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【Objective】 To explore the learning curve of single-surgeon robot-assisted laparoscopic radical prostatectomy (RARP), which provides a reference for physicians who intend to carry out RARP. 【Methods】 The clinical data of 65 prostate cancer patients who underwent RARP in our hospital during Sep.2022 and Dec.2023 were retrospectively analyzed.The patients’ median age was 67.5(58.1-82.4) years, median total prostate-specific antigen (PSA) was 15.6 (6.7-98.4) ng/mL, median body mass index (BMI) was 20.8(17.4-27.3) and preoperative clinical stage of tumor was T2aN0M0-T3bN1M0.The cumulative sum (CUSUM) method was used to fit the learning curves of machine installation time and operation time.According to the inflection points, the learning curves were divided into different learning stages, and the clinical data of patients at different learning stages were compared. 【Results】 The learning curve of RARP was 12 cases.The 65 cases were divided into three stages: 1st-12th cases in the learning stage, 13rd-43rd cases in the mastery stage, and 44th-65th cases in the proficiency stage.With the increase of the number of surgical cases, the median operation time [191(100-360) min vs. 116(83-165) min vs. 90(75-105) min] and median intraoperative blood loss [403(180-900) mL vs. 236(180-305) mL vs. 94(30-200) mL] in the three stages showed a gradual downward trend (P<0.05).The median machines installation time of the learning stage was significantly longer than that in the mastery stage and the proficiency stage [25(21-28) min vs. 12(11-15) min vs. 12(11-14) min] (P<0.05).The positive surgical marginrate (PSM) in the learning stage was significantly higher than that in the mastery stage and proficiency stage (41.7% vs.22.6% vs.22.7%) (P<0.05). 【Conclusion】 For surgeons with rich experience in traditional laparoscopic surgery, the learning curve of RARP is about 12 cases, and after 43 cases, the operation time and intraoperative blood loss can be further reduced.
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Objective:To investigate the effect of gracilis flap in repair of radiation-induced vesicovaginal fistula.Methods:The data of 18 patients with radiation-induced vesicovaginal fistula treated in the Sixth People’s Hospital Affiliated to Shanghai Jiaotong University School of Medicine from March 2021 to August 2022 were retrospectively reviewed. Their age was (57.3±10.4) years. All patients underwent radical surgery for cervical cancer, and received (24.6±2.8)(range from 20 to 30)times of radiotherapy after surger. The median time between the end of radiotherapy and the onset of vesicovaginal fistula was 14.0(7.8, 18.2)months. The median duration of fistula urine was 12.0(9.8, 18.0)months. All patients were required to use median 19.5(15.8, 27.5) pads per day before surgery. The life quality score(QOL)of 18 cases was median 5.0(5.0, 6.0) points. Three cases had performed laparoscopic vesicovaginal fistula repair, two cases had underwent transvaginal vesicovaginal fistula repair, one case had underwent transvaginal and laparoscopic vesicovaginal fistula repair successively, and the remaining 12 cases were new vesicovaginal fistulas. Two cases were combined with rectovaginal fistulas. All patients underwent the repair of vesicovaginal fistula with gracilis flap interposition in prone and folded knife position, by transvaginal route, the vesicovaginal fistula was mobilized and the two layers were closed, and the vascular pedicle gracilis flap of left inner leg was romoved under the skin tunnel to repair the vesicovaginal fistula. Meanwhile, two cases combined rectovaginal fistulas were repaired and closed the rectovaginal fistulas. The urinary catheters were removed at 3 weeks after the operation and urination was recorded.Results:All patients underwent smooth surgery in (96.6±13.2) minutes. The median follow-up was 13.0(9.8, 20.2)(range from 6 to 24)months. The median number of urine pads used per day in 18 patients was 2.0(1.0, 11.8), and significantly reduced ( P<0.01).QOL score was median 1.0(0, 4.2) point and significantly reduced ( P<0.01).Successful outcome was achieved in 12 patients with no leakage of urine in the vagina. Two cases developed urinary incontinence and required conservative treatment, but the curative effect was poor. Two cases still had vaginal urine leakage performed vesicovaginal fistula repair again. One case was successfully repaired without significant urine leakage.The other case still had significant urine leakage and the QOL score was 3 points. She refused further treatment for self-satisfied. Two cases still had vesicovaginal fistula and rectovaginal fistula after the surgery, and refused further surgery. Conclusions:Repair with gracilis flap interposition is a surgical method with few complications and reliable surgical effect for patients with radiation-induced vesicovaginal fistula.
