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INTRODUCTION AND OBJECTIVE:Recurrence after URF repair usually occurs from the urinary side of the fistula. This study evaluates the clinical significance of a radiological leak on pericatheter ure...

Penile urethral strictures have been managed by a staged surgical approach. In selected cases, spongiofibrosis can be excised, a neo-urethral plate created using buccal mucosa graft (BMG) and tubularized during the same procedure, performing a “two-in-one” stage approach. We aim to identify stricture factors which indicate suitability for this two-in-one stage approach. We assess surgical outcome and compare with staged reconstruction. We conducted an observational descriptive study. The data were prospectively collected from two-in-one stage and staged penile urethroplasties using BMG in a single center between 2007 and 2017. The minimum follow-up was 6 months. Outcomes were assessed clinically, radiologically, and by flow-rate analysis. Failure was defined as recurrent stricture or any subsequent surgical or endoscopic intervention. Descriptive analysis of stricture characteristics and statistical comparison was made between groups. Of 425 penile urethroplasties, 139 met the inclusion criteria: 59 two-in-one stage and 80 staged. The mean stricture length was 2.8 cm (single stage) and 4.5 cm (staged). Etiology was lichen sclerosus (LS) 52.5% (single stage) and 73.8% hypospadias related (staged). 40.7% of patients had previous failed urethroplasties in the single-stage group and 81.2% in the staged. The most common stricture locations were navicular fossa (39.0%) and distal penile urethra (59.3%) in the single-stage group and mid or proximal penile urethra (58.7%) in the staged group. Success rates were 89.8% (single stage) and 81.3% (staged). A trend toward a single-stage approach for select penile urethral strictures was noted. We conclude that a single-stage substitution penile urethroplasty using BMG as a “two-in-one” approach is associated with excellent functional outcomes. The most suitable strictures for this approach are distal, primary, and LS-related strictures.

Cowper's syringoceles are uncommon, usually described in children and most commonly limited to the ducts. We describe more complex variants in an adult population affecting with varying degrees of severity, the glands themselves, and the complications they may lead to. One hundred consecutive urethrograms of patients with unreconstructed strictures were reviewed. Twenty-six patients (mean age: 41.1 years) with Cowper's syringoceles who were managed between 2009 and 2016 were subsequently evaluated. Presentation, radiological appearance, treatment (when indicated), and outcomes were assessed. Of 100 urethrograms in patients with strictures, 33.0% demonstrated filling of Cowper's ducts or glands, occurring predominantly in patients with bulbar strictures. Only 1 of 26 patients with non-bulbar strictures had a visible duct/gland. Of 26 symptomatic patients, 15 presented with poor flow. In four patients, a grossly dilated Cowper's duct obstructed the urethra. In the remaining 11 patients, a bulbar stricture caused the symptoms and the syringocele was identified incidentally. Eight patients presented with perineal pain. In six of them, fluoroscopy and magnetic resonance imaging (MRI) revealed complex multicystic lesions within the bulbourethral glands. Four patients developed perineoscrotal abscesses. In the 11 patients with strictures, the syringocele was no longer visible after urethroplasty. In three of four patients with urethral obstruction secondary to a dilated Cowper's duct, this resolved after transperineal excision (n = 2) and endoscopic deroofing (n = 1). Five of six patients with complex syringoceles involving Cowper's glands were excised surgically with symptomatic relief in all. In conclusion, Cowper's syringocele in adults is more common than previously thought and may cause lower urinary tract symptoms or be associated with serious complications which usually require surgical treatment.

INTRODUCTION AND OBJECTIVE:Urethro-cutaneous fistula (UCF) originating from the anterior urethra in adult men is an uncommon presentation. We describe our experience in managing this problem.METHOD...

The standard treatment of bulbar urethral strictures of appropriate length is excision and primary anastomosis (EPA), irrespective of the cause of the stricture. This involves transection of the corpus spongiosum (CS) and disruption of the blood flow within the CS as a consequence. The success rate of EPA in curing these strictures is very high, but there is a considerable body of evidence and of opinion to suggest that there is a significant risk of sexual dysfunction and, potentially, of other adverse consequences that occur because of transection of the CS.

