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Purpose: To determine the prevalence of concomitant squamous metaplasia (SM), the initial histological change from normal urethra to urethral stricture, in bulbar urethral strictures and to investigate the associated clinical factors., Methods: A retrospective review was conducted on 165 male patients with bulbar urethral strictures who underwent excision and primary anastomosis (EPA) between 2010 and 2020, for whom complete clinical data and excised urethral specimens were available. An experienced pathologist histologically evaluated concomitant SM in paraffin sections of the proximal end of the excised urethra blinded to the clinical data. Disease duration was calculated as the period from the initial diagnosis of urethral stricture to the date of EPA. The association between concomitant SM and clinical background was investigated., Results: SM was identified in 86 (52.1%) patients. The median disease duration in patients with SM (38 months) was significantly longer than that in patients without SM (9 months, p < 0.0001). In multivariate analysis, the longer disease duration, non-traumatic stricture etiology, and failure to maintain urethral rest with urinary diversion via a suprapubic tube for more than 90 days were independent factors predicting concomitant SM. No significant difference was observed in success rates of EPA between patients with SM (93.2%) and those without SM (97.5%, p = 0.18)., Conclusions: Reconstructive urologists need to be aware that concomitant SM is frequent in patients with bulbar urethral stricture, especially in those with long disease duration and those who were voiding volitionally during the period of urethral rest., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: We report our experience with urethral reconstruction for hypospadias surgery-related urethral stricture in terms of surgical and patient-reported outcomes., Methods: Twenty-nine adult males who underwent urethral reconstruction for hypospadias surgery-related urethral stricture between August 2008 and January 2022 were retrospectively reviewed. Uroflowmetry and patient-reported outcomes were evaluated at 3, 6, and 12 months, and annually thereafter. Surgical success was defined as the absence of additional procedures. Patients were asked to rate their satisfaction with urethral reconstruction as "very satisfied", "satisfied", "unsatisfied", or "very unsatisfied"., Results: The median patient age at referral was 43 years. The median number of previously performed hypospadias surgeries was three, and 18 patients (62.8%) had been treated with repeated transurethral procedures. The median stricture length was 54 mm (interquartile range 36-81). Performed urethral reconstruction included staged urethroplasty in 22 (75.9%), one-stage onlay augmentation in 3 (10.2%), and perineal urethrostomy in 4 (13.8%) cases. Urethral reconstruction was successful in 26 patients (89.7%) over a median postoperative period of 31 months. Patient-reported outcomes were assessed in 25 (86.2%) patients. The mean maximum flow rate, international prostate symptom score total score, international prostate symptom score quality of life score, and EuroQol-5 dimensions index significantly improved postoperatively. Twenty-three patients (92%) were "very satisfied" or "satisfied" with the outcome of their urethral reconstruction., Conclusions: Urethral reconstruction is a highly successful and patient-satisfying treatment for hypospadias surgery-related urethral stricture in adult patients. Perineal urethrostomy is a reasonable alternative for elderly patients and for patients with complicated hypospadias surgery-related urethral strictures., (© 2022 The Japanese Urological Association.)

Objectives: We report our surgical experience of transperineal bulbovesical anastomosis (BVA) for extensive posterior urethral stenosis (PUS)., Methods: Six male patients who had extensive PUS extending from the bulbomembranous urethra to the bladder neck due to prostatic disease treatment and underwent transperineal BVA between 2014 and 2020 were retrospectively reviewed. BVA was performed according to the elaborate perineal approach for pelvic fracture urethral repair with minor modifications. After confirming the absence of recurrent stenosis 6 months postoperatively, the patients were offered artificial urinary sphincter (AUS) placement for subsequent urinary incontinence (UI)., Results: Median patient age was 68, and the etiology of PUS was radical prostatectomy for prostate cancer in four patients, brachytherapy for prostate cancer in one, and transurethral resection of the prostate for benign prostatic hyperplasia in one. All patients had been previously treated with multiple transurethral procedures such as urethrotomy and dilation. Median operative time and blood loss were 211 min and 154 ml, respectively. Five cases (83.3%) had no recurrent stenosis with a median follow-up of 45 months, but a single direct vision internal urethrotomy was performed in one (16.7%) due to restenosis. Four (66.7%) patients underwent AUS placement via transcorporal approach for subsequent UI, but two had it removed due to urethral erosion., Conclusion: Transperineal BVA could effectively manage extensive PUS after prostatic disease treatment. Staged AUS placement could be a viable option for subsequent UI, but the risk of urethral erosion seemed high., (© 2022 The Japanese Urological Association.)

