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An alternative technique for treating complex ureteral strictures and defects

==inizio objective==

Mid-ureteral strictures and defects represent one of the most serious reconstructive challenges for urologists. We describe a new technique of ureteral reconstruction using a peritoneal graft in 8 highly selected cases.

==fine objective==

==inizio methodsresults==

Between January 2006 and December 2015, 8 patients with mid-ureteral narrowing and obstruction were treated using a peritoneal graft. Stricture/defect length ranged from 4 to 12 cm. Due to their length, all cases would have otherwise required an ileal ureter, nephrectomy or autotransplantation. Two cases were secondary to long strictures from retroperitoneal fibrosis after vascular surgical procedures, three cases followed an extensive resection, required for large intraureteral masses (2 papillomas and 1 pTaG1) resulting in insufficient ureteral width for closure, 2 cases were secondary to repeated endoscopic procedures for urinary stones and 1 case followed repeated pyeloplastics.
After ureteral incision a free peritoneal graft was harvested from nearby healthy peritoneum. An onlay patch was fixed with running suture to the remaining ureteral plate after placement of an indwelling ureteral catheter. Finally, the ureter was complete wrapped with greater omentum.

==fine methodsresults==

==inizio results==

Patient follow-up has ranged from 6 to 76 months (average 34.5 months). All postoperative courses were uneventful. The urethral catheter was removed after intravenous pyelography on the 10thpostoperative day. The ureteral stent was removed six weeks post-operatively in 3 patients and after 3 months in the other 5 patients. Five patients were free from stricture recurrence after 6, 30, 36, 54 and 60 months, showing no obstruction and good passage of the contrast without dilatation of the upper urinary tract on the uro-CT or urography. In one patient occurred a stricture recurrence below the reconstructed ureter after 60 months without symptoms and with mild hydronephrosis: the patient died 16 months later with stable disease at 92 years. One patient became symptomatic after removal of the stent; after temporary stenting, also this patient became asymptomatic with narrowing of the ureter below the reconstructed patent ureteric segment and mild hydronephrosis. In the last patient, who had an ureter fissus, the intravenous urography showed obstruction of the reconstructed segment of ureter with hydronephrosis of the upper pole system 6 months after the surgical procedure; the patient was asymptomatic and didn’t required surgery.

==fine results==

==inizio discussions==

Mid-ureteral strictures and defects represent one of the most serious reconstructive challenges for urologists and might require more complex treatment like bowel replacement or autotransplantation. These procedure are of considerable magnitude and associated with high rates of complications and long term morbidity [1-2]. As alternative to these complex procedures, Naude and other Authors [3-4] have reported the successfull use of buccal mucosal patch graft for the reconstruction of a variety of ureteric lesions without major complications. Based on this findings we have treated these patients with long mid-ureteral strictures using a peritoneal patch graft, wrapped with greater omentum. The advantage of this technique is the unlimited availability of the material, which can be simply harvested from nearby healthy peritoneum without related complications. Furthermore this technique of reconstruction is simple and devoid of complications; it allows a good drainage of the upper tract and patency of the ureter, preserving as much as possible the vascular supply and reducing the risk of ischemic necrosis. The limitations of this study are the small sample series and its retrospective nature. This approach should be considered in all patients, who would need ureteric replacement for long mid-ureteral strictures, and specially in those with renal impairment, to avoid metabolic problems or increasing morbidity.

==fine discussions==

==inizio conclusion==

We describe a novel technique for treating long mid-ureteral strictures or defects using a peritoneal graft. The technique allows for preservation of any remaining vascular supply of the ureter and can be a feasible and usefull alternative to nephrectomy, ileal ureter and autotransplantation in highly selected cases.