INTRODUCTION AND OBJECTIVES:This study evaluates the outcome of redo-urethroplasty in patients with recurrent penile, bulbar or posterior urethral strictures with a particular view to identifying a...

Fistulation is a relatively uncommon complication resulting from the treatment of pelvic malignancy but one which is associated with significant patient morbidity. Fistulae complicating treatment with radiation, when compared to those arising from surgical management alone, are usually more difficult to treat by virtue of tissue ischaemia and fibrosis. They are also commonly associated with other complications resulting from the effect of radiation on adjacent organs such as the bladder, lower intestinal tract and pelvic bones as well as the frequent occurrence of intervening cavitation and chronic pelvic sepsis, all of which render these fistulae complex. Complex radiotherapy fistulae necessitate a change in the standard approach to fistula management. In a non-tertiary setting, they are often treated by urinary or bowel diversion (or both). Surgical correction of complex fistulae following radiotherapy is nonetheless possible in experienced hands but commonly requires extensive reconstructive procedures via an abdominoperineal approach with a protracted recovery and reduced potential for return to complete functional normality.

Augmentation urethroplasty using oral mucosal graft has become the standard surgical treatment of long bulbar strictures. In very tight strictures the urethral plate is narrowed to the extent that an almost circumferential substitution with oral graft is necessary, with suboptimal results. If the obliterative segment within a longer stricture is short it is possible, through a dorsal stricturotomy, to excise it in a non-transecting manner, leaving the ventral spongiosum intact and anastomose the mucosal edges to reconstitute the urethral plate to an adequate calibre. The stricturotomy is subsequently augmented with an oral mucosal graft. We describe this technique as the augmented non-transecting anastomotic bulbar urethroplasty. It also allows for use of a narrower and shorter graft. In our hands this procedure is associated with a 100% radiological success rate and a 95% patient satisfaction rate at a mean follow-up of 14.8 months (5.7–52.6 months). Keywords: Urethral stricture; Bulbar urethroplasty; Non-transecting; Buccal mucosal graft

Chronic pubic pain after the treatment of prostate cancer is often attributed to osteitis pubis. We have become aware of another complication, namely fistulation into the pubic symphysis, which is more serious and more common than previously thought.A total of 16 patients were treated for urosymphyseal fistulas after the treatment of prostate cancer between January 2011 and April 2014. Clinical presentation was characterized by chronic, debilitating pubic/pelvic/groin pain in all patients. Diagnosis was confirmed by magnetic resonance imaging. Conservative management was successful in only 1 patient. The remaining patients were treated surgically with excision of the fistulous track and involved symphyseal bone and omentoplasty, followed by reconstruction when feasible.All 16 patients had had radiotherapy as primary treatment (8) or after prostatectomy (8). There were 5 patients (31.3%) who underwent various combinations of brachytherapy, external beam radiotherapy and cryotherapy. Bladder neck contractures developed in 13 patients (81.3%), whose treatment (endoscopic or open reconstruction) resulted in urinary leak leading to urosymphyseal fistulas. Reconstruction was possible in 7 of 15 patients (46.7%) with salvage radical prostatectomy and substitution/augmentation cystoplasty. The other 8 patients (53.3%) underwent cystectomy and ileal conduit diversion. All patients experienced resolution of symptoms, most significantly the almost immediate resolution of pain.A high index of suspicion must be maintained in irradiated patients presenting with symptoms suggestive of urosymphyseal fistulas, especially after having undergone treatment of bladder neck contractures or prostatic urethral stenoses. Although extensive, surgery for urosymphyseal fistulas, with a high risk of morbidity and mortality and a protracted recovery, leads to immediate and dramatic improvement in symptoms.

