the technique. World J Urol 2023; 41:2459-2463. [PMID: 37450009 DOI: 10.1007/s00345-023-04514-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023] Open
Abstract
PURPOSE To report the 12-month results of a novel urethroplasty technique relying on a spiral preputial graft for panurethral stricture disease. MATERIALS AND METHODS Twenty consecutive patients were treated between May and October 2021 at our center. A spiral preputial mucocutaneous graft is a foreskin-based graft, developed from a 5-cm-wide preputial skin, which is harvested using a helicoidal shape and can reach up to 20 cm in length. Stricture characteristics were assessed through preoperative retrograde and voiding cystourethrogram and maximum uroflowmetry data (Qmax). Complications were collected up to 30 days after surgery and graded using the Clavien-Dindo (C-D) classification. The patients were followed up to 12 months. RESULTS Preoperative median Qmax was 6.5 ml/s [interquartile range (IQR): 4.0-8.7]. After a median follow-up of 12 months (IQR 12-13), six patients experienced at least one complication. Of them, two patients had grade 2 C-D complications, while only one developed a grade 3a C-D complication. The median postoperative Qmax was 16 ml/s (IQR: 13-18). Only one patient had early urethral stricture recurrence treated with dilatation after catheter removal. At one-year follow-up, no other patients had urethral stricture recurrence with an overall median Qmax of 15.1 ml/s (IQR 13.5-16.4). CONCLUSIONS Our novel single-stage spiral preputial graft urethroplasty for panurethral stricture treatment appears to be safe and could be used as a valid alternative to two-stage procedures or even to single-stage buccal mucosa graft augmentation.
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Affiliation(s)
| | | | - Giuseppe Basile
- Unit of Urology, Urological Research Institute (URI), San Raffaele Hospital, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - Marco Bandini
- Kulkarni Reconstructive Urology Center, Pune, India
- Unit of Urology, Urological Research Institute (URI), San Raffaele Hospital, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
- Center for Reconstructive Urethral Surgery, Arezzo, Rome, Milan, Italy
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Oszczudlowski M, Yepes C, Dobruch J, Martins FE. Outcomes of transecting versus non-transecting urethroplasty for bulbar urethral stricture: a meta-analysis. BJU Int 2023; 132:252-261. [PMID: 37402622 DOI: 10.1111/bju.16108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
OBJECTIVES To assess outcomes of transecting vs non-transecting urethroplasty for bulbar urethral stricture in terms of stricture recurrence rate, sexual dysfunction, and patient-reported outcome measures (PROMs) related to lower urinary tract (LUT) function. METHODS Electronic literature searches were conducted using PubMed, Cochrane Library, Web of Science and Embase databases. The studied population was limited to men with bulbar urethral stricture included in studies that compared outcomes after transecting and non-transecting urethroplasty. The main outcome appraised was the stricture recurrence rate. Additionally, the incidence of sexual dysfunction appraised in three domains (erectile function, penile complications, and ejaculatory function) and PROMs related to LUT function after transecting vs non-transecting urethroplasty were assessed. The pooled risk ratio (RR) respectively for stricture recurrence, erectile dysfunction and penile complications was calculated using a fixed-effect model with inverse variance method. RESULTS In all, 694 studies were screened with 72 identified as relevant. Finally, 19 studies were suitable for analysis. The pooled difference between the transecting and non-transecting groups relating to stricture recurrence was not significant. Overall, the RR was 1.06 (95% confidence interval [CI] 0.82-1.36) and the 95% CI crossed the line of no effect (line RR = 1). Overall, the RR for erectile dysfunction was 0.73 (95% CI 0.49-1.08) and the 95% CI crossed the line of no effect (line RR = 1). Overall, the RR for penile complications was 0.47 (95% CI 0.28-0.76) and the 95% CI did not cross the line of no effect (line RR = 1). Hence, the risk of penile complications was significantly lower in the non-transecting group. CONCLUSIONS Our analysis of available evidence indicates that both transecting and non-transecting urethroplasties, are equal in terms of the recurrence rate. On the other hand, non-transecting techniques are better in terms of sexual function, causing less penile complications.
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Affiliation(s)
| | - Christian Yepes
- Belgrade Centre for Genital Reconstructive Surgery, Belgrade, Serbia
| | - Jakub Dobruch
- Urology Clinic, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Francisco E Martins
- Department of Urology, School of Medicine, Hospital Santa Maria, University of Lisbon, Lisbon, Portugal
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Basile G, Karakiewicz PI, Tian Z, Djinović R, Montorsi F, Barbagli G, Joshi P, Kulkarni SB, Bandini M. The impact of surgical volume on perioperative safety after urethroplasty: a population-based study. Minerva Urol Nephrol 2023; 75:381-387. [PMID: 35622351 DOI: 10.23736/s2724-6051.22.04893-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of the study was to assess whether the risk of perioperative complications after urethroplasty was affected by hospital annual surgical volume (ASV). METHODS In the Nationwide Inpatient Sample, we searched for patients who underwent urethroplasty between 2001 and 2015. Hospitals were categorized into empirically determined tertiles, according to ASV of performed urethroplasties and divided into low (<3) (LVC), intermediate (3-19) (IVC) and high (>20) volume centers (HVC). Multivariable logistic regression (MLR) analyses examined the effect of ASV on perioperative complications and on four specific sub-types of post-operative complications. RESULTS A weighted estimate of 39 912 patients underwent urethroplasty in the US. 34.9% were operated in HVC, while the rate of performed urethroplasties increased in LVC and decreased in HVC. Overall, 1.1%, 18.8% and 2.1% patients respectively experienced intraoperative, post-operative, and transfusions complications. At MLR, IVC and LVC were associated with higher risk of both intraoperative (IVC: OR 2.65, P=0.0008; LVC: OR 4.98, P<0.0001), post-operative (IVC: OR 1.14, P=0.01; LVC: OR 1.26, P=0.001) and transfusions complications (IVC: OR 1.85, P<0.001; LVC: OR 3.03, P=0.01). LVC was also associated with higher risk of hematuria (OR 3.77), urinary infections (OR 1.60) and sepsis (OR 2.83) complications. CONCLUSIONS Approximately 65% of patients were operated in IVC and LVC, and patients treated in IVC or LVC had higher risk of developing both intra and post-operative complications. These data provide important indicators for policy makers to categorize institution based on urethroplasty outcomes.
