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Objectives: To evaluate and compare the 2 surgical approaches of urethral reconstruction for management of refractory female urethral strictures (FUS) in a prospective randomized setting. Early surgical reconstruction is becoming the preferred management strategy for recurrent FUS. Reconstructive techniques have been described as using either dorsal (12-o'clock) or ventral approach (6-o'clock), each with their own advantages. To our best knowledge, a direct comparison between the 2 techniques to prospectively compare outcomes hasn't been made., Methods: We performed a prospective randomized study in a single tertiary care center on a total of 24 patients, randomizing them into 2 groups of 12 patients each. One group underwent dorsal onlay and other underwent ventral onlay urethroplasty. Preoperative, intraoperative and postoperative outcomes were evaluated and compared for the 2 approaches., Results: There was high success rate (91%) with significant but comparable improvements in flow rates, post void residue and symptomatic outcomes without any major complication. There was 1 recurrence of stricture each in both groups. Important technical differences were noted with easier meatus preservation, lesser bleeding and wider operative field in the ventral approach, while the dorsal approach proving better in distal urethral strictures requiring meatal reconstruction., Conclusion: Both approaches of urethroplasty present a very promising modality of management of FUS with comparable outcomes but with important technical differences which must be considered to best tailor the approach for each patient., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: An ill-defined proportion of patients undergoing urethroplasty fail to experience improvement in lower urinary tract symptoms (LUTS) despite being stricture-free. We aim to identify the incidence, associations and causes of "LUTS failure" after urethroplasty., Materials and Methods: Patients undergoing urethroplasty over a 6-year period were offered enrollment in a prospective study examining urinary function after urethroplasty. Patients were assessed preoperatively and 6 months postoperatively using the International Prostate Symptom Score (IPSS) and cystoscopy. "LUTS failure" was defined as ≤3-point improvement in IPSS despite an anatomically successful urethroplasty. Multivariable logistic regression was utilized to evaluate the association between patient factors and "LUTS failure.", Results: Of 365 patients meeting inclusion criteria, mean postoperative IPSS (20.3 vs. 5.4, p <0.0001) and median urinary quality of life (UQOL; 5 vs. 1; p <0.0001) were significantly improved. Despite being stricture-free, 7.7% of patients reported "LUTS failure" and 10.1% reported UQOL nonresponse. On multivariable logistic regression, increasing age (OR 1.04, 95% CI 1.01-1.06; p=0.006) and hypospadias (OR 18.2, 95% CI 2.1-156.0; p=0.008) were associated with "LUTS failure," while stricture location (p=0.76), length (p=0.14), previous urethroplasty (p=0.96), failed endoscopic treatment (p=0.17), type of urethroplasty (p=0.93) and other etiologies were not. Qualitatively, the most likely causes of "LUTS failure" were detrusor underactivity (39.3%), overactivity (21.4%), pelvic floor dysfunction (21.4%) or benign prostatic hyperplasia (14.3%). Only increasing age was associated with UQOL nonresponse (OR 1.03, 95% CI 1.01-1.07; p=0.02)., Conclusions: While many patients experience improved voiding function after urethroplasty, 7.7% experience "LUTS failure" and 10.1% report UQOL nonresponse. Both occurrences are independently associated with increasing patient age and most commonly related to detrusor underactivity.

Objectives: To investigate the risk factors for postoperative infection, including systemic inflammatory response syndrome, sepsis and surgical site infection, after posterior urethral anastomosis for the treatment of male posterior urethral stenosis with pelvic fractures., Methods: We retrospectively analyzed data from patients who underwent transperineal end-to-end anastomotic urethroplasty between January 2016 and December 2018. Descriptive statistics were used to analyze patient characteristics and perioperative features. Univariate analysis was performed to identify prognostic factors associated with postoperative infection. Multivariate analysis was used to identify independent risk factors for postoperative infection., Results: Among 261 patients included in the analysis, 16.48% had SIRS, 3.83% had sepsis, and 8.05% had SSI. The primary results suggested that penile septum separation, inferior pubic resection, operating duration, preoperative urine culture result, preoperative waiting time, urethral stenosis length, and draining method were significant predictors of postoperative infections. Multivariate analysis revealed that more complex surgical procedures, operating duration and positive urine culture results were independent risk factors for SIRS and preoperative positive urine culture result was an independent risk factor for sepsis and SSI., Conclusions: Positive preoperative urine culture was the main risk factor for postoperative infections. More complex surgical procedures, such as penile septum separation and inferior pubic resection, and longer operating duration were more likely to be associated with postoperative SIRS., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To better define patient-reported outcomes after urethroplasty. While urethroplasty is the most effective treatment for urethral stricture, the majority of outcomes are reported using surgeon-defined endpoints., Methods: Patients were enrolled in a prospective study evaluating patient-reported outcomes after urethroplasty from 2012 to 2018. A number of domains were assessed preoperatively and 6 months postoperatively using both validated and nonvalidated measures including satisfaction, voiding function, urinary quality of life, erectile/ejaculatory function, penile appearance/curvature, and genitourinary pain., Results: Of 357 patients completing the study, mean age was 49.7 years with mean stricture length of 4.4 cm. Total 95.9% of patients were stricture-free on 6-month cystoscopy. Eighty percent of patients reported being satisfied with surgery, while 7.3% of patients were unsatisfied. Voiding function was globally improved after urethroplasty including International Prostate Symptom Score (19.3 vs 6.0; P < .0001), urinary quality of life (4.7 vs 1.6; P < .0001), postvoid dribbling (2.7 vs 2.5; P = .04), and sitting to void (2.4 vs 1.9; P < .0001). Additionally, genitourinary pain improved postoperatively (2.2 vs 1.6; P < .0001). Mean erectile function remained unchanged (17.7 vs 17.2; P = .46) but 12.0% of patients reported new onset erectile dysfunction. Reported ejaculatory dysfunction did not change significantly postoperatively (P = .13) but 7.1% of patients reported new ejaculatory dysfunction. Total 6.7% and 3.1% of patients complained of bothersome loss of penile length or curvature, respectively., Conclusion: Urethroplasty improves voiding function and genitourinary pain associated with urethral stricture. While sexual function is preserved for the majority of patients, a small proportion of patients describe new onset erectile dysfunction, penile shortening or curvature and should be counselled accordingly., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Anterior urethral anomalies (AUA) which present as anterior urethral valve, stenosis or atresia, are a rare cause for congenital urinary tract obstruction. We present our AUA prenatal diagnosis case series., Methods: Fetuses presenting with prenatal findings suggestive for AUA according to postnatal reported clinical and imaging signs (urinary tract dilatation, dilated bladder, enlarged edematous fetal penis, dilatation of the fetal urethra and diverticula) were followed prospectively., Results: Six fetuses were diagnosed with AUA. Diagnosis was confirmed upon examination of the neonate or the abortus. All cases presented with variable degrees of urinary tract dilatation. Four fetuses who presented with additional congenital anomalies of the kidneys and urinary tract (CAKUT) developed intra-uterine or early postnatal renal failure, while two isolated AUA cases have a normal renal outcome., Conclusions: AUA is a rare diagnosis. However, high index of suspicion and careful sonographic assessment of the male fetal urethra in cases referred for urinary tract dilatation may enable appropriate parent counseling, optimal prenatal surveillance and timed postnatal urological intervention. As in other lower urinary tract obstructions, future renal function seems to correlate with associated CAKUT, therefore close follow up throughout pregnancy and meticulous sonographic assessment is recommended., (© 2019 John Wiley & Sons, Ltd.)