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Objective:To summarize the ideal strategy for the treatment of female hypospadias.Methods:The data of 12 female patients with hypospadias admitted to the Sixth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine from December 2011 to December 2019 were retrospectively analyzed. The patients was (31.0±16.6) years old (7-67 years old). Among them, 3 cases had a history of pelvic fracture trauma, 3 cases had a history of birth trauma, and the remaining 6 cases had no history of trauma and surgery. Among them, there were 6 cases of congenital hypospadias and 6 cases of acquired hypospadias. The clinical manifestations were urinary incontinence in 6 cases and dysuria in 6 cases. Examination of the normal position of the external opening of the genital urethra did not show the opening of the urethra, but moved down to different parts of the anterior wall of the vagina. All patients underwent urethral lengthening. For congenital hypospadias, the urethral plate is used to cut the coiled tube during the operation to prolong the urethra. For acquired hypospadias, the stenotic urethra was enlarged and lengthened with a labial pedicled flap coil. The subcutaneous fat pad of the labia majora was mobilized and transferred to the outside of the newly constructed urethra to prevent the occurrence of urethro-vaginal fistula and increase the pressure of the urethra. Five patients with significant urinary incontinence underwent bladder neck reconstruction at the same time. Anatomical success of the procedure was defined as the appearance of a normal-shaped external urethral opening beneath the clitoris. Functional success was defined as the absence of moderate to severe urinary incontinence after surgery, and the maximum urinary flow rate was >15ml/s during the 12-month follow-up period.Results:All operations were successfully completed. All patients had no perioperative complications, and were followed up for 18-96 months, with an average of 57.3±32.5 months. All patients were able to urinate spontaneously after operation, 4 cases of urinary incontinence disappeared, and 2 cases improved significantly; 4 cases of patients with strenuous urination urinated smoothly. The remaining 2 cases still complained of dysuria after operation, which was solved by subsequent urethral dilatation. The anatomical repair success rate was 100.0%(12/12) and the functional success rate was 83.3% (10/12).Conclusions:Urethral lengthening is an effective method for female hypospadias. The pedicled fat pad helps to increase urethral pressure and prevent fistulas. For female patients with hypospadias and severe urinary incontinence, bladder neck reconstruction is an ideal method. of the technique.
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Objective:To explore the efficacy of pedicled bladder muscle flap in the repair of urinary tract obstruction.Methods:The data of 26 patients with urinary tract obstruction admitted to Shanghai Sixth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine from March 2016 to June 2021 were retrospectively reviewed. There were 14 males and 12 females, with the age ranged from 2 to 75 years old. Refractory bladder neck obstruction after prostatic hyperplasia surgery in 12 cases, with the age of (70.0±3.5) years old.They all experienced at least 2 times of transurethral stenosis incisionor resection. Transpubic cystostomy tube was placed in 9 patients. Posttraumatic pelvic fractures lead to bladder neck atresia and urethral injury in 6 girls, with the age of (10.5±2.1) years old. The bladder neck atresia and urethral obliteration length was 1-2 cm determined by urethrography. Eight cases suffered ureteral strictures after gynecological myomectomy or ureteroscopy holmium laser lithotripsy(4 cases of each type), including two males and six females, with the age of (55.0±3.2) years old. The length of ureteral stricture or defect was 5-6 cm determined by intravenous urography(IVU) or CT urography(CTU). The patients with bladder neck obstruction underwent the following surgery: The "Y" incision of the bladder and stenosis of the prostate urethra was performed and the pedicled bladder muscle flap was inserted into the normal urethral mucosa to complete the Y-V plasty. In the 6 girl patients, pedicled bladder muscle flap(2-4 cm) augmented reconstruction were performed. All above 18 patients, whose urethral catheter was indwelled for 3-4 weeks, urinary flow rate and urethroscopy examination were performed to evaluate the effect of surgery 4 weeks and 3 months after the operation. As the 8 cases with ureteral strictures, the pedicled bladder muscle flap (7-8 cm) ureteroplasty was performed and the ureteral stent was retained for 4 weeks. Ultrasonography and IVU/CTU were performed 4 weeks and 3 months postoperatively. The patency of the ureteral lumen and whether it is accompanied by hydronephrosis, lower back pain, and urinary tract infection were assessed.Results:All patients underwent pedicled bladder muscle flap reconstructive surgery successfully and no serious complications occurred postoperatively. The patients were followed up for (8.2± 2.2) months. As urethral catheters were removed, 10 patients with refractory neck obstruction could return to normal urination with the urinary flow Q max (17.2±2.8)ml/s, while 2 patient had dysuria and were treated with regular urethral dilatation. The catheter was removed 4 weeks after the reconstructive surgery in 6 girls with bladder neck atresia and urethral injury after posttraumatic pelvic fracture. Five could successfully urinate with the urinary flow Q max of (16.7±1.1)ml/s, and one girl had urinary incontinence, waiting for further operation.The ureteral stent was removed after ureteroplasty in 8 patients. CTU and IVU examination showed no ureters with obstruction.No one had low back pain, discomfort, or urinary tract infection. Conclusions:The reconstruction using the pedicled bladder muscle flap was a convenient, minimally invasive and effective technique for the management of adjacent lower ureters, bladder neck, and proximal urethra.
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Rectourethral fistula (RUF) has been difficult to manage in urology due to its special anatomical location,complicated condition and uncertain prognosis. With the increasing incidence of prostate cancer,the incidence of RUF as a serious complication is also rising. Major treatment methods of RUF include conservative treatment and surgical treatment such as transabdominal approach,trans-perineal approach,trans-sphincter approach and trans-anal approach. However,there is no explicit treatment protocol. In recent years,the application of modified York-Mason technique has achieved good results. This article details the key steps and surgical experience of the technique.
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【Objective】 To evaluate the safety and efficacy of transobturator bulbourethral suspension with modified four-armed pelvic sling for post-prostatectomy incontinence (PPI). 【Methods】 The clinical data of 78 male PPI patients treated during Jan.2012 and Dec.2017 in our hospital were collected. The incontinence quality of life (I-QOL) score, daily use of urine pad, 1-hour urine pad test, residual urine volume (RUV), and maximum flow rate (Qmax) were assessed before and after surgery. 【Results】 The total success rate was 79.5%, of which the cure rate was 56.4% and the improvement rate was 23.1%. The preoperative I-QOL score was (54.6±3.9), daily use of urinary pad was (3.6±0.7), and increase in weight of the 1-hour urine pad test was (33.6±5.0) g. Three years after surgery, the I-QOL score was (80.4±5.7), daily use of a urinary pad was (1.9±0.4), and increase in weight of the 1-hour urine pad test was (7.4±1.3) g. Compared to preoperative status, the I-QOL score, daily use of urine pad, and increase in weight of the 1-hour urine pad test 3 years after surgery improved significantly (P<0.05). During the mean follow-up of (61.4±20.5) months, no significant changes in the I-QOL score, daily use of a urinary pad, 1-hour urinary pad test, RUV or Qmax were observed, and no complications occurred. 【Conclusion】 Transobturator bulbourethral suspension with modified four-armed pelvic sling is an effective and safe procedure to treat post-prostatectomy incontinence. The long-term efficacy is satisfactory.