==fine conclusion==

==inizio reference==

1. Schoeneich G, Winter P, Albers P, Frohlich G, Muller S. Management of complete ureteral replacement. Experiences and review of the literature. Scand J Urol Nephrol 1997; 31 (4): 383-388
2. Bonfig R, Gerharz EW, Riedmiller H. Ileal ureteric replacement in complex reconstruction of the urinary tract. BJU Int 2004; 93: 575-580.
3. Naude JH. Buccal mucosal grafts in the treatment of ureteric lesions. BJU International 1999; 83:751-4
4. Kroepfl D, Loewen H, Klevecka V, Musch M. Treatment of long ureteric strictures with buccal mucosal grafts. BJU Int 2009; 105: 1452-1455

==fine reference==

A new original surgical technique for Peyronie disease: albugineal graft-free lengthening z-plasty. Results with mean follow up over 24 months

==inizio objective==

We present an original lengthening albugineal Z-plasty for the treatment of penile curvature due to Peyronie Disease (PD) with the aim to reduce the post-operative Erectile Dysfunction (ED) due to Veno-Occlusive Dysfunction (VOD) as major functional complication of incision and grafting surgical procedures performed for PD(1,2).

==fine objective==

==inizio methodsresults==

Surgical technique: circumcision and deglooving of the penis; dorsal neurovascular bundle isolation and setup plaque size and direction by saline hydraulic erection; Z-shape plaque incision and translocation of albugineal flaps using 4/0 Vycril suture; saline hydraulic erection to confirm absence of residual curvature. From May 2013 to September 2016, 20 patients affected by PD have been enrolled in a surgical experimental pilot study with local Aethical Comitee certification. Inclusion criteria comprise: age up to 18 years (yr), penile curvature due to PD in stable phase(3) (=>6 months), no ED (IIEF-5>19; EHS>3(4)), specific informed file subscription. History (IIEF-5 and PDQ Scale Q2 to Q6(5)), physical examination (EHS), dynamic penile ecocolorDoppler ultrasound examination (longitudinal plaque size, curvature degree) have been reported for each patients as soon as operating time procedure, intraoperative complications, post-surgical complication. Each patients has been re-evaluated after surgery at 1, 3, 6 and 12 mo.

==fine methodsresults==

==inizio results==

Median values of age, curvature degree, plaque diameter, IIEF-5, PDQ Scale and operating time has been: 59 yr; 66° dorsal site; 24,4 mm; 22,8 points, 3,33 points; 140 minutes. Fourteen patients has been available for evaluation with post-surgery follow up (FU) up to 18 mo. Complete resolution of the curvature has been jointed all cases with a complete subjective satisfaction with median IIEF-5 22,8; median PDQ Scale 3,33; non residual ED. Minor gland hypoesteshia in all of the ten patients from 6 to 12 mo. from surgery.

==fine results==

==inizio discussions==

Our results seem to be effective in term of restoration of the penile shape with a complete functional straight of the penis and also effective in terms of erection rigidity for sexual intercourse (all patients refers absence of ED with a post-operatory mean IIEF-5 score of 22,8) in a range follow up observation over 24 months. We assay the subjective satisfaction of the patients using the PDQ Scale (from Q2 to Q6) score, that decrease from a mean value of 16,7 at baseline to 3,33 post-operatory and, with a “clinical” intent, using three direct questions submitted to them at the time of the 12 month follow up visit. All the fourteen patients eligible for the evaluation describe as full satisfaction (Q1, answer 1) after surgery and, at the same time, they answer “yes” at the Q2 and Q3 question. The answers at these last two questions represent the most important result that encourage us to continue in this surgical strategy for PD, because patients suggest that they would re-do the surgery and they would be suggest the same surgery to relations or friends meaning the complete real subjective satisfaction in terms of sexual behavior and sexual wellbeing.
Moreover, we focus our attention on the operating time and immediate or delayed post-operative complication. Mean operating time has been 140 minutes (ranging from 120-170) is lower than the 180 minutes that could be considered the limit to perform surgery with spinal anesthesia. We have had not any immediate complication and all our patients was discharged in post-op day one achieving a short hospitalization time that, considering that this is a graft-free procedure, leads to reduction of the economic impact of this kind of surgery on the budget destined to our unit. The only delayed post-op complication referred by patients has been a persistence of glandular hypo-anesthesia that otherwise improving until a complete resolution in six months after surgery. This complication is basically due to the extensive penile dorsal neurovascular bundle (DNVB) isolation and it is a common post-op complication in all the surgical procedure for PD in which it is necessary to proceed to isolate the DNVB and producing a transitorial neuropraxy of the DNVB itself.

