Management of penile urethral strictures: Challenges and future directions

The anatomy of the penile urethra presents additional challenges when compared to other urethral segments during open stricture surgery particularly because of its unsuitability for excision and primary anastomosis and its relatively deficient corpus spongiosum. Stricture aetiology, location, length and previous surgical intervention remain the primary factors influencing the choice of penile urethroplasty technique. We have identified what we feel are the most important challenges and controversies in penile urethral stricture reconstruction, namely the use of flaps vs grafts, use of skin or oral mucosal tissue for augmentation/substitution and when a single or a staged approach is indicated to give the best possible outcome. The management of more complex cases such as panurethral lichen-sclerosus strictures and hypospadias "cripples" is outlined and potential developments for the future are presented.

Single-stage tubular urethral reconstruction using oral grafts is an alternative to classical staged approach for selected penile urethral strictures

Penile urethral strictures have been managed by a staged surgical approach.In selected cases,spongiofibrosis can be excised,a neo-urethral plate created using buccal mucosa graft(BMG)and tubularized during the same procedure,performing a“twoin-one”stage approach.We aim to identify stricture factors which indicate suitability for this two-in-one stage approach.We assess surgical outcome and compare with staged reconstruction.We conducted an observational descriptive study.The data were prospectively collected from two-in-one stage and staged penile urethroplasties using BMG in a single center between 2007 and 2017.The minimum follow-up was 6 months.Outcomes were assessed clinically,radiologically,and by flow-rate analysis.Failure was defined as recurrent stricture or any subsequent surgical or endoscopic intervention.Descriptive analysis of stricture characteristics and statistical comparison was made between groups.Of 425 penile urethroplasties,139 met the inclusion criteria:59 two-in-one stage and 80 staged.The mean stricture length was 2.8 cm(single stage)and 4.5 cm(staged).Etiology was lichen sclerosus(LS)52.5%(single stage)and 73.8%hypospadias related(staged).40.7%of patients had previous failed urethroplasties in the single-stage group and 81.2%in the staged.The most common stricture locations were navicular fossa(39.0%)and distal penile urethra(59.3%)in the single-stage group and mid or proximal penile urethra(58.7%)in the staged group.Success rates were 89.8%(single stage)and 81.3%(staged).A trend toward a single-stage approach for select penile urethral strictures was noted.We conclude that a single-stage substitution penile urethroplasty using BMG as a“two-in-one”approach is associated with excellent functional outcomes.The most suitable strictures for this approach are distal,primary,and LS-related strictures.

Syringoceles of Cowper’s ducts and glands in adult men

Cowper’s syringoceles are uncommon,usually described in children and most commonly limited to the ducts.We describe more complex variants in an adult population affecting with varying degrees of severity,the glands themselves,and the complications they may lead to.One hundred consecutive urethrograms of patients with unreconstructed strictures were reviewed.Twenty-six patients(mean age:41.1 years)with Cowper’s syringoceles who were managed between 2009 and 2016 were subsequently evaluated.Presentation,radiological appearance,treatment(when indicated),and outcomes were assessed.Of 100 urethrograms in patients with strictures,33.0%demonstrated filling of Cowper’s ducts or glands,occurring predominantly in patients with bulbar strictures.Only 1 of 26 patients with non-bulbar strictures had a visible duct/gland.Of 26 symptomatic patients,15 presented with poor flow.In four patients,a grossly dilated Cowper’s duct obstructed the urethra.In the remaining 11 patients,a bulbar stricture caused the symptoms and the syringocele was identified incidentally.Eight patients presented with perineal pain.In six of them,fluoroscopy and magnetic resonance imaging(MRI)revealed complex multicystic lesions within the bulbourethral glands.Four patients developed perineoscrotal abscesses.In the 11 patients with strictures,the syringocele was no longer visible after urethroplasty.In three of four patients with urethral obstruction secondary to a dilated Cowper’s duct,this resolved after transperineal excision(n=2)and endoscopic deroofing(n=1).Five of six patients with complex syringoceles involving Cowper’s glands were excised surgically with symptomatic relief in all.In conclusion,Cowper’s syringocele in adults is more common than previously thought and may cause lower urinary tract symptoms or be associated with serious complications which usually require surgical treatment.

Funneling of the bladder neck - radiological appearance after radical retropubic prostatectomy and clinical relevance

Several authors have commented on the anatomical changes following radical prostatectomy(RP)for prostate cancer and their characteristic radiological appearances.1,2 Most of these relate to periurethral fibrosis and its clinical significance in patients with postprostatectomy sphincter weakness incontinence.3,4 On magnetic resonance imaging(MRI),this postsurgical fibrosis appears as a focus of low-signal intensity in the periurethral tissues at and around the level of the vesicourethral anastomosis(VUA)which is appreciable on both T1-and T2-weighted images.