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Uğur R, Şimşek A. The best method for erection function in urethroplasty; is excision and primary anastomosis or buccal mucosal graft urethroplasty? Actas Urol Esp 2024; 48:170-176. [PMID: 37981167 DOI: 10.1016/j.acuroe.2023.11.002] [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] [Received: 07/22/2023] [Revised: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 11/21/2023]
Abstract
INTRODUCTION The aim of this study is to evaluate and compare erection function (EF) after Excision and Primary Anastomosis Urethroplasty (EPAU) and Buccal Mucosal Graft Urethroplasty (BMGU) in bulbar urethral stricture. METHODS Patients who underwent urethroplasty were identified retrospectively. The criteria for inclusion in the study were determined as being over 18 years old and under 70 years old, being sexually active. Exclusion criteria are; preoperative severe erectile dysfunction, stricture outside the bulbar urethra, psychosocial incompatibility, urethral stricture related to pelvic fracture, follow-up time less than a year. As the primary endpoint, the International Index of Erectile Function-5 (IIEF-5) was determined as a comparison of EF in the preoperative and third, sixth and twelfth months after surgery. The secondary endpoint was the evaluation of the effects of demographic data, stricture and treatment characteristics on EF. RESULTS Fifty patients were identified considering the inclusion/exclusion criteria. It was observed that there were 30 patients who underwent EPAU and 20 patients who underwent BMGU. At the third month after surgery, EF showed a statistically significant decrease in the EPAU group. In both patient groups, it was observed that the early negative effects after the operation in EF started to improve in the sixth month and returned to the baseline level by the first year. CONCLUSION EPAU and BMGU techniques have a similar effect on EF in the medium and long term. Both methods can be used safely and effectively in the appropriate patient group.
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Affiliation(s)
- R Uğur
- Servicio de Urología, Hospital Urbano de Basaksehir Cam y Sakura, Estambul, Turkey.
| | - A Şimşek
- Servicio de Urología, Hospital Urbano de Basaksehir Cam y Sakura, Estambul, Turkey
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2
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Jamil ML, Perecman A, Sherman A, Sullivan T, Christ K, Hansma A, Burks E, Vanni AJ. Urinary microbiome differences between lichen sclerosus induced and non-lichen sclerosus induced urethral stricture disease. World J Urol 2023; 41:2495-2501. [PMID: 37421420 DOI: 10.1007/s00345-023-04490-0] [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: 02/26/2023] [Accepted: 06/09/2023] [Indexed: 07/10/2023] Open
Abstract
OBJECTIVE To describe differences in the urinary microbiome of patients with pathologically confirmed lichen sclerosus (LS) urethral stricture disease (USD) vs non-lichen sclerosus (non-LS) USD pre- and post-operatively. METHODS Patients were pre-operatively identified and prospectively followed, all underwent surgical repair and had tissue samples obtained to make a pathological diagnosis of LS. Pre- and post-operative urine samples were collected. Bacterial genomic DNA was extracted. Alpha and beta diversity measurements were calculated and compared. A zero-inflated negative binomial model was utilized to compare taxa abundances between disease status and surgery status. RESULTS Urine samples were obtained from both cohorts, 69 samples in total: 36 samples were obtained pre-operatively and 33 samples were obtained post-operatively. Ten patients provided both a pre-operative and post-operative urine sample. Twenty-six patients had pathological evidence of LS and 33 patients did not. There was a statistically significant difference in alpha diversity between the pre-operative urine samples of patients with non-LS USD and LS USD, (p = 0.01). There was no significant difference in alpha diversity within post-operative urine samples between patients with non-LS USD and LS USD, (p = 0.1). A significant difference was observed in Weighed UniFrac distances with respect to disease and operative status, (p = 0.001 and 0.002). CONCLUSIONS LS USD have significant alterations in diversity and differential abundance of urine microbiota compared to non-LS USD controls. These findings could be used to guide further investigations into the role of the urinary microbiome in LS USD pathogenesis, severity of presentation, and stricture recurrence.
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Affiliation(s)
- Marcus L Jamil
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Aaron Perecman
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Amanda Sherman
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Travis Sullivan
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Kimberly Christ
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Alexandra Hansma
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
- Tufts University, Medford, MA, USA
| | - Eric Burks
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
- Tufts University, Medford, MA, USA
- Boston Medical Center, Boston, Massachusetts, USA
| | - Alex J Vanni
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA.
