- Email: [email protected]
BUCCAL PATCH URETHROPLASTY IN MEN WITH RECURRENT URETHRAL STRICTURES
P6
URETHRAL STRICTURES Wednesday, 5 April, 12.45-14.15, Room Havana / Level 3 85 URETHRAL ULTRASOUND VALUE IN INTERNAL URETHROTOMY Cauni V., Geavlete P., Nita G., Georgescu D. Saint John Clinical Emergency Hospital, Dept. of Urology, Bucharest, Romania INTRODUCTION & OBJECTIVES: The recurrence rate of internal urethrotomy (IU) is still high (long-term curative success rate between 20 and 45% after the first IU). We aimed to establish the value of urethral ultrasound in inflammatory urethral stricture (IUS) diagnosis and treatment. MATERIAL & METHODS: Between June 1994 and May 2005, we performed IU in 562 cases with IUS (under 1.5 cm.). In order to evaluate the results obtained by guided incision according to the echographic evaluation, patients have been divided into 2 groups. For the first group (319 cases), the IU technique has been adapted to the echographic aspect of the stricture zone, and to the fibrosis location on the urethral circumference. For patients of the second group (243 cases) we practiced IU with a “classical” 12 o’clock incision. The mean follow-up period was 38.7 months (range 4 to 71 months) and 37.9 months (range 5 to 69 months) for the second group. We used the SPSS 8.0 for Windows statistical analysis (Cox regression) with Kaplan-Mayer curves in order to compare the recurrence-free survival time. RESULTS: In the first group (44.5% recurrence rate) we found 4 specific locations of urethral stricture fibrosis according to ultrasound evaluation: dorsal urethral fibrosis (274), ventral urethral fibrosis (36), circular urethral fibrosis (136), dorsal and ventral fibrosis (114). The best results have been obtained for the dorsal and ventral location of the spongious fibrosis (45/153 recurrences – 29.4% and 9/22 recurrences – 41%). The recurrence rate was higher in the circular and concomitant dorsal and ventral location of the spongious fibrosis: 67.5% (52/77 cases) and 55.2% (37/67 cases). Cox regression (-2LL=360.859, Chi-square=47.670, Sig=0.137) demonstrated statistical significance in these series. (p<0.5) In the second group (51.5% recurrence rate) we found 64.2% recurrences for the ventral location, 83% for the circular location and 72.3% for the dorsal and ventral location of the spongious fibrosis. CONCLUSIONS: According to our experience, the high recurrence rate of IUS after IU may be explained by the inadequate type of incision. So, urethral ultrasound could improve the IU technique by better location of the fibrosis area.
86 URETHRAL GRAY-SCALE AND COLOUR DOPPLER SONOGRAPHY IN THE DIAGNOSTIC EVALUATION OF ANTERIOR URETHRAL STRICTURES Pelzer A.E.1, Bektic J.1, Berger A.P.1, Pallwein L.2, Akkad T.1, Bartsch G.1, Horninger W.1 1
Medical University Innsbruck, Dept. of Urology, Innsbruck, Austria, 2Medical University Innsbruck, Dept. of Radiology, Innsbruck, Austria INTRODUCTION & OBJECTIVES: To evaluate the role of urethral sonography and color Doppler imaging in the evaluation of anterior urethral strictures. MATERIAL & METHODS: 120 paired urethrography and sono-urethrography studies were performed on 93 patients with urethral strictures. Gray-scale and color Doppler sonography was performed with a multi-D linear array transducer operating at 10.0 MHz (VFX 13-5, Siemens, Issaquah, WA). Color Doppler imaging was performed to assess the spongiosa tissue blood flow and the location of urethral arteries. In all cases the urethra was evaluated either cystoscopically or at open surgery. The findings obtained by sonography and urethrography were compared with the findings at cystoscopy or surgery.
RESULTS: Urethral sonography correctly identified the stricture and its site in all cases. There was a statistically significant difference between stricture lengths as measured by urethrography compared to that measured by urethral sonography (p < 0.005). Based on anatomical location, there was a good correlation and no statistically significant difference in the penile urethra (correlation coefficient = 0.95, p = 0.77) but poor a correlation and a statistically significant difference in the bulbar urethra (correlation coefficient = 0.62, p = 0.003). Comparison of urethrography and sono-urethrography stricture lengths with operative lengths, demonstrated a good correlation in the penile urethra (correlation coefficient = 0.91 versus 0.98), whereas a poor correlation was found in bulbar urethra (correlation coefficient = 0.65 versus 0.92). In 18 patients (19%) urethral sonography correctly indicated a reconstructive procedure different from that originally suggested by conventional urethrography. Color Doppler imaging provided additional information about stricture involvement of the spongiosum and location of urethral arteries. CONCLUSIONS: Urethral gray-scale and colour Doppler sonography exactly identifies stricture site, number and caliber. Compared with conventional urethrography, it more accurately measures stricture length and diameter in the bulbar urethra. This technique seems to be superior to urethrography for the evaluation of anterior urethral strictures.
