Vladimir P. Glukhov

BACKGROUND:The combination of benign prostatic hyperplasia and bulbar urethral stricture is a major clinical challenge, as both conditions represent the most common causes of bladder outlet obstruction in men. The optimal surgical management for these patients remains poorly understood. AIM:To evaluate the efficacy of various treatment methods for bladder outlet obstruction in patients with combined benign prostatic hyperplasia and bulbar urethral stricture. METHODS:This study included 135 male patients with combined benign prostatic hyperplasia and bulbar urethral stricture. Patients were divided into four groups: group 1 received internal optical urethrotomy with transurethral resection of the prostate (n= 32); group 2 received excision urethroplasty with end-to-end anastomosis and simultaneous transurethral resection of the prostate (n= 35); group 3 received two-stage strategy (urethrostomy + transurethral resection of the prostate via urethrostomy access + delayed urethroplasty,n= 31); group 4 received urethroplasty with conservative therapy for benign prostatic hyperplasia using alpha blockers (n= 37). Efficacy was evaluated at 1, 6, and 12 months postoperatively. RESULTS:At 12 months, groups 2 and 3 demonstrated the best outcomes, with success criteria met by 100% and 97% of patients, respectively (p= 0.287 between the groups). TheQmaxvalues in these groups were 24.1 ± 2.3 and 24.9 ± 2.5 mL/s, theQavevalues were 17.2 ± 2.1 mL/s and 18.6 ± 2.3 mL/s, and IPSS was 3.1 ± 1.2 and 2.3 ± 1.1, respectively. In groups 1 and 4, the efficacy was significantly lower, with success criteria achieved in 63% and 70% of patients, respectively (p 0.001 compared to group 2). Differences between groups 2 and 3 in all parameters at all follow-up time points did not reach statistical significance (p 0.05). CONCLUSION:Both single-stage excision urethroplasty with transurethral resection of the prostate and a two-stage strategy (urethrostomy with transurethral resection of the prostate via urethrostomy access followed by delayed urethroplasty) represent the most effective treatment approaches for patients with combined benign prostatic hyperplasia and bulbar urethral stricture. Both strategies yield consistently high functional outcomes at 1-year follow-up. Methods that do not provide complete relief of prostatic obstruction (internal optical urethrotomy with transurethral resection of the prostate, urethroplasty with conservative therapy of benign prostatic hyperplasia using alpha blockers) are associated with recurrent obstruction at long-term follow-up and cannot be recommended as optimal.

BACKGROUND: Bladder cancer ranks tenth among all malignant neoplasms worldwide, with about 573,300 newly diagnosed cases and about 212,500 deaths annually. Patients with very high-risk non–muscle-invasive bladder cancer, as well as those with tumor progression, are eligible for the same treatment as patients with muscle-invasive bladder cancer—namely, immediate radical cystectomy. AIM: This study aimed to assess morbidity in patients undergoing radical cystectomy for non–muscle-invasive bladder cancer and bladder cancer with minimal muscle invasion. METHODS: The study analyzed outcomes of radical treatment in 151 patients who underwent radical cystectomy. Based on postoperative pathological examination, two study groups were formed: group 1 included 49 patients with non–muscle-invasive bladder cancer (pT1 stage), and group 2 included 102 patients with bladder cancer with minimal muscle invasion (pT2a stage). RESULTS: Early postoperative complications not related to urinary diversion were observed in 44.9% of patients in group 1 and in 32.4% of patients in group 2 (p = 0.135). The incidence of these complications was 77.6 ± 12.6 versus 51.0 ± 7.1 cases per 100 patients in the comparison groups, respectively (p 0.05). Urinary diversion–related complications occurred in 13.3% and 16.7% of patients in groups 1 and 2, respectively. The incidence of these complications in groups 1 and 2 was 14.3 ± 5.4 and 16.6 ± 4.0 cases per 100 patients, respectively. At the same time, significant differences were identified in the distribution of patients across Clavien–Dindo complication grades 1, 2–3a, 3b, and more severe complications: 43.5%, 21.7%, and 34.8% in group 1, and 23.8%, 42.9%, and 33.3% in group 2, respectively (p = 0.0025). CONCLUSION: Substantial differences in the pattern of early postoperative complications after radical cystectomy were identified in the pT1 group, likely attributable to multiple prior organ-sparing interventions and other treatment modalities. In addition, more severe Clavien–Dindo complications were more frequently observed in the pT2a group compared with group 1.