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3
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Mora EMM, Champer MI, Huang W, Campagnola PJ, Grimes MD. Collagen is More Abundant and Structurally Altered in Lichen Sclerosus. Urology 2023; 173:192-197. [PMID: 36509210 PMCID: PMC10038846 DOI: 10.1016/j.urology.2022.11.036] [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: 10/10/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To test the hypothesis that genital skin and male urethra affected by lichen sclerosus (LS) has increased collagen content and altered collagen structure. METHODS We used picrosirius red to stain and image collagen in human urethral, vulvar, and foreskin specimens with and without LS. Using Image J software, we quantified and compared (1) collagen content (using 2o metrics: collagen proportionate area [CPA] and collagen fiber count), (2) collagen fiber length and width, and (3) collagen structure using the texture analysis technique gray level co-localization matrix (GLCM) with respect to LS status and tissue type. RESULTS We analyzed 23 LS specimens (vulva n=9, urethra n=7, foreskin n=7) and 29 non-LS specimens (vulva n=9, urethra n=7, foreskin n=13). Fiber count and CPA were significantly higher in all LS specimens compared to non-LS specimens (CPA: mean±SD 0.971±0.03 vs 0.948±0.02, P < .007; fiber count: mean±SD = 2906±127 vs 2509±78 fibers; P = .003). Collagen fiber width and length were similar with respect to LS status. GLCM analysis showed decreased inverse difference moment and increased entropy in LS tissues indicative of less homogeneous and more disorganized tissue structure (P<.001). CONCLUSION LS tissues have greater collagen content compared to non-LS tissues. Quantitative assessment of collagen organization, using GLCM, revealed less homogeneity and more disorganization of collagen in LS compared to non-LS tissues. Taken together, our findings suggest that alterations in physical tissue properties seen in LS may be due to both increased collagen abundance and altered structure.
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Affiliation(s)
- Eduardo M Miranda Mora
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Melissa I Champer
- Department of Biomedical Engineering, University of Wisconsin, Madison, WI
| | - Wei Huang
- Department of Pathology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Paul J Campagnola
- Department of Biomedical Engineering, University of Wisconsin, Madison, WI
| | - Matthew D Grimes
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI.
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Periurethral Abscess Following Urethral Reconstruction: Clinical Features and Prognosis. Urology 2021; 161:111-117. [PMID: 34979218 DOI: 10.1016/j.urology.2021.12.020] [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: 09/27/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate the clinical and prognostic details of periurethral abscess (PUA) formation following urethroplasty (UP). METHODS A retrospective review was performed to identify men who developed PUA after UP between 2007 and 2019 at a single tertiary care referral center. Patient demographics, stricture characteristics, and UP technique were recorded. Outcomes included time to PUA, presenting symptoms, wound cultures, imaging, and ultimate management. Comparative analysis between PUA and non-PUA patients was performed using Fisher's Exact test and Student's t-test. RESULTS Among 1499 UP cases, 9 (0.6%) developed PUA. Mean stricture length was 4.6 cm with most located in the bulbar urethra (5/9, 56%), while 4/9 (44%) had undergone prior UP. PUA rates were 7/288 (2.4%) and 2/815 (0.3%) for substitution and anastomotic UP respectively. Voiding cystourethrogram (VCUG) demonstrated extravasation in 67% (4/6) of available UP cases imaged. Subsequent VCUG confirmed leak improvement or resolution in all cases. Wound cultures were frequently polymicrobial (4/6, 67%). Management included antibiotics with (6/9) and without (3/9) incision and drainage (I/D). Urinary drainage was performed in 5 patients using suprapubic tube (3/5) and foley placement (2/5). PUA resolution was observed in all patients while stricture symptom recurrence was observed in 2/9 (22%) patients with mean time to recurrence of 15 months. Overall mean follow-up time was 22 months. CONCLUSION PUA is a rare complication of UP that may be more common in setting of postoperative urine leak. PUA is safely managed with I/D, urethral rest, and antibiotics, with low risk of recurrent stricture formation thereafter.
