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PURPOSE: We prospectively compared buccal mucosa graft and lingual mucosa graft urethroplasty with respect to donor site morbidity and urethroplasty outcome. MATERIALS AND METHODS: Patients treated with buccal mucosa graft (29) or lingual mucosa graft (29) urethroplasty were included in the study. Oral pain and morbidity were assessed using the numeric rating scale (scale 0 to 10) as well as an in-home questionnaire administered 3 days, 2 weeks and 6 months postoperatively. RESULTS: After a mean (± SD) followup of 30 (± 13) months successful urethroplasty was achieved in 24 (82.8%) and 26 (89.7%) patients treated with buccal mucosa graft and lingual mucosa graft, respectively (p = 0.306). Median numeric rating scale after 3 days, 2 weeks and 6 months was 4, 2 and 0 for buccal mucosa graft and 6, 3 and 0 for lingual mucosa graft, respectively, with no statistical differences between the groups. At day 3 significantly more patients in the lingual mucosa graft group had severe difficulties with eating and drinking (62.1% vs 24.1%, p = 0.004) and speaking (93.1% vs 55.2%, p = 0.001), and had dysgeusia (48.3% vs 13.8%, p = 0.01). Two weeks postoperatively speech impairment was still more frequent with lingual mucosa graft (55.2% vs 13.8%, p = 0.002), whereas oral tightness was more frequent with buccal mucosa graft (41.4% vs 6.9%, p = 0.005). After 6 months 44.8% and 31% of patients treated with buccal mucosa graft and lingual mucosa graft, respectively, still reported sensitivity disorders (p = 0.279). CONCLUSIONS: The success of urethroplasty with lingual and buccal mucosa grafts was similar. Oral pain was not different after both grafts. In the early postoperative period there were differences in oral morbidity between buccal and lingual mucosa grafts. Long-term oral morbidity was not infrequent with both grafts.

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Established beliefs concerning outcomes following anterior urethral reconstruction are changing, both with regards to the genital cosmetics and to the impact on sexual activity. Today, the aim of stricture repair is not only to reinstate urinary function but also to safeguard sexual activity and guarantee genital cosmesis. A thorough evaluation of anterior urethroplasty results should include the sexual viewpoint which appears to play an important role in overall post-operative patient satisfaction. The most commonly reported sexual problems following anterior urethroplasty include: erectile and ejaculatory dysfunction, penile curvature or shortening, dissatisfaction with genital cosmetic appearance, sensorial impairment of glans. The prevalence of specific post-operative sexual problems may be related to the site of reconstruction (penile or bulbar) and to the technique of urethroplasty employed. In penile urethral reconstruction, the wide use of buccal mucosa grafts seems to excel the use of skin flaps which easily distort the cosmesis and elasticity of the penis. In bulbar reconstructions, graft augmentation techniques seem to impact less on sexual outcome than excision anastomotic techniques. Therefore, the policy of primarily indicating an excision anastomotic procedure, whenever possible, should come under scrutiny. Eventual sexual outcomes should be incorporated in the choice of the optimal anterior urethral reconstruction and in pre-operative patient counselling.

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PURPOSE: In this observational descriptive study we reviewed the histology and the clinical records of 130 patients with LS involving the male genitalia to determine the presence of premalignant or malignant lesions. MATERIALS AND METHODS: A total of 130 male patients (from 1991 to 2001) with genital LS were treated at our centers. Mean patient age at diagnosis was 42.5 years. In all patients with a clinical diagnosis of LS, the histology was reexamined to look for evidence of LS, applying strict histological criteria. All cases of histologically proven epithelial malignancy, namely SCC, VC and EQ, were reviewed to confirm the presence of neoplastic changes and ascertain the degree of SCC differentiation. RESULTS: Of 130 men 11 (8.4%) with genital LS showed premalignant or malignant histopathological features including 7 (64%) with SCC, 2 (18%) with VC, 1 (9%) with EQ and 1 (9%) with SCC associated with VC. In 6 of 11 patients (55%) the histological study showed the presence of epithelial dysplasia. CONCLUSIONS: Survival of patients with penile carcinoma depends on early diagnosis and treatment, and all patients with genital LS should be observed closely to detect the development of neoplastic or preneoplastic lesions as early as possible.

