Perineostomy: the last oportunity

Analysis of prognostic factors of failure in perineal urethrostomy

PURPOSE

To identify prognostic factors of failure in patients undergoing perineal urethrostomy (PU) with Blandy technique, with inverted U-shaped perineal flap.

METHODS

This is a retrospective study of PU of non-oncological causes (2001-2017). Data of age, BMI, history of diabetes mellitus, etiology of urethral stricture, type of stricture, previous surgeries, dilatation and suprapubic catheter were collected. Failure was defined as the need for any instrumentation after surgery. Variables were analyzed by Cox regression and Kaplan-Meier curves were used for survival analysis.

RESULTS

A total of 115 PU were performed. Median age was 61 years (IQR 53-68) and BMI 27.9 (IQR 25-30.9). The most frequent etiologies were: lichen sclerosus (30.4%), iatrogenic (27%), and idiopathic (25.7%). 62.6% had panurethral stricture. There were no complications in 73%. Clavien I complications occurred in 25.2%, Clavien II in 0.9% and Clavien IVa in 0.9%. The overall success rate was 51.3% with a median follow-up of 71 months. In the last 8 years, it was 75%. In the multivariate analysis, we found that age (p = 0.01), BMI (p = 0.01), date of surgery (p = 0.01), and suprapubic catheter (p = 0.003) were predictive variables. The voiding satisfaction rate was 88.7%.

CONCLUSIONS

PU with Blandy technique is a surgery with low morbidity. During the entire study period, it had a failure rate of 48.7% but the failure rate decreased to 25% over the last 8 years. Age, BMI, date of surgery and suprapubic catheter are the most important prognostic factor of failure.

Lichen sclerosis-induced long segment anterior urethral stricture: The early outcome of one-stage repair using dorsolateral onlay buccal mucosa graft

BACKGROUND

Substitution urethroplasty using buccal mucosal grafts can be performed by several approaches including ventral onlay graft, dorsal onlay graft, or ventral urethrotomy with dorsal inlay graft. Our study aims to evaluate the surgical outcome of dorsolateral buccal mucosal graft for long segment anterior urethral stricture >6 cm in patients with Lichen sclerosus (LS).

METHODS

A retrospective study included patients who underwent repair for long segment anterior urethral stricture >6 cm due to LS between January 2013 and April 2019. All patients were followed-up at 3, 6, 9, and 12 months postoperatively and then yearly by clinical symptoms, uroflowmetry, and calculation of post-void residual urine volume. Retrograde urethrogram was requested for patients with voiding symptoms or decreased maximum flow rate. Stricture recurrence that required subsequent urethrotomy or urethroplasty was considered failure. The success rate and surgical complications were collected and analyzed.

RESULTS

Thirty patients were identified. The median age (range) was 39 (25-61) years and a median (range) stricture length was 8 (6-14) cm. Most of postoperative complications were of minor degree. The success rate at median follow-up of 15 (12-24) months was 86.5%. The median maximum flow rate increased significantly from 6 (2-11) ml/s preoperatively to 18 (range: 6-23) ml/s at the 6th month (p value < 0.001).

CONCLUSION

Dorsolateral buccal mucosal grafts urethroplasty for long anterior urethral stricture caused by LS has a high success rate and low risk of complications including stricture recurrence.

Permanent perineal urethrostomy for anterior urethral strictures: A critical appraisal of long-term outcomes and erectile function

OBJECTIVE

In complex strictures, especially in elderly patients, perineal urethrostomy (PU) provide excellent voiding function. This study aimed at evaluating the long-term voiding and erectile function of PU as a permanent procedure for such strictures.

MATERIAL AND METHODS

We retrospectively evaluated 146 patients who underwent permanent PU at our institution from January 2000 to December 2018. All patients had complex urethral strictures. Patients with posterior urethral involvement were excluded. Patients were followed up at 3 months and then yearly. Failure was defined as the need for any additional procedures. They were also evaluated with the International Index of Erectile Function (IIEF-5) questionnaire. Fisher's exact test and χ² test were used for statistical analysis.

RESULTS

The median age at the time of surgery was 58±7.3 years. The mean stricture length was 6.5±2.1 cm. All the patients had a history of previous surgery, and the average number of procedures per patient was 2.4. The median follow-up period was 26 months. The most common early and late postoperative complications were bleeding and stenosis of the urethrostomy, respectively. A total of 129 (88.3%) patients had a successful surgery. The number of patients with no erectile dysfunction increased from 55.4% to 67.8% after PU. The mean IIEF-5 score improved from 20.07 to 21.31 after PU, but this did not achieve statistical significance (p=0.3558).

CONCLUSION

Permanent PU is an acceptable option for complex long-segment anterior urethral strictures, especially in elderly patients, with an excellent long-term outcome. A majority of patients also maintain a satisfactory erectile function.

Perineal Urethrostomy for Complicated Anterior Urethral Strictures: Indications and Patient's Choice. An Analysis at a Single Institution

OBJECTIVES

To explore indications for a definitive perineal urethrostomy (PU). To objectify the proportion of patients not completing the final stage procedure in an intended multi-stage urethroplasty. To analyze the incentives for both of these scenarios.

MATERIALS AND METHODS

Since 2000, data of all men undergoing urethroplasty at our center have been collected in a database. This study included patients with a definitive PU and patients after ≥1 stages of an intended multi-stage urethroplasty. Patients <18 years or with a follow-up <3 m were excluded. Descriptive statistics were used and groups were compared with nonparametric statistical tests.

RESULTS

Among 1015 urethroplasties, 34 patients underwent a definitive PU and 63 underwent ≥1 stages of an intended multi-stage urethroplasty with a median (IQR) follow-up of respectively 57 (31-120) and 32 (14-101) months. In the definitive PU group, patients were significantly older (P < .001) and had more cardiovascular comorbidity (P = .01), panurethral stricture disease (P = .02) and longer strictures (P = .02) than patients in the multi-stage urethroplasty group. Half of the definitive PUs were surgeon driven and 33% were patient driven. Final stage procedures were completed by 35/63 (56%) patients. Patients not completing the final stage were significantly older (P = .001).

CONCLUSION

Definitive PU is particularly performed in older patients with worse cardiovascular condition, panurethral stricture disease and longer strictures. PU is often explicitly chosen by well informed patients and as nearly half of the patients refuse closure of the urethrostomy after the first stage, a definitive PU should be proposed as reasonable alternative to complicated urethral reconstruction from the start, especially in older patients.

Recent advances in understanding urethral lichen sclerosus

Lichen sclerosus affecting the male genitalia is a poorly understood but potentially devastating condition. The natural history of the condition is beginning to be understood better with longer follow-up of patients. Recent long-term data suggest that circumcision for lichen sclerosus limited to the prepuce may not be curative as was once thought. In addition, surgical treatments should be followed up for longer periods as recurrences may occur after urethroplasty and perineal urethrostomy.