Urethral Stricture Disease

88 Pages·2016·20.21 MB·English

Advances in Urology
Urethral Stricture Disease:
Challenges and Ongoing
Controversies
Guest Editors: Miroslav L. Djordjevic, Francisco E. Martins,
Vladimir Kojovic, and Dmitry Kurbatov
Urethral Stricture Disease:
Challenges and Ongoing Controversies
Advances in Urology
Urethral Stricture Disease:
Challenges and Ongoing Controversies
Guest Editors: Miroslav L. Djordjevic, Francisco E. Martins,
Vladimir Kojovic, and Dmitry Kurbatov
Copyright©2016HindawiPublishingCorporation.Allrightsreserved.
Thisisaspecialissuepublishedin“AdvancesinUrology.”AllarticlesareopenaccessarticlesdistributedundertheCreativeCommons
AttributionLicense,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisprop-
erlycited.
Editorial Board
MohammadH.Ather,Pakistan ChristopherM.Gonzalez,USA SangtaePark,USA
DariusJ.Bagli,Canada NarmadaPrasadGupta,India AlejandroR.Rodriguez,USA
StevenB.Brandes,USA KostisGyftopoulos,Greece JoséRubio-Briones,Spain
JamesA.Brown,USA JasonM.Hafron,USA MatthewRutman,USA
FabioCampodonico,Italy DanielW.Lin,USA DouglasS.Scherr,USA
InHoChang,RepublicofKorea WilliamLynch,Australia NormD.Smith,USA
FelixChun,Germany MartinMarszalek,Austria NazarenoSuardi,Italy
PaddyDewan,Australia VirajMaster,USA FlavioTrigoRocha,Brazil
MiroslavL.Djordjevic,Serbia MaxwellV.Meng,USA VassiliosTzortzis,Greece
CarlosEstrada,USA HiepT.Nguyen,USA WillieUnderwood,USA
WalidA.Farhat,Canada YuanjieNiu,China OuidaL.Westney,USA
Contents
UrethralStrictureDisease:ChallengesandOngoingControversies
MiroslavL.Djordjevic,FranciscoE.Martins,VladimirKojovic,andDmitryKurbatov
Volume2016,ArticleID1238369,2pages
Sexual(Dys)functionafterUrethroplasty
LuísXambre
Volume2016,ArticleID9671297,10pages
AnteriorUrethralStrictureDiseaseNegativelyImpactstheQualityofLifeofFamilyMembers
JonathanR.Weese,ValaryT.Raup,JairamR.Eswara,StephenD.Marshall,AndrewJ.Chang,JoelVetter,
andStevenB.Brandes
Volume2016,ArticleID3582862,4pages
ManagementofLong-SegmentandPanurethralStrictureDisease
FranciscoE.Martins,SanjayB.Kulkarni,PankajJoshi,JonathanWarner,andNataliaMartins
Volume2015,ArticleID853914,15pages
PosteriorUrethralStrictures
JoelGelmanandEricS.Wisenbaugh
Volume2015,ArticleID628107,11pages
TheUseofFlapsandGraftsintheTreatmentofUrethralStrictureDisease
EricS.WisenbaughandJoelGelman
Volume2015,ArticleID979868,8pages
SurgicalRepairofBulbarUrethralStrictures:AdvantagesofVentral,Dorsal,andLateralApproaches
andWhentoChooseThem
KrishnanVenkatesan,StephenBlakely,andDmitriyNikolavsky
Volume2015,ArticleID397936,4pages
BipolarTransurethralIncisionofBladderNeckStenoseswithMitomycinCInjection
TimothyD.Lyon,OmarM.Ayyash,MatthewC.Ferroni,KevinJ.Rycyna,andMangL.Chen
Volume2015,ArticleID758536,5pages
TreatmentofUrethralStricturesfromIrradiationandOtherNonsurgicalFormsofPelvicCancer
Treatment
IyadKhourdaji,JacobParke,AvinashChennamsetty,andFrankBurks
Volume2015,ArticleID476390,7pages
ImpactofShort-StayUrethroplastyonHealth-RelatedQualityofLifeandPatient’sPerceptionof
TimingofDischarge
HenryOkaforandDmitriyNikolavsky
Volume2015,ArticleID806357,5pages