Objectives: We investigated the efficacy of urethral reconstruction in male patients with iatrogenic urethral stricture after transurethral prostate surgery., Methods: We retrospectively reviewed the cases of 82 patients who underwent urethral reconstruction for iatrogenic urethral stricture caused by transurethral prostate surgery between August 2011 and July 2021. Patients were followed up postoperatively with uroflowmetry, postvoid residual urine measurement, and questionnaires using Peeling's picture score, International Prostate Symptom Score, International Consultation on Incontinence Questionnaire Short Form, Sexual Health Inventory for Men, EuroQol-5 dimensions, and EuroQol-5 dimensions visual analog scores. Successful urethral reconstruction was defined as the absence of a postoperative decrease in urinary force and any additional treatment., Results: The median patient age was 72 years, and the stricture site was the urethral meatus in eight (9.8%) patients, penoscrotal junction in 42 (51.2%), and proximal bulbar urethra in 26 (31.7%). Six patients (7.3%) had synchronous urethral strictures. Urethral reconstruction was successful in 78 patients (95.1%), with a median follow-up of 43 months. The mean maximum flow rate (P < 0.0001), postvoid residual urine (P = 0.004), Peeling's picture score (P < 0.0001), the score for each question and total International Prostate Symptom Score and International Prostate Symptom Score-quality of life scores (P < 0.0001 for all comparisons), and EuroQol-5 dimensions and EuroQol-5 dimensions visual analog scores (P < 0.0001 for both) significantly improved postoperatively. However, the Sexual Health Inventory for Men and International Consultation on Incontinence Questionnaire Short Form scores remained unchanged (P = 0.09 and 0.70, respectively)., Conclusions: Urethral reconstruction was effective for urethral stricture due to transurethral prostate surgery in both subjective and objective aspects., (© 2022 The Japanese Urological Association.)

Objectives: To evaluate the ability of photocurable gelatin to prevent stricture recurrence after urethral dilation in a rabbit urethral stricture model., Methods: We created urethral strictures in the bulbar urethras of 10 male Japanese white rabbits using electrocoagulation. After 1 month, the rabbits were randomly divided into Group A (n = 5; urethral stricture dilation and the local application of photocurable gelatin using a ruthenium photoinitiator and irradiation with a light-emitting diode light [λ = 455 nm, 50 mW/cm 2 ] for 1 min) and Group B (n = 5; dilation only). Urethral stricture status was evaluated 1-2 months later by retrograde urethrography and urethroscopy. The lumen ratio (urethral width at the stricture site to the normal urethral width on retrograde urethrography) was calculated. Urethral patency was considered to be improved when the urethral lumen could accommodate a 10-Fr urethroscope without resistance. Urethral specimens were harvested for histopathological examination., Results: The mean lumen ratio did not differ significantly between Groups A and B before dilation (25.8% vs 23.4%; P = 0.40), but differed significantly after dilation (65.5% vs 27.3%, respectively; P = 0.03). Urethral patency improved in all rabbits in Group A (100%) versus one rabbit in Group B (20%; P = 0.02). The mean circumference of the regenerated urethral epithelium at the stricture site was larger in Group A than in Group B (14 mm vs 6.6 mm; P = 0.06)., Conclusions: Photocurable gelatin can reduce urethral stricture recurrence after dilation in a rabbit model., (© 2021 The Japanese Urological Association.)

Objectives: To investigate the incidence of overactive bladder in men with anterior urethral stricture and to evaluate the impact of urethroplasty on its improvement., Methods: A total of 104 men with anterior urethral stricture who underwent urethroplasty between 2016 and 2020 completed a validated urethral stricture surgery patient-reported outcome measure comprising six lower urinary tract symptoms questions on voiding symptoms and overactive bladder symptom score before and 3, 6, and 12 months after urethroplasty. Patients with an urgency score of ≥2 for overactive bladder symptom score question 3, and a total overactive bladder symptom score of ≥3 were considered to have overactive bladder. An improvement in overactive bladder was defined as a decrease in the total overactive bladder symptom score by at least three points., Results: Thirty-nine patients (37.5%) were considered to have overactive bladder, and improvement in overactive bladder after urethroplasty was found in 30 (76.9%). Maximum flow rate on uroflowmetry, postvoid residual urine volume, lower urinary tract symptoms total score, and total overactive bladder symptom score were all significantly improved after urethroplasty (P < 0.0001 for all variables). There was a positive correlation between changes in lower urinary tract symptoms total score and total overactive bladder symptom score (Spearman's correlation 0.48, P < 0.0001). Multivariate logistic regression analysis showed that greater change in lower urinary tract symptoms score was an independent predictor of improvement in overactive bladder (odds ratio 1.30, 95% confidence interval 1.06-1.59; P = 0.002)., Conclusions: Overactive bladder is prevalent in patients with anterior urethral stricture, and can be effectively improved after urethroplasty. Improvement of voiding symptoms are key for improving overactive bladder symptoms., (© 2021 The Japanese Urological Association.)

