Single-stage preputial skin flap urethroplasty for long-segment urethral strictures: evaluation and determinants of success

Trilayer composite scaffold for urethral reconstruction:in vitroevaluation of mechanical, biological, and angiogenic properties

Regeneration of damaged urethral tissue remains a major challenge in the field of lower urinary tract reconstruction. To address this issue, various synthetic and natural biodegradable biomaterials are currently being explored for the fabrication of scaffolds that promote urethral regeneration and healing. In this study, we present an approach to fabricate a trilayer hybrid scaffold comprising a central layer of poly(lactic acid) (PLA) between two layers of chitosan. The chitosan/PLA/chitosan (CPC) scaffolds were fabricated by a sequential electrospinning process and their properties were evaluated for their suitability for urethral tissue engineering. The physical and biological properties of the CPC scaffolds were evaluated in comparison to electrospun PLA scaffolds and acellular dermis (Alloderm) as controls for a synthetic and a natural scaffold, respectively. Compared to the controls, the CPC scaffolds exhibited higher elastic modulus and ultimate tensile strength, while maintaining extensibility and suture retention strength appropriate for clinical use. The CPC scaffolds displayed significant hydrophilicity, which was associated with a higher water absorption capacity of the chitosan nanofibres. The degradation products of the CPC scaffolds did not exhibit cytotoxicity and promoted wound closure by fibroblastsin vitro. In addition, CPC scaffolds showed increased growth of smooth muscle cells, an essential component for functional regeneration of urethral tissue. Furthermore, in a chicken embryo-based assay, CPC scaffolds demonstrated significantly higher angiogenic potential, indicating their ability to promote vascularisation, a crucial aspect for successful urethral reconstruction. Overall, these results suggest that CPC hybrid scaffolds containing both natural and synthetic components offer significant advantages over conventional acellular or synthetic materials alone. CPC scaffolds show promise as potential candidates for further research into the reconstruction of the urethrain vivo.

Urethral Complications After Metoidioplasty for Genital Gender Affirming Surgery

BACKGROUND

Possible options of genital gender affirming surgery in transmasculine are metoidioplasty or phalloplasty. As opposed to phalloplasty, no flapbased neophallic reconstruction is needed in metoidioplasty. Urethral lengthening is needed in metoidioplasty if the patient desires voiding at the tip of the neophallus. This urethral lengthening poses the patient at risk for urethral complications.

AIM

Our primary goal was to describe the morbidity and specific the urethral complications related to metoidioplasty. Second, we sought for predictors of these urethral complications.

METHODS

Our institutional database was retrospectively analyzed to identify transmasculine who underwent metoidioplasty between 2006 and 2020. This cohort was further evaluated for surgical morbidity, urethral complications and potential predictors for urethral complications.

OUTCOMES

The rate of surgical morbidity and urethral complications (temporary/permanent fistula, stricture or fistula and stricture) was calculated. Potential predictors evaluated herein were BMI, concomitant vaginectomy, active smoking and additional urethral lengthening (AUL). They were tested with logistic regression analysis with calculation of Odds Ratio (OR).

RESULTS

Seventy-four patients underwent metoidioplasty with a median follow-up of 44 months. Median age was 26 years. AUL was done in 36 (48.6%) patients and established by a transverse preputial skin island and labium minus flap in respectively 34 and 2 patients. Within 30 days after metoidioplasty, 3 (4.1%) high-grade complications were noted. Urethral complications of any kind were noted in 42 (56.8%) patients. All fistulas, permanent fistulas and strictures were seen in resp. 34 (45.9%), 27 (36.5%) and 14 (18.9%) patients. AUL is a significant predictor for all urethral complications (OR 15.5), strictures (OR 24.5), all fistula's (OR 6.07) and permanent fistulas (OR 3.83). In contrast, smoking is only a predictor for all fistulas (OR 6.54) and permanent fistulas (OR 3.76).

CLINICAL IMPLICATIONS

Obtaining information about the risk of complications is important in preoperative patient counselling. Patient who desires AUL are at higher risk to develop urethral complications and patients who continue to smoke at the period of metoidioplasty have a higher risk of fistula formation.

STRENGTH & LIMITATIONS

Sufficient events to calculate predictors for urethral complications. However, this is a retrospective study with still a small number of patients with a relative short follow-up.

CONCLUSION

Urethral complications are frequent after metoidioplasty and approximately 50% needs corrective surgery. AUL is an independent risk factor for fistula and stricture formation, whereas smoking is a risk factor for fistula formation. Waterschoot M, Hoebeke P, Verla W, et al. Urethral Complications After Metoidioplasty for Genital Gender Affirming Surgery. J Sex Med 2021;18:1271-1279.

A Comprehensive Review Emphasizing Anatomy, Etiology, Diagnosis, and Treatment of Male Urethral Stricture Disease

To date, urethral stricture disease in men, though relatively common, represents an often poorly managed condition. Therefore, this article is dedicated to encompassing the currently existing data upon anatomy, etiology, symptoms, diagnosis, and treatment of the disease, based on more than 40 years of experience at a tertiary referral center and a PubMed literature review enclosing publications until September 2018.

Contemporary analysis of management of isolated pendulous urethral strictures using pedicled skin flap urethroplasty repair

OBJECTIVES

To evaluate contemporary outcomes of urethroplasty employing a pedicled skin flap for isolated pendulous urethral strictures.

SUBJECTS/PATIENTS

Inclusion of males > 18 years of age with isolated pendulous urethral strictures treated between 1996 and 2012.

