Staged reconstruction of long segment urethral strictures in men with previous pediatric hypospadias repair

Lateral incision 1-stage urethroplasty with oral mucosal graft for patients with penile urethral stricture after hypospadias repair-a preliminary report

PURPOSE

To report our early experience of a novel surgical approach for penile urethral strictures after hypospadias repair, using a lateral incision to keep the ventral tissue and vasculature of the penis intact and to avoid the need for tissue interposition.

PATIENTS AND METHODS

A total of 21 patients underwent lateral incision 1-stage urethroplasty with oral mucosal graft. The median age of the patients was 21 years old (range, 13-47). The median number of prior procedures for hypospadias repair was 3 (range, 1-9) with 18 of 21 patients (85.7%) undergoing greater than 1 prior reconstructive procedure. The mean length of the penile urethral strictures was 4.5 ± 1.7 cm, with a range of 1.0 to 8.0 cm. Selection criteria for lateral incision 1-stage urethroplasty include: non-obliterative stricture, no or mild penile curvature and no urethrocutaneous fistula.

RESULTS

Median follow-up was 30 months (range, 6-73). Success was achieved in 17 of 21 patients (80.9%). The 4 (19.0%) patients with treatment failure developed recurrent urethral strictures. Of the 4 men with recurrent strictures, 3 were ultimately treated successfully by DVIU (2) or two-stage urethroplasty (1), and one patient chose repeated dilation.

CONCLUSIONS

For patients with penile urethral stricture after hypospadias repair with non-obliterative stricture, no significant penile curvature and no urethrocutaneous fistula, a lateral approach with oral mucosal graft is a simple technique that avoids the need for tissue interposition and keeps the penile ventral tissue and vasculature intact, resulting in a low risk of complications.

Efficacy of urethral reconstruction for urethral stricture associated with hypospadias surgery in adults

OBJECTIVES

We report our experience with urethral reconstruction for hypospadias surgery-related urethral stricture in terms of surgical and patient-reported outcomes.

METHODS

Twenty-nine adult males who underwent urethral reconstruction for hypospadias surgery-related urethral stricture between August 2008 and January 2022 were retrospectively reviewed. Uroflowmetry and patient-reported outcomes were evaluated at 3, 6, and 12 months, and annually thereafter. Surgical success was defined as the absence of additional procedures. Patients were asked to rate their satisfaction with urethral reconstruction as "very satisfied", "satisfied", "unsatisfied", or "very unsatisfied".

RESULTS

The median patient age at referral was 43 years. The median number of previously performed hypospadias surgeries was three, and 18 patients (62.8%) had been treated with repeated transurethral procedures. The median stricture length was 54 mm (interquartile range 36-81). Performed urethral reconstruction included staged urethroplasty in 22 (75.9%), one-stage onlay augmentation in 3 (10.2%), and perineal urethrostomy in 4 (13.8%) cases. Urethral reconstruction was successful in 26 patients (89.7%) over a median postoperative period of 31 months. Patient-reported outcomes were assessed in 25 (86.2%) patients. The mean maximum flow rate, international prostate symptom score total score, international prostate symptom score quality of life score, and EuroQol-5 dimensions index significantly improved postoperatively. Twenty-three patients (92%) were "very satisfied" or "satisfied" with the outcome of their urethral reconstruction.

CONCLUSIONS

Urethral reconstruction is a highly successful and patient-satisfying treatment for hypospadias surgery-related urethral stricture in adult patients. Perineal urethrostomy is a reasonable alternative for elderly patients and for patients with complicated hypospadias surgery-related urethral strictures.

Adults with previous hypospadias surgery during childhood: Beware of bulbar strictures

BACKGROUND

Urethral strictures represent the most frequent long-term complication in men after history of hypospadias surgery.

OBJECTIVES

To better define the spectrum of men previously treated for hypospadias during childhood, presenting at an adult urology clinic with persistent urethral complications.

STUDY DESIGN

Retrospective review of the records of 42 consecutive adult patients with a personal history of hypospadias repair during childhood referred at one adult tertiary urology center between 2004 and 2017. Those with persistent urethral strictures were included: 28 patients (median age 28yr [17-81]). Residual chordee, aesthetic concerns, isolated fistulas, and motives of consultation unrelated to hypospadias were excluded. Early initial success rate and location of urethral stricture were studied. Statistical Analysis was done by non-parametric tests.

RESULTS

On the 42 consecutive adults eligible, a total of 28 patients had a persistent urethral stricture. During childhood, 13/28 boys had required multiple surgical revision procedures, including six of them for postoperative urethral strictures. During adulthood, initial urethral assessment revealed 29 urethral strictures in 28 patients (penile urethra 23/29, bulbar urethra 8/29). The early initial success rate of stricture treatment was 50% (median follow-up: 4 years [1-7]). Additional surgical procedures were needed and performed in 11 patients. Eight patients were eventually diagnosed with a bulbar stricture, either isolated (n = 5) or combined with a distal stricture (n = 3), without significant relationship with initial position of meatus.

DISCUSSION

Predictive factors for bulbar strictures locations could not be identified. It was however observed that symptomatic bulbar strictures do exist in adults, in the long term after penile hypospadias repair during childhood, independently of the initial site of hypospadias, initial success of primary repair, and the type of surgical reconstructions performed during childhood.

CONCLUSION

Bulbar strictures represent more than 25% of the overall strictures diagnosed in adult patients treated for hypospadias during childhood, independently of the original site of urethral reconstruction.