Background and Objectives: Posterior urethral valve is the most common cause of bladder outlet obstruction in infants. We aimed to describe the rate and timing of kidney-related and survival outcomes for children diagnosed with posterior urethral valves in United States children's hospitals using the Pediatric Health Information System database., Design, Setting, Participants, & Measurements: This retrospective cohort study included children hospitalized between January 1, 1992 and December 31, 2006, who were in their first year of life, had a diagnosis of congenital urethral stenosis, and underwent endoscopic valve ablation or urinary drainage intervention, or died. Records were searched up to December 31, 2018 for kidney-related mortality, placement of a dialysis catheter, and kidney transplantation. Cox regression analysis was used to identify risk factors, and Kaplan-Meier survival analysis used to determine time-to-event probability. Subgroup survival analysis was performed with outcomes stratified by the strongest identified risk factor., Results: Included were 685 children hospitalized at a median age of 7 (interquartile range, 1-37) days. Thirty four children (5%) died, over half during their initial hospitalization. Pulmonary hypoplasia was the strongest risk factor for death (hazard ratio, 7.5; 95% confidence interval [95% CI], 3.3 to 17.0). Ten-year survival probability was 94%. Fifty-nine children (9%) underwent one or more dialysis catheter placements. Children with kidney dysplasia had over four-fold risk of dialysis catheter placement (hazard ratio, 4.6; 95% CI, 2.6 to 8.1). Thirty-six (7%) children underwent kidney transplant at a median age of 3 (interquartile range, 2-8) years. Kidney dysplasia had a nine-fold higher risk of kidney transplant (hazard ratio, 9.5; 95% CI, 4.1 to 22.2)., Conclusions: Patients in this multicenter cohort with posterior urethral valves had a 5% risk of death, and were most likely to die during their initial hospitalization. Risk of death was higher with a diagnosis of pulmonary hypoplasia. Kidney dysplasia was associated with a higher risk of need for dialysis/transplant., Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019&#95;10&#95;03&#95;CJN04350419.mp3., (Copyright © 2019 by the American Society of Nephrology.)

Purpose: We sought to characterize a standardized postoperative radiographic and functional voiding trial, and determine its impact on outcomes after substitution urethroplasty., Materials and Methods: This is an observational, monocenter study of men who underwent 1-stage ventral onlay buccal mucosal graft urethroplasty for bulbar urethral stricture between January 2009 and December 2016. Patients were stratified by voiding trial success vs failure, including radiographic (extravasation or residual narrowness) and functional (post-void residual volume greater than 100 ml) failure, 21 days postoperatively. End points were voiding trial failure and recurrence-free survival. Regression models were created to determine risk factors of voiding trial failure and evaluate the impact of voiding trial failure on recurrence., Results: The voiding trial succeeded and failed in 437 (85.2%) and 76 (14.8%), respectively, of 513 men. Of the latter men 54 (71.1%) showed evidence of extravasation and 22 (28.9%) had residual narrowness or functional failure. On multivariable logistic regression analyses no preoperative predictor of voiding trial failure was found (all p >0.05). At a median followup of 32 months Kaplan-Meier analyses (log rank test p = 0.033) and multivariable Cox regression analyses (HR 1.86, p = 0.037) revealed an association of voiding trial failure and stricture recurrence. When further stratifying voiding trial failure, residual narrowness or functional failure (HR 4.60, p <0.001) but not extravasation (HR 1.08, p = 0.9) was a risk factor for recurrence. Limitations include the retrospective assessment of investigated end points., Conclusions: Residual narrowness or functional failure at an early voiding trial after buccal mucosal graft urethroplasty may predict stricture recurrence. Identifying intraoperative complexity factors predicting initial voiding trial failure might be a key to identifying those individuals with early recurrence.

Purpose: The purpose of this multi-institutional study was to compare outcomes of transecting and nontransecting anastomotic bulbar urethroplasty., Materials and Methods: We performed a retrospective, multi-institutional review of the records of 352 patients who underwent transecting or nontransecting anastomotic bulbar urethroplasty performed by 1 of 4 reconstructive urologists from September 2003 to March 2017. Study outcomes were urethroplasty success, defined as urethral patency greater than 16Fr on cystoscopy; de novo sexual dysfunction assessed at 6 months, defined as a 5-point or greater change in the SHIM (Sexual Health Inventory for Men) or a patient reported adverse change; and 90-day complications, defined as Clavien 2 or greater. When appropriate, comparisons were made between the transecting and nontransecting cohorts using the Mantel-Cox test, the t-test or the chi-square test., Results: Of the 352 patients with a mean stricture length of 1.7 cm (range 0.5 to 5) 258 and 94 underwent transecting and nontransecting anastomotic bulbar urethroplasty, respectively. The overall success rate was 94.9% at a mean followup of 64.2 months (range 6 to 170). Of the patients 7.1% experienced a 90-day complication and 11.6% reported sexual dysfunction. When comparing transecting and nontransecting techniques, there was no difference in success (93.8% vs 97.9%, Mantel-Cox test p = 0.18) or postoperative complications (8.1% vs 4.3%, p = 0.25). Patients treated with transecting anastomotic urethroplasty were more likely to report an adverse change in sexual function (14.3% vs 4.3%, p = 0.008). On multivariate analysis only transecting urethroplasty was associated with sexual dysfunction (p = 0.01) while age (p = 0.29), stricture length (p = 0.42), etiology (p = 0.99) and surgeon (p = 0.88) were not., Conclusions: Anastomotic urethroplasty is a highly effective surgery with relatively minimal associated morbidity. Nontransecting anastomotic urethroplasty compares quite favorably to the transecting technique and likely reduces the risk of associated sexual dysfunction.