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Objective:To investigate the effect of modified York-Mason technique on urethrorectal fistula after radical prostatectomy.Methods:A retrospective analysis of clinical data from 20 patients with urethrorectal fistula after radical prostatectomy admitted to Shanghai Sixth People's Hospital from May 2016 to October 2022 was conducted. Patients’ average age was (76.6±4.2) years. The etiology was rectal injury during radical prostatectomy. Patients present urine leakage from the anus during micturition. 2 cases also had bladder neck stenosis, and 1 case had urinary incontinence.3 cases had radiotherapy history because of prostate cancer. The average duration of urethrorectal fistula was (1.8±2.3)years. Preoperative imaging confirmed the presence of contrast agent flowing from the bladder neck into the rectum. Three suspicious patients also underwent CT three-dimensional reconstruction. Urethroscopy revealed a depression at the bladder neck in five cases. Anorectal examination in five cases showed the formation of gas bubbles in the lower anterior wall of the rectum, along with a concave anterior wall. The distance from the fistula to the anal margin was (6.0±2.1) cm, with fistula diameters ≥1 cm in twelve cases, <1 cm in eight cases. Twelve patients had previously undergone cystotomy, and seventeen patients had undergone colostomy. The modified York-Mason procedure was adopted for all 20 cases. The patients were under general anesthesia and placed in the prone jackknife position, with the buttocks spread and fixed to the sides to expose the anus. An 8 cm-long incision was made from two points near the sacrococcygeal joint to the anal edge, representing the modified York-Mason approach. After dividing the anal sphincter muscle, both sides were marked using 3-0 chromium thread for subsequent anal reconstruction. The urethrorectal fistula was exposed, and the urethral side of the fistula was sutured with 4-0 absorbable thread, while the anterior rectal wall side was sutured with 3-0 absorbable thread. In cases of bladder neck stenosis, urethral internal incision was performed, and a urethral catheter was retained for 3 weeks postoperatively. Perianal incision drainage tubes were removed after three days. Patients had colostomy repair could eat the day after surgery, while those who didn’t were fast for five days and received intravenous nutrition.Results:All 20 cases in this group were successfully completed without complications during surgery. Follow-up ranged from 10 to 48 months after surgery. Seventeen (17/20)cases had unobstructed urination, with a maximum urine flow rate >15 ml, and no urine leakage from the anus. Postoperative urethrography and cystourethroscopy showed there were no urethrorectal fistulas in 15 cases. None of the patients experienced fecal incontinence after the surgery, except for three patients with a history of radiotherapy who continued to experience anal leakage. One patient underwent a second modified York-Mason procedure and achieved complete recovery three months after the second surgery. Another patient had anal discharge, and the fistula healed after two weeks of urethral catheter retention. One patient refused further treatment due to advanced age and frailty but still had anal leakage. Another patient experienced regular urethral dilation for urination difficulties, while one patient continued to have urinary incontinence.Conclusions:The modified York-Mason technique could be an effective method for urethrorectal fistula after radical prostatectomy with high success rate and few side effects.
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The treatment of vesicovaginal fistula after radiotherapy is difficult. Surgical repair is challenging and the success rate is low. The gracilis flap is widely used in the repair surgery of the perineal region, while it is rarely reported for the repair of vesicovaginal fistula domestically. This article reports a case of vesicovaginal fistula after radiotherapy treated with gracilis flap tamponade. The patient was admitted to the hospital because of continuous vaginal leakage of urine for more than 3 years. Digital vaginal examination and urethroscopy showed that a fistula with a diameter of about 3 cm located at the bladder triangle leading to the vagina. The patient had history of cervical cancer surgery and 23 times of postoperative adjuvant radiotherapy. She underwent vesicovaginal fistula repair with gracilis muscle flap. The urethral catheter was removed 3 weeks after the operation. The patient could urinate normally without vaginal leakage. After 10 months of follow-up, there was no vaginal leakage of urine and patient remains continent.
