Echographic diagnosis of female urethral diverticulum

OBJECTIVE: To describe the utility of transrectal ultrasound as an alternative imaging technique in the diagnosis of diverticulum of the female urethra. METHODS/RESULTS: A 35-year-old female that had been initially diagnosed as having a benign tumor of the vagina is described. The voiding cystogram, positive pressure urethrography with a double balloon catheter and urethroscopy were falsely negative for urethral diverticulum of the female urethra. Subsequent evaluation by transrectal ultrasound disclosed on oval-shaped, anechoic lesion located posteriorly to base of the bladder. CONCLUSIONS: Transrectal ultrasound could be the diagnostic imaging technique of choice in patients suspected as having diverticulum of the female urethra.     

Congenital urethral strictures

We present 12 patients with presumed congenital urethral stricture (mean age at diagnosis 20 years). They complained of various urological symptoms, including dysuria, transient urinary retention, urgency and reduced flow. The time from onset of symptoms to diagnosis averaged 18 months. The strictures were presumed congenital because no patient had a history of urethral infection or of instrumentation, and all the strictures were at the proximal bulbar urethra, as has been described for congenital, bulbar, urethral stricture. We treated 5 patients initially by internal urethrotomy, of whom 2 required transurethral dilatation at follow-up. 7 others were treated initially by transurethral dilatation, 4 of whom required more than 1 treatment. Follow-up has averaged 21 months. In 8 of 10 patients the maximal urinary flow at latest follow-up is greater than 20 ml/sec.     

Management of obliterative posttraumatic posterior urethral strictures after failed initial urethroplasty

PURPOSE: We evaluate the problems encountered during surgery and assess the results of different endoscopic and open surgical methods following failed urethroplasty for posttraumatic posterior urethral stricture. MATERIALS AND METHODS: Since 1992 we have treated 23 patients in whom urethroplasty for posterior urethral strictures failed. Of these patients, 3 had undergone 2 previous repairs and 6 had additional complicating factors, such as fistula, periurethral cavity and false passage. End-to-end anastomosis was done in 14 patients via a transperineal (7) or transpubic (7) approach. In 1 patient substitution urethroplasty using a radial artery based forearm free flap was performed. In 3 patients a 2-stage urethroplasty was done, 4 underwent core-through optical internal urethrotomy and 1 underwent endoscopic marsupialization of a false passage. RESULTS: At 1 to 5-year followup 3 of the 23 patients had restenoses (13%), including 2 in whom previous treatment failed. The remaining 87% of the patients void well and are continent, and there is no worsening of the preexisting potency status. CONCLUSIONS: Previous failed urethral stricture repair complicates management due to fibrosis, impaired vascularity and limited urethra available for mobilization. Recurrent strictures less than 1.5 cm. can be managed successfully with core-through internal urethrotomy. End-to-end anastomosis is possible in the majority with generous use of inferior pubectomy or the transpubic approach with certain modifications. When residual inflammation or long strictures are present a 2-stage procedure is a safer option. Overall, reoperation can offer a successful outcome for the majority of these complex strictures.     

Giant urethral calculus

This is a case report of a 56-year-old Malay male presenting with a giant urethral calculus. The stone measuring 70 X 50 X 40 mm and weighing 45 g was impacted in the posterior urethra. The giant urethral calculus was removed successfully through external urethrotomy.     

The use of urethral stents for the treatment of urethral strictures

Three types of urethral stents can be used in the treatment of recurrent strictures: Urolume/Wallstent is a self-expanding mesh which is incorporated into the urethral epithelium; the ASI Titanium stent is a short rigid mesh of Titanium wire which is also incorporated into the urethra; Nitinol is a flexible spring in one or two parts connected by a steel wire. It remains endoluminal. The Urolume/Wallstent has been used since 1987. It is indicated in iatrogenic strictures. No statistical results are presented. The ASI stent should be reserved for strictures of the prostatic and posterior urethra. The Niticol UroCoil system can be used at all levels of the urethra; two models are available: simple or twin. The author has inserted 65 stents in 56 patients. The stent was removed after one year in 41 patients. The use of these stents has considerably decreased the number of repeated dilatations and urethrotomies.     

