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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.
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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
Figure 1
Discussion point • Which treatment is advisable? and was referred to our centre without any detailed reports of the previous procedures. A new urethrogram was done (Fig. 1).
Case provided by Dr. Amin Bouker, Clinique Taoufik, Tunis, Tunesia. E-mail: aminbouker@gmail.com
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. 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.
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.
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 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 procedures for bulbar and penile strictures, again with an inlay – onlay graft for the proximal one by a perineal approach. A perineal incision may be appropriate to treat bulbar stricture and can be extended to the scrotum for the distal one. Alternatively, a circumcisionlike incision and degloving of penile skin can be used. However, the patient should be treated in a highvolume centre.
Figure 1 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 spongiofibrosis. • If VCUG graphs are inconclusive, we routinely perform an intra-operative flexible cystourethroscopy, especially in this patient whose proximal stricture may not allow the passage of even a fine urethroscope without a new trauma. • Anastomotic urethroplasty is not an option in this patient.
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 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).
Incoming Education Office Chairman hails strength and reputation of School
Prof. Evangelos Liatsikos (Patras, GR) has succeeded Prof. Joan Palou (Barcelona, ES) as Chairman of the EAU’s Education Office following EAU21. We asked him about his previous experience and his plans for the European School of Urology in the coming years.
Evangelos Liatsikos is currently Professor and Chairman of the Department of Urology at the University Hospital of Patras in Greece. He serves as visiting professor in Leipzig and until recently in Vienna. He is specialised in endourologic, laparoscopic and robotic urological surgery, including single-port surgery.
Liatsikos has previously served as Chairman of the EAU Section of Uro-Technology (ESUT) since 2016 and has also served as a board member of the European School of Urology (ESU) for eight years.
A powerful tool “I finished my eight-year term at our last board meeting,” Liatsikos says. “They were nice years. My responsibilities centred mainly on laparoscopic and endourological training. I assisted and advised the board in that regard, helping devise new surgical training programmes. My experience as ESUT Chairman for the past four years has also helped in this regard, though I only represented the ESUT informally on the ESU Board.”
Having observed the inner workings of the European School of Urology over the past eight years, Liatsikos has a deep respect for its status and the achievements of his predecessor. “The School is a powerful tool for the EAU. Urological education really makes a difference.”
“The school is well-structured and Joan Palou did an excellent job during his tenure. He has really improved the school, it’s now world-famous and a great ambassador for the EAU. We hold courses all around Europe and beyond, we’ve standardised a lot of the training, and our standardisation procedures have been adopted by many international societies. Working for the ESU is rewarding because you see you have such a big audience, and the potential to reach so many people.”
The chairman’s shoes Prof. Palou stepped down after nine successful years, leaving big shoes to fill. As to what the ESU Chairman’s primary tasks are, Prof. Liatsikos puts emphasis on assembling a good team around him. “The chairman’s job is to choose a good board! This is not one person’s job. You need to select people who have vision, are motivated and prepared to work hard.”
Around half of the ESU board members are currently at the end of their term and Prof. Liatsikos has been looking for new members to join the ESU after the congress. “We take a lot of things into account when selecting board members. We’ve found people from all around Europe with different backgrounds. It is important to find people who not only seek the glory of being board members but who are also prepared to do the work.” Prof. Liatsikos feels that his work as ESUT chairman, in addition to his day-to-day duties has prepared him for finding a balance between his responsibilities in this new position.
“Also, as chairman you need to be able to work in harmony with the people behind the scenes: the people at the EAU Central Office who work for the School but also specifically for online platforms and training programmes. The same goes for urologists who work for the EAU in the Guidelines Office, the Sections, the Young Academic Urologists and all other Offices. You need to coordinate everyone’s efforts, listen to everyone’s input and decide how to proceed. It’s not an easy job: you have to foresee what is interesting and what new developments in education are worth pursuing.”
Goals Prof. Liatsikos feels that the school is “on the right track”, going in generally the right direction. “Clearly, we will be seeing some minor corrections to make the track a bit more straight, but it’s already a great effort to keep the train going. With new board members come new collaborations and a new dynamic within the School. Together we will look at expanding our activities, especially beyond Europe.”
Personally and, as former ESUT Chairman, understandably, the new Chairman would like to see the ESU embrace technology in its methods. “During the pandemic we adapted to new online training
Prof. Liatsikos in his previous guise as ESUT Chairman, leading discussion at ESUT18 in Modena, Italy
activities that were really appreciated by our audience. After the end of this unpleasant worldwide experience our online platforms will play a key role in the educational process. After all, we are educating young urologists, those who are always engaged with their phones and tablets.”