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Affiliation(s)
- Giuseppe Basile
- Unit of Urology, Division of Experimental Oncology, Department of Urology, Urological Research Institute (URI), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy -
| | - Pierre I Karakiewicz
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CR-CHUM), Cancer Institute of Montréal, Montréal, QC, Canada
| | - Zhe Tian
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CR-CHUM), Cancer Institute of Montréal, Montréal, QC, Canada
| | - Radoš Djinović
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, Belgrade, Serbia
| | - Francesco Montorsi
- Unit of Urology, Division of Experimental Oncology, Department of Urology, Urological Research Institute (URI), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Pankaj Joshi
- Kulkarni Reconstructive Urology Center, Pune, India
| | | | - Marco Bandini
- Unit of Urology, Division of Experimental Oncology, Department of Urology, Urological Research Institute (URI), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CR-CHUM), Cancer Institute of Montréal, Montréal, QC, Canada
- Centro Chirurgico Toscano, Arezzo, Italy
- Kulkarni Reconstructive Urology Center, Pune, India
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Verla W, Barratt R, Chan G, Dimitropoulos K, Esperto F, Yuhong Y, Greenwell T, Lumen N, Martins F, Osman N, Ploumidis A, Riechardt S, Waterloos M, Campos-Juanatey F. Is a Course of Intermittent Self-dilatation with Topical Corticosteroids Superior at Stabilising Urethral Stricture Disease in Men and Improving Functional Outcomes over a Course of Intermittent Self-dilatation Alone? A Systematic Review and Meta-analysis. EUR UROL SUPPL 2023; 51:95-105. [PMID: 37122691 PMCID: PMC10130070 DOI: 10.1016/j.euros.2023.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 05/02/2023] Open
Abstract
Context Intermittent self-dilatation (ISD) is a therapeutic strategy used to stabilise a urethral stricture and postpone or avoid further treatment. Adding corticosteroids to this mode of management might further enhance its outcomes by downregulation of collagen deposition and excessive scar tissue formation. Objective To explore whether a course of ISD with topical corticosteroids is superior at stabilising urethral stricture disease in men and improving functional outcomes over a course of ISD alone. Evidence acquisition This systematic review and meta-analysis was undertaken by the European Association of Urology Urethral Strictures Guideline Panel according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (CRD42021256744). The primary benefit outcome was successful stabilisation of the urethral stricture. Treatment-related complications were the primary harm outcome. Evidence synthesis In total, 978 records were screened for eligibility, ultimately leading to five included studies, all randomised controlled trials, comprising 250 patients, of whom 124 underwent a course of ISD with corticosteroids and 126 underwent a course of ISD alone, all after direct vision internal urethrotomy (DVIU). Successful stabilisation of the stricture was achieved in 77% and 64% of patients in the group with and without corticosteroids, respectively (p = 0.04). No extra complications related to the addition of corticosteroids to the ISD regimen were reported. The risk of bias of the included studies was generally unclear to high. Conclusions Based on the currently available data, a course of ISD with topical corticosteroids appears to be safe and superior at stabilising a urethral stricture after DVIU in the short term to a course of ISD alone. However, given the unclear to high risk of bias in the included studies, further high-quality studies are needed to fully underpin this. Patient summary This study shows that addition of topical corticosteroids to intermittent self-dilatation after direct vision internal urethrotomy can better stabilise the stricture in the short term.
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Affiliation(s)
- Wesley Verla
- Dept. of Urology, Ghent University Hospital, Ghent, Belgium
- Corresponding author. Tel.: (+32) 9 332 22 76. Fax.: (+32) 9 332 38 89.
| | - Rachel Barratt
- Dept. of Urology, University College London Hospital, London, UK
| | - Garson Chan
- Dept. of Urology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | | | - Yuan Yuhong
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, ON, Canada
| | - Tamsin Greenwell
- Dept. of Urology, University College London Hospital, London, UK
| | - Nicolaas Lumen
- Dept. of Urology, Ghent University Hospital, Ghent, Belgium
| | - Francisco Martins
- Dept. of Urology, Universidade de Lisboa, Hospital de Santa Maria, Lisbon, Portugal
| | - Nadir Osman
- Dept. of Urology, Royal Hallamshire Hospital, Sheffield, UK
| | | | - Silke Riechardt
- Dept. of Urology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Marjan Waterloos
- Dept. of Urology, Ghent University Hospital, Ghent, Belgium
- Dept. of Urology, AZ Maria Middelares, Ghent, Belgium
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Song L, Zhang R, Lu C, Chen Y. Factors to Consider in Augmentation Urethroplasty with Oral Mucosa Graft or Penile Skin Flap for Anterior Urethral Stricture: A Systematic Review and Meta-analysis. EUR UROL SUPPL 2023; 50:113-122. [PMID: 36942323 PMCID: PMC10023910 DOI: 10.1016/j.euros.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 03/11/2023] Open
Abstract
Context Oral mucosa graft (OMG) and penile skin flap (PSF) are common substitutions in urethroplasty; however, the recommended substitution for anterior urethral strictures remains uncertain. Objective To compare the efficacy of OMG and PSF in anterior urethral strictures in terms of success rate and prevalence of postvoid dribbling based on current studies. Evidence acquisition A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and registered at PROSPERO (ID: CRD42022313879). All publications until March 1, 2022, were searched in the PubMed, EMBASE, and Cochrane Library databases without any restriction. Studies that focused on patients with anterior urethral strictures undergoing single-stage augmentation urethroplasty with OMG and PSF, and reported comparable success rates between the two substitutions were included. Evidence synthesis Thirteen studies involving a total of 1216 patients were included in the screening procedures, and 12 studies were eventually included in the meta-analysis. No significant difference in success rates was identified between OMG and PSF (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 0.96-2.07, p = 0.08). No significant difference was observed in the comparison of success rates in penile urethral strictures (OR: 0.95, 95% CI: 0.53-1.70, p = 0.86) and in the comparison of postvoid dribbling (OR: 0.59, 95% CI: 0.31-1.11, p = 0.10). However, a subgroup analysis suggested that OMG had a higher success rate than PSF in studies with the top 50% sample size (six studies, OR: 1.678, 95% CI: 1.055-2.668, p = 0.029) and the top 50% follow-up period (five studies, OR: 2.279, 95% CI: 1.193-4.352, p = 0.013). Conclusions OMG provides the same success rate and postvoid dribbling as PSF. However, based on the existing evidence, OMG is more likely to perform better in a cohort with long-term follow-up and a relatively large sample size. More studies on the two substitutions are necessary to evaluate the factors of urethroplasty success rate, performance of substitutions in penile urethral strictures, and indicators of quality of life. Patient summary In this research, we compared the outcomes of oral mucosa graft (OMG) and penile skin flap for urethroplasty in anterior urethral stricture patients in 13 studies. We found that these were similar in terms of success rate and postvoid dribbling. However, OMG could probably provide a higher success rate when the studies had more patients or a longer follow-up period.