To investigate the concept of 'urethral atrophy', which is often cited as a cause of recurrent incontinence after initially successful implantation of an artificial urinary sphincter (AUS); and to investigate the specific cause of the malfunction of the AUS in these patients and address their management.Between January 2006 and May 2013, 50 consecutive patients (mean age 54.3 years) with recurrent incontinence had their AUS explored for malfunction and replaced with a new device with components of exactly the same size, unless there was a particular reason to use something different. Average time to replacement of the device was 10.1 years. The mean follow-up after replacement of the device was 24.7 months. All patients without an obvious cause for their recurrent incontinence had preoperative urodynamic evaluation, including measurement of the Valsalva leak point pressure (VLPP) and the retrograde cuff occlusion pressure (RCOP). After explantation of the AUS in patients without any apparent abnormality of the device at the time of replacement, the pressure generated by the explanted pressure-regulating balloon (PRB) was measured manometrically, when this was possible. In a select group of six consecutive patients of this type, the fibrous capsule surrounding the old cuff was incised then excised to expose and evaluate the underlying corpus spongiosum.In 31 of the 50 patients (62%) undergoing exploration, a specific cause for the malfunction of their AUS was defined. In the other 19 patients (38%) no cause was found, either preoperatively or at the time of exploration, other than a low VLPP and RCOP. A typical 'waisted' or 'hour-glass' appearance of the underlying corpus spongiosum was demonstrable, to some degree, on explanting the cuff in all cases. In the six patients in whom the restrictive sheath surrounding the cuff was excised, the urethral circumference immediately returned to normal after the compressive effect of the sheath was released. Manometry of the explanted PRBs, when this was possible, showed a loss of pressure in all instances. Replacement of the explanted AUS with a new device with the same size cuff and PRB in 14 of these 19 patients was successful in 12 (85.7%).These results, and other theoretical considerations, suggest that recurrent incontinence, years after initially successful implantation of an AUS, is because of material failure of the PRB, probably attributable to its age and consequent loss of its ability to generate the pressure it was designed to produce, and that urethral atrophy does not occur. Simply replacing the old device with a new one with the same characteristics, unless there is a particular reason to do otherwise, is usually successful and avoids the complications of alternatives such as as cuff downsizing, implanting a PRB with a higher pressure range, implantation of a second cuff or transcorporeal cuff placement, all of which have been advocated in these patients.

Most urethral strictures are either idiopathic or iatrogenic secondary to urethral instrumentation or failed surgery for hypospadias. In this article, the authors provide a concise general overview of urethral stricture and its management.

Background Intermittent self-dilatation (ISD) may be recommended to reduce the risk of recurrent urethral stricture. Level one evidence to support the use of this intervention is lacking. Objectives Determine the clinical and cost-effectiveness of ISD for the management of urethral stricture disease in males. Search Methods The strategy developed for the Cochrane Incontinence Review Group as a whole (last searched May 7, 2014). Selection Criteria Randomised trials where one arm was a programme of ISD for urethral stricture. Data Collection and Analysis At least two independent review authors carried out trial assessment, selection, and data abstraction. Results Data from six trials that were pooled and collectively rated very low quality per the GRADE approach, indicated that recurrent urethral stricture was less likely in men who performed ISD than those who did not (RR 0.70, 95% CI 0.48–1.00). Two trials compared programmes of ISD but the data were not combined and neither were sufficiently robust to draw firm conclusions. Three trials compared devices for performing ISD, results from one of which were too uncertain to determine the effects of a low friction hydrophilic catheter versus a polyvinyl chloride catheter on risk of recurrent urethral stricture (RR 0.32, 95% CI 0.07 to 1.40); another did not find evidence of a difference between 1% triamcinolone gel for lubricating the ISD catheter versus water-based gel on risk of recurrent urethral stricture (RR 0.68, 95% CI 0.35 to 1.32). No trials gave cost-effectiveness or validated PRO data. Conclusions ISD may decrease the risk of recurrent urethral stricture. A well-designed RCT is required to determine whether that benefit alone is sufficient to make this intervention worthwhile and in whom. Neurourol. Urodynam. 35:759–763, 2016. © 2015 Wiley Periodicals, Inc.

Lower urinary tract trauma is common. Indeed, iatrogenic lower urinary tract trauma is the commonest type of urological injury. External trauma is much less common but potentially life-threatening, if only because of the force needed to cause it. This chapter describes the incidence, aetiology, pathology, clinical features, and management of both types of injury and draws attention to the controversies in management of the most serious of these injuries which remain controversial after nearly 100 years of debate. Despite the controversies, the three fundamental principles of treatment remain unchallenged: to provide urinary drainage to prevent or relieve urinary retention; to prevent or treat urinary extravasation; and to provide the best possible conditions for recovery of the injury.

