Clinical challenge

Prof. Oliver Hakenberg Section editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de

Case study No. 73

A 29-year-old man had previous hypospadias surgery with good functional and cosmetic results on the distal urethra. But a few years later, he complains of dysuria. A voiding urethrogram showed a short bulbar stricture (Fig. 1). Two direct vision internal urethrotomies were performed without lasting success. Following that, another excision and primary anastomosis was done, also with complete failure.

Fig. 1

Discussion point 1:

What was wrong in the decision-making? An open redo-surgery was done. One year later, the patient presents with dysuria and a urethrocutaneous fistula. A new urethrogram was performed (Fig. 2).

Discussion point 2

Which surgical option is advisable?

Fig. 2

Case provided by Dr. Amin Bouker, Coral Médical, Tunis, Tunisia Email: aminbouker@gmail.com

Excisional augmented bulbar urethroplasty recommended

Comments by Dr. Tamsin Greenwell London (GB)

In men with hypospadias there is underdevelopment of the glans penis and inadequacy of the retrograde blood supply from the glans – making a transecting urethroplasty a poor option. It is safest to perform a non-transecting technique with or without graft substitution.

The man now has an almost obliterative short segment of distal bulbar stricture with fistulation, contiguous proximally with a mid-proximal bulbar stricture. His options are: Augmented bulbar urethroplasty with excision of the short segment obliteration and fistula or staged bulbar urethroplasty. The augmentation could be standard dorsal or ventral or may require a dorsal and ventral substitution in order to create an adequate calibre urethra.

Significant deconditioning is almost certain to occur and thus any major surgical intervention may need to be deferred for some time.

Compromised blood supply is reason for failure

Comments by Dr. Steven Brandes New York (US)

1. The blood supply of the male urethra is bipedal. The proximal urethral blood supply is by the bulbar artery, but the distal penile urethra is from the dorsal artery of the penis, perforators and circumflex vessels. Patients with hypospadias have deficient retrograde collateral blood flow. The urethra is just a skin tube and not a well vascularised corpus spongiosum. For that reason trying to do an anastomotic urethroplasty in the bulbar urethra with hypospadias is often compromised by poor collateral blood flow.

This is the reason why the EPA failed in this case. 2. From a technical point of view, the retrograde urethrogram has some deficiencies. The patient is over-rotated. Ideally one would just like the contralateral obturator fossa to be closed on imaging by placing the patient at 15 or 20 degrees oblique. Also, one would prefer the penis to be on full stretch so there is no bend at the penoscrotal junction and the right leg to be bent at the knee and pulled cephalad more. Ideally, there should be no bone overlying the urethra. As a rule of thumb, I usually say the inferior pubic ramus in the oblique images is about 2 cm in width.

So the urethral stricture here in the RUG is about 4 cm in the proximal bulb - starting about 1 cm from the ES.

The retrograde urethrogram is not an ideal and sufficient evaluation, and one would prefer also a voiding cystourethrogram to determine the functional significance of the stricture. I also always employ a flexible paediatric cystoscope which is 7.5 French in diameter to better assess the degree of narrowness of the stricture. If the scope can pass through the stricture, I can always do an augmentation with a buccal graft. If any segment of the stricture is less than 7.5 French, it is typically necessary to do some excision of the stricture.

As the stricture is very proximal, I prefer to do a ventral augmentation with buccal graft. It is technically easier to sew ventrally when so proximal. I also prefer to use the perineal Bookwalter for such cases - as it helps to compress the rectum out of the way.

The Clinical challenge section presents interesting or difficult clinical problems which in a subsequent issue of EUT will be discussed by experts from different European countries as to how they would manage the problem.

Readers are encouraged to provide interesting and challenging cases for discussion at h.lurvink@uroweb.org

Case study No. 74

This 70-year-old man underwent left radical nephrectomy with cavotomy and extraction of a long intracaval tumour thrombus extending into the atrium in April 2022. The operation was performed together with cardiac surgeons and went well. The histology was clear cell renal carcinoma and some parts of the tumour thrombus had been adherent to the vena cava. Post-operative recovery was prolonged and complicated by a pulmonary embolism.

Now the patient presents with a follow-up CAT scan showing extensive recurrence of the intracaval tumour thrombus, again extending into the right atrium.

Fig. 1

Fig. 2

Discussion point 1: What management is possible and advisable?

Case provided by Prof. Oliver Hakenberg, Dept. of Urology, University Hospital Rostock, Germany. E-mail: oliver.hakenberg@med.uni-rostock.de

Case study No. 73 continued

Due to the fistulation and bad quality tissue, an omega-shaped skin incision is performed in order to perform a perineal urethrostomy if needed (Fig. 1).

As soon as bulbar urethra is dissected out, stones are palpated within the lumen and are extracted via ventral incision (Fig. 2).

The presence of hair indicates that a scrotal flap has been involved during the first procedure. It is excised until its very proximal aspect where a lumen is identified (Fig. 3)

As a guidewire could not be inserted in the lumen, a flexible antegrade cystoscopy was performed and allowed to locate the proximal urethral segment (Fig. 4)

Complete excision of unhealthy tissues was done and perineal urethrostomy was performed together with a dorsal buccal mucosa graft (Fig. 5)

6 months later, due to partial graft contracture, an additional graft was quilted dorsally which allowed nice urethral closure (Fig. 6)

3 months later, the urethrogram shows a nice urethral caliber with complete bladder emptying (Fig. 7)

Fig. 1 Fig. 2 Fig. 3 Fig. 4