Purpose: To examine the efficacy of perineal urethrostomy (PU) in patients with anterior urethral stricture., Methods: Patients who underwent PU for anterior urethral stricture between 2013 and 2020 were retrospectively reviewed (n = 56). Surgical success was defined as no need for additional intervention. Uroflowmetry and measurement of residual urine volume (PVR) were examined postoperatively, and the patients were asked to fill out sexual health inventory for men (SHIM) and the validated Urethral Stricture Surgery Patient-reported Outcome Measure questionnaires before and after PU. The overall patient satisfaction was also assessed., Results: PU was successful in 92.9% of patients (n = 52), with a median follow-up of 34 months. Two of four were salvaged by re-do PU, and one was salvaged by forming a composite stoma using a penile skin graft. Thirty-nine patients (69.6%) filled out the questionnaires 6 months after surgery. The mean maximum flow rate, PVR, lower urinary tract symptoms (LUTS)-total score, LUTS-specific quality of life, and EuroQol-visual analog scale scores improved significantly from 3.8 mL/s, 77.6 mL, 12.9, 2.6, and 53.6 at baseline to 17.6 mL/s, 21.3 mL, 4.1, 0.9, and 74.9 postoperatively (p = 0.003, p = 0.004, p = 0.005, p < 0.0001, p < 0.0001, respectively). The SHIM score did not change significantly (from 2.6 at baseline to 2.3 postoperatively; p = 0.59). As for patient satisfaction, 84.6% of patients (33/39) were "satisfied" (46.1%) or "very satisfied" (38.5%) with the outcome., Conclusions: PU had a high surgical success rate, and significantly improved patients' subjective symptoms and achieved a high level of satisfaction., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To report our experience with excision and primary anastomosis (EPA) for bulbar urethral stricture., Methods: Patients who underwent EPA for bulbar stricture between 2012 and 2019 were retrospectively analyzed (n = 308). Successful urethroplasty was defined as the absence of the need for additional treatment. For follow-up, uroflowmetry was performed and the patients completed the validated Urethral Stricture Surgery Patient-reported Outcome Measure and Sexual Health Inventory for Men (SHIM) questionnaires before (baseline) and 6 months after EPA. Overall patient satisfaction after urethroplasty was also evaluated., Results: Urethroplasty was successful in 97.1% of patients (n = 299) with a median follow-up of 37 months. A total of 215 patients (69.8%) completed the questionnaires at 6 months postoperatively. The mean maximum flow rate, lower urinary tract symptom (LUTS)-total score, Peeling's picture score, LUTS-specific quality of life, and EuroQol-visual analog scale scores improved significantly from 7.7 ml/s, 11.6, 3.3, 2.4, and 58.0 at baseline to 24.1 ml/s, 2.7, 1.9, 0.4, and 82.1 postoperatively (p < 0.0001 for all comparisons). However, five-point or greater deterioration in the SHIM score was found in 41 patients (19.1%). Regarding patient satisfaction, 98.6% of patients (212/215) were "satisfied" (32.6%) or "very satisfied" (66.0%) with the outcome. A low postoperative LUTS-total score and Peeling's picture score were independent predictors of a "very satisfied" patient (p = 0.001 and p = 0.01, respectively)., Conclusions: EPA had a high success rate and was associated with significant benefits in both subjective and objective outcomes. Contrarily, a high incidence of postoperative erectile dysfunction was observed., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: To verify the utility of triangular extension of a hinge flap in buccal mucosal staged urethroplasty to resolve stomal stenosis after the first stage and ultimately prevent restenosis., Methods: A total of 23 patients (triangular extension group) were studied in 2013-2019. In the first stage, buccal mucosa was transplanted, and an extended triangle portion of the mucosa was placed beside the proximal and/or distal stoma that was created when the stricture segment of the urethra was resected. In the second stage, during tubularization of the urethral plate, an incision was made at the stoma to increase the caliber to which the triangular extension was inserted. The procedure was considered successful when a 17-Fr flexible cystoscope passed through the reconstructed urethra at 6 months after the second-stage urethroplasty and no additional surgery or bougie dilation required. The clinical course of the triangular extension group was compared with 24 patients who underwent conventional staged urethroplasty (control group)., Results: In total, 20 patients from each group underwent second-stage surgery. No patients in the triangular extension group required additional revision surgery because of stomal stenosis after first-stage surgery, whereas five (20%) control patients did. Urethroplasty was successful in 19 patients (95%) in the triangular extension group and in 19 patients (95%) in the control group. Uroflowmetry after the second-stage surgery indicated that the mean maximum urinary flow rate was 21.5 and 15.8 mL/s after triangular extension and the control procedure, respectively (P = 0.027)., Conclusions: The triangular extension technique reduces the need for revision surgery and prevents postoperative restenosis., (© 2021 The Japanese Urological Association.)