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5
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Esperto F, Verla W, Ploumidis A, Barratt R, La Rocca R, Lumen N, Yuan Y, Campos-Juanatey F, Greenwell T, Martins F, Osman N, Riechardt S, Waterloos M, Dimitropoulos K. What is the role of single-stage oral mucosa graft urethroplasty in the surgical management of lichen sclerosus-related stricture disease in men? A systematic review. World J Urol 2021; 40:393-408. [PMID: 34448008 DOI: 10.1007/s00345-021-03803-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The benefits and harms of the available types of surgical management for lichen sclerosus-related (LS) strictures remain unclear and, thus, clear and robust clinical practice recommendations cannot be given. MATERIALS AND METHODS To assess the role of single-stage OMGU in the management of LS strictures and explore how its benefits and harms compare with the alternative management options. Medline, Embase and Cochrane controlled trial databases (CENTRAL, CDSR) were systematically searched. Randomized (RCTs) and nonrandomized studies (NRCSs) comparing single-stage OMGU with other surgical management options for LS strictures and single-arm studies on single-stage OMGU were included. Risk of bias (RoB) was assessed. RESULTS Of the 1912 abstracts identified, 15 studies (1 NRCS and 14 single-arm studies) were included, recruiting in total 649 patients. All studies were at high RoB. In the only NRCS available, stricture-free rate (SFR) for single-stage and staged OMGU was 88% vs 60%, respectively (p = 0.05), at a mean follow-up of 66.5 months. SFR range for single-stage OMGU in single-arm studies was 65-100% (mean/median follow-up, 12-59 months). Single-stage OMGU had low complication rates and beneficial impact on LUTS and QoL. CONCLUSIONS The present SR highlights the methodological limitations of the available literature. In the absence of adverse local tissue conditions, and taking into consideration benefit-harm balance and surgeon's skills and expertise, single-stage OMGU can be justified in patients with LS strictures.
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Affiliation(s)
- Francesco Esperto
- Department of Urology, Campus Biomedico University of Rome, Via Álvaro Del Portillo, 200 00128, Rome, Italy.
| | - Wesley Verla
- Division of Urology, Gent University Hospital, Gent, Belgium
| | | | - Rachel Barratt
- Department of Urology, University College London Hospital, London, UK
| | - Roberto La Rocca
- Department of Urology, University of Naples Federico II, Naples, Italy
| | - Nicolaas Lumen
- Division of Urology, Gent University Hospital, Gent, Belgium
| | - Yuhong Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, ON, Canada
| | | | - Tamsin Greenwell
- Department of Urology, University College London Hospital, London, UK
| | - Francisco Martins
- Department of Urology, Santa Maria University Hospital, University of Lisbon, School of Medicine, Lisbon, Portugal
| | - Nadir Osman
- Department of Urology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Silke Riechardt
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Mershon JP, Baradaran N. Recurrent Anterior Urethral Stricture: Challenges and Solutions. Res Rep Urol 2021; 13:237-249. [PMID: 34012927 PMCID: PMC8128502 DOI: 10.2147/rru.s198792] [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: 03/07/2021] [Accepted: 04/14/2021] [Indexed: 12/05/2022] Open
Abstract
Recurrent male anterior urethral stricture disease is a complex surgical challenge that should be managed by reconstructive urologists with experience in stricture management. Diagnosis of recurrence requires both anatomic narrowing and patient symptoms identified on validated questionnaires, with limited role for intervention in asymptomatic treatment “failures”. Endoscopic management has a very specific role in recurrence, and the choice of technique for urethroplasty depends on pre-operative urethrography and cystoscopy. Surgical success depends on addressing patient concerns, complete stricture excision, tissue quality optimization, and the use of multi-stage repair when indicated. Augmentation with genital skin flaps and/or grafts is often required, with buccal mucosa as the ideal graft source if local tissue is compromised. Salvage options including urinary diversion and perineal urethrostomy must also be considered in debilitated patients with severe disease or repeated treatment failures. Unique patient populations including patients with hypospadias and lichen sclerosis are among the highest risk for repeated recurrence and require special care in surgical technique, graft selection, and post-operative management.
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Affiliation(s)
| | - Nima Baradaran
- The Ohio State University Department of Urology, Columbus, OH, USA
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7
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Rao S, Khattar N, Akhtar A, Varshney A, Goel H. Everted Saphenous Vein Graft (eSVG) urethroplasty in long-segment anterior urethral strictures: Medium-term follow-up results. UROLOGICAL SCIENCE 2021. [DOI: 10.4103/uros.uros_70_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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8
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Favre GA, Villa SG, Scherñuk J, Tobia IP, Giudice CR. Glans Preservation in Surgical Treatment of Distal Urethral Strictures With Dorsal Buccal Mucosa Graft Onlay by Subcoronal Approach. Urology 2020; 152:148-152. [PMID: 33359490 DOI: 10.1016/j.urology.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe dorsal onlay buccal mucosa graft urethroplasty technique by subcoronal approach and glans preservation in distal penile urethral strictures with fossa navicularis involvement and to report safety, effectiveness, and cosmetic outcomes. METHODS Retrospective review of a prospective database of patients treated at Hospital Italiano de Buenos Aires between January 2011 and December 2019. Main surgical steps: ventral subcoronal incision, dorsal dissection of glandelar urethra until piercing the tip of the glans, dorsal urethrotomy, and graft transposition. Low urinary tract symptoms, uroflowmetry, and urinalysis were assessed at follow-up. Simplified International Index Erectile Function and Hypospadias Objective Scoring Evaluation were applied 1 year after surgery. RESULTS Sixteen patients with a median age of 56.5 years (IQR 35.7-66.7) were included. Median stricture length was 5.5 cm (IQR 4-8.7). In 3 patients, Clavien-Dindo grade I-II complications were reported. At 1 year, median peak flow was 18 mL/seg (IQR 12.7-27.4) and median mean flow 7.8 mL/seg (IQR 6.1-9.9). At 41.5 months follow-up (IQR 13.2-74), all patients were stricture free and had no changes in erectile function. Hypospadias Objective Scoring Evaluation score ≥14 points was achieved by 14 patients (87.5%). CONCLUSION For treatment of distal penile urethral strictures with fossa navicularis involvement, dorsal onlay buccal mucosa graft by subcoronal approach and glans preservation is a feasible technique with excellent functional outcomes, minimal complications, and substantial cosmetic results.