[Which management for anterior urethral stricture in male? 2021 guidelines from the uro-genital reconstruction urologist group (GURU) under the aegis of CAMS-AFU (Committee of Andrology and Sexual Medicine of the French Association of Urology)]

OBJECTIVE

The purpose of this first french guideline is to provide a clinical framework for the diagnosis, treatment and follow-up of anterior urethral strictures. The statements are established by the subgroup working on uro-genital reconstruction surgery (GURU) from the CAMS-AFU (Andrology and Sexual Medicine Committee from the French Association of Urology).

MATERIAL AND METHODS

These guidelines are adapted from the Male Urethral Stricture : American Urological Association Guideline 2016, updated by an additional bibliography from January 2016 to December 2019. Twenty-seven main scenarios seen in clinical practice are identified: from diagnosis, to treatment and follow-up. In addition, this guidelines are powered by anatomical diagrams, treatment algorithms, summaries and follow-up tables.

RESULTS

Anterior urethral strictures are a common condition (0,1 à 1,4 %) in men. The diagnosis is based on a trifecta including an examination with patient reported questionnaires, urethroscopy and retrograde urethrography with voiding cystourethrography. Short meatal stenosis can be treated by dilation or meatotomy, otherwise a urethroplasty can be performed. First line treatment of penile strictures is urethroplasty. Short bulbar strictures (<2cm) may benefit from endourethral treatment (direct visual internal urethrotomy or dilation). In case of recurrence or when the stenosis measures more than 2 cm, a urethroplasty will be proposed. Repeated endourethral treatment management are no longer recommended except in case of palliative option. Urethroplasty is usually done with oral mucosa graft as the primary option, in one or two stages approach depending on the extent of the stenosis and the quality of the tissues. Excision and primary anastomosis or non-transecting techniques are discussed for bulbar urethra strictures. Follow-up by clinical monitoring with urethroscopy, or retrograde urethrography with voiding cystourethrography, is performed at least the first year and then on demand according to symptoms.

CONCLUSION

Anterior urethral strictures need an open surgical approach and should be treated by urethroplasty in most cases. This statement requires a major paradigm shift in practices. Training urologist through reconstructive surgery is the next challenge in order to meet the demand.

Calibration of urethra with anti-scar gel as a new preventive method for stricture recurrence after urethroplasty performed due to refractory anterior urethral stricture disease

Introduction

The aim of this article was to determine if scar contraction can be prevented by calibration of urethra with anti-scar gel (ASG).

Material and methods

The authors operated on 36 men with recurrent urethral strictures (US). Strictures were localized in the penile (n = 26), penile and bulbar (8) or in the bulbar (2) part of the urethra. In 34 patients, dorsal inlay buccal mucosa graft urethroplasty (BMGU) was performed and in the remaining 2 patients dorsal onlay BMGU was performed. First calibration was done one month after operation by hegar size 3.5 (diameter in millimeters) with ASG. Patients were instructed how to perform this action and repeated this action for 4-6 weeks. Then, every 4-6 weeks, the size of the calibrator was increased by 0.5 up to 6.0, if it was introduced with ease. Results were assessed by uroflowmetry and urethral calibration. Afterwards, calibrations were carried out twice a week for 6 months and then once a week for another 6 months followed by once a month.

Results

Mean follow-up was 61 months. In uroflowmetry examination, voiding improved in all patients. Both preoperative mean Qmax and mean Qavg increased, the former from 6.2 to 22.5 ml/s, the latter from 4.3 to 12.4 ml/s, (p <0.001), at 12 months post-operation. Mean post-void residual volume (PVR) decreased from 89 ml before operation to 10 ml, (p <0.001), at 12 months post-operation. Mean inner urethral size increased from 3.9 mm one month post-operation to 5.4 mm, (p <0.001), 9 months post-operation. No recurrent US was detected in any of the patients.

Conclusions

Routine calibration with ASG prevents scar contraction after urethroplasty in the long-term. Calibration of urethra with ASG is a safe and effective method of postoperative management.

Assessment of long term outcomes after buccal mucosal graft urethroplasty: the impact of chronic kidney disease

Objectives

To compare and assess various outcomes and success of buccal mucosal graft urethroplasty (BMGU) in patients with CKD versus patients having normal renal function.

Material and Methods

This was a retrospective, single centre study, during period 2013 to 2017. Patients were grouped into two groups. Group 1 had patients with estimated Glomerular Filtration Rate (eGFR)>60mL/min/1.73m2 while group 2 had patients with eGFR <60mL/min/1.73m². eGFR was calculated according to the MDRD equation. The two groups were compared with regard to various outcomes like length, location of stricture, technique of graft placement, intra-operative blood loss (haemoglobin drop), duration of hospital stay, post-operative complications and recurrence.

Results

A total of 223 patients were included in study with group 1 had 130 patients and group 2 had 93 patients. Mean age of patients with CKD were higher (47.49 years versus 29.13 years). The mean follow-up period was comparable between both groups (23.29 months and 22.54 months respectively). Patients with CKD had more post-operative Clavien Grade 2 or higher complications (p=0.01) and a greater recurrence rates (p<0.001) than in non-CKD patients. On multivariate analysis, age and CKD status was significant predictor of urethroplasty success (p=0.004) (OR= 14.98 (1.952-114.94, 95% CI).

Conclusions

CKD patients are more prone to post-operative complications in terms of wound infection, graft uptake and graft failure and higher recurrence rates following BMGU.

Outcome of surgical management of urethral stricture following hypospadias repair

INTRODUCTION

Reconstruction of urethral strictures in patients with a history of hypospadias repair is controversial. The authors policy has been that if a residual healthy urethral plate is present, single-stage urethroplasty is recommended. However, if the urethral plate is fibrotic or absent or if lichen sclerosus is present, two-stage repair is utilized.

OBJECTIVES

In this study, the authors report their experience in management of patients with urethral stricture and prior hypospadias surgery.