Objective: To understand the prevalence of chronic perineal pain, activity limitations, and patient satisfaction after urethroplasty., Methods: From 2014 to 2016, we prospectively enrolled men undergoing urethroplasty for bulbar urethral strictures. Patients, before and after surgery, completed questions from the Core Lower Urinary Tract Symptom Score assessing pain frequency in the bladder and penis or urethra, as well as nonvalidated questions assessing perineal pain. Overall satisfaction with their current urinary condition and pain-related activity limitations at home, work, or during exercise were also measured. Patients with <3 months of follow-up were excluded. Pre-and postoperative scores were compared using the Wilcoxon signed-rank test., Results: Thirty-five men were included in the study. Mean age and body mass index were 44.6 years and 30.9 kg/m 2 , respectively. Urethroplasties were anastomotic in 24 (69%) and were single-stage buccal graft substitution in 11 (31%). Median follow-up after surgery was 483 days (range: 90-810 days). A total of 10 patients (29%) reported worsening perineal pain intensity after surgery, whereas 8 (23%) reported improvement and 17 (48%) reported no change. Overall, pain frequency in the bladder, penis or urethra, and perineum improved. Home and exercise pain-related activity restrictions improved significantly after surgery. Satisfaction with current urinary condition also improved with 91% reporting feeling "delighted," "pleased," or "mostly satisfied" with their current condition., Conclusion: Patients are highly satisfied with their urinary condition after urethroplasty. Pain frequency in the bladder and the urethra significantly improves after urethroplasty; however, perineal pain intensity can worsen and become chronic after surgery in some patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We investigated long-term functional changes in the kidney and bladder of patients with posterior urethral valve (PUV) who underwent fetal intervention or postnatal surgery.We retrospectively reviewed the medical records of 28 consecutive patients treated for PUV at our institution. Detailed data on medical and surgical histories, particularly on pre- and postnatal treatment modality, including fetal vesicoamniotic shunt, endoscopic valve ablation, and vesicostomy, were collected and analyzed. Long-term renal function was evaluated based on serum levels of creatinine (sCr), estimated glomerular filtration rate (eGFR), and renal scans. Voiding function was evaluated in urodynamic tests.Vesicoamniotic shunting was performed in 12 (42.8%) patients. Although the mean initial sCr was significantly higher in patients in whom a fetal shunt was placed than in others (2.04 vs 1.17 mg/L, P = .038), the sCr at long-term follow-up was not significantly different between them (0.64 vs 0.40 mg/L, P = .186). The mean maximum detrusor pressure was significantly lower in patients with a fetal shunt than in others (37.7 vs 73.0 cm H2O, P = .019). Postnatal vesicostomy was performed in 14 patients, and primary valve ablation was performed in 13 patients. The mean initial sCr was higher in patients in the vesicostomy group than in the primary valve ablation group (2.08 vs 0.86 mg/L, P = .014). However, no significant differences were found in sCr (0.9 vs 0.3 mg/L, P = .252) or GFR (59.1 vs 68.5 mL/min/1.73 m, P = .338) at long-term follow-up. Bladder capacity was greater and residual urine volume was less in the vesicostomy group than in the primary valve ablation group, but without statistical significance.Vesicostomy is more beneficial in the recovery of renal function and is not inferior in terms of bladder function, even in patients with severe PUV disorder. It is a reliable surgical option that can spare renal function and guarantee adequate bladder function in the long term.

Introduction: Testosterone plays an important role in the functioning of various organs and systems of the male body. Its diagnostic and prognostic values are studied both in urological diseases and in the patients undergoing non-urologic surgery., Aim: To investigate changes in testosterone level in patients with urethral strictures (US) depending on its baseline level, the cause of US, the age of patients and the number of surgeries., Materials and Methods: The study comprised 30 patients aged 19-63 years with traumatic (76.7%) and inflammatory (23.3%) US. Primary and recurrent US were diagnosed in 25 (83.3%) and 5 (16.7%) patients, respectively. Nineteen (63.3%) patients underwent excision and primary anastomosis, while replacement urethroplasty was performed in 11 (36.7%) patients. In addition to the standard diagnostic work-up, all patients were tested for total serum testosterone 24 hours prior to surgery and at 1, 3, 7, 14 days after the operation., Results: 33.3% of men with US had a testosterone deficiency in the absence of any testicular or endocrine injuries and diseases. Surgery was associated with a drop in testosteronemia in 83.3% of patients. The degree of postoperative testosterone level decline and its changes were significantly influenced by the age of patients and the number of operations. Men who had baseline testosterone deficiency and underwent repeat surgeries remained in a hypogonadal state throughout the postoperative period., Conclusion: Investigating the clinical value of testosterone in men with US and the risks of their surgical treatment associated with testosterone deficiency will provide insight into the role of testosterone in the treatment of this condition and the decision-making regarding pharmacological correction of testosterone deficiency in patients undergoing surgery for US.

Purpose of Review: Urethral strictures that are refractory to initial management present unique challenges to the reconstructive surgeon. Treatment trends have shifted as new tissue resources are becoming available. There is renewed interest in old methods as skill and technique have improved. We describe the scope of the surgical armamentarium available to develop creative approaches and successful outcomes., Recent Findings: We discuss techniques to maximize the availability of oral mucosa, harvest and use of rectal mucosa, and developments in tissue engineering. Evolving methods to assess success of repair are also described. Urethral reconstruction for refractory urethral strictures requires proficiency with multiple methods as these strictures often require combining techniques for successful treatment.

Purpose of Review: Male urethral stricture disease is characterized by the formation of scar tissue within the urethra resulting in lower urinary tract symptoms, infection, and potentially kidney dysfunction. There is significant variability in clinical practice for the treatment of urethral stricture. We sought to summarize the known data on endoscopic management of urethral stricture disease as part of this larger edition on urethral stricture management., Recent Findings: Older studies quoted high rates of success with endoscopic management of urethral stricture, including repeated DVIU. There is now evidence to support a limited role of endoscopic intervention in the management of urethral stricture, and especially strong evidence that repeated endoscopic procedures are not effective. There is poor evidence to support the long-term efficacy of endoscopic urethral stricture management. Furthermore, novel advances in adjunctive therapies have not yet demonstrated durable patency. We discuss the limited role of endoscopic management and suggest an algorithm for its use in stricture management.

