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Anadani A, Obaidin A, Badawi B, Lutfi MY. One-stage urethroplasty using a combination of buccal mucosa graft and Q penile skin flap for a complicated urethral stricture: A challenging case report. Medicine (Baltimore) 2025; 104:e41888. [PMID: 40128034 PMCID: PMC11936549 DOI: 10.1097/md.0000000000041888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Accepted: 02/28/2025] [Indexed: 03/26/2025] Open
Abstract
RATIONALE Strictures of the male urethra are common, often caused by trauma or occur idiopathically. The primary clinical symptoms include chronic obstructive voiding issues, and some patients may experience sexual dysfunction. Treatment choices mainly depend on the stricture's location and length. PATIENT CONCERNS A 37-year-old man visited the urology department with lower urinary tract symptoms and recurrent urinary tract infections. He had a 5 cm urethral stricture previously treated with urethroplasty, which was unsuccessful. DIAGNOSES A retrograde urethrography revealed the stricture, an extra-anatomical bypass, and a diverticulum. INTERVENTIONS A second urethroplasty was performed, using a combination of a buccal mucosa graft and a penile skin flap. OUTCOMES Postoperative follow-up indicated improvement in the patient's voiding symptoms. A retrograde urethrography was done 3 months after the procedure showing a well-patent urethra with no complications. LESSONS The key factors in deciding the treatment for urethral strictures are their location and length. Both grafts and flaps are effective for urethroplasties. However, complex long strictures with damaged urethral plates pose challenges for successful single-stage reconstruction. Combining a dorsal buccal mucosa graft to augment the urethral plate with a ventral onlay penile skin flap is a promising approach, leveraging the benefits of both tissue types. Combining grafts and flaps is advisable for reconstructing complicated urethral strictures with damaged urethral plates. Consulting a more experienced surgeon is recommended to minimize the risk of complications.
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Affiliation(s)
| | - Aya Obaidin
- Faculty of Medicine, Hama University, Hama, Syria
| | - Bashar Badawi
- Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - M. Yasin Lutfi
- Clinical Specialist in Urology, Hama National Hospital, Hama, Syria
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Guo Y, Ma N, Wang M, Chen S, Liu P, Yang Z, Li Y. Comparing the tissue properties of human buccal mucosa and penile skin flap: insights for urethral graft substitution. World J Urol 2025; 43:137. [PMID: 39992424 DOI: 10.1007/s00345-025-05519-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2024] [Accepted: 02/13/2025] [Indexed: 02/25/2025] Open
Abstract
OBJECTIVES To compare the histological features, biomechanical properties, water permeability, and osmotic stress responses of human buccal mucosa and penile skin flaps to evaluate their suitability as urethral graft substitutes. METHODS Buccal mucosa (n = 53) and penile skin flap (n = 59) were prepared for histological assessment of tissue structural characteristics and vascular patterns using H&E staining and immunofluorescence. Biomechanical properties were evaluated through mechanical testing, water permeability through deuterium oxide diffusion assays, and osmotic stress responses under hypo-, iso-, and hypertonic conditions. RESULTS H&E staining revealed that the buccal mucosa epithelium was significantly thicker (628.8 ± 213.3 μm) than that of the penile skin flap (148.2 ± 62.1 μm; p < 0.05). Mechanical testing demonstrated that the buccal mucosa had significantly higher elastic modulus and tensile strength and lower tensile strain compared with penile skin flap (p < 0.05). Water permeability testing revealed that the cumulative diffusion of deuterium oxide (D2O) through the buccal mucosa was consistently higher at all time points compared to the penile skin flap (p < 0.05). In the Hypo group, the ratio of variation in epithelial thickness was significantly higher in the penile skin flap compared to the buccal mucosa. No statistical differences in the ratio of epithelial thickness variation were observed under Iso (p = 0.43) and Hyper (p = 0.07) conditions. The primary limitation of this study is the relatively small sample size. Additionally, the in vitro model lacks the ability to fully replicate the urethral microenvironment, where multiple interacting factors influence graft survival. CONCLUSION This study presents the first comprehensive comparison of the tissue properties of buccal mucosa and penile skin flaps. Our findings provide valuable insights for surgical decision-making, postoperative management, personalized treatment strategies, and the advancement of bioengineered urethral substitutes.
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Affiliation(s)
- Yilong Guo
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, NO. 33 Badachu Rd, Beijing, 100144, China
| | - Ning Ma
- Department of Hypospadias Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, NO. 33 Badachu Rd, Beijing, 100144, China
| | - Mengtong Wang
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Beijing, 100020, China
| | - Sen Chen
- Department of Hypospadias Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, NO. 33 Badachu Rd, Beijing, 100144, China
| | - Pingping Liu
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, NO. 33 Badachu Rd, Beijing, 100144, China
| | - Zhe Yang
- Department of Hypospadias Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, NO. 33 Badachu Rd, Beijing, 100144, China
| | - Yangqun Li
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, NO. 33 Badachu Rd, Beijing, 100144, China.
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Guo Y, Ma N, Zhang J, Chen S, Liu P, Yang Z, Li Y. Surgical Management of Anterior Urethral Stricture: A 23-year Single-Center Study. Res Rep Urol 2025; 17:31-42. [PMID: 39990963 PMCID: PMC11847449 DOI: 10.2147/rru.s507169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Accepted: 02/04/2025] [Indexed: 02/25/2025] Open
Abstract
Purpose Anterior urethral stricture is a common clinical condition in urology with significant socioeconomic impacts and is associated with high recurrence rates of and postoperative complications. However, the long-term outcome of surgical management of urethra stricture and the associated risk factors of stricture recurrence remain limited. We conducted a 23-year single-center retrospective study to evaluate the long-term surgical outcomes of anterior urethral strictures with different clinical characteristics and to study factors that contribute to stricture recurrence. Methods A retrospective study was conducted on 145 male patients diagnosed with anterior urethral stricture, who underwent meatotomy, anastomotic urethroplasty (AU), penile skin flap urethroplasty (PFU), single-stage buccal mucosa grafting (SSU), or multistage buccal mucosa grafting (MSU) between April 2000 and August 2023. We defined 100 months as the cut-off time point to distinguish short-term and long-term follow-up. Early surgical complications were scored using the Clavien-Dindo classification at 3 months. Patient-Reported Outcome Measure (PROM) was applied to evaluate surgical success. Risk factors for wound complications were evaluated using univariable and multivariable analysis. Results The overall mean stricture length was 2.3 ± 1.8 cm (a range of 0.3-7.0). Stricture locations were at the meatus, fossa navicularis, penile, bulbar, and multifocal in 15, 36, 79, 9, and 6. The short-term and long-term success rate for meatotomy, AU, PFU, SSU, and MSU were 70.0%/80%, 70.4%/62.5%, 77.8%/69.2%, 100%/75%, and 81.8%/66.7%, respectively. The early complications classified as Clavien grades I, II, III, IV, and V were 39, 5, 5, 0, and 0. The late complication rate in the short-term and long-term groups were 20.3% and 30.3% (p > 0.05). The satisfaction survey showed that 74.5% (108 of 145) patients were satisfied or very satisfied with the surgical result. There was no statistically significant difference in stricture-free survival among the five surgical groups (Log rank test: χ² = 3.83, p > 0.05). The binary univariate logistic regression analysis showed that stricture symptom duration (p < 0.05) and previous urethroplasty (p < 0.05) were independent predictors of surgery failure. Conclusion This long-term retrospective study on male anterior urethral stricture disease demonstrates that surgical management is an effective and functional treatment. However, the success rate of urethroplasty shows a declining trend with longer follow-up. Stricture symptom duration and previous urethroplasty carry a high risk of surgical failure.
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Affiliation(s)
- Yilong Guo
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Ning Ma
- Department of Hypospadias Plastic Surgery, Plastic Surgery Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Jiaxiong Zhang
- Department of Geriatric Medicine, Coronary Circulation Center of Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
| | - Sen Chen
- Department of Hypospadias Plastic Surgery, Plastic Surgery Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Pingping Liu
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Zhe Yang
- Department of Hypospadias Plastic Surgery, Plastic Surgery Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Yangqun Li
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
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Yilmaz S, Coguplugil AE, Topuz B, Zor M, Kaya E. Endoscopic holmium laser harvesting of bladder mucosal graft for urethroplasty: retrospective analysis of single center preliminary results. World J Urol 2024; 43:2. [PMID: 39612008 DOI: 10.1007/s00345-024-05367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2024] [Accepted: 11/06/2024] [Indexed: 11/30/2024] Open
Abstract
PURPOSE Urethral stricture disease (USD) incidence is estimated to be as high as 0.6-1.2%. In 2022, it was published that the bladder mucosal graft to be used in urethroplasty can be obtained endoscopically with a holmium laser. We aimed to present our single center graft urethroplasty results obtained with the endoscopic holmium laser harvesting of bladder mucosal graft technique. METHODS We retrospectively reviewed the results of patients who underwent bladder mucosal graft (BlMG) urethroplasty by single surgeon at our center hospital between December 2022 and May 2023. RESULTS A total of 14 patients underwent BlMG urethroplasty surgery. Of them 8 were male and 6 were female patients. The mean patient age was 53 (range 26-76) years. The mean length of stricture was 4,35 (range 1-11) cm. The maximum postoperative flow rate was < 10 ml/sec in three of the 14 patients. CONCLUSION To our knowledge this is the first study investigating the preliminary results of substitution urethroplasties that is performed with bladder mucosal grafts harvested with laser energy via transurethral (endoscopic) route. Though more work is needed to better understand its current role in complex urethral reconstruction, our patient cohort will be a niche for further studies.
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Affiliation(s)
- Sercan Yilmaz
- Liv Ulus Hospital Department of Urology, Istanbul, Turkey.
- Istanbul Medical and Science University Department of Urology, Istanbul, Turkey.
| | | | - Bahadir Topuz
- Gulhane Training and Research Hospital Department of Urology, Ankara, Turkey
- Urohealth Urology Clinic, Istanbul, Turkey
| | - Murat Zor
- Liv Ulus Hospital Department of Urology, Istanbul, Turkey
- Istanbul Medical and Science University Department of Urology, Istanbul, Turkey
| | - Engin Kaya
- Liv Ulus Hospital Department of Urology, Istanbul, Turkey
- Istanbul Medical and Science University Department of Urology, Istanbul, Turkey
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Rieker FG, Rajaram-Gilkes M, Barr K, Falkenstein C, Fung K, Marcincavage D, Moglia T, Segireddy R, Frank R. Urethrovaginal Septum: A Histological Study on a Cadaver and Its Clinical Significance. Cureus 2024; 16:e73078. [PMID: 39640100 PMCID: PMC11620788 DOI: 10.7759/cureus.73078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2024] [Indexed: 12/07/2024] Open
Abstract
The academic literature concerning the tissue bridging the anterior vaginal wall and the posterior urethral wall, the urethrovaginal septum, is lacking and inconsistent, not only when compared to non-reproductive anatomy but also when compared to male reproductive anatomy. This knowledge gap must be addressed, given the implication of this tissue in numerous female reproductive pathologies and functions, including pelvic organ prolapse, intercourse and orgasm, urethral strictures, vaginal cancers, and stress urinary incontinence. This study seeks to characterize the histological composition of the urethrovaginal septum, including type I and III collagen proportions, elastin content, neurovascular distribution, and smooth muscle arrangement. Specimens were resected bilaterally from the bisected pelvic region of a postmenopausal female cadaver, spanning antero-posteriorly from the lumen of the urethra to the lumen of the vagina. The specimens were divided into medial and lateral portions, sectioned, and stained with hematoxylin and eosin, trichrome, reticulin, and elastin stains. Images were obtained through virtual microscopy. Type I collagen was confirmed as the major connective tissue component. Reticular fibers were mainly limited to blood and lymphatic vessel walls, as well as the perineurium and epineurium of nerve fibers. The elastic fiber content was minimal, appearing mainly in the lamina propria and vascular walls and interspersed with type I collagen in the connective tissue matrix of the septum. Smooth muscle bundles were mainly observed in the muscularis layers of both walls, but to a greater extent in the anterior vagina. These findings largely confirm those of the few published histological studies of this tissue while contributing to the current state of knowledge regarding the distribution of elastin and reticulin. Further research in premenopausal females and increased awareness of the microanatomy of the urethrovaginal septum is advised.
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Affiliation(s)
- Finn G Rieker
- Medical Education, Geisinger Commonwealth School of Medicine, Scranton, USA
| | | | - Kelly Barr
- Medical Education, Geisinger Commonwealth School of Medicine, Scranton, USA
| | | | - Kristi Fung
- Medical Education, Geisinger Commonwealth School of Medicine, Scranton, USA
| | | | - Taylor Moglia
- Medical Education, Geisinger Commonwealth School of Medicine, Scranton, USA
| | - Ritika Segireddy
- Medical Education, Geisinger Commonwealth School of Medicine, Scranton, USA
| | - Renee Frank
- Anatomic and Clinical Pathology, Geisinger Community Medical Center, Scranton, USA
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Zhou Y, Gong WY, Zhang JY, Li CG, Xu B, Zhang DQ, Fan K. The effect of combined pudendal nerve and spermatic cord block or caudal epidural block on postoperative analgesia after posterior urethroplasty: a randomized trial. BMC Anesthesiol 2024; 24:380. [PMID: 39438789 PMCID: PMC11494940 DOI: 10.1186/s12871-024-02744-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 09/26/2024] [Indexed: 10/25/2024] Open
Abstract
BACKGROUND Postoperative pain management remains a significant challenge for patients undergoing posterior urethroplasty (PU). In a previous study, we proposed a novel technique of combined pudendal nerve (PN) and spermatic cord (SC) block to manage pain after PU. The present trial was conducted to test the hypothesis that this technique is effective for pain control after PU and provides longer-lasting analgesia than caudal epidural block (CB). METHODS Sixty patients undergoing PU were randomized into two groups: Group NB received combined PN and SC block, and Group CB received CB. General anesthesia with a laryngeal mask was performed. The primary outcome was the postoperative analgesic duration, and the secondary outcomes included the Numeric Rating Scale (NRS) scores for pain and the number of patients with different motor scores of the lower limb at 3, 6, 12, and 24 h postoperatively. RESULTS Two patients in Group CB were withdrawn due to block failure. The postoperative analgesic duration was statistically longer in Group NB compared with Group CB (mean difference [95% confidence interval], 115.78 min [17.80, 213.75]; P = 0.021). The NRS scores for pain at 12 and 24 h after surgery were statistically lower in Group NB compared with Group CB. Group NB had statistically more patients with motor score 0 at 3 h postoperatively than Group CB. CONCLUSIONS PN combined with SC block is an effective technique for postoperative analgesia in PU. This technique can achieve a longer duration of analgesia and lower pain scores, especially 12 h after surgery, than a CB. TRIAL REGISTRATION This study was registered in the Chinese Clinical Trial Register (registration no. ChiCTR2100042971, registration date on 2/2/2021).