VisualInternalUrethrotomyforAdultMaleUrethralStrictureHasPoorLong-TermResults
WaleedAlTaweelandRaoufSeyam
Volume2015,ArticleID656459,4pages
AnastomoticRepairversusFreeGraftUrethroplastyforBulbarStrictures:AFocusontheImpacton
SexualFunction
MatthiasBeysens,EnzoPalminteri,WillemOosterlinck,Anne-FrançoiseSpinoit,PietHoebeke,
PhilippeFrançois,KarelDecaestecker,andNicolaasLumen
Volume2015,ArticleID912438,7pages
Hindawi Publishing Corporation
Advances in Urology
Volume 2016, Article ID 1238369, 2 pages
http://dx.doi.org/10.1155/2016/1238369
Editorial
Urethral Stricture Disease: Challenges and
Ongoing Controversies
MiroslavL.Djordjevic,1FranciscoE.Martins,2VladimirKojovic,1andDmitryKurbatov3
1SchoolofMedicine,UniversityofBelgrade,11000Belgrade,Serbia
2UniversityofLisbon,1649-004Lisbon,Portugal
3EndocrinologyResearchCenter,AndrologyandUrologyDepartment,Moscow117036,Russia
CorrespondenceshouldbeaddressedtoMiroslavL.Djordjevic;[email protected]
Received25February2016;Accepted25February2016
Copyright©2016MiroslavL.Djordjevicetal.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttribution
License,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperly
cited.
Management of urethral stricture disease presents constant E. Martins and colleagues evaluated etiology, pathogenesis,
challengeforallreconstructiveurologists.Urethralstricture and diagnostic work-up and, finally, presented different
diseaseisgenerallydefinedasstenosesthataretypicallylong, surgical options for treatment, together with outcomes and
involving broad areas of varying spongiofibrosis, and result complications. They concluded that one-stage repair with
from inflammation and/or infection, rather than trauma. buccal mucosa grafts presents an excellent option in the
Although the management of urethral strictures may be treatmentoflongurethralstricture.However,forobliterative
complexandchallenging,veryoftentheyaretreatedbyhealth disease,two-stageurethroplastyoffersaviablealternative.
carepersonnelwithoutthenecessaryandpropertrainingand J.GelmanandE.S.Wisenbaughpresentedareviewarticle
knowledgeofthecurrent,modern,validatedtechniquesand about management of patients who suffer pelvic fracture
procedures.Notablechangesinsurgicalapproachhavebeen urethral injuries which usually develop into obliterative
adopted worldwide, resulting in significant improvement strictureswithdistractiondefect.Theycomprehensivelyeval-
of successful outcomes and simultaneously decreasing the uatedinitialmanagement,preoperativeplanning,andtech-
complication rate. Nowadays, most urethral strictures can niques for posterior urethral stricture disease. The authors
be reconstructed in a one-stage procedure, leaving some emphasize the importance of adequate vascularization of
complex cases for a less convenient, but safer, two-stage urethraforsuccessfulrepair.Theybelievethatpossiblefuture
repairstrategy.Theexcitingandenjoyable“nature”ofrecon- modificationofoperativetechniquecouldbeabulbarartery
structivesurgery,ingeneral,andurethralreconstruction,in sparing surgery during posterior urethral reconstruction.
