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Fascia lata autologous free graft for patch urethroplasty: experimental model in rabbit
341 U R E T H R A L S T R I C T U R E REPAIR USING FASCIOCUTANEOUS FLAP T E C H N I Q U E EXPERIENCE
T H E CIRCULAR FIRST C L I N I C A L
Radmayr Christian ~, Klauser Andrea 2, Fauscher Ferdina 2, Bartsch Georg ~ ~Urology, University of Innsbruck, Innsbruck, Austria, '-Radiology, University of Innsbruck, Innsbruck, Austria INTRODUCTION & OBJECTIVES: Since 1998 we use the penile circular fasciocutaneous skin flap method as described by Mc Aninch in the one-stage reconstruction of complex anterior urethral strictures. We report our first clinical experience with this approach. MATERIALS & METHODS: During the period from 1998 until now, we operated on a total of 27 patients with a mean age of 48.3 years representing with complex urethral penile and/or bulbar strictures. In our series the average stricture length was 5.6 cm. All patients underwent standard radiologic imaging (retrograde urethrography and voiding cystourethrography) as well as sonographic staging of their strictures. A circumferential island of distal penile skin or foreskin was mobilised on a vascularised pedicle and used for urethral reconstruction. RESULTS: All patients received a stricture repair in an onlay fashion. No tubularised repairs were performed. All 27 patients were available for evaluation. Unfortunately the mean follow-up is very short (12.9 months) with a maximum of 32 months only. So far, only in 1 patient a short bulbar stricture at the proximal anastomotic site was noted postoperatively and successfully treated with direct vision urethrotomy. No penile skin necrosis proximal to the flap was observed. In two patients a dehiscent glans was noted and secondarily closed. Regardless whether prolonged lithotomy position, no neurovascular lower extremity complications occured. CONCLUSION: Our first clinical experience using the circular fasciocutaneous flap technique in the reconstruction of complex penile and/or bulbar strictures revealed satisfying postoperative results with low morbidity. We assume that this represents a highly effective one-stage method bringing well vascularised tissue to the compromised area. However, this must be confirmed by adequate long term results.
342 FASCIA LATA AUTOLOGOUS FREE GRAFT FOR URETHROPLASTY: EXPERIMENTAL MODEL IN RABBIT
Campodonico Fabio ~, Corbu Carlo ~, Michelazzi Alberto 2, Oneto Francesco ~, Ognio Emanuela 3, Brizzolara Antonella z, Carmignani Giorgio ~ ~Urology, University of Genoa, Genoa, 2Pediatric Surgery, University of Genoa, Genoa, Italy, 3Advanced Biotechnology Centre, National Institute for Cancer Research, Genoa, Italy INTRODUCTION & OBJECTIVES: The treatment of chronic urethral strictures following traumas or failed hypospadias has prompted the development of various surgical procedures and particularly requires adequate amount of tissue. Many types of biological tissues have been attempted as vascularised skin flap, full-thickness free skin graft, vesical or buccal graft and more recently acellular tissue matrix. The aim of this study is to evaluate a new type of antologous graft in reconstructive surgery of the urethra. MATERIALS & METHODS: Twelve male New Zealand rabbits underwent urethroplasty after creating a partial defect on the ventral penile urethra. The defect was repaired with a rectangular patch of fascia lata sutured on the urethra under magnification with a 6/0 running absorbable suture, maintaining the polarity of the fascia. A radiologic control was performed two weeks after surgery and histological analysis at various intervals of time, up to 3 months postoperatively. RESULTS: In ten rabbits the defect was completely repaired, while in two rabbits a loss of contrast was present during urethrography corresponding to fistula at histological analysis. In the other animals the histology shows absence of fibrosis, good vascularisation of the fascial graft and a new line of urothelium. CONCLUSION: The harvesting of free fascia lata graft is easy and quick. The fascial graft has showed its adaptability to urinary tract with the onset of a uniform line of normal urothelium.