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Objective:To compare the outcomes of combined lingual mucosal graft with buccal mucosal graft urethroplasty and combined lingual mucosal graft with ADM (acellular dermal matrix) urethroplasty for the treatment of repair failed hypospadias.Methods:From February 2017 to February 2019, 26 patients with failed hypospadias repairs were treated with combined lingual mucosal graft with buccal mucosal graft urethroplasty (14 cases in Group A), and combined lingual mucosal graft with ADM urethroplasty (12 cases in Group B). The mean age of Group A was (29.5±1.2) years (range 18.0-41.0 years), and (26.5±0.8) years (range 20.0-38.0 years) in Group B. The previous operation times was mean (3.6±0.7)(range 2-5 times) and (4.6±0.8)(range 3-5 times) in Group A and Group B respectively. Operation method: All patients were nasally intubated, the remaining curvature was corrected, the fibrous tissue or scar was removed, and the defected urethra was measured. In Group A, the lingual mucosa was spread and fixed to the corpora cavernosa over the midline as the urethral plate, the buccal mucosa was covered the lingual mucosa as ventral urethra, both the mucosa lateral edges was sutured. In Group B, the lingual mucosa was harvested and fixed to the corpora cavernosa the same as in Group A, the ADM was made appropriate length and width, covered and sutured with the lingual mucosa. The lingual mucosa was harvested mean (5.0±0.2)cm(range 4-6cm)long, mean (1.2±0.2)cm (range 1.0-1.5cm)wide and mean (5.0±0.2)cm(range 5-6cm)long, mean (1.2±0.2)cm (range 1.0-1.5cm)wide in Group A and Group B respectively( P<0.05). In Group A, the buccal mucosa was harvested mean (4.1±0.2)cm(range 3.5-5.5cm)long, mean (1.2±0.2)cm wide. Criteria for successful repair of hypospadias were set as: ①The appearance of the penis is nearly normal; ②The penis curvature was corrected; ③Urethra orifice in normal position; ④Urine flow line is normal. The outcomes of the two groups were analyzed and compared, statistical analysis was done using SPSS 18.0 software. Results:The mean follow-up time was (16.3±1.6)(8-24) months. The age, number of preoperative surgeries, number of previous oral mucous membranes, and length of urethral defects were no statistically significant differences between the two groups in A and B( P>0.05). The length of oral mucosa was harvested during the operation between group A and Group B were statistically significant differences( P<0.05). The incidence of oral complications in group A and B: Oral pain 7/14, 1/12; The feeling of tension in mouth 8/14, 1/12; The numbness in the oral 8/14, 1/12, A and Group B were statistically significant differences( P<0.05). The incidence of urethral complications in group A and Group B: the urethra fistula 1/14, 4/12; the urethral stricture 2/14, 6/12, there were statistically significant differences between the two groups ( P<0.05). Penile curvature 2/14, 1/12, ( P>0.05). The success rate was 12/14 and 5/12 in Group A and B respectively, with statistical difference( P<0.05). Conclusions:Combined lingual mucosal graft with buccal mucosal graft urethroplasty could be a good choice for repeated failed hypospadias repairs. Combined lingual mucosal graft with ADM urethroplasty has many complications and less success, should be performed in caution.
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Objective:To investigate the characteristics and the management of male genital lichen sclerosus (MGLSc)accompanied by urethral carcinoma.Methods:A retrospective analysis was performed on 16MGLSc accompanied by urethral carcinoma patients who were referred to Shanghai Sixth People’s Hospital between June 2000 and August 2019. The average age was 53.7 (45-69) years. All of the patients had a mean history of MGLSc 15(6-35) years, anterior urethral stricture received urethral dilatation and other inappropriate urethrotomy treatment for 10 (8-15) years. There were 5 cases of solid mass 4.5 (3-7) cm in scrotum, accompanied by obviously pain. There were 11 cases of infective masses 6(4-10)cm in the perineum, and the masses were ulcerated with purulent secretions and residue-like pus mixed with necrotic tissues draining from the wounds. Urethrocutaneous fistula developed in 9 cases, and the secretions in the fistula cannot heal. The diseased tissue was confirmed by pathology as the metastasis of invasive urothelial carcinoma in 12 patients and urethral squamous cell carcinoma in 4 patients. 9 cases of tumor invaded corpus spongiosum or corpus cavernosum, 5 cases invaded corpus spongiosum or corpus cavernosum, with enlarged firm one side inguinal node. 2 cases of tumor invaded corpus cavernosum, beyond prostatic capsule and bladder neck, bilateral palpable inguinal lymph nodes metastasis were found, one case found tumor involved the left testis. 9 cases were T 2-3N 0M 0, 5 cases T 2-3N 1M 0, 1 case T 3N 2M 0, 1 case T 4N 2M 1. 5 patients with substantial tumors located in the scrotum, penile-sparing scrotum tumor, urethral tumor resection and urethrostomy was performed in 2 patients. Partial phallectomy, urethral tumor resection and perineal urethrostomy were performed in 3 patients. 11 patients with urethral cancer complicated with perineal infectious mass, 2 patients underwent extensive resection of the tumor and suprapubic cystostomy. 8 cases with perineal tumor infection complicated with urethrocutaneous fistulas formation, of which 2 patients received perineal mass, urethral tumor, fistula resection and suprapubic cystostomy, 4 patients with unilateral inguinal lymph node metastasis and received perineal mass, urethral tumor, fistula, lymph node resection and suprapubic cystostomy. 2 patients with bilateral inguinal node metastasis underwent total phallectomy and urethrectomy, inguinal lymph node resection and suprapubic cystostomy. One case of perineal infectious mass with urethral cutaneous fistula and unilateral inguinal lymph node metastasis (T 2-3N 1M 0) gave up tumor resection. Results:The pathological examination of surgical resection of the glans and urethra showed typical MGLSc manifestations as epithelial keratinization, basal cell vacuoles degeneration, dermis lymphocyte infiltration. The pathological examination of the surgical excised diseased urethra and surrounding tumor tissue showed invasive urothelial carcinoma in 12 patients. Immunohistochemical staining showed positive expression of P53, Ki-67 and GATA3. 4 patients of urethral squamous carcinoma and immunohistochemical staining showed positive expression of Ki-67, P40 and GATA3. All patients received cisplatin combined with gemcitabine chemotherapy for an average of 4.8 (2-6)courses and received local radiotherapy (50-70Gy/5w). The mean postoperative survival time of the 16 patients was 26 (3-48) months, and the survival time of urethral transitional cell carcinoma and squamous cell carcinoma was 29 (18-48) months and 18 (3-24) months, respectively. All patients died of tumor metastasis, with 6 patients of lung metastsis, 2 patients of lumbar and bone metastasis, 3 patients of liver metastasis, 2 patients of brain metastasis and 3 patients of lung combined with bone metastasis.Conclusions:MGLSc can cause urethal stricture and urethral carcinoma. The clinical manifestations are dysuria, urinary tumor, repeated infection and urethral fistula. Tumor excision and urinary diversion are common surgical methods. Urethral transitional cell carcinoma and squamous cell carcinoma are common pathological types. Postoperative combined radiotherapy and chemotherapy can be used, but the overall prognosis is poor.
