Standing the test of time: the long-term results of urethroplasty.

The principle indication for urethral surgery is stricture disease. There are a number of factors that influence the outcome of surgery including location of the stricture, stricture length, aetiology, previous surgery and selection of procedure. Outcomes for different techniques are summarised. The gold standard remains anastomotic urethroplasty, where appropriate, with patch urethroplasty or two-stage stage procedures for more complicated strictures especially the penile urethra.

Structural assessment of the urethral sphincter in women with urinary retention.

PURPOSE: The pathophysiology of urinary retention in women is generally unknown but a subgroup of women with urinary retention have been diagnosed as having so-called primary disorder of sphincter relaxation on the basis of an abnormal urethral sphincter electromyogram. It was suggested this sphincter overactivity could lead to work hypertrophy of the urethral rhabdosphincter and in this study we looked for any evidence of such muscle fiber hypertrophy. MATERIALS AND METHODS: In 9 women 18 to 45 years old (mean age 31.6) with urinary retention and overactive urethral sphincter electromyogram, light and electron microscopy were used to examine core needle biopsies of the urethral rhabdosphincter taken under transvaginal ultrasound control. Of the 9 patients only 5 biopsies processed for light microscopy and 4 processed for electron microscopy contained striated urethral muscle fibers. The results of these biopsies were compared to the morphology of a control specimen from a postmenopausal woman without a history of urinary retention. RESULTS: On light microscopy the urethral rhabdosphincter fiber diameter did not differ among patients (mean average 7.6 mum), was less than that reported in the literature (15 to 20), but did not differ from that of the control (mean 9.9). In all patients electron microscopy showed excessive peripheral sarcoplasm with lipid and glycogen deposition, and sarcoplasmic accumulation of normal mitochondria. These ultrastructural abnormalities were not seen in the control. CONCLUSIONS: To our knowledge this is the first morphological description of the urethral rhabdosphincter in a subgroup of women with urinary retention. Mean rhabdosphincter fiber diameter was approximately the same in patients and controls. This study does not support the previous theory that urethral sphincter overactivity in a subgroup of women with urinary retention leads to work hyperplasia of urethral rhabdosphincter fibers. An alternative hypothesis is suggested.

The morbidity of buccal mucosal graft harvest for urethroplasty and the effect of nonclosure of the graft harvest site on postoperative pain.

PURPOSE: We assess the medium and long-term morbidity of buccal mucosal graft (BMG) harvest for urethroplasty, and evaluate the effect of nonclosure of the graft harvest site on postoperative pain. MATERIALS AND METHODS: A questionnaire was mailed to 110 men who underwent BMG urethroplasty between January 1, 1997 and August 31, 2002. Demographic data and side effects of BMG harvest, including oral pain, sensation and intake, were assessed postoperatively. A prospective study was then performed to compare 20 unselected men whose BMG donor site was closed with a group of 20 men in whom it was left open using a 5-point analog pain score that was completed twice daily for the first 5 postoperative days. RESULTS: A total of 49 men with a median age of 49 years (range 23 to 73) returned questionnaires relating to 57 BMG harvests. Of the graft harvests 47 (83%) were associated with postoperative pain, which was worse than expected in 24 (51%). Of the 57 patients 51 (90%) resumed oral liquid intake within 24 hours and 44 (77%) resumed normal diet within 1 week. Postoperative side effects included perioral numbness in 39 (68%) patients with 15 (26%) having residual numbness after 6 months, initial difficulty with mouth opening in 38 (67%) with 5 (9%) having persistent problems, changes in salivation in 6 (11%) and mucous retention cyst that required excision in 1 (2%). The men in the prospective donor site study had a median age of 51 years (range 24 to 70). Mean pain score for patients with donor site closure was 3.68 and was significantly higher than that for patients without donor site closure (2.26, p < 0.01). CONCLUSIONS: Buccal mucosal graft harvest is not a pain-free procedure. Closure of the harvest donor site appears to worsen this pain and it may be best to leave harvest sites open. The main long-term complications are perioral numbness, persistent difficulty with mouth opening and change in salivary function.

Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective.

PURPOSE: We developed an algorithm for the management of urethral stricture based on cost-effectiveness. MATERIALS AND METHODS: United Kingdom medical and hospital costs associated with the current management of urethral stricture were calculated using private medical insurance schedules of reimbursement and clean intermittent self-catheterization supply costs. These costs were applied to 126 new patients treated endoscopically for urethral stricture in a general urological setting between January 1, 1991 and December 31, 1999. Treatment failure was defined as recurrent symptomatic stricture requiring further operative intervention following initial intervention. Mean followup available was 25 months (range 1 to 132). RESULTS: The costs were urethrotomy/urethral dilation 2,250.00 pounds sterling (3,375.00 dollars, ratio 1.00), simple 1-stage urethroplasty 5,015.00 pounds sterling (7,522.50 dollars, ratio 2.23), complex 1-stage urethroplasty 5,335.00 pounds sterling (8,002.50 dollars, ratio 2.37) and 2-stage urethroplasty 10,370 pounds sterling (15,555.00 dollars, ratio 4.61). Of the 126 patients assessed 60 (47.6%) required more than 1 endoscopic retreatments (mean 3.13 each), 50 performed biweekly clean intermittent self-catheterization and 7 underwent urethroplasty during followup. The total cost per patient for all 126 patients for stricture treatment during followup was 6,113 pounds sterling (9,170 dollars). This cost was calculated by multiplying procedure cost by the number of procedures performed. A strategy of urethrotomy or urethral dilation as first line treatment, followed by urethroplasty for recurrence yielded a total cost per patient of 5,866 pounds sterling (8,799 dollars). CONCLUSIONS: A strategy of initial urethrotomy or urethral dilation followed by urethroplasty in patients with recurrent stricture proves to be the most cost-effective strategy. This financially based strategy concurs with evidence based best practice for urethral stricture management.

Outcome analysis and patient satisfaction following octant transrectal ultrasound-guided prostate biopsy: a prospective study comparing consultant urologist, specialist registrar and nurse practitioner in urology.

PURPOSE: To determine whether transrectal ultrasound-guided biopsy of the prostate is equally reliable and acceptable if performed by urology nurse practitioner or urologist. SCOPE: Octant biopsies were taken by each operator (consultant urologist n=2, urology specialist registrar n=1 and urology nurse practitioner n=2) from 50 consecutive unselected patients and demographics and cancer detection rate were compared between the groups. A postal survey was performed following nurse practitioner biopsy to assess patient satisfaction and acceptance of nurse practitioner biopsy. CONCLUSION: Transrectal ultrasound-biopsy of prostate whether performed by nurse practitioner or urologist is equally reliable if adequate training is provided. Patients are happy to undergo prostate biopsy and receive information about the diagnosis from an appropriately trained prostate cancer nurse specialist.

The type of urethroplasty for a pelvic fracture urethral distraction defect cannot be predicted preoperatively.

PURPOSE: Pelvic fracture urethral distraction defects (PFUDDs) are generally treated surgically by a so-called progression approach consisting of 4 steps to achieve a tension-free bulboprostatic anastomosis. Implicitly the need for each step in turn is predictable according to the length of the defect on preoperative x-ray. MATERIALS AND METHODS: In 62 evaluable patients with PFUDD the length of the radiological defect was compared with the surgical steps that subsequently proved necessary to achieve a tension-free bulboprostatic anastomosis. RESULTS: Except at the extremes of length there was no association between defect length and the scale of the surgery performed. CONCLUSIONS: Surgeons preparing to repair an apparently short PFUDD cannot assume that simple repair is all that is necessary.

The problems of penile urethroplasty with particular reference to 2-stage reconstructions.