Objectives: To investigate the efficacy of re-do urethroplasty for post-traumatic urethral stricture in terms of anatomical and functional outcomes., Methods: A total of 48 patients who underwent re-do urethroplasty for post-traumatic urethral stricture due to perineal trauma (n = 21) and pelvic fracture urethral injury (n = 27) between October 2010 and March 2020 were retrospectively reviewed. Patients were followed by uroflowmetry, post-void residual volume assessment and 17-Fr flexible cystoscopy after re-do urethroplasty. Successful urethroplasty was defined as having a urethral caliber adequate for the passage of a cystoscope and requiring no additional treatments. Patients completed a validated patient-reported outcome measure for urethral stricture surgery, including overall satisfaction, and the sexual health inventory for men., Results: The type of re-do urethroplasty was anastomotic urethroplasty in 45 (94%) patients and buccal mucosa urethroplasty in three (6%) patients. Urethroplasty was successful in 47 (98%) patients (median follow up 35 months, interquartile range 21-75). The patient-reported outcome measure for urethral stricture surgery and Sexual Health Inventory for Men were assessed in 36 (75%) patients, and the mean lower urinary tract symptom-specific quality of life, EuroQol-5D and EuroQol-visual analog scale scores improved from 2.86, 0.63 and 54.17 preoperatively to 0.78 (P < 0.001), 0.86 (P < 0.001) and 76.94 (P < 0.001) postoperatively, respectively. The pre- and postoperative mean Sexual Health Inventory for Men scores (5.92 and 4.94, respectively) did not significantly differ (P = 0.318). All 36 patients were satisfied with their urethroplasty outcomes, with 20 (56%) very satisfied patients., Conclusions: Re-do urethroplasty for post-traumatic urethral stricture shows a high success rate and beneficial effects on both anatomical and functional outcomes., (© 2021 The Japanese Urological Association.)

Objectives: To evaluate whether the management of anterior urethral strictures prior to definitive urethroplasty is appropriate., Methods: Of a total of 419 men diagnosed with anterior urethral strictures at hospitals across Japan and thereafter referred to our institution for definitive urethroplasty between 2004 and 2019, the medical records of 371, for whom data on stricture characteristics at the initial diagnosis and pre-referral management were available, were retrospectively reviewed. A pre-referral single transurethral procedure, such as direct vision internal urethrotomy or urethral dilation, was considered appropriate only for favorable stricture, defined as a single nontraumatic untreated bulbar urethral stricture ≤2 cm in size, and repeat transurethral procedures were considered inappropriate in any circumstances. The association between the appropriateness of the pre-referral management strategy and patient and clinical characteristics was analyzed., Results: A total of 242 patients (65.2%) had a pre-referral history of at least one transurethral procedure, and performing the procedure was considered inappropriate for 221 patients (59.6%). On multivariate logistic regression analysis, location of the patient's residence far from our institution (outside of the Kanto area; odds ratio 3.35, 95% confidence interval 1.86-6.04; P < 0.0001), voiding with intermittent dilation (odds ratio 2.38, 95% confidence interval 1.38-4.12; P = 0.002), iatrogenic stricture (odds ratio 11.18, 95% confidence interval 5.30-23.61; P < 0.0001), and stricture longer than 20 mm (odds ratio 3.05, 95% confidence interval 1.47-6.38; P = 0.003) were the independent predictors of inappropriate use of transurethral procedures., Conclusions: Transurethral procedures are often inappropriately used. There is a clear need to promote appropriate management strategies for urethral strictures among general urologists., (© 2020 The Japanese Urological Association.)