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Objective To analysis the risk factors for stricture recurrence after excision and primary anastomotic urethroplasty (EPA).Methods 209 urethral stricture cases managed with EPA were retrospectively studied from January 2017 to December 2018 in our center.Of all the patients,183 cases were diagnosed as posterior urethral stricture and 26 cases were diagnosed as bulbar urethral stricture.Their age ranged from 5 to 78 years(mean 42.1 years).25 cases(12.0％) were defined as the obesity,whose BMI was more than 28 kg/m2.12 cases(5.7％) has the history of diabetes mellitus.103 cases(49.3％) smoked at least three months before operation.127 cases(60.8％) didn't have the history of dilation.42 cases(20.1％)had the history of dilation once or twice.40 cases (19.1％)had the history of dilation more than three times.The history of urethroplasty included once in 38 cases(18.2％) and more than twice in 8 cases (3.8％).The location of stricture included posterior urethral stricture in 183 cases and bulbar stricture in 26 cases.The history of stricture ranged from 1 to 360 months(mean 35.1 months).The stricture length was(3.19 ±0.65)cm.The causes including trauma in 190 cases,iatrogenic urethral injury in 12 cases,inflammatory in 2 cases and others in 5 cases.The standard of stricture recurrence were defined as the urination dificulty after removal of catheter and endoscopic or radiographic evidence of obstruction in the area of repair.Univariate and multivariate analysis were performed by the use of Cox's proportional hazards regression model to identify the related factors for stricture recurrence.Result The following up period was ranged from 3 to 32 months(average 18.78 months).Recurrence occurred in 31 cases in the period of 1.0 to 18.0 months(average 5.34 months).Factors had statistical differences in univariate analysis including stricture period(HR =1.007,P ＜ 0.001),stricture length (HR =5.334,P ＜ 0.001),history of direct vision internal urethrotomy (DVIU) (HR =2.901,P =0.003),history of urethral dilation ≥ 3 times (HR =6.214,P ＜ 0.001),history of urethroplasty 1 time,≥2 times (HR =4.175,P =0.001,HR =9.885,P ＜ 0.001),3 months smoking before surgery(HR =2.605,P =0.016),suprapubic cystostomy (HR =0.231,P =0.006),inferior pubectomy(HR =6.603,P ＜0.001).In multivariate analysis stricture length (HR =4.911,P ＜ 0.001),history of urethroplasty 1 time,≥ 2 times (HR =2.387,P =0.045,HR =3.688,P =0.015),3 months smoking before surgery (HR =2.730,P =0.030) were independent risk factors.Conclusion The urethral stricture recurrence mainly occurred within 6 months after surgery.The length of stricture,history of urethroplasty and 3 months smoking before surgery were the independent risk factors for stricture recurrence.
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Objective:To investigate the clinical efficacy of lingual mucosa graft coupled penis flap urethroplasty for crippled hypospadias.Methods:Between January 2016 and August 2019, 16 patients with crippled hypospadias in Shanghai Sixth People's Hospital were included in this study. Their mean age was 35.2 years (range from 25 to 44 years). All patients presented voiding difficulty and failed after 2 or more times of urethroplasty. Their mean times was 4.6(range from 2 to 7 times). Uroflowmetry examination showed their mean Q max was 6.7 ml/s (range from 3.8 to 9.6ml/s). Chordee was found in six patients. Urethrocele was found in 2 patients. Urethrocutaneous fistula was found in 2 patients. All patients received lingual mucosa graft coupled penis flap urethroplasty. By removing the ischemic and fibrotic urethra, urethral plate was reconstructed with lingual mucosa graft and the penis flap was transplanted to cover the reconstructed urethra plate to form a new urethral lumen, which was used to repair the defective urethra. The catheters were removed three weeks after the surgery. Uroflowmetry examination, cystourethrography and cystoscope were performed after the catheters out. Results:All patients underwent smooth surgery with an average duration of 128.4 minutes (range from 105 to 150 minutes). After mean follow-up of 18.6 months (range from 3 to 30 months), successful outcome was achieved in 14 patients and uroflowmetry examination at the seventh week after surgery showed their mean Q max was 22.4 ml/s (range from 15.6 to 29.8 ml/s). 2 cases had urethrocutaneous fistula which were cured after repair of penile urethral fistula. 2 patients still had a certain level of chordee while they were satisfied with the appearance of their penis, so there was no further treatment. Conclusions:Single stage lingual mucosa graft coupled penis flap urethroplasty has short operation period, relatively high success rate and relatively few complications. Single stage lingual mucosa graft coupled penile flap urethroplasty is an available option for crippled hypospadias with several times of failed urethroplasty.
