Challenging non-traumatic posterior urethral strictures treated with urethroplasty : a preliminary report

Introduction: Posterior urethral strictures after prostatic radiotherapy or surgery for benign prostatic hyperplasia (BPH) refractory to minimal invasive procedures (dilation and/or endoscopic urethrotomy) are challenging to treat. Published reports of alternative curative management are extremely rare. This is a preliminary report on the treatment of these difficult strictures by urethroplasty. Materials and Methods: Seven cases were treated: 4 cases occurred after open prostatectomy or transurethral resection of the prostate for BPH, one case after external beam irradiation and 2 after brachytherapy. The 4 cases after BPH-related surgery were in fact complete obstructions at the bladder neck and the membranous urethra with the prostatic urethra still partially patent. Anastomotic repair by perineal route was done in all cases with bladder neck incision in the BPH-cases and prostatic apex resection in the radiotherapy cases. Results: Mean follow-up was 31 months (range: 12-72 months). The operation was successful, with preserved continence, in 3 of the 4 BPH-cases and in 2 of the 3 radiotherapy cases. An endoscopic incision was able to treat a short re-stricture in the BPH-patient and a longer stricture at the bulbar urethra could be managed with a perineostomy in the radiotherapy-patient. Conclusion: Posterior non-traumatic strictures refractory to minimal invasive procedures (dilation/endoscopic urethrotomy) can be treated by urethroplasty using an anastomotic repair with a bladder neck incision if necessary

Pelvic lymph node dissection in prostate cancer staging : evaluation of morbidity and oncological outcomes

Background: To evaluate the morbidity of different surgical approaches for pelvic lymph node dissection (PLND), to evaluate the influence of morbidity on radiotherapy (RT) planning and to evaluate a possible therapeutic effect of a more extensive yield of PLND. Methods: From 2000-2016, 228 patients received staging PLND before primary RT in a single tertiary care center. Nine patients were excluded for the evaluation of morbidity. Fifty patients were operated in an open approach, 96 laparoscopic and 73 robot-assisted (RA). Clavien-Dindo classification was used for evaluating complications. Predictors of biochemical recurrence (BCR), clinical relapse (CR), cancer-specific survival (CSS) and overall survival (OS) were evaluated by regression analyses to determine a possible therapeutic effect. Results: Minimal invasive surgery (laparoscopic or RA) caused five times less major complications (22% vs. 4.3%, p = .001) and a median 3 days shorter hospital stay (5 days versus 2 days, p < .001). Major complications resulted in a delayed (23 days, p < .001) RT start but no oncological effect was seen. Independent oncological predictors were the number of positive nodes (BCR, CR, CSS, OS), a lower age (CR), a higher level of initial prostate-specific antigen (PSA) (BCR) and post-RT PSA (BCR). Conclusion: Minimal invasive surgery can diminish major complications which delay RT start. Nodal staging proved to be of importance for prognosis but no therapeutic effect was seen of performing PLND as such

Revision of perineal urethrostomy using a meshed split-thickness skin graft

Perineal urethrostomy is considered to be the last option to restore voiding in complex/recurrent urethral stricture disease. It is also a necessary procedure after penectomy or urethrectomy. Stenosis of the perineal urethrostomy has been reported in up to 30% of cases. There is no consensus on how to treat a stenotic perineal urethrostomy, but, in general, a form of urinary diversion is offered to the patient. We present the case of a young male who underwent perineal urethrostomy after urethrectomy for urethral cancer. The postoperative period was complicated by wound dehiscence with subsequent complete obliteration of the perineal urethrostomy. Revision surgery was performed with reopening of the obliterated urethral stump and coverage of the skin defect between the urethra and the perineal/scrotal skin with a meshed split-thickness skin graft. To date, this patient is voiding well and satisfied with the offered solution

Vessel-sparing excision and primary anastomosis

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short bulbar or posterior urethral strictures, urethroplasty by excision and primary anastomosis (EPA) is recommended. As EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full-thickness transection of the corpus spongiosum, as performed in the traditional transecting EPA (tEPA), is usually unnecessary. Jordan et al. introduced the idea of a vessel-sparing approach in 2007, aiming to reduce surgical trauma, especially to the dual arterial blood supply of the urethra, and, thus, potentially reducing the risk of postoperative erectile dysfunction or glans ischemia. This approach could also be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking. Moreover, vessel-sparing EPA (vsEPA) should at least be able to provide similar surgical outcomes as tEPA. The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main objective of this manuscript is to outline the surgical technique and to report the representative surgical outcome. A total of 117 patients were managed according to the described protocol. The analysis was performed on the entire patient cohort and on the bulbar (n = 91) and posterior (n = 26) vsEPA group separately. Success rates were 93.4% and 88.5% for the bulbar and posterior vsEPA, respectively. To conclude, vsEPA, as outlined in the protocol, provides excellent success rates with low complication rates for isolated short bulbar and posterior urethral strictures