Introduction. There is evidence of a connection between infectious and inflammatory lesions of the lower urinary tract and bladder cancer (BCa). However, there is virtually no data on the urine microbiota of middle-aged and elderly men with suspected BCa. This knowledge is extremely important from the point of view of studying the role of the infectious-inflammatory hypothesis in the genesis of BCa.Objective. To conduct a comparative assessment of the microbiota of bladder urine obtained during natural urination and bladder catheterization through standard and extended cultural studies in men with a presumptive diagnosis of non-muscle-invasive bladder cancer (NMIBC).Materials & methods. The prospective comparative study with consecutive patient recruitment included 23 men older than 45 years with suspected NMIBC based on clinical, laboratory and sonographic data, as well as with no history of infectious and inflammatory diseases of the kidneys and urinary tract, including sexually transmitted infections and recurrent infections of other organs and systems. A midstream urine samples and catheter-drained urine immediately before urethrocystoscopy were subjected to bacteriological analysis. Urine culture study was carried out using a standard set of nutrient media under aerobic cultivation conditions and an expanded set of nutrient media under aerobic and anaerobic cultivation conditions.Results. An anaerobic spectrum of microorganisms was predominantly detected in the urine of patients with suspected NMIBC. Moreover, Peptococcus spp. was more often found among anaerobic taxa. (70%), Eubacterium spp., Propionibacterium spp. (45% each, respectively), among representatives of the aerobes — Corynebacterium spp. (60%), S. lentus (up to 45%), S. haemolyticus (35%) and E. faecalis (30%). Data from a comparative analysis of the detection frequencies of microorganisms depending on the method of collecting material and the set of media for cultivation showed that more isolates are isolated in the midstream urine samples than in the study of catheter urine (2.9- and 1.9-fold with the standard and extended sets of media, respectively). In addition, when performing an extended bacteriological study compared to the standard method, the detection of microorganisms is 3.5-fold higher when examining an average portion of urine and 5.1-fold higher when examining catheter urine. The average number of microorganisms per one patient is also higher when using the extended method (midstream portion — 4.7 ± 1.9; catheterised urine — 2.3 ± 1.0) in comparison with the standard one (midstream portion — 1.3 ± 0.9; catheterised urine — 0.3 ± 0.5).Conclusion. Middle-aged and older men with NMIBC are characterized by asymptomatic bacteriuria in the form of a wide range of aerobic and anaerobic microorganisms. The urine pattern obtained with a urethral catheter contains a significantly narrower range of bacteria compared to the sample obtained through natural urination. It is advisable to carry out an extended cultural urine examination to study the characteristics of the microbiota / microbiome of the urine of the bladder immediately before the urethrocystoscopy procedure by collecting urine with a urethral catheter.