RESULTS

A total of 81 patients with isolated pendulous urethral stricture were identified. Twenty-eight patients underwent repair with a pedicled skin flap during the study period. The median age of the patients treated with a pedicled skin flap was 47 years old (range 21-74). The etiology of the strictures was considered to be idiopathic in 10 patients (35.7%), iatrogenic in 9 patients (32.1%), as a complication of prior hypospadias repair in 6 patients (21.4%), infectious in 2 patients (7.1%), and traumatic in 1 patient (3.6%). The median follow-up was 27 months (range 1-214). Urethroplasty success was noted in 19/21 patients (90.5%). Urethral stricture recurrence occurred in 2 of the 21 patients (9.5%).

CONCLUSIONS

The pedicled skin flap repair for pendulous urethral strictures remains a durable and safe technique in patients without LS.

Management of traumatic urethral injuries in children using different techniques: A case series and review of literature

INTRODUCTION

Most pediatric urethral injuries are a result of pelvic fracture after high-impact blunt trauma, mainly due to motor vehicle accidents. The management of urethral injuries depends on if the rupture is complete or partial as well as the timing of surgical intervention.

PRESENTATION OF CASES

Three male children with urethral trauma caused by motor vehicles accidents are presented in this article. Preoperative suprapubic catheterization was initially carried out in all patients. Each patient then received one of three different techniques during the deferred time to surgical intervention: anterior sagittal transanorectal approach (ASTRA) for end-to-end urethral anastomosis, perineal approach for urethroplasty using buccal mucosa, and urethroplasty with preputial skin flap. The three techniques were successfully performed.

DISCUSSION

In the initial management suprapubic cystostomy has been a good solution in urgent situations. Deferred urethroplasty is the procedure of choice for the definite treatment of posterior urethral distraction defects. The anterior sagittal transanorectal approach provides excellent exposure of the posterior urethra and retrovesicular region, and allows the surgeon to perform dissection under direct vision.

CONCLUSION

It's very important for the pediatric urologist to be familiar with the different techniques available in order to choose the best approach for each particular patient.

Urological disease and tobacco. A review for raising the awareness of urologists

CONTEXT

Smoking is the leading cause of preventable death in our community. Its relationship with urological disease is well documented.

OBJECTIVE

To present an updated review on the relationship between urological disease and tobacco consumption and the importance of involving urologists in smoking prevention.

ACQUISITION AND SYNTHESIS OF EVIDENCE

We conducted a review of current literature, primarily by searching PubMed and using as the main base the report on the consequences of smoking on health performed by the Surgeon General.

CONCLUSION

Urologists play an essential role in informing patients of the relationship between smoking and urological disease. It is the duty of every urologist to play a more active role in educating patients and promoting smoking cessation.

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.

Preparation of PCL/silk fibroin/collagen electrospun fiber for urethral reconstruction

PURPOSE

To prepare polycaprolactone (PCL)/silk fibroin/collagen electrospun nanofiber scaffold and test its effects on growth and proliferation of oral mucosal epithelial cells.

METHODS

Regenerated silk fibroin film, water-soluble collagen powder, and PCL, at mass ratios of 1:1:4, 1:1:8, and 1:1:10, were dissolved in hexafluoroisopropanol, and electrostatic spinning method was adopted to prepare PCL/silk fibroin/collagen electrospun nanofiber scaffold. In vitro cultured oral mucosal epithelial cells were inoculated on the material surface, MTT assay and scanning electron microscopy were adopted to study the growth and proliferation of oral mucosal epithelial cells on the material surface, and cell compatibility of PCL/silk fibroin/collagen electrospun nanofiber was evaluated.

RESULTS

The result of MTT assay showed that oral mucosal epithelial cells were growing well on the PCL/silk fibroin/collagen electrospun nanofiber scaffold. Scanning electron microscopy showed that the prepared electrospun fiber was uniform in diameter and presented an interconnected porous net structure, and oral mucosal epithelial cells had a good growth form on the surface of the modified material.

CONCLUSIONS

PCL/silk fibroin/collagen electrospun nanofiber scaffold has appropriate pore size and porosity, is suitable for the growth of oral mucosal epithelial cells, has good cell compatibility, and is a good scaffold for tissue engineering urethral reconstruction.

Histopathological characteristics of buccal mucosa transplants in humans after engraftment to the urethra: a prospective study

PURPOSE

Histopathological changes in buccal mucosa transplants after engraftment to the urethra and exposure to urine remain nebulous. We investigated histopathological changes in buccal mucosa transplants integrated into the urethra in humans.

MATERIALS AND METHODS

We prospectively evaluated 22 patients with recurrent urethral stricture after buccal mucosa urethroplasty between November 2012 and October 2013. All patients underwent repeat buccal mucosa urethroplasty performed by a single surgeon. Intraoperatively we harvested a sample of the integrated buccal mucosa transplant previously engrafted to the urethra, a sample of healthy urethra, a sample of freshly harvested buccal mucosa from the contralateral inner cheek and a sample of fibrotic tissue from the area of the current stricture. A dedicated uropathologist performed meticulous histopathological examination of all tissue samples using hematoxylin and eosin staining. Preoperative clinical data were also collected on all patients.

RESULTS

The mean interval from previous to current buccal mucosa urethroplasty was 22.2 months (range 4.1 to 76.0). Mean stricture length at repeat urethroplasty was 52.7 mm (range 30.0 to 70.0). Histopathological characteristics of the integrated buccal mucosa transplants were completely preserved in all patients, consisting of thick sheets of stratified nonkeratinized squamous epithelium with a stratum spinosum. Transplants were not partially or entirely overgrown with urothelium.

CONCLUSIONS

Buccal mucosa transplants retain their histopathological characteristics and are not overgrown with urothelium after urethral engraftment and urine exposure in humans. These findings may explain the superiority of buccal mucosa transplants on the outcome of substitution urethroplasty compared to that of other materials.