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Affiliation(s)
- Ying Zhou
- Department of Anesthesiology, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, No. 600, Yishan Road, Shanghai, 200233, China
| | - Wen-Yi Gong
- Department of Anesthesiology, Zhongshan-Xuhui Hospital Affiliated to Fudan University, Shanghai, China
| | - Jing-Yu Zhang
- Department of Anesthesiology, The Second Hospital Affiliated to Lanzhou University, Gansu, China
| | - Chen-Guang Li
- Department of Anesthesiology, Tianshui First People's Hospital, Gansu, China
| | - Bing Xu
- Department of Anesthesiology, Zhongshan-Xuhui Hospital Affiliated to Fudan University, Shanghai, China
| | - Da-Qian Zhang
- Department of Radiology, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, No. 600, Yishan Road, Shanghai, 200233, China.
| | - Kun Fan
- Department of Anesthesiology, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, No. 600, Yishan Road, Shanghai, 200233, China.
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Skonieczna-Kurpiel J, Madej JP, Klekiel T, Mackiewicz A, Będziński R, Noszczyk-Nowak A, Piasecki T, Ceccopieri C. Histological and morphometrical evaluation of the urethral wall after bioresorbable stent implantation in male New Zealand White Rabbits: A preliminary study. Histol Histopathol 2024; 39:1285-1294. [PMID: 38410985 DOI: 10.14670/hh-18-722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
The aim of the study was the histological and morphometrical evaluation of the urethral wall at three time points after bioresorbable stent implantation in male New Zealand White Rabbits. The research was performed on 26 male New Zealand White rabbits aged 3-4 months and weighing 2.1-3.0 kg. Two models of bioresorbable sodium alginate-based stents were developed and implanted into the urethral lumen for one (T1), three (T3), and six weeks (T6). Sections of 5 µm thickness were cut from the urethra at intervals of 2 mm. The sliced sections were stained with hematoxylin-eosin (H&E), Van Gieson's (VG), Von Kossa, and Movat-Russell modified pentachrome (MOVAT) staining methods. The study provided valuable information for future models of urethral stents. The first model of the stent failed to fit the requirements due to inadequate mechanical properties. It curled up on itself losing the ability to adhere to the animals' urethra and was bioresorbed three weeks after implantation. The more rigid no. 2 stent was effective in widening the urethral lumen but did not biodegrade during the experiment. A comprehensive assessment of the second model's properties of biosorption and biointegration requires an extended observation of at least 12 months for an in depth morphological analysis. Stent migration is not likely to be caused solely by the mechanical properties of the urethra or urinary flow but mainly by muscle contraction of the organ wall.
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Affiliation(s)
- Joanna Skonieczna-Kurpiel
- Department of Food Hygiene and Consumer Health Protection, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland.
| | - Jan P Madej
- Department of Immunology, Pathophysiology and Veterinary Prevention, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland
| | - Tomasz Klekiel
- Institute of Material and Biomedical Engineering, University of Zielona Góra, Zielona Góra, Poland
| | - Agnieszka Mackiewicz
- Institute of Material and Biomedical Engineering, University of Zielona Góra, Zielona Góra, Poland
| | - Romuald Będziński
- Institute of Material and Biomedical Engineering, University of Zielona Góra, Zielona Góra, Poland
| | - Agnieszka Noszczyk-Nowak
- Department of Internal Medicine and Clinic of Diseases of Horses, Dogs and Cats, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland
| | - Tomasz Piasecki
- Department of Epizootiology with Exotic Animal and Bird Clinic, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland
| | - Cassandra Ceccopieri
- Department of Immunology, Pathophysiology and Veterinary Prevention, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland
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Wong HPN, So WZ, Fong KY, Tiong HY, Kulkarni S, Castellani D, Somani B, Gauhar V. Advances in urethral stricture diagnostics and urethral reconstruction beyond traditional imaging: a scoping review. Cent European J Urol 2024; 77:528-537. [PMID: 40115474 PMCID: PMC11921950 DOI: 10.5173/ceju.2024.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 05/26/2024] [Indexed: 03/23/2025] Open
Abstract
Introduction Urethral stricture disease is considered one of the more functionally bothersome aspects of urological conditions. The management of such disease is also traditionally managed with urethroplasty, or in severe cases, reconstruction. With the rise of artificial intelligence (AI) playing its part in diagnostics and treatment of urological conditions, we sought to determine its use case in urethral conditions in today's era of advanced surgical care. Material and methods A comprehensive literature search was performed to identify literature on advances in diagnosis and management of urethral strictures. Publications in English were selected, whilst studies that were case reports, abstracts only, reviews, or conference posters were excluded. Results Twelve studies were finalised for review. Conventional neural networks and computational fluid dynamics implemented in retrograde urethrography reduced false positive and negative rates of urethral stricture diagnosis. Four-detector row computed tomography and magnetic resonance imaging voiding with virtual urethroscopy are also emerging imaging combination options for identification, offering decreased duration needed for diagnosis and increased correlation with intra-operative findings of urethral stricturing. For tissue re-engineering for urethral strictures, the role of 3-dimensional bioprinting of both autologous and allogenic sources has been on the rise, with promising findings of sustained tissue viability demonstrated in several in vitro animal studies and showing potential for expansion into human utilisation. Conclusions Advances in detection and management of urethral strictures have steadily been increasing its capacity, especially with the rise in artificial AI-driven learning algorithms and more accurate objectivity. Further studies are awaited to validate the use case of AI models in fields of urethral stricturing disease.
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Affiliation(s)
| | - Wei Zheng So
- Department of Urology, National University Hospital, Singapore
| | - Khi Yung Fong
- Department of Urology, National University Hospital, Singapore
| | - Ho Yee Tiong
- Department of Urology, National University Hospital, Singapore
| | | | - Daniele Castellani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Universita Politecnica delle Marche, Ancona, Italy
| | - Bhaskar Somani
- Department of Urology, University Hospital, Southampton, United Kingdom
| | - Vineet Gauhar
- Department of Urology, Ng Teng Fong General Hospital, Singapore
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Mahenthiran AK, Burns RT, Soyster ME, Black M, Arnold PJ, Love HL, Mellon MJ. A single-institution experience with the Optilume Urethral Drug Coated Balloon for management of urethral stricture disease. Transl Androl Urol 2024; 13:1498-1505. [PMID: 39280647 PMCID: PMC11399038 DOI: 10.21037/tau-24-104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 06/23/2024] [Indexed: 09/18/2024] Open
Abstract
Background Urethral stricture disease is detrimental to quality of life. The Optilume Urethral Drug Coated Balloon (DCB) offers a solution utilizing a paclitaxel-coated balloon to expand strictures and prevent recurrence. Following the ROBUST trials, it has been proposed that DCB is more effective than conventional endoscopic management for recurrent, small anterior urethral strictures. Our study provides insights into practical applications and outcomes using DCB for urethral stricture disease. Methods A retrospective review was performed of patients who underwent DCB for urethral strictures at our institution from November 2022 to August 2023 with follow-up evaluated through January 2024. Demographics, stricture characteristics, operative details, and postoperative outcomes were collected. Primary endpoint was need for repeat intervention as determined by symptomatic burden and subsequently postoperative post-void residual if obtained. Secondary endpoint was complication rate. Statistical analysis was conducted using STATA/BE17.0 software to create Kaplan-Meier curves for time to repeat intervention after treatment with DCB. Results Of 43 patients, 16 had no prior treatment. The other 27 had endoscopic treatment and of this group, 11 also had additional urethroplasty. Stricture etiologies included 20 iatrogenic, 14 idiopathic, 5 radiation-related, 2 inflammatory, and 2 traumatic. Stricture locations were 2 fossa navicularis, 7 pendulous, 17 bulbar, 7 membranous, 3 prostatic, and 7 bladder neck contractures. Mean balloon dilation lasted 8.4±2.7 minutes. All patients had a minimum follow-up of 150 days postoperatively and the mean duration of follow-up for the cohort was 290.3±87.0 days. The average postoperative post-void residual was 33.4±90.6 milliliters. Two patients had immediate complications: 1 with urinary retention after catheter removal requiring suprapubic tube placement and 1 with urinary tract infection requiring antibiotics. Four patients required repeat interventions: 1 endoscopic dilation, 1 graft urethroplasty, and 2 repeat DCB procedures. Mean time to repeat intervention was 203.5±82.6 days, and no patient required repeat intervention within 145 days of initial surgery. Conclusions DCB offers a safe and less invasive treatment for both treatment-naïve and recurrent urethral strictures with paclitaxel coating to prevent recurrence. Repeat intervention was not required for 90.7% of our cohort within an average follow-up duration of 9 months postoperatively. As DCB grows in clinical use, investigation into its long-term efficacy is justified.
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Affiliation(s)
| | - Ramzy T Burns
- Department of Urology, Indiana University, Indianapolis, IN, USA
| | - Mary E Soyster
- Department of Urology, Indiana University, Indianapolis, IN, USA
| | - Morgan Black
- Department of Urology, Indiana University, Indianapolis, IN, USA
| | - Peter J Arnold
- Department of Urology, Indiana University, Indianapolis, IN, USA
| | - Harrison L Love
- Department of Urology, Indiana University, Indianapolis, IN, USA
| | - Matthew J Mellon
- Department of Urology, Indiana University, Indianapolis, IN, USA
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10
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Faizan M, Mahboob E, Samad MA, Fatima L, Fatima A, Iqbal A, Rauf R, Naeem M, Shoaib UB, Siddiqui SA, Imran MH. Safety and efficacy of lasers compared to cold knife in direct visual internal urethrotomy: a systematic review and Meta-analysis. Lasers Med Sci 2024; 39:209. [PMID: 39101963 DOI: 10.1007/s10103-024-04134-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 07/08/2024] [Indexed: 08/06/2024]
Abstract
Cold knife urethrotome was introduced in 1971 and it had an 80% success rate. New advancements in this field have shed light on the use of various lasers such as carbon dioxide, Nd: YAG, KTP, Argon, Ho: YAG, and excimer lasers. It has been observed that cold knife urethrotomy has a higher recurrence rate than laser urethrotomy, but the superiority of either treatment modality has not been established yet. Data were thoroughly searched through PubMed, Scopus, and clinicaltrials.gov. We also used clinicaltrials.gov for ongoing and published research. The data was analyzed via R studio version 2023.12.1 (oceanstorm). For dichotomous variables, Odds Ratio (OR) were used to pool data and standardized mean difference was used for continuous variables with 95% confidence intervals (CIs). A total of 14 studies including 1114 participants were included in this meta-analysis. The results of the combined analysis revealed significant relation with a mean difference of 0.99 (95% CI: 0.37; 1.62), and favored laser group. The overall results have shown the laser to have a significant favorable profile demonstrating a recurrence, Odds Ratio of 0.42 (95% CI:0.27;0.65). Patients with laser therapy had a lower risk of complication rate (OR 0.49, 95% Cl: 0.35; 0.67). All the findings obtained by the analysis in this study favour lasers significantly over the cold knife technique especially when mean Qmax, with recurrence and complications taken into account.
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Affiliation(s)
| | - Eman Mahboob
- Dow University of Health Sciences, Karachi, Pakistan
| | | | - Leenah Fatima
- Dow University of Health Sciences, Karachi, Pakistan
| | - Ammara Fatima
- Dow University of Health Sciences, Karachi, Pakistan
| | - Amna Iqbal
- Dow University of Health Sciences, Karachi, Pakistan
| | - Rafia Rauf
- Sindh Institute of Urology and Transplant, Karachi, Pakistan
| | - Mustafa Naeem
- Liaquat University of Health Sciences, Karachi, Pakistan
| | - Umer Bin Shoaib
- Sindh Institute of Urology and Transplant, Karachi, Pakistan
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11
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Gul A, Ekici O, Zengin S, Barali D, Keskin T. Investigation of risk factors in the development of recurrent urethral stricture after internal urethrotomy. World J Clin Cases 2024; 12:2324-2331. [PMID: 38765734 PMCID: PMC11099401 DOI: 10.12998/wjcc.v12.i14.2324] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/08/2024] [Accepted: 04/01/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Urethral stricture is a condition that often develops with trauma and results in narrowing of the urethral lumen. Although endoscopic methods are mostly used in its treatment, it has high recurrence rates. Therefore, open urethroplasty is recommended after unsuccessful endoscopic treatments. AIM To investigate the risk factors associated with urethral stricture recurrence. METHODS The data of male patients who underwent internal urethrotomy for urethral stricture between January 2017 and January 2023 were retrospectively analyzed. Demographic data, comorbidities, preoperative haemogram, and biochemical values obtained from peripheral blood and operative data were recorded. Patients were divided into two groups in terms of recurrence development; recurrence and non-recurrence. Initially recorded data were compared between the two groups. RESULTS A total of 303 patients were included in the study. The mean age of the patients was 66.6 ± 13.6 years. The mean duration of recurrence development was 9.63 ± 9.84 (min-max: 1-39) months in the recurrence group. Recurrence did not occur in non-recurrence group throughout the follow-up period with an average time of 44.15 ± 24.07 (min-max: 12-84) months. In the comparison of both groups, the presence of diabetes mellitus (DM), hypertension (HT), and multiple comorbidities were significantly higher in the recurrence (+) group (P = 0.038, P = 0.012, P = 0.013). Blood group, postoperative use of non-steroidal anti-inflammatory drugs, preoperative cystostomy, cause of stricture, iatrogenic cause of stricture, location and length of stricture, indwelling urinary cathater size and day of catheter removal did not differ between the two groups. No statistically significant difference was observed between the two groups in terms of age, uroflowmetric maximum flow rate value, hemogram parameters, aspartate aminotransferase (AST), alanine aminotransferase (ALT), fasting blood sugar, creatinine, glomerular filtration rate, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio, monocyte-lymphocyte ratio and AST/ALT ratios. CONCLUSION In patients with urethral stricture recurrence, only the frequency of DM and HT was high, while inflammation marker levels and stricture-related parameters were similar between the groups.