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BUCCAL PATCH URETHROPLASTY IN MEN WITH RECURRENT URETHRAL STRICTURES
LINGUAL MUCOSA URETHROPLASTY
O’Riordan A., Pickard R.
Simonato A.1, Gregori A.2, Lissiani A.3, Traverso P.1, Ambruosi C.1, Romagnoli A.1, Carmignani G.1
Freeman Hospital, Department of Urology, Newcastle upon Tyne, United Kingdom INTRODUCTION & OBJECTIVES: We have prospectively audited the use of single stage dorsal buccal mucosal grafts for the treatment of recurrent bulbar urethral stricture between September 1999 and July 2004. Failure was defined as the need for further intervention and the standard was set as 85% success rate at 12 months. MATERIAL & METHODS: During this period 35 men with underwent buccal patch urethroplasty. Data was collected prospectively. The mean (range) age was 31 years (19-77). Stricture aetiology was identified for 51% of men comprising catheterisation in 6, infection in 6, trauma in 3 and surgery in 3. The average number of urethrotomies performed for each subject prior to urethroplasty was 3 (range 1-15), with 50% of the patients having performed self-dilation for varying periods. RESULTS: The mean (range) stricture length was 3.6 cm (1-11). Severe or moderately severe spongiofibrosis was seen in 80% of subjects at the time of surgery. Minor complications were encountered in 29% patients of whom the majority was infection related with one return to theatre. Mean (range) duration of follow up was 26 (1-69) months. Maximum flow rate (Qmax) increased from a mean of 6.4 (+/- 0.9) ml/s pre-operatively to 21.3 (+/- 2) ml/s post-operatively. Five patients (14%) have developed a recurrent stricture at the previous site and required further optical urethrotomy. Two men are awaiting flexible cystoscopy for recurrent symptoms. All men with recurrent strictures had moderate or severe spongiofibrosis pre-operatively. There did not appear to be any association between the number of urethrotomies and the outcome. Erectile function was unchanged in all men except one. This gives an overall success rate of 85%. CONCLUSIONS: Buccal patch urethroplasty is an effective treatment for men with recurrent bulbar urethral stricture and can be achieved with minimal morbidity. Our success rate for the procedure is consistent with previous reports. Although failure of surgery does not appear to be related to the number of previous interventions, this operation should be considered earlier in younger men since repeated urethrotomies are unlikely to give successful long-term management. Eur Urol Suppl 2006;5(2):44
AS
AN
ALTERNATIVE
GRAFT
FOR
Ospedale S. Martino, Dept. of Urology, Genoa, Italy, 2Ospedale L. Sacco, Dept. of Urology, Milan, Italy, 3Ospedale Cattinara, Dept. of Urology, Trieste, Italy
1
INTRODUCTION & OBJECTIVES: Urethroplasty with buccal mucosal graft (BMG) gives excellent clinical results but may also give oral complications in some cases. The mucosal covering the lateral and under surface of the tongue is identical in structure with that lining the rest of the oral cavity. We evaluated lingual mucosal grafts (LMG) for urethroplasty. MATERIAL & METHODS: From January 2001 to September 2004 8 men, 34 to 65 years old (mean age 46.1 years), with urethral strictures (length from 1.5 to 4.5 cm) were selected for 1-stage dorsal onlay urethroplasty. The site of the harvest graft was the lateral mucosal lining of the tongue. Postoperatively all patients were followed with urethrography, uroflowmetry, cystourethrography and flexible urethroscopy after 3 and 12 months. Successful reconstruction criteria were a peak flow rate greater than 15 mL/s, and no need of postoperative urethral dilations. RESULTS: Median follow up is 18 months (mean 22.1 months, range 3 to 47 months). Seven cases were successful. One patient had a partial urethral stricture. In the successful cases cystourethrography revealed no significant graft contractures or sacculations and at flexible ureteroscopy LMG is nearly indistinguishable from native urethra. There were no pain, aesthetic or functional complications at the donor-site. CONCLUSIONS: Harvesting the LMG is feasible and easy to perform. Compared with BMG, LMG seems to be associated with less postoperative pain and a minor risk of donor site complications. These preliminary functional and aesthetic data are satisfactory.
