Objective To provide the anatomic basis for the posterior urethral repair via the perineal approach. Methods The anatomicconstructions andtheir relationships of the perineal approach from skin to the membranous and prostate apical urethra were observed and some related data were measured in 12 adult male specimens by microanatomy, and the procedures of urethral repair via the perineal approach were carried out in 3 fresh male specimens. Results All the blood vessels and nerves, which supplied the scrotum, the perineum, and bulbourethra, passed lateral-medially. The cavernous nerves coursed posterolaterally from the bottom to the apex of the prostate, pierced the urogenital diaphragm and passed laterally to themembranous urethra in a status of gridding, whose width was (12.11±2.32) mm.Conclusion The structures of the perineum and around the posterior urethra are complicated. The strategy for diminishing the damages to them is that all structures must be dissected strictly in the midline. Confining the dissections strictly to the range of 5 mm from the membranous urethra and resecting the apical prostatic tissues anterolaterally could avoid impairments of the cavernous nerves.
Objective To review the surgical management for Chinese children urethral injury (CUI). Methods According to the evidence-based medicine principal and the approach of systematic review, we searched Chinese Biomedicine Database and PubMed, all literature retrievals were updated until September 8th, 2008. At least two reviewers independently screened the studies for eligibility, evaluated the quality with the Joanna Briggs Institute critical appraisal checklist for descriptive/cases series studies and extracted the data with excel 2003 from the eligible literatures, with confirmation of cross-check. Different views were consulted by the third party. The characteristics of literature, research quality, study content, cases characteristics, diagnosis and treatment, outcome appraisal and follow-up were analyzed. Results A total of 22 studies involving 1019 patients were included, most patients were male children. All 22 studies were descriptive researches and the study quality was low. The etiologies were mainly pelvic fracture and straddle injury as results of misadventure. The diagnosis was based on the relatively objective diagnostic tests such as urethrography, operations research and the exploration of urethral bougie etc in 16 studies. The most categories of CUI were obsolete urethral injuries such as stricture and atresia, the injury sites mainly lied in posterior urethra. The management of CUI were divided into the primary treatment included the first-stage operation and delayed-stage repair, and the second-stage management. Moreover, the individual operation was according to the injury sites and patterns. A total of 14 studies reported the outcomes of operation at various success rates (52%-100%). Except 4 studies, the others reported incomplete follow-up time, from 3 months to 16 years, but few adopted objective methods such as urethrography and urodynamic test. The main complications were urethral stricture, urinary fistula and sexual dysfunction etc. Conclusion The quality of CUI studies was low for lack of prospective randomized controlled trials. The major patients were male children with posterior urethra injuries. Because of the heterogeneitiy of the individual case, different surgeon’s managements and the variety of treatment options, we cannot make identical conclusion. We need more researches with high methodological quality. Moreover, we recommend that, following the clinical practice guideline of CUI made by Chinese Urological Association for the Chinese urologist, and then performing individual surgical management.
Objective To explore and describe the clinical feasibility and value of reconstruction of complex urethral stricture with free postauricular graft. Methods Urethroplasties-with free postauricular grafts were performed in 17 patients with complex urethral strictures, including 6 cases in anterior urethras and11 cases in posterior urethras.The grafts were transplanted onto the opened urethras in the first stage;6 months later, the new urethras were shaped with the second stage urethroplasties in 14 patients.There patients succeeded in single-stage urethroplasties. The urethras and bladders were washed with antibiotic solution everyday after urethroplasties. Results Good- and satisfactoryresults were obtained in 15 cases 6 months after urethroplasties, regardless of the strictured sites and lengths. Maximal urinary flow rates ranged 14-32 ml/s. There were 2 cases accompanied with complications 6 months after urethroplasties,1 case of fistula was repaired,1 case of severe urethral stricture was reconstructed with opposite side free postauricular graft later. Three patients had mild urethral strictures 6 months after urethroplasties, they were cured with urethral dilatationsfor 4-8 times. Conclusion Reconstruction of complex urethralstricture with freepostauricular graft is a good and effective method to treat long or complex urethral strictures, especially for patients without adequate foreskin or penis skin.
