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In this review we present an update on the anatomy and vascularization of the male urethra. The real objective of this review is to make the following chapters more understandable, both to know the physio-pathological mechanisms of urethral pathology and also to help us in their surgical management.
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In this article we present the causes of urethral stenosis in the adult male and review data about incidence. Regarding disease physiopathology we emphasize the inflammatory causes and, more specifically lichen sclerosus, as the clinical scenario that presents the greater difficulty for the management of urethral stenosis since we do not know its natural evolution.Regarding treatment of urethral stenosis we discuss the various options from excision and terminal-terminal anastomosis to oral mucosal graft augmentation urethroplasty, passing by two-step operations in more severe cases.Looking forward to the future a real gate opens with the application of tissue engineering to obtain oral mucosa.
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Reconstructive surgery of large urethral stenosis and the management of congenital anomalies such as hypospadias and epispadias require covering large cutaneous and mucosal defects with different techniques. The objective of this work is to define the main differences between tissues to be transferred and to study the principles that must govern the management of the various flaps and grafts used for these techniques. We analyze the anatomical and physiological features that may be key to understand the success and possible failures of these procedures, and we review technical details that must accompany in every case, not only during the operation, but also during the preoperative and postoperative period. We conclude stating that grafts (mainly oral and preputial mucosa) and flaps are increasingly used for the repair of urethral stenosis. Grafts must be prepared adequately in the back table and thinned to the maximum, and also be fixed properly, to guarantee their immobility until neovascularization is assured.
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Urethral strictures are one of the mostcommon urological problems, yet the natural limitationsof wound healing and the physiologic demands on theanatomic structures combine to also make urethral stric-tures one of the most challenging urological problems tomanage. Proper wound healing demands well approxi-mated edges because prolonged inflammation andgranulation, required to close large, deep wounds, willresult in excess collagen production, fibrosis, and theformation of a scar or, in the urethra, a stricture. Bioma-terials have successfully been used to approximate theECM of several different tissue types and can define athree dimensional space suitable for the formation of newtissues with both appropriate structure and appropriate function. Biomaterials can be broadly categorized as ei-ther synthetic polymers or tissue matrices, each with theiradvantages and limitations. Recent studies utilizing cellseeded natural biomaterials in urethral repair has yiel-ded some promising results. However, advancements inthe use of alternative sources of cells for matrix seedingand cell-seeded synthetic materials hold the possibility ofeven better results in the future
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Penile urethra stenoses generally appear as a sequel after acute (sexually transmitted diseases) or chronic urethritis processes, associated with diseases such as lichen sclerosus or as a consequence of traumatism, iatrogeny and forced distention of the urethral lumen. One third of these lesions may be congenital and they usually present in the youngest patients.When there is indication for surgical urethral reconstruction there are multiple surgical techniques and different tissues. The selection of the best technique depends on the availability of different tissue sources, the knowledge of the various technical options, and being familiar or having personal experience with the surgical techniques.This chapter aims to review the various technical options of more frequent use for urethral lumen reconstruction, to offer the greatest number of resources to solve a medical problem of complex solution.
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Hypospadias is one of the most frequent male congenital anomalies. Its surgical correction is under permanent review and it is always controversial. The best surgical technique can only be chosen intrao-peratively, since it is the level of corpus spongiosum di-vision what marks the severity of the case, although it is essential to evaluate position of the meatus, penile curvature, quality of the preputial skin and penile size. It is recommended treatment age between 6-12 months. Nowadays, The most frequently used technique for hy-pospadias repair is the Snodgrass tubularized incised urethral plate (TIP). Moreover, distal and medial hypos-padias may be treated with urethral advance or flap te-chniques and proximal hypospadias with modifications of these in one-step or two-step procedures. Neverthe-less, there are other controversies about hypospadias, such as to preserve or not the prepuce, the use of central or peripheral anesthesia blockade, or the use of wound dressings.