344
343 COMBINED ENDOSCOPIC REALIGNMENT: IN POSTERIOR URETHRAL TRAUMATIC INJURIES IMPROVES THE OUTCOME OF SUBSEQUENT SURGICAL REPAIR
PATCH
TREATMENT OF URETHRAL URETHROTOMY: LATE OUTCOME
STRICTURES
BY
LASER
Fleury Nicolas, lselin Christnphe, Schmidlin Franz Traverso Paolo, Corbu Carlo, Germinale Francesco, Campodonico Fabio, Oneto Francesco, Carmignani Giorgio Urology, University of Genoa, Genoa, Italy INTRODUCTION & OBJECTIVES: The anatomic components of the urethra are affected in up to 25% of pelvic traumas, especially when pubis and pubic symphysis are involved. The most common injury is that of the prostatomembranous tract. We have assessed the results, safety and efficacy of the early combined endoscopic realignment technique. MATERIALS & METHODS: From November 1994 to June 2001 we have treated 7 patients who were hospitalised in our department following multiple pelvic fractures and secondary partial or complete rupture of the membranous urethra. Mean age was 39.5 years (range 22-50). Prior to the accident all the patients were in good health and were not showing pathologies of the urinary district and/or impaired erectile function. Upon diagnosis, all the patients presented, in addition to the general polytraumatic picture, urinary retention and ureterorrhagia, in one case the rectum was also injured and another one presented the complete diasthasis of the pelvic floor. All the patients underwent the positioning of an epicystostomic catheter and bladder contrastography, in addition to an adequate broad-spectrum antibiotic therapy, in agreement with our orthopedic colleagues. We performed the endoscopic realignment after a time varying from 7 to 18 days from the trauma.
Geneva University Hospital, Urology Clinic, Geneva, Switzerland INTRODUCTION AND OBJECTIVES: Over the last ten years, LASER energy has attracted interest for the treatment of ureteral strictures, since it induces scarce tissue damage and enables tissue vaporisation. As yet, studies have reported favourable short-term outcome (6-12 months). However, few if at all data have been published with cohorts being followed more than 2 years. The goal of this work was to revisit our population of LASER urethrotomies, in order to assess whether the initial outcome reported (81% success with a mean follow-up time of 6 months, n=20) had remained stable. MATERIAL AND METHODS: We reviewed the files of 44 patients who underwent LASER urethrotomy (KTP or Ho: YAG) at our institution between December 1994 and March 1998. Of these, 28 (63%) could undergo clinical reassessment (uroflowmetry, postvoid residual). Sixteen patients either refused to be reassessed, could not be found or had died. In case of pathologic uroflowmetry, a retrograde urethrogram was performed. Patient outcome was classified in 4 groups good (peak uroflow >15 ml/", no symptoms), moderate (peak uroflow between 8 and 15 ml/", no symptoms), bad (peak uroflow <8 ml/" and/or retrograde ureterogram showing stricture recurrence) and failure (need for second LASER session or other treatment). Treatment was judged successful when the outcome was good or moderate.
RESULTS: In 1 patient, the caliber of the urethral lumen and the micturition, checked with contrastography and uroflowmetry, were satisfactory, as well as the erectile function, thus requiring no further treatment. In 6 patients, a posttreatment stenosis was found on the injury site, and hence we proceeded with a deferred surgical reconstruction of the affected urethral tract by means of termino-terminal urethroplasty or oral mucous membrane patch (1 case). In all the 6 patients who underwent urethroplasty we achieved an adequate and physiological recanalisation of the urethral lumen, as well as the preservation of continence and erectile function.
RESULTS: Mean age was 61 years (19-83) at operation. Mean follow-up time was 33 months (21-53 months). Of the 28 patients, 7 had a double stenosis, thereby leading to a total stricture number of 35. In 16 patients (57%), stricture treatment had already been performed. Stricture etiology was iatrogenic in 14, infectious in 3, traumatic in 1 and unknown in 10. Stricture localisation was bulbar (n=27; 77%), penile (n=5; 14%), at a vesico-uretbral anastomosis (n=3; 9%). Mean stricture length was I 1 mm (3-20 ram). Two patients (7%) had a good result, 4 (14%) a moderate result, 4 (14%) a bad result and 18 (60%) were failures (10 of these underwent urethroplasty, 4 have repeat dilations and 3 had redo LASER). Hence, treatment was successful in 21% of patients (n=6). Of these, 5 were bulbar strictures and one was penile, and their mean length was 12 ram.
CONCLUSION: The endoscopic urethral realignment is a safe and effective procedure. There are far fewer complications compared with immediate surgical repair. The subsequent urethroplasty was greatly facilitated by the presence of close and coherently aligned urethral stumps.
CONCLUSIONS: At a median follow-up of nearly 3 years, the efficiency of LASER urethrotomy decreases drastically. Although the numbers of this study are too small to draw definite conclusions, the strictures that may benefit from LASER urethrotomy appear to be short bulbar strictures at first presentation.