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Affiliation(s)
- Lujie Song
- Corresponding author. Department of Urology, Shanghai Jiao Tong University Affiliated 6th People's Hospital, Shanghai, China. Tel. +8618930172157.
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A TriNetX Registry Analysis of the Need for Second Procedures following Index Anterior and Posterior Urethroplasty. J Clin Med 2023; 12:jcm12052055. [PMID: 36902842 PMCID: PMC10004265 DOI: 10.3390/jcm12052055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND We queried a global database to understand re-intervention rates following urethroplasty with the goal of evaluating whether they align with previously published data. METHODS Using the TriNetX database and Common Procedural Terminology (CPT) and International Classification of Diseases-10 (ICD) codes, we identified adult male patients with urethral stricture disease (ICD N35) who underwent one-stage anterior (CPT 53410) or posterior urethroplasty (CPT 53415), with or without (substitution urethroplasty) a tissue flap (CPT 15740) or buccal graft (CPT 15240 or 15241). We set urethroplasty as the index event and used descriptive statistics to report the incidence of secondary procedures (using CPT codes) within 10 years after the index event. RESULTS There were 6606 patients who underwent urethroplasty within the last 20 years, with 14.3% of patients undergoing a second procedure after index event. Upon subgroup analysis, reintervention rates were 14.5% for anterior urethroplasty vs. 12.4% of patients with an anterior substitution urethroplasty (RR 1.7, p = 0.09) and 13.3% for posterior urethroplasty vs. 8.2% for patients with a posterior substitution urethroplasty (RR 1.6, p < 0.01). CONCLUSIONS Most patients will not need any form of re-intervention following urethroplasty. These data align with previously described recurrence rates, which may help urologists counsel patients considering urethroplasty.
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Bandini M, Basile G, Lazzeri M, Montorsi F, Valli B, Balò S, Barbagli G. Optimizing decision-making after ventral onlay buccal mucosa graft urethroplasty failure. BJU Int 2023; 131:339-347. [PMID: 36114780 DOI: 10.1111/bju.15895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate factors predicting recurrence after treatment and to assess the best rescue option for patients failing buccal mucosa graft (BMG) urethroplasty. MATERIALS AND METHODS We evaluated the data from 575 patients treated with ventral onlay BMG urethroplasty. Multivariable Cox regression analysis was performed to identify predictors of BMG urethroplasty failure, and their effect on failure risk was estimated using the Kaplan-Meier method and compared using log-rank tests. Then, for those patients who underwent a rescue treatment, namely, direct visual internal urethrotomy (DVIU) vs open urethroplasty, we assessed the probability of success after retreatment using the Kaplan-Meier method and regression tree analyses. RESULTS On multivariable Cox regression analysis, only stricture length ≥5 cm (hazard ratio 3.46, 95% confidence interval 1.50-7.94; P = 0.003) was a predictor of failure. A total of 103 patients had at least one re-intervention. Notably, 12-month success rates after first rescue DVIU, second rescue DVIU, third rescue DVIU, and fourth rescue DVIU were 66.3%, 62.5%, 37.5% and 25%, respectively. Conversely, for those patients who underwent open urethroplasty retreatment, success rates at 12 months were 83.3%, 79%, 92.3% and 75% after BMG ventral onlay, first rescue DVIU, second rescue DVIU and third rescue DVIU, respectively. These data were confirmed in regression tree analyses. CONCLUSION Ventral BMG urethroplasty fails in approximately one out of five patients. Despite DVIU as a rescue treatment being a good option, its success rate becomes lower as the number of DVIU treatments performed increases. Conversely, open urethroplasty improves patient outcomes in almost three out of four patients, even in the case of previous failed DVIU treatments for stricture recurrence.
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Affiliation(s)
- Marco Bandini
- Unit of Urology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy.,Centro Chirurgico Toscano, Arezzo, Italy
| | - Giuseppe Basile
- Unit of Urology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Lazzeri
- Instituto Clinico Humanitas IRCCS-Clinical and Researcher Hospital, Rozzano, Italy
| | - Francesco Montorsi
- Unit of Urology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Sofia Balò
- Centro Chirurgico Toscano, Arezzo, Italy
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Kommentar zu Urethrarekonstruktion: Antibiotikaeinsatz minimieren. Aktuelle Urol 2023; 54:14. [PMID: 36787770 DOI: 10.1055/a-1947-0886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Li K, Lai C, Hei S, Liu C, Li Z, Kewei X. Single-cell transcriptome reveals cellular heterogeneity and lineage-specific regulatory changes of fibroblasts in post-traumatic urethral stricture. Biochem Biophys Rep 2023; 33:101431. [PMID: 36748064 PMCID: PMC9898624 DOI: 10.1016/j.bbrep.2023.101431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 01/24/2023] Open
Abstract
Fibroblast is the critical repair cell for urethral wound healing. The dysfunction of fibroblasts can lead to excessive fibrosis and hypertrophic scar, which eventually leads to post-traumatic urethral stricture. However, the fibroblast subpopulation and intercellular communication in urethral stricture remains poorly understood. Therefore, a comprehensive single-cell resolution transcript landscape of human PTUS needs to be reported. We performed single-cell RNA-sequencing of 13,411 cells from post-urethral stricture tissue and adjacent normal tissue. Unsupervised clustering, function enrichment analysis, cell trajectory construction and intercellular communication analysis were applied to explore the cellular microenvironment and intercellular communication at single-cell level. We found that there is highly cell heterogeneity in urethral stricture tissue, which includes 11 cell lineages based on the cell markers. We identified the molecular typing of fibroblasts and indicated the key fibroblast subpopulations in the process of fibrogenesis during urethral stricture. The intercellular communication between fibroblasts and vascular endothelial cells was identified. As an important bridge in the communication, integrins may be a potential therapeutic target for post-traumatic urethral stricture. In conclusion, this study reveals the cellular heterogeneity and lineage-specific regulatory changes of fibroblasts in post-traumatic urethral stricture, thereby providing new insights and potential genes for post-traumatic urethral stricture treatment.