Of all the major urological injuries, injury to the kidney is the most common. Indeed it is the most commonly injured intra-abdominal organ. Blunt or penetrating external injury is almost always the cause. The diagnosis and treatment of renal trauma has changed dramatically in the last 30 years or so reflecting the development of CT scanning for diagnosis and of endovascular interventional radiological techniques for treatment, at the expense of intravenous urography and surgery, respectively. Complications can be divided into early and late. The commonest early complications are bleeding and extravasation of urine, which may in turn lead to a urinoma, infection, and abscess formation. The best way of handling bleeding is by selective microembolization or surgery if necessary, which is usually only when embolization fails. A urinoma can usually be drained percutaneously through the flank, but may require surgery occasionally.

Urethral strictures are common and almost all urologists will deal with them on a regular if not daily basis. They have always been common and the history of the subject stretches back to 3,000 BC. Urethral dilators have been found in the tombs of the pharaohs so that they might be able to catheterize themselves or dilate their own strictures in the afterlife. Urethrotomy and dilatation are two of the most frequently performed procedures in urology. But these are usually only palliative, and curative treatment by urethroplasty is performed by very few urologists. In part this is because most strictures are bulbar strictures and most non-bulbar strictures are seen only by reconstructive urologists; but in part this represents a somewhat ambivalent attitude of most urologists to urethral stricture disease. In this chapter, we will attempt to clarify the current approach to this problem.

In clinical practice, most reconstructive urological procedures performed are for urethral strictures and otherwise on the lower urinary tract. Bladder augmentation and substitution are widely used by urologists and increasingly so in other subspecialties across the spectrum of urology for what used to be reconstructive problems, but new problems have developed to challenge reconstructive urologists, requiring a different approach but based on the same general principles. Thus, as augmentation and substitution cystoplasty become increasingly part of ‘general urology’, so reconstructive urologists are adapting these principles to deal with the complications of the treatment of prostate cancer, gynaecological cancer and rectal cancer.

Genital trauma is the commonest type of both blunt and penetrating external trauma. Unlike renal trauma, the diagnosis is mainly clinical and the treatment is commonly surgical but the degree of trauma is rarely life-threatening, albeit a potential cause of infertility or erectile dysfunction. Iatrogenic trauma does occur but most trauma is blunt or penetrating external non-iatrogenic trauma. The commonest type of significant blunt trauma is penile fracture due to sexual intercourse or masturbation. Scrotal trauma causing a ruptured testis or haematocele is less common. Penetrating trauma can occur as a result of animal or human bites, or as a result of amputation other sharp injury, or as a result of gunshot wounds or other military injuries.

This chapter addresses the problem of dealing with a ruptured, ligated or transected ureter, or a ureteric defect caused accidentally or intentionally by surgery. Ureteric strictures may occur as a result of tuberculosis or schistosomiasis. Tuberculous strictures may occur at either end of the ureter; schistosomal strictures occur primarily in the distal ureter. Ureteric stones are another cause of stricture formation and these tend to occur at the common sites of impaction of a stone; therefore, particularly just above the pelvic brim and just outside the bladder. It also develops the theme known as ‘bridging the gap’ and describes the techniques of ureteroureterostomy; the psoas hitch and Boari flap with ureteric reimplantation; transureteroureterostomy (TUU); and the ileal ureter; and briefly refers to renal autotransplantation. Finally, we introduce the concept of ‘complexity’ by reference to the problems of the patient with ureteric obstruction because of, or otherwise associated with radiotherapy.