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PURPOSE: We update our interim results of bulbar urethroplasty using a skin graft placed on the dorsal urethral surface. MATERIALS AND METHODS: A total of 45 patients with an average age of 45 years underwent dorsal onlay skin graft urethroplasty between January 1994 and December 2000. Of the patients 23 had undergone an average of 2.6 prior endoscopic procedures (range 1 to 14). Preoperative evaluation include clinical history, physical examination, retrograde and voiding urethrography, and ultrasonography. In all patients the bulbar urethra was opened along its dorsal surface, the graft was sutured, splayed and quilted to the corpora cavernosa, and the urethra was rotated to cover the graft. In all patients was used penile skin as substitution material. Mean graft length was 4.7 cm (range 2.5 to 11). Three weeks after surgery voiding cystourethrography was performed. RESULTS: Average followup was 71 months (range 41 to 110). Clinical outcome was considered a failure when postoperative instrumentation was needed, including dilation. Of 45 cases 33 (73%) were classified as successful and 12 (27%) were failures. The 12 failures were treated with internal urethrotomy (1), end-to-end-anastomosis (1), skin graft urethroplasty (2) and 2-stage urethroplasty (6). Six of the 12 initial failures had a satisfactory final outcome. The remaining 6 patients refused further surgical procedures and received a definitive perineal urethrostomy. CONCLUSIONS: Penile skin grafts used as a dorsal onlay for bulbar urethral reconstruction in a homogeneous series of patients showed a tendency to deteriorate with time. Longer followup is required to compare penile skin with buccal mucosa as substitute materials for bulbar urethral reconstruction.

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The surgical treatment of adult anterior urethral strictures has developed continuously. Recently considerable changes have been introduced, involving the cause of the urethral disease and surgical techniques. The criteria for selecting the reconstructive surgical technique are presented according to the cause and a new classification of urethral strictures. The main surgical procedures are presented and fully illustrated, with an updated and comprehensive review of recent publications.

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PURPOSE: A urethral stricture recurring after repeat urethrotomy challenges even a skilled urologist. To address the question of whether to repeat urethrotomy or perform open reconstructive surgery, we retrospectively review a series of 93 patients comparing those who underwent primary repair versus those who had undergone urethrotomy and underwent secondary treatment. MATERIALS AND METHODS: From 1975 to 1998, 93 males between age 13 and 78 years (mean 39) underwent surgical treatment for bulbar urethral stricture. In 46 (49%) of the patients urethroplasty was performed as primary repair, and in 47 (51%) after previously failed urethrotomy. The strictures were localized in the bulbous urethra without involvement of penile or membranous tracts. The etiology was ischemic in 37 patients, traumatic in 23, unknown in 17 and inflammatory in 16. To simplify evaluation of the results, the clinical outcome was considered either a success or a failure at the time any postoperative procedure was needed, including dilation. RESULTS: In our 93 patients primary urethroplasty had a final success rate of 85%, and after failed urethrotomy 87%. Previously failed urethrotomy did not influence the long-term outcome of urethroplasty. The long-term results of different urethroplasty techniques had a final success rate ranging from 77% to 96%. CONCLUSIONS: We conclude that failed urethrotomy does not condition the long-term result of surgical repair. With extended followup, the success rate of urethroplasty decreases with time but it is in fact still higher than that of urethrotomy.

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La estenosis de uretra bulbar supone un difícil problema para los urólogos. Existe una amplia variedad de técnicas de cirugía reconstructiva para la enfermedad estenótica de la uretra, que incluyen la uretroplastia terminoterminal, y el uso de injertos libres o pediculados de diversas formas. En 1995-96 describimos una nueva uretroplastia que coloca el injerto en posición dorsal en lugar de ventral, en contacto directo con los cuerpos cavernosos. Este principio de colocación dorsal de los injertos libres también se puede aplicar a los injertos pediculados en la reconstrucción de las estenosis de uretra bulbar. Este artículo de revisión describe la técnica y sus variantes, y los resultados alentadores publicados hasta la fecha con este nuevo abordaje para la reconstrucción de la estenosis de la uretra bulbar. (AU)

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PURPOSE: Preputial skin graft is used routinely for urethral reconstruction in patients with stricture disease. Alternative donor sites include extrapenile skin, bladder mucosa and buccal mucosa. Recently buccal mucosa graft has been suggested when local epithelial tissue is not available. We describe our experience with 37 patients undergoing 1-stage correction of bulbar urethral stricture using a penile skin (31) or buccal mucosa (6) graft. MATERIALS AND METHODS: In 37 patients with bulbar urethral strictures a nontubularized dorsal onlay graft was used for urethral reconstruction. A preputial skin graft was used in 31 patients and a buccal mucosa graft in 6 with a paucity of local skin. Buccal mucosa graft length ranged from 2.5 to 5 cm. (average 4) and preputial skin graft was 2.5 to 12 cm. long (average 4.7). A dorsal approach to the urethral lumen was used in all patients who underwent onlay graft urethroplasty. RESULTS: Mean followup was 21.5 months for all 37 patients, 23 months for 31 treated with preputial skin graft and 13.5 months for 6 treated with buccal mucosa graft. The clinical outcomes were considered a failure anytime postoperative instrumentation was needed, including dilatation. In the series 34 cases (92%) were classified as a success and 3 (8%) as failure. CONCLUSIONS: Onlay graft urethroplasty provided excellent results in 92% of adults with bulbourethral stricture. The dorsal approach to the urethra allowed the use of foreskin or buccal mucosa graft for reconstruction of the adequate urethral lumen.