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Affiliation(s)
- Abdullah Gul
- Department of Urology, University of Health Sciences, Bursa Yüksek İhtisas Education and Research Hospital, Bursa 16100, Türkiye
| | - Ozgur Ekici
- Department of Urology, University of Health Sciences, Bursa City Hospital, Bursa 16000, Türkiye
| | - Salim Zengin
- Department of Urology, University of Health Sciences, Bursa Yüksek İhtisas Education and Research Hospital, Bursa 16100, Türkiye
| | - Deniz Barali
- Department of Urology, University of Health Sciences, Bursa Yüksek İhtisas Education and Research Hospital, Bursa 16100, Türkiye
| | - Tarik Keskin
- Department of Urology, University of Health Sciences, Bursa Yüksek İhtisas Education and Research Hospital, Bursa 16100, Türkiye
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12
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Calenda CD, Toohey CR, Levy M, Vanmali N, Ubhi J, Ishak N, Marshall SD. Acute Kidney Injury in a Previously Healthy 56-Year-Old Male Following a Direct Visual Internal Urethrotomy of a Bulbar Stricture. Cureus 2024; 16:e59310. [PMID: 38817513 PMCID: PMC11136589 DOI: 10.7759/cureus.59310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024] Open
Abstract
Acute kidney injury (AKI) is a frequent finding in acutely ill and hospitalized patients arising from various etiologies. Anuric AKI, a more pronounced form of AKI in which less than 100 cc of urine is produced per day, is most frequently encountered in hospitalized, septic, and post-surgical patients, often secondary to shock or bilateral urinary tract obstruction. The development of anuric AKI in previously healthy patients after outpatient urological procedures presents a unique challenge to physicians, as many outpatient procedures require the routine perioperative administration of multiple nephrotoxic medications. Further complicating this clinical scenario, some surgical procedures that intrinsically involve iatrogenic injury to the kidney, ureter, bladder, or nearby organ can rarely lead to a phenomenon known as reflex anuria, an anuric state typically associated with AKI. Here, we report an unusual case of a previously healthy 56-year-old male who developed anuric AKI two days after direct visual internal urethrotomy (DVIU) for the treatment of a bulbar stricture. Non-contrast CT revealed no signs of an obstructive process, and laboratory findings supported an intrarenal cause of AKI. Consideration was given to non-steroidal anti-inflammatory drugs (NSAID)-induced nephrotoxicity, gentamicin-associated acute tubular necrosis, and propofol infusion syndrome, in addition to their potential synergistic effects. We also explore this as the first reported case of reflex anuria occurring at the level of the bulbar urethra, as most cases have involved direct injury to the kidney or ureter. Over the course of 10 days, our patient responded well to treatment with supportive measures and dialysis, with his vomiting, electrolyte abnormalities, renal state, and anuria eventually improving.
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Affiliation(s)
- Charles D Calenda
- College of Osteopathic Medicine, University of New England, Biddeford, USA
| | - Cameron R Toohey
- College of Osteopathic Medicine, University of New England, Biddeford, USA
| | - Madeline Levy
- College of Osteopathic Medicine, University of New England, Biddeford, USA
| | - Nisha Vanmali
- Department of Internal Medicine, Concord Hospital - Laconia, Laconia, USA
| | - Jaspreet Ubhi
- Department of Internal Medicine, Concord Hospital - Laconia, Laconia, USA
| | - Noshi Ishak
- Department of Nephrology, Concord Hospital - Laconia, Laconia, USA
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13
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Desai D, Harrison W, Raveenthiran S, Samaratunga H, De Win G. UrethroNAV: the aetiology and extent of idiopathic urethral stricture in an Australian population. Transl Androl Urol 2024; 13:423-432. [PMID: 38590965 PMCID: PMC10999018 DOI: 10.21037/tau-23-549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/18/2024] [Indexed: 04/10/2024] Open
Abstract
Background Lichen sclerosus (LS) is considered a causative factor in 10% of cases of idiopathic urethral stricture disease (IUSD), which is important for determining management strategies due to the underlying pathophysiology. Traditional excision urethroplasty may not be effective as inflammation often extends beyond the macroscopic stricture. This pilot study aims to answer two research questions: is LS an underlying cause of some idiopathic cause of strictures, and, if there is histological evidence suggesting predisposition of the surrounding tissue to strictures. Methods Biopsies were taken from the stricture site as well as 1 and 2 cm proximal and distal in patients with IUSD. Histological features, including macroscopic and microscopic findings, were reported, including the presence of LS, hyperkeratosis, epidermal changes, lichenoid infiltrates, ulceration, scarring, and inflammation. Methylene blue was used to aid in locating damaged urothelium. Patients were prospectively followed up after urethroplasty. Results From 109 urethroplasties performed between 2019 to 2022, 15 male patients were enrolled after meeting specific inclusion criteria. These criteria included a diagnosis of IUSD and the absence of any evidence of trauma, macroscopic inflammatory disease, or previous endoscopic instrumentation of the urethra. Patients had to be at least 16 years old and medically suitable for undergoing urethroplasty. The study was approved by the hospitals ethics committees. None had macroscopic evidence of LS. One patient had microscopic evidence of LS at the 2 cm proximal biopsy only. A total of 93% of patients had scarring proximal and distal to the stricture, while 20-40% had inflammatory change. The patient with microscopic LS and two inflammatory change patients had stricture recurrence after urethroplasty. Additionally, one patient with inflammatory changes was diagnosed with penile intraepithelial neoplasia (PeIN) and underwent partial penectomy. Conclusions Findings suggest that an underlying cause of IUSD could be LS. Additionally, the pathophysiology may involve scarring and inflammation beyond the limits of the stricture with extension distal from the stricture site. Careful evaluation for concomitant urethral pathology should be considered in cases of inflammatory changes. These findings should be considered in the surgical management of IUSD and warrant further research into the role of routine biopsy and drug targets in USD.
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Affiliation(s)
- Devang Desai
- Department of Urology, Toowoomba Hospital, Toowoomba, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Faculty of Medicine, Griffith University, Mount Gravatt, QLD, Australia
- Faculty of Medicine, University of Southern Queensland, Darling Heights, QLD, Australia
- Department of Urology, St Andrew’s Toowoomba Hospital, Rockville, QLD, Australia
- Department of Urology, St Vincent’s Private Hospital Toowoomba, East Toowoomba, QLD, Australia
- Department of Urology, Toowoomba Specialists, East Toowoomba, QLD, Australia
| | - William Harrison
- Department of Urology, Toowoomba Hospital, Toowoomba, QLD, Australia
- Department of Urology, Toowoomba Specialists, East Toowoomba, QLD, Australia
| | - Sheliyan Raveenthiran
- Department of Urology, Toowoomba Hospital, Toowoomba, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Urology, Toowoomba Specialists, East Toowoomba, QLD, Australia
| | - Hemamali Samaratunga
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Pathology, Aquesta Specialised Uropathology, Toowong, QLD, Australia
- Department of Pathology, Greenslopes Private Hospital, Greenslopes, QLD, Australia
| | - Gunter De Win
- Department of Urology, Antwerp University Hospital, Edegem, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, Antwerp University, Wilrijk, Antwerp, Belgium
- Department of Adolescent Urology, University College London Hospital, London, UK
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14
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Frank CH, Ramesh P, Lyu Q, Ruan D, Park SJ, Chang AJ, Venkat PS, Kishan AU, Sheng K. Analytical HDR prostate brachytherapy planning with automatic catheter and isotope selection. Med Phys 2023; 50:6525-6534. [PMID: 37650773 PMCID: PMC10635680 DOI: 10.1002/mp.16677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 06/27/2023] [Accepted: 07/30/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND High dose rate (HDR) brachytherapy is commonly used to treat prostate cancer. Existing HDR planning systems solve the dwell time problem for predetermined catheters and a single energy source. PURPOSE Additional degrees of freedom can be obtained by relaxing the catheters' pre-designation and introducing more source types, and may have a dosimetric benefit, particularly in improving conformality to spare the urethra. This study presents a novel analytical approach to solving the corresponding HDR planning problem. METHODS The catheter and dual-energy source selection problem was formulated as a constrained optimization problem with a non-convex group sparsity regularization. The optimization problem was solved using the fast-iterative shrinkage-thresholding algorithm (FISTA). Two isotopes were considered. The dose rates for the HDR 4140 Ytterbium (Yb-169) source and the Elekta Iridium (Ir-192) HDR Flexisource were modeled according to the TG-43U1 formalism and benchmarked accordingly. Twenty-two retrospective HDR prostate brachytherapy patients treated with Ir-192 were considered. An Ir-192 only (IRO), Yb-169 only (YBO), and dual-source (DS) plan with optimized catheter location was created for each patient with N catheters, where N is the number of catheters used in the clinically delivered plans. The DS plans jointly optimized Yb-169 and Ir-192 dwell times. All plans and the clinical plans were normalized to deliver a 15 Gy prescription (Rx) dose to 95% of the clinical treatment volume (CTV) and evaluated for the CTV D90%, V150%, and V200%, urethra D0.1cc and D1cc, bladder V75%, and rectum V75%. Dose-volume histograms (DVHs) were generated for each structure. RESULTS The DS plans ubiquitously selected Ir-192 as the only treatment source. IRO outperformed YBO in organ at risk (OARs) OAR sparing, reducing the urethra D0.1cc and D1cc by 0.98% (p = 2.22 ∗ 10 - 9 $p\ = \ 2.22*{10^{ - 9}}$ ) and 1.09% (p = 1.22 ∗ 10 - 10 $p\ = \ 1.22*{10^{ - 10}}$ ) of the Rx dose, respectively, and reducing the bladder and rectum V75% by 0.09 (p = 0.0023 $p\ = \ 0.0023$ ) and 0.13 cubic centimeters (cc) (p = 0.033 $p\ = \ 0.033$ ), respectively. The YBO plans delivered a more homogenous dose to the CTV, with a smaller V150% and V200% by 3.20 (p = 4.67 ∗ 10 - 10 $p\ = \ 4.67*{10^{ - 10}}$ ) and 1.91 cc (p = 5.79 ∗ 10 - 10 $p\ = \ 5.79*{10^{ - 10}}$ ), respectively, and a lower CTV D90% by 0.49% (p = 0.0056 $p\ = \ 0.0056$ ) of the prescription dose. The IRO plans reduce the urethral D1cc by 2.82% (p = 1.38 ∗ 10 - 4 $p\ = \ 1.38*{10^{ - 4}}$ ) of the Rx dose compared to the clinical plans, at the cost of increased bladder and rectal V75% by 0.57 (p = 0.0022 $p\ = \ 0.0022$ ) and 0.21 cc (p = 0.019 $p\ = \ 0.019$ ), respectively, and increased CTV V150% by a mean of 1.46 cc (p = 0.010 $p\ = \ 0.010$ ) and CTV D90% by an average of 1.40% of the Rx dose (p = 8.80 ∗ 10 - 8 $p\ = \ 8.80*{10^{ - 8}}$ ). While these differences are statistically significant, the clinical differences between the plans are minimal. CONCLUSIONS The proposed analytical HDR planning algorithm integrates catheter and isotope selection with dwell time optimization for varying clinical goals, including urethra sparing. The planning method can guide HDR implants and identify promising isotopes for specific HDR clinical goals, such as target conformality or OAR sparing.
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Affiliation(s)
- Catherine Holly Frank
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095
| | - Pavitra Ramesh
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095
| | - Qihui Lyu
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095
| | - Dan Ruan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095
| | - Sang-June Park
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095
| | - Albert J. Chang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095
| | - Puja S. Venkat
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095
| | - Ke Sheng
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA 94115
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15
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Asfuroglu A, Balci M, Koseoglu B, Senel C, Ozercan AY, Aykanat IC, Yildizhan M, Guzel O, Aslan Y, Tuncel A. Male Urethral Stricture in Patients with Metabolic Syndrome. UROLOGY RESEARCH & PRACTICE 2023; 49:131-137. [PMID: 37877861 PMCID: PMC10192717 DOI: 10.5152/tud.2023.22129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 12/26/2022] [Indexed: 10/26/2023]
Abstract
OBJECTIVE Urethral stricture is characterized by fibrosis that decreases urine flow. Metabolic syndrome is a complex disorder that causes fibrosis in many organs. This study aimed to evaluate the relationship between metabolic syndrome and appearance of urethral stricture and effects of metabolic syndrome on the recurrence of urethral stricture in patients with primary urethral stricture who underwent direct visual internal urethrotomy. MATERIALS AND METHODS One hundred thirty-two male patients who underwent direct visual internal urethrotomy between 2014 and 2021 because of primary urethral stricture were included. Location, length, and type of urethral stricture, time from diagnosis to surgery, postoperative follow-up, time from surgery to recurrence, and postoperative follow-up duration with a urethral catheter were retrospectively analyzed and association with metabolic syndrome was evaluated. RESULTS The mean age was 50.48 ± 17.94 years. Recurrence was found in 34.1% and metabolic syndrome in 27.3%. Postoperative follow-up duration was significantly longer in patients with recurrence than in those without (P=.033). There was no statistically significant difference in terms of metabolic syndrome and postoperative urethral catheterization between patients with and without recurrence (P=.126, P=.714, respectively). Postoperative clean intermittent self-catheterization use was found to be statistically higher in patients with recurrence than in patients without recurrence (P=.018). Postoperative urinary tract infection rate was found to be significantly higher in patients with metabolic syndrome compared to patients without metabolic syndrome (P=.001). CONCLUSION Metabolic syndrome was not associated with recurrence. However, postoperative urinary tract infections were more common in patients with metabolic syndrome than in patients without. Clean intermittent self-catheterization used postoperatively may increase the risk of stricture.
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Affiliation(s)
| | - Melih Balci
- Department of Urology, Memorial Bahçelievler Hospital, Istanbul, Turkey
| | - Burak Koseoglu
- Department of Urology, Ankara City Hospital, Ankara, Turkey
| | - Cagdas Senel
- Department of Urology, Balıkesir University Faculty of Medicine, Balıkesir, Turkey
| | | | | | | | - Ozer Guzel
- Department of Urology, Ankara City Hospital, Ankara, Turkey
| | - Yilmaz Aslan
- Department of Urology, Memorial Bahçelievler Hospital, Istanbul, Turkey
| | - Altug Tuncel
- Department of Urology, Ankara City Hospital, Ankara, Turkey
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16
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Ha JY, Lee MS. Interventional urethral balloon dilatation before endoscopic visual internal urethrotomy for post-traumatic bulbous urethral stricture: A case report. World J Clin Cases 2022; 10:12787-12792. [PMID: 36579103 PMCID: PMC9791538 DOI: 10.12998/wjcc.v10.i34.12787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/22/2022] [Accepted: 11/07/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND While several treatment options are available for pediatric urethral strictures, the appropriate treatment must be based on several factors. Although endoscopic visual internal urethrotomy (EVIU) could be a first-line treatment option for short pediatric urethral strictures, it is not feasible if the urethroscope cannot pass through the stricture point. Herein, we present a pediatric case of severe post-traumatic bulbous urethral stricture that was successfully treated by EVIU after securing the urethral route via interventional balloon dilatation.
CASE SUMMARY A 12-year-old boy presented at our outpatient clinic with the inability to urinate. He had sustained a straddle injury three months prior. The post-void residual urine volume was 644 mL, and retrograde urethrography confirmed severe stricture of the bulbous urethra. EVIU was planned; however, the first attempt to treat the stricture failed because the urethroscope could not pass through the stricture point. The urethral route was subsequently secured via balloon dilatation of the stricture, which was performed in collaboration with specialists from the department of interventional radiology. The urethroscope was then able to pass, and the repeat EVIU was successful.