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Affiliation(s)
- Kuiqing Li
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Cong Lai
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shangyan Hei
- Traditional Chinese Medicine Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Cheng Liu
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhuohang Li
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xu Kewei
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China,Corresponding author. No. 107 Yan Jiang West Road, Guangzhou, China.510120
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Alternatives to oral mucosa grafts for urethral reconstruction. Nat Rev Urol 2022; 20:259-260. [PMID: 36536071 DOI: 10.1038/s41585-022-00707-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Mantica G, Verla W, Cocci A, Frankiewicz M, Adamowicz J, Campos-Juanatey F, Rosenbaum CM, Waterloos M, Kluth LA, Vetterlein MW. Reaching Consensus for Comprehensive Outcome Measurement After Urethral Stricture Surgery: Development of Study Protocol for Stricture-Fecta Criteria. Res Rep Urol 2022; 14:423-426. [PMID: 36568569 PMCID: PMC9785114 DOI: 10.2147/rru.s396025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Urethral stricture disease is a very heterogeneous condition where different urethral segments can be involved as a result of diverse etiologies which come with variable prognosis. The surgical management of urethral strictures, and in particular urethroplasties can result in very diverse outcomes on many levels and, currently, there is absolutely no consensus about what should and what should not be considered a "success" after urethral surgery. In the wake of well-established quality criteria in urologic oncology, such as tri- or pentafecta outcomes, and given the lack of agreement on meaningful outcomes after urethral surgery, we aim to introduce our study protocol as the first step of a multistep research endeavor to reach consensus on comprehensive urethroplasty outcomes within a novel conceptual framework: the "stricture-fecta criteria". The development of stricture-fecta will be based on a Delphi consensus involving some of worldwide most influencing reconstructive urologists.
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Affiliation(s)
- Guglielmo Mantica
- IRCCS Ospedale Policlinico San Martino, Genova, Italy,Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy,Correspondence: Guglielmo Mantica, IRCCS San Martino Hospital, University of Genova, Largo Rosanna Benzi 10, Genova, 16132, Italy, Tel +390105555964, Email
| | - Wesley Verla
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Andrea Cocci
- Department of Urology and Andrology, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Jan Adamowicz
- Department of Regenerative Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Felix Campos-Juanatey
- Andrology and Reconstructive Urology Unit, Marques de Valdecilla University Hospital, IDIVAL, Santander, Spain
| | | | - Marjan Waterloos
- Department of Urology, Division of Reconstructive Urology, Ghent University Hospital, Ghent, Belgium
| | - Luis A Kluth
- Department of Urology, University Medical Center Frankfurt, Frankfurt/Main, Germany
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Zhu Z, Yang J, Ji X, Wang Z, Dai C, Li S, Li X, Xie Y, Zheng Y, Lin J, Zhou L. Clinical application of a double-modified sulfated bacterial cellulose scaffold material loaded with FGFR2-modified adipose-derived stem cells in urethral reconstruction. Stem Cell Res Ther 2022; 13:463. [PMID: 36068613 PMCID: PMC9450280 DOI: 10.1186/s13287-022-03164-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/18/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Urethral stricture and reconstruction are one of the thorny difficult problems in the field of urology. The continuous development of tissue engineering and biomaterials has given new therapeutic thinking to this problem. Bacterial cellulose (BC) is an excellent biomaterial due to its accessibility and strong plasticity. Moreover, adipose-derived stem cells (ADSCs) could enhance their wound healing ability through directional modification. METHODS First, we used physical drilling and sulfonation in this study to make BC more conducive to cell attachment and degradation. We tested the relevant mechanical properties of these materials. After that, we attached Fibroblast Growth Factor Receptor 2 (FGFR2)-modified ADSCs to the material to construct a urethra for tissue engineering. Afterward, we verified this finding in the male New Zealand rabbit model and carried out immunohistochemical and imaging examinations 1 and 3 months after the operation. At the same time, we detected the potential biological function of FGFR2 by bioinformatics and a cytokine chip. RESULTS The results show that the composite has excellent repairability and that this ability is correlated with angiogenesis. The new composite in this study provides new insight and therapeutic methods for urethral reconstruction. The preliminary mechanism showed that FGFR2 could promote angiogenesis and tissue repair by promoting the secretion of Vascular Endothelial Growth Factor A (VEGFA) from ADSCs. CONCLUSIONS Double-modified sulfonated bacterial cellulose scaffolds combined with FGFR2-modified ADSCs provide new sight and treatments for patients with urethral strictures.
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Affiliation(s)
- Zhenpeng Zhu
- Department of Urology, Peking University First Hospital, Beijing, 100034, China
- Institution of Urology, Peking University, Beijing, 100034, China
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China
| | - Jiayu Yang
- University of Science and Technology, Beijing, Beijing, 100083, China
| | - Xing Ji
- Department of Urology, Peking University First Hospital, Beijing, 100034, China
- Institution of Urology, Peking University, Beijing, 100034, China
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China
| | - Zicheng Wang
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, China
| | - Chengxiang Dai
- University of Science and Technology, Beijing, Beijing, 100083, China
- Cellular Biomedicine Group Inc. (CBMG), Shanghai, 200234, China
| | - Suke Li
- Cellular Biomedicine Group Inc. (CBMG), Shanghai, 200234, China
| | - Xuesong Li
- Department of Urology, Peking University First Hospital, Beijing, 100034, China
- Institution of Urology, Peking University, Beijing, 100034, China
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China
| | - Yajie Xie
- University of Science and Technology, Beijing, Beijing, 100083, China
| | - Yudong Zheng
- University of Science and Technology, Beijing, Beijing, 100083, China.
| | - Jian Lin
- Department of Urology, Peking University First Hospital, Beijing, 100034, China.
- Institution of Urology, Peking University, Beijing, 100034, China.
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China.
| | - Liqun Zhou
- Department of Urology, Peking University First Hospital, Beijing, 100034, China.
- Institution of Urology, Peking University, Beijing, 100034, China.
- Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, 100034, China.
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Naud E, Rourke K. Recent Trends and Advances in Anterior Urethroplasty. Urol Clin North Am 2022; 49:371-382. [PMID: 35931430 DOI: 10.1016/j.ucl.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
While patient preference often helps guide treatment decisions, poor long-term success combined with cumulative risk of repeat endoscopic treatments and the complications innately associated with urethral stricture emphasize that urethroplasty is most often the best choice for successful treatment in the long-term. This has led to the need to better refine urethroplasty techniques and optimize patient outcomes. Urethroplasty has now largely transitioned to a day-surgery procedure in the majority of centers. Some evidence suggests that avoiding urethral transection and/or avoiding overzealous urethral mobilization may lead to a reduction in post-operative sexual dysfunction. The trend toward single stage penile urethroplasty with buccal mucosal grafts likely minimizes patient morbidity without compromising urethroplasty success. For urethroplasty success to further improve particularly in patients at high risk for stricture recurrence, the synergistic potential of combining wound healing enhancing agents with evolving tissue-engineering represents an exciting future opportunity in the quest to perfect urethroplasty outcomes.