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PURPOSE: We analyzed the long-term results of different urethroplasty techniques. MATERIALS AND METHODS: We performed a retrospective review of 98 patients who underwent different procedures for anterior (78) and posterior (20) urethral strictures. Mean followup was 53 months. A total of 20 patients underwent end-to-end anastomosis (group 1), 30 underwent 1-stage procedures (group 2), 28 underwent 2-stage procedures (group 3), and 20 underwent bulboprostatic anastomosis (group 4). The results were analyzed using Kaplan-Meier curves and log rank test. RESULTS: The success rate was 95% for group 1, 93.4% for group 2, 78.6% for group 3, and 70% for group 4. Statistical evaluation of the actuarial success rates failed to show significant differences among the 4 groups. CONCLUSIONS: The stricture recurrences were uniformly distributed over time. Urethroplasty patients must be followed for the rest of their lives.

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In a pilot trial, we treated thirty-three hormone resistant metastatic prostate cancer patients with a combination of androgen blockade plus weekly cytotoxic therapy and determined both response and toxicity in 32 of them. Their median Karnofsky performance status at the time of entry was 65. We administered Epidoxorubicin (EpiDx) intravenously, at a dose of 35 mg/m2, every week for 4 months. Initially, all patients had only hormonal therapy and chemotherapy was added once they progressed. In terms of W.H.O. criteria, 9 patients (28%) had a partial response, the disease was stable in 14 (44%), and progressive in 9 (28%); even in this last group, 6 patients with bone metastases experienced lasting relief from pain. No patients had to interrupt treatment due to leukopenia or cardiotoxicity. Other toxicities, including nausea and vomiting, mucositis and alopecia, were mild. Pretreatment prostate-specific antigen (PSA) levels decreased significantly (p < 0.05) in 26 patients (81%) after treatment. In our view, weekly EpiDx administration serves as an active regimen in hormone-refractory prostate cancer.

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Granulomatous prostatitis is a rare chronic inflammation and its etiology is not well understood. There is difficulty in differential diagnosis with prostatic cancer. But RMN and ultrasound guided biopsy can confirm the diagnosis. The authors report 15 cases and discuss etiological, clinical and diagnostic aspects.

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OBJECTIVES: We evaluated the clinical and radiological aspects of isolated duplications of the bulbous urethra and assessed the results of surgical treatment. METHODS: The experience with 11 male patients presenting with duplications of the bulbous urethra is reported. The duplications were incomplete in 7 cases and complete in 4, the accessory channel was ventral in 8 patients and dorsal in 3. The presenting symptoms were seldom indicative of the condition. Surgical treatment was performed in 10 cases and consisted in transurethral resection of the septum between the two channels in 2 patients, one-stage urethroplasty in 6 and two-stage urethroplasty in 2. RESULTS: With a follow-up ranging between 1 and 4 years the results were considered satisfactory in 4 cases and excellent in 6. CONCLUSIONS: Duplications of the bulbous urethra deserve careful evaluation of the cost-benefit ratio when surgical treatment is considered. The goal of reconstructive surgery, which can be open or transurethral, should be a functional urethral channel.

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PURPOSE: Dorsal free graft urethroplasty was performed to reduce the incidence of urethrocele. MATERIALS AND METHODS: We treated 12 patients with penile and 13 with bulbous strictures. Of the 13 patients with a bulbous stricture 6 received a dorsally placed tube graft and 7 received a patch graft. RESULTS: Temporary fistulas were seen on postoperative urethrography in 5 cases but they all resolved spontaneously. At a mean followup of 35.8 months clinical and radiological findings were excellent in 23 cases and good in 2. No signs of graft weakening, such as post-void dribbling or diminished ejaculation, were apparent. CONCLUSIONS: The use of free skin grafts for urethral reconstruction is anatomically healthier in the dorsal than in the ventral position.

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