CONCLUSION Interventional urethral balloon dilatation before EVIU may help secure the urethral route in the treatment of pediatric urethral strictures.
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Affiliation(s)
- Ji Yong Ha
- Department of Urology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, South Korea
| | - Mu Sook Lee
- Department of Radiology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, South Korea
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17
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Ding K, Li D, Zhang R, Zuo M. Circ_0047339 promotes the activation of fibroblasts and affects the development of urethral stricture by targeting the miR-4691-5p/TSP-1 axis. Sci Rep 2022; 12:14746. [PMID: 36042279 PMCID: PMC9428161 DOI: 10.1038/s41598-022-19141-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022] Open
Abstract
Urethral stricture is related to scar tissue fibrosis, but its pathogenesis is still unclear. This study aims to explore the regulatory mechanism of circular RNA (circRNA) in the occurrence and development of urethral stricture. CircRNA microarray was employed to analyze circRNA expression profiles between human urethral scar tissue and normal urethral tissue. The results of circRNA microarray showed that there were 296 differentially expressed genes between urethral scar tissue and normal urethral tissue. The enrichment analysis of Kyoto encyclopedia of genes and genomes showed that these circRNAs were significantly correlated with ECM–receptor interaction. The first nine differentially expressed circRNA were selected to predict the circRNA–miRNA network. RT-qPCR results showed that circ_0047339 was upregulated considerably in urethral scar tissue. Urethral scar fibroblasts were isolated from human urethral scar tissue and cultured in vitro. After silencing circ_0047339, the proliferation of urethral scar cells decreased significantly, and the expressions of Collagen I (COL-1) and α-smooth muscle actin (α-SMA) also reduced. As a competing endogenous RNA, circ_0047339 could increase the expression of TSP-1 by competitively binding miR-4691-5p. In addition, miR-4691-5p mimic transfection could inhibit the proliferation of urethral scar fibroblasts and the presentation of thrombospondin-1 (TSP-1), α-SMA and COL-1, while circ_0047339 overexpression eliminated this inhibition. Our results showed that circ_0047339 might promote the growth and fibrosis of urethral scar fibroblasts through miR-4691-5p/TSP-1 axis, thus promoting the development of urethral stricture.
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Affiliation(s)
- Ke Ding
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Daoyuan Li
- Department of Urology, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China.,Department of Urology, Hainan General Hospital, Haikou, China
| | - Rui Zhang
- Hunan Traditional Chinese Medical College, Changsha, China
| | - Meilin Zuo
- Department of Anesthesiology, Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
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18
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Comparative review of the guidelines for anterior urethral stricture. World J Urol 2022; 40:1971-1980. [PMID: 35316387 DOI: 10.1007/s00345-022-03988-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE We aimed to provide a detailed comparison between the American Urologic Association (AUA), Société Internationale d'Urologie (SIU), and the European Association of Urology (EAU) guidelines on the evaluation, management, and follow-up of the patients with anterior urethral stricture disease (USD). METHODS The urethral stricture guidelines from SUI, AUA, and EAU were collected and evaluated regarding the recommendations on diagnosis, evaluation, and treatment of anterior USD. The strength of evidence for each statement was included and discussed when guidelines differed. RESULTS While the guidelines remarkably align in terms of the diagnostic workup and follow-up, there is discordance in the management of anterior urethral strictures, specifically for the use of endoscopic treatment and stenting. Further, the EAU offers more comprehensive recommendations regarding urethroplasty techniques and patient follow-up. The EAU guidelines are the most recent and first to offer guidance for USD in transgender people and women. CONCLUSION Reconstructive urology is a rapidly adapting field, and best practices change accordingly. Guideline statements have become more inclusive and expansive but will require further research to improve the level of evidence and continue to provide patients and providers with the best treatment plans.
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19
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Faraj S, Loubersac T, Bouchot O, Heloury Y, Leclair MD. Adults with previous hypospadias surgery during childhood: Beware of bulbar strictures. J Pediatr Urol 2022; 18:4.e1-4.e8. [PMID: 34863623 DOI: 10.1016/j.jpurol.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 10/12/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Urethral strictures represent the most frequent long-term complication in men after history of hypospadias surgery. OBJECTIVES To better define the spectrum of men previously treated for hypospadias during childhood, presenting at an adult urology clinic with persistent urethral complications. STUDY DESIGN Retrospective review of the records of 42 consecutive adult patients with a personal history of hypospadias repair during childhood referred at one adult tertiary urology center between 2004 and 2017. Those with persistent urethral strictures were included: 28 patients (median age 28yr [17-81]). Residual chordee, aesthetic concerns, isolated fistulas, and motives of consultation unrelated to hypospadias were excluded. Early initial success rate and location of urethral stricture were studied. Statistical Analysis was done by non-parametric tests. RESULTS On the 42 consecutive adults eligible, a total of 28 patients had a persistent urethral stricture. During childhood, 13/28 boys had required multiple surgical revision procedures, including six of them for postoperative urethral strictures. During adulthood, initial urethral assessment revealed 29 urethral strictures in 28 patients (penile urethra 23/29, bulbar urethra 8/29). The early initial success rate of stricture treatment was 50% (median follow-up: 4 years [1-7]). Additional surgical procedures were needed and performed in 11 patients. Eight patients were eventually diagnosed with a bulbar stricture, either isolated (n = 5) or combined with a distal stricture (n = 3), without significant relationship with initial position of meatus. DISCUSSION Predictive factors for bulbar strictures locations could not be identified. It was however observed that symptomatic bulbar strictures do exist in adults, in the long term after penile hypospadias repair during childhood, independently of the initial site of hypospadias, initial success of primary repair, and the type of surgical reconstructions performed during childhood. CONCLUSION Bulbar strictures represent more than 25% of the overall strictures diagnosed in adult patients treated for hypospadias during childhood, independently of the original site of urethral reconstruction.
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Affiliation(s)
| | - Thomas Loubersac
- Chirurgie infantile, CHU de Nantes, Nantes, France; Urologie, CHU de Nantes, Nantes, France.
| | | | - Yves Heloury
- Chirurgie infantile, Hopital Necker Enfants Malades, Paris, France.
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20
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Bonatsos V, Batura D. Urethral stricture after bleomycin for the treatment of metastatic testicular cancer. Int Urol Nephrol 2022; 54:551-552. [PMID: 35024998 DOI: 10.1007/s11255-022-03106-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/08/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Vasileios Bonatsos
- Department of Urology, London North West University Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK
| | - Deepak Batura
- Department of Urology, London North West University Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK.
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21
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Abstract
Urethral strictures most frequently affect the bulbar but are also observed in the penile, glandular, or membranous urethra. They are often iatrogenic. Radiologic diagnosis can be established easily and safely by cystourethrography. Simple Sachse urethrotomy can result in permanent relief in the case of short bulbar strictures in initial findings. Recurrent structures or strictures in other locations should however be treated by open surgery, as cure cannot be achieved by other means. Depending on the diagnosis and comorbidities, end-to-end anastomosis, graft/flap urethroplasty, or perineal urethrostomy can be performed. If open surgery is delayed, aggravation of the diagnosis and worsening of the prognosis can be expected, regardless of the applied treatment.
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Affiliation(s)
- Stefan Tritschler
- Klinik für Urologie und urologische Onkologie, Loretto-Krankenhaus Freiburg, Mercystraße 6-14, 79100, Freiburg, Deutschland.
| | - Vincent Beck
- Klinik für Urologie und urologische Onkologie, Loretto-Krankenhaus Freiburg, Mercystraße 6-14, 79100, Freiburg, Deutschland
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22
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The use of local therapy in preventing urethral strictures: A systematic review. PLoS One 2021; 16:e0258256. [PMID: 34614033 PMCID: PMC8494308 DOI: 10.1371/journal.pone.0258256] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/22/2021] [Indexed: 12/09/2022] Open
Abstract
Background Urethral stricture disease is a common problem amongst men in Western countries often leading to a decreased quality of life. Current endoscopic treatment procedure shows an unsatisfying stricture recurrence rate which could be improved by addition of local therapies. Objectives To provide an overview of both preclinical and clinical studies in order to investigate current level of evidence on the addition of local therapy to improve urethral stricture recurrence rates after endoscopic procedures. Methods We performed a literature search in December 2020 and August 2021 using Cochrane, Embase, PubMed, Scopus and Web of Science and identified articles through combinations of search terms for ‘urethral stricture disease’, ‘stricture formation’ and ‘local interventions’. We used the SYRCLE, RoB-2 and ROBINS-I tools to assess risk of bias across included studies. We did not perform a meta-analysis due to methodological differences between studies. Results We included 32 articles in the qualitative analysis, 20 of which were preclinical studies and 12 clinical studies. Regarding preclinical articles using an animal model, nearly all interventions showed to have a positive effect on either urethral fibrosis, urethral stricture formation and/or fibrotic protein expression levels. Here, immunosuppressants and chemotherapeutics seemed most promising for possible clinical purposes. Regarding clinical studies, mitomycin-C and hyaluronic acid and carboxymethylcellulose showed positive effects on urethral stricture recurrence rates with low to intermediate risk of bias across studies. However, the positive clinical effects of mitomycin-C and steroids seemed to decrease in studies with a longer follow-up time. Conclusion Although local adjuvant use of mitomycin-C or hyaluronic acid and carboxymethylcellulose may carry clinical potential to improve urethral structure recurrence rates after endoscopic procedures, we believe that a large, well-designed RCT with a yearlong follow-up time is necessary to identify the true clinical value.
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Cell-Seeded Acellular Artery for Reconstruction of Long Urethral Defects in a Canine Model. Stem Cells Int 2021; 2021:8854479. [PMID: 34194508 PMCID: PMC8203373 DOI: 10.1155/2021/8854479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 03/25/2021] [Accepted: 05/16/2021] [Indexed: 11/18/2022] Open
Abstract
The management of urethral stricture remains a major therapeutic challenge in clinics. Herein, we explored the feasibility of reconstructing a relatively long segment of the urethra by the cell-seeded acellular artery in a canine model. The acellular arterial matrix was obtained from the excised carotid artery of donor dogs. Autologous adipose-derived stem cells (ADSCs) from 6 male dogs were grown and seeded onto the premade acellular arterial matrix. A 3 cm long segment of the urethra was resected in 12 male dogs. Urethroplasty was performed with the acellular arterial matrix seeded with ADSCs in 6 animals and without cells in 6. Serial urethrography was performed at 1 and 3 months postoperatively. Wide urethral calibers without any signs of strictures were confirmed in all 6 animals in the experimental group. In contrast, urethral stricture was demonstrated in 3 animals in the control group. The graft was highly epithelialized and smooth in the experimental group, while graft contracture and scar formation were showed in the control group. Histologic analysis of the cell-seeded arterial matrix at 1 month confirmed the presence of multilayered urothelium and muscle. The levels of tissue formation developed over time with a progressive increase in muscle content. In contrast, extensive fibrosis and sparse smooth muscle were seen in animals treated with matrix without ADSCs. This study provides preclinical evidence that the ADSC-seeded arterial matrix can be used as a tubularized scaffold in the reconstruction of 3 cm long urethral defect in a male canine model. The ADSC-seeded arterial matrix remodels and regenerates normal-appearing urethral tissue layers over time.
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Mershon JP, Baradaran N. Recurrent Anterior Urethral Stricture: Challenges and Solutions. Res Rep Urol 2021; 13:237-249. [PMID: 34012927 PMCID: PMC8128502 DOI: 10.2147/rru.s198792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 04/14/2021] [Indexed: 12/05/2022] Open
Abstract
Recurrent male anterior urethral stricture disease is a complex surgical challenge that should be managed by reconstructive urologists with experience in stricture management. Diagnosis of recurrence requires both anatomic narrowing and patient symptoms identified on validated questionnaires, with limited role for intervention in asymptomatic treatment “failures”. Endoscopic management has a very specific role in recurrence, and the choice of technique for urethroplasty depends on pre-operative urethrography and cystoscopy. Surgical success depends on addressing patient concerns, complete stricture excision, tissue quality optimization, and the use of multi-stage repair when indicated. Augmentation with genital skin flaps and/or grafts is often required, with buccal mucosa as the ideal graft source if local tissue is compromised. Salvage options including urinary diversion and perineal urethrostomy must also be considered in debilitated patients with severe disease or repeated treatment failures. Unique patient populations including patients with hypospadias and lichen sclerosis are among the highest risk for repeated recurrence and require special care in surgical technique, graft selection, and post-operative management.
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Affiliation(s)
| | - Nima Baradaran
- The Ohio State University Department of Urology, Columbus, OH, USA
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25
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Mazdak H, Tolou Ghamari Z, Khorrami A. Investigation of Triamcinolone Instillation in the Long-term Rate of Anterior Urethral Strictures' Recurrence. Curr Urol 2021; 14:206-210. [PMID: 33488339 DOI: 10.1159/000499237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/08/2019] [Indexed: 11/19/2022] Open
Abstract
Background/Aims Previous publications confirmed that after internal urethrotomy success rates in the short-term (less than 6 months) are varied (70-80%) and in the long-term results are generally low. In this study, the efficacy of triamcinolone instillation based on a newly introduced protocol on the rate of recurrence in patients with anterior urethral strictures was evaluated. Methods A total of 66 patients were divided into treatment group (n = 33), in which triamcinolone was instilled on urethra after removing of Foley catheter and control group (n = 33) that not received any intervention. Each 40 mg/1 ml of triamcinolone vial was dissolved in 9 ml of distilled water and then a 2 ml of diluted solution was used for each instillation and 8 ml was kept in 4°C. Triamcinolone was instilled based on daily in week 1, every other day for week 2 and then every Monday and Friday for 2 months. Penile clamp was used after instillation for 1 hour. Treatment failure was based on urine flow rate, rate of recurrence and time to appearance of recurrence. Results There were not any significant differences regrading to age (p = 0.09), length (p = 0.41) and diameter (p = 0.36) of stricture between 2 groups. Time to appearance of recurrence showed significantly in the treatment group when compared with that in the control group (1,350 ± 900 vs. 124.3 ±112 days; p < 0.01). In the treatment group, 88% had reasonable consequence, while in control 48%. There were 3 patients with a mean length-diameter of stricture around 0.3-5 cm who showed recurrence free with the mean of 720 days after intervention. Conclusion Administration of triamcinolone instillation in urethra is associated with a decreased risk of stricture recurrence. Superior outcomes were seen in patients with a stricture length of more than 2 cm and this may in part reflect the increasing efficacy of the instillation method in the management of urethral strictures. These findings help identify patients with aggressive features of strictures in urethra who may benefit from intensified treatment efficacy of triamcinolone instillation.