==fine discussions==

==inizio conclusion==

Results obtained suggests that the length of the PD plaque, and the traslocation of the PD scar forces, on the short site of the penis with a graft free Z-plasty seems to be effectiveness to reduce penile curvature and avoid post-operative ED due to VOD.

==fine conclusion==

==inizio reference==

(1) Montorsi F, Salonia A, Maga T, et al. Evidence based assessment of long-term results of plaque incision and vein grafting for Peyronie’s disease. J Urol 2000; 163: 1704-8
(2) Ralph DJ. Long-term results of the surgical treatment of Peyronie’s disease with plaque incisione and grafting. Asian Journal of Andrology 2011; 13: 797
(3) Hatzimouratidis K, Eardley I, Giuliano F, Hatzichristou D, Moncada I, Salonia A, Vardi Y, Wespes E. European Association of Urology Guidelines on penile curvature. Europena Urology 2012; 62: 543-552
(4) Mulhall JP, Goldstein I, Bushmakin AG, Cappelleri JC, Hvidsten K. Validation of the erection hardness score. J Sex Med 2007 Nov; 4(6): 1626-34
(5) Rosen R, Catania J, Lue T, S Althof, J Henne, W Hellstrom, L Levine. Impact of Peyronie’s disease on sexual and psychosocial functioning: qualitative finding in patientd and controls. J Sex Med 2008; 5: 1977-1984

==fine reference==

A modified ileo conduit tecnique to avoid ureteroenteric stricture

==inizio objective==

Despite the popularity of continent urinary diversion and neobladder recostruction, radical cistectomy with ileal conduit urinary diversion remains the most commonly performed curative surgical treatment option for invasive bladder cancer. Commonly, the ileal conduit is created using a 15-20 cm ileum length. The distal left ureter passage under mesosigmoid previous its extensive dissection, in order to allow a tension-free ureteroileal anastomosis, often leads to a compromised blood supply to the left ureter, resulting in a higher incidence of delayed ischemic damage of the distal ureter, wich is the most common cause of ureteroenteric stricture. In literature, ileoureteral stricture rate reported is 1,7-14%, being more common on the left side. Of some interest is the fact that no significant diferrence is been reported in strictures occurrance rate between Bricker anastomosis type and Wallace type. The strictures resulting from urinary diversion are difficult to treat, have a high risk of recurrence and may lead to renal function deterioration. We presented our results with a modified ileal conduit tecnique (MICT) and left ileoureteral anastomosis aimed to prevent uretero-ileal anastomosis stricture.

==fine objective==

==inizio methodsresults==

We prepared an ileal tract of 20 cm medium lenght. The proximal end of the ileal conduit tract was brought on the left side through the mesosigmoid and was fixed to the parietal peritoneum, to avoid an extensive dissection and mobilization of the left ureter and to perform a tension free anastomosis. On the right side, we performed a classical Bricker ureteroileal anastomosis, while on the left side the ureter was sutured directly to the end of ileal conduit, according to our modified ureteroileal anastomosis in Y shape ileal neobladder. Between 2001 and 2010, 98 consecutive patients underwent to radical cistectomy with ileal conduit diversion with Bricker anastomotic tecnique; from 2011 to 2015, 46 consecutine patients underwent to new tecnique.

==fine methodsresults==

==inizio results==

The MICT was easily performed in all cases, leading to neither intraoperative nor postoperative complications, without increasing intraoperative time. The ileoureteral stricture rate was 9.1% (8/98 patients, 1/8 patients with bilateral stricture) in the traditional tecnique; no patient had ureteral stricture with the modified tecnique.

==fine results==

==inizio discussions==

There are several potential etiologies for ureteroileal stricture formation. Ischemia of the distal ureter due to prior radiation therapy, during surgical dissection. Tension caused by tunneling the left ureter below the sigmoid mesocolon has also been implicated as left sided strictures have been observed more comonly. The latter etiology may be of additional relevance in an increasingly obese population. No significant diferrence is been reported in strictures occurrance rate between Bricker anastomosis type and Wallace type.