particular,istheunexpectedandunpredictablenatureofthe Resultsfromreferralcentersconfirmthatwhenopenrepair
strictureand,consequently,theneedforthecreativecombi- fails, excision and primary anastomosis still remains the
nationofdifferenttechniquesandstrategies,ofteninvolving procedure of choice and offers a very high success rate. In
tissue transfer procedures, either as grafts or as flaps, for another article entitled “The Use of Flaps and Grafts in the
achieving a successful outcome. This special issue contains Treatment of Urethral Stricture Disease,” the same authors
a number of articles with description of different aspects, describedtheuseofversatileflapsandgraftsinthevarious
presentations, and treatments of urethral stricture disease clinical presentations of anterior urethral stricture disease.
withtheaimtomakefurtherimprovementofunderstanding Selectingtheappropriatetechniqueforeachpatientishighly
andmanagingthisseveresurgicalcondition. individualized and dependent on stricture characteristics.
Multi-institutional review article from Portugal, India, However, the proper selection of tissue transfer technique
and USA presents modality of challenging treatment of is paramount to success. The authors provided a logical,
long-segment and panurethral stricture disease. Francisco easilycomprehensibleapproachtotheappropriateselection
2 AdvancesinUrology
of grafts and flaps in urethral reconstruction, followed by standardized questionnaires as IPSS, IIIEF-5, and Ejacula-
practicalclinicalguidelines. tion/OrgasmScoreandquestionsongenitalsensitivity.The
Another article, trying to give answers when to choose authorsconcludedthatanastomoticrepairisassociatedwith
dorsal,ventral,orlateralonlayapproachforbuccalmucosa a transient decline in erectile and ejaculatory function, and
grafturethralreconstruction,ispresentedbyK.Venkatesan that was not observed with free graft urethroplasty. Bulbar
and colleagues. The authors concluded that comparative anastomotic repair and free graft urethroplasty are likely to
studies are limited and choice of techniques is typically altergenitalsensitivity.However,itshouldbenotedthatthe
determinedonlocationandlengthofstrictureandsurgeon authors are highly experienced and expert urologists, and
preference. results from any surgery performed at center of excellence
Thearticletitled“BipolarTransurethralIncisionofBlad- maynotbegeneralizable.
derNeckStenoseswithMitomycinCInjection,”writtenbyT. Finally, the management of urethral stricture disease
D.LyonandcolleaguesfromPittsburgh,presentedefficacyof is continually evolving. Although numerous strategies are
bipolartransurethralincisionwithmitomycinCinjectionon available,thereisstillnosingleoptimumsolutionsuitablefor
thirteen patients who had refractory bladder neck stenosis. all conditions. The clinical selection of stricture recurrence
Overall success was achieved in 77% (10/13) of patients. prevention techniques should be carefully tailored to every
Bipolar transurethral incision with mitomycin C injection individualpatient.Lastbutnotleast,reconstructiveurologist
wascomparableinefficacytopreviouslyreportedtechniques mustbefamiliarwithavarietyofthesetechniques,toensure
anddidnotresultinanyseriousadverseevents. theuseofthebestone,asdictatedbysituation.
Urethral stricture disease is an underrecognized and
MiroslavL.Djordjevic
poorlyreportedcomplicationafterradiationtherapy,andthat
FranciscoE.Martins
can cause severe morbidity for cancer survivors. Radiated
VladimirKojovic
urethral tissue in particular poses a great challenge for
DmitryKurbatov
the reconstructive urologist. I. Khourdaji and colleagues
providedacomprehensivediscussionofetiology,incidence,
andavailabletreatmentoptionsforurethralstricturedisease
followingpelvicradiationinthearticletitled“Treatmentof
UrethralStricturesfromIrradiationandOtherNonsurgical
FormsofPelvicCancerTreatment.”