STUDY DESIGN

Between 1993 and 2015, 62 patients with urethral stricture and a prior history of hypospadias repair underwent urethroplasty. Patients were divided into two groups; patients in group 1 (n = 39) found to have a healthy residual urethral plate and underwent single-stage urethral stricture repair using either an island skin flap or a buccal mucosa graft. Patients in group 2 (n = 23) had either a scarred urethra or evidence of lichen sclerosus and underwent staged repair using a buccal mucosa graft. Post-operatively, patients were evaluated at 3 months, 6 months, 1 year, and then annually.

RESULTS

The median age of the patients was 10.5 years (2.5-33 years). The mean stricture length was 6.3 cm in group 1 and 7.1 cm in group 2. Overall success rate was 87.1% in group 1; a urethral fistula occurred in one patient (7.1%) who underwent skin flap onlay repair and one patient (4.5%) with a buccal mucosa graft. Recurrent urethral stricture was also diagnosed in one patient (7.1%) after repair using an island skin flap and in two patients (9%) following buccal mucosa graft. In group 2, three patients (13%) developed graft contracture and were revised before the second stage. Two patients (8.6%) had glans dehiscence following second stage urethroplasty. The final success rate in group 2 was 90.4%.

DISCUSSION

Both single-stage and 2-stage repair showed successful outcome in management of urethral stricture following hypospadias repair. However, the authors continue to believe that the status of the urethral plate dictates the type of surgery to be utilized. In accordance to the previously published data, the study results also further support promising outcomes of application of buccal mucosa in surgical management of these patients.

CONCLUSION

In patients with urethral stricture after hypospadias surgery who have a healthy residual urethral plate, single-stage repair using buccal mucosa graft is a viable option with high success rate. In patients with scarred urethral plate, a 2-stage repair is recommended.

Characterization and outcomes of urethroplasty for hypospadias-associated urethral strictures in adults

INTRODUCTION

Urethral stricture is one of the most commonly encountered complications after hypospadias repair but remains poorly described. The aim of this study is to better characterize hypospadias-associated urethral strictures (HAUS) and treatment outcomes.

METHODS

We conducted a retrospective analysis of 84 patients who underwent urethroplasty (UP) for HAUS from 2003-2017. Patients were characterized with regard to demographics, stricture length, location, concurrent pathology, previous surgery, type of urethroplasty, 90-day complications, and surgical success defined as the absence of stricture on cystoscopy. Univariate and survival multivariate analysis was performed.

RESULTS

Overall success was 88.1% at a mean followup of 19 months, with a 90-day complication rate of 9.5%, a 21.4% rate of urethrocutaneous fistula requiring a mean of 1.4 surgeries. Patients were categorized into one of four groups based on stricture length, location, and number of previous procedures: group 1 (66.7%) - previous failed hypospadias repair (HR) with stricture involving the entire repair; group 2 (7.1%) - "junctional stricture" at the junction of the "neourethra" and native urethra; group 3 (11.9%) - isolated bulbar stricture outside the repaired urethra; group 4 (14.3%) - urethral stricture in untreated hypospadias. Despite differing by technique (p<0.0001), stricture length (p=0.02), location (p<0.001), and number of previous repairs (p<0.001), groups did not significantly differ by success (p=0.82), complications (p=0.16), or urethrocutaneous fistula (p=0.19), whereas individual techniques did.

CONCLUSIONS

UP for HAUS is often successful but patients frequently require more than one operation and have a significant risk of associated complications. Despite a broad spectrum of presentation, patients can often be categorized into one of four groups, which can help direct decision-making and obtain similar outcomes regardless of baseline differences.

Redo-urethroplasty for the management of recurrent urethral strictures in males: a systematic review

Purpose

Redo-urethroplasty is a challenge for any genitourethral surgeon, with a number of techniques previously described. This systematic review aims to identify the surgical techniques described in the literature and evaluate the evidence for their effectiveness in managing recurrent urethral strictures.

Materials and methods

A systematic review of the MEDLINE and EMBASE databases from 1945 to July 2018 was performed and the urethroplasty procedures were classified according to the site and surgical technique. Primary outcomes included success rates measured via re-stricture rates and the post-op maximum urinary flow rate. Secondary outcomes included complication rates and patient-reported quality of life.

Results

A total of 39 identified studies met the inclusion criteria. Twenty-two studies described the use of excision and primary anastomotic urethroplasty with success rates showing wide variability (58–100%). Success rates reported according to the site of the stricture also varied: bulbar (58–100%) and posterior (69–100%) recurrent strictures. One-stage substitution urethroplasty was described in 25 studies with success rates of 18–100%, with the best outcomes reported for bulbar (58–100%) and hypospadias-related (78.6–82%) strictures. Two-stage substitution urethroplasty was described in 12 studies with the success rates of 20–100%, with the best evidence related to hypospadias-related and posterior urethral strictures. The buccal mucosa graft was the graft source with the best evidence for substitution urethroplasty (18–100%).

Conclusions

Trends of effectiveness were identified for redo-urethroplasty modalities in different locations. However, the current levels of evidence are limited to small observational studies, highlighting the need for further larger prospective data to evaluate different techniques used for recurrent urethral strictures.

Electronic supplementary material

The online version of this article (10.1007/s00345-019-02709-7) contains supplementary material, which is available to authorized users.

Contemporary outcomes of hypospadias retrieval surgery in adults

OBJECTIVE

To describe the surgical approach and outcomes in the treatment of adult patients with complications of childhood hypospadias surgery, as such patients present a significant reconstructive challenge due to the combination of anatomical and cosmetic deformity, which often results in major functional and psychosexual sequelae.

