Clinical challenge Prof. Oliver Hakenberg Section editor Rostock (DE)
Oliver.Hakenberg@ med.uni-rostock.de
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. 69 A 35-year-old man suffered a straddle injury to the urethra without pelvic fracture. A few weeks later, he complained of dysuria and a urethrogram showed a stricture which was treated by direct vision internal urethrotomy (DVIU). Already three weeks later, a recurrence occurred. During the following two years, the patient underwent eight endoscopic procedures, either dilatation or DVIU. Eventually, a urethroplasty was performed. One year later, the patient is still complaining of dysuria
and was referred to our centre without any detailed reports of the previous procedures. A new urethrogram was done (Fig. 1).
Case study No. 70 This 61-year-old woman was referred with an incrustated ureteral stent on the left side for further management (fig.1). The stent had been in situ for almost four years and had been inserted because of symptomatic lower calyx stones. The patient suffers from severe cardiac insufficiency (NYHA 3-4) due to coronary artery disease, rheumatoid arthritis with prednisolone medication and COPD (Gold 4) requiring permanent oxygen treatment. For those reasons the symptoms of left stone disease were at the time treated just by stent insertion. Somehow, the stent was “forgotten”. A urologist now tried to take the stent out but was unsuccessful. Therefore the patient was referred to us.
Case provided by Dr. Amin Bouker, Clinique Taoufik, Tunis, Tunesia. E-mail: aminbouker@gmail.com
Figure 1
Discussion point • Which treatment is advisable?
Traumatic strictures need open urethroplasty up-front Comments by Dr. Marco Bandini Pune, Maharastra (IN)
Dr. Pankaj Joshi Pune, Maharastra (IN)
Dr. Sanjay Kulkarni Pune, Maharastra (IN)
The initial etiology of the stricture was traumatic. Thus, it must be criticized that DVIU was done as the first management and it is quite wrong that
this treatment was repeated thereafter. Indeed, DVIU is useless in strictures due to trauma where a complete spongiofibrosis is present and the success of DVIU is unlikely. We do not offer DVIU in patients with post-traumatic stricture as initial treatment! According to the urethrogram provided, the patient presents multiple bulbar and peno-bulbar urethral strictures with the most significant in the proximal bulbar urethra with a nearly obliterated segment of approximately 3-4 cm. Based on our experience, we believe that the urethra may end up in such a condition precisely because of multiple DVIU/ dilatations and previously failed urethroplasty. Although the details are not given, we believe that an anastomotic urethroplasty was attempted, but unfortunately it failed leaving a long ischemic tract of distal bulbar urethra. Thus, based on the fragmented history, the previous failed urethroplasty and the present situation shown on the urethrogram, we believe that a graft-plusflap urethroplasty may represent a good solution for this case.
Accordingly, we start with intra-operative endoscopy with a small caliber endoscope to assess the entire urethra. We prefer a complete perineal approach with penile invagination and unilateral dissection of the urethra with dorsal urethrotomy. An oral mucosa graft would be fixed to the corpora to create the dorsal wall of the neourethra. Then, a preputial or distal penile skin flap would be harvested and transposed to the perineum with its vascular pedicle. The flap will create the ventral wall of the neourethra from the proximal bulbar end up to the distal end of the stricture. The residual corpus spongiosum will be sutured back to the cavernosa covering the flap to prevent sacculation. Clearly, such difficult cases should be referred to high-volume centres. I would like to stress the following points for cases such as this one: 1. Avoid DVIU in traumatic stricture, go directly for anastomotic urethroplasty.
Fig. 1
Discussion point • Which management and treatment is advisable? Case provided by Oliver Hakenberg, Rostock, Germany. email: oliver.hakenberg@med.uni-rostock.de
2. Use a small caliber endoscope (ureteroscope) to assess the entire urethra. 3. Perineal incision, penile invagination and dorsal approach is best suited. 4. Aim for a single stage reconstruction. 5. Obliterative stricture segment may need the addition of a ventral flap.
Double graft technique or graft + flap augmentation required Comments by Prof. Jalil Hosseini Tehran (IR)
Ass. Prof. Farzin Soleimanzadeh Tabriz (IR)
Based on the history and looking at the urethrogram, this seems to be a rather complex case. At least four abnormal / questionable points can be detected in this urethrogram: 1) there is a long segment severe mid-bulbar urethral stricture, 2) there is a shorter segment of penile urethral stricture, 3) there is a proximal bulbar urethral filling
Case study No. 69 continued The patient underwent endoscopic assessment which showed that the two distal short strictures allowed easy passage of an 18 Fr. cystoscope and were then dilated to 24 Fr. A guidewire was passed through the proximal stricture (fig. 1) and a perineal incision was made. Palpation showed a thick bulbar urethra which allowed for a ventral approach. Surprisingly, there was a scrotal tube anastomosed to the native urethra just below the sphincter together with a dorsal
August/September 2021
defect (maybe the remnant of a urethroplasty), and 4) there is a notch in the penobulbar junction (which can be clinically important if the view angle changes slightly). The first and the second strictures appear straight forward but the third and fourth ones need further evaluation. Number 3 – if significant - looks like a growth rather than a stricture or, indeed, the remnant of a previous urethroplasty. More importantly, we know little about the proximal urethra and a voiding cystourethrogram might be helpful. If all of the above-mentioned findings are recognizable, this is indeed a penobulbar multi-stricture case. A long augmentation urethroplasty would be necessary, keeping in mind that the main bulbar stricture is quite narrow and may need a double graft (inlay – onlay) technique or graft + flap augmentation. If areas number 3 and 4 prove to be insignificant findings, one may treat this patient by two separate short graft
Important notes • It is a pity that this patient has undergone several endoscopic procedures. • Endoscopic treatment for this patient was an absolute mistake at least for the last seven times. Even some parts of the strictures may be the result of the repeated procedures. • Unfortunately, multiple procedures may negatively affect the graft take process as well, depending on the degree of resultant Figure 1 spongiofibrosis. • If VCUG graphs are inconclusive, we routinely perform an intra-operative flexible cystoprocedures for bulbar and penile strictures, again with urethroscopy, especially in this patient whose an inlay – onlay graft for the proximal one by a perineal proximal stricture may not allow the passage approach. A perineal incision may be appropriate to of even a fine urethroscope without a new treat bulbar stricture and can be extended to the trauma. scrotum for the distal one. Alternatively, a circumcision- • Anastomotic urethroplasty is not an option in like incision and degloving of penile skin can be used. this patient. However, the patient should be treated in a highvolume centre.
graft (fig.2). Diseased tissue was excised and a skin to skin dorsal anastomosis was done. Then, the dorsal aspect of the urethra was incised (fig.3) and
grafted with buccal mucosa (fig. 4). Then, the urethra was closed with another ventral buccal
mucosa graft (fig.5) and the spongiosum was closed over that. (fig6).
Figure 1
Figure 3
Figure 5
Figure 2
Figure 4
Figure 6
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