Introduction: Although pelvic fracture urethral injuries (PFUIs) are rare, approximately half these patients will report erectile dysfunction (ED) after their injuries. The anatomic relations of the cavernosal nerves and arteries to the bones of the pelvis and the urethra put these structures at significant risk at the time of PFUI. This review examines the epidemiology, evaluation, and management of ED in this patient population., Aim: To evaluate the epidemiology, pathophysiology, diagnosis, and management of patients with ED after PFUI., Methods: A literature review was performed to identify articles on PubMed published before May 2017 addressing PFUI and ED., Main Outcome Measures: Incidence, mechanisms, risk factors, evaluation, and management strategies of ED after PFUI were analyzed., Results: Patients with pelvic fractures are at risk of post-injury ED, whereas those with PFUI appear to be at even higher risk. Different potential mechanisms contributing to the pathophysiology of ED in this setting have been described in the literature, including damage to the nervous supply to the penis, arterial insufficiency, and veno-occlusive dysfunction. However, there is a lack of consensus on the predominant etiology. Appropriate diagnostic evaluation can help to elucidate the underlying pathophysiology on an individual basis and can help guide management. Oral therapies, intracavernosal injections, and inflatable penile prostheses have shown great success. Furthermore, unlike patients with ED from other causes, select patients with isolated arteriogenic ED are potentially eligible for penile revascularization procedures., Conclusion: Because most patients with pelvic trauma are younger than 40 years with a significant life expectancy, appropriate diagnosis and management of ED after PFUI can greatly improve quality of life and allow resumption of post-injury sexual function. Identification of the causative pathology can help tailor treatment on an individual basis. Johnsen NV, Kaufman MR, Dmochowski RR, Milam DF. Erectile Dysfunction Following Pelvic Fracture Urethral Injury. Sex Med Rev 2018;6;114-123., (Copyright © 2017 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Context: Elderly men are an increasing proportion of the aging population in the 21st century. Urinary incontinence reduces the quality of life and increases the burden of care for the aging population., Objective: The primary objective of this review is to explore the etiopathology of common causes of incontinence in aging male patients. The focus is on the algorithm of the initial evaluation of these patients from both a primary care and a urologic standpoint., Evidence Acquisition: A nonsystematic review of the literature was performed in September 2017. The data and evidence of this paper have been obtained by a PubMed search, and through official statements and recommendations from the International Consultation on Incontinence. Our search incorporated terms such as elderly, urinary incontinence, male, urodynamics, bladder outlet obstruction, BPH, neurologic, urethral stricture, spinal shock, and urethral sphincter injury., Evidence Synthesis: A total of 7204 papers were identified; 6838 were excluded for female populations and populations <65 yr. A broad differential diagnosis exists for urinary incontinence in aging male patients, and many patients will be found to have multifactorial incontinence, compounding the issue. Neurologic etiologies common in this population include cerebrovascular accidents, Parkinson's disease, and dementia. Spinal cord injuries and multiple sclerosis are less common. In this analysis, non-neurologic etiologies leading to incontinence are broadly grouped under bladder outlet obstruction, sphincter injury, overactive bladder, underactive bladder, polypharmacy, and urinary tract infections., Conclusions: We provide a review of the differential diagnosis of incontinence in an elderly male patient. There is a need for understanding etiopathology and recognizing that many patients may have a combination of the above. The assessment algorithm, modified from the International Continence Society, provides a pathway for the provider in evaluating and treating elderly patients., Patient Summary: In this review, we have identified the sources of urinary incontinence in elderly male patients by neurologic and non-neurologic causes. We also discuss the basic evaluation and workup of an incontinent patient., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: Little published data exist on the impact of urethral stricture surgery on urinary urgency. We evaluated urinary urgency and urge incontinence before and after anterior urethroplasty., Materials and Methods: Male patients who underwent 1-stage anterior urethroplasty were retrospectively identified at 8 centers. Patients with preoperative and 2-month or greater postoperative subjective urinary urgency assessments were included in study. Patients who received anticholinergic medications preoperatively were excluded. Univariate and multivariate analysis was done to analyze the association of patient characteristics with preoperative and postoperative symptoms as well as improvement or worsening of symptoms after surgery., Results: Symptom and followup data on urgency and urge incontinence were available in in 439 and 305 patients, respectively. Preoperatively 58% of the men reported urgency and 31% reported urge incontinence. Postoperatively this decreased to 40% of men for urgency and 12% for urge incontinence (each p <0.01). Of the men 37% reported improvement in urgency and 74% experienced improvement in urge incontinence. Few of those without preoperative symptoms showed worse symptoms, including urgency in 9% and urge incontinence in 5%. New urgency was more likely to develop in men with a higher body mass index (OR 1.09, p = 0.02). Men with stricture recurrence were less likely to show improvement in urgency (OR 0.24, p = 0.03). Older men were more likely to have new urge incontinence (OR 1.06, p = 0.01) and less likely to notice improvement in urge symptoms (OR 0.92, p <0.01)., Conclusions: The prevalence of urgency and urge incontinence in male patients with anterior urethral stricture is high. The majority of men experience symptom stability or improvement in urinary urge symptoms following anterior urethroplasty., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the effect of urethroplasty on overactive bladder (OAB) symptoms., Materials and Methods: From March 2011 to November 2014, 47 anterior urethroplasties were performed by a single surgeon (RSP). Of these, 42 men prospectively completed the validated Overactive Bladder Symptom Score (OABSS) prior to and after urethroplasty. Comparative analysis of preoperative to postoperative OABSS results was performed., Results: The median (range) age of men who comprised our cohort was 49 (22-90). Questionnaires were completed preoperatively and at a median of 12 months (2.3-74.6) postoperatively. Stricture location included the following: bulbar (75%), penile (15%), and membranous (7.5%) urethra. Median stricture length was 3 cm (1-6). Half of the men underwent an excision and anastomotic repair, and half underwent buccal mucosal graft. Men experienced significant improvement in urinary flow rate, postvoid residual urine, and OAB symptoms reported on the OABSS. Of the 28/42 men with preoperative, clinically significant OAB (ie, OABSS ≥ 8), 25/28 reported a 54.2% (0%-100%) median reduction in OABSS, with only 1 patient reporting worsening of symptoms following surgery. Those men with the highest preoperative OABSS experienced the greatest improvement in OAB symptoms postoperatively., Conclusion: In men with anterior urethral strictures and OAB, urethroplasty decreased reported OABSS by >50% and cured 90% of men with clinically significant OAB symptoms., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To explore selection of the procedures in one-stage urethroplasty for treatment of coexisting urethral strictures in the anterior and posterior urethra., Methods: Between 2008 and 2014, a total of 27 patients with existing strictures simultaneously at anterior urethra and posterior urethra were treated in our hospital. Two types of procedures were selected for treatment of the anterior urethral strictures. A penile skin flap and the lingual mucosa were used for augmented urethroplasty in 20 and 7 cases, respectively. Three types of procedures, namely, non-transecting end-to-end urethral anastomosis (n = 3), traditional end-to-end urethral anastomosis (n = 17), other grafts substitution urethroplasty, including pedicle scrotal skin urethroplasty (n = 2), and lingual mucosal graft urethroplasty (n = 5), were utilized in the treatment of posterior urethral strictures., Results: The patients were mean followed up 30 months with an overall success rate of 88.9%. The majority of the patients exhibited wide patent urethras on retrograde urethrography and the patients' urinary peak flow ranged from 14.2 to 37.9 ml/s. Complications developed in 3 patients (11.1%). Of the 17 patients who underwent traditional urethral end-to-end anastomosis, urethral strictures occurred in 2 patients at 4 and 6 months after the operation. These patients achieved a satisfactory voiding function after salvage pedicle scrotal skin urethroplasty. A urethral pseudodiverticulum was observed in another patient 9 months after pedicle penile flap urethroplasty; and after a salvage procedure, he regained excellent voiding function., Conclusion: Synchronous anterior and posterior strictures can be successfully reconstructed with a combination of substitution and anastomotic urethroplasty techniques., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: To present an updated experience using our previously reported lateral perineal '7-flap' technique for perineal urethrostomy (PU), highlighting its role in a variety of patients with advanced urethral stricture disease., Materials and Methods: All patients who underwent 7-flap PU from 2009-2013 were reviewed. PU was constructed by advancing a "7"-shaped laterally based perineal skin flap into a spatulated, amputated bulbomembranous urethra. The contralateral side of the amputated proximal urethra was then matured to the advanced perineal skin. Patients were stratified by body mass index (BMI) and outcomes were compared., Results: Among 748 patients undergoing urethroplasty during the study period, 22 men (2.9%; mean age 61, range 31-80) received a 7-flap PU for advanced stricture disease (mean follow up 32 months). A majority of patients (14/22, 64%) were obese (BMI = 30). Disease etiologies consisted primarily of lichen sclerosus (9/22, 41%) while 6/22 (27%) had failed prior urethral reconstructions elsewhere. Mean operative time was 108 min (range 54-214), mean estimated blood loss (EBL) was 76 cc (30-200), and all patients were discharged immediately after surgery. Urethrostomy creation was possible in all patients regardless of BMI (mean 33, range 22-43), and there were no differences with regards to EBL (p = 0.71), operative time (p = 0.38), or success rate (p = 0.76) in obese versus non-obese patients undergoing 7-flap PU. Nearly all patients (21/22, 95%) are voiding spontaneously on follow up without the need for any additional procedure., Conclusion: In our updated experience, performance of 7-flap urethrostomy has resulted in durable long term success with acceptable performance in technically challenging cases.