PATIENTS AND METHODS

We analysed prospectively collected data on 79 adults with complications of childhood hypospadias surgery, who were operated on between 2004 and 2016. Of the 79 patients, 48 underwent a two-stage urethroplasty using a buccal mucosa graft, and 31 underwent a one-stage distal urethroplasty.

RESULTS

Patients were followed up using flexible cystoscopy (every 6-9 months). The mean (range) follow-up was 48 (12-96) months. Of the 48 patients who underwent a two-stage repair, eight (16%) needed a revision of the first-stage graft. In total, nine of the 48 patients (16%) developed fistula requiring closure after the second stage; all but one was closed successfully on the first attempt, whilst one required two attempts before closure. Only two of the 48 patients that underwent a two-stage procedure required a re-do urethroplasty within 3 years. Of the 31 patients who underwent a one-stage repair, six (19%) needed fistula closure, all of which were successful. No patient required a further urethroplasty during follow-up.

CONCLUSIONS

Despite the significant surgical challenges found in this patient group, excellent long-term functional outcomes can be achieved. As expected there is a need for additional intervention, either for revision of the first stage or to close fistulae and less commonly for further reconstruction for stricture recurrence.

Transitioning patients with hypospadias and other penile abnormalities to adulthood: What to expect?

Hypospadias patients presenting to adult urologists do so with a wide range of symptoms and problems, including urethral stricture (45-72%), lower urinary tract symptoms (with or without stricture) (50-82%), urethrocutaneous fistula (16-30%), persisting hypospadias (14-43%), micturition spraying (24%), ventral curvature (14-24%), urinary tract infection (15-25%), or lichen sclerosus (13%; range 8-43). Many of these men have concurrent complications as the result of multiple operations and a variety of techniques. Patients with childhood repairs performed by a pediatric urologist are often lost to followup during adolescence and will reemerge in adulthood after what appeared to be a successful pediatric single-stage repair, stressing the need for long-term followup and transitional care. One of the major challenges in successful transitional care is that patients can feel traumatized with feelings of hopelessness surrounding their defects, leaving them hesitant to seek care. As well, these patients often have little knowledge regarding the type of repair or original location of the meatus. Urethral stricture is the most common presenting complication and could be related to various factors, with the clear etiology still under debate. These strictures can fall under four categories based on length, location, and previous surgeries. To lessen the difficulties in transitioning hypospadias patients from pediatric to adult practitioners, followup throughout childhood and adolescence for physical examination, as well as uroflowmetry, is mandatory.

The hypospadias classification affected the surgical outcomes of staged oral mucosa graft urethroplasty in hypospadias reoperation: An observational study

The staged graft urethroplasty is a recommended technique for repairing complex hypospadias. This retrospective study aimed to investigate the outcomes of this technique in hypospadias patients undergoing reoperation and to analyze the underlying contributing factors including age, meatus location, and graft and suture type.We retrospectively analyzed 40 hypospadias patients undergoing reoperation who received a staged oral graft urethroplasty, including 15 buccal mucosal grafts and 25 lingual mucosal grafts. Median age at presentation was 18.5 years, and median follow-up was 17.5 months (range 8-30 months). The patients were classified according to their original meatus location.Twenty-five complications developed in 12 of 40 (30%) cases, including 6 fistulas (15%), 7 infections (17.5%), 9 cases of glans dehiscence (22.5%), and 3 cases of stenosis (7.5%). There was no significant difference in the overall complication rates between prepuberty and postpuberty groups. In addition, no significant difference in complications was found between the 2 graft techniques. The complications were significantly higher in the original perineal type compared with the original penoscrotal type (7/10 vs 5/30, P = .0031). Seven patients who originally had perineal hypospadias developed multiple complications.Based on this study, the staged graft urethroplasty is an effective technique in reoperative hypospadias repairs with reasonable complication risk. The hypospadias classification affects the surgical outcomes.

Buccal mucosal graft urethroplasty in men-risk factors for recurrence and complications: a third referral centre experience in anterior urethroplasty using buccal mucosal graft

BACKGROUND

Urethral stricture disease is a challenging condition to treat and several approaches including direct visual internal urethrotomy (DVIU) and anastomotic or augmentation urethroplasties based on the use of flaps and graft have been reported. The aim of this study is to determine risk factors for stricture recurrence and complications in patients having buccal mucosal graft (BMG) urethroplasty for anterior urethral stricture under a single surgeon in a third referral centre in UK.

METHODS

We conducted a retrospective review of a prospectively gathered database of 128 patients having various forms of BMG urethroplasty between 2001 and 2015. Success and failure in terms of stricture recurrence, patient demographics, stricture aetiology and anatomy, and the adverse outcomes of: post-micturition dribbling (PMD), erectile dysfunction (ED) >12 months and complications were recorded in order to determine risk factors for recurrent stricture and complications.

RESULTS

The mean age of all patients was 42.8 years (range, 16-74 years). Average follow-up was 45 months (range, 3-159 months). The total re-stricture rate was 19% (24 men). PMD was reported in 16% (n=20) and ED in 12.5% (n=16). All ED was none organic and responded to oral PDE5 inhibitor treatment. Post-operative complications were reported in 16 patients (12.5%). The most frequent complications recorded were urinary fistula (n=4; 3.1%), graft contracture (n=4; 3.1%) and graft failure (n=4; 3.1%), all reported after penile urethroplasty. Univariate analysis indicated that age at surgery, stricture length, site and aetiology were all significant risk factors for stricture recurrence. On multivariate analysis penile site was the only significant independent variable for restricture.

CONCLUSIONS

BMG urethroplasty represents a reliable therapeutic option for patient with urethral strictures with a success rate of 81% at 45 months of follow-up. Complications are more common in complex stricture of the penile urethra. On multivariate analysis penile site was the only significant independent variable for re-stricture.