Objective To investigate the effect of scrotal septum vascular pedicle flap with two wing-l ike spl itthickness skin graft in reconstructing urethra in patients with hypospadias and in reducing the compl ications. Methods From January 2007 to March 2008, 30 cases of hypospadias were treated, with a median age of 10 years (2-20 years). There were 13 cases of proximal shaft type, 12 cases of penoscrotal type and 5 cases of scrotal type. There were 8 cases with operation history. The flap size ranged from 4.0 cm × 0.8 cm to 9.0 cm × 1.0 cm and 5 mm with two wing-l ike spl it-thickness skin graft.When the downward curvature corrected, length of the flap could be determined by the length of the urethra that neededto be reconstructed. Results All flaps survived. The incision healed by first intention in all patients except one whose incision healed after change dressing because of frequent erection. Incision at donor site healed well. Eighteen patients were followed up for 6-12 months, including 8 with second operation history. The reconstructed urethras were unobstructed and no urethrostenosis or urinary fistula happened. Conclusion This is an improved technique of the scrotal septum flap in urethra reconstruction. It takes advantages of both flap and spl it-thickness skin graft in reconstructing urethra and avoides the disadvantages of a single tissue. It is a good choice for treating hypospadias whose urinary meatus locates neighborly to penoscrotal junctional zone.
Objective To explore the feasibility of one-stage repair of hypospadias using the meatalbased flap overlapping with buccal mucosal graft. Methods From March 2002 to May 2004, 21 patients with hypospadias were treated with the meatal-based flap overlapping with buccal mucosal graft. Their ages ranged from 14 months to 8 years. The procedure were as follows:urethralplate at proximal corona was cut to correct glandular tilt and chordee; the buccal mucosa taking from inner cheek was then fixed on tunica albuginea of ventral shaft with suture; and the meatalbased flap was rotated distally and overlaid with buccal mucosal graft to repair urethra.Results All patients were followed up 318 months (7 months on average). A cosmetic glans and a vertically oriented, normal appearing slit meatus were achieved. Two patients had fistulas on lateral corona. Fistula spontaneously healed in 1 case and the other one was repaired after 6months. Conclusion The technique of meatal-based flap overlapping with buccal mucosal graft can completely correct glandular tilt and chordee, prove good cosmetic and functional glans and meatus.
Objective To summarize the methods of repairingthe urethral defect in the penis of an adult and the clinical application of the island skin flaps of the scrotum septum to the reparative treatment. Methods From January 2000 to November 2005, twenty-six cases of urethral defect in penis, including 16 cases of congenital urethral defect, 6 cases of traumatic urethral defect in middle penis, and 4 cases of distal urethral defect, were repairedby the local penis fascia flaps.The island skin flaps of the scrotum septum were transferred to cover the penis wound. The pedicle contained the artery of the posterior scrotum and the artery of the anterior scrotum. The flap taken from the scrotum septum was 2.5 cm×5.5 cm in area. Results After a follow-up of 7months to 4 years, all the 26 patients had the healing of the first intention without urethral fistula, urethral narrowness or penis curvature, except 4 patients who developedinfection and leakage of urine, but the wounds healed spontaneously 2-4 weeks after operation. Conclusion The penis fascia flaps and the island skin flaps of the scrotum septum can be used to repair the urethral defect in the penis of an adult. The blood supply to the flaps is sufficient and all theflaps can survive well. A good shape and function of the penis can be obtained.
Objective To compare and assess the efficacy of ventral/dorsal onlay graft urethroplasty in the treatment of urethral stricture. Methods We searched pertinent English literature via MEDLINE (1966 to 2007), EMBASE (1977 to 2007) and The Cochrane Library (Issue 4, 2007) for the use of ventral/dorsal graft urethroplasty in the reconstruction of urethral defect associated with urethral stricture. Data were extracted by two reviewers independently and analyzed by SPSS 13.0 software. Results A total of 50 studies involving 1 264 patients were included. Ventral onlay graft urethroplasty was used in 751 patients with a success rate of 82.6%, while dorsal onlay graft urethroplasty was used in 513 patients with a success rate of 86.9% (ventral vs. dorsal, χ2=4.432, P=0.035). Oral mucosa graft had the highest success rate (88.1%) of all grafts, and the success rate of free skin graft onlay urethroplasty was associated with the location of graft placement (ventral vs. dorsal, P=0.016). Concerning the location of stricture, urethroplasty for bulbar urethral stricture achieved the best results, with a success rate of 87.7%, which was also associated with the location of graft placement (ventral vs. dorsal, P=0.025). Conclusion Dorsal onlay graft urethroplasty is better than ventral onlay. It is better to place the free skin graft in the dorsal part of urethra. Bulbar urethral stricture is more suitable for graft onlay urethroplasty than penile urethral stricture.