Role of preoperative sonourethrography in bulbar urethral reconstruction

PURPOSE: The accuracy of sonourethrography for the evaluation of bulbar urethral strictures has been well documented. Thus, we sought to define the role of preoperative sonourethrography in establishing objective criteria for procedure selection during bulbar urethral reconstruction. MATERIALS AND METHODS: Sonourethrography was performed preoperatively, just before incision, in 67 men selected for bulbar urethroplasty. All patients had strictures 25 mm. or less in length on preoperative radiographic retrograde urethrography, thus potentially amenable to resection and end-to-end anastomosis. Ultrasonic measurements were prospectively recorded, compared with those on preoperative retrograde urethrography, and used to guide the selection of urethroplasty technique. RESULTS: Overall, a significant trend for retrograde urethrography to underestimate stricture length was demonstrated (r = 0.678, p < 0.0001). Indeed, sonographic measurements were frequently twice those of retrograde urethrography, occasionally more. All 26 patients with short strictures on retrograde urethrography (10 mm. or less) were successfully treated by resection and end-to-end anastomosis, and sonographic assessment did not alter management. However, ultrasonic measurement changed the reconstructive procedure selected in 15 of 41 patients (37%, 3 penile flaps, 12 graft procedures) with bulbar strictures of intermediate length on retrograde urethrography (11 to 25 mm.). CONCLUSIONS: Sonourethrography has a major influence on selection of therapy in patients with bulbar strictures of intermediate length. By prospectively identifying strictures too long for resection and end-to-end anastomosis, sonourethrography enables quantitative criteria for selection of patients who may be more appropriately treated by flap or graft procedures. We advocate excisional therapy for strictures appearing sonographically to be 25 mm. or less, and substitution urethroplasty for longer strictures.     

Multiple urethral calculi in children: report of two cases

Multiple urethral calculi are rarely found in children. We report herein two unusual cases of children found to have multiple urethral calculi. In one, the calculi formed proximal to a stricture and in the other they formed within a diverticulum. Both patients required urethrotomy for removal of the calculi. A unique cause of urethral stricture is also described in case 1.     

Incomplete urethral duplication with cyst formation in a dog

Incomplete urethral duplication with cyst formation was diagnosed in a dog that had soft, fluctuant, subcutaneous swellings in the ventral perineal and penile areas and a history of nocturia and incontinence during recumbency that were unresponsive to treatment with antibiotics. Retrograde urethrocystography, voiding urethrography, double-contrast cystography, radiography after direct administration of contrast medium into cystic structures, and excretory urography were performed to evaluate the urinary tract. Communication between the cysts and the urethra was demonstrated radiographically only after intralesional injection of contrast medium. Nocturia and incontinence resolved after surgical removal of the urethral duplication and cysts. The dog was clinically normal 1 year after surgery.     

The endoscopic treatment of extensive urethral strictures and obliteration of the urethra and bladder neck

Extensive urethral strictures, obliteration of the urethra and bladder cervix are thought to be the most complicated urological diseases. They occur more frequently in young and middle-aged persons consequently to pelvic and perineal traumas or they are complications of surgical interventions. Open surgery often cause complications such as suppuration of the operative wound, emergence of urinary fistulas, enuresis, recurrence of the structure or obliteration. Negative results of these operations are also shortening of the penis, erectile dysfunction causing serious social dysadaptation. Current advances in endoscopic instruments and imaging provided design of endoscopic techniques able to represent an effective alternative to open surgical interventions in urethral strictures, obliteration of the urethra and bladder cervix. The experience gained in the Clinic of the Research Institute of Urology in the practice of updated and novel endoscopic interventions aimed at recovery of urethral patency (strictures longer than 1 cm--inner optic urethrotomy, obliteration of the urethra and bladder cervix--endoscopic recanalization) has proved the advantages of the endoscopic techniques over open operative interventions. They are most cost-effective, result in better outcomes, bring about no erectile dysfunction.     