European Urology Supplements 1 (2002) No. 1, pp. 88
T H E CIRCULAR FIRST C L I N I C A L
Radmayr Christian ~, Klauser Andrea 2, Fauscher Ferdina 2, Bartsch Georg ~ ~Urology, University of Innsbruck, Innsbruck, Austria, '-Radiology, University of Innsbruck, Innsbruck, Austria INTRODUCTION & OBJECTIVES: Since 1998 we use the penile circular fasciocutaneous skin flap method as described by Mc Aninch in the one-stage reconstruction of complex anterior urethral strictures. We report our first clinical experience with this approach. MATERIALS & METHODS: During the period from 1998 until now, we operated on a total of 27 patients with a mean age of 48.3 years representing with complex urethral penile and/or bulbar strictures. In our series the average stricture length was 5.6 cm. All patients underwent standard radiologic imaging (retrograde urethrography and voiding cystourethrography) as well as sonographic staging of their strictures. A circumferential island of distal penile skin or foreskin was mobilised on a vascularised pedicle and used for urethral reconstruction. RESULTS: All patients received a stricture repair in an onlay fashion. No tubularised repairs were performed. All 27 patients were available for evaluation. Unfortunately the mean follow-up is very short (12.9 months) with a maximum of 32 months only. So far, only in 1 patient a short bulbar stricture at the proximal anastomotic site was noted postoperatively and successfully treated with direct vision urethrotomy. No penile skin necrosis proximal to the flap was observed. In two patients a dehiscent glans was noted and secondarily closed. Regardless whether prolonged lithotomy position, no neurovascular lower extremity complications occured. CONCLUSION: Our first clinical experience using the circular fasciocutaneous flap technique in the reconstruction of complex penile and/or bulbar strictures revealed satisfying postoperative results with low morbidity. We assume that this represents a highly effective one-stage method bringing well vascularised tissue to the compromised area. However, this must be confirmed by adequate long term results.
342 FASCIA LATA AUTOLOGOUS FREE GRAFT FOR URETHROPLASTY: EXPERIMENTAL MODEL IN RABBIT
Campodonico Fabio ~, Corbu Carlo ~, Michelazzi Alberto 2, Oneto Francesco ~, Ognio Emanuela 3, Brizzolara Antonella z, Carmignani Giorgio ~ ~Urology, University of Genoa, Genoa, 2Pediatric Surgery, University of Genoa, Genoa, Italy, 3Advanced Biotechnology Centre, National Institute for Cancer Research, Genoa, Italy INTRODUCTION & OBJECTIVES: The treatment of chronic urethral strictures following traumas or failed hypospadias has prompted the development of various surgical procedures and particularly requires adequate amount of tissue. Many types of biological tissues have been attempted as vascularised skin flap, full-thickness free skin graft, vesical or buccal graft and more recently acellular tissue matrix. The aim of this study is to evaluate a new type of antologous graft in reconstructive surgery of the urethra. MATERIALS & METHODS: Twelve male New Zealand rabbits underwent urethroplasty after creating a partial defect on the ventral penile urethra. The defect was repaired with a rectangular patch of fascia lata sutured on the urethra under magnification with a 6/0 running absorbable suture, maintaining the polarity of the fascia. A radiologic control was performed two weeks after surgery and histological analysis at various intervals of time, up to 3 months postoperatively. RESULTS: In ten rabbits the defect was completely repaired, while in two rabbits a loss of contrast was present during urethrography corresponding to fistula at histological analysis. In the other animals the histology shows absence of fibrosis, good vascularisation of the fascial graft and a new line of urothelium. CONCLUSION: The harvesting of free fascia lata graft is easy and quick. The fascial graft has showed its adaptability to urinary tract with the onset of a uniform line of normal urothelium.