In this systematic review of the literature, a search of the PubMed database was conducted to identify articles dealing with augmentation/substitution urethral reconstruction of the anterior urethral stricture. The evidence was categorized by stricture site, surgical technique, and the type of tissue used. The committee appointed by the International Consultation on Urological Disease reviewed this data and produced a consensus statement relating to the augmentation and substitution of the anterior urethra. In this review article, the background pathophysiology is discussed. Most cases of urethral stricture disease in the anterior urethra are consequent on an ischemic spongiofibrosis. The choice of technique and the surgical approach are discussed along with the potential pros and cons of the use of a graft vs a flap. There is research potential for tissue engineering. The efficacy of the surgical approach to the urethra is reviewed. Whenever possible, a 1-stage approach is preferable from the patient's perspective. In some cases, with complex penile urethral strictures, a 2-stage procedure might be appropriate, and there is an important potential role for the use of a perineal urethrostomy in cases where there is an extensive anterior urethral stricture or where the patient does not wish to undergo complex surgery, or medical contraindications make this hazardous. It is important to have accurate outcome measures for the follow-up of patients, and in this context, a full account needs to be taken of patients' perspectives by the use of appropriate patient-reported outcome measures. The use of symptoms and a flow rate can be misleading. It is well established that with a normally functioning bladder, the flow rate does not diminish until the caliber of the urethra falls below 10F. The most accurate means of following up patients after stricture surgery are by the use of endoscopy or visualization by urethrography. Careful consideration needs to be made of the outcomes reported in the world literature, bearing in mind these aforementioned points. The article concludes with an overview of the key recommendations provided by the committee.

PurposeRectourethral fistula is a known complication of prostate cancer treatment. Reports in the literature on rectourethral fistula repair technique and outcomes are limited to single institution series. We examined the variations in technique and outcomes of rectourethral fistula repair in a multi-institutional setting.Materials and methodsWe retrospectively identified patients who underwent rectourethral fistula repair after prostate cancer treatment at 1 of 4 large volume reconstructive urology centers, including University of California-San Francisco, University College London Hospitals, Lahey Clinic and Devine-Jordan Center for Reconstructive Surgery, in a 15-year period. We examined the types of prostate cancer treatment, technical aspects of rectourethral fistula repair and outcomes.ResultsAfter prostate cancer treatment 201 patients underwent rectourethral fistula repair. The fistula developed in 97 men (48.2%) after radical prostatectomy alone and in 104 (51.8%) who received a form of energy ablation. In the ablation group 84% of patients underwent bowel diversion before rectourethral fistula repair compared to 65% in the prostatectomy group. An interposition flap or graft was placed in 91% and 92% of the 2 groups, respectively. Concomitant bladder neck contracture or urethral stricture developed in 26% of patients in the ablation group and in 14% in the prostatectomy group. Postoperatively the rates of urinary incontinence and complications were higher in the energy ablation group at 35% and 25% vs 16% and 11%, respectively. The ultimate success rate of fistula repair in the energy ablation and radical prostatectomy groups was 87% and 99% with 92% overall success.ConclusionsRectourethral fistulas due to prostate cancer therapy can be reconstructed successfully in a high percent of patients. This avoids permanent urinary diversion in these complex cases.

INTRODUCTION AND OBJECTIVES: Bulbo-prostatic anastomotic urethroplasty (BPA) for urethral injuries associated with traumatic disruption of the pelvic ring is notoriously a surgical challenge, often requiring various manouvres to straighten the course of the bulbar urethra and bridge the resulting defect. There are however other factors which may render the reconstructive procedure more complex. This study investigates these factors. METHODS: 360 BPAs were performed in a single tertiary referral centre between October 1996 and October 2014. 77 (21%) were revision procedures. Mean patient age was 37.9 years. Mean follow-up was 51 months (range 9-115 months). Recurrence was defined radiologically and/or by the need for any further surgical intervention including dilatation or urethrotomy. RESULTS: 286 (79%) procedures were carried out transperineally (Step 1-4) while 74 (21%) required additional abdominal exposure to mobilise the bladder bladder base (n1⁄416), repair associated injuries (n1⁄441) or perform an entero-urethroplasty (n1⁄417). 29 of 74 (39%) abdomino-perineal (AP) procedures were revisions. 48 of 77 revisions (62%) were performed via a transperineal approach. The restricture rate was higher for revision procedures compared to primary ones when approached transperineally (15% vs 8%) but not for AP procedures (21% in both primary and revision cases). Overall, the recurrence rate for AP procedures was 21% compared to 9% for the transperineal approach. Associated bladder neck injury (n1⁄418), uro-rectal/perineal fistulae (n1⁄415), perineal degloving injury (n1⁄46), anterior urethral stricture (n1⁄419) and osteomyelitis/pelvic sepsis (n1⁄410) were identified as factors adding complexity to the procedure. CONCLUSIONS: A longer defect and revisional surgery often require corporal separation, inferior wedge pubectomy and rerouting of the urethra around the crura in a stepwise fashion in order to guarantee a tension-free anastomosis. These render the procedure more difficult but do not necessarily imply increasing complexity. Factors necessitating a change in approach (usually but not exclusively requiring additional abdominal exposure) to deal with multiple pathologies such as the need for bladder neck reconstruction or concominant anterior urethral strictures are what render the procedure complex.