“Finally, as incoming chair I would like to encourage the readers of European Urology Today that they need to familiarise themselves with the ESU’s activities, and ideally participate in them. We have so many great things to offer young urologists and they need to get to know our portfolio.”
All of the EAU’s educational activities, including workshops, online education, exchange programmes and scholarships can be found on: www.uroweb.org/education
Profiles EAU welcomes new Chair of the Guidelines Office
An exclusive interview with Prof. Ribal
Prof. Maria Jose Ribal Caparros (ES) is the newly-appointed Chair of the EAU Guidelines Office. In this exclusive interview, she expounds on what her new role entails, her aims and aspirations, and the pivotal moment she knew she wanted to be a urologist.
Congratulations on your new appointment! Thank you. It is an immense honour to lead the EAU Guidelines Office (GO). The previous leadership under Prof. James N’Dow was a very fruitful period; the way our EAU Guidelines are conceived underwent a profound transformation. His example will be my motivation. Preserving the excellence achieved in recent years is an important challenge and a great responsibility.
Could tell us about your tasks and responsibilities in this role? My main responsibilities include leading the GO and ensuring that everything is facilitated to the EAU Panels. These tasks require reaching a consensus on the basis for producing the Guidelines, managing logistical tasks, and promoting the EAU GO and EAU activities.
My role also involves working together with EAU Offices on a regular basis and participating in the EAU organisation since as Guidelines Chair, I am also an EAU Board member. I will also liaise with different societies and organisations involved in the Guidelines production to promote collaborations and joint-venture projects which will:
• Ensure transparency in both production and composition of our Guidelines • Aid in the integration of the patients’ voice to our Guidelines • Develop research projects to produce recommendations based on real-world evidence • Facilitate dialogue among the members of the
EAU GO • Assist the group that the Guidelines represent to maintain and improve their production as the
EAU Guidelines are now considered among the best (if not the best) in the field and endorsed by 75 countries.
What are your aims and aspirations for the EAU Guidelines Office? My first objective will be to consolidate and improve the current structure in the elaboration of the Guidelines by developing areas such as prevention in urological diseases, treatment of complications, the inclusion of patient-reported outcomes, and directives for the follow-up of patients.
The second objective is to ensure that patients in Europe receive standardised treatment in order to improve the quality of and the homogenization of care.
As medicine progresses towards a more patientcentred model, it is crucial to maintain the existing initiative and to take the patients’ perspective into account with regard to our Guidelines recommendations. Additionally, we are undergoing a great evolution in data management and the integration of massive data analysis. Therefore, our Guidelines must be pioneers in the incorporation of real-world data and evidence into the structure, methodology, and production of the recommendations. Looking ahead, we must focus our attention on having our Guidelines as a reference for establishing health policies in urology as well.
You have many urological interests. What fascinates you about these fields? I feel passionate about my work. I’ve been dedicated to uro-oncology for more than 20 years now, and I couldn’t have chosen a better subspecialty. Major oncology surgery is exciting. I’ve been fortunate to know open surgery, as well as, laparoscopy and robotics which have revolutionized the world of cancer surgery. and devoting time to research have been very satisfying. I always liked the process of learning. Cultivating facets beyond your own speciality opens your mind.
How was it like for you as a recipient of the coveted Crystal Matula Award? For me, the Matula was the award. Not only did I take it as a recognition but also, a welcomed challenge. It has brought me great joy and it has opened many doors. I have it in my office. The award has always been a source of motivation.
When did you know that you wanted to be a urologist? Without a doubt, I always wanted to become a surgeon ever since I was 3 years old! I don’t know why this was so apparent to me because there aren’t any doctors nor surgeons in my family.
In medical school, I was already impressed with urology because of its comprehensive reach. A urologist diagnoses, operates, and follows up. There are research opportunities, too. I am proud of this field and of myself for making the right choice. I’m convinced that urology is the best speciality in the world.
Who or what inspires you, and why? Inspiration is a complex thing. I admire many, who during my career, have supported me and helped me. I have so many names in mind and I wouldn’t dare to leave any of them forgotten. They know how grateful I am to them because no road is truly travelled alone.
I am inspired by honesty, courage, commitment, enthusiasm, and loyalty. I am inspired by the values that have been instilled in me by my family, as well as, by the love, strength and support of all those who believe in me.