Introduction. The adverse effects of urine on unadapted tissues are known. This is also entirely relevant for buccal grafts used in augmentation urethroplasty, where these effects have not been thoroughly studied so far.Objective. To assess the ongoing pathomorphosis in buccal grafts used for urethral augmentation of extensive strictures in the bulbous region and to evaluate how much urine influences their histological transformation following surgery.Materials & methods. The study included 15 patients with extensive strictures of the bulbous urethra, who underwent a two-stage augmentation urethroplasty with buccal grafts. The grafts pathomorphosis was studied 6 months after the first surgery stage where urethrotomy had been performed with graft augmentation of the dorsal semicircle and the formation of distal and proximal neomeatuses. Natural urination through the latter was restored on days 14 – 20 following the surgery. During the second stage, six months later, urethral tubularisation was performed with two preliminary biopsies of the proximal and distal segments of the grafts implanted in the areas of the neomeatuses formed earlier. The distal area of the graft had no contact with urine, while this contact has occurred in the proximal segment since restoration of natural urination. In biopsy specimens, pathomorphosis of the grafts was studied using immunohistochemical markers: vimentin, clone SRL33; CD34, clone QBEnd/10; MSA HHF-35; СD3, clone LN10; Bcl-2, clone bcl-2\100\D5; CK-HMW 34BE-12.Results. It was found that inflammation was minimal in areas of grafts implanted that had no contact with urine, while in areas where such contact occurred it was verified to be pronounced even 6 months after the operation. On the submucosal level, this was manifested by an uneven arrangement of collagen fibers, a dysplastically developed vascular network, uneven proliferation of the endothelium with swelling and loss of cellular connectivity, in contrast to areas where there was no contact with urine. In such areas, the graft submucosa had a dense collagen framework with organized microvasculature and uniform epithelial surface.Conclusion. The impact of urine on buccal grafts used in augmentation urethroplasty is characterised by the disorganisation of its collagen framework, with a pronounced inflammatory component and the “reactivity” of the epithelial lining to the “toxic agent” that persists even 6 months after surgery. This may underlie the risk of a stenosis relapse in the proximal anastomosis area.

BACKGROUND: The progress made in reconstructive urethral surgery over the past 20 years has shown the effectiveness of one-stage repair of anterior urethral strictures. Nevertheless, multi-stage urethroplasty retains its primary role in the treatment of patients with the most complex urethral narrowing and obliterations. AIM: To evaluate the immediate and long-term surgical results of multi-stage urethroplasty for penile and bulbar urethral strictures. MATERIALS AND METHODS: The study included 110 men aged 1884 years who underwent multi-stage urethroplasty for the anterior urethral structures in 20102019. The techniques of buccal and skin augmentation or urethral replacement plastics were applied. Before surgery, all patients underwent a standard urological examination. Early surgical complications were evaluated from medical records. Late surgical complications were determined according to examinations that included symptomatic assessment with specialized questionnaires, laboratory tests of serum and urine, physical examination, uroflowmetry, and retrograde urethrography and ureteroscopy (if urinary disorders were detected). The median follow-up was 5 years and 2 months. RESULTS: Early surgical complications were detected in 27 (24.5%) patients. Surgical interventions to resolve them were required in 7 (31.8%) cases: urethrocutaneous fistulas (5), acute urinary retention (1), scrotal hematoma (1). Late surgical complications were detected in 33 (30.0%) patients, including 29 (26.7%) cases of recurrent urethral strictures. All late complications cases were classified as Clavien-Dindo IIIb, and a total of 49 additional operations were performed to eliminate them. The primary success rate for multi-stage urethroplasty was 67.3 % with a median follow-up of 62 months. Only 73 (66.4%) completed all stages of the planned surgery. Urethral integrity throughout its entire length was restored in 67 (60.9%) cases, spontaneous urination in 106 (96.4%) cases. CONCLUSIONS: Multi-stage surgery for anterior urethral strictures is associated with relatively high risks of surgical complications at each stage of treatment. The probability of surgical revision of complications can reach 31.8%. Patients should be informed about the risks of developing surgical complications and the potential for more than two surgeries to achieve treatment goals when planning multi-stage urethroplasty.