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Affiliation(s)
- Gabriel Andrés Favre
- Genitourinary Reconstructive Surgery Division, Department of Urology, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Sergio Gil Villa
- Genitourinary Reconstructive Surgery Division, Department of Urology, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Jordán Scherñuk
- Genitourinary Reconstructive Surgery Division, Department of Urology, Italian Hospital of Buenos Aires, Buenos Aires, Argentina.
| | - Ignacio Pablo Tobia
- Genitourinary Reconstructive Surgery Division, Department of Urology, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Carlos Roberto Giudice
- Genitourinary Reconstructive Surgery Division, Department of Urology, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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9
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Rourke KF, Welk B, Kodama R, Bailly G, Davies T, Santesso N, Violette PD. Canadian Urological Association guideline on male urethral stricture. Can Urol Assoc J 2020; 14:305-316. [PMID: 33275550 DOI: 10.5489/cuaj.6792] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Urethral stricture is fundamentally a fibrosis of the urethral epithelial and associated corpus spongiosum, which in turn, causes obstruction of the urethral lumen. Patients with urethral stricture most commonly present with lower urinary tract symptoms, urinary retention or urinary tract infection but may also experience a broad spectrum of other signs and symptoms, including genitourinary pain, hematuria, abscess, ejaculatory dysfunction, or renal failure. When urethral stricture is initially suspected based on clinical assessment, cystoscopy is suggested as the modality that most accurately establishes the diagnosis. This recommendation is based on several factors, including the accuracy of cystoscopy, as well as its wide availability, lesser overall cost, and comfort of urologists with this technique. When recurrent urethral stricture is suspected, we suggest performing retrograde urethrography to further stage the length and location of the stricture or referring the patient to a physician with expertise in reconstructive urology. Ultimately, the treatment decision depends on several factors, including the type and acuity of patient symptoms, the presence of complications, prior interventions, and the overall impact of the urethral stricture on the patient's quality of life. Endoscopic treatment, either as dilation or internal urethrotomy, is suggested rather than urethroplasty for the initial treatment of urethral stricture. This recommendation applies to men with undifferentiated urethral stricture and does not apply to trauma-related urethral injuries, penile urethral strictures (hypospadias, lichen sclerosus), or suspected urethral malignancy. In the setting of recurrent urethral stricture, urethroplasty is suggested rather than repeat endoscopic management but this may vary depending on patient preference and impact of the symptoms on the patient.The purpose of this guideline is to provide a practical summary outlining the diagnosis and treatment of urethral stricture in the Canadian setting.
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Affiliation(s)
- Keith F Rourke
- Division of Urology, University of Alberta, Edmonton, AB, Canada
| | - Blayne Welk
- Division of Urology, Western University, London, ON, Canada
| | - Ron Kodama
- Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Greg Bailly
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Tim Davies
- McMaster University, Hamilton, ON, Canada
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10
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Abstract
Lichen sclerosus (LS), or balanitis xerotica obliterans as it was previously known, is a chronic inflammatory lymphocyte-mediated scarring dermatosis that often affects the preputial skin and glans, leading to phimosis and urethral strictures if left untreated. We present a narrative review of the literature assessing its aetiology and pathogenesis and discuss its links to penile cancer and its medical and surgical management. Possible hypotheses for the development of LS include chronic exposure to trapped urine, leading to changes in the epithelial structure. This is supported by the fact that circumcision is often curative in the early stages of the disease. Although circumcision can be curative, the use of topical steroids is typically the first-line treatment and may preserve the foreskin and forgo the need for circumcision altogether. Patients should be made aware of a possible association with penile cancer. Although the majority of cases can be treated by medical therapy and circumcision, a significant number of patients may also require penile reconstructive procedures.