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Objective@#To analysis the risk factors for stricture recurrence after excision and primary anastomotic urethroplasty(EPA).@*Methods@#209 urethral stricture cases managed with EPA were retrospectively studied from January 2017 to December 2018 in our center. Of all the patients, 183 cases were diagnosed as posterior urethral stricture and 26 cases were diagnosed as bulbar urethral stricture. Their age ranged from 5 to 78 years(mean 42.1 years). 25 cases(12.0%) were defined as the obesity, whose BMI was more than 28 kg/m2. 12 cases(5.7%) has the history of diabetes mellitus. 103 cases(49.3%) smoked at least three months before operation. 127 cases(60.8%) didn't have the history of dilation. 42 cases(20.1%)had the history of dilation once or twice. 40 cases (19.1%)had the history of dilation more than three times. The history of urethroplasty included once in 38 cases(18.2%)and more than twice in 8 cases(3.8%). The location of stricture included posterior urethral stricture in 183 cases and bulbar stricture in 26 cases. The history of stricture ranged from 1 to 360 months(mean 35.1 months). The stricture length was(3.19±0.65)cm. The causes including trauma in 190 cases, iatrogenic urethral injury in 12 cases, inflammatory in 2 cases and others in 5 cases. The standard of stricture recurrence were defined as the urination difficulty after removal of catheter and endoscopic or radiographic evidence of obstruction in the area of repair. Univariate and multivariate analysis were performed by the use of Cox′s proportional hazards regression model to identify the related factors for stricture recurrence.@*Result@#The following up period was ranged from 3 to 32 months(average 18.78 months). Recurrence occurred in 31 cases in the period of 1.0 to 18.0 months(average 5.34 months). Factors had statistical differences in univariate analysis including stricture period(HR=1.007, P<0.001), stricture length(HR=5.334, P<0.001), history of direct vision internal urethrotomy (DVIU)(HR=2.901, P=0.003), history of urethral dilation ≥3 times(HR=6.214, P<0.001), history of urethroplasty 1 time, ≥2 times(HR=4.175, P=0.001, HR=9.885, P<0.001), 3 months smoking before surgery(HR=2.605, P=0.016), suprapubic cystostomy(HR=0.231, P=0.006), inferior pubectomy(HR=6.603, P<0.001). In multivariate analysis stricture length(HR=4.911, P<0.001), history of urethroplasty 1 time, ≥2 times(HR=2.387, P=0.045, HR=3.688, P=0.015), 3 months smoking before surgery(HR=2.730, P=0.030)were independent risk factors.@*Conclusion@#The urethral stricture recurrence mainly occurred within 6 months after surgery. The length of stricture, history of urethroplasty and 3 months smoking before surgery were the independent risk factors for stricture recurrence.
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Objective To explore the erectile function preservational mechanism of Non-transecting urethroplasty(NTU) for posterior urethral stricture.Methods From May 2012 to September 2016,62 patients with posterior urethral stricture,who were treated with NTU,were enrolled in this study.The mean age was 37.5 years old,ranging 18-48 years old.The causes were pelvic fracture urethral injury in 53 cases and iatrogenic injury in 9 cases.Preoperative urethrography and urethroscopy revealed the strictures located in posterior urethra,which was at the distal of verumontanum.The mean length of stricture was 2.1 cm,ranging 0.5-2.5 cm.The average period between trauma and surgery was 6.4 months,ranging 3 months-2 years.All patients had no previous history of urethroplasty.Their sexual hormones were in normal level.Among those patients,the IIEF-5 scores were more than 12 and number of events during NPT test were more than twice.Finally,43 cases were underwent NTU and 19 cases accepted inferior pubectomy (IP)+ NTU.All patients had a general anesthesia.The bulbar urethra was mobilized dorsally from the tunica albuginea of the corpora cavernosa and then extended proximally up toward the perineal membrane.Scar tissue surrounding the urethra was excised and inferior pubectomy (IP) was performed as a supplemental technique to keep the suturing position without tension.The ventral hemi-circumference was then sutured with interrupted 4-0 polyglycolic sutures with tension-free anastomosis.The 18-Fr indwelling catheter was inserted.Result Average follow-up was 20.2 months,ranged from 12 to 36 months.In NTU group,NPT test revealed no significant difference in number of events (2.7 ± 0.7 vs.3.0 ± 1.0,P ＞ 0.05),duration of best episode [(16.4 ± 3.5) min vs.(16.4 ± 3.8) min,P ＞ 0.05)] or tip rigidity [(31.2 ± 4.7) ％ vs.(30.8 ± 3.5) ％,P ＞ 0.05)] between pre-and post-operation,respectively.The IIEF-5 score (19.7 ± 1.9 vs.20.4±2.1,P＜0.05)and Qmax[(8.7 ±4.0)ml/s vs.(25.5 ±4.7)ml/s,P＜0.05)] increased significant pre-and post-operation,respectively.In IP + NTU group,Qmax [(8.4 ± 4.4) ml/s vs.(23.1 ± 3.5)ml/s,P ＜ 0.05)] increased significant pre and post operation.The NPT test revealed slight decrease in number of events(2.3 ± 0.6 vs.1.6 ± 1.0,P ＜ 0.05),duration of best episode [(15.6 ± 2.4) min vs.(14.5±2.4)min,P＜0.05)] or tip rigidity [(29.8±3.0)％ vs.(25.6 ±7.1)％,P＜0.05)] between pre-and post-operation,respectively.However,the IIEF-5 scores (17.3 ± 1.6 vs.16.5 ± 2.1,P ＜ 0.05) didn't show significant difference pre-and post-operation.Stricture recurrence occurred in 3 patients,the success rate was 95.2％ (59/62) during 12 months following.Conclusion NTU is not only a safe and promising procedure for posterior urethral stricture less than 2.5cm,but also a new minimally invasive approach to preserve erectile function.