Purpose: Recalcitrant posterior urethral stenosis is a challenging disease. When combined with a defunctionalized bladder, cutaneous urinary diversion is the most common surgical option. We present a novel technique of total lower urinary tract reconstruction, combining salvage cystectomy, ileal neobladder formation and urethral pull-through, as an orthotopic alternative in patients with a defunctionalized bladder and recalcitrant posterior urethral stenosis., Materials and Methods: We completed a retrospective review of 8 patients who underwent salvage cystectomy, orthotopic ileal neobladder formation and urethral pull-through. Artificial urinary sphincter placement was performed in a staged fashion. Six patients received prostate cancer treatment including radiation therapy, 1 had urethral disruption after robotic radical prostatectomy, and 1 experienced bladder rupture and urethral distraction injury during a motorcycle accident. Patient demographics, operative variables and postoperative outcomes were examined., Results: No high grade complications were observed after salvage cystectomy, orthotopic neobladder formation and urethral pull-through. After staged artificial urinary sphincter placement, a median of 2 revision surgeries (range 0 to 4) was required to establish social continence. All patients maintained functional urinary storage, urethral patency and social continence at a median followup of 58 months. No patient had complications related to orthotopic neobladder formation, including ureteroileal anastomotic stricture or pyelonephritis, and no patient required cutaneous diversion., Conclusions: Total lower urinary tract reconstruction with cystectomy, ileal neobladder formation and urethral pull-through offers an orthotopic alternative for patients with recalcitrant posterior urethral stenosis and defunctionalized bladders. Although it requires staged placement of an artificial urinary sphincter, this approach can offer functional urinary storage, durable urethral patency and avoidance of cutaneous urinary diversion., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the safety and efficacy of valgus mucosa anastomosis in posterior urethra reconstruction., Methods: We retrospectively reviewed the medical records of 116 patients who had undergone anastomotic repair of posterior urethral strictures between 2009 and 2013. Seventy-six patients underwent valgus urethral mucosa anastomosis (group A), and 40 underwent traditional end-to-end anastomosis (group B). The voiding status, complication rate, and adjuvant therapy were compared between the two groups. The clinical outcome was considered a failure when any postoperative intervention was needed., Results: Patient age ranged from 11 to 68 years (mean 38.2 ± 10.6). Follow-up was 5-59 months (mean 19.5 ± 13.2). The estimated urethral stricture length was 0.5-3.5 cm (mean 1.85 ± 0.40). Of all patients, the number of patients with simple stricture and complicated stricture were 47 and 69 respectively, and there was no significant difference in the complexity of stricture between group A and group B (60.5 vs. 57.5%, P > 0.05). Besides, there was no significant difference in the follow-up time and length of stricture between the two groups (31.6 ± 12.0 vs. 35.1 ± 14.8 months, P > 0.05). Compared to group B, the operation success rate in group A was greatly improved (92.1 vs. 80%, P < 0.05), while the incidence of complication was similar between the two groups (31.6 vs. 27.5%, P > 0.05)., Conclusions: The valgus urethral mucosa anastomosis could significantly improve the operation success rate of end-to-end anastomosis, reduce the stricture recurrence rate, improve the long-term urination function, and not increase the incidence of complications. So, valgus urethral mucosa anastomosis is an easy, effective and reliable urethral anastomosis technique.