What's known on the subject? and What does the study add? Urethral strictures, bladder neck and posterior urethral contractures, and urorectal fistulation are three well-recognised complications of the treatment of prostate cancer, whether by surgery or non-surgical treatment. Because these are relatively rare problems the treatment is uncertain. There is a heavy reliance on endoscopic or instrumental management of urethral strictures and of bladder neck and posterior urethral contractures, and there is little discrimination in any of these conditions between those that are the result of surgery and those that are the result of radiotherapy and other treatment methods using external energy sources. This review aims to clarify out current understanding of these three clinical problems and draws attention to the role of reconstructive surgery, particularly when dealing with bladder neck contractures, prostatic urethral stenoses and urorectal fistula. This also shows that the nature of the problem, the recovery time after treatment and the degree of functional recovery is radically different in the surgical as against the non-surgical group, to a degree that the authors believe is not sufficiently stressed when patients are counselled and consented before their primary treatment. • To review the less common and not widely discussed, but much more serious complications of prostate cancer treatment of: urethral stricture, bladder neck contracture and urorectal fistula. • The treatment options for patients with organ-confirmed prostate cancer include: radical prostatectomy (RP), brachytherapy (BT), external beam radiotherapy (EBRT), high-intensity focussed ultrasound (HIFU) and cryotherapy; with each method or combination of methods having associated complications. • Complications resulting from RP are relatively easy to manage, with rapid recovery and return to normal activities, and usually a return to normal bodily functions. • However, after non-surgical treatments, i.e. BT, EBRT, HIFU and cryotherapy, these same problems are more difficult to treat with a much slower return to a much lower level of function. • When counselling patients about the primary treatment of prostate cancer they should be advised that although the same type of complication may occur after surgical or non-surgical treatment, the scope and scale of that complication, the ease with which it is treated and the degree of restoration of normality after treatment, is altogether in favour of surgery in those for whom surgery is appropriate and who are fit for surgery.

Objective To report our early experience with a novel approach to the excision and end-to-end anastomotic repair of bulbar urethral strictures. Patients and methods A total of 22 patients underwent excision and end-to-end anastomosis of a proximal bulbar urethral stricture using a technique in which the corpus spongiosum is not transected, so as to maintain its blood supply intact. The range of follow-up was 6-21 months and for 16 patients the follow up was ≥1 year. Results At 1 year of follow-up there was no evidence of a recurrent stricture on symptomatic assessment or uroflowmetry in the 16 patients. On urethrography one patient has a urethral calibre 80% of normal. In the other 15 the calibre is normal or greater than normal. Conclusion The non-transecting anastomotic bulbar urethroplasty technique used appears to give results that are as good as those of traditional anastomotic urethroplasty with less surgical trauma.

What’s known on the subject? and What does the study add? Iatrogenic trauma aside, urethral injuries are not common. Nonetheless, there have been a large number of cohort studies, generally of small numbers of patients. This review pulls together all of the information available to try and produce a coherent narrative.

What’s known on the subject? and What does the study add? Iatrogenic trauma aside, urethral injuries are not common. Nonetheless, there have been a large number of cohort studies, generally of small numbers of patients. This review pulls together all of the information available to try and produce a coherent narrative.