Advances in urethral stricture management

Urethral stricture/stenosis is a narrowing of the urethral lumen. These conditions greatly impact the health and quality of life of patients. Management of urethral strictures/stenosis is complex and requires careful evaluation. The treatment options for urethral stricture vary in their success rates. Urethral dilation and internal urethrotomy are the most commonly performed procedures but carry the lowest chance for long-term success (0–9%). Urethroplasty has a much higher chance of success (85–90%) and is considered the gold-standard treatment. The most common urethroplasty techniques are excision and primary anastomosis and graft onlay urethroplasty. Anastomotic urethroplasty and graft urethroplasty have similar long-term success rates, although long-term data have yet to confirm equal efficacy. Anastomotic urethroplasty may have higher rates of sexual dysfunction. Posterior urethral stenosis is typically caused by previous urologic surgery. It is treated endoscopically with radial incisions. The use of mitomycin C may decrease recurrence. An exciting area of research is tissue engineering and scar modulation to augment stricture treatment. These include the use of acellular matrices or tissue-engineered buccal mucosa to produce grafting material for urethroplasty. Other experimental strategies aim to prevent scar formation altogether.

Better Defining the Spectrum of Adult Hypospadias: Examining the Effect of Childhood Surgery on Adult Presentation

OBJECTIVE

To describe the spectrum of adult presentations with hypospadias-related complications and examine the effect of childhood surgical repair on these adult presentations.

METHODS

A retrospective chart review over a 10-year period, from August 2004 to December 2014, demonstrated 93 adult patients who presented to a reconstructive urologist with complications related to hypospadias. Patients were divided into 2 groups: those with no prior hypospadias surgery (Group 1, N = 19) and those who underwent surgical correction as a child (Group 2, N = 74). Charts were reviewed for age at presentation, initial complaints, history of repair, and surgical intervention required.

RESULTS

The mean age at presentation was 34.6 ± 0.6 years. Overall, lower urinary tract symptoms (LUTS) (49%) was the most common presenting complaint, followed by spraying (24%), urethrocutaneous fistula (18%), recurrent urinary tract infections (UTIs) (15%), and chordee (14%). Comparison demonstrated that Group 2 patients were more likely to present with LUTS (55% vs 26%; P = .038) and recurrent UTIs (19% vs 0%; P = .050). There was a trend toward Group 1 patients presenting more commonly with cosmetic dissatisfaction (16% vs 4%; P = .06). Urethral stricture was demonstrated more commonly in Group 2 (47% vs 11%; P = .0043). Of these, strictures were significantly longer in the previous surgery group (5.5 ± 0.6 cm vs 3.0 ± 0.6 cm, P = .019).

CONCLUSION

Correction of hypospadias as a child likely increases the future risk of urethral stricture, recurrent UTIs, and subsequent LUTS, with a trend toward improving patient satisfaction with cosmesis compared to nonsurgical management. Follow-up of hypospadias repair patients should extend into adulthood, as a significant portion of adult presentations ultimately require surgical intervention.

Staged urethroplasty in the management of complex anterior urethral stricture disease

Staged buccal mucosa graft urethroplasty has emerged as a reliable procedure for difficult anterior urethral strictures not amenable to one-stage graft or flap reconstruction. It has primarily been used for strictures and/or fistulae occurring after previous surgery for hypospadias or those related to lichen sclerosus (LS). Success rates in these patient populations have improved when compared to earlier techniques. However, prior studies have demonstrated a number of patients requiring more than two procedures to complete the reconstruction, as well as some who have been content with their voiding pattern after the first operation and therefore elected to forego second stage tubularization. In this setting, we have reviewed the surgical technique and summarized previously published work. There may be an opportunity to complete more of these repairs in two operations using additional oral mucosa at the time of tubularization.

Management of adults with prior failed hypospadias surgery

Hypospadias is one of the most prevalent anomalies of the male genitalia. Contemporary hypospadias repair is very successful, but patients that have the surgery fail often require multiple surgeries throughout their life. Complications from failed hypospadias repairs have a significant impact on patients both psychologically and physically. Failed hypospadias repair encompasses a spectrum of problems that include hypospadias recurrence with an ectopic meatus, urethral fistula, urethral stricture, and ventral penile curvature. Repairs of hypospadias complications can be challenging due to the poor quality of surrounding tissue from disruption of normal vasculature in the re-operative field associated with the underlying disorder. One of the most challenging issues is dealing with urethral strictures. There have been multiple methods described at repairs of these in both a single stage and multiple staged procedures. Particular attention has been directed towards applications of grafts due to worse outcomes with flaps. Buccal mucosa has emerged as the leading graft material in staged repairs. When counseling patients with failed hypospadias it is important to discuss the expected outcome as repairs directed towards a terminally positioned meatus with a straight phallus may require multiple surgeries due to post-operative complications as well as the necessity of proceeding in a staged approach.

Tissue transfer techniques in reconstructive urology

Tissue transfer techniques are an essential part of the reconstructive urologist's armamentarium. Flaps and graft techniques are widely used in genital and urethral reconstruction. A graft is tissue that is moved from a donor site to a recipient site without its native blood supply. The main types of grafts used in urology are full thickness grafts, split thickness skin grafts and buccal mucosa grafts. Flaps are transferred from the donor site to the recipient site on a pedicle containing its native blood supply. Flaps can be classified based on blood supply, elevation methods or the method of transfer. The most used flaps in urology include penile, preputial, and scrotal skin. We review the various techniques used in reconstructive urology and the outcomes of these techniques.

[Urethroplasty with buccal mucosa graft or penile skin graft for anterior urethral stricture?]