H. Okafor and D. Nikolavsky examined the impact of
short-stayurethroplastyonhealth-relatedqualityoflifeand
patient’s perception of timing of discharge. Over a 2-year
period, a validated health-related quality-of-life question-
naire, EuroQol (EQ-5D), and additional question assessing
timing of discharge were administered to all patients after
urethroplasty. Postoperatively, patients were offered to be
senthomeimmediatelyortostayovernight.Inthisresearch
article, the authors concluded that the majority of patients
discharged soon after their procedure felt that discharge
timingwasappropriateandtheirhealth-relatedqualityoflife
wasonlyminimallyaffected.
A clinical study, published by W. Al Taweel and R.
Seyam,hasagoaltodeterminethelong-termstricture-free
rate after visual internal urethrotomy following initial and
follow-up urethrotomies. During a period of eight years,
301 patients underwent visual internal urethrotomy. The
overall stricture-free rate at the 36-month follow-up was
8.3% with a median time to recurrence of 10 months. The
authorsconfirmedthatvisualinternalurethrotomyforadult
male urethral stricture has poor long-term results without
significantdifferenceinthestricture-freeratebetweensingle
andmultipleprocedures.
Inamulticentricclinicalstudythathasbeenconducted
in Italy and two centers from Belgium, M. Beysens and
colleaguesevaluatedalterationsinsexualfunctionandgen-
ital sensitivity after anastomotic repair and free graft ure-
throplasty for bulbar urethral strictures. The patients who
underwent anastomotic repair or free graft urethroplasty
were prospectively evaluated before urethroplasty and 6
weeksand6monthsafterurethroplasty.Evaluationincluded
Hindawi Publishing Corporation
Advances in Urology
Volume 2016, Article ID 9671297, 10 pages
http://dx.doi.org/10.1155/2016/9671297
Review Article
Sexual (Dys)function after Urethroplasty
LuísXambre
CentroHospitalardeV.N.Gaia/Espinho,Servi¸codeUrologia,RuaConcei¸ca˜oFernandes,4434-502VilaNovadeGaia,Portugal
CorrespondenceshouldbeaddressedtoLu´ısXambre;[email protected]
Received11October2015;Accepted3February2016
AcademicEditor:VladimirKojovic
Copyright©2016Lu´ısXambre.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,which
permitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
Thereisapaucityofpublishedliteratureontheandrologicalconsequencesofurethralrepair.Untilrecentlyauthorshavefocused
mainlyontechnicalaspectsandobjectiveresults.Reportedoutcomesofurethralreconstructionsurgeryhavetraditionallyfocused
onlyonurodynamicparameterssuchasflowrates.Patientreportedoutcomemeasureshavelargelybeenneglectedandthereisa
scarcityofwellconductedsystematicstudiesonthesubject.Forthesereasonswhetherthedifferentcomponentsofsexuallifeare
moreorlessaffectedbydifferenttypesofurethralreconstructionremainslargelyunknown.Inanattempttoclarifytheavailable
scientificevidence,theauthorsmakeacriticalreviewofavailableliterature,systematizingitbysexualdomainandstudytype.Brief
pathophysiologicalcorrelationsarediscussed.
1.Introduction a urethral reconstruction failure/success between treatment
physicians and patients [12–14]. Aspects such as aesthetics
Urethral stenosis, although relatively uncommon in the or those related to sexual function are obviously important
universeofurologicdiseases,isbynomeansararecondition. from the perspective of patients and often overlooked in
It accounts for about 52% of urethral and 1.8% of urologic the literature. If we do a simple exercise as, for example,
pathology,respectively,andpresentsanestimatedprevalence an electronic search using the most widespread scientific
of0.6%[1,2].Relativelyyoung,activeindividualsaremostly literaturedatabase,PubMed,thisdisparitybecomesobvious.