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Affiliation(s)
- Rachel Kwok
- Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Taimur T Shah
- Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Suks Minhas
- Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
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11
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Chung ASJ, Suarez OA. Current treatment of lichen sclerosus and stricture. World J Urol 2019; 38:3061-3067. [DOI: 10.1007/s00345-019-03030-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022] Open
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12
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Versatile algorithmic midline approach to perineal urethrostomy for complex urethral strictures. World J Urol 2018; 37:1403-1408. [DOI: 10.1007/s00345-018-2522-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 10/08/2018] [Indexed: 10/28/2022] Open
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13
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Lewis F, Tatnall F, Velangi S, Bunker C, Kumar A, Brackenbury F, Mohd Mustapa M, Exton L, McHenry P, Leslie T, Wakelin S, Hunasehally R, Cork M, Johnston G, Chiang N, Worsnop F, Buckley D, Petrof G, Salin A, Callachand N, Saunders C, Salad A. British Association of Dermatologists guidelines for the management of lichen sclerosus, 2018. Br J Dermatol 2018; 178:839-853. [DOI: 10.1111/bjd.16241] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2017] [Indexed: 12/18/2022]
Affiliation(s)
- F.M. Lewis
- Frimley Health NHS Foundation Trust Slough SL2 4HL U.K
- St John's Institute of Dermatology Guy's & St Thomas’ NHS Foundation Trust London SE1 9RT U.K
| | - F.M. Tatnall
- West Hertfordshire NHS Trust Watford WD18 0HB U.K
| | - S.S. Velangi
- University Hospitals Birmingham NHS Foundation Trust Birmingham B15 2TH U.K
| | - C.B. Bunker
- University College London Hospitals NHS Foundation Trust University College Hospital London NW1 2BU U.K
- Chelsea & Westminster NHS Foundation Trust London SW10 9NH U.K
| | - A. Kumar
- King's College London London SE1 3ER U.K
| | - F. Brackenbury
- Association for Lichen Sclerosus and Vulval Health Brighton U.K
| | - M.F. Mohd Mustapa
- British Association of Dermatologists Willan House, 4 Fitzroy Square London W1T 5HQ U.K
| | - L.S. Exton
- British Association of Dermatologists Willan House, 4 Fitzroy Square London W1T 5HQ U.K
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Abstract
PURPOSE OF REVIEW Urethral strictures that are refractory to initial management present unique challenges to the reconstructive surgeon. Treatment trends have shifted as new tissue resources are becoming available. There is renewed interest in old methods as skill and technique have improved. We describe the scope of the surgical armamentarium available to develop creative approaches and successful outcomes. RECENT FINDINGS We discuss techniques to maximize the availability of oral mucosa, harvest and use of rectal mucosa, and developments in tissue engineering. Evolving methods to assess success of repair are also described. Urethral reconstruction for refractory urethral strictures requires proficiency with multiple methods as these strictures often require combining techniques for successful treatment.
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15
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Abstract
Distal urethral strictures comprise meatal or glandular stenoses and occur due to trauma, iatrogenic instrumentalization, infection, skin diseases such as lichen sclerosus or idiopathically. Given that 18% of anterior strictures (bulbar, penile, or glandular) are located in the very distal part, meatal/glandular stricture disease represents a non-negligible subgroup among all urethral strictures. The prevalence within Western industrialized countries is estimated to be approximately 0.6-0.9%, which translates into a total of 250,000 men being affected in Germany. Without any therapy, there is a severe risk of functional damage to the kidneys and the remaining urinary tract as well as significant reduction of quality of life. The therapeutic success of regaining sufficient micturition and a satisfying cosmetic result can only be obtained by means of surgical intervention. Besides dilatation and urethrotomy, preferably a single or multiple staged open urethroplasty with transplantation of autogenous genital or non-genital tissue can be performed. The choice of the appropriate surgical concept depends on stricture etiology, comorbidity status, and the patient's compliance. In case of histologically diagnosed lichen sclerosus, the use of genital skin should be avoided. To date, there are no universally accepted recommendations regarding the optimal use of substitution techniques. However, the use of oral mucosal tissue grafts seem to be the most promising, given low recurrence rates, and thus can be considered as the current gold standard.
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Affiliation(s)
- Simon Zeller
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Malte W Vetterlein
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Margit Fisch
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Luis A Kluth
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- Klinik für Urologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
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