(Introduction) Percutaneous cystostomy is a standard urological procedure; however, very few reports have focused on the many cases of this procedure performed in Japan. We analyzed the background of the procedure and its approach as well as the incidence of its complications at our institution. (Material and methods) We examined 95 patients who underwent percutaneous cystostomy between April 2010 and March 2019. A comparative analysis was conducted for each type of procedure performed. Furthermore, cases that experienced accidental catheter extraction before the first catheter replacement were analyzed, and the three patient groups were compared based on the type of procedure performed and cases that needed another operation. (Result) The indications for cystostomy were urethral stricture (56.3%), neuropathic bladder (13.5%), and prostatic hyperplasia (11.5%). The complications included hemorrhage, peritoneal injury, urinary tract infection, and catheter damage caused by a puncture needle. The overall complication rate was 10.5%. Based on type of the procedure performed, the incidence of hemorrhage was found to be as high as 25% in patients who underwent the procedure using a cannula puncture needle. Accidental catheter extraction before the first catheter replacement occurred most frequently in patients treated with Seldinger technique (17.0%). The rate of complications including accidental catheter extraction ranged from 25.0% to 25.4% among the three groups. (Conclusion) We prefer the Seldinger technique for the first placement of the cystostomy catheter because of its low rate of hemorrhage, but a cannula puncture needle may also be used by using exploratory puncture if vascular damage and accidental catheter extraction are avoided.

Objectives: Pubectomy is an ancillary technique used to increase exposure of the disrupted urethra and reduce anastomotic tension, which can be difficult for inexperienced surgeons. The objective of the present study was to illustrate the use of an air drill enabling delicate and precise bone resection in pubectomy for delayed anastomotic urethroplasty for pelvic fracture urethral injury., Methods: Between 2009 and 2019, 88 male patients underwent delayed anastomotic urethroplasty with pubectomy for pelvic fracture urethral injury. A total of 73 procedures used a high-speed surgical air drill (HiLAN HS; Aesculap, Tuttlingen, Germany) equipped with a short-hand piece. Operative time and blood loss in the air drill patient group (group 1) were compared with that of patients who underwent pubectomy using a rongeur and/or gouge (group 2, n = 15)., Results: In 65 group 1 patients, urethroplasty was carried out using the perineal approach, with partial inferior pubectomy. Eight group 1 patients, whose proximal urethral end was displaced upward superior to the upper edge of pubis, underwent urethroplasty using the perineal and abdominal approach, with a superior partial pubectomy and supracrural urethral rerouting. No difficulty was encountered using the air drill in any of the cases. There was no significant difference in median operative time between the groups (group 1 256 min vs group 2 228 min; P = 0.31). The median blood loss in group 1 was significantly lower than group 2 (149 mL vs 453 mL; P < 0.0001)., Conclusions: Surgical air drills might facilitate pubectomy in patients undergoing delayed anastomotic urethroplasty for pelvic fracture urethral injury. This tool offers the advantage of a delicate bone resection with reduced blood loss., (© 2020 The Japanese Urological Association.)

Purpose: To report our experience with urethroplasty for bulbar stricture due to a straddle injury based on surgical and patient-reported outcomes., Methods: Patients who underwent urethroplasty for bulbar stricture due to a straddle injury between 2010 and 2018 were retrospectively analyzed (N = 132). Successful urethroplasty was defined as the absence of the need for additional treatment. The patients completed the validated Urethral Stricture Surgery Patient-reported Outcome Measure and Sexual Health Inventory for Men (SHIM) questionnaires before (baseline) and 1 year after urethroplasty., Results: The median (interquartile range) age was 50 (36-62) years; urethral stricture length estimated from urethrograms, 8.6 (5.1-12.5) mm; and postoperative follow-up, 41 (22-56) months. Urethroplasty was performed through excision with primary anastomosis in 95.5% (n = 126) and onlay augmentation with a buccal mucosa graft in 4.5% (n = 6). Urethroplasty was successful in 98.5% (n = 130). The 2 failures due to periurethral abscess were successfully salvaged with another urethroplasty. Eighty-four patients (63.6%) completed the questionnaires at 1 year postoperatively. The mean lower urinary tract (LUT)-specific quality of life, SHIM, and EuroQol-visual analog scale scores all improved significantly from 2.6, 8.5, and 57.5 at baseline to 0.3, 11.6, and 84.6 postoperatively (p < 0.0001, p = 0.004, p < 0.0001, respectively). All patients were either "satisfied" (19/84, 22.6%) or "very satisfied" (65/84, 77.3%). Lower postoperative LUT symptom score was an independent predictor of a "very satisfied" patient (odds ratio 0.81, 95% confidence interval 0.67-0.98, p = 0.002)., Conclusions: Urethroplasty for bulbar stricture due to a straddle injury has a high success rate and is beneficial for both subjective and objective symptoms.