==fine discussions==

==inizio conclusion==

Our preliminary experience with the MICT are very encouraging; further randomized studies with a larger series are needed to confirm our results.

==fine conclusion==

==inizio reference==

– A.Evangelidis, E. K. Lee, M. E. Karellas, J. B. Thrasher and J. M. Holzbeierlein. Evaluation of Ureterointestinal Anastomosis: Wallace vs Bricker. J Urol Vol. 175, 1755-1758, May 2006
– N. F. Davis, MD; J P. Burke, MD; T McDermott, MD; R. Flynn, MD; R. P. Manecksha, MD; J. A. Thornhill, MD. Bricker versus Wallace anastomosis: A meta-analysis of ureteroenteric stricture rates after ileal conduit urinary diversion. CUAJ, Volume 9, Issues 5-6, May-June 2015
– M. Cheng MD, S. W. Looney MD, J. A. Brown MD. Ureteroileal anastomotic strictures after a Bricker ileal conduit 50 case assestment of the impact of conversion from a slit incision to a “shield shaped” ileotomy. The Canadian Journal of Urology; 18 (2); April 2011

==fine reference==

ANALYZING SATISFACTION RATE IN PATIENTS WITH PEYRONIE’S DISEASE UNDERWENT ALBUGINEAL GRAFTING AND PENILE IMPLANT

==inizio objective==

Peyronie’s disease (PD) is a benign, localized connective tissue disorder characterized by the abnormal deposition of collagen with the formation of fibrous, inelastic plaques in the tunica albuginea of the corpora cavernosa, which causes penile deformity during erection and Erectile Dysfunction (ED)[1].This disorder is frequently associated with anatomical alterations of the shaft and penile shortening and has a major impact on quality of life and significant psychological effects [2].The aim of this study is to analyze the satisfaction rate in patients underwent albugineal grafting and penile implant.

==fine objective==

==inizio methodsresults==

From March 2015 to April 2016 13 patients with PD were recruited. with stable disease at list for six months. 9 patients reported ED assessed by questionnaire IIEF – 5 (14 + – 2), degree of curvature> 50 ° in 9 patients, complex deformities in 3 patients and in one patient there was a penile shortening due cavernosal fibrosis.
The surgical procedure started with a sub coronal approach. The penis was degloved.  Buck’s fascia was dissected from the albuginea.With an artificial erection we identified the maximum curvature point, thanks to dermographic pen in order to asses the angle of curvature. A double Y incision is performed on the tunica albuginea.
The defect was musered and covered with a patch of porcine derma and sutured to the albuginea with a continuous suture in 4-0 polydioxanone.
Penile prosthesis (AMS 700 CX) was inserted using using a peno-scrotal incision and inflated at 80% of the maximum capacity for the next two weeks. The patients were discharged 2-3 days after surgery.
All patients were proposed therapy Vacuum[3] device for the next 6 months.
The assessment of patient satisfaction was measured with modified EDITS[4] questionnaire at 6 months after surgery.
This consists of 5 macro areas (overall satisfaction, self-confidence, loss of post-operative sensitivity, length of postoperative penile length loss of the post -operatoria penis); the patient could validate only one choice among the three proposals (satisfied, not very satisfied and not satisfied).

==fine methodsresults==

==inizio results==

The results at 6 months after surgery were:
84% (11 patients) of the patients was satisfied with the result of surgery.
2 patient (7.7%) was half satisfied with the result.
10 patients (76.9%) of patients had received greater security in the relationship with their partners after the surgery.
The third macro areas regard the loss of post-operative sensitivity of the 13 analyzed patients, 9 (69.2%) reported no loss of post – operative sensitivity, and only 4 (38.4%) reported minimal loss of sensitivity.
92.3% of patients, when asked about the length of the penis were satisfied, and only 1 patient (7.7%) not at all satisfied.
Finally, in no patient it was found loss of penile length.

