Anderson, Katherine

Introduction: Urethral strictures affect about 1% of men over 65 in the United States and significantly impact quality of life. 1 Most strictures (92.2%) occur anteriorly. 2 Urethroplasty, the gold standard treatment, is traditionally open but can be performed endoscopically with comparable results. This prospective study describes a technique for transmeatal urethral surgery with buccal graft urethroplasty for anterior urethral strictures. Methods: A 21 French direct vision internal urethrotomy (DVIU) cystoscope is used to inspect the stricture and make an incision along its ventral aspect. After the stricture is measured, a graft of buccal mucosa is harvested. For graft deployment, we utilize a 26 French Wolf Offset Nephroscope™ and a rigid injeTAK® cystoscopy needle. At the distal aspect of the urethrotomy, the needle is passed through the urethra and out the perineum. A pair of the sutures is placed on either side of the urethrotomy and held externally at the meatus. The graft is oriented with the lamina propria facing the spongiosum. The previously placed sutures are then passed from lamina propria to mucosa at the distal aspect of the graft. The sutures are tied, creating a knot on the mucosal side. The external sutures are then pulled, and the graft retracts into the urethra. The JNW Urtract™ and Securestrap® are then used for graft fixation. Graft Deployment: At the distal aspect of the urethrotomy, the injeTAK® needle is passed through the urethra and out of the perineum. A pair of the sutures is then placed on either side of the urethrotomy. These are held in place at the meatus to maintain proper laterality and avoid twisting. The graft is oriented into position, with the anti-mucosa facing the exposed spongiosum and the mucosa facing the lumen. The previously placed sutures are then passed from anti-mucosa to mucosa using a free Mayo needle at the distal aspect of the graft. The suture pairs are tied, creating a knot on the mucosal side. The external sutures are then pulled, and the graft retracts into the urethra. Cystoscopy is performed to ensure the graft is covering the urethrotomy. Graft Fixation: The JNW Urtract was then introduced with the Securestrap® (a Vicryl tacking suture). While a finger externally compresses the perineum toward the tip of the Securestrap®, the ventral midline portion of the graft is secured. A 22 French Foley catheter is then placed over a wire. Results: Out of 20 total patients, 13 are eligible for their 4-month follow-up. Of those who have completed follow-up, 86% had urethral patency on cystoscopy. The average duration of foley catheterization was 2.4 weeks. The average operative time was 100.8 minutes, and the average estimated blood loss was 37.5 cc. Conclusion: Transmeatal urethral surgery is a safe and effective repair option for management of anterior urethral stricture disease. The authors have no disclosures or commercial associations that might create a conflict of interest. Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. Data and video obtained during the treatment of patients at Mayo Clinic in Rochester, Minnesota. Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. No conflicts of interest or obligations resulted from data collection. Runtime of video: 8 mins 52 secs.

Objective: To describe a step-by-step guide for successful implementation of transmeatal urethral surgery for obliterated membranous urethral strictures. Patient and Methods: The patient is placed in the dorsal lithotomy position. Cystoscopy will be performed through both the suprapubic tube above and transmeatally from below. A Libri rigid endoscopic needle will be passed under guidance, with placement of a 0.38 wire through the inner lumen. Subsequently, over the wire, a tiger tail catheter will be placed and the wire exchanged for a rigid sensor wire, over which a charger balloon will be passed and used for dilation. The Olympus resectoscope will be used to resect the area of the stricture. The RD180 from LSI solutions will be used to situate the graft over the area of the stricture. Results: Our number of cases is five, of which 4 have had no recurrence. The median follow-up is 6 months. We have three from radiation and two from pelvic fractures. In the radiation population, one patient did recur. However, he was not obliterated and has been voiding even though he has a 14 French urethra. Conclusion: This technique appears to be a safe and effective repair option for management of obliterated membranous urethra strictures. Author disclosure statement: J.N.W. is a consultant for Olympus. The other authors have no conflicts of interest to disclose. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure . Runtime of video: 7 min 38 sec.

Abstract Introduction Spongiosal sparing non-transecting anastomotic bulbar urethroplasty has rapidly become the preferred technique for many reconstructive urologists due to reported improvement in postoperative erectile function outcomes. For strictures <2cm, non-transecting techniques without the use of graft augmentation are typically deployed. However, for lengthy bulbar strictures (≥2cm), many advocate for oral mucosa substitution urethroplasty due to the theoretical concern of penile shortening, tethering, or other erectile function related side effects. Although effective, substitution bulbar urethroplasty is associated with additional graft harvest morbidity and may have lower success rates relative to non-substitution non-transecting techniques. Objective We describe outcomes of an extended non-transecting excision-anastomosis urethroplasty for lengthy urethral strictures without the use of graft augmentation. Methods A tertiary center’s urethroplasty database was queried for patients that underwent non-transecting bulbar urethroplasty from 2017-2023. Patients with penile urethral strictures or concurrent urethroplasty procedures were excluded. Stretch penile length (SPL) was assessed by applying gentle traction on the penis and measuring from the base of the penis to the tip of the glans. SPL was assessed perioperatively and at 3-6 month follow-up. Urethral stricture recurrence was defined as need for repeat urethral intervention. Urethral stricture length was determined by intra-operative measurement. Accordingly, patients were then stratified based on stricture length (<2 cm vs ≥2 cm) and tested for association between categorical outcomes (worsening erectile function and reconstructive success) and continuous outcomes (change in SPL) using Fischer’s exact test and Mann Whitney U test. Results A final cohort of 90 patients were identified, with a median urethral stricture length of 1.5 cm (range 0.5-6cm). In addition to dorsal urethrotomy (median 3cm), ventral mucosectomy was performed in 29 (32%) patients (median 2cm). Early postoperative complications occurred in 13 (15%) including UTI (N=4), contrast extravasation at VCUG (N=3), and epididymo-orchitis (N=3). At a median follow up of 13 months (IQR 4-18), a total of 5.5% (5/90) developed stricture recurrence. The overall median change in SPL was 0% (IQR 0-6.7%). De novo ED occurred in 7% (5/67). When stratified by stricture length ≥2cm (N=41) and <2cm (N=49) median length of urethrotomy was 3 cm (2.6-4.0) vs 2 cm (2.0-3.0; p <0.001), respectively. Those with strictures ≥2 cm had greater decreases in relative SPL (median 3.5% vs. 0%, p = 0.003) and higher absolute PVR (median 71 ml vs. 34 ml, p =0.03) at 3 months after surgery. There were no significant differences in relative improvement of Qmax or PVR, stricture recurrence (8% vs 4%), worsening erectile function (10% vs 6%), or complication rates (15% vs 14%) between groups (p-value> 0.05 for all comparisons). Conclusions Spongiosal sparing non-transecting urethroplasty is an effective surgical option for patients with lengthy urethral strictures. It offers comparable relative improvement in functional (Qmax, PVR) and erectile function outcomes, while having a modest impact on SPL all while avoiding the morbidity of graft harvesting. Disclosure No.