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Objective To investigate the clinical effect of transverse island fasciocutaneous penile flap in the treatment of meatus and navicular fossa stricture.Methods Fifteen patients with urethral reconstruction with transverse island fasciocutaneous penile flap from October 2014 to December 2018 were enrolled.Six patients had a history of urethroscopic surgery,three had a history of lichensclerosus,three had a history of urethral dilation,and three had no obvious causes.All patients underwent transverse incision under the coronal sulcus,and after fully dissecting the urethra,the urethra was opened longitudinally ventrally.After measuring the actual length of stenosis,the irradiance fascia flap with the corresponding length of the incision was reconstructed.The patients were reviewed at 1 and 3 months after operation,and any complications such as recurrence or urinary fistula were recorded.The urine flow rate was tested 3 months after surgery.Results All 15 patients in this group underwent a successfully operation.The actual measurement of urethral stricture length was 0.5-4.0 cm during operation,with the average of 2.82 cm.Three months after the operation,the urine flow rate ranged from 13.5 ml/s to 23.7 ml/s,with an average of 18.5 ml/s.The overall successful rate was 93.3％ (14/15).The rate of post-operative fistula was 20.0％ (3/15).Two cases complained of needle-like fistula at the incision.One case healed after 3 months,and the other gave up further treatment.One patient developed urethral stricture and urethral skin spasm again 1 month later and was surgically repaired again.Conclusions The initial experience of pedicled island fascia flap for the treatment of urethral stenosis and scaphoid stenosis is safe,feasible and effective for the treatment of urethral stricture.
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Objective To investigate the clinical effect of laparoscopic modified bladder neck Y-V plasty in the treatment of recurrent bladder outlet obstruction after surgery for prostatic hyperplasia.Methods Seventeen patients with recurrent bladder outlet obstruction after prostatic hyperplasia operation from May 2017 to January 2019 was treated by laparoscopic bladder neck Y-V plasty,with the median age of 71 years old (65-81 years).All had a history of repeated urination obstruction and urinary tract infection,and experienced at least 2 times transurethral stenosis incision,resection or repeated urethral dilatation,with 12 cases of bladder neck stenosis (type Ⅰ) and 5 cases of middle prostate stenosis (type Ⅱ).Three-port laparoscopy surgery was performed with outer-peritoneal route into the Retzius Gap.After revealing the bladder and prostate junction,the "Y" incision of the bladder and stenosis of the prostate urethra was firstly performed,and inverted symmetrical "V" shape suture was performed with two 3-0 Stratifix suture for two layers,including the 1th layer suture of mucosal and inner muscle layer,and the 2nd layer suture of the outer muscle and the serous layer.F22 silicone catheter was indwelled for 2 weeks postoperatively.Urinary flow rate and bladder urethral examination were perfrmed to evaluate the effect of surgery 2 weeks and 3 months after the operation respectively.Results Seventeen operations were completed successfully,with the median operation time of 100 minutes (30-100 minutes),the median operation blood loss of 50 ml (20-100 ml),and the median hospital stay of 5 days (1-7 days).The patient had unobstructed voiding after removing the urinary catheter 2 weeks postoperatively,and had no urinary incontinence.Postoperative median follow-up was 7 months (3-17 months) and no stenosis of the urethra was detected.Conclusions Laparoscopic modified bladder neck Y-V Plasty has the advantages of high success rate,low recurrence rate and minimally invasiveness in the treatment of recurrent bladder outlet obstruction after prostatic hyperplasia surgery,which is worthy of clinical application.
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Objective To evaluate the clinical efficacy of different tissue flaps interposition in reconstructing urethra-rectal fistulas associated with posterior urethral strictures.Methods Twenty-nine patients with urethra-rectal fistulas associated with posterior urethral strictures (15 patients after traffic accident trauma,9 after falling injury,and 5 after pelvic crush injury) were included in this study.Transperineal urethral reconstruction and fistula repair with perineal subcutaneous dartos pedicled flap transposition was performed in 15 patients in whom fistulas were near the anus (＜ 5 cm) and the perineal subcutaneous tissues were rich in blood supply.An interposition gracilis muscle flap was placed in 14 patients with fistulas located farther from the anus (≥Scm) or poor perineal local tissue condition.Results After a mean follow-up of 24.5 months (5-67 months),successful repair was achieved in 12 of 15 patients (80.0％) undergoing perineal subcutaneous dartos pedicled flap transposition,and in 11 of 14 patients (78.6％) undergoing gracilis muscle transposition.The overall success rate was 79.3％.No longterm procedure related complications occurred except medial thigh numbness in 1 patient.Conclusions The perineal subcutaneous dartos pedicled flap is suitable for hypervascular and low-positioned urethra-rectal fistulas located less than 5 cm from the anus.For patients with high-positioned fistulas or poor perineal local tissue conditions,the gracilis muscle flap is recommended.The technique of vascularized tissue pedicled flap transposition is essential for urethra-rectal fistula repair.
