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Alberca-Del Arco F, Santos-Pérez DE LA Blanca R, Amores Vergara C, Herrera-Imbroda B, Sáez-Barranquero F. Bulbar urethroplasty techniques and stricture recurrence: differences between end-to-end urethroplasty versus the use of graft. Minerva Urol Nephrol 2024; 76:563-569. [PMID: 39045660 DOI: 10.23736/s2724-6051.24.05812-9] [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: 07/25/2024]
Abstract
Urethral stricture (US) affects most commonly the anterior portion of the urethra, concretely the bulbar, with a significant incidence in men. Open urethroplasty is the gold standard treatment. However, stricture recurrence (SR) remains a current subject of concern. The aim of the present review is to provide an updated literature summary on surgical urethroplasty techniques for bulbar US and prognostic factors for SR, comparing the different approaches. For short strictures, excision and primary anastomosis (EPA) is the preferred option, with success rates exceeding 90%. Substitution techniques are usually required for longer strictures (>2-3cm). Buccal mucosa graft (BMG) remains the first choice as it complies with ideal features, with no significant differences regarding the site of graft implantation. Stricture length, time since urethroplasty and number of previous urethral interventions are risk factors for failure. Also, surgeon's experience affects technique selection and future outcomes. There seems to be consensus on a higher SR rate following substitution techniques compared to EPA, which appears to be influenced by the stricture length, usually longer in the former group. Furthermore, there is a trend in favor of endoscopic management of SR, except for long and complex recurrences where grafts should be used. In conclusion, multiple urethroplasty techniques are available and selection must be carefully individualized, focusing on stricture characteristics, patient's history, and surgeon's experience. Well-designed studies with clear definitions and follow-up protocols are still necessary to develop standardized guidelines on the management of bulbar US.
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Zhao X, Guo Q, Zhang X, Xing Q, Ren S, Song Y, Li C, Hao C, Wang J. The urinary and sexual outcomes of buccal mucosal graft urethroplasty versus end-to-end anastomosis: a systematic review with meta-analysis. Sex Med 2024; 12:qfae064. [PMID: 39315305 PMCID: PMC11416911 DOI: 10.1093/sexmed/qfae064] [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: 06/24/2024] [Revised: 08/24/2024] [Accepted: 09/10/2024] [Indexed: 09/25/2024] Open
Abstract
Background The urinary and sexual outcomes after urethroplasty may be a concern for patients, but there are still some controversies regarding the consequences of buccal mucosal graft urethroplasty (BMG) in terms of erectile dysfunction (ED). Aim This meta-analysis aimed to compare urinary and sexual outcomes of BMG and end-to-end urethroplasty (EE). Methods The PubMed, Web of Science, Cochrane, and Embase databases were searched until February 31, 2023. Data extraction and quality assessment were performed by 2 designated researchers. Dichotomous data were analyzed as odds ratios with 95% confidence intervals (CIs). Heterogeneity across studies was assessed by the I2 quantification, and publication bias using Begg's and Egger's tests. Meta-analysis was performed using RevMan software. Outcomes Outcomes included stricture recurrence, ED, penile complications, and voiding symptoms. Results Eighteen studies, including 1648 participants, were included in our meta-analysis. The meta-analysis revealed that there was no significant difference in stricture recurrence (OR = 0.74; 95% CI, 0.48-1.13; P = .17) and voiding symptoms (OR = 1.12; 95% CI, 0.32-3.88; P = .86) between the BMG group and the EE group. BMG was associated with lower risk of penile complications (OR = 0.40; 95% CI, 0.24-0.69; P = .001) and ED (OR = 0.53, 95% CI, 0.32-0.90, P = .02). Clinical Implications The study may help clinicians choose procedures that achieve better recovery of the urological and sexual function in the treatment of urethral stricture. Strengths and Limitations This meta-analysis is the first to evaluate the urinary and sexual outcomes of BMG vs EE. A limitation is that most of the included studies were retrospective cohort studies. Conclusion BMG is as effective as EE in the treatment of bulbar urethral stricture, but BMG has fewer complications and ED than EE.
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Affiliation(s)
- Xingming Zhao
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, China
- Second Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi Province 030001, China
| | - Qiang Guo
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, China
| | - Xi Zhang
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, China
| | - Qi Xing
- Department of Urology, Shanxi Medical University, Taiyuan, Shanxi Province 030001, China
| | - Sheng Ren
- Second Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi Province 030001, China
| | - Yuting Song
- Department of Histology and Embryology, Shanxi Medical University, Taiyuan, Shanxi Province 030001, China
| | - Chengyong Li
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, China
| | - Chuan Hao
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, China
| | - Jingqi Wang
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, China
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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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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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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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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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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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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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Non-Transecting Urethroplasty for Bulbar Urethral Strictures-Narrative Review and Treatment Algorithm. J Clin Med 2022; 11:jcm11237033. [PMID: 36498607 PMCID: PMC9740840 DOI: 10.3390/jcm11237033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/08/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
The bulbar urethra is the most common site of stricture disease for which urethroplasty remains standard of care. A decrease in trauma as an etiology in the developed world and concerns regarding sexual dysfunction related to transection of the corpus spongiosum have placed a renewed emphasis on non-transecting urethroplasty techniques. Here, we present our surgical algorithm with emphasis on non-transecting techniques for bulbar urethral stricture disease and review the current state of literature comparing transecting to non-transecting approaches in order to provide guidance to practitioners on patient selection, counseling, and technique.
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Ortac M. Re: Ole Jacob Nilsen, Henriette Veiby Holm, Teresa O. Ekerhult, et al. 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. Eur Urol 2022; 82:e50. [PMID: 35473675 DOI: 10.1016/j.eururo.2022.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/25/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Mazhar Ortac
- Department of Urology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey.
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Riechardt S. Penile Complications After Urethroplasty: Who Cares? Eur Urol 2022; 81:383-384. [PMID: 35078697 DOI: 10.1016/j.eururo.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/07/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Silke Riechardt
- Department of Urology, University of Hamburg, Hamburg, Germany.
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