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OBJECTIVES: To evaluate the results of various reconstructive surgical procedures in patients with failed hypospadias repair.METHODS: We performed a retrospective, observational, descriptive chart analysis of patients treated for complications after primary hypospadias repair at two tertiary European centers from 1998 to 2007. Study inclusion criteria were: patients presenting urethral, glans or corpora cavernosa defects and/or penile and genital deformities. Exclusion criteria were: precancerous or malignant penile lesions, incomplete data on medical charts and any condition that would interfere with the patient’s ability to provide an informed consent. Preoperative evaluation included urine culture, urethrography and urethroscopy. The patients were classified into four groups according to the type of surgery. Success was defined as a normal functional urethra with apical meatus, no residual chordee or cosmetic deformity of the genitalia. The need for meatal or urethral dilation, complications or poor cosmesis requiring revision was considered a failure.RESULTS: A total of 1.176 patients (mean age 31 years) were evaluated and treated. Nine hundred fifty-three patients (81%) were treated in Serbia and 223 (19%) in Italy. Mean follow-up was 60.4 months. Group 1 included 301 patients (25.6%) who underwent urethroplasty. Group 2 included 60 patients (5.1%) who underwent corporoplasty. Group 3 included 166 patients (14.1%) who underwent urethroplasty and corporoplasty. Group 4 included 649 patients (55.2%) requiring complex resurfacing of the genitalia. Evaluations were scheduled 3, 6 and 9 months post-operatively and annually thereafter. At follow-up, patients underwent a physical examination and uroflowmetry. Out of the 1.176 cases, 1.036 (88.1%) were classified as successful and 140 (11.9%) as failures. The success rate was 89.7% in Group 1, 96.7% in Group 2, 88.5% in Group 3, and 86.4% in Group 4, respectively.CONCLUSIONS: Failed hypospadias presents a variety of surgical difficulties. Patients requiring complex repair should be referred to a specialized center of expertise.
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Traditionally, anastomotic procedures with transection and urethral excision are suggested for short bulbar strictures, while longer strictures are treated by patch graft urethroplasty preferably using the buccal mucosa as gold-standard material due to its histological characteristics.However, anastomotic urethroplasties may cause sexual complications related to vascular damage of the spongiosum following the urethral section or to excessive urethral shortening.On the other hand, one-sided graft procedures, using either dorsal or ventral graft location, could be insufficient in providing a lumen of adequate width in strictures with a particularly narrow area.The double buccal graft urethroplasty is a new technique that aims to obtain a sufficient “two-sided” augmentation of the urethra avoiding its transection and preserving the urethral plate.In this chapter we discuss the rationale for utilizing our procedure. In addition, the surgical technique is described in detail.
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Posterior urethral injuries typically arise in the context of a pelvic fracture. The correct and appropriate initial treatment of associated urethral rupture is critical to the proper healing of the injury.In this paper, we provide a comprehensive review of the literature with special emphasis on the various treatments available: open or endoscopic primary realignment, immediate or delayed urethroplasty after suprapubic cystostomy, and delayed optical urethrotomy.
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The surgical and non-surgical treatment of localised prostate cancer may be complicated by bladder neck contractures, prostatic urethral stenoses and bulbomembranous urethral strictures. In general, such complications following radical prostatectomy are less extensive, easier to treat and associated with a better outcome and more rapid recovery than the same complications following radiotherapy, high-intensity focussed ultrasound and cryotherapy. Treatment options range from minimally invasive endoscopic procedures to moreArch. Esp. Urol. 2014; 67 (1): 77-91complex and specialised open surgical reconstruction.In this chapter the surgical management of bladder neck contractures following the treatment of prostate cancer is described together with the management of prostatic urethral stenoses and bulbomembranous urethral strictures, given the difficulty in distinguishing them from one another clinically.
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OBJECTIVES: There are various treatments forprostate cancer nowadays, including techniques that have been used for manyyears such as surgery and radiotherapy, and newer procedures that are gaining prominence in the Urological field like cryotherapy or HIFU (high intensity focused ultrasound). Rectourethral fistula is a rare complication that demands the urologist a great capacity; it may happen after either existent treatment.EVIDENCE ACQUISITION: PubMed literature review with articles published during the last 10 years using the terms “rectourethral fistula” and “prostate cancer”.EVIDENCE SINTHESIS: We present the current situation of rectourethral fistula secondary to prostate cancer in terms of epidemiology, diagnosis and treatment, with special focus on the various types of fistulae and their management. We comment on general features in relation to surgical management of this pathology; type of approach, type of repair, use of flaps, concomitant fistula and urethralstenosis, delay of surgery and bowel diversion. We describe the surgical techniques more frequently used today and their limitations. We present theresults published by different groups with each of these techniques, as well as the corresponding recommendations based on each group`s experience.CONCLUSIONS: Rectourethral fistula is a surgical challenge for the urologist. We must choose the appropriate management in accordance to the characteristics of the fistula.