Introduction. Multi-stage urethral surgery is used in cases of the most complex urethral strictures. The evaluation of surgical treatment results given by patients is a significant criterion for the efficacy of urethroplasty along with the assessment of urethral patency through instrumental examinations.Objective. To evaluate the long-term efficacy of multistage urethroplasty for complex anterior urethral strictures considering the patients' quality of life and satisfaction with the surgical outcomes.Materials and methods. The study included 73 patients aged 18 – 84 years with anterior urethral strictures who underwent multi-stage urethroplasty in 2010 – 2019. Surgical and functional outcomes of urethroplasty were assessed through general blood and urine tests, physical examination, uroflowmetry, and retrograde urethrography and urethroscopy in case of urinary disorders. Subjective parameters of treatment efficacy were studied using questionnaires: International Prostate Symptom Score (IPSS); Quality of life (QoL); Patient-reported Outcome Measure for Urethral Stricture Surgery (USS-PROM); Patient Global Impression of Improvement (PGI-I).Results. Recurrent urethral stricture was detected in 19 (26,0%) patients with the average follow-up period being 65 months. Independent urination was restored in 71 (97.3%) cases, including repeated interventions. After surgery, there was a significant increase in urinary flow rate parameters (Q max: 8.1 vs 19.1 ml/s, p < 0.0001; Q ave: 5.5 vs 10.7 ml/s; p = 0.0004), decrease in residual urine volume (62.4 vs 18.6 ml, p < 0.0001), decrease in total IPSS score (18.7 vs 5.7 points; p < 0.0001) and QoL index (4.3 vs 1 .8 points, p < 0.0001). A comparative analysis of preoperative and postoperative USS-PROM questionnaire results demonstrated an improvement in indicators assessing LUTS (12.9 vs 3.4 points; p < 0.0001; 3.6 vs 1.7 points; p < 0.0001), and urination-associated quality of life (2.6 vs 0.6 points; p < 0.0001) and overall health (EQ-5D index: 0.73 vs 0.91 points; p = 0.025; EQ-VAS: 68.0 vs 88.1 points, p = 0.004). Fifty-seven (81.4%) men were “very satisfied” or “satisfied” with the treatment outcomes, while nine (12.9%) respondents noted a moderate effect of residual urinary disorders on the quality of life. Significantly higher satisfaction was observed among cystostomy patients and in cases where repeated interventions were unnecessary.Conclusion. Multi-stage urethroplasty for complex anterior urethral strictures achieves efficacy in 97.3% of cases and is accompanied by high levels of quality of life and patient’s satisfaction during long-term follow-up.

Introduction. Any sexual dysfunction or complications associated with urethral stricture reconstruction can negatively affect quality of life and patient satisfaction with treatment results, even if the operation is considered 'successful' and urethral patency is restored. According to the literature data, the frequency of erectile dysfunction detected after urethroplasty varies from 0 to 40%. However, most publications are focused on the study of sexual disorders caused bulbar urethral reconstruction and one-stage surgical techniques. Purpose of the study. To evaluate sexual function in patients undergoing multi-stage urethroplasty. Materials and methods. The study included 73 men aged 18–84 years who underwent multi-stage urethroplasty for the anterior urethral structures in 2010–2019. Penile strictures were present in 39 (53.4%) patients, bulbar strictures in 7 (9.6%), penile bulbar strictures in 15 (20.5%) and multifocal strictures in 12 (16.4%) cases. The length of the strictures was 7.27 ± 3.26 (2–18) cm. The effect of staged urethral surgery on sexual function was studied using the IIEF-5, MSHQ-EjD, and MSHQ-InS questionnaires. The mean time from surgery to evaluation of sexual function was 67.8 ± 32.3 (14–134) months. Wilcoxon signed rank test, Mann-Whitney U test, and Kruskal-Wallis H test were used to test for differences in preoperative and postoperative values. Differences were considered significant at p < 0.05. Results. There were no significant changes in the initial indicators of the IIEF-5 questionnaire compared to the postoperative ones (19.67 ± 3.45 (5 – 25) vs 21.73 ± 2.47 (6 – 24) points; the mean difference was (Δ) 2.1, 95% confidence interval (95% CI) 16.1 – 20.2, p = 0.468). The total score of the MSHQ-EjD questionnaire increased from 14.67 ± 3.33 (1 – 28) to 25.41 ± 5.65 (1 – 34) points, the mean difference (Δ) was 10.8, 95% confidence interval (95% CI) – 15.4 – 18.9 (p < 0.001). Similar improvements were observed in the analysis of preoperative and postoperative scores of the MSHQ-InS questionnaire (17.31 ± 4.67 (5 – 30) vs. 24.61 ± 4.13 (8 – 30) points; Δ = 7.2; 95% CI: 15.4 – 18.8, p = 0.036). Conclusions. Patients who underwent multi-stage urethroplasty have minimal changes in erectile function and significant improvements in ejaculatory function, as well as the expressiveness of sexual satisfaction.