The effect of internal urethrotomy and urethral dilatation on the postoperative course of patients undergoing surgery for stress incontinence

Three years' experience of a total of 128 patients undergoing surgery for stress incontinence is described. Forty-three patients had an internal urethrotomy performed routinely at the end of the operation, 26 had routine urethral dilatation and 59 had neither procedure. Internal urethrotomy, and to a lesser extent urethral dilatation, resulted in prompt return of spontaneous and efficient micturition following removal of the Foley catheter on the third postoperative day. The postoperative stay averaged 6-4 days in the urethrotomy group of patients, 7-6 days in those who had urethral dilatation and 10-6 days in the others. The two-year cure rate in the patients who had neither procedure performed was 85 per cent and as yet no failures have occurred in the patients who had internal urethrotomy or urethral dilatation performed.     

Organ distribution of 99mTc-labelled aminethiols

Voiding urethrography with compression of the urethral meatus was evaluated as part of excretory urography in patients with symptoms involving the lower urinary tract. Meatal compression permits distension of the urethra distal to any area of increased resistance to flow, obviating the need for retrograde urethrography. The examination can be performed as part of routine excretory urography and avoids the hazards of urethral catheterization. In selected patients, excretion voiding urethrography with compression has given as much information as the combination of noncompression voiding urethrography and retrograde urethrography.     

Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures

PURPOSE: We review the applications and outcomes of penile circular fasciocutaneous flap urethroplasty in 66 patients at our institution. MATERIALS AND METHODS: We used a circular distal penile skin flap for urethral reconstruction in 66 men with complex urethral strictures. Average stricture length in this series was 9.08 cm. and mean followup was 41 months (range 1 to 7 years). RESULTS: The initial overall success rate was 79% (52 of 66 cases). Recurrent stenosis was noted in 7 of the 54 onlay (13%) and 7 of the 12 tubularized repairs (58%). Most recurrent strictures were successfully treated with a single subsequent procedure, including repeat urethroplasty in 5 cases and optical urethrotomy or dilation in 6. Two patients required perineal urethrostomy and 1 awaits further reconstruction. Including subsequent procedures, the overall long-term followup success rate was 95%. Neurovascular lower extremity complications developed in 4 patients after prolonged high lithotomy positioning. CONCLUSIONS: Circular fasciocutaneous flap urethroplasty is a highly effective 1-stage method of reconstructing complex urethral strictures. Onlay repairs appear to be more successful than those involving flap tubularization. Limiting the time that the patient spends in the high lithotomy position appears to prevent neurovascular extremity complications.     

Thoracic CT in the intensive care unit: assessment of clinical usefulness

PURPOSE: To enlarge the prostatic urethra with thermal coagulation with transrectal radio-frequency (RF) application in dogs. MATERIALS AND METHODS: Eight aged dogs underwent RF ablation of periurethral prostatic tissue for 6 minutes. Eighteen-gauge electrodes were placed into the periurethral tissues with a transrectal approach and ultrasound (US) guidance. Prostatic and rectal temperatures were measured during RF application. US, conventional and computed tomographic (CT) retrograde urethrography (RUG), and CT were performed immediately (n = 8) and at 3-96 days (n = 6) after ablation. Histopathologic analysis was performed at sacrifice immediately (n = 2), at 28 days (n = 2), or at 3 months (n = 4) after treatment. RESULTS: All procedures were successful with no complications and were performed in less than 30 minutes. Rectal mucosal temperature did not exceed 38 degrees C. Immediately after treatment, CT and US demonstrated 1.2-cm foci of altered periurethral tissue that corresponded to solid coagulated tissue at histopathologic analysis. By day 3, CT, RUG, and US demonstrated that these foci had begun to cavitate, resulting in enlargement of the urethra. Complete cavitation was demonstrated by day 28. Minimal reduction in the degree of urethral enlargement was noted by day 60, but narrowing, urethral strictures, or fistulas were not observed at 3 months. At histopathologic analysis, focal cavitary enlargement with at least doubling of the urethral diameter and with normal urothelium was noted in all dogs surviving at least 28 days. CONCLUSION: Transrectal RF urethral enlargement is feasible and safe in animals and merits investigation for alleviating urethral obstruction due to benign prostatic hyperplasia.     