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Patients with panurethral and complex urethral strictures after failed urethral reconstruction due to strictures and hypospadias repair is a rare but challenging condition. Contemporary surgical techniques include one and two staged urethroplasties using different graft substitutes (i.e., buccal mucosa) or full thickness skin grafts (i.e., from the inner thigh), thereby providing satisfactory results with reducing the re-stricture rate in these patients. However, all current techniques do so at the expense of higher revision rates and thus requiring multiple procedures. Studies investigating the outcomes of reconstruction in panurethral and complex urethral strictures often have heterogeneous patient cohorts including children and adults, different underlying causes, and different techniques, thus allowing only limited interpretation of the published data. In the field of urethral reconstruction, where personal experience and expertise presents an accepted necessity, however, leading to rather small single center studies,only well-designed randomized clinical trials can truly answer the question of which technique will be advantageous in these patients.
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OBJECTIVE: To describe the anatomicalcharacteristics and vascularization of the biaxial hairfree scrotal flap (BAES-flap) and to detail its surgicalapplication to reconstruction of the more complexurethral strictures.METHODS: We performed macro and micro anatomicaldissections of the scrotum in 15 cryopreserved cadaversfor the study of the arterial microvascularization of theBAES flap, and this anatomical knowledge has beenimplemented with the aim to improve the anterior andposterior urethra reconstructive surgical technique. Forscrotal skin conditioning we performed definitive hairremoval with the alexandrite laser.RESULTS: The BAES flap, thanks to its rich biaxialvascularization, its anatomical disposition over theurethral axis, and the suitable characteristics of hair freescrotal skin, has allowed us to perform successful one-step urethral reconstruction in complex cases such aspanurethral disease, multioperated hypospadias, failedurethroplasties and obliterative stenosis.CONCLUSIONS: Detailed study of scrotal skin arterialvascularization is essential to design reliable andversatile genital skin flaps that result appropriate for themost complex reconstructive urethral surgery. The BAESscrotal flap complies with these requirements offeringthe patient a one step reconstructive option with a verysatisfactory surgical experience over more than 20years
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Endoscopic urethrotomy is a simple, reproducible, highly widespread technique that enables an appropriate management of patients with urethral stenosis, if the indication is well established. Determinants of success of this procedure are stenosis length, site, number, degree of spongiofibrosis and previous treatments. The best results would be obtained in single, short bulbar stenoses with limited spongiofibrosis, in which it may be the first choice. Its main limitation is the fact that the procedure itself is a controlled intentional trauma the result of which depends on multiple variables, including the technique employed.
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OBJECTIVES: To update the topic of endourethral prosthesis for the treatment of recurrent urethral stenosis comprehensively, focusing on current indications, materials and types of prosthesis in use nowadays.METHODS: We used the PubMed database (1995-2013) with the terms “endourethral”, “prostheses”, ”endourethral prosthesis” and selected the most relevant articles for this publication.RESULTS: Results were variable depending on the series published, with great differences among them. They are not homogeneous groups, so they are not comparable to each other.CONCLUSIONS: Endourethral prostheses have an important role today in the treatment of recurrent urethral stenosis. More studies are required, with longer follow up to be able to establish which one is the one with the lowest complication rates and best results in terms of urethral caliber and symptom questionnaire.