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Affiliation(s)
- Hamid Mazdak
- Isfahan Kidney Transplantation Research Center.,Department of Urology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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26
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Oyelowo N, Ahmed M, Bello A, Lawal AT, Awaisu M, Sudi A, Muhammad MS, Tolani MA, Lawal BB, Lovely F, Maitama HY, Ibrahim KA, Hamza R. Extent of spongiofibrosis and length of strictures: Findings at sonourethrography and urethroplasty. Urol Ann 2021; 13:41-46. [PMID: 33897163 PMCID: PMC8052901 DOI: 10.4103/ua.ua_161_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 06/19/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The purpose of this study was to diagnose urethral stricture and to determine the extent of spongiofibrosis as well as the length of stricture using sonourethrography and compare it with intraoperative findings. PATIENTS AND METHODS It was a cross sectional observational study from September 2017-August 2018. All patients who presented with urethral stricture, scheduled for urethroplasty, and consented to the study were enrolled. The extent of spongiofibrosis and length of strictures were determined at sonourethrography and subsequently at urethroplasty. Sensitivity, specificity, positive predictive value and negative predictive values of sonourethrography in the determination of length of stricture was done. Spearman correlation coefficient(r) was used to describe the association between the extent of spongiofibrosis found at sonourethrography and at urethroplasty. RESULTS A total of 84 patients were evaluated during the study period. The median age at presentation was 45years. 81% of the patients had moderate spongiofibrosis on sonourethrography. There was a significant correlation of 71.4% between the extent of spongiofibrosis on sonourethrography and at urethroplasty. In evaluation for the length of strictures, sonourethrography had a sensitivity of 84.6% specificity of 82.7%, PPV of 68.7% and NPV 92.3%. CONCLUSION Sonourethrography is a valuable tool in the evaluation of urethral strictures. Its radiation free readily available even in resource-poor settings and gives a good evaluation of extent of spongiofibrosis as well as the length of strictures. It's use in the preoperative evaluation of strictures may improve the outcome of the management of strictures.
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Affiliation(s)
- Nasir Oyelowo
- Division of Urology, Ahmadu Bello University, Zaria, Nigeria
| | - Muhammed Ahmed
- Division of Urology, Ahmadu Bello University, Zaria, Nigeria
| | - Ahmad Bello
- Division of Urology, Ahmadu Bello University, Zaria, Nigeria
| | | | - Mudi Awaisu
- Division of Urology, Ahmadu Bello University, Zaria, Nigeria
| | - Abdullahi Sudi
- Division of Urology, Ahmadu Bello University, Zaria, Nigeria
| | | | | | | | - Fidelis Lovely
- Division of Urology, Ahmadu Bello University, Zaria, Nigeria
| | | | | | - Ridwan Hamza
- Division of Urology, Ahmadu Bello University, Zaria, Nigeria
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27
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Pickard R, Goulao B, Carnell S, Shen J, MacLennan G, Norrie J, Breckons M, Vale L, Whybrow P, Rapley T, Forbes R, Currer S, Forrest M, Wilkinson J, McColl E, Andrich D, Barclay S, Cook J, Mundy A, N'Dow J, Payne S, Watkin N. Open urethroplasty versus endoscopic urethrotomy for recurrent urethral stricture in men: the OPEN RCT. Health Technol Assess 2020; 24:1-110. [PMID: 33228846 PMCID: PMC7750862 DOI: 10.3310/hta24610] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Men who suffer recurrence of bulbar urethral stricture have to decide between endoscopic urethrotomy and open urethroplasty to manage their urinary symptoms. Evidence of relative clinical effectiveness and cost-effectiveness is lacking. OBJECTIVES To assess benefit, harms and cost-effectiveness of open urethroplasty compared with endoscopic urethrotomy as treatment for recurrent urethral stricture in men. DESIGN Parallel-group, open-label, patient-randomised trial of allocated intervention with 6-monthly follow-ups over 24 months. Target sample size was 210 participants providing outcome data. Participants, clinicians and local research staff could not be blinded to allocation. Central trial staff were blinded when needed. SETTING UK NHS with recruitment from 38 hospital sites. PARTICIPANTS A total of 222 men requiring operative treatment for recurrence of bulbar urethral stricture who had received at least one previous intervention for stricture. INTERVENTIONS A centralised randomisation system using random blocks allocated participants 1 : 1 to open urethroplasty (experimental group) or endoscopic urethrotomy (control group). MAIN OUTCOME MEASURES The primary clinical outcome was control of urinary symptoms. Cost-effectiveness was assessed by cost per quality-adjusted life-year (QALY) gained over 24 months. The main secondary outcome was the need for reintervention for stricture recurrence. RESULTS The mean difference in the area under the curve of repeated measurement of voiding symptoms scored from 0 (no symptoms) to 24 (severe symptoms) between the two groups was -0.36 [95% confidence interval (CI) -1.78 to 1.02; p = 0.6]. Mean voiding symptom scores improved between baseline and 24 months after randomisation from 13.4 [standard deviation (SD) 4.5] to 6 (SD 5.5) for urethroplasty group and from 13.2 (SD 4.7) to 6.4 (SD 5.3) for urethrotomy. Reintervention was less frequent and occurred earlier in the urethroplasty group (hazard ratio 0.52, 95% CI 0.31 to 0.89; p = 0.02). There were two postoperative complications requiring reinterventions in the group that received urethroplasty and five, including one death from pulmonary embolism, in the group that received urethrotomy. Over 24 months, urethroplasty cost on average more than urethrotomy (cost difference £2148, 95% CI £689 to £3606) and resulted in a similar number of QALYs (QALY difference -0.01, 95% CI -0.17 to 0.14). Therefore, based on current evidence, urethrotomy is considered to be cost-effective. LIMITATIONS We were able to include only 69 (63%) of the 109 men allocated to urethroplasty and 90 (80%) of the 113 men allocated to urethrotomy in the primary complete-case intention-to-treat analysis. CONCLUSIONS The similar magnitude of symptom improvement seen for the two procedures over 24 months of follow-up shows that both provide effective symptom control. The lower likelihood of further intervention favours urethroplasty, but this had a higher cost over the 24 months of follow-up and was unlikely to be considered cost-effective. FUTURE WORK Formulate methods to incorporate short-term disutility data into cost-effectiveness analysis. Survey pathways of care for men with urethral stricture, including the use of enhanced recovery after urethroplasty. Establish a pragmatic follow-up schedule to allow national audit of outcomes following urethral surgery with linkage to NHS Hospital Episode Statistics. TRIAL REGISTRATION Current Controlled Trials ISRCTN98009168. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 61. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Robert Pickard
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jing Shen
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare and Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Matt Breckons
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Tim Rapley
- Social Work, Education & Community Wellbeing, University of Northumbria, Newcastle upon Tyne, UK
| | - Rebecca Forbes
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Stephanie Currer
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Mark Forrest
- Centre for Healthcare and Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Jennifer Wilkinson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Daniela Andrich
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Jonathan Cook
- Oxford Clinical Trials Research Unit, Oxford University, Oxford, UK
| | - Anthony Mundy
- University College London Hospitals NHS Foundation Trust, London, UK
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Stephen Payne
- Central Manchester Hospitals NHS Foundation Trust, Manchester, UK
| | - Nick Watkin
- St George's University Hospitals NHS Foundation Trust, London, UK
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Kim YJ, Ahn H, Kim CS, Kim YS. Phase I/IIa trial of androgen deprivation therapy, external beam radiotherapy, and stereotactic body radiotherapy boost for high-risk prostate cancer (ADEBAR). Radiat Oncol 2020; 15:234. [PMID: 33032643 PMCID: PMC7542889 DOI: 10.1186/s13014-020-01665-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background To evaluate the clinical outcomes of combination of androgen deprivation therapy (ADT), whole pelvic radiotherapy (WPRT), and stereotactic body radiotherapy (SBRT) boost in high-risk prostate cancer patients. Methods This prospective phase I/IIa study was conducted between 2016 and 2017. Following WPRT of 44 Gy in 20 fractions, patients were randomized to two boost doses, 18 Gy and 21 Gy, in 3 fractions using the Cyberknife system. Primary endpoints were incidences of acute toxicities and short-term biochemical recurrence-free survival (BCRFS). Secondary endpoints included late toxicities and short-term clinical progression-free survival (CPFS). Results A total of 26 patients were enrolled. Twelve patients received a boost dose of 18 Gy, and the rest received 21 Gy. The Median follow-up duration was 35 months. There were no grade ≥ 3 genitourinary (GU) or gastrointestinal (GI) toxicities. Sixty-one and 4% of patients experienced grade 1–2 acute GU and GI toxicities, respectively. There were 12% late grade 1–2 GU toxicities and 8% late grade 1–2 GI toxicities. Patient-reported outcomes of urinary symptoms were aggravated after WPRT and SBRT boost. However, they resolved at 1 month and returned to the baseline level at 4 months. Three-year BCRFS was 88.1%, and CPFS was 92.3%. Conclusions The present study protocol demonstrated that the combination of ADT, WPRT, and SBRT boosts for high-risk prostate cancer is safe and feasible, and may reduce total treatment time to 5 weeks. Boost dose of 21 Gy in 3 fractions seems appropriate. Trial registration ClinicalTrials.gov, ID; NCT03322020 - Retrospectively registered on 26 October 2017.
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Affiliation(s)
- Yeon Joo Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hanjong Ahn
- Department of Urology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Choung-Soo Kim
- Department of Urology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Young Seok Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Mackiewicz AG, Klekiel T, Kurowiak J, Piasecki T, Bedzinski R. Determination of Stent Load Conditions in New Zealand White Rabbit Urethra. J Funct Biomater 2020; 11:jfb11040070. [PMID: 32992694 PMCID: PMC7712058 DOI: 10.3390/jfb11040070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Frequency of urethral stenosis makes it necessary to develop new innovative methods of treating this disease. This pathology most often occurs in men and manifests itself in painful urination, reduced urine flow, or total urinary retention. This is a condition that requires immediate medical intervention. Methods: Experimental tests were carried out on a rabbit in order to determine the changes of pressure in the urethra system and to estimate the velocity of urine flow. For this purpose, a measuring system was proposed to measure the pressure of a fluid-filled urethra. A fluoroscope was used to observe the deformability of the bladder and urethra canal. Results: Based on these tests, the range of changes in the urethra tube diameter, the pressures inside the system, and the flow velocity during micturition were determined. Conclusions: The presented studies allowed determining the behavior of the urethra under the conditions of urinary filling. The fluid-filled bladder and urethra increased their dimensions significantly. Such large changes require that the stents used for the treatment of urethral stenosis should not have a fixed diameter but should adapt to changing urethral dimensions.
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Affiliation(s)
- Agnieszka G. Mackiewicz
- Department of Biomedical Engineering, Institute of Material and Biomedical Engineering, University of Zielona Gora, Licealna 9 Street, 65-417 Zielona Gora, Poland; (T.K.); (J.K.); (R.B.)
- Correspondence:
| | - Tomasz Klekiel
- Department of Biomedical Engineering, Institute of Material and Biomedical Engineering, University of Zielona Gora, Licealna 9 Street, 65-417 Zielona Gora, Poland; (T.K.); (J.K.); (R.B.)
| | - Jagoda Kurowiak
- Department of Biomedical Engineering, Institute of Material and Biomedical Engineering, University of Zielona Gora, Licealna 9 Street, 65-417 Zielona Gora, Poland; (T.K.); (J.K.); (R.B.)
| | - Tomasz Piasecki
- Department of Epizootiology and Clinic of Birds and Exotic Animals, Faculty of Veterinary Medicine, Wroclaw University of Environmental and Life Sciences, C. K. Norwida 25 Street, 50-375 Wroclaw, Poland;
| | - Romuald Bedzinski
- Department of Biomedical Engineering, Institute of Material and Biomedical Engineering, University of Zielona Gora, Licealna 9 Street, 65-417 Zielona Gora, Poland; (T.K.); (J.K.); (R.B.)
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Almannie R, Alturki A, AlSufyani A, Alkhamis W, Binsaleh S, Alyami F. Exposure of Urology Residents to the Management of Urethral Strictures in Saudi Arabia: Should the Program for Postgraduates Be Customized? Res Rep Urol 2020; 12:367-372. [PMID: 32984084 PMCID: PMC7490046 DOI: 10.2147/rru.s268628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/19/2020] [Indexed: 11/26/2022] Open
Abstract
PURPOSE This study aimed to assess the exposure and knowledge of urology residents in the management of urethral stricture (US) and to determine if they would be able to perform urethroplasty after graduation and whether urethroplasty should be included as a competency in the training program. PATIENTS AND METHODS An online survey was sent to all residents enrolled in any urology training program in Saudi Arabia. Fifty-eight (approximately 50%) of the 114 residents who were sent the survey provided responses. RESULTS Most of the residents (45 residents, 77.6%) who responded were exposed to fewer than ten cases of US during their last year of training. Fifty-six residents (96.6%) attended five or fewer urethroplasty procedures in their last year of training. Twenty-three (40%) residents did not attend any urethroplasty procedure in the last year. The most common procedures attended by the residents were minimally invasive treatments (89% cystoscopy with dilatation and 79% direct visual internal urethrotomy (DVIU)). Most residents responded that they would manage newly diagnosed 1 cm US with either cystoscopy and dilatation or with DVIU 53 (91%). For the first recurrence of US, 46 (79%) residents responded that they would still prefer dilatation or DVIU. For the second, third, and chronic recurrences of US, 20 (34.5%), 6 (10.3%), and 5 (8.6%) residents, respectively, responded that they would perform dilatation or DVIU. Residents had low expectations for the success rate of urethroplasty; only 32 (55.2%) residents thought it had a high success rate. CONCLUSION Urethroplasty is a specialized urological procedure, one that residents have variable exposure to. Privilege to perform such a procedure after graduating should be modified to ensure the best outcome for patients.