Objective: To compare the clinical courses of patients with straddle injuries to the bulbar urethra based on the initial management strategy for urinary drainage, mainly suprapubic tube placement (SPT) and primary realignment (PR), and to examine whether PR has a beneficial effect on subsequent urethroplasty with regards to surgical and patient-reported outcomes., Methods: We reviewed the clinical courses of 126 patients with bulbar urethral stricture following straddle injuries who underwent delayed urethroplasty between August 2010 and April 2019. Patients were categorized as being initially treated with SPT (82 patients) or PR (44 patients). Stricture was considered complicated if preoperative urethrography or cystoscopy revealed iatrogenic scarring or a stricture away from the injury site., Results: The percentage of patients who experienced delayed transurethral treatment at least once before referral was significantly higher in patients treated with PR than in those treated with SPT (25/44, 56.8% vs 16/82, 19.8%, P < .0001). Although there was no difference in stricture length in both cohorts, the fraction of patients with complicated stricture was significantly higher in patients treated with PR than in those treated with SPT (15/44, 34.1% vs 14/82, 17.1%, P = .003). There was no significant difference in the selected type of urethroplasty, operative time, blood loss, success rate, postoperative maximum urinary flow rate, voiding symptoms, or erectile function between the 2 groups., Conclusion: PR does not facilitate delayed urethroplasty and had no beneficial effect on urethroplasty outcome. PR might lead to delayed transurethral procedures, resulting in increased risk of complicated strictures., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To evaluate the magnetic resonance imaging (MRI) findings of traumatic bulbar stricture and to evaluate their ability to estimate repair complexity., Methods: Eighty-nine men with traumatic bulbar stricture who underwent urethrography and MRI at least 3 months postinjury and subsequent excision and primary anastomosis were retrospectively analyzed. The associations of MRI findings, including continuity of the tunica albuginea of the corpus spongiosum, periurethral fistula, spongiofibrosis length (SFL), and distal and proximal bulbar urethral length from the stricture, with urethrography and operative parameters were evaluated., Results: Mean SFL was significantly longer than mean stricture length on urethrography (14.9 vs 7.9 mm, P <.0001). Periurethral fistula was found in 18 (20.2%) patients on MRI but not in 10 (55.6%) of them on urethrography. The corpus spongiosum was disrupted in 40 patients (55.1%) on MRI. On multivariate linear regression, SFL (standard coefficient, 0.25; t value, 2.31; P = .02) predicted operation time, while SFL (standard coefficient, 0.22; t value, 2.04; P = .04) and proximal bulbar urethral length (standard coefficient, -0.25; t value, -2.11; P = .04) independently predicted blood loss. Corporal splitting to reduce anastomotic tension and/or increase visualization during repair was needed in 33 patients (37.1%). Stricture length on urethrography (odds ratio [OR], 1.22; 95% confidence interval, 1.04-1.42; P = .006) and corpus spongiosum disruption (odds ratio, 5.51; 95% confidence interval, 1.57-19.34, P = .005) were independent predictors for the need of corporal splitting., Conclusion: In contrast to urethrography findings, MRI findings help predict traumatic bulbar stricture repair complexity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To evaluate the preventive effect of an insulin-like growth factor 1 sustained-release collagen urethral catheter on urethral stricture after urethral injury in a rabbit model., Methods: We made urethral catheters coated either with insulin-like growth factor 1 impregnated collagen or with only collagen, and we divided 19 male Japanese white rabbits into three groups according to the kind of catheter inserted immediately after the rabbit's urethra was injured by electrocoagulation. Group 1 (n = 7) had a catheter coated with insulin-like growth factor 1 impregnated collagen inserted; group 2 (n = 7) had a catheter coated with only collagen inserted; and group 3 (n = 5) had an uncoated catheter inserted. A total of 14 days later, the injured urethras were evaluated by urethrography and urethroscopy, and were also histologically examined., Results: Urethrography showed that the ratio of the urethral lumen diameter in injured urethra to that in normal urethra was the largest in group 1 (P < 0.0001). In addition, five of the seven rabbits in group 1 (71.4%) had a urethral lumen large enough for passage of a urethroscope, a fraction larger than the corresponding fractions in groups 2 (57.1%) and 3 (20%). On histological analysis, the injured area not covered with regenerated urethral epithelium tended to be smaller in group 1 than the other two groups, but the mean difference was not significant (P = 0.19)., Conclusions: An insulin-like growth factor 1 sustained-release collagen urethral catheter significantly improves wound healing and prevents urethral stricture after urethral injury., (© 2019 The Japanese Urological Association.)