Currently the treatment for urethral stricture considers various techniques, including augmentation urethroplasty using tissue from different parts of the body. The more used are the buccal mucosa and penile skin, but are there any differences in success between both tissues? Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified one systematic review including 18 primary studies addressing this question, six of them prospective. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded there is uncertainty about the superiority of one technique over another because the certainty of the evidence is very low. A new systematic review is urgently needed on this topic as randomized studies have been published after the most recent review, which could provide greater certainty.

Buccal mucosa urethroplasty: a 10-year retrospective review of maxillofacial and urological outcomes

BACKGROUND

Reconstruction of a urethral stricture poses a difficult surgical problem. Anastomotic repair remains the gold standard. Strictures longer than 2 cm may require substitution urethroplasty. This is a retrospective review of all patients who underwent urethral reconstruction with an autologous free buccal mucosa graft at a Regional hospital between 1998 and 2009.

METHODS

Variables recorded included; demographics: patient gender/age; follow-up period. Urology: pre-operative diagnosis/aetiology; presenting complaint; previous urological surgery, pre-operative retrograde urethrogram, stricture length, graft size, operative time/blood loss, morbidity, complications. Maxillofacial: pre-/post-operative inter-incisal opening, patency of Stenson's parotid duct, ipsilateral parotid swelling, sensory nerve deficit.

RESULTS

A total of eight male patients were included. Mean age was 33 years. Two patients had one-stage dorsal onlay urethroplasty, and the remaining six had a two-stage BMG urethroplasty. All patients underwent a urethrogram 20 days post-operatively, which demonstrated no leak, and a good caliber grafted urethra in all cases. A flexible cystoscopy scope was accommodated in all patients 8 weeks post-operatively. Mean follow-up was 42 months. At long-term follow-up, there was no evidence of stricture formation, and all patients were voiding well. There were no long-term intra-oral complications.

CONCLUSION

This study suggests that anterior urethral strictures up to 6 cm in length may be predictably and safely managed with buccal mucosal urethroplasty. The buccal mucosa is easy to harvest, and can be used successfully in one- and two-stage grafting procedures. The rate of complications, from both a urological and maxillofacial perspective, in the group of patients studied was low.

Use of buccal mucosa grafts for urethral reconstruction in children: a retrospective cohort study

BACKGROUND

The use of buccal mucosa grafts (BMG) for urethral reconstruction has increased in popularity over the last several decades. Our aim was to describe our institutional experience with and outcomes after BMG urethroplasty.

METHODS

We conducted a retrospective cohort study of boys undergoing BMG urethral reconstruction. Preoperative and perioperative characteristics and postoperative outcomes were evaluated.

RESULTS

Twenty-nine patients (median age 8.2 years) underwent BMG urethroplasty from 1995-2012. Of the 10 patients undergoing 1-stage repairs, 6 had tubularized grafts, the last of which was performed in 2000 due to an unacceptably high revision rate (100%). A 2-stage approach was elected for 19 patients (median follow-up 21.3 months). Complications including stricture, fistula, or chordee were seen in 60% of patients completing both stages and 32% required ≥1 revision. However, 71% of 2-stage patients were free of significant problems at last follow-up.

CONCLUSIONS

We found BMG to be a reasonable option for use in complex pediatric urethral reconstruction. Tubularized grafts had poor results, and we no longer use them. We favor a 2-stage approach for all patients except those with "simple" non-hypospadiac strictures. Although revision procedures were not uncommon, the majority of patients were ultimately free of long-term problems.

Pseudospongioplasty using periurethral vascularized tissue to support ventral buccal mucosa grafts in the distal urethra

PURPOSE

For ventral buccal mucosa graft onlay during bulbar urethroplasty, spongioplasty with advancement and closure of the corpus spongiosum is ordinarily performed to stabilize the graft. In the pendulous and distal bulbar urethra the spongiosum is often too thin to allow complete graft coverage. We describe the results of what to our knowledge is a novel technique for ventral graft coverage using periurethral vascularized tissue. We compared these results to those of conventional spongioplasty.

MATERIALS AND METHODS

We retrospectively reviewed all urethroplasties performed by 2 surgeons at separate tertiary care facilities from July 2007 to July 2012. One-stage urethroplasties involving ventral buccal mucosa graft placement were selected for analysis. Conventional spongioplasty was performed when possible. When spongiosal tissue was inadequate for graft coverage, periurethral tissue flaps were mobilized bilaterally and sutured together in the midline as pseudospongioplasty to provide coverage. We compared the outcomes of the 2 techniques.

RESULTS

Of 637 urethroplasties performed during the 5-year study period 102 (16%) with a buccal mucosa graft onlay met study inclusion criteria. Pseudospongioplasty was performed in 46 of 102 cases (45%), predominantly in the pendulous urethra (34 of 46 or 74%), with success in 37 of 46 (80%) at a mean followup of 41 months. Conventional spongioplasty had a similar 84% success rate (47 of 56 cases) at a mean followup of 39 months (p = 0.645). For conventional spongioplasty mean stricture length was 4.7 cm compared to 5.8 cm for pseudospongioplasty (p = 0.028).

CONCLUSIONS

Ventral buccal mucosa grafts can be applied reliably to various locations throughout the anterior urethra. For distal grafts, flaps of periurethral tissue provide a suitable host bed for revascularization with results equivalent to those of conventional spongioplasty.

Current management of urethral stricture

The surgical treatment of urethral stricture diseases is continually evolving. Although various surgical techniques are available for the treatment of anterior urethral stricture, no one technique has been identified as the method of choice. This article provides a brief updated review of the surgical options for the management of different sites and different types of anterior urethral stricture. This review also covers present controversies in urethral reconstruction. Among the various procedures available for treating urethral stricture, one-stage buccal mucosal graft urethroplasty is currently widely used. The choice of technique for urethroplasty for an individual case largely depends on the expertise of the surgeon. Therefore, urologists working in this field should keep themselves updated on the numerous surgical techniques to deal with any condition of the urethra that might surface at the time of surgery.