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To perform a bibliographic review on female urethra stenosis, following the criteria for evidence based medicine.METHODS: We performed a PubMed Search with the following keywords: “female urethral stricture”, “women urethral stricture”, “female urethral reconstruction” and “ female urethral stricture treatment”, without time limits, both in English and Spanish languages.RESULTS: Female urethra stenosis is a rare pathology, in which the working diagnosis is essential, as much as detailed physical examination, urodynamic study and radiological tests.We found in the literature a total of 73 cases treated with dilation with or without maintenance self catheterization, 120 cases treated with meatotomy, 65 cases treated by flap urethroplasty (46 with vaginal flap, 17 with vestibular flap and 12 with labia minora graft and 28 with oral mucosa grafts).There are not comparative studies between the various techniques, making it difficult to set up a therapeutic algorithm.CONCLUSIONS: The surgical treatment with flaps/grafts has the highest success rate; whereas less invasive procedures such as urethrotomy/meatotomy/dilations/self-catheterization should be reserved for short female urethra stenosis or women with high comorbidity
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OBJECTIVES: Limited articles are publis-hed on re-operative urethroplasty outcomes. We soughtto perform a systematic review of re-operative urethro-plasty articles over the past fifteen years.METHODS: A systematic review was performed on Pub-Med using the search terms “Urethra” AND “SurgicalProcedures, Operative” OR “Urethroplasty”.RESULTS: Five articles out of 3,541 articles identifiedbetween 1998 and 2012 specifically addressed re-operative urethroplasty patients. A total of 212 patientswere included in these five studies. Re-operative urethro-plasty success rates ranged from 35% to 84%. Successrates were higher in the two studies with over 40 pa-tients and ranged from 78-84%.CONCLUSION: Limited studies address re-operativeurethroplasty outcomes. Success rates for re-operationare lower than those for initial urethroplasty procedures.Overall, studies with a higher number of patients had anincreased success rate
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OBJECTIVES: Urethral stenosis is a complex pathology that severely affects the quality of life of patients who suffer it. There are multiple therapeutic options, the main objective of which is to eliminate obstruction and improve symptoms, and consequently maintain or improve the quality of life of the patient. The objective of this article is to perform a systematic review of the literature with the aim to evaluate the results regarding the sexual sphere after urethral surgery.METHODS: We performed a bibliographic search in PubMed, identifying studies that analyzed the results in sexual function after various types of urethroplasties. Preference have been given to those articles evaluating sexual function both preoperative and postoperative, to determine the degree of involvement conditioned by surgery. Fourteen articles have been selected, including those making reference to sexual function (sexual desire, erectile and ejaculatory function).RESULTS: A total of 14 studies were selected to perform the analysis; they were divided into two groups depending of the perspective they have to evaluate results: Use of validated tests for data collection before and after surgery and a second group analyzing more qualitative features of the stenosis making the evaluation of results this way. Site of stenosis is not uniformly distributed in these articles, with predominance of those performing anterior urethra surgery. They have a comprehensive analysis of the various features that may affect directly or indirectly the result of the operation both in the short and long term.CONCLUSIONS: Most articles conclude that specific standardized tools are necessary for this type of pathology, with the aim of obtain results that are more adjusted to urethral surgery. Patient perception of the results of urethroplasty is a parameter that has gained great importance lately. Globally the results of postoperative sexual function are very satisfactory, mainly in young patients. It is important to globally analyze the results and surgical techniques currently in use with the aim to minimize deleterious effects on sexual function; moreover taking into account that the objective of surgery is to try to improve the patient`s quality of life.
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OBJECTIVES: While efforts have been made to study erectile function in patients with urethral stricture, very few prior investigations have specifically assessed erectile function in men with failed hypospadias surgery. We set forth to assess the baseline erectile function of men with hypospadias failure presenting for urethroplasty as adults.METHODS: Retrospective data was analyzed on 163 adult patients with prior failed hypospadias repair who presented for urethroplasty from 2002-2007 at two sites in the United States and Italy. All patients had completed the International Index of Erectile Function (IIEF) preoperatively. Standard IIEF-6 categories were used to assess baseline level of erectile dysfunction (ED) defined as none (≥26), minimal (18-25), moderate (11-17), and severe (≤10). A subset of 13 hypospadias patients prospectively completed the IIEF questionnaire pre and post-operatively.RESULTS: The mean age at presentation for urethroplasty was 39.7 years. Based on IIEF-6 scores, 54% of patients presented with some degree of ED with 22.1%, 3.7%, and 28.2% reporting severe, moderate and mild ED respectively. While the oldest patient population (>50) had the highest incidence of severe ED (38.9%), the youngest age group (≤30) had a 60% rate of ED with 18% classified as severe (Table I). Subset analysis of 13 failed hypospadias patients following urethroplasty revealed that 11 (85%) patients had the same or improved erectile function following surgery. CONCLUSIONS: Patients presenting for repair after hypospadias failure often require complex penile reconstruction impacting both urinary as well as sexual quality of life. Among these patients there appears to be a high baseline prevalence of ED. Older patients had a higher incidence of more severe ED; however, the majority of younger patients still presented with some form of ED and a significant number with severe ED. Urethroplasty does not appear to negatively impact erectile function in men with previous hypospadias failure; however a disease specific questionnaire is needed to fully address this issue.
