Management of Urethral Stent Failure for Recurrent Anterior Urethral Strictures

Background: Urethral stent placement for recurrent anterior urethral strictures may cause restenosis and complications. Objective: To describe our experience with patients who had restenoses and complications following urethral stent placement for the treatment of recurrent anterior urethral strictures. Design, setting, and participants: We evaluated retrospectively the records of 13 men with anterior urethral stricture who experienced restenosis and complications after stent insertion. We recorded stent position, prestent and poststent urethral procedures, restenosis location, stent-related complications, and management of stent failures. Surgical procedure: The stent was removed en bloc with the whole strictured urethral segment or wire by wire after a ventral or a double-ventral plus dorsal-sagittal urethrotomy and stent section. Measurements: Successful outcome was defined as standard voiding, without need of any postoperative procedure, and full recovery from complications. Results and limitations: Four patients did not undergo surgery and the stent was left in situ. Of these patients, two required permanent suprapubic cystostomy. Nine patients underwent challenging surgical stent removal and salvage urethrostomy: After the first stage, three patients are waiting for further reconstructive steps, five elected the urethrostomy as a permanent diversion, and one completed the staged reconstruction using a buccal mucosa graft at the second stage. After surgery, seven of the nine patients (77.8%) were free of strictures and stent-related complications, while a restenosis occurred in two of the nine (22.2%) cases. Conclusions: The management of urethral stent failure represents a therapeutic challenge. The stent risks converting a simple stenosis into a complex stenosis requiring a staged urethroplasty, a definitive urethrostomy, or a permanent suprapubic diversion. (c) 2009 European Association of Urology. Published by Elsevier B. V. All rights reserved

Contemporary Urethral Stricture Characteristics in the Developed World

To assess the current etiology, features, and natural history of urethral stricture disease in the developed world

Two-Sided Bulbar Urethroplasty Using Dorsal Plus Ventral Oral Graft: Urinary and Sexual Outcomes of a New Technique

Purpose: Repair of bulbar strictures using anastomotic techniques may cause sexual complications, while 1-side graft urethroplasties may not be sufficient to provide an adequate lumen in narrow strictures. We evaluated the urinary and sexual results of a 2-sided dorsal plus ventral graft urethroplasty by preserving the narrow urethral plate in tight strictures. Materials and Methods: Between 2002 and 2010, 105 men with bulbar strictures underwent dorsal plus ventral graft urethroplasty. The results are reported in a homogeneous group of 73 of 105 cases in which buccal mucosa was used as a graft with findings after 1 year or more of followup. The urethra was opened ventrally, and the exposed dorsal urethra was incised in the midline to create a raw area over the tunica albuginea where the first graft was placed dorsal-inlay. Thereafter the urethra was augmented by the ventral-onlay second graft and the spongiosum was closed over itself. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Postoperative sexual dysfunction was investigated using a validated questionnaire. Results: Mean followup was 48.9 months and mean stricture length was 3.3 cm. Of these 73 cases 64 (88%) were successful and 9 (12%) were treatment failures with re-stricture. Furthermore, of 49 of 73 cases who were preoperatively sexually active, none reported postoperative erectile impairment and all were satisfied with their sexual life. Conclusions: In cases of tight bulbar stricture the dorsal plus ventral buccal mucosa graft provides adequate urethral augmentation by preserving the urethral plate and avoiding postoperative sexual complications

Sexual dysfunctions after anterior urethroplasty

Established beliefs concerning outcomes following anterior urethral reconstruction are changing, both with regards to the genital cosmetics and to the impact on the sexual activity. To-day, the aim of the stricture repair is not only to reinstate urinary function but also to safeguard sexual activity and guarantee genital cosmesis. A thorough evaluation of anterior urethroplasty results should include the sexual viewpoint which appears to play an important role in overall post-operative patient satisfaction. The most commonly reported sexual problems following anterior urethroplasty include: erectile and ejaculatory dysfunction, penile curvature or shortening, dissatisfaction with genital cosmetic appearance, sensorial impairments of glans. The prevalence of specific postoperative sexual problems may be related to the site of reconstruction (penile or bulbar) and to the technique of urethroplasty employed. In penile urethral reconstruction, the wide use of buccal mucosa grafts seems to excel the use of skin flaps which easily distort the cosmesis and elasticity of the penis. In bulbar reconstructions, graft augmentation techniques seem to impact less on sexual outcome than excision anastomotic techniques. Therefore, the policy of primarily indicating an excision anastomotic procedure, whenever possible, should come under scrutiny. Eventual sexual outcomes should be incorporated in the choice of the optimal anterior urethral reconstruction and in preoperative patient counselling

Two-sided dorsal plus ventral oral graft bulbar urethroplasty: long-term results and predictive factors

OBJECTIVE: To evaluate long-term outcomes of the 2-sided dorsal plus ventral oral graft (DVOG) urethroplasty by preserving the narrow urethral plate in tight bulbar strictures and investigate which factors might influence long-term outcomes. METHODS: This is a single-center retrospective study of 166 patients who underwent DVOG urethroplasty for tight bulbar strictures by a single surgeon (E.P.) between 2002 and 2013. The strictured urethra was opened ventrally; the exposed urethral plate was incised in the midline and augmented dorsally and ventrally using 2 oral grafts. Outcome was considered a failure when any postoperative instrumentation was needed. According to stricture length, patients were classified in 3 groups as follows: ≤1.5 cm (group 1), >1.5 and ≤3.9 cm (group 2), and ≥4 cm (group 3). Time to failure was analyzed using Kaplan-Meier estimates and Cox regression. RESULTS: Median follow-up was 47 months (interquartile range, 33-95.5 months). Of the 166 patients, 149 (89.8%) were successful and 17 (10.2%) were failures. Most of the failures (90%) were observed during the first 5 years of follow-up; afterward, the success rate remained stable. The stricture length was a significant predictor of surgical outcome (odds ratio, 1.743 per cm; confidence interval, 1.2-2.5; P <.001); patients with a urethral stricture ≥4 cm presented a higher risk of late failure. Age, stricture etiology, and previous treatment were not significant predictors of surgical outcome. CONCLUSION: With long-term follow-up, the treatment of tight bulbar strictures using a 2-sided DVOG urethroplasty showed a high success rate. The stricture length is an independent predictor of failur