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Affiliation(s)
- Elizabeth Naud
- Division of Urology, Department of Surgery, University of Alberta, Kipnes Urology Centre, 7th Floor, Kaye Edmonton Clinic, 11400 University Avenue, Edmonton, Alberta T6G1Z1, Canada
| | - Keith Rourke
- Division of Urology, Department of Surgery, University of Alberta, Kipnes Urology Centre, 7th Floor, Kaye Edmonton Clinic, 11400 University Avenue, Edmonton, Alberta T6G1Z1, Canada.
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Bandini M, Yepes C, Joshi PM, Basile G, Naranjo D, Bhadranavar S, Alrefaey A, Bafna S, Montorsi F, Kulkarni SB. Which are the commonest sites and characteristics of post- transurethral prostate surgery (TPS) strictures in a high-volume reconstructive center? J Endourol 2022; 36:1309-1316. [PMID: 35699078 DOI: 10.1089/end.2022.0130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Urethral stricture is a well-known complication after transurethral prostate surgery (TPS) and it is usually considered an easy-to-treat condition. We aimed to examine characteristics of post-TPS urethral stricture cases that were referred for urethroplasty at our tertiary center. METHODS We identified 201 patients with TPS-induced stricture treated with urethroplasty at our institution from 2017-2021. First, stricture length and location were evaluated during preoperative assessment. Second, multiple sets of multivariable logistic regression (MLR) analyses were run to assess whether clinical variables were associated with the location of the stricture. RESULTS Median stricture length was 5 cm (4-7). 141 (70.1%) patients received previous no-invasive treatments (dilatation and/or DVIU). Proximal bulbar urethra was the commonest site for stricture, while panurethral stricture (≥10cm) was diagnosed in 41 (20.4%) patients. Lichen sclerosus was more common in patients with penile stricture location, compared to patients with other involved segments (26% vs 19%, p=0.03), and it was the only predictor of penile and mid bulbar urethra location at MLR. Surgical approaches were augmented urethroplasty in 94% of patients, especially for patients with previous treatment including urethroplasty (95.8% vs 82.5% for naïve, p=0.004). Dorsal onlay was the preferred approach for bulbar (53.4%) and penile urethra (90.7%), while ventral onlay (38.2%) and double face augmentation (20.6%) were the preferred approach in membranous strictures. CONCLUSIONS The majority of patients that were referred for TPS-induced stricture attempted previous non-invasive managements. Referred TPS-induced urethral stricture were long and frequently involving multiple segments of urethra. Augmentation urethroplasty was our preferred surgical approach due to the characteristics and complexity of these strictures. The presence of lichen may increase the risk of post-TPS stricture in specific segment of urethra, namely the penile and mid-bulbar urethra.
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Affiliation(s)
| | - Christian Yepes
- Kulkarni EndoSurgery Institute and Reconstructive Urology Centre, 80252, Pune, Maharashtra, India;
| | - Pankaj M Joshi
- Kulkarni EndoSurgery Institute and Reconstructive Urology Centre, 80252, Pune, Maharashtra, India;
| | | | - David Naranjo
- Kulkarni EndoSurgery Institute and Reconstructive Urology Centre, 80252, Pune, Maharashtra, India;
| | - Shreyas Bhadranavar
- Kulkarni EndoSurgery Institute and Reconstructive Urology Centre, 80252, Pune, Maharashtra, India;
| | - Ahmed Alrefaey
- Kulkarni EndoSurgery Institute and Reconstructive Urology Centre, 80252, Pune, Maharashtra, India;
| | - Sandeep Bafna
- Kulkarni EndoSurgery Institute and Reconstructive Urology Centre, 80252, Pune, Maharashtra, India;
| | | | - Sanjay B Kulkarni
- Kulkarni EndoSurgery Institute and Reconstructive Urology Centre, 80252, Pune, Maharashtra, India;
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González-Espinosa C, Castro-Nuñez P, Averbeck MA, Gomez R, Castaño-Botero JC, Aparicio A, Moreno-Palacios J. Diagnosis and treatment of urethral stricture in men with neurogenic lower urinary tract dysfunction: A systematic review. Neurourol Urodyn 2022; 41:1248-1257. [PMID: 35686544 DOI: 10.1002/nau.24982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/16/2022] [Accepted: 05/24/2022] [Indexed: 11/05/2022]
Abstract
AIM To summarize available data focused on diagnosis and management of urethral stricture in men with neurogenic lower urinary tract dysfunction by a systematic review of the literature. MATERIALS AND METHODS A systematic review of the literature was carried out through an extensive electronic database search performed in PubMed/MEDLINE and Scopus databases for full texts, and International Continence Society, American Urology Association, and European Association of Urology abstracts for citations related to urethral structure. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. RESULTS A total of 316 articles were identified, 48 of which were selected for this review. Different strategies are currently being used for the management of urethral strictures, such as clean intermittent catheterization (CIC) which reduces stricture by up to 68%; direct vision internal urethrotomy which shows lower rates of renarrowing; urethroplasty which shows a success rate up to 70%; urinary diversion is the treatment of choice when reconstruction is not possible. CONCLUSIONS Further studies are needed in this population because of the heterogeneity of the outcomes and the lack of a standardized definition and classification of this population.
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Affiliation(s)
- Carlos González-Espinosa
- Urology Department, UMAE, Hospital de Especialidades "Dr. Bernardo Sepúlveda Gutiérrez", IMSS, Ciudad de México, México
| | - Patricia Castro-Nuñez
- Urology Department, UMAE, Hospital de Especialidades "Dr. Bernardo Sepúlveda Gutiérrez", IMSS, Ciudad de México, México
| | - Marcio A Averbeck
- Neuro-Urology Department, Moinhos de Vento Hospital, Porto Alegre, Brazil
| | - Reynaldo Gomez
- Urology Department-Hospital del Trabajador, Santiago, Chile
| | | | | | - Jorge Moreno-Palacios
- Urology Department, UMAE, Hospital de Especialidades "Dr. Bernardo Sepúlveda Gutiérrez", IMSS, Ciudad de México, México
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Klemm J, Marks P, Dahlem R, Riechardt S, Fisch M, Vetterlein MW. [Contemporary management of pelvic fracture urethral injuries]. Urologe A 2022; 61:602-608. [PMID: 35476111 DOI: 10.1007/s00120-022-01833-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 12/01/2022]
Abstract
Posterior urethral injuries in men usually result from polytrauma with pelvic fractures and severe associated injuries. If left untreated, posterior urethral injury can lead to severe complications and even death, so precise diagnosis should be made when urethral injury is suspected. The cardinal symptom of urethral injury is blood leakage from the meatus. Retrograde urethrography is the diagnostic tool of choice. In the case of complete urethral avulsion, the formation of a urethral stricture due to pronounced scarring fibrosis is inevitable. In principle, various therapeutic approaches are available. Often, urinary diversion by means of a transurethral or suprapubic catheter is performed first. However, there is also the possibility of direct endoscopic or open urethral realignment with subsequent temporary catheterization. Immediate surgical reconstruction is useful only in exceptional cases of simultaneous bladder neck or rectal injury. In cases of complete urethral avulsion, secondary transperineal bulboprostatic reanastomosis at the interval after three months of suprapubic continuous drainage with excellent success rate is the gold standard and can be supplemented with ancillary maneuvers if necessary to ensure a tension-free anastomosis.