URETHRAL STRICTURES Wednesday, 5 April, 12.45-14.15, Room Havana / Level 3 85 URETHRAL ULTRASOUND VALUE IN INTERNAL URETHROTOMY Cauni V., Geavlete P., Nita G., Georgescu D. Saint John Clinical Emergency Hospital, Dept. of Urology, Bucharest, Romania INTRODUCTION & OBJECTIVES: The recurrence rate of internal urethrotomy (IU) is still high (long-term curative success rate between 20 and 45% after the first IU). We aimed to establish the value of urethral ultrasound in inflammatory urethral stricture (IUS) diagnosis and treatment. MATERIAL & METHODS: Between June 1994 and May 2005, we performed IU in 562 cases with IUS (under 1.5 cm.). In order to evaluate the results obtained by guided incision according to the echographic evaluation, patients have been divided into 2 groups. For the first group (319 cases), the IU technique has been adapted to the echographic aspect of the stricture zone, and to the fibrosis location on the urethral circumference. For patients of the second group (243 cases) we practiced IU with a “classical” 12 o’clock incision. The mean follow-up period was 38.7 months (range 4 to 71 months) and 37.9 months (range 5 to 69 months) for the second group. We used the SPSS 8.0 for Windows statistical analysis (Cox regression) with Kaplan-Mayer curves in order to compare the recurrence-free survival time. RESULTS: In the first group (44.5% recurrence rate) we found 4 specific locations of urethral stricture fibrosis according to ultrasound evaluation: dorsal urethral fibrosis (274), ventral urethral fibrosis (36), circular urethral fibrosis (136), dorsal and ventral fibrosis (114). The best results have been obtained for the dorsal and ventral location of the spongious fibrosis (45/153 recurrences – 29.4% and 9/22 recurrences – 41%). The recurrence rate was higher in the circular and concomitant dorsal and ventral location of the spongious fibrosis: 67.5% (52/77 cases) and 55.2% (37/67 cases). Cox regression (-2LL=360.859, Chi-square=47.670, Sig=0.137) demonstrated statistical significance in these series. (p<0.5) In the second group (51.5% recurrence rate) we found 64.2% recurrences for the ventral location, 83% for the circular location and 72.3% for the dorsal and ventral location of the spongious fibrosis. CONCLUSIONS: According to our experience, the high recurrence rate of IUS after IU may be explained by the inadequate type of incision. So, urethral ultrasound could improve the IU technique by better location of the fibrosis area.
86 URETHRAL GRAY-SCALE AND COLOUR DOPPLER SONOGRAPHY IN THE DIAGNOSTIC EVALUATION OF ANTERIOR URETHRAL STRICTURES Pelzer A.E.1, Bektic J.1, Berger A.P.1, Pallwein L.2, Akkad T.1, Bartsch G.1, Horninger W.1 1
Medical University Innsbruck, Dept. of Urology, Innsbruck, Austria, 2Medical University Innsbruck, Dept. of Radiology, Innsbruck, Austria INTRODUCTION & OBJECTIVES: To evaluate the role of urethral sonography and color Doppler imaging in the evaluation of anterior urethral strictures. MATERIAL & METHODS: 120 paired urethrography and sono-urethrography studies were performed on 93 patients with urethral strictures. Gray-scale and color Doppler sonography was performed with a multi-D linear array transducer operating at 10.0 MHz (VFX 13-5, Siemens, Issaquah, WA). Color Doppler imaging was performed to assess the spongiosa tissue blood flow and the location of urethral arteries. In all cases the urethra was evaluated either cystoscopically or at open surgery. The findings obtained by sonography and urethrography were compared with the findings at cystoscopy or surgery.
RESULTS: Urethral sonography correctly identified the stricture and its site in all cases. There was a statistically significant difference between stricture lengths as measured by urethrography compared to that measured by urethral sonography (p < 0.005). Based on anatomical location, there was a good correlation and no statistically significant difference in the penile urethra (correlation coefficient = 0.95, p = 0.77) but poor a correlation and a statistically significant difference in the bulbar urethra (correlation coefficient = 0.62, p = 0.003). Comparison of urethrography and sono-urethrography stricture lengths with operative lengths, demonstrated a good correlation in the penile urethra (correlation coefficient = 0.91 versus 0.98), whereas a poor correlation was found in bulbar urethra (correlation coefficient = 0.65 versus 0.92). In 18 patients (19%) urethral sonography correctly indicated a reconstructive procedure different from that originally suggested by conventional urethrography. Color Doppler imaging provided additional information about stricture involvement of the spongiosum and location of urethral arteries. CONCLUSIONS: Urethral gray-scale and colour Doppler sonography exactly identifies stricture site, number and caliber. Compared with conventional urethrography, it more accurately measures stricture length and diameter in the bulbar urethra. This technique seems to be superior to urethrography for the evaluation of anterior urethral strictures.