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Objective To compare donor site complications of buccal or lingual mucosa grafts harvesting for substitution urethroplasty.Methods From June 2014 to December 2016,a total of 50 patients who were diagnosed anterior urethral strictures or hypospadias underwent buccal or lingual mucosa grafts urethroplasty.The mean age of the patients was 43.6 years (range 32-56 years).25 patients used buccal mucosa grafts (BMG group) for urethroplasty with the median age of 43.1 years (range 32-54 years);the other 25 patients received lingual mucosa grafts (LMG group) for urethroplasty,aged 44.2 years (range 35-56 years).Patients were evaluated for postoperative oral pain morbidity using the visual analogue pain scale (0-10) as well as an questionnaire for difficulty with eating,speech impairment,dysgeusia,tightness of the mouth.The evaluations were carried out at 3 days,2 weeks and 3 months postoperatively.Results In BMG group,the length and width of the graft was (5.24 ± 0.89) cm and (1.48 ± 0.50) cm;the graft length was (5.68 ± 0.90) cm and the width was (1.56 ± 0.51) cm in LMG group.There was no difference between the two groups.The mean followup time was (7.8 ± 1.2) months (6-12 months).The median visual analogue pain scale scores of the BMG group 3 days,2 weeks after surgery was 5.84 ±0.85,3.04 ±0.45,and the LMG group 7.20 ±0.57,4.16 ±0.62,respectively,with no statistical difference between two groups.The incidence of events with LMG group versus the BMG group were as follows:difficulty with eating (64％ vs.24％,P =0.004),speech impairment (92％ vs.56％,P=0.004) and dysgeusia (48％ vs.16％,P =0.015)at day 3.The difficulty of eating,speech impairment and dysgeusia of BMG group were lower than that of the LMG group(16％ vs.32％,P =0.031;8％ vs.40％,P =0.008;12％ vs.40％,P =0.024) two weeks after the surgery,whereas the incidence of tightness of the mouth was higher in BMG group(36％ vs.12％,P =0.04).After 3 months,36％ and 32％ of patients treated with buccal and lingual mucosa grafts urethroplasty still reported sensitivity perioral numbness(P ＞ 0.05).Conclusions Oral mucosa grafts are good for substitution urethroplasty,but also with some donor site complications.The early postoperative complications are more common in lingual mucosa graft donor site.Buccal mucosa may be used as the preferred graft for urethroplasty.Lingual mucosal graft may be considered in cases of unavailable buccal mucosa graft or the length of the graft not enough and combined graft treatment.
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Objective To explore the reason that the neo-urethra infection after urethroplasty,and improve the perioperation procedures to reduce infection rate.Methods The clinical data of 62 anterior urethral stricture patients undergoing surgical treatment from July 2014 to April 2017 were analyzed.Then samples from urine,material for urethral reconstruction,urethra orifice and urethra were collected respectively.The bacterial culture,identification and pulsed field gel electrophoresis (PFGE) was performed.All the patients were males,and the mean age was 35.6 years (ranging 10-68 years).Operation methods were urethroplasty using oral mucosa in 40 cases,using penile flap in 23,using scrotal flap in 5,using penile flap combined with oral mucosa in 9,using penile flap combined with scrotal flap in 3 and using preputial flap in 1.Results The bacteria isolated from urethra orifice after operation were consistent with bacteria isolated from the neo-urethral lumen in 41 cases.There were 18 cases that shared the identical bacteria isolated from material for urethral reconstruction and neo-urethral lumen.In 7 patients,under careful isolation and identification,same bacteria were found to exist in both preoperative urethral lumen and neo-urethral lumen.Bacteria were not detected in the neo-urethral lumen in 13 cases.The bacteria isolated from urine were consistent with bacteria isolated from the neo-urethral lumen in 3 cases.Conclusions The bacteria in the neo-urethra mainly come from urethra orifice.Urine is not the main source for bacteria in neo-urethra.Perioperative intervention for sources of bacteria is an effective measure to improve the success rate of operation.
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Objective To assess the feasibility and efficacy of multi-modality three dimensional imaging reconstructive technology in diagnosing the urethral stricture.Methods Totally,121 male patients,suffered with urethral strictures,were enrolled in this study between January 2012 and June 2017.Their age ranged from 17 to 63 years old.The etiology included pelvic fracture in 71 cases,straddle injury in 16 cases,iatrogenic injury in 25 cases,infection in 9 cases.All patients accepted the routine antegrade and retrograde urethrography.The slim CT scan and 3D image reconstruction were performed in patients with posterior urethral stricture.The 3D ultrasound detection and image reconstruction were used in patients with anterior urethral strictures.The fly-through mode was used in each 3D image in order to simulate the process of endoscopic examination.The length of stricture was compared between that in traditional urethrography and in 3D dimensional image,based on the results from anastomotic procedure and substitution.Result Among patients,71 cases were diagnosed as posterior urethral stricture and 50 cases were diagnosed as anterior urethral stricture.In those patients with posterior urethral stricture,no statistical significant difference of stricture length was noticed between traditional urethrography and 3 D dimensional image [(2.30 ± 1.60)cm vs.(2.18 ± 1.55)cm,P =0.91)].In patients who complained about the urine leakage from anus,higher detective rate of fistula could be seen in the CT 3D image than that in traditional endoscopic examination (87.9％ vs.77.6％).To patients with anterior urethral strictures,no statistical significant difference of stricture length was noticed between traditional urethrography and 3D dimensional image [Penile:(2.13 ±0.34) cm vs.(2.24 ± 0.31) cm,P =0.13;Bulbar:(1.98 ± 0.47) cm vs.(2.13 ± 0.32) cm,P =0.23)].However,the advantage of 3D image could be shown in detecting the lesion of navicular fossa and periurethral pathologic fibrosis.In the fly-through mode,the effect of 3D CT image seems to be superior to that in the 3D ultrasound image,which could show more smooth urethral wall and longer urethral segment.The limitation of those 3D image reconstructive technology was that long time consuming was needed during the 3D image reconstruction.Conclusion Our study showed that the multi-modality three dimensional imaging reconstructive technology can improve the sensitivity and specify in diagnosing the urethral stricture.After some modification,it will become the alternative method in diagnosing the urethral stricture.