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Affiliation(s)
- Raed Almannie
- Urology Division, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah Alturki
- Urology Division, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah AlSufyani
- Urology Division, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Waleed Alkhamis
- Urology Division, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saleh Binsaleh
- Urology Division, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad Alyami
- Urology Division, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Shen J, Breckons M, Vale L, Pickard R. Using Time Trade-Off Methods to Elicit Short-Term Utilities Associated with Treatments for Bulbar Urethral Stricture. PHARMACOECONOMICS - OPEN 2019; 3:551-558. [PMID: 31240689 PMCID: PMC6861395 DOI: 10.1007/s41669-019-0133-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Recurrent urethral stricture is usually treated with either open urethroplasty or endoscopic urethrotomy. Both of the procedures cause short-term utility loss, which may not be captured by standard utility questionnaires due to the challenges of completing a standard instrument at the time of an acute episode of short duration, especially within a clinical trial setting. We propose to use time trade-off (TTO) methods to estimate these short-term utility losses. OBJECTIVE The aim was to compare the use of two alternative TTO methods to elicit patients' short-term utilities following surgical treatments for recurrent urethral stricture. METHOD Two variants of TTO (chained and conventional) were used. Six health profiles were developed-three for each procedure. Forty participants took part, with 20 randomly allocated to each TTO method. RESULTS Thirty-eight participants provided usable data for analysis. Estimated utility values decreased as the severity of the health profiles increased. There was no evidence that utility values differed between elicitation methods or procedures for mild {ranging from 0.79 (standard deviation [SD] 0.17) to 0.83 [SD 0.20]} and moderate (ranging from 0.54 [SD 0.24] to 0.67 [SD 0.21]) health states, although they appeared to differ for severe health states (ranging from 0.29 [SD 0.20] to 0.56 [SD 0.24]). CONCLUSION The study demonstrates the feasibility and value of eliciting patients' short-term utilities. Given the small sample size, the study findings are tentative. Further research with a larger sample size is needed to determine the appropriate TTO method to use and how the elicited utilities can be used in combination with standard cost-utility assessments to aid decision making.
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Affiliation(s)
- Jing Shen
- Health Economics Group, Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, Tyne and Wear, NE2 4AX, UK.
| | - Matthew Breckons
- Health Economics Group, Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, Tyne and Wear, NE2 4AX, UK
| | - Luke Vale
- Health Economics Group, Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, Tyne and Wear, NE2 4AX, UK
| | - Robert Pickard
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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32
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Das SK, Jana D, Ghosh B, Pal DK. A comparative study between the outcomes of visual internal urethrotomy for short segment anterior urethral strictures done under spinal anesthesia and local anesthesia. Turk J Urol 2019; 45:431-436. [PMID: 31603417 DOI: 10.5152/tud.2019.49354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 02/19/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study is a randomized controlled study comparing the effectiveness and outcomes of direct visual inter urethrotomy (DVIU) for short segment anterior urethral strictures performed under local anesthesia versus spinal anesthesia. MATERIAL AND METHODS Patients presenting with an anterior urethral stricture up to 2 cm were randomized into two interventional groups: Group I-DVIU done under spinal anesthesia and Group II-DVIU performed under local anesthesia. Procedural discomfort was analyzed with a visual analog scale (VAS) immediately postoperatively and after one hour of the procedure. The changes in the vital parameters (systolic blood pressure and pulse rate) were recorded. The success of the procedure was defined as the absence of symptoms of recurrent stricture along with the ability of self-urethral calibration with an 18Fr catheter on follow-up. RESULTS One hundred and twenty patients, between December 2015 and February 2017, were randomized into the two above-mentioned groups with 60 patients each. The demographic profile, the stricture characteristics (etiology, length, and duration of symptoms), and the preoperative parameters (Qmax, preoperative pulse rate, and systolic blood pressures) were comparable in both the groups. The mean (±SD) intraoperative and one-hour postoperative VAS scores were 1.96 (±1.04) and 1.20 (±0.73), respectively, for Group I, which were significantly less (p<0.05) than the VAS scores 4.26 (± 1.98) and 2.13 (±1.71), respectively, for Group II. The intraoperative mean increases in pulse rate and systolic blood pressure were also significantly lower in Group I (p<0.05). The change in postoperative Qmax (mL/sec) was comparable in both the groups (mean of 20.75±4.31 vs. 19.041 4.88) and so is the stricture free rate at a one-year follow-up. No significant differences in complication rates were observed in both the groups. CONCLUSION Although perioperative procedural parameters seem to be in favor of spinal anesthesia, the outcome of DVIU is independent of the type of anesthesia used.
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Affiliation(s)
- Susanta Kumar Das
- Department of Urology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Debarshi Jana
- Department of Urology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Bastab Ghosh
- Department of Urology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Dilip Kumar Pal
- Department of Urology, Institute of Post Graduate Medical Education and Research, Kolkata, India
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Austen M, Breul J, Tritschler S. [Bulbar urethral strictures : A trivial urological disease or a surgical challenge?]. Urologe A 2019; 57:17-20. [PMID: 29236143 DOI: 10.1007/s00120-017-0545-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Urethral strictures are often located in the bulbar urethra, and bulbar strictures are commonly due to urethral trauma. Diagnosis is confirmed by radiographic imaging of the urethra. In cases of short primary bulbar strictures, a simple internal urethrotomy may be curative. In contrast, open surgery should be performed in long segment or recurrent strictures because recurrence rates are near 100% in these cases. Depending of the actual findings and comorbidities, end-to-end anastomosis, graft urethroplasty, flap urethroplasty, or perineal urethrostomy may be used. If definitive treatment using open surgery is delayed and multiple endoscopic treatments are tried, urethroplasty becomes more complex and success rates of definitive treatment decline.
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Affiliation(s)
- M Austen
- Klinik für Urologie und urologische Onkologie, Loretto-Krankenhaus Freiburg, Mercystraße 6-14, 79100, Freiburg, Deutschland.
| | - J Breul
- Klinik für Urologie und urologische Onkologie, Loretto-Krankenhaus Freiburg, Mercystraße 6-14, 79100, Freiburg, Deutschland
| | - S Tritschler
- Urologische Klinik und Poliklinik, Klinikum Großhadern, LMU München, München, Deutschland
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The effect of platelet-rich plasma injection on post-internal urethrotomy stricture recurrence. World J Urol 2018; 37:1959-1964. [DOI: 10.1007/s00345-018-2597-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/04/2018] [Indexed: 12/12/2022] Open
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Mathers MJ, Degener S, Sperling H, Roth S. Hematospermia-a Symptom With Many Possible Causes. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:186-191. [PMID: 28382905 DOI: 10.3238/arztebl.2017.0186] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 06/02/2016] [Accepted: 12/08/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hematospermia, or blood in the ejaculate, is a symptom with many possible causes that often gives rise to worry. Precise figures on its prevalence are unavailable. It is most common in men under 40, and its cause is usually benign; nonetheless, even a single episode of hematospermia calls for a basic diagnostic evaluation. METHODS This review is based on pertinent articles re trieved by a search in PubMed with the key words "hemato spermia," "hemospermia," "ejaculation," "male semen," and "transrectal ultrasound." RESULTS A diagnostic algorithm for hematospermia is described. The most common cause is iatrogenic trauma, in particular transrectal ultrasound-guided prostate biopsy to rule out prostate cancer. Urogenital infections are the second most common cause. Pathological changes of the prostate should be considered along with systemic causes, e.g., arterial hypertension or various hematologic disorders. A single event in men under 40 should be evaluated by precise history-taking, a meticulous physical examination including blood-pressure measurement, and urinalysis. Repeated episodes, or hematospermia in men over 40, calls for additional evaluation with further laboratory tests, imaging studies, and, in some cases, interventional diagnostic procedures. CONCLUSION Further tests, preferably imaging studies, seem a reasonable way to detect or exclude potential causes of hematospermia, especially malignant ones. The treatment is directed at the underlying cause.
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Affiliation(s)
- Michael J Mathers
- Joint Urological Practice Remscheid, PandaMED, Cooperative Practice of the Department of Urology and Pediatric Urology, Helios Hospital Group Wuppertal, University of Witten/Herdecke; Department of Urology and Pediatric Urology, Wuppertal Hospital, Helios Hospital Group Wuppertal, University of Witten/Herdecke; Department of Urology, Maria Hilf Hospital Group, Mönchengladbach
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Viergutz T, Terboven T, Henzler T, Schäfer D, Schönberg SO, Sudarski S. [Relevant incidental findings and iatrogenic injuries : A retrospective analysis of 1165 resuscitation room patients]. Anaesthesist 2018; 67:901-906. [PMID: 30367211 DOI: 10.1007/s00101-018-0505-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/27/2018] [Accepted: 10/08/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Whole-body computed tomography (CT) is increasingly being used as the diagnostic modality of choice in patients admitted to the resuscitation room. Beyond findings related to the suspected diagnosis it often additionally reveals incidental findings. The aim of this investigation was the evaluation of these findings in patients admitted via the emergency room after suffering potential major trauma or life-threatening medical conditions. Furthermore, the number of iatrogenic injuries as well as misplaced catheters and endotracheal tubes was investigated. METHODS All patients admitted from 1 February 2012 to 31 January 2014 via the resuscitation area of the Mannheim University Medical Center, a tertiary care hospital and level 1 trauma center, were included in this study if they had undergone a whole-body CT scan at admission. Data from 1362 patients were collected retrospectively and 197 patients were excluded because of missing data so that the final cohort consisted of 1165 patients (1038 trauma and 127 internal neurological patients). Reports from the whole-body CT scans were screened for incidental findings. These findings were then classified as either clinically relevant or not. Furthermore, the reports were checked for iatrogenic injuries as well as misplaced catheters and endotracheal tubes. RESULTS A total of 465 incidental findings were reported in 293 patients (25.1%) of the final cohort. In the synopsis of the radiological and clinical findings, 72 were rated as clinically relevant. In one patient two relevant incidental findings were reported and one patient presented with three incidental findings. In total, relevant incidental findings could be detected in 5.8% of the study patients (68/1165). In the discharge letters and/or the radiological report 16.2% of the incidental findings rated as clinically relevant were reported to be previously known, 66.2% were reported to be unknown and 17.6% could not be unequivocally classified as known or unknown due to missing references in the discharge letters. The group of internal neurological patients were clearly older than the trauma patients (61.6 years vs. 45.5 years). The rate of relevant incidental findings in the internal neurological group was more than twice as high as in the trauma group (11.0% vs. 5.2%); however, in the relatively young trauma group 1 in 20 patients showed an incidental finding classified as clinically relevant. In 43 (3.7%) patients a total of 46 iatrogenic injuries or misplaced catheters were reported. The most common finding was a too deeply placed endotracheal tube and five transurethral catheters placed in the emergency room were found to be blocked within the urethra. CONCLUSION In addition to the main diagnosis, clinically relevant incidental findings were reported in nearly 25% of whole-body CT scans of patients admitted to the resuscitation room. Approximately 6% of patients had incidental findings rated as clinically relevant. In the internal neurological group of patients the rate of incidental findings was doubled compared to the trauma group; however, the latter were significantly younger. Whole-body CT was also useful for diagnosing iatrogenic injuries and misplaced catheters in approximately 4% of the study patients.
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Affiliation(s)
- T Viergutz
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - T Terboven
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - T Henzler
- Institut für klinische Radiologie und Nuklearmedizin, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - D Schäfer
- Institut für klinische Radiologie und Nuklearmedizin, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - S O Schönberg
- Institut für klinische Radiologie und Nuklearmedizin, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - S Sudarski
- Institut für klinische Radiologie und Nuklearmedizin, Universitätsmedizin Mannheim, Mannheim, Deutschland
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Repair of injured urethras with silk fibroin scaffolds in a rabbit model of onlay urethroplasty. J Surg Res 2018; 229:192-199. [PMID: 29936989 DOI: 10.1016/j.jss.2018.04.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/19/2018] [Accepted: 04/03/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Preclinical validation of scaffold-based technologies in animal models of urethral disease is desired to assess wound healing efficacy in scenarios that mimic the target patient population. This study investigates the feasibility of bilayer silk fibroin (BLSF) scaffolds for the repair of previously damaged urethras in a rabbit model of onlay urethroplasty. MATERIALS AND METHODS A focal, partial thickness urethral injury was created in adult male rabbits (n = 12) via electrocoagulation and then onlay urethroplasty with 50 mm2 BLSF grafts was carried out 2 wk after injury. Animals were randomly divided into three experimental groups and harvested at 2 wk after electrocoagulation (n = 3), and 1 (n = 3) or 3 (n = 6) months after scaffold implantation. Outcome analyses were performed preoperatively and at 2 wk after injury in all groups as well as at 1 or 3 mo after scaffold grafting and included urethroscopy, retrograde urethrography (RUG), and histological and immunohistochemical analyses. RESULTS At 2 wk after electrocoagulation, urethroscopic and RUG evaluations confirmed urethral stricture formation in 92% (n = 11/12) of rabbits. Gross tissue assessments at 1 (n = 3) and 3 (n = 6) mo after onlay urethroplasty revealed host tissue ingrowth covering the entire implant site. At 3 mo post-op, RUG analyses of repaired urethral segments demonstrated a 39% reduction in urethral stenosis detected following electrocoagulation injury. Histological and immunohistochemical analyses revealed the formation of innervated, vascularized neotissues with α-smooth muscle actin+ and SM22α+ smooth muscle bundles and pan-cytokeratin + epithelium at graft sites. CONCLUSIONS These results demonstrate the feasibility of BLSF matrices to support the repair of previously damaged urethral tissues.
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Birder LA, Kullmann FA. Role of neurogenic inflammation in local communication in the visceral mucosa. Semin Immunopathol 2018; 40:261-279. [PMID: 29582112 PMCID: PMC5960632 DOI: 10.1007/s00281-018-0674-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/06/2018] [Indexed: 12/27/2022]
Abstract
Intense research has focused on the involvement of the nervous system in regard to cellular mechanisms underlying neurogenic inflammation in the pelvic viscera. Evidence supports the neural release of inflammatory factors, trophic factors, and neuropeptides in the initiation of inflammation. However, more recently, non-neuronal cells including epithelia, endothelial, mast cells, and paraneurons are likely important participants in nervous system functions. For example, the urinary bladder urothelial cells are emerging as key elements in the detection and transmission of both physiological and nociceptive stimuli in the lower urinary tract. There is mounting evidence that these cells are involved in sensory mechanisms and can release mediators. Further, localization of afferent nerves next to the urothelium suggests these cells may be targets for transmitters released from bladder nerves and that chemicals released by urothelial cells may alter afferent excitability. Modifications of this type of communication in a number of pathological conditions can result in altered release of epithelial-derived mediators, which can activate local sensory nerves. Taken together, these and other findings highlighted in this review suggest that neurogenic inflammation involves complex anatomical and physiological interactions among a number of cell types in the bladder wall. The specific factors and pathways that mediate inflammatory responses in both acute and chronic conditions are not well understood and need to be further examined. Elucidation of mechanisms impacting on these pathways may provide insights into the pathology of various types of disorders involving the pelvic viscera.