Failed hypospadias in paediatric patients

Failed hypospadias refers to any hypospadias repair that leads to complications or causes patient dissatisfaction. The complication rate after hypospadias repairs ranges from 5-70%, but the actual incidence of failed hypospadias is unknown as complications can become apparent many years after surgery and series with lifelong follow-up data do not exist. Moreover, little is known about uncomplicated repairs that fail in terms of patient satisfaction. Risk factors for complications include factors related to the hypospadias (severity of the condition and characteristics of the urethral plate), the patient (age at surgery, endocrine environment, and wound healing impairment), the surgeon (technique selection and surgeon expertise), and the procedure (technical details and postoperative management). The most important factors for preventing complications are surgeon expertise (number of cases treated per year), interposition of a barrier layer between the urethroplasty and the skin, and postoperative urinary drainage. Major complications associated with failed hypospadias include residual curvature, healing complications (preputial dehiscence, glans dehiscence, fistula formation, and urethral breakdown), urethral obstruction (meatal stenosis, urethral stricture, and functional obstruction), urethral diverticula, hairy urethra, and penile skin deficiency.

Urethral reconstruction using buccal mucosa or penile skin grafts: systematic review and meta-analysis

INTRODUCTION

Different types of grafts have been described in urethral reconstruction (UR), with penile skin graft (PSG) and buccal mucosa graft (BMG) as the most frequently used ones. It still remains unclear whether one graft is superior in terms of success when compared to the other.

MATERIAL AND METHODS

A systematic review of the literature was performed searching the MEDLINE database with the following search strategy: 'urethroplasty' AND 'penile skin'/ 'urethroplasty' AND 'buccal mucosa'. 266 and 144 records were retrieved for urethroplasty with PSG and BMG, respectively. These records were reviewed to identify papers where PSG and BMG were used in UR and where individualized data on success were available within the same series.

RESULTS

18 papers were found eligible for further analysis. In total, 428 and 483 patients were respectively treated with PSG or BMG. If available, follow-up duration was 64.1 versus 42.1 months (p < 0.0001) and stricture length 6.2 versus 4.6 cm (p < 0.0001) for PSG and BMG, respectively. Success of UR with PSG was 81.8 versus 85.9% with BMG (p = 0.01).

CONCLUSIONS

Success of UR using BMG is significantly better compared to PSG. Results might be seriously biased by a longer follow-up duration and stricture length for PSG compared to BMG.

Treatment of adults with complications from previous hypospadias surgery

PURPOSE

Adults with complications from previous hypospadias surgery experience various problems, including urethral stricture, persistent hypospadias and urethrocutaneous fistula. Innate deficiencies of the corpus spongiosum and multiple failed operations makes further management challenging.

MATERIALS AND METHODS

We reviewed our prospective urethroplasty database of men who presented with complications of previous hypospadias surgery. Patients were included in study if they had greater than 6 months of followup. Our surgical management was defined as an initial success if there were no urethral complications. The overall success rate included men with the same result after additional treatment.

RESULTS

A total of 50 men had followup greater than 6 months (median 89) and were included in study. These 50 patients presented with urethral stricture (36), urethrocutaneous fistula (12), persistent hypospadias (7), hair in the urethra (6) and severe penile chordee (7). Patients underwent a total of 74 urethroplasties, including stage 1 urethroplasty in 19, a penile skin flap in 11, stage 2 urethroplasty in 11, urethrocutaneous fistula closure in 9, permanent perineal urethrostomy in 6, excision and primary anastomosis in 6, a 1-stage buccal mucosa onlay in 4, tubularized plate urethroplasty in 3, combined techniques in 3 and chordee correction in 1. In 25 men (50%) treatment was initially successfully. Of the 25 men in whom surgery failed 18 underwent additional procedures, including 13 who were ultimately treated successfully for an overall 76% success rate (38 of 50).

CONCLUSIONS

Managing problems from previous hypospadias surgery is difficult with a high initial failure rate. Additional procedures are commonly needed.

Single-stage segmental urethral replacement using combined ventral onlay fasciocutaneous flap with dorsal onlay buccal grafting for long segment strictures

Study Type--Therapy (case series). Level of Evidence 4. What's known on the subject? And what does the study add? Single-stage urethral segment replacement has historically poor outcomes and two-stage repairs are now more common. We present a novel approach to the single-stage repair with initial outcomes similar to two-stage repairs.

OBJECTIVE

• To present our experience with repairing long-segment urethral strictures in a single-stage using a combined tissue-transfer technique.

PATIENTS AND METHODS

• In all, 14 men underwent urethroplasty where a segment of urethra was completely replaced using a dorsal onlay buccal mucosa graft and a ventral onlay fasciocutaneous flap in a single stage. • Primary success was defined as an open urethra at >6 months follow-up with no need for additional surgical intervention. • Secondary success was defined as the need for a single postoperative endoscopic procedure before stricture stabilization. • Failure was the need for multiple endoscopic procedures, repeat urethroplasty, urinary diversion or intermittent dilatation.

RESULTS

• The mean (SD) stricture length was 9.75 (4.6) cm. The mean (SD) neourethral length was 5.4 (2.7) cm. Stricture location was penile/bulbar in 12 men, and bulbar alone in two. Primary success was achieved in nine of the 14 men at a median (range) follow-up of 2.5 (0.5-9.43) years. • The mean (SD) time to recurrence in the five initial failures was 340 (376) days. • Secondary success was achieved in two men after a single endoscopic procedure for an overall success in 11 of 14 men. • Patients that recurred had longer strictures (12.8 vs 8.7 cm, P= 0.04) than initial successes, but neourethral lengths were similar (6.2 vs 5.1 cm, P= 0.5). • In all, three of the 14 men failed, two of whom required a repeat urethroplasty.