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Affiliation(s)
- Jakob Klemm
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Phillip Marks
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Roland Dahlem
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Silke Riechardt
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Margit Fisch
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Malte W Vetterlein
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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Contemporary Management of Male Anterior Urethral Strictures by Reconstructive Urology Experts-Results from an International Survey among ESGURS Members. J Clin Med 2022; 11:jcm11092353. [PMID: 35566479 PMCID: PMC9103897 DOI: 10.3390/jcm11092353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/30/2022] [Accepted: 04/19/2022] [Indexed: 11/29/2022] Open
Abstract
Assessment of anterior urethral stricture (US) management of European urology experts is relevant to evaluate the quality of care given to the patients and plan future educational interventions. We assessed the practice patterns of the management of adult male anterior US among reconstructive urology experts from European countries. A 23-question online survey was conducted among European Association of Urology Section of Genito-Urinary Reconstructive Surgeons (ESGURS) members. A total of 88 invitations were sent by email at two different times (May and October 2019). Data were prospectively collected from May 2019 to December 2019. The response rate was 55.6%. Most of the responders were between 50 and 59 y.o. and mainly from University Public Teaching/Academic Hospitals. A total of 73.5% treated ≥20 patients/year with US. Retrograde urethrogram (RUG) was the commonest diagnostic tool, followed by uroflowmetry (UF) +/− post-void residual (PVR). Urethroplasty using grafts was the most frequent treatment (91.8%). Of responders, 55.3% performed >20 urethroplasties/year. Anastomotic urethroplasties were performed by 83.7%, skin flap repairs by 61.2%, perineal urethrostomy by 77.6% and non-transecting techniques by 63.3%. UF was the most common follow-up tool. Most of the responders considered urethroplasty as the primary option when indicated. Male anterior US among ESGURS members are treated mainly using urethroplasty graft procedures. RUG is preferred for diagnosis, and UF for follow-up.
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Histological Comparison of Buccal and Lingual Mucosa Grafts for Urethroplasty: Do They Share Tissue Structures and Vascular Supply? J Clin Med 2022; 11:jcm11072064. [PMID: 35407672 PMCID: PMC8999541 DOI: 10.3390/jcm11072064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/30/2022] [Accepted: 04/03/2022] [Indexed: 01/08/2023] Open
Abstract
Comparable outcomes were published using a buccal mucosa graft (BMG) from the cheek and a lingual mucosa graft (LMG) from the sublingual area, for urethral augmentation or substitution. To date, no histological comparison between both grafts has been conducted. We histologically assessed BMG and LMG harvested during urethral surgeries, aiming to compare graft properties and vascular support. We conducted a prospective single cohort study, including oral mucosa urethroplasty patients. During surgery, graft dimensions and donor sites were collected, and a 0.5 × 0.5 cm sample was obtained from the prepared graft. Formalin-fixed paraffin-embedded samples were sliced at 4 micrometres (µm) and hematoxylin-eosin stained. Using a telepathology tool, all slides were digitalized and measured from 10× to 40× magnification. In each graft, global and individual layers thicknesses were assessed, including vascular density and area. Descriptive and comparative (parametrical and non-parametrical) statistical analysis occurred. We collected 57 grafts during 33 urethroplasties, with 30 BMG and 22 LMG, finally, included. The mean age was 56.6 (SD 15.2) years, and the mean graft length was 5.8 (SD 1.7) cm and the width was 1.7 (SD 0.4) cm. The median graft thickness was 1598.9 (IQR 1200–2100) µm, the mean epithelium layer was 510.2 (SD 223.7) µm, the median submucosa was 654 (IQR 378–943) µm. the median muscular was 477.6 (IQR 286–772) µm, the median vascular area was 5% (IQR 5–10), and the median adipose tissue area was 5% (IQR 0–20). LMG were significantly longer and narrower than BMG. Total graft thickness was similar between LMG and BMG, but the epithelium and submucosa layers were significantly thinner in LMG. The muscular layer was significantly thicker in LMG. Vascular density and vascular areas were not significantly different between both types of grafts. LMG showed significantly less adipose tissue compared with BMG. Our findings show LMG and BMG for urethroplasty surgeries share the same thickness and blood supply, despite having significantly different graft sizes as well as mucosal and submucosal layers thickness.
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Re: One-year Results for the ROBUST III Randomized Controlled Trial Evaluating the Optilume® Drug-coated Balloon for Anterior Urethral Strictures. Eur Urol 2022; 82:238-239. [DOI: 10.1016/j.eururo.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/07/2022] [Indexed: 11/18/2022]
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Nilsen OJ, Holm HV, Ekerhult TO, Lindqvist K, Grabowska B, Persson B, Sairanen J. To Transect or Not Transect: Results from the Scandinavian Urethroplasty Study, A Multicentre Randomised Study of Bulbar Urethroplasty Comparing Excision and Primary Anastomosis Versus Buccal Mucosal Grafting. Eur Urol 2022; 81:375-382. [PMID: 35012771 DOI: 10.1016/j.eururo.2021.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/20/2021] [Accepted: 12/14/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Open surgical treatment of short bulbar urethral strictures (urethroplasty) is commonly performed as transecting excision and primary anastomosis (tEPA) or buccal mucosa grafting (BMG). Erectile dysfunction and penile complications have been reported, but there is an absence of randomised trials. OBJECTIVE To evaluate sexual dysfunction and penile complications after urethroplasty with tEPA versus BMG. DESIGN, SETTING, AND PARTICIPANTS Centres in Finland, Sweden and Norway participated. Patients with a bulbar urethral stricture of ≤2 cm without previous urethroplasty were randomised. The primary endpoints were the degree of erectile dysfunction and penile complications. Follow-up was 12 mo. INTERVENTION Patients were randomised to either tEPA or BMG urethroplasty. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Sexual dysfunction was measured using the International Index of Erectile Function, 5-item version (IIEF-5) and a penile complications questionnaire (PCQ) designed for this study. Continuous data were analysed using analysis of covariance and categorical data were compared using a χ2 test. RESULTS AND LIMITATIONS A total of 151 patients were randomised to either tEPA (n = 75) or BMG (n = 76). The tEPA group reported more penile complications (p = 0.02), especially reduced glans filling (p = 0.03) and a shortened penis (p = 0.001). There were no differences in postoperative IIEF-5 total scores. Recurrence rates were similar in both groups (12.9%) but the study was not designed to detect differences in recurrence rates. The PCQ is not validated, which is a limitation. CONCLUSIONS More patients reported penile complications after urethroplasty with tEPA than with BMG. This should be considered when choosing the operative method, and patients should be informed accordingly. PATIENT SUMMARY This study compared two common operations for repair of narrowing of the male urethra. Neither of the two methods seems to cause worsened erections. However, penile problems are more common after the transection technique than after the grafting technique.