Purpose: Anterior urethral stricture disease most commonly presents as urinary obstruction. Lower urinary tract pain is not commonly reported as a presenting symptom. We prospectively characterized lower urinary tract pain in association with urethral stricture disease and assessed the effects of urethroplasty on this pain., Materials and Methods: Men (18 years old or older) with anterior urethral stricture disease were prospectively enrolled in a longitudinal, multi-institutional, urethral reconstruction outcomes study from June 2010 to January 2013 as part of TURNS (Trauma and Urologic Reconstruction Network of Surgeons). Preoperative and postoperative lower urinary tract pain was assessed by the validated CLSS. Voiding and sexual function was assessed using validated patient-reported measures, including I-PSS., Results: Preoperatively 118 of 167 men (71%) reported urethral pain and 68 (41%) reported bladder pain. Age was the only predictor of urethral pain with men 40 years or younger reporting more pain than those 60 years old or older (81% vs 58%, p = 0.0104). Lower urinary tract pain was associated with worse quality of life and overall voiding symptoms on CLSS and I-PSS (each p <0.01). Postoperatively lower urinary tract pain completely resolved in 64% of men with urethral pain and in 73.5% with bladder pain. There were no predictive factors for changes in lower urinary tract pain after urethral reconstruction., Conclusions: Lower urinary tract pain is common in urethral stricture disease, especially in younger men. It is associated with worse quality of life and voiding function. In most men lower urinary tract pain resolves after urethral reconstruction., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To report the outcome of 1-stage urethroplasty using lingual mucosal grafts (LMGs) and buccal mucosal grafts (BMGs) for the treatment of male urethral strictures associated with genital lichen sclerosus (LS)., Materials and Methods: This was a descriptive, observational retrospective study of male patients with urethral strictures who underwent 1-stage mucosal graft urethroplasty using different substitute materials for reconstructive urethral surgery. Study inclusion criteria were patients with histologically proven LS presenting with urethral strictures. Exclusion criteria were patients without histologically proven LS, traumatic strictures, failed hypospadias, and malignant lesions. Successful reconstruction was defined as normal voiding with a peak flow >12 mL/s, no obstructive symptoms, and no postoperative procedure, including dilation., Results: Between January 2003 and December 2011, urethral strictures in 54 patients were considered associated with genital LS according to the inclusion and exclusion criteria, and 36 underwent 1-stage urethroplasty using oral mucosal grafts. The median age was 52 years (range, 32-80 years). The median stricture length was 12.5 ± 1.6 cm (range, 6-18 cm). One-stage single-sided dorsal LMG urethroplasty was performed in 22 of 36 patients. The remaining 14 patients received the same procedure combined with dual BMGs (n = 5) or with LMG combined with BMG (n = 9). The success rate was 88.9%. Postoperative urinary fistula occurred in 1 patient, and meatal stenosis developed in 3 patients. Mean follow-up was 38.7 months (range, 12-110 months)., Conclusion: Our survey suggests that 1-stage urethroplasty with single or combined LMGs or BMGs may be an effective option to treat urethral stricture associated with LS., (Copyright © 2014. Published by Elsevier Inc.)

Urethro-ejaculatory duct reflux (UEDR) is an uncommonly discussed entity that may result in devastating complications. We discuss the case of a young married male with obstructive voiding symptoms along with intermittent left scrotal pain for last the 2 years. On voiding cystourethrography, he had intravasation of contrast into the prostatic ducts, vas deferens and epididymal ducts suggestive of UEDR which might be the cause of his scrotal pain due to recurrent episodes of epididymitis. Complete resolution of voiding symptoms and recurrent scrotal pain occurred after management of urethral stricture. The possibility of UEDR should be kept in mind while dealing with men suffering from recurrent prostatitis, seminal vesiculitis, epididymitis or, less commonly, infertility., (Copyright © 2013 S. Karger AG, Basel.)

Objective: To evaluate the likelihood of developing de novo erectile dysfunction (ED) after anterior urethroplasty and to determine if this likelihood is influenced by age, stricture length, number of previous procedures or timing of evaluation., Materials and Methods: PubMed, Embase, Cochrane, and Google Scholar databases were searched for the terms 'urethroplasty', 'urethral obstruction', 'urethral stricture', 'sexual function', 'erection', 'erectile function', 'erectile dysfunction', 'impotence' and 'sexual dysfunction'. Two reviewers evaluated articles for inclusion based on predetermined criteria., Results: In a meta-analysis of 36 studies with a total of 2323 patients, de novo ED was rare, with an incidence of 1%. In studies that assessed postoperative erectile function at more than one time point, ED was transient and resolved at between 6 and 12 months in 86% of cases., Conclusions: Men should be counselled regarding the possibility of transient or permanent de novo ED after anterior urethroplasty procedures. Increasing mean age was associated with an increased likelihood of de novo ED, but this was not statistically significant., (© 2013 BJU International.)

Objective: To evaluate the pre- and postoperative aspects of sexual life (SL) in patients with bulbar urethral stricture who underwent ventral oral graft urethroplasty., Methods: Between 2009 and 2010, 52 men (mean age 36 years) were enrolled in our prospective study to ascertain sexual disorders before and after surgery. The validated Male Sexual Health Questionnaire-Long Form (MSHQ-LF) was completed pre- and postoperatively; the unvalidated but adapted Post-Urethroplasty Sexual Questionnaire (PUSQ) was completed postoperatively. Data were compared using the non parametric Wilcoxon test., Results: Before urethroplasty, most of the patients reported sexual disorders, in particular reduced ejaculatory stream (85%); many of them (35%) feared the risk of a postoperative worsening in the quality of SL. After urethroplasty, nobody reported a worsened erection, while most of the patients noticed a significant improvement in erection, ejaculation, relationship with their partner, sexual activity, and desire. Modifications in the scrotoperineal sensitivity were reported by 42% and 15% noticed esthetic changes without impact on SL. All patients reported an improvement in quality of life (QOL) and were satisfied with the outcome of urethroplasty., Conclusion: Urethral stricture disease may be responsible for sexual disorders that have a significant impact upon SL. Patients confessed a marked anxiety tackling urethroplasty and declared that one of their deepest fears regarded a potential further deterioration in the quality of SL. At short-term follow-up, the minimally invasive ventral graft urethroplasty does not cause sexual complications, apart from the post-ejaculation dribbling. On the contrary, this technique showed to restore SL in all its aspects., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Functional bladder capacity at a certain age can be accurately estimated and expressed as a function of age. We present a 13-year-old boy with abdominal distention who was presumed to have ascites. Abdominal ultrasound revealed that the bladder was severely distended, and cystoscopy showed a short stricture in the bulbar urethra followed by a large bladder without obvious borders. Under general anesthesia, bladder capacity was 9250 cc. Reduction cystoplasty was performed. At the 2-year follow-up, he voided spontaneously with 20 cc post-void residual urine., (Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objectives: To determine whether obesity increases the risk of urethroplasty failure., Methods: A total of 381 patients underwent urethroplasty and had complete body mass index (BMI) data. Stricture recurrence-free survival was defined as subjective and objective improvement in urinary flow, an absence of radiographic evidence of stricture, and no further need for urethral instrumentation. Cox proportional hazards regression analysis was used to identify both univariate and multivariate predictors of urethroplasty outcome., Results: The median patient age was 40 years (range 18-90). The median follow-up was 5.9 years (range 1 month to 10 years). Of the 381 patients, 60 developed recurrent stricture (15.7%). Overweight (BMI 25-30 kg/m(2)) and obese (BMI 30-35 kg/m(2)) patients were more likely to have urethroplasty failure, reaching significance and near significance on univariate and multivariate analysis, respectively (P = .03 and P = .07, respectively). Patients who were severely (BMI 35-40 kg/m(2)) or morbidly obese (BMI >40 kg/m(2)) did not have an increased risk of urethroplasty failure., Conclusions: Although obesity's relationship with urethroplasty failure is not linear, it does appear to affect outcomes after urethroplasty.