CONCLUSIONS

• Our initial outcomes were favourable using the combined tissue-transfer technique for segmental urethral replacement with initial and secondary success rates similar to those reported for two-stage repairs. • This technique is not suitable for all patients as it requires healthy penile skin, but appears to be effective when a single-stage repair is desirable.

"Hanging" of the buccal mucosal graft for urethral stricture repair after failed hypospadias

PURPOSE

Urethral stricture is the second most common complication of hypospadias repair after urethrocutaneous fistula. Usually more than 1 procedure is needed for correction due to a lack of available tissue after previous repairs. We evaluated 1-stage urethral stricture management after hypospadias repair using a ventral buccal mucosal graft. We describe the importance of graft hanging and coverage.

MATERIALS AND METHODS

From August 2004 to April 2009, 15 patients 9 to 17 years old underwent urethral stricture repair after failed hypospadias surgery. Mean time after primary surgery was 7.2 years (range 4 to 13). Vascularized periurethral tissue around the stenotic part of the neourethra was dissected. The urethra was opened ventrally and a buccal mucosal graft of appropriate size was inserted to allow urethral augmentation. Using several U stitches the graft was anchored to the surrounding periurethral tissue to prevent its folding and retraction. Recurrent chordee in 12 patients and secondary vesicoureteral reflux in 3 were also corrected at this time.

RESULTS

Mean followup was 37 months (range 17 to 73). Successful results were confirmed in all patients by urethrography and uroflowmetry. One urethral fistula was corrected 3 months later by minor surgery. Recurvature did not develop in this group. There was no recurrent reflux in endoscopically treated patients.

CONCLUSIONS

Ventral buccal mucosal grafting is a simple, safe option for urethral stricture repair. Hanging the graft to periurethral tissue is important for its survival and to prevent postoperative folding and retraction.

Complicated urethroplasty: a guide for surgeons

Although straightforward male urethral stricture disease is commonly encountered in the scope of general urologic practice, complex urethral strictures are less common and require a more systematic approach. Complex urethral stricture surgery for long and panurethral strictures, after failed hypospadias repair, and for recurrent posterior urethral distraction defects requires a dynamic treatment paradigm. A multistaged urethral reconstruction is often necessary owing to hostile urethral tissue, especially after multiple previous procedures. A perineal urethrostomy sometimes offers improved quality of life for patients with complex urethral stricture disease, particularly if they have undergone previous failed repairs. Recurrent posterior urethral distraction defects are best treated with excision of the scarred urethral segment and re-anastomosis. Urethral stricture disease after treatment for prostate cancer requires multiple treatment approaches given the often poor tissue quality and likelihood of stricture recurrence.

Surgical reconstruction of the male urethral diverticulum

OBJECTIVES

To describe the outcomes and reconstructive techniques used for men with symptomatic urethral diverticula in an attempt to standardize treatment based on the length of the urethral defect after diverticulum excision and the type of repair used. Urethral diverticula are rare in men and may be either congenital or acquired.

METHODS

Between 2003 and 2008, 13 men were treated surgically for symptomatic urethral diverticula at a single institution by a single surgeon (C.M.G.). A total of 6 (46.2%) patients had urethral defects of < 4 cm and underwent excision of the diverticulum with primary anastomosis. Substitution urethroplasty using either penile skin or buccal mucosa was used in 7 (53.8%) patients with urethral defects of >or= 4 cm. Demographic and preoperative characteristics were compared among patients according to the length of the urethral defect.

RESULTS

The mean age of men at the time of surgery was 38.4 years (+/- 13.0; range, 20.4-63.7), with a median follow-up time of 21.7 (+/- 29.0; range, 0.9-84.0) months. Neither age at the time of surgery, length of follow-up, or diverticulum volume was significantly different between men who underwent primary repair vs substitution urethroplasty. The overall success rate was 92% (12/13) with an overall complication rate of 42% at intermediate follow-up.

CONCLUSIONS

Outcomes after excision and primary anastomosis for diverticula associated with defects of < 4 cm were similar to outcomes after diverticulum excision and substitution urethroplasty for defect of >or= 4 cm.

Algorithm for comprehensive approach to hypospadias reoperation using 3 techniques

PURPOSE

We describe comprehensive hypospadias reoperation based on presence or absence of a supple urethral plate using the 3 surgical techniques of transurethral incised plate, 1-stage inlay graft and 2-stage buccal graft.

MATERIALS AND METHODS

We reviewed prospective data from all reoperative hypospadias urethroplasties performed by one of us (WTS) between 2000 and 2008. Patient age, number of operations, indications for additional surgery, meatal location, reoperative surgical technique and outcomes were extracted.

RESULTS

A total of 133 patients underwent reoperation by transurethral incised plate (69), 1-stage inlay graft (16) or 2-stage buccal graft (48) urethroplasty. Mean number of prior failed repairs was 1.1, 1.9 and 4.3, respectively. Followup was available in 121 patients (91%), with 90 (74%) undergoing 1 successful reoperative urethroplasty. Complications occurred in 19%, 15% and 38% of patients, respectively, and most often consisted of fistulas or glans dehiscence.

CONCLUSIONS

Hypospadias reoperation can be accomplished using these 3 techniques without skin flaps, a potential advantage given the relative paucity of skin after failed repair. Fistulas after transurethral incised plate urethroplasty correlate with barrier layers used, while glans dehiscence is more likely in 2-stage buccal graft repairs when cheek rather than lip is used within the glans.