344
343 COMBINED ENDOSCOPIC REALIGNMENT: IN POSTERIOR URETHRAL TRAUMATIC INJURIES IMPROVES THE OUTCOME OF SUBSEQUENT SURGICAL REPAIR
PATCH
TREATMENT OF URETHRAL URETHROTOMY: LATE OUTCOME
STRICTURES
BY
LASER
Fleury Nicolas, lselin Christnphe, Schmidlin Franz Traverso Paolo, Corbu Carlo, Germinale Francesco, Campodonico Fabio, Oneto Francesco, Carmignani Giorgio Urology, University of Genoa, Genoa, Italy INTRODUCTION & OBJECTIVES: The anatomic components of the urethra are affected in up to 25% of pelvic traumas, especially when pubis and pubic symphysis are involved. The most common injury is that of the prostatomembranous tract. We have assessed the results, safety and efficacy of the early combined endoscopic realignment technique. MATERIALS & METHODS: From November 1994 to June 2001 we have treated 7 patients who were hospitalised in our department following multiple pelvic fractures and secondary partial or complete rupture of the membranous urethra. Mean age was 39.5 years (range 22-50). Prior to the accident all the patients were in good health and were not showing pathologies of the urinary district and/or impaired erectile function. Upon diagnosis, all the patients presented, in addition to the general polytraumatic picture, urinary retention and ureterorrhagia, in one case the rectum was also injured and another one presented the complete diasthasis of the pelvic floor. All the patients underwent the positioning of an epicystostomic catheter and bladder contrastography, in addition to an adequate broad-spectrum antibiotic therapy, in agreement with our orthopedic colleagues. We performed the endoscopic realignment after a time varying from 7 to 18 days from the trauma.
Geneva University Hospital, Urology Clinic, Geneva, Switzerland INTRODUCTION AND OBJECTIVES: Over the last ten years, LASER energy has attracted interest for the treatment of ureteral strictures, since it induces scarce tissue damage and enables tissue vaporisation. As yet, studies have reported favourable short-term outcome (6-12 months). However, few if at all data have been published with cohorts being followed more than 2 years. The goal of this work was to revisit our population of LASER urethrotomies, in order to assess whether the initial outcome reported (81% success with a mean follow-up time of 6 months, n=20) had remained stable. MATERIAL AND METHODS: We reviewed the files of 44 patients who underwent LASER urethrotomy (KTP or Ho: YAG) at our institution between December 1994 and March 1998. Of these, 28 (63%) could undergo clinical reassessment (uroflowmetry, postvoid residual). Sixteen patients either refused to be reassessed, could not be found or had died. In case of pathologic uroflowmetry, a retrograde urethrogram was performed. Patient outcome was classified in 4 groups good (peak uroflow >15 ml/", no symptoms), moderate (peak uroflow between 8 and 15 ml/", no symptoms), bad (peak uroflow <8 ml/" and/or retrograde ureterogram showing stricture recurrence) and failure (need for second LASER session or other treatment). Treatment was judged successful when the outcome was good or moderate.
RESULTS: In 1 patient, the caliber of the urethral lumen and the micturition, checked with contrastography and uroflowmetry, were satisfactory, as well as the erectile function, thus requiring no further treatment. In 6 patients, a posttreatment stenosis was found on the injury site, and hence we proceeded with a deferred surgical reconstruction of the affected urethral tract by means of termino-terminal urethroplasty or oral mucous membrane patch (1 case). In all the 6 patients who underwent urethroplasty we achieved an adequate and physiological recanalisation of the urethral lumen, as well as the preservation of continence and erectile function.
RESULTS: Mean age was 61 years (19-83) at operation. Mean follow-up time was 33 months (21-53 months). Of the 28 patients, 7 had a double stenosis, thereby leading to a total stricture number of 35. In 16 patients (57%), stricture treatment had already been performed. Stricture etiology was iatrogenic in 14, infectious in 3, traumatic in 1 and unknown in 10. Stricture localisation was bulbar (n=27; 77%), penile (n=5; 14%), at a vesico-uretbral anastomosis (n=3; 9%). Mean stricture length was I 1 mm (3-20 ram). Two patients (7%) had a good result, 4 (14%) a moderate result, 4 (14%) a bad result and 18 (60%) were failures (10 of these underwent urethroplasty, 4 have repeat dilations and 3 had redo LASER). Hence, treatment was successful in 21% of patients (n=6). Of these, 5 were bulbar strictures and one was penile, and their mean length was 12 ram.
CONCLUSION: The endoscopic urethral realignment is a safe and effective procedure. There are far fewer complications compared with immediate surgical repair. The subsequent urethroplasty was greatly facilitated by the presence of close and coherently aligned urethral stumps.
CONCLUSIONS: At a median follow-up of nearly 3 years, the efficiency of LASER urethrotomy decreases drastically. Although the numbers of this study are too small to draw definite conclusions, the strictures that may benefit from LASER urethrotomy appear to be short bulbar strictures at first presentation.
European Urology Supplements 1 (2002) No. 1, pp. 88