affected.Itsassociationwithanunequivocalnegativeimpact Ifresearchesusingtermslike“urethroplastyandresults”pro-
on the quality of life, whether resulting from the disease videthousandsofreferences,termssuchas“urethralstenosis”
itself and its complications or whether consequence of the or“urethroplasty”and“erectiledysfunction”or“impotence”
treatment(s)employed,iswellestablished. resultinonlyafewdozenscientificpapers.Moreover,many
Atpresent,thereisnodoubtthatreconstructivesurgery booksthatspecificallyaddressurethralreconstructionalmost
in the form of different types of urethroplasty represents exclusivelyfocusonanatomicalortechnicalaspectsandthere
the “gold standard” in the treatment of these patients. is a virtual absence of information about the andrological
Urethroplastyisassociatedwithreproductivelyhighsuccess aspectsofurethroplasty.
rates, when properly employed. There is enough data in Althoughinrecentyearstherehasbeenagrowinginterest
the literature regarding the results obtained with several inrelationtourethralstricture’sandrologicimplications,the
techniques, anastomotic or substitution. When objective relationshipbetweenurethroplastyanderectiledysfunction,
variables such as flow rates are considered, several authors forexample,remainscontroversialuptothepresentday.The
describesuccessratesthatexceedinmanycases80%whether existenceoffewspecificstudies,heterogeneousstudypopu-
foranteriorurethra,bulbar[3–5]orpenile[6–8],orwhether lations,differingmethodologies,anddiversityofprocedures
forposteriorurethra[9–11]. analyzedmakesitverydifficulttoprovidedefinitiveanswers.
Thesedatareflecthoweveronlyoneaspectofresults,as
patientscarryoutasubstantiallydifferentperceptionofsuc- Pathophysiology of Sexual Dysfunction. Surgical approaches
cessthanphysicians,notonlytakingintoaccountflowrates involvingtheexternalgenitaliahaveanunmistakablenoxious
and radiological or endoscopic data. It is well known that potentialinseveraldomainsofsexualfunction,aestheticand
there is a significant mismatch between what is considered dysmorphicchanges.
2 AdvancesinUrology
Consequences in aesthetics and change of body image, 3.ResultsandDiscussion
mostly related to the distal urethroplasties, have obvious
3.1. Body Image/Self-Esteem. Literatureisabsolutelylacking
potentialimpactintermsofself-esteemandpossiblysexual
intermsofevaluationoftheaestheticconsequencesofure-
behavior.Althoughofsubjectivenature,theseaspectsarepar-
throplasties performed in adulthood for urethral strictures.
ticularly noticeable in multioperated hypospadias patients,
Wecanonlyinferconclusionsbasedonfindingsfromlitera-
a group of patients of increasing importance in percentage
tureinthecontextofhypospadiology,astudypopulationwith
termsthatposeaparticularlydifficultapproach.
necessarilydifferentandveryparticularcharacteristics.
Concerningerectileandejaculatorydysfunction,poten-
Despite all the limitations pointed out, there are a few
tiallyinjuredstructuresinthecourseofurethroplastyinclude
studiesthatlookedspecificallyatthecosmeticaspectofthe
severalarterialstructures,nervebranches(autonomicand/or reconstructionofthepenileurethrainthiscontextthatallow
somatic),andeventuallymyogeniccomponents. usatleastsomecriticalreflections.
Thereisarecognizedpotentialforinjuryofbranchesof AuthorsasBubanjetal.[25]usedapostalquestionnaire
the CommonPenile Artery, essential in the hemodynamics includingquestionsaboutgenitosexualfunctioningandsex-
of erection in posterior urethroplasties, and of more distal ualbehaviorinacomparativestudyof37patientssubmitted
vessels,ofsmallerandquestionablepracticalimportance,in to urethroplasty for hypospadias repair 2–15 years earlier
anteriorurethroplasties. (mean age 27.8 ± 6.2 years/average number of surgeries
3.81±3.37)andagroupof39normalmen(meanage25.5±
Equallyimportantareneurogenicautonomiclesionsdue
5.3 years). No significant differences were found between
totheproximityoftheneurovascularbundlestothemembra-
the groups with regard to inhibition of search for sexual
nousurethra,potentiallydamagedininstrumentationofthe
contactsorsexualrelationshippatterns.Participantsinboth
posterior urethra [15, 16]. Somatic neurogenic components,
groupsweremostlysatisfiedwiththeirbodyimage(83,78%
either sensory or motor, involving the dorsal penile or
of patients with hypospadias versus 89.74% in the control
perinealnerveanditsbranches,arealsoatrisk,particularly
arm).However,thereweresignificantdifferencesbetweenthe
duringanteriorurethroplasties[17–19].