The article reviews the 2000-2020 literature on the use of perineal urethrostomy in the treatment of patients with anterior urethral strictures. Historical issues of the development of urethrostomy techniques are considered. The algorithms to choose the method of treatment of urethral strictures in favor of perineal urethrostomy are highlighted, according to the guidelines of the world's professional urological associations. The performance indicators of perineal urethrostomy were studied considering the age characteristics of the patients, the etiological genesis of the strictures, their length and location, as well as depending on the surgical technique and the follow-up period. Considerable attention is paid to studies devoted to the analysis of the functional results of urethrostomy, as well as the quality of life of patients associated with urination and sexual activity. Data are presented on the incidence of early and late surgical complications, including urethrostomy stenosis, as one of the most common. An analysis of studies evaluating factors that negatively affect the outcome of surgery was carried out. The main reasons for the growing demand for the technique in surgery for complex anterior urethral strictures and the importance of the technique among other treatment methods are discussed.

Introduction. Currently, the most common method of treating extended urethral strictures is augmentation urethroplasty using oral mucosa grafts. Analysis of the long-term outcomes of this surgery type shows a high incidence of relapses and complications.Purpose of the study. To improve the outcomes of augmentation urethroplasty, in particular the dorsal inlay (Asopa) technique, in patients with extended spongy urethral strictures by minimizing the risk of recurrent strictures.Materials and methods. The study is based on an analysis of the surgery in 90 patients (aged 18-72 years) with extended spongy urethral strictures. Seventy patients (group I) underwent dorsal inlay augmentation urethroplasty according to the Asopa technique, and 20 patients (group II) — according to the author's modified technique. Statistical data analysis was carried out using the SPSS ver.26 software (SPSS Inc. Chicago, IL, USA).Results. A comparative analysis of the course of the early postoperative period showed a lower number of complications in group II patients compared to group I — 20.0% versus 34.3%, respectively. The recurrent strictures were registered for groups I and II in 18.8% and 5.6% of cases 6 months after surgery, respectively. The recurrent urethral narrowing was most often localized in the area of distal anastomosis between the buccal graft and the native urethra in patients from both groups.Conclusion. The modified dorsal inlay augmentation urethroplasty technique developed and implemented in clinical practice by increasing the internal urethral lumen in the areas of proximal and distal anastomosis between the buccal graft and the native spongy urethral body allows minimizing the risks of recurrent urethral narrowing after augmentation urethroplasty.

Introduction. Extended spongy urethral strictures require the use of plastic surgery techniques. In most cases, a one-stage urethral repair can be performed. However, staged urethroplasty and permanent urethrostomy are important in patients with extremely complex urethral strictures. Purpose of the study. To determine the clinical features of spongy urethral strictures, which cannot be cured by one-stage urethroplasty, but are subject to multistage plastic or permanent urethrostomy. Materials and methods. The study included 158 patients who underwent surgery for urethral strictures in 2010 − 2019. Inclusion criteria: spongy urethral strictures requiring staged urethroplasty or permanent urethrostomy. Exclusion criteria: age<18 years, proximal urethral strictures, urethra-vesical anastomosis and bladder neck stenosis, previously untreated congenital anomalies (hypospadias and epispadias), and history of any other urethral surgery not meeting the inclusion criteria. Results. The age of the patients ranged from 18 to 88 years. Iatrogenic (34.8%) and inflammatory (32.3%) urethral lesions predominate in the structure of etiological factors with the most common penile localization of narrowing (43.7%). The length of strictures in half of the patients exceeds 6 cm; a quarter of the sample has subtotal and total spongy urethral lesions. The proportion of recurrent urethral strictures is 56.3%. The average duration of the urethral stricture disease reaches 8 years. In 61.3% of cases, the disease is accompanied by complications from both local tissues and organs of the urinary and reproductive systems. Conclusion. Clinical evaluation of patients with spongy urethral strictures requiring multi-stage urethroplasty or permanent urethrostomy reveals a particular severity of urethral stricture disease. This category of patients has a high risk of unsuccessful outcomes with one-stage surgery. In these cases, patients require a multi-staged urethroplasty or a permanent urethrostomy.