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Affiliation(s)
- Lori A Birder
- Department of Medicine, University of Pittsburgh School of Medicine, A 1217 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
- Department of Chemical Biology and Pharmacology, University of Pittsburgh School of Medicine, A 1217 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - F Aura Kullmann
- Department of Medicine, University of Pittsburgh School of Medicine, A 1217 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
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Rapamycin Inhibits the Growth and Collagen Production of Fibroblasts Derived from Human Urethral Scar Tissue. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7851327. [PMID: 29850566 PMCID: PMC5932518 DOI: 10.1155/2018/7851327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/15/2018] [Accepted: 03/01/2018] [Indexed: 11/17/2022]
Abstract
Rapamycin can inhibit fibroblast proliferation, collagen accumulation, and urethral stricture in rabbits. Transforming growth factor-beta-1 (TGF-β1) signaling, with downstream recruitment of Smad2, is known to promote fibrosis. This in vitro study examined the effects of rapamycin on fibroblasts derived from human urethral scar tissue (FHUS) and investigated the possible mechanism with respect to regulation of TGF-β1 signaling. FHUS were cultured from urethral scar tissues collected from four patients with urethral stricture. The cells were exposed to different concentrations of rapamycin (0, 10, 20, 40, 80, or 160 ng/ml) for 24 or 48 hours. Cell growth was assessed by the MTT assay. Collagen content was measured based on hydroxyproline levels. The mRNA expressions of Smad2, eIF-4E, and alpha-1 chains of collagen types I and III (Col1α1 and Col3α1) were determined by semiquantitative reverse-transcription PCR. The protein expressions of Smad2, phospho-Smad2, and eIF-4E were evaluated by western blot. Rapamycin caused a concentration-dependent inhibition of FHUS growth at 24 and 48 hours (P < 0.01). Rapamycin decreased total collagen content (P < 0.01), collagen content per 105 cells (P < 0.05), and mRNA expressions of Col1α1 and Col3α1 (P < 0.05) in a concentration-dependent manner. Rapamycin elicited concentration-dependent reductions in the mRNA (P < 0.05) and protein (P < 0.01) expressions of Smad2 and eIF-4E. The two highest concentrations of rapamycin also enhanced phospho-Smad2 levels (P < 0.01). In conclusion, the present study confirmed that rapamycin may reduce the growth and collagen production of FHUS, possibly through inhibition of TGF-β1 signaling.
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Lin Y, Luo D, Liao B, Yang T, Tian Y, Jin T, Wang G, Zhou H, Li H, Wang K. Perineal midline vertical incision verses inverted-U incision in the urethroplasty: which is better? World J Urol 2018. [PMID: 29541891 DOI: 10.1007/s00345-018-2267-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To compare postoperative outcomes between the perineal inverted-U and the vertical midline incision approaches of the urethroplasty and clarify them via gross anatomy. PATIENTS AND METHODS A total of 461 male patients, from Jan. 2006 to Jun. 2014, who underwent the urethroplasty via perineal midline vertical or inverted-U incision approach were recruited retrospectively. By match pairing for etiology and stricture length, 410 patients from two groups (205 for each group) were selected. Anatomy experiments were also performed. Outcome measurements and statistical analysis: the Chi-square, Student's t and binary logistic regression analyses were performed to compare the operative and postoperative data on the two groups. RESULTS With regard to patients with bulbar urethral stricture, the rate of surgical site infection (SSI) in perineal inverted-U group was 18.6% while 1.9% in the midline vertical group (p < 0.001). As for patients with posterior urethral stricture, the rate of SSI in the perineal inverted-U group was 16.4% while 3.1% in the midline vertical group (p = 0.001). Mean hospital stay between both groups were 15.8 ± 9.0 vs. 12.7 ± 3.8 days (p < 0.001). Anatomy experiments showed the number of damaged vessels and nerves involved in the inverted-U incision were approximately 1.6 to 2.0 folds more than the vertical midline, but the visual operation fields are similar between two approaches. CONCLUSIONS The perineal midline vertical incision is a safer approach with fewer SSI and shorter hospital stay than the perineal inverted-U incision for bulbar and posterior urethroplasty.
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Affiliation(s)
- Yifei Lin
- Urology Department, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu, Sichuan, 610041, People's Republic of China
| | - Deyi Luo
- Urology Department, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu, Sichuan, 610041, People's Republic of China
| | - Banghua Liao
- Urology Department, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu, Sichuan, 610041, People's Republic of China
| | - Tongxin Yang
- Urology Department, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu, Sichuan, 610041, People's Republic of China
| | - Ye Tian
- Urology Department, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu, Sichuan, 610041, People's Republic of China
| | - Tao Jin
- Urology Department, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu, Sichuan, 610041, People's Republic of China
| | - Guiming Wang
- Department of Human Anatomy, West China School of Preclinical and Forensic Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Hongying Zhou
- Department of Human Anatomy, West China School of Preclinical and Forensic Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Hong Li
- Urology Department, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu, Sichuan, 610041, People's Republic of China
| | - Kunjie Wang
- Urology Department, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu, Sichuan, 610041, People's Republic of China.
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Zhang K, Chen J, Zhang D, Wang L, Zhao W, Lin DYT, Chen R, Xie H, Hu X, Fang X, Fu Q. microRNA expression profiles of scar and normal tissue from patients with posterior urethral stricture caused by pelvic fracture urethral distraction defects. Int J Mol Med 2018; 41:2733-2743. [PMID: 29436608 PMCID: PMC5846665 DOI: 10.3892/ijmm.2018.3487] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/23/2018] [Indexed: 12/31/2022] Open
Abstract
Pelvic fracture urethral distraction defect (PFUDD) seriously affects the quality of life of patients. At present, there are few effective drug treatments available for PFUDD-induced urethral stricture, which is associated with fibrosis and scar formation in urethra lumen. Emerging evidence suggests that microRNAs (miRNAs/miRs) may be involved in the regulation of fibrosis, and analysis of miRNA expression profiles in urethral scar and normal urethra tissues may therefore benefit the discovery of novel treatments for urethral stricture with micro invasive procedures. In the present study, miRNA sequencing and quantitative polymerase chain reaction (qPCR) validation using paired scar and normal tissues from patients with PFUDD, and functional analysis of the miRNAs involved in the fibrosis associated signaling pathway was performed. A total of 94 differentially expressed miRNAs were identified in the scar tissue of patients with PFUDD. Among them, 26 miRNAs had significantly altered expression in the scar tissue compared with the normal tissue from the same patient. qPCR validation confirmed that miR-129-5p was overexpressed in scar tissue. The TGF-β pathway-associated functions of a total of 5 miRNAs (hsa-miR-129-5p, hsa-miR-135a-5p, hsa-miR-363-3p, hsa-miR-6720-3p and hsa-miR-9-5p) were further analyzed, as well as their key molecular targets and functional mechanisms in signaling regulation. To conclude the miRNA sequencing indicated a significantly altered expression of hsa-miR-129-5p, hsa-miR-135a-5p, hsa-miR-363-3p, hsa-miR-6720-3p and hsa-miR-9-5p in patients with PFUDD. These miRNAs and their potential target genes were associated with fibrosis in several diseases, and the data from the present study may help explore potential miRNA targets for future precision treatments for urethral stricture.
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Affiliation(s)
- Kaile Zhang
- Department of Urology, Affiliated Sixth People's Hospital, Shanghai JiaoTong University, Shanghai 200233, P.R. China
| | - Jun Chen
- Department of Urology, Affiliated Sixth People's Hospital, Shanghai JiaoTong University, Shanghai 200233, P.R. China
| | - Dongliang Zhang
- Department of Urology, Affiliated Sixth People's Hospital, Shanghai JiaoTong University, Shanghai 200233, P.R. China
| | - Lin Wang
- Department of Urology, Affiliated Sixth People's Hospital, Shanghai JiaoTong University, Shanghai 200233, P.R. China
| | - Weixin Zhao
- Wake Forest Institute for Regenerative Medicine, Winston‑Salem, NC 27157, USA
| | | | - Rong Chen
- Department of Urology, Affiliated Sixth People's Hospital, Shanghai JiaoTong University, Shanghai 200233, P.R. China
| | - Hong Xie
- Department of Urology, Affiliated Sixth People's Hospital, Shanghai JiaoTong University, Shanghai 200233, P.R. China
| | - Xiaoyong Hu
- Department of Urology, Affiliated Sixth People's Hospital, Shanghai JiaoTong University, Shanghai 200233, P.R. China
| | | | - Qiang Fu
- Department of Urology, Affiliated Sixth People's Hospital, Shanghai JiaoTong University, Shanghai 200233, P.R. China
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Kullmann FA, Chang HH, Gauthier C, McDonnell BM, Yeh JC, Clayton DR, Kanai AJ, de Groat WC, Apodaca GL, Birder LA. Serotonergic paraneurones in the female mouse urethral epithelium and their potential role in peripheral sensory information processing. Acta Physiol (Oxf) 2018; 222:10.1111/apha.12919. [PMID: 28719042 PMCID: PMC5963688 DOI: 10.1111/apha.12919] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/19/2017] [Accepted: 07/13/2017] [Indexed: 01/01/2023]
Abstract
AIM The mechanisms underlying detection and transmission of sensory signals arising from visceral organs, such as the urethra, are poorly understood. Recently, specialized ACh-expressing cells embedded in the urethral epithelium have been proposed as chemosensory sentinels for detection of bacterial infection. Here, we examined the morphology and potential role in sensory signalling of a different class of specialized cells that express serotonin (5-HT), termed paraneurones. METHODS Urethrae, dorsal root ganglia neurones and spinal cords were isolated from adult female mice and used for immunohistochemistry and calcium imaging. Visceromotor reflexes (VMRs) were recorded in vivo. RESULTS We identified two morphologically distinct groups of 5-HT+ cells with distinct regional locations: bipolar-like cells predominant in the mid-urethra and multipolar-like cells predominant in the proximal and distal urethra. Sensory nerve fibres positive for calcitonin gene-related peptide, substance P, and TRPV1 were found in close proximity to 5-HT+ paraneurones. In vitro 5-HT (1 μm) stimulation of urethral primary afferent neurones, mimicking 5-HT release from paraneurones, elicited changes in the intracellular calcium concentration ([Ca2+ ]i ) mediated by 5-HT2 and 5-HT3 receptors. Approximately 50% of 5-HT responding cells also responded to capsaicin with changes in the [Ca2+ ]i . In vivo intra-urethral 5-HT application increased VMRs induced by urethral distention and activated pERK in lumbosacral spinal cord neurones. CONCLUSION These morphological and functional findings provide insights into a putative paraneurone-neural network within the urethra that utilizes 5-HT signalling, presumably from paraneurones, to modulate primary sensory pathways carrying nociceptive and non-nociceptive (mechano-sensitive) information to the central nervous system.
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Affiliation(s)
- F. A. Kullmann
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - H. H. Chang
- Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - C. Gauthier
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - B. M. McDonnell
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J.-C. Yeh
- Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - D. R. Clayton
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - A. J. Kanai
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - W. C. de Groat
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - G. L. Apodaca
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L. A. Birder
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Yenice MG, Seker KG, Sam E, Colakoglu Y, Atar FA, Sahin S, Simsek A, Tugcu V. Comparison of cold-knife optical internal urethrotomy and holmium:YAG laser internal urethrotomy in bulbar urethral strictures. Cent European J Urol 2017; 71:114-120. [PMID: 29732217 PMCID: PMC5926630 DOI: 10.5173/ceju.2017.1391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 09/12/2017] [Accepted: 11/13/2017] [Indexed: 01/28/2023] Open
Abstract
Introduction To compare the results of cold-knife optical internal urethrotomy (OIU) and Holmium:YAG laser internal urethrotomy (HIU) in primary bulbar urethral strictures. Material and methods A total of 63 patients diagnosed with primary bulbar urethral stricture between August 2014 and September 2015 were assigned to the OIU (n = 29) and HIU (n = 34) groups. The demographic variables, biochemistry panels, and preoperative and postoperative uroflowmetry results including the maximum flow rate (Qmax) and mean flow rate (Qmean) values, retrograde urethrography, and diagnostic flexible urethroscopy findings were recorded prospectively. Demographic features and preoperative values were not statistically different between groups (p >0.05). Mean surgical times were 18.4 ±2.3 min for OIU and 21.9 ±3.8 min for HIU groups, which was statistically significant (p <0.05). There was no significant difference in complication rates in both groups (p = 0.618). Results Postoperative Qmax values were increased in both groups even though postoperative Qmax values were not significantly different between the two groups in the short- and long-term results at 3, 6, and 12 months (p >0.05). There was no recurrence in the first 3 months in either group. The urethral stricture recurrence rate up to month 12 was not statistically significant for the OIU group (n = 6, 20.7%) as compared to the HIU group (n = 11, 32.4%; p = 0.299). At follow-up, the SFR and IFR was 96% and 88% at 3-months, and 82% and 71% at 12-months, respectively (p <0.001). While almost three-quarters of patients were stone and infection free at 12-months, the majority of those with stones recurrence also had recurrence of their UTI. Conclusions HIU is an alternative method to OIU, and it has similar success rates in the treatment of short segment bulbar urethral strictures.
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Affiliation(s)
- Mustafa Gurkan Yenice
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Turkey, Istanbul
| | - Kamil Gokhan Seker
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Turkey, Istanbul
| | - Emre Sam
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Turkey, Istanbul
| | - Yunus Colakoglu
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Turkey, Istanbul
| | - Feyzi Arda Atar
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Turkey, Istanbul
| | - Selcuk Sahin
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Turkey, Istanbul
| | - Abdulmuttalip Simsek
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Turkey, Istanbul
| | - Volkan Tugcu
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Turkey, Istanbul
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Kurt O, Gevher F, Yazici CM, Erboga M, Dogru M, Aktas C. Effect of Mitomycin - C and Triamcinolone on Preventing Urethral Strictures. Int Braz J Urol 2017; 43:939-945. [PMID: 28537690 PMCID: PMC5678528 DOI: 10.1590/s1677-5538.ibju.2016.0191] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 07/17/2016] [Indexed: 08/26/2023] Open
Abstract
Urethral stricture is a common disease with high recurrence rate. Several manipulations were defined to prevent the recurrence but the results were disappointing. This study aimed to evaluate the efficacy of triamcinolone and mitomycin-C on urethral stricture formation and their effect on inhibition of urethral fibrosis. A total of 24 New Zealand rabbits were divided into 3 groups. Urethras of rabbits were traumatized with pediatric resectoscope. Resection area was irrigated with 10mL saline, swapped with a cotton wool soaked with 0.5mg/mL MMC and injected by 40mg triamcinolone in groups 1, 2 and 3 respectively. Retrograde urethrogram was performed at 28th day of procedure and the urethra was removed for histopathologic evaluation. There were significant differences in urethral diameters and in lumen reduction rate between the control and study groups (p<0.001). Compared to control group, all treatment groups showed mild fibrosis, less collagen bundle irregularity, and lower numbers of fibroblasts (p=0.003). The Tunnel assay showed that the number of apoptotic cells in the submucosal connective tissue was quantitatively higher in control groups (p=0.034). In the view of efficacy and safety, MMC and triamcinolone have the potential to replace the use of stents, clean intermittent catheterization, or long term catheters following internal urethrotomy. There were no statistically significant differences between two agents in terms of preventing urethral stricture formation in the present study. Mitomycin C and triamcinolone decreased the recurrence rates of urethral stricture.