Purpose: To better understand our urethroplasty outcome, we translated the English version of a urethral stricture surgery patient-reported outcome measure (USS-PROM) into Japanese and used it to evaluate the effect of urethroplasty for anterior urethral strictures., Methods: The PROM quantifies lower urinary tract symptoms (LUTS) and health-related quality of life (EQ-5D), and it evaluates overall satisfaction by asking patients to choose "very satisfied", "satisfied", "unsatisfied", or "very unsatisfied". 93 Japanese-speaking male patients with anterior urethral stricture who underwent urethroplasty completed it before (baseline) and 6 months after urethroplasty. The psychometric criteria evaluated in the present study were the PROM's internal consistency, test-retest reliability, criterion validity, and responsiveness., Results: Q max was negatively correlated with the LUTS-total scores (r = - 0.61). Cronbach's alpha was 0.80 and the test-retest intraclass correlation coefficient for the LUTS-total score was 0.82. 83 patients (89.2%) achieved stricture-free, which was defined as no re-stricture on cystoscopy and no need for additional treatment. The mean total LUTS-score improved from 12.4 at baseline to 3.7 postoperatively (p < 0.0001). The mean EQ-5D visual analogue scores and EQ-5D index improved from 61.2 and 0.76, respectively, at baseline to 77.9 and 0.89 postoperatively (p < 0.0001, p < 0.0001). 55 patients (59.1%) were "very satisfied" with the outcome of their urethroplasty and 33 (35.5%) were "satisfied"., Conclusions: The Japanese version of the USS-PROM has adequate psychometric properties. Urethroplasty improved not only objective data but also voiding symptoms and health-related QOL, and it resulted in a high rate of patient satisfaction.

Purpose: We examined the impact on urethral stricture complexity at urethroplasty of previous transurethral treatments such as dilation, urethrotomy and stenting, which are most commonly performed when treating male urethral stricture., Materials and Methods: We retrospectively reviewed the records of 45 males who had undergone transurethral treatments before urethroplasty. We compared urethrography findings at initial diagnosis with those at urethroplasty. Males with failed hypospadias repair, lichen sclerosis or a history of prior urethroplasty were excluded from analysis. We considered stricture complexity increased if the number and/or length of strictures on urethrography at urethroplasty was greater than that at initial diagnosis or false passage was newly identified., Results: Of the patients 39 (87%), 32 (71%) and 13 (29%) had undergone urethral dilation, urethrotomy and urethral stenting, respectively, and 39 (87%) had undergone repeat or multiple kinds of transurethral treatments. Stricture complexity was increased in 22 men (49%) while 7 (16%) required urethroplasty more complex than that anticipated from urethrography findings at initial diagnosis. Increased stricture complexity was significantly associated with a history of urethrotomy (p = 0.03), urethral stenting (p = 0.0002) and repeat transurethral treatments (p = 0.01). Multivariate analysis revealed that urethral stenting (p = 0.01) and repeat transurethral treatments (p = 0.01) were independent predictors of increased stricture complexity., Conclusions: Repeat transurethral treatments increase stricture complexity and are potentially counterproductive. Even a single application of temporary urethral stenting carries a high risk of complicating the stricture and requiring complex urethroplasty., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the clinical courses of patients with pelvic fracture urethral injury (PFUI) according to initial management strategy., Methods: We reviewed the clinical courses of 63 patients with PFUI who were initially treated elsewhere and underwent delayed anastomotic urethroplasty by a single surgeon between 2008 and 2015. Patients were grouped according to their initial treatment: by suprapubic tube placement alone (49 patients, SPT group) or primary realignment (14 patients, PR group). Time to urethroplasty was defined as the period between injury and delayed urethroplasty. Clinical data regarding the status of urethral stenosis, urethroplasty procedure, and treatment outcome were analyzed., Results: The mean time to urethroplasty in the PR group was about 3 times than that in the SPT group (133 months vs 47 months, P = .035). Fifty percent of the PR group (7 of 14) had a history of repeated urethrotomy or dilation before referral, a percentage significantly higher than that of the SPT