Objective To investigate the effect of ventral urethroplasty for postoperative anastomotic stricture in patients with hypospadias. Methods From August 2000 to December 2005, 20 patients with anastomotic stricture after hypospadias repair were treated with ventral urethroplasty. The age ranged from 2 to 27 years with an average of 6.4 years. All patients showed dysuria after operation. Main clinical manifestation included dysuria and acraturesis. Interruption of urinary stream occurred in 17 cases; of them, 3 cases had urinary stasis and 4cases had frequent micturition, urgent micturition and pain in urination. Urethrography and cystourethrography showed 0.5-1.0 cm stricture with proximal dilat ion of urethra in 16 cases and obvious diverticularization in 9 cases. Urine routine examination showed that white blood cell was ++ to ++++ in 16 cases and pus cell was ± to++ in 13 cases.Results Twenty cases were followed up 2 months to 4 years (mean 2.3 years). All the cases achieved good results in urination with normosthenuria and normal force of urinary stream. No recurrent stricture, urethrocutaneous fistula, or penile curvature occurred. The cosmesis was satisfactory, and the results of urine routine examination was normal. Conclusion Ventral urethroplasty for postoperative anastomotic stricture inpatients with hypospadias is a simple and effective procedure.
OBJECTIVE: To study the technique and method of urethral epithelium culture in vitro, so as to lay the groundwork for reconstructing a tissue engineering urethra and to provide an experimental model of urethral mucosa in physiological, pathological, toxicological and microbiological study. METHODS: The urethral mucosa from a young male New Zealand hare that had just been out of milk, was digested into single cell liquid with Dispase II and mixed enzyme, and the fibroblast were removed. After being seeded, the cells were cultured by using L929 cells as trophoderm. The medium was changed regularly and the cells were subcultured when they grew to mix together 80% to 90%. The cultured cells were analyzed with histochemistry, immunohistochemistry dyeing and flow cytometry examination. We observed the ultrastructure of cells with scanning electron microscope and transmission electron microscope. RESULTS: The primary cultured cells fused when they had been cultured for about ten days. They were the same in size like road rocks. The cultured cells were all epithelial cells without fibroblasts and were diploid cells. The cells could be subcultured 11-13 generations, and could survive 50-60 days. CONCLUSION: The urethral epithelium of young New Zealand hare can be cultured in vitro and maintain the ability to proliferate within a certain time. The study result not only sets a role in reconstructing a tissue engineering urethral mucosa, but also provides an experimental model for the research of urethral mucosa in vitro.
Objective To find the difference between the collagenase activity and tissue inhibitor of metalloproteinase-1 (TIMP-1) expression level in normal urethral tissue and in urethral scar tissue, and to study the effect of collagenase activity and TIMP-1 expression level on the degradation of urethral scar. Methods The urethral tissues were derived from 10 human surgical specimens of urethral stricture scar and 10 human normal urethral specimens from patients with brain death. The collagenase activity was detected by ELISA assay, and the TIMP-1 mRNA level by RT-PCR. Results The collagenase activity of urethral scar tissue was (15.32±2.29) U and lower than that of normal urethral tissue (24.67±6.78) U, there was significant difference between them (P lt; 0.01). The TIMP-1 expression level of urethral scar tissue was higher than that of normal urethral tissue, there was significant difference between them (P lt; 0.05). Conclusion The high level of TIMP-1 expression and the low collagenase activity in urethral scar tissue may inhibit the degradation of urethral scar, and may be one of important causes of the scar tissue hyperplasia.