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Affiliation(s)
- Omer Kurt
- Department of Urology, Namik Kemal University, School of Medicine, Tekirdag, Turkey
| | | | - Cenk Murat Yazici
- Department of Urology, Namik Kemal University, School of Medicine, Tekirdag, Turkey
| | - Mustafa Erboga
- Department of Histology, Namik Kemal University, School of Medicine, Tekirdag, Turkey
| | - Mucahit Dogru
- Department of Radiology, Namik Kemal University, School of Medicine, Tekirdag, Turkey
| | - Cevat Aktas
- Department of Histology, Namik Kemal University, School of Medicine, Tekirdag, Turkey
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Ram-Liebig G, Barbagli G, Heidenreich A, Fahlenkamp D, Romano G, Rebmann U, Standhaft D, van Ahlen H, Schakaki S, Balsmeyer U, Spiegler M, Knispel H. Results of Use of Tissue-Engineered Autologous Oral Mucosa Graft for Urethral Reconstruction: A Multicenter, Prospective, Observational Trial. EBioMedicine 2017; 23:185-192. [PMID: 28827035 PMCID: PMC5605371 DOI: 10.1016/j.ebiom.2017.08.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 07/30/2017] [Accepted: 08/15/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Harvest of oral mucosa for urethroplasty due to urethral stricture is associated with donor-site-morbidity. We assessed functionality and safety of an authorized tissue-engineered oral mucosa graft (TEOMG) under routine practice in stricture recurrences of any etiology, location, length and severity (real-world data). METHODS 99 patients from eight centers with heterogenous urethroplasty experience levels were included in this prospective, non-interventional observational study. Primary and secondary outcomes were success rate (SR) and safety at 12 and 24months. FINDINGS All but one patient had ≥1, 77.1% (64 of 83)≥2 and 31.3% (26 of 83)≥4 previous surgical treatments. Pre- and postoperative mean±SD peak flow rate (Qmax) were 8.3±4.7mL/s (n=57) and 25.4±14.7mL/s (n=51). SR was 67.3% (95% CI 57.6-77.0) at 12 and 58.2% (95% CI 47.7-68.7) at 24months (conservative Kaplan Meier assessment). SR ranged between 85.7% and 0% in case of high and low surgical experience. Simple proportions of 12-month and 24-month SR for evaluable patients in all centers were 70.8% (46 of 65) and 76.9% (30 of 39). Except for one patient, no oral adverse event was reported. INTERPRETATIONS TEOMG is safe and efficient in urethroplasty.
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Affiliation(s)
| | - Guido Barbagli
- Centro Chirurgico Toscana, Via dei Lecci, 22, 52100 Arezzo, Italy
| | - Axel Heidenreich
- University Clinic and Policlinic for Urology, Kerpener Str. 62, 50937 Cologne, Germany
| | - Dirk Fahlenkamp
- Zeisigwald Clinics Bethanien, Department of Urology, Zeisigwaldstrasse 101, 09130 Chemnitz, Germany
| | - Giuseppe Romano
- Urology Unit, Ospedale del Valdarno, Santa Maria alla Gruccia, Piazza del Volontariato, 1, 52025 Montevarchi-Arezzo, Italy
| | - Udo Rebmann
- Diakonissen Clinics Dessau, Department of Urology, Gropiusallee 3, 06846 Dessau-Roßlau, Germany
| | - Diana Standhaft
- Diakonissen Clinics Dessau, Department of Urology, Gropiusallee 3, 06846 Dessau-Roßlau, Germany
| | - Hermann van Ahlen
- Osnabrueck Clinic, Department of Urology, Am Finkenhügel 1, 49076 Osnabrück, Germany
| | - Samer Schakaki
- Osnabrueck Clinic, Department of Urology, Am Finkenhügel 1, 49076 Osnabrück, Germany
| | - Ulf Balsmeyer
- Zeisigwald Clinics Bethanien, Department of Urology, Zeisigwaldstrasse 101, 09130 Chemnitz, Germany
| | - Maria Spiegler
- St. Hedwig Hospital, Department of Urology, Große Hamburger Strasse 5-11, 10115 Berlin, Germany
| | - Helmut Knispel
- St. Hedwig Hospital, Department of Urology, Große Hamburger Strasse 5-11, 10115 Berlin, Germany
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Xu N, Chen SH, Qu GY, Li XD, Lin W, Xue XY, Lin YZ, Zheng QS, Wei Y. Fasudil inhibits proliferation and collagen synthesis and induces apoptosis of human fibroblasts derived from urethral scar via the Rho/ROCK signaling pathway. Am J Transl Res 2017; 9:1317-1325. [PMID: 28386357 PMCID: PMC5376022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 01/30/2017] [Indexed: 06/07/2023]
Abstract
Fasudil has shown antifibrotic effects in various fibrotic diseases. However, its effects on human urethral fibroblasts are unknown. This study evaluated the effects of fasudil on cellular proliferation, migration, apoptosis, and collagen synthesis in human fibroblasts derived from urethral scar tissues. Human urethral scar fibroblasts were cultured by explant and incubated for 24 h or 48 h with fasudil (12.5, 25, 50 µmol/L) with or without transforming growth factor β1 (TGF-β1, 10 ng/mL), or left untreated (control). Cell proliferation and migration was determined by MTT assay and Transwell chambers, respectively. Apoptosis was measured by flow cytometry. Levels of α-smooth muscle actin (α-SMA), myosin light-chain phosphatase (MLCP), LIM domain kinase 1 (LIMK1), phospho-cofilin (p-cofilin), collagen I, and collagen III were determined by Western blot. Compared with the control group, TGF-β1 was associated with a significant increase in urethral fibroblast proliferation and migration, and α-SMA, MLCP, LIMK1, p-cofilin, collagen I, and collagen III levels. Compared with the control group, fasudil (with or without TGF-β1), significantly and negatively correlated, in a dose-dependent manner, with the proliferation and migration of urethral fibroblasts, as well as α-SMA, MLCP, LIMK1, p-cofilin, collagen I, and collagen III levels. Moreover, fasudil significantly induced apoptosis of fibroblasts induced by TGF-β1. Higher concentrations of fasudil (50 μmol/L) were associated with greater cell apoptosis without TGF-β1 stimulation compared with the normal control group. Fasudil, with or without TGF-β1 stimulation, may inhibit human urethral fibroblasts proliferation, migration, apoptosis, and collagen synthesis via the Rho/ROCK signaling pathway.
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Affiliation(s)
- Ning Xu
- Department of Urology, First Affiliated Hospital of Fujian Medical UniversityFuzhou, China
| | - Shao-Hao Chen
- Department of Urology, First Affiliated Hospital of Fujian Medical UniversityFuzhou, China
| | - Gen-Yi Qu
- Department of Urology, First Affiliated Hospital of Fujian Medical UniversityFuzhou, China
| | - Xiao-Dong Li
- Department of Urology, First Affiliated Hospital of Fujian Medical UniversityFuzhou, China
| | - Wen Lin
- Department of Urology, Chinese PLA 476 HospitalFuzhou, China
| | - Xue-Yi Xue
- Department of Urology, First Affiliated Hospital of Fujian Medical UniversityFuzhou, China
| | - Yun-Zhi Lin
- Department of Urology, First Affiliated Hospital of Fujian Medical UniversityFuzhou, China
| | - Qing-Shui Zheng
- Department of Urology, First Affiliated Hospital of Fujian Medical UniversityFuzhou, China
| | - Yong Wei
- Department of Urology, First Affiliated Hospital of Fujian Medical UniversityFuzhou, China
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Zhou SK, Zhang J, Sa YL, Jin SB, Xu YM, Fu Q, Lazzeri M. Etiology and Management of Male Iatrogenic Urethral Stricture: Retrospective Analysis of 172 Cases in a Single Medical Center. Urol Int 2016; 97:386-391. [PMID: 27296973 DOI: 10.1159/000444592] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 02/08/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE To investigate the etiology and management of male iatrogenic urethral stricture in China. METHODS The data of 172 patients with iatrogenic urethral stricture who underwent treatment at a high volume reference center in China from January 2008 to February 2014 were analyzed retrospectively. Databases were analyzed to understand the impact of different types of iatrogenic injury on stricture location, length and treatment of urethral strictures, as well as success rates. RESULTS The most common type of iatrogenic stricture was urethral instrumentations in 80 patients (46.51%). Mean stricture length was 3.3 ± 2.54 cm and the longest strictures were those caused by intravesical instillation. Substitution urethroplasty was the most common intervention and was performed in 60.47% (104/172) of patients. The overall success rate was 85.00% (136/160). Univariable analyses revealed that the type of iatrogenic injury was significantly related to restenosis (p = 0.036), and it is more apt to postoperative restenosis in the type of intravesical instillation than others. CONCLUSION Our results showed that urethral instrumentation is the most common etiology of iatrogenic urethral stricture, and most iatrogenic urethral strictures involve the anterior urethra. The different etiologies are closely associated with stricture location, length and the overall prognosis of urethral strictures.
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Affiliation(s)
- Shu-Kui Zhou
- Department of Urology, Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Mathur R, Patil LA, Khan F. Evaluating efficacy of various operative procedures done in anterior urethral stricture using urethral stricture score. Urol Ann 2016; 8:42-5. [PMID: 26834400 PMCID: PMC4719510 DOI: 10.4103/0974-7796.162213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Context: Scoring systems have been an important tool of clinical decision making in medicine. As scoring systems like Glasgow Coma scale have made a revolutionary change in stratifying the patient, in particular, clinical scenario. Wiegand et al. in 2012 proposed UREThRAL Score a novel method to quantify anterior urethral stricture. Aims: The aim was to validate urethral stricture score (USS) for evaluating the efficacy of operative procedures. Settings and Design: Study was done in a retrospective manner and includes patients operated for anterior urethral stricture by a single surgeon in tertiary care center over the period of 2008–2014. Subjects and Methods: A total of 57 cases were included in this study who met the inclusion criteria, of these cases 7 underwent excision and primary anastomosis (EPA), 20 underwent preputial flap urethroplasty (PFUP), 22 underwent tunica albuginea urethroplasty (TAU), and rest 8 underwent scrotal flap urethroplasty (SFUP). Procedures were assigned different complexity level, and USS was compared with the particular procedure to see the relation between both. Statistical Analysis Used: Data were analyzed using ANOVA on SPSS software. Results: Mean USS for EPA, PFUP, TAU, and SFUP in our study group was found to be 6.57, 8.95, 9.00, and 10.00, respectively, with an overall USS of 9.03, with a standard deviation of 1.56. USS was significantly associated with complexity. Conclusions: Mean USS increased with increase in surgical complexity indicating that higher USS correlates with more complex surgery. Strongest association between complexity and the individual parameter was found with location and length.
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Affiliation(s)
- Rajkumar Mathur
- Department of Surgery, MGM Medical College and MY Group of Hospitals, Indore, Madhya Pradesh, India
| | - Lukesh A Patil
- Department of Surgery, MGM Medical College and MY Group of Hospitals, Indore, Madhya Pradesh, India
| | - Fareed Khan
- Department of Surgery, MGM Medical College and MY Group of Hospitals, Indore, Madhya Pradesh, India
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Application of Wnt Pathway Inhibitor Delivering Scaffold for Inhibiting Fibrosis in Urethra Strictures: In Vitro and in Vivo Study. Int J Mol Sci 2015; 16:27659-76. [PMID: 26610467 PMCID: PMC4661908 DOI: 10.3390/ijms161126050] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 11/04/2015] [Accepted: 11/06/2015] [Indexed: 01/06/2023] Open
Abstract
Objective: To evaluate the mechanical property and biocompatibility of the Wnt pathway inhibitor (ICG-001) delivering collagen/poly(l-lactide-co-caprolactone) (P(LLA-CL)) scaffold for urethroplasty, and also the feasibility of inhibiting the extracellular matrix (ECM) expression in vitro and in vivo. Methods: ICG-001 (1 mg (2 mM)) was loaded into a (P(LLA-CL)) scaffold with the co-axial electrospinning technique. The characteristics of the mechanical property and drug release fashion of scaffolds were tested with a mechanical testing machine (Instron) and high-performance liquid chromatography (HPLC). Rabbit bladder epithelial cells and the dermal fibroblasts were isolated by enzymatic digestion method. (3-(4,5-Dimethylthiazol-2-yl)-2,5-Diphenyltetrazolium Bromide (MTT) assay) and scanning electron microscopy (SEM) were used to evaluate the viability and proliferation of the cells on the scaffolds. Fibrolasts treated with TGF-β1 and ICG-001 released medium from scaffolds were used to evaluate the anti-fibrosis effect through immunofluorescence, real time PCR and western blot. Urethrography and histology were used to evaluate the efficacy of urethral implantation. Results: The scaffold delivering ICG-001 was fabricated, the fiber diameter and mechanical strength of scaffolds with inhibitor were comparable with the non-drug scaffold. The SEM and MTT assay showed no toxic effect of ICG-001 to the proliferation of epithelial cells on the collagen/P(LLA-CL) scaffold with ICG-001. After treatment with culture medium released from the drug-delivering scaffold, the expression of Collagen type 1, 3 and fibronectin of fibroblasts could be inhibited significantly at the mRNA and protein levels. In the results of urethrography, urethral strictures and fistulas were found in the rabbits treated with non-ICG-001 delivering scaffolds, but all the rabbits treated with ICG-001-delivering scaffolds showed wide caliber in urethras. Histology results showed less collagen but more smooth muscle and thicker epithelium in urethras repaired with ICG-001 delivering scaffolds. Conclusion: After loading with the Wnt signal pathway inhibitor ICG-001, the Collagen/P(LLA-CL) scaffold could facilitate a decrease in the ECM deposition of fibroblasts. The ICG-001 delivering Collagen/P(LLA-CL) nanofibrous scaffold seeded with epithelial cells has the potential to be a promising substitute material for urethroplasty. Longer follow-up study in larger animals is needed in the future.
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A simple technique to facilitate treatment of urethral strictures with optical internal urethrotomy. Case Rep Urol 2014; 2014:137605. [PMID: 25405054 PMCID: PMC4227455 DOI: 10.1155/2014/137605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 10/04/2014] [Indexed: 11/30/2022] Open
Abstract
Urethral stricture is a common condition that can lead to serious complications such as urinary infections and renal insufficiency secondary to urinary retention. Treatment options include catheterization, urethroplasty, endoscopic internal urethrotomy, and dilation. Optical internal urethrotomy offers faster recovery, minimal scarring, and less risk of infection, although recurrence is possible. However, technical difficulties associated with poor visualization of the stenosis or of the urethral lumen may increase procedural time and substantially increase the failure rates of internal urethrotomy. In this report we describe a technique for urethral catheterization via a suprapubic, percutaneous approach through the urinary bladder in order to facilitate endoscopic internal urethrotomy.
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