group (20.4%, 10 of 49, P = .027). The percentage of patients having a false passage and iatrogenic scar was significantly higher in the PR group (42.9% vs 16.3%, P = .035), but there was no significant between-group difference in urethral stenosis length, operative time, operative blood loss, or the percentage of patients requiring inferior pubectomy or urethral rerouting., Conclusion: PR does not facilitate delayed urethroplasty, and patients who undergo PR are at high risk of having a more complicated stenosis and longer time to urethroplasty, presumably because of repeated transurethral procedures., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Direct vision internal urethrotomy (DVIU) has been considered to be a low invasive and widely used therapeutic modality for male urethral stricture. However, its efficacy is still controversial. We herein evaluated the efficacy of DVIU for male urethral stricture., Patients and Methods: Nineteen patients 27 to 78 years old (median age = 59) underwent DVIU for urethral strictures at our hospital were included in this study. Strictures were at bulbar urethra in 17 patients, membranous urethra in 1 patient, and pendulous urethra in 1 patient. The stricture lengths estimated on retrograde urethrography were less than 1 cm in 13 patients, 1-2 cm in 2 patients, and more than 2 cm in 4 patients. The etiology of stricture was straddle injury in 7 patients, post transurethral surgery in 7 patients, pelvic fracture in 1 patient, and unknown in 4 patients. The operation was done by cold knife incision using guidewire. The duration of postoperative urethral catheterization was 5 to 35 days (mean 12.8 days). Follow up duration ranged from 1 month to 139 months (mean 48.2 months). The definition of postoperative re-stricture was the confirmation of re-stricture on retrograde urethrography or deterioration of symptom., Results: While no severe complication was observed, postoperative re-stricture was seen in 13 patients. Stricture-free rates at 3 months, 6 months, and 5 years after the first DVIU were 44.4%, 38.1%, 20.3% respectively. Although second DVIU was done for 7 patients with re-stricture, six patients resulted in failure. Stricture-free rates at 3 months, 6 months, and 5 years after the second DVIU were 42.2%, 28.6%, 14.3% respectively. Though the third DVIU was done for two of them, they were unable to void just immediately after the removal of urethral catheters. Stricture-free rate in stricture less than 1 cm was higher than that in 1 cm or longer, though it did not reach significant difference (p = 0.1813)., Conclusion: The efficacy of DVIU is lesser than we expected. DVIU seems to be excessively applied to male urethral strictures and should not be performed for long and recurrent urethral stricture.

Objective: We evaluated the efficacy and outcome of one-stage oral mucosa graft urethroplasty, which is currently the procedure of choice for treating lengthy and complicated urethral strictures not amenable to excision and primary end-to-end anastomosis., Patients and Methods: Seven patients 33 to 74 years old (mean age = 53.7) underwent one-stage oral mucosa graft urethroplasty for a stricture in either the bulbar urethra (four patients), penile urethra (two patients), or pan-anterior urethra (one patient). Three of the strictures were due to trauma, one was due to inflammation, and one was due to a failed hypospadia repair. The other two were iatrogenic. All patients had previously undergone either internal urethrotomy or repeated urethral dilation. Three patients received a tube graft, three received a ventral onlay, and one received a dorsal onlay. A free graft of oral mucosa was harvested from the inside of each patient's left cheek, and if necessary to obtain a sufficient length, the harvest was extended to include mucosa from the lower lip and the right cheek. The graft lengths ranged from 2.5 to 12 cm (mean = 4.6 cm). A urethral catheter was left in place for 3 weeks postoperatively., Results: While no severe complications at the donor site were observed during follow-up periods ranging from 3 to 55 months (mean = 14 months), two patients who had received a tube graft developed distal anastomotic ring strictures that were managed by internal urethrotomy. The other five required no postoperative urological procedure even though one who had received a ventral onlay developed a penoscrotal fistula., Conclusion: Oral mucosa is an ideal urethral graft, and oral mucosa graft urethroplasty is an effective procedure for repairing complicated urethral strictures involving long portions of the urethra.