87
88
BUCCAL PATCH URETHROPLASTY IN MEN WITH RECURRENT URETHRAL STRICTURES
LINGUAL MUCOSA URETHROPLASTY
O’Riordan A., Pickard R.
Simonato A.1, Gregori A.2, Lissiani A.3, Traverso P.1, Ambruosi C.1, Romagnoli A.1, Carmignani G.1
Freeman Hospital, Department of Urology, Newcastle upon Tyne, United Kingdom INTRODUCTION & OBJECTIVES: We have prospectively audited the use of single stage dorsal buccal mucosal grafts for the treatment of recurrent bulbar urethral stricture between September 1999 and July 2004. Failure was defined as the need for further intervention and the standard was set as 85% success rate at 12 months. MATERIAL & METHODS: During this period 35 men with underwent buccal patch urethroplasty. Data was collected prospectively. The mean (range) age was 31 years (19-77). Stricture aetiology was identified for 51% of men comprising catheterisation in 6, infection in 6, trauma in 3 and surgery in 3. The average number of urethrotomies performed for each subject prior to urethroplasty was 3 (range 1-15), with 50% of the patients having performed self-dilation for varying periods. RESULTS: The mean (range) stricture length was 3.6 cm (1-11). Severe or moderately severe spongiofibrosis was seen in 80% of subjects at the time of surgery. Minor complications were encountered in 29% patients of whom the majority was infection related with one return to theatre. Mean (range) duration of follow up was 26 (1-69) months. Maximum flow rate (Qmax) increased from a mean of 6.4 (+/- 0.9) ml/s pre-operatively to 21.3 (+/- 2) ml/s post-operatively. Five patients (14%) have developed a recurrent stricture at the previous site and required further optical urethrotomy. Two men are awaiting flexible cystoscopy for recurrent symptoms. All men with recurrent strictures had moderate or severe spongiofibrosis pre-operatively. There did not appear to be any association between the number of urethrotomies and the outcome. Erectile function was unchanged in all men except one. This gives an overall success rate of 85%. CONCLUSIONS: Buccal patch urethroplasty is an effective treatment for men with recurrent bulbar urethral stricture and can be achieved with minimal morbidity. Our success rate for the procedure is consistent with previous reports. Although failure of surgery does not appear to be related to the number of previous interventions, this operation should be considered earlier in younger men since repeated urethrotomies are unlikely to give successful long-term management. Eur Urol Suppl 2006;5(2):44
AS
AN
ALTERNATIVE
GRAFT
FOR
Ospedale S. Martino, Dept. of Urology, Genoa, Italy, 2Ospedale L. Sacco, Dept. of Urology, Milan, Italy, 3Ospedale Cattinara, Dept. of Urology, Trieste, Italy
1
INTRODUCTION & OBJECTIVES: Urethroplasty with buccal mucosal graft (BMG) gives excellent clinical results but may also give oral complications in some cases. The mucosal covering the lateral and under surface of the tongue is identical in structure with that lining the rest of the oral cavity. We evaluated lingual mucosal grafts (LMG) for urethroplasty. MATERIAL & METHODS: From January 2001 to September 2004 8 men, 34 to 65 years old (mean age 46.1 years), with urethral strictures (length from 1.5 to 4.5 cm) were selected for 1-stage dorsal onlay urethroplasty. The site of the harvest graft was the lateral mucosal lining of the tongue. Postoperatively all patients were followed with urethrography, uroflowmetry, cystourethrography and flexible urethroscopy after 3 and 12 months. Successful reconstruction criteria were a peak flow rate greater than 15 mL/s, and no need of postoperative urethral dilations. RESULTS: Median follow up is 18 months (mean 22.1 months, range 3 to 47 months). Seven cases were successful. One patient had a partial urethral stricture. In the successful cases cystourethrography revealed no significant graft contractures or sacculations and at flexible ureteroscopy LMG is nearly indistinguishable from native urethra. There were no pain, aesthetic or functional complications at the donor-site. CONCLUSIONS: Harvesting the LMG is feasible and easy to perform. Compared with BMG, LMG seems to be associated with less postoperative pain and a minor risk of donor site complications. These preliminary functional and aesthetic data are satisfactory.