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Affiliation(s)
- Ole Jacob Nilsen
- Department of Urology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | | | - Teresa O Ekerhult
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Urology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Klas Lindqvist
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Urology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Beata Grabowska
- Department of Urology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Beata Persson
- Department of Urology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jukka Sairanen
- Department of Urology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Tuygun C, Aghayev A, Durak HM, Ekenci BY. Penoscrotal fistula secondary to urethral diverticulum treated with ventral penile skin flap urethroplasty: A case report. Urol Case Rep 2021; 40:101954. [PMID: 34900599 PMCID: PMC8637481 DOI: 10.1016/j.eucr.2021.101954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/18/2021] [Accepted: 11/21/2021] [Indexed: 11/19/2022] Open
Abstract
Voiding symptoms and penoscrotal mass with/without fistula are typical findings of urethral diverticulum. We present a case of 55-year-old male patient who was evaluated for voiding symptoms, soft palpable penoscrotal mass and fistula. Retrograde urethrography, scrotal ultrasonography and cystoscopy revealed a urethral diverticulum and fistula. The defect developed after excision of the diverticulum associated with the penile ventral urethra was closed with a penile skin flap. In the 6-month follow-up, the patient did not have any voiding complaints and no signs of recurrence. Urethroplasty using a penile skin flap may be preferred in the repair of penile ventral urethral defect.
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Joshi PM, Bandini M, Bafna S, Sharma V, Patil A, Bhadranavar S, Yepes C, Barbagli G, Montorsi F, Kulkarni SB. Graft Plus Fasciocutaneous Penile Flap for Nearly or Completely Obliterated Long Bulbar and Penobulbar Strictures. EUR UROL SUPPL 2021; 35:21-28. [PMID: 34877550 PMCID: PMC8633879 DOI: 10.1016/j.euros.2021.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2021] [Indexed: 11/08/2022] Open
Abstract
Background Graft plus flap urethroplasty is gaining momentum in patients with nearly or completely obliterated urethral strictures, in whom staged procedures or perineal urethrostomy is the only possible alternative. However, graft plus flap urethroplasty is mainly adopted for strictures involving the penile urethra. Objective To report our experience on graft plus flap urethroplasty for bulbar and penobulbar reconstruction. Design, setting, and participants Between January 2014 and June 2020, patients with nearly or completely obliterated long (>4 cm) bulbar or penobulbar strictures, who required graft plus flap urethroplasty, were considered for this study. Surgical procedure The bulbar and the penile urethra were accessed through a perineal incision and penile invagination when required. Grafts were harvested from cheek, lingual, or preputial skin and quilted over the corpora to reconstruct the dorsal plate of the neourethra. The fasciocutaneous penile flap recreated the ventral plate of the neourethra. The corpus spongiosum was flapped over the neourethra to prevent the formation of diverticula. Measurements Any need for instrumentation after surgery was defined as the primary failure. Obstructive symptoms or maximum flow rate (Qmax) below 10 ml/s, with or without a need for instrumentation, was defined as a secondary failure. Results and limitations We identified 15 patients who met the inclusion criteria. The median stricture length was 7 cm (interquartile range [IQR] 5–8 cm). The inner cheek was the preferred site for graft harvesting (53.3%). No perioperative complication of Clavien-Dindo grade ≥III were recorded in the first 30 postoperative days. The median Qmax at catheter removal was 23 ml/min (IQR 21.5–26 ml/min). The median follow-up was 25 mo (IQR 10–30 mo). The primary success rate was 86.7% (13/15) and the secondary success rate was 73.3% (11/15). Post-traumatic strictures represent a contraindication for this technique. Conclusions In referral centers, graft plus flap urethroplasty represents a feasible option for patients with nearly or completely obliterated long (>4 cm) strictures. Our study demonstrated that this option is also feasible for strictures involving mainly the bulbar urethra. Patient summary Perineal urethrostomy should be considered as the last option in patients with a nearly or completely obliterated bulbar urethral stricture. Nowadays, graft plus fasciocutaneous penile flap augmentation enriched our armamentarium of bulbar urethra reconstruction.
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Affiliation(s)
| | - Marco Bandini
- Kulkarni Reconstructive Urology Center, Pune, India.,Unit of Urology, Urological Research Institute (URI), San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.,Centro Chirurgico Toscano, Arezzo, Italy
| | | | - Vipin Sharma
- Kulkarni Reconstructive Urology Center, Pune, India
| | - Amey Patil
- Kulkarni Reconstructive Urology Center, Pune, India
| | | | | | | | - Francesco Montorsi
- Unit of Urology, Urological Research Institute (URI), San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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Wirtz M, Claeys W, Francois P, Waterloos M, Waterschoot M, Lumen N. Treatment of Meatal Strictures by Dorsal Inlay Oral Mucosa Graft Urethroplasty: A Single-Center Experience. J Clin Med 2021; 10:jcm10194312. [PMID: 34640331 PMCID: PMC8509526 DOI: 10.3390/jcm10194312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/01/2021] [Accepted: 09/16/2021] [Indexed: 11/16/2022] Open
Abstract
Background: To report on the use of oral mucosa graft urethroplasty for meatal strictures using the dorsal inlay technique. Methods: Patients who underwent a single-stage dorsal inlay oral mucosal graft urethroplasty between January 2000 and May 2021 were included in this study. A follow-up of a minimum of 12 months was necessary for inclusion. Exclusion criteria were stricture extension into the penile urethra, concomitant stricture at another location, flap urethroplasty for a meatal stricture, dorsal inlay urethroplasty with another type of graft, ventral onlay graft urethroplasty or staged urethroplasty. Recurrence was defined by the inability to pass a 14F metal sound through the reconstructed meatus irrespective of patients’ complaints. Results: Our study cohort included 40 patients. Buccal mucosal graft (BMG) urethroplasty was used in 25 patients and 15 patients were treated with the aid of lingual mucosal graft (LMG). The median follow-up was 85 (IQR: 69–110) months. Seven (17.5%) patients suffered a stricture recurrence of which four (10%) needed re-intervention. The median 5-y recurrent free survival (RFS) for the entire cohort was 85 (±6)%. The median 5-y RFS was 96 (±4)% versus 65 (±13)% for respectively BMG and LMG (p = 0.03). Post-operative complications were identified in 11 (27.5%) patients with only one (2.5%) patient who had a grade 3a complication. Conclusions: Dorsal inlay oral mucosa graft urethroplasty is a safe and feasible technique for selected patients with meatal stenosis.