Purpose: This study investigates whether the location and dose of urethral radiation received during transperineal interstitial permanent prostate brachytherapy determine the degree and type of urinary symptoms experienced subsequently., Methods and Materials: Data from a prospectively acquired database of 219 men treated with transperineal interstitial permanent prostate brachytherapy using (125)I (prescribed dose 145Gy) between May 2001 and June 2003 were reviewed. To assess the effect of regional urethral dosimetry, the prostate was divided into equal thirds (proximal, mid, and apical) with doses beyond this considered distal. Mean and peak doses for each region were correlated with total International Prostate Symptom Score (IPSS) and the irritative and obstructive components of the score. IPSS values at 1 month postimplant, time to resolution of IPSS, and the need for catheterization were used as outcome variables and analyzed with respect to dose using logistic and linear regression., Results: Peak and average doses with standard deviations to the proximal urethra were 168 (24) and 147 (24)Gy, mid prostatic urethra 192 (24) and 181 (21)Gy, and apical urethra 201 (28) and 192 (26)Gy. Catheterization was required for 28 men and was predicted by larger pretreatment transrectal ultrasound (TRUS) volume (OR 1.06 per unit change; 95% CI 1.03-1.10; p<0.001) and lower UV(150) (OR 0.30; 95% CI 0.13-0.68; p=0.004) in multivariate analysis. Greater IPSS at baseline (p<0.001) and preoperative TRUS volume (p=0.012) but conversely smaller D(30) doses (p=0.003) were predictive of IPSS outcomes at 1 month. IPSS returned to within two points of baseline for 72.2% of men by 1 year and 83.3% by 24 months. This was predicted by higher IPSS at baseline (OR 6.0; 95% CI 2.72-13.22; p<0.001), higher D(30) (OR 1.17; 95% CI 1.01-1.36; p=0.031), and lower V(100) (OR 0.39; 95% CI 0.22-0.70; p=0.002). Prostatic urethral segmental dosimetry failed to predict the need for catheterization, the nature of the urinary symptoms, or their time to resolution., Conclusions: Previously identified factors of importance for urinary morbidity such as pretreatment prostate volume and baseline urinary function were reemphasized in this study. Regional urethral dosimetry within contemporary practice does not seem to influence the nature or extent of urinary symptoms after prostate brachytherapy. Consequently, region sparing dosimetric modifications are not warranted to alter symptomatic outcomes.

Background: In the pathogenesis of urethral stricture, fibrosis is associated with an excessive collagen increase. After the recognition that topical application of Mitomycin-C (MMC) inhibits fibroblast proliferation and is effective in preventing scar formation, many studies have been carried out on this subject outside the scope of urology. The aim of the present study is to observe the intraurethral impact of the employment of low doses of MMC on scar formation and fibrosis in experimental rat model., Methods: Urethral injuries were made by internal urethrotomy knife. The study was carried out with 35 adult male Wistar albino rats. Five rats were allocated to the control group (group 1), 10 to a group that was administered 2 mg/L MMC (group 2) and 20 to a group that was administered 10 mg/L MMC (group 3). Mitomycin-C was administered to the injured urethra in the form of irrigation for 5 min. The rats were sacrificed 14 days later in order to evaluate chronic inflammation and fibrosis and their penises were histopathologically examined under light microscopy with hematoxilen eosin and trichrom stains., Results: When group 2 was compared with control group, the differences in hemosiderin-laden macrophages (HLM), mononuclear cell infiltration (MCI) and fibrosis were found to be statistically significant (P < 0.01, P < 0.05, P < 0.005, respectively). When group 3 was compared with control group, the differences in HLM, MCI and fibrosis were also found to be statistically significant (P < 0.05, P < 0.05, P < 0.005, respectively). In the comparison of group 2 with group 3, no statistically significant differences were found in terms of the these parameters., Conclusions: Although MMC is toxic at high doses, the antifibrotic effect of the intraurethral low dose MMC may be useful in combination therapy for internal urethrotomy.

Objective: Based on 4 cases of infravesical obstruction due to extreme caliber disproportion between the posterior urethra and the penile urethra, a pathophysiological mechanism for this dynamic obstruction is given and endoscopic treatment is described., Subjects: Four cases of membrano-bulbo-urethral junction (MBUJ) stenosis, seen between September 1995 and April 1996, are described. Two boys had previous successful valve resection but still showed extreme ballooning of the posterior urethra. The other 2 boys showed bladder instability on urodynamics and the male variant of the spinning top urethra on voiding cystourethrography (VCUG)., Results: All cases were successfully treated by endoscopic incision at the 12 o'clock position of the kink between the posterior and the penile urethra which is seen when the full bladder is expressed. Disproportion in the posterior urethra, seen on VCUG, together with bad urinary flow measured on uroflowmetry raise the suspicion of MBUJ stenosis., Conclusion: Although rarely seen, extreme caliber disproportion in the male urethra can cause obstruction. Ballooning of the posterior urethra, caused by urethral valves, bladder instability resisted by voluntary sphincter contraction or congenital posterior urethral dilatation, creates an obstructive kink in the urethra comparable to some obstructions in ureteropelvic junction stenosis. If suspicion of such a form of obstruction arises, cystoscopy during pressure on the full bladder is mandatory in order to see the obstruction, descending as a membrane from the vault of the urethra.

According to the author, impotence associated with traumatic urethral strictures arises rather due to operative intervention than primary trauma. Inaccurate manipulations of the surgeon may cause destruction of the bulbocavernous muscles and blood vessels reaching the penis at bulbar level. Another cause of impotence is chronic prostatitis which may follow long-term bougienage. Adequate operation allowing for anatomic and functional features of the perineum does not entail impotence.

We report a case of extensive traumatic membranous urethral obliteration with a 4-cm gap that was successfully treated with a transperineal-transurethral puncture technique to reestablish urethral continuity in association with endourethroplasty to repair the long fibrotic gap. The injury also involved the bladder neck, and the patient had subsequent stress urinary incontinence. Because endourologic treatment of his stricture did not require mobilization of the bulbous urethra, an artificial sphincter was placed 13 months later without difficulty. The patient is continent and remains stricture free at 3 years. This case illustrates the potential of endourologic treatment for severe membranous urethral disruptions.

