Dynamic three-dimensional spiral computed tomographic cysto-urethrography: a novel technique for evaluating post-traumatic posterior urethral defects.

OBJECTIVE: To present a new method of identifying the anatomy of posterior urethral distraction defects (PUDDs) using three-dimensional spiral computed tomography/cysto-urethrography (CTCUG), as conventional two-dimensional CUG can give a false interpretation of the exact anatomy. PATIENTS AND METHODS: Twenty-one patients presenting with a PUDD were assessed between February 2001 and October 2002. All patients initially underwent combined ascending and micturating CUG (ACUG), followed by CTCUG analysed using special software. In this technique all soft-tissue densities were subtracted from the volume of interest leaving only high-density images, i.e. pelvic bony structure and the contrast medium-filled bladder and urethra. The images were taken over a sequence and 36 different images viewed by 'roll and spin' techniques, each of which had a different plane of vision. Images were supplied as static CT films and as a movie on a compact disk using a computer program. RESULTS: The technique allows one CT image to be viewed from 36 different angles both dynamically and statically, allowing the surgeon the unique opportunity to view the PUDD through several planes and precisely identify its anatomy. By comparing the data obtained with this technique to those obtained by conventional ACUG, and each in relation to the operative findings, the following aspects could be more thoroughly evaluated by CTCUG: the location of the distraction injury, the length of the distraction defect, the degree and direction of urethral end-alignment, the relation of the ectopic bony fragments and bone callus to the urethra, and the presence of various pathological defects, e.g. fistulae, false passages and diverticulae. CONCLUSION: With CTCUG, both static and dynamic images can be obtained, allowing the easier staging of a PUDD and thus better surgical planning and consequently better results from reconstruction.

Congenital penile curvature with orthotopic meatus : a report on the management of 62 cases following a systematic approach

Objectives We are presenting our experience with a systematic approach in the management of congenital penile curvature (CPC). Patients and Methods Between 1993 and 2000; 62 cases of CPC were treated. Ten of 34 cases (30) presenting with ventral curvature were corrected via excision of the dysgenetic tissue and complete mobilization of the corpus spongiosum only. Two cases (6) had a minimal corporeal disproportion that required a ventral longitudinal deep intercorporeal incision. Six cases (18) were managed with Nesbit's procedure; and tunica albuginea plication (TAP) was done in 8 cases (24). These cases required mobilization of the neurovascular bundle (NVB). Four patients (12) had a small phallus and required ventral grafts (dermal in two and venous grafts in another two). The remaining four patients (12) had a short urethra and were managed by excision of the tethering corpus urethrae and neourethral reconstruction. Cases presenting with lateral curvature (14 patients) were managed by a lateral longitudinal incision at the point of maximum curvature followed by TAP in 10 cases (71) and Nesbit's procedure in four (29). Dorsal curvatures (6 cases) were managed by ventral Nesbit in four (67) and ventral TAP in the remaining two cases (33). Patients with a complex curvature (8 cases) were managed by sequential TAP on an individual basis according to the results of intraoperative artificial erection in 5 cases (63) and by complete penile disassembly: The follow-up period ranged from 6 months to 2 years; and the results were satisfactory in the majority of patients. None of our patients developed impotence. Penile haematoma occurred in 6.4and penile numbness in 19(persistent in 3); while foreign body sensation was felt in 8. None of our patients experienced painful erections beyond three months after operation. A residual curvature was noticed in 9.6; and it required a second step Nesbit's procedure in only 3. Conclusion Management of CPC can result in a very high success rate as long as a systematic stepwise approach is applied with an appropriate preoperative patients counseling. We recommend the limited use of Nesbit's procedure (unless TAP fails to correct the curvature) together with a gentle handling of the NVB

Corporoplasty with saphenous vein graft in the surgical management of peyronie's Disease

Objectives The aim of this study is to evaluate the use of the saphenous vein in grafting the tunica albuginea defect after excision/incision of Peyronie's plaque in cases of disabling penile deformity. Patients and Methods A total of 12 patients with significant penile curvature due to Peyronie's disease interfering with their sexual activity were subjected to plaque excision/ incision and corporoplasty by saphenous vein patch grafting of the tunica albuginea. Results Penile straightening was achieved in 9 patients. One patient had a minimal residual curvature with induration at the graft site which; however; did not interfere with his sexual activity. Two patients complained of less rigid erections and are currently responding to oral measures and ICI. Penile numbness occurred in four patients with dorsal plaques; and it was self limiting within six months. We encountered no complaint of penile shortening or impotence. Conclusion The saphenous vein presents a reasonable alternative grafting material for the repair of tunica albuginea defects in patients with Peyronie's disease after plaque excision/incision. It is particularly useful in large plaque remnants and yields a satisfactory and appreciable outcome

Perineal subcutaneous dartos pedicled flap as a new technique for repairing urethrorectal fistula.

PURPOSE: Urethrorectal fistulas are rare, and the etiology is usually traumatic or iatrogenic (postoperative). Several operative approaches and techniques have been used for fistulous repair but no procedure has proved to be the best or universally acceptable. We present a new technique for repairing urethrorectal fistulas. MATERIALS AND METHODS: We successfully treated 12 male patients 7 to 65 years old who presented with urethrorectal fistula from 1990 to 1997 using the perineal subcutaneous dartos pedicled flap procedure. Urethrorectal fistulas resulted from crush pelvic injury in 6 cases and gunshot in 2, and developed after prostatectomy in 4. The fistula was associated with urethral stricture in 4 cases. A perineal approach was used in all cases of urethrorectal fistula and combined with the transsymphyseal approach in the 4 patients with posterior urethral stricture. We interposed a subcutaneous dartos pedicled flap as a vascularized tissue flap between the repaired rectum and urethra. RESULTS: The results of our technique were excellent in all cases. No leakage or perineal collection developed and there was no fistula recurrence. In 1 patient urethral stricture was managed by visual internal urethrotomy. Loss of the internal and external sphincters resulted in urinary incontinence in 4 cases, involving gunshot injury (2), crush pelvic injury (1) and prostatectomy (1). Followup ranged from 9 to 42 months. CONCLUSIONS: Our technique of a perineal subcutaneous dartos pedicled flap fulfills all principles of the successful repair of urethrorectal fistula. We consider it to be an ideal solution to this urological dilemma.

[Treatment of stenoses of the penile urethra by urethroplasty with dorsal pedicled patch: roofing urethroplasty]. / Traitement des sténoses de l'urètre pénien par urétroplastie avec patch pédiculé dorsal: "Urétroplastie en toit".

OBJECTIVE: Treatment of long or multiple anterior urethral stricture(s) when Monseur technique is not applicable. Our technique entails augmentation of the dorsally slit open stenosed urethra using pedicled non-hair bearing penile skin. PATIENTS AND METHODS: Between June 1991 and May 1996, 26 men (median age 34 years) with anterior urethral strictures underwent roofing urethroplasty. Nine patients had long stricture (average 3.2 cm) and 17 had multiple short segment strictures (average 7 cm). All patients were circumcised, and dorsal urethral augmentation was performed using transversely oriented non-hair bearing penile skin pedicled flap. RESULTS: Median follow-up was 38 months (range 3-50). A successful outcome with no recurrent stricture as evidenced by normal retrograde urethrography and voiding history was achieved in 23 of 26 men (88%). Two patients had fistula in early postoperative period; one of them needed surgical closure. CONCLUSION: Roofing urethroplasty is a practical alternative for repair of long anterior urethral stricture(s) when Monseur technique cannot be applied.