Diverticula of the female urethra

OBJECTIVES: The contribution of ultrasonography to pretreatment morphological assessment of strictures of the anterior urethra and assessment of the risk of recurrence after internal urethrotomy. MATERIAL AND METHODS: 33 patients (16-89 years) operated by internal urethrotomy for stricture of the anterior urethra and followed for at least 6 months. Preoperative urethral ultrasonography, recording the number, length and degree of strictures and echostructure of the peristenotic fibrosis of the corpus spongiosium. RESULTS: Ultrasound visualization of all urethral strictures, with no false-positives and no false-negatives. 11 patients relapsed after a mean interval of 5.7 months (1-16 months), 22 patients did not present recurrence: mean interval: 15.5 months (6-36 months). Corpus spongiosum fibrosis associated with urethral stricture is isoechoic to the corpus spongiosum (19 cases) or hyperechoic to the corpus spongiosum (14 cases). No statistical correlation was observed between the echostructure of the fibrous tissue and the risk of recurrence after internal urethrotomy. CONCLUSION: Ultrasonography allows excellent analysis of the morphological characteristics of a stricture of the male anterior urethra. In our experience, and in contrast with the limited data of the literature, no correlation was observed between the echostructure of the peristenotic fibrosis and the risk of recurrence after internal urethrotomy.     

A prospective randomized controlled trial comparing suprapubic with urethral catheterization in rectal surgery

BACKGROUND: Bladder drainage is necessary for several days following rectal surgery. Urethral catheterization has long been known to be associated with significant morbidity. Therefore a prospective randomized trial was performed to determine if this morbidity could be decreased by suprapubic catheterization. METHODS: One hundred and thirty-seven patients undergoing rectal surgery were prospectively randomized to either suprapubic or urethral catheterization. RESULTS: After exclusions, 108 patients were analysed. Of the 49 patients with suprapubic catheters there was 14% morbidity, and of the 59 patients with urethral catheters there was 32% morbidity. Significant bacteriuria was halved with suprapubic catheterization. Patient acceptability of suprapubic catheterization was high, and there was no increased morbidity in any of the areas studied. CONCLUSIONS: This study suggests that suprapubic catheterization has advantages over urethral catheterization with decreased bacteriuria, and greater patient acceptability. However, the significance of decreased bacteriuria is not clear and therefore we can only say suprapubic catheter drainage is comparable to urethral catheter drainage.     

Female urethral diverticulum

Female urethral diverticulum is a rare condition. The reported incidence varies from 1.4-5%, depending on the population studied. The correct diagnosis is often delayed because of unspecific symptoms from the patients' lower urogenital tract. The classic triad of female urethral diverticulum is dribbling of purulent matter, dyspareunia and dysuria. The majority of patients have a palpable mass located on the anterior vaginal wall. The presentation and management of 11 women with urethral diverticulum who where admitted to the Surgical Department of the Central Hospital in Akershus during the period 1.1. 1975 to 1.4. 1996 is reviewed. Investigations included vaginal examination, urethrocystoscopy, urography and urethrography with a double balloon catheter. A palpable mass was found in all 11 patients. The urethrography was positive in eight out of ten patients. Diverticulectomy was performed on nine patients. In follow-up interviews from three months to 21 years after treatment, one patient was found to suffer from incontinence after surgery, two patients noticed recurrence of some symptoms, and six patients were completely relieved of their complaints.     

Treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful?

PURPOSE: We evaluate the efficacy of repeated dilation or urethrotomy as treatment of male urethral strictures. MATERIALS AND METHODS: Between January 1991 and January 1994, 210 men with proved urethral strictures were prospectively randomized to undergo filiform dilation (106) or internal urethrotomy (104). Followup was scheduled at 3, 6, 9, 12, 24, 36 and 48 months. Dilation or internal urethrotomy was repeated at the first and second stricture recurrence. The Kaplan-Meier method was used to estimate survivor function for the treatment methods (survival time being the time to first stricture recurrence) and the log rank test was used to compare the efficacy of different treatments. RESULTS: Followup (mean 24 months, range 2 to 63) was available in 163 patients (78%). After a single dilation or urethrotomy not followed by re-stricturing at 3 months, the estimated stricture-free rate was 55 to 60% at 24 months and 50 to 60% at 48 months. After a second dilation or urethrotomy for stricture recurrence at 3 months the stricture-free rate was 30 to 50% at 24 months and 0 to 40% at 48 months. After a third dilation or urethrotomy for stricture recurrence at 3 and 6 months the stricture-free rate at 24 months was 0 (p <0.0001). CONCLUSIONS: Dilation and internal urethrotomy are useful in a select group (approximately 70% of all patients) who are stricture-free at 3 months, and of whom 50 to 60% will remain stricture-free up to 48 months. A second dilation or urethrotomy for early stricture recurrence (at 3 months) is of limited value in the short term (24 months) but of no value in the long term (48 months), whereas a third repeated dilation or urethrotomy is of no value.     