We reviewed charts with adequate documentation and followup (mean 24.6 months) between 1970 and 1987 of 110 patients who had undergone 1-stage urethroplasty for urethral stricture disease at our institutions. Two age peaks were observed, 1 in the younger population (21 to 30 years old) with traumatic strictures (50% of all strictures) and 1 in elderly men (61 to 70 years old) with mainly post-inflammatory strictures (28.2% of all strictures). The majority of all strictures (63.6%) were in the bulbous urethra. Only strictures induced by trauma were located in the membranous urethra (total 28.2%). A patch graft repair was used in 49.1% of all cases, an end-to-end technique in 29.1% and a transpubic repair in 21.8%. Overall, a 57% rate of excellent results was observed with 24% failures. The results were best for patch graft repairs (65% excellent), followed by end-to-end repairs (56% excellent) and transpubic repairs (42% excellent). The choice of the surgical approach in urethral stricture surgery is dictated by the location of the stricture. The location in turn is dependent on the etiology of the stricture. Consequently, the cause of the stricture affects the location and character of the stricture and, therefore, has an immediate impact on the choice of the surgical approach and, thus, the outcome of the patient. The failure rate doubled overall when the patients had a previous manipulation for the stricture disease or if the urine was infected preoperatively despite antibiotic coverage. While our patient population may not be representative for other institutions, some general conclusions regarding proper management and treatment selection can be drawn from our experience.

The influence of uresis disorders, injuries of pelvic neural plexuses, anatomic pathways between urethra and spermiducts on the disease course and prognosis was studied in 128 patients with complicated and recurrent urethral stricture. Data concerning mechanism of pathologic process spread are adduced, classification of complicated and recurrent traumatic urethral stricture is proposed. Indications for urethral stricture resection with prostatectomy and prostatovesiculectomy, anastomosis between urethra and neck of the urinary bladder for urea passage disorders by upper and lower urinary tracts.

We present our experience with the self-expanding urethral endoprosthesis Wallstent for the treatment of recurrent posterior urethral strictures. The stent is made of a surgical-grade stainless steel alloy wire, woven into braided mesh and shaped to a tubular form. It was originally developed for use in endovascular stenoses. Immediately before implantation of the stent an internal urethrotomy with subsequent urethral dilatation is done. So far, 23 patients have been treated by this new technique of therapy, with follow-up periods of up to 25 months (mean 16.8 months). The endoprosthesis has been tolerated very well by all patients. Successful treatment of the strictures is confirmed by the physiological uroflow obtained and the absence of residual urine after emptying of the bladder. We have seen no recurrences of stricture. After 6 months, urethroscopic control examination demonstrates complete epithelialization of the urethral stent. One year after implantation the endoprosthesis is completely incorporated. The original diameter of 21.5 Charr is maintained, which allows subsequent transurethral endoscopic manipulation if necessary. Our encouraging results so far give reason to hope that this is a simple, safe and recurrence-free treatment for posterior strictures of the urethra.

The membranous part of the urethra has anatomic specificity influencing its trauma mechanism and allowed for in the trauma treatment policy. In 239 patients with an injured membranous part of the urethra described in the paper, the rupture was mainly due to the hip fracture. 85% of the patients developed a complete rupture with subsequent obliteration, 15% had strictures. Cicatrization involved the whole membranous part in 74% of the cases. In relevant traumas common are severe rectourethral and peritoneal fistulas surgical treatment of which as well as obliterations involves great technical difficulties. There is a variety of operative approaches and techniques (perineal, original anteropubic and anorectal). Urethral reconstruction should not be followed by bougienage. Typical are also frequent renal and genital complications (phlegmons, nephroliths, ureteroliths, epididymitis, orchitis, prostatitis, pyelonephritis). The number of complications depends on the choice of the adequate operative technique and due consideration of anatomical characteristics of the membranous part of the urethra.

Our study was intended to verify the efficacy and the side effects of intraluminal dilatation of the distal urinary tract with vascular balloon catheter in a group of patients with urethral stenosis. In 6 out of 10 patients, there was a significant increase in urethral diameter (by 70% to 150%). In 4 patients, the stenosis was only slightly improved (increase in urethral diameter by 10% to 20%). Only 5 patients, all belonging to the group in which dilatation was anatomically effective, have been having normal micturition and have been asymptomatic. According to data in our possession, transurethral dilatation does not seem to be very effective, since it restores adequate micturition in only 50% of cases. In view of the absence of severe side effects, however, this technique may be indicated in patients with medical problems that preclude surgery.

Many techniques have been described for the repair of recurrent urethral strictures. Experience with 1-stage correction of hypospadias and epispadias, using a vascularized island flap technique, has led to its increased application for complicated adult urethral strictures. The advantage of the vascularized island flap technique is that reconstruction can be completed with only 1 operation, and it provides good subjective and objective results. Analysis of 50 consecutive cases treated by this approach has proved its validity. Of the 50 cases fistulas occurred in 20%, of which 12% required surgical correction, and stricture recurred in 32%. The largest proportion of recurrence was noted in patients who were primarily treated with 3 or more urethrotomies within a short time. Therefore, we recommend open surgical repair when 1 or 2 internal urethrotomies fail to produce a good result.

The urogenital tract has been examined in 35 patients who required 3 or more years of therapy. A range of studies revealed a short urethral stricture in 11, long urethral stricture in 26, megalocystis in 6, domicile urinary bladder in 2 and bladder diverticulosis in 6 patients. Simple and diuretic excretory urography showed normal bilateral renal function in 5, moderately impaired function in 14 and severe loss of function in 6 patients. Single-kidney functional impairment was seen in 10 patients. Over 504 of patients showed prolonged urographic retention of urine in the pelvis and ureter. Bilateral ureterohydronephrosis was found in 3 and unilateral one in 3 patients. Descending, ascending and micturitional urethrocystography revealed urinary reflux into the prostate (n = 13), seminiferous ducts (n = 3), seminal vesicles (n = 4) and ureters (n = 4). Vasovesiculographic sizes and shapes of the seminal vesicles were normal in 2 patients while the vesicles were uni- or bilaterally dilated or constricted in other patients. The treatment was operative in 34 patients. Histological examination of scars and resected tissues showed fibrous sclerotic lesions in the prostate and suppurative inflammatory and fibrous lesions in seminal vesicular walls. With long treatment of urethral strictures, micturition disorders were superimposed by reflux of infected urine into the prostate, seminal vesicles and ureters, inducing inflammation and functional abnormalities; these caused shrinkage and compression of the posterior urethra, bladder cervix, intramural and prevesical ureteral segments, resulting in chronic renal failure. An early and radical plastic operation on the urethra may prevent the mentioned disorders.

The cause of deviation of the erectile penis after urethral manipulations is shown to be periurethral scarring which can be outlined by ultrasound investigation of the urethra and periurethral structures. Sonographic findings are demonstrated. 6 case reports are presented.

From 1977 to December 1983 a total of 64 patients with posterior, anterior or extended urethral stricture have been treated by using free-foreskin grafts after the mesh transplant procedure. This operation is completed as a two-stage procedure. Of paramount importance for success is the open and dry treatment of the graft to assure an ideal situation for later reconstruction. Healing without the formation of fibrous tissue is the rule. In 63 patients this method was applied with an excellent anatomical and functional result. The most important indications are recurrent strictures after several operations, extended strictures of the whole length of the urethra, strictures with chronic inflammations, as well as problematic strictures in paraplegics.