PURPOSE: We evaluate the anecdotal high revision rate of 2-stage urethroplasty. MATERIALS AND METHODS: The short-term revision rates after 1-stage (139 cases) and 2-stage (103) urethroplasties were compared. RESULTS: There were 4 revisions after 1-stage urethroplasty (4 of 139, 3%) and all involved the penile urethra (20%). The revision rate was 37.8% after stage 1 and 25.3% after stage 2 and of 2-stage urethroplasty 85%, involved the penile urethra. CONCLUSIONS: Although 2-stage has a significantly lower re-stricture rate than 1-stage urethroplasty for complex strictures in the penile urethra, it does so at the expense of a significantly higher revision rate particularly of the penile urethra.

The long-term results of urethroplasty.

PURPOSE: We update our long-term data on the effectiveness of urethroplasty. MATERIALS AND METHODS: A total of 166 patients operated on before 1990 are currently under followup or lived at least 10 years after surgery. Anastomotic urethroplasty was performed in 82 patients and substitution urethroplasty in 84. RESULTS: The 5, 10 and 15-year re-stricture rates after anastomotic urethroplasty were 12%, 13% and 14%, respectively, and the complication rate was 7%. The 5, 10 and 15-year re-stricture rates after substitution urethroplasty were 21%, 31% and 58%, respectively, and the complication rate was 33%. CONCLUSIONS: The results of anastomotic urethroplasty are good and sustained in the long term, while the results of substitution urethroplasty deteriorate steadily with time and there is definite room for improvement. An anastomotic repair should be performed in preference to a substitution repair when possible.

The Barbagli procedure gives the best results for patch urethroplasty of the bulbar urethra.

OBJECTIVE: To compare the surgical outcome using buccal mucosal free grafts in the Barbagli procedure (dorsal stricturotomy and patch technique) with the traditional ventral approach, for long bulbar urethral strictures. PATIENTS AND METHODS: Over a period of 6 years, a total of 71 patients with bulbar urethral strictures underwent buccal mucosal graft urethroplasty. Twenty-nine patients had a traditional ventral urethroplasty and 42 were managed by the Barbagli procedure with the stricturotomy and patch on the dorsal aspect of the urethra. RESULTS: At 5 years of follow-up 5% of patients who underwent the Barbagli procedure developed recurrent strictures, compared to 14% in the traditional ventral stricturotomy group. All patients developed postmicturition dribble of urine to some degree, which was troublesome in 17% in the Barbagli group and 21% in the ventral stricturotomy group. Complications attributable to out-pouching of the graft were not seen in either group. CONCLUSIONS: The dorsal stricturotomy and patch (Barbagli) procedure had a higher success rate than the traditional ventral urethroplasty. Comparing these results with our experience of skin inlay urethroplasty, buccal mucosal grafts seem to have advantages however they are used.

The nature of urethral injury in cases of pelvic fracture urethral trauma.

PURPOSE: We examine the urethral injury associated with pelvic fracture that is said to be due to a shearing force through the membranous urethra which inevitably destroys the urethral sphincter mechanism. MATERIALS AND METHODS: A total of 20 asymptomatic cases were prospectively studied, including symptomatically, radiologically, endoscopically and urodynamically, 1 to 4 years after an apparently successful anastomotic repair of a pelvic fracture urethral distraction defect. RESULTS: There was evidence of urethral sphincter function, including urodynamically in 11 (55%), endoscopically in 13 (65%) and functionally in 17 (85%) patients. CONCLUSIONS: These findings, coupled with surgical observation, suggest that the urethral injury associated with pelvic fracture is avulsion of the membranous urethra from the bulbar urethra rather than a shearing through the membranous urethra, and that some degree of urethral sphincter function is preserved in a significant percentage of patients.

Substitution urethroplasty with buccal mucosal-free grafts.

PURPOSE: Buccal mucosal grafts and the Barbagli technique are recent developments in the treatment of urethral strictures. MATERIALS AND METHODS: We reviewed the results of and experience with urethroplasty using buccal mucosal graft in 128 patients. RESULTS: The re-stricture rate was 11% for patch grafts and 45% for tube grafts. There were no other complications. CONCLUSIONS: Buccal mucosal graft is at least as good as any other material for substitution urethroplasty with fewer complications. The 2-stage is more reliable than the stage 1 approach for circumferential reconstruction of the urethra.