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Affiliation(s)
- Michel Wirtz
- Department of Urology, Ghent University Hospital, 9000 Gent, Belgium; (W.C.); (M.W.); (M.W.); (N.L.)
- Correspondence:
| | - Wietse Claeys
- Department of Urology, Ghent University Hospital, 9000 Gent, Belgium; (W.C.); (M.W.); (M.W.); (N.L.)
| | | | - Marjan Waterloos
- Department of Urology, Ghent University Hospital, 9000 Gent, Belgium; (W.C.); (M.W.); (M.W.); (N.L.)
| | - Mieke Waterschoot
- Department of Urology, Ghent University Hospital, 9000 Gent, Belgium; (W.C.); (M.W.); (M.W.); (N.L.)
| | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, 9000 Gent, Belgium; (W.C.); (M.W.); (M.W.); (N.L.)
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Vetterlein MW, Fisch MM, Zumstein V. Update on the management of penile and meatal strictures. Curr Opin Urol 2021; 31:493-497. [PMID: 34224436 DOI: 10.1097/mou.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Treatment of penile and distal urethral strictures including the fossa navicularis and the meatus remains challenging due to their adverse etiology and lack of ventral tissue support. In this contemporary review, we summarize the available evidence and recent advancements in reconstructive techniques. RECENT FINDINGS Over the last years, several refinements of already established techniques have been added to the reconstructive armamentarium in the management of penile urethral strictures. These include the single-stage combination of flap and graft, the additional use of tissue glue, or an optimized single-stage tubularization using a free graft. SUMMARY There is a shift toward an increased use of single-stage procedures even in complex strictures of the penile and distal urethra. This is reflected by advancements and refinements in operative techniques. Nonetheless, staged urethroplasty remains a cornerstone of curative management in such patients with durable success rates. Future research should focus on identifying distinct patient and stricture characteristics to determine the individual therapeutic approach with optimal functional outcomes.
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Affiliation(s)
- Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit M Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valentin Zumstein
- Department of Urology, School of Medicine, University of St. Gallen, St. Gallen, Switzerland
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Treatment of Urethral Strictures in Transmasculine Patients. J Clin Med 2021; 10:jcm10173912. [PMID: 34501359 PMCID: PMC8432136 DOI: 10.3390/jcm10173912] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/02/2021] [Accepted: 08/22/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Urethral strictures are a common complication after genital gender-affirming surgery (GGAS) in transmasculine patients. Studies that specifically focus on the management of urethral strictures are scarce. The aim of this systematic review is to collect all available evidence on the management of urethral strictures in transmasculine patients who underwent urethral lengthening. Methods: We performed a systematic review of the management of urethral strictures in transmasculine patients after phalloplasty or metoidioplasty (PROSPERO, CRD42021215811) with literature from PubMed, Embase, Web of Science and Cochrane. Preferred Reporting Items for Systematic reviews and Meta-Analysis-(PRISMA) guidelines were followed, and risk of bias was assessed for every individual study using the 5-criterion quality appraisal checklist. Results: Eight case series were included with a total of 179 transmasculine patients. Only one study discussed the management of urethral strictures after metoidioplasty. Urethral strictures were most often seen at the anastomosis between the fixed and pendulous urethra. For each stricture location, different techniques have been reported. All studies were at a high risk of bias. The current evidence is insufficient to favor one technique over another. Conclusions: Different techniques have been described for the different clinical scenarios of urethral stricture disease after GGAS. In the absence of comparative studies, however, it is impossible to advocate for one technique over another. This calls for additional research, ideally well-designed prospective randomized controlled trials (RCTs), focusing on both surgical and functional outcome parameters.
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Evaluation of the efficacy of perineal urethrostomy for patients with anterior urethral stricture: insights from surgical and patient-reported outcomes. World J Urol 2021; 39:4443-4448. [PMID: 34328540 DOI: 10.1007/s00345-021-03795-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To examine the efficacy of perineal urethrostomy (PU) in patients with anterior urethral stricture. METHODS Patients who underwent PU for anterior urethral stricture between 2013 and 2020 were retrospectively reviewed (n = 56). Surgical success was defined as no need for additional intervention. Uroflowmetry and measurement of residual urine volume (PVR) were examined postoperatively, and the patients were asked to fill out sexual health inventory for men (SHIM) and the validated Urethral Stricture Surgery Patient-reported Outcome Measure questionnaires before and after PU. The overall patient satisfaction was also assessed. RESULTS PU was successful in 92.9% of patients (n = 52), with a median follow-up of 34 months. Two of four were salvaged by re-do PU, and one was salvaged by forming a composite stoma using a penile skin graft. Thirty-nine patients (69.6%) filled out the questionnaires 6 months after surgery. The mean maximum flow rate, PVR, lower urinary tract symptoms (LUTS)-total score, LUTS-specific quality of life, and EuroQol-visual analog scale scores improved significantly from 3.8 mL/s, 77.6 mL, 12.9, 2.6, and 53.6 at baseline to 17.6 mL/s, 21.3 mL, 4.1, 0.9, and 74.9 postoperatively (p = 0.003, p = 0.004, p = 0.005, p < 0.0001, p < 0.0001, respectively). The SHIM score did not change significantly (from 2.6 at baseline to 2.3 postoperatively; p = 0.59). As for patient satisfaction, 84.6% of patients (33/39) were "satisfied" (46.1%) or "very satisfied" (38.5%) with the outcome. CONCLUSIONS PU had a high surgical success rate, and significantly improved patients' subjective symptoms and achieved a high level of satisfaction.
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