Relative contributions of smooth and striated muscles to the canine urethral pressure profile

Canine urethral pressure profiles were analysed using pharmacological and nerve sectioning techniques. The presence of significant sympathetic and somatic neural components was detected and their locations along the proximal urethra were identified. The neural components peaked at different points in the urethra but overlapped. The non-neural component appeared to form an even base along the whole proximal urethra. It was concluded that in the proximal part of the profile the non-neural and the sympathetic components are significant. The sympathetic component becomes larger in the peak pressure zone. More distally and overlapping with the sympathetic component is the contribution of the striated external sphincter.     

Surgical repair of urethral circumcision injuries

PURPOSE: The 2 types of urethral injury that can occur during circumcision are urethrocutaneous fistula and urethral distortion secondary to partial glans amputation. We report the surgical repair of these rare injuries. MATERIALS AND METHODS: In 8 patients urethrocutaneous fistulas located on the distal penile shaft or at the coronal margin were managed by splitting the glans and using a Mathieu style skin flap in 4 or vascularized penile skin flap in 4 to bridge the urethral defect. Three patients underwent repair of a hypospadiac deviated urethra secondary to partial glans amputation by 1 cm. of urethral mobilization and repositioning the meatus into a terminal position within the remaining glans tissue. RESULTS: The 8 patients with urethrocutaneous fistulas voided via a terminal meatus without fistula recurrence at a mean followup of 3.2 years (range 1 to 6). The 3 patients with partial glans amputation and urethral deviation repaired by short urethral advancement had functionally acceptable results, defined as a normal urinary stream, although 1 required meatal dilation postoperatively. CONCLUSIONS: The 2 types of urethral injuries that can occur during circumcision are a subcoronal urethrocutaneous fistula and scarred abnormal urethra from partial glans amputation. The urethrocutaneous fistula can be successfully repaired by splitting the glans and forming a neourethra from a vascularized pedicle flap of penile skin. The abnormal urethra after partial glans amputation is more difficult to repair but repositioning the urethra in a more cosmetic location has restored function.     

Preservation of the anterior urethral ligamentous attachments in maintaining post-prostatectomy urinary continence: a comparative study

PURPOSE: The impact was determined on post-prostatectomy urinary incontinence of a technique preserving the anterior attachments of the proximal urethra to the posterior pubis by comparison to the results of other surgical methods. MATERIALS AND METHODS: Urinary continence in 51 patients undergoing preservation of the anterior urethral attachments was compared to that of 70 patients undergoing an anatomical prostatectomy with resection of the bladder neck, 55 patients with preservation of the bladder neck and 14 patients undergoing a dorsal vein gathering procedure. Comparisons were made for rate of total continence, time to return of continence, incidence of extra organ disease and operative blood loss. RESULTS: Total continence at 1 year was 84.3%, 89.1%, 85.7% and 100% respectively. Immediate total continence after catheter removal was seen in 25.5% after preservation of the anterior urethral attachments, 80.4% at 3 months compared to 41.4%, 50.9% and 50% at 3 months for anatomical prostatectomy with bladder neck resection, preservation and dorsal vein gathering. Clinical staging with the incidence of specimen confined disease was similar in all groups. Mean operative blood loss was 1,031 ml. for those patients undergoing anatomical prostatectomy compared to 681 ml. for those with preservation of the anterior urethral attachments. CONCLUSIONS: Preservation of the anterior urethral attachments results in improved urinary continence and lower operative blood loss without an increase in positive surgical margins.