==fine results==

==inizio discussions==

Surgery is the only effective tool in the management of severe PD. Unfortunately albugineal grafting results in a high rate of postoperative ED. Albugineal grafting and penile prosthesis implantation is the only technique able to restore penile size and guarantee pts’ satisfaction.

==fine discussions==

==inizio conclusion==

The psychological implications of Peyronie’s disease is a factor to be considered when setting the therapy with surgery.
In this study, we have shown that the ‘surgery and penile prosthesis implantation, associated with post-operative rehabilitation with vacuum device, leads to a high satisfaction rate and greater self-confidence.

==fine conclusion==

==inizio reference==

1. Pryor J., Akkus E., Alter G., Lebret T., Levine L., et. All. Peyronie’s disease. J Sex Med. 2004;Jul;1(1):110-5.
2. Egydio PH. Surgical treatment of Peyronie’s disease: Choos- ing the best approach to improve patient satisfaction. Asian J Androl 2008;10:158–66.
3. Raheem AA, et al. The role of vacuum pump therapy to mechanically straighten the penis in Peyronie’s disease. BJU Int 2010 p.1178-80
4. 1. Stanley E. Althof, Eric W: Edits: Development of Questionnaires for evaluating satisfaction with treatments for erectile dysfunction. Adult Urology 1999.

==fine reference==

Treatment of urethral strictures using buccal mucosa graft. A single group experience

==inizio objective==

Urethral stricture is complex urological disease characterized by a narrowing of the urethral lumen. These conditions affects patients psychologically too having a severe impact on health and quality of life of these patients. Management of urethral strictures is difficult and requires careful evaluation. There are different treatment options for urethral stricture. Urethral dilation and internal urethrotomy represent the most commonly performed procedures but they have very low success rate.. Urethroplasty has a much higher chance of success (85-90%) and is considered the gold-standard treatment. Buccal mucosa seems to be the best graft for uretroplasty [1].

==fine objective==

==inizio methodsresults==

In this study 20 patients (pts) were enrolled : 2 pts with penile stricture, 3 pts with penile stricture and failed hypospadia repair, 1 pt penile stricture with lichen sclerosus and failed hypospadia repair, 14 pts with bulbar stricture. Median age was 51 years.
Stricture etiology was idiopathic, failed hypospadias and flogistic. All pts underwent previous surgery. 2 pts had sovrapubic catheter.
1 patient with failed hypospadia and lichen sclerosus underwent 2 stages uretroplasty (2 stage at six months after the first surgery).
Average stricture length was 3.2 cm.
All patient underwent preoperatively evaluation using : uroflowmetry , retrograde urethrography, ultrasound, cystoscopy. Maximum flow rate (Qmax) and post-void residual urine were collected before surgery and at 3 and 6 months follow-up.

==fine methodsresults==

==inizio results==

All patients were very satisfied with the result of the surgery.
In 2 pts (10%) a second surgery was needed in order to dilate the urethral lumen endoscopically.
At 6 months follow-up the mean Qmax increased from 4.64mL/s to 21mL/s at 6 months follow-up.
Mean post-void residual urine was 48 mL.

==fine results==

==inizio discussions==

The use of buccal mucosa graft urethroplasty for bulbar urethral strictures has gained widespread popularity since the first report in 1996 [2].
Buccal mucosa seems to be the ideal tissue to reconstruct the urethra. Regarding bulbar strictures, the best approach for the placement of the graft remains controversial.
Medium- and long-term outcomes of all three approaches were comparable ranging between 80 and 88% [3].
For failed hypospadia patients with concomitant uretral strictures the management seems to be more complex due the number of previous surgeries starting from pediatric age.

==fine discussions==

==inizio conclusion==

In our opinion uretroplasty is the only procedures that provides satisfying results. Uretrotomy is suggested in naive pts with strictures < 1 cm with a success rate of 30%. End-to-end anastomosis is valid with short strictures or in posterio strictures. At the state of art, buccal mucosa is still the best graft for long strictures affecting the urethra. ==fine conclusion== ==inizio reference== ==fine reference==