groupsregardingthefrequencyofsexualactivityandnumber
Of potential functional importance, though debatable of sexual partners. Only 51.35% of men with hypospadias
andstillpracticallyinthefieldofscientificcuriosity,arethe regardedtheirsexlifeasfullysatisfyingagainst76.92%ofthe
neuronal connections identified between autonomic and controlgroup.
somatic pelvic, perineal, and even genital nerve terminals, Evenetal.[26]analyzedagroupof15youngadulthypo-
making the latter capable of nitrergic activity. Authors like spadiaspatients(meanage21.2years)operatedinchildhood,
YucelandBaskin[20]andAlsaidetal.[21]usingimmuno- employing instruments such as EuroQol 5, IIEF-15, and a
histochemistry-basedstudiesinfetusesunequivocallydem- nonvalidated questionnaire. One-third of patients thought
onstrate connections between the neurovascular bundles thatoverallqualityoflifewasdistorted,although80%were
from the pelvic plexus, nitrergic, and components of the mostly satisfied with their sexual quality of life. The most
somatic nervous system (branches of the pudendal nerve importantcomplaintswererelativetothepenileappearance.
such as the dorsal nerve of the penis and perineal nerve), Althoughsubjecttowidevariationinindividualpercep-
givingthemthecapacitytoreleaseerectogenicmediators. tion,theseaspectsmustofcoursebeconsideredinaddressing
Finally,sectionandaggressivemobilizationordenerva- these patients and integrated with the other facets of the
tion of the bulbospongiosus muscle to expose the bulbar pathology/treatmentstrategy.
urethramayresultinmoreorlesssubtlechangesinejacula-
tiondynamics,sincetherhythmiccontractionsofthemuscle
3.2.ErectileDysfunction
duringtheexpulsionphasearefundamentalinseminalfluid
expulsion[22–24].
3.2.1. Anterior Urethra: Prospective Studies. There are few
prospective studies with correct methodology, making use
2.MaterialsandMethods of fully validated questionnaires such as the IIEF (Inter-
national Index of Erectile Function) or the BMSFI (Brief
AsystematicreviewofseveraldatabasesincludingPubMed, Male Sexual Function Inventory) specifically dealing with
Cochrane Library, Embase, and Google Scholar was con- anterior urethroplasties. Table 1 [27–31] lists these studies
ducted. Systematic searches of these databases used terms and the results obtained. It is evident that all these studies
as“urethroplasty,”“urethralreconstruction,”“urethralanas- show statistical limitations. The small sample size by itself
tomosis,” “urethral stricture,” “urethral stenosis,” and “ure- can obscure statistically significant differences simply as a
thralobstruction,”andtermssuchas“erectiledysfunction,” consequence of underpowered studies. In fact, none of the
“impotence,” “sexual dysfunction,” “ejaculatory dysfunc- studies makes explicit reference to calculations in order to
tion,”and“orgasmicdysfunction.”Thesearchstrategyused define a minimum sample size that would be required to
bothkeywordsandMeSHtermsandwaslimitedtohuman show5to10%differenceinoutcomesforexample.Although
studies. with relatively small samples and relatively short follow-
The purpose of this study was to review the existing up, the overwhelming majority of studies did not find
literatureabouttheimpactofurethroplastyinalldomainsof statisticallysignificantdegradationoferectilefunctionafter
sexualfunctionandtoanalyzeit. urethroplastycomparedtobaseline.