Urethral Stricture my treatment algorithm Sanjay Kulkarni Prof of Urology KULKARNI

Urethroplasty Centre

Pune, India

.

Urethra is Urethra, Penis is Penis

Don ’t touch Penis Italian Patient to Guido Barbagli Genital skin flaps are used rarely now

Retrograde Urethrography and MCU Site •Penile •Bulbar: Proximal Mid to Distal •Posterior

Urethro- Cystoscopy 6Fr URS Non-obliterative Obliterative

Management

DVIU Dilation CIC Stent

Cure

Trauma Anastomotic Bulbar Posterior Long gaps

To Create Stable urethra of Normal Caliber

Penile 1 Asopa 2 Kulkarni- Barbagli 3 Two stage BMG Bulbar Proximal -Ventral BMG Mid-Distal- Dorsal BMG Long Obliterative Double Face BMG Pan Urethral-Kulkarni Diversion Perineal Urethrostomy Augmented Anastomosis Substitution Oral Mucosa Flap

Management • Dilatation rarely cures a stricture • Results of Dilation and DVIU are same • DVIU followed by CIC should NEVER be the first line of treatment • CIC- Unfit pt.

Pt. refuses surgery Multiple failed urethroplastie s

Injury -Posterior urethra plucked away Surgery -Bulbar urethra mobilized

Management of the patient with Pelvic fracture urethral injury Resuscitation of the patient to preserve life Preserve the bladder neck Supra Pubic Catheter Avoid jeopardizing sexual function residual to the trauma

SPC

MCU+ RGU

Impotence due to Posterior Urethral Injuries Duplex Color Doppler

Posterior urethral injury The goal of surgery Tension free Bulbo-Membranous anastomosis

Instruments

Lithotomy with Allen stirrups

Posterior urethral trauma

Simple

• • • • • • • • •

Complex

Failed urethroplasty Boys Girls Recto urethral fistula Long gap > 4cm BN incompetence Impotence Bulbar urethral ischemia Abscesses and fistulae

Approaches Perineal 1. Bulbar urethral mobilization 2. Crural separation Elaborated perineal (Webster) 3. Inferior pubectomy 4. Supra-crural rerouting of urethra Perineo abdominal (Turner Warwick) 5. Total pubectomy 6. Omental wrap

Simple perineal repair 1.Bulbar urethra mobilized 2.Crural separation

Ancilliary procedures 3.Inferior pubectomy 4.Supra-crural rerouting

Abdominal Approach 5.Total Pubectomy 6.Omental Wrap

Omental wrap

SPC-Flexible cystoscopy

Veru Montanum SPC Flexible cystoscopy During surgery

Prostate apex and pubic bone Prostate

low

Step 1: Bulbar urethra mobilized Prostate

high

Step 3: Inferior pubectomy Prostate

back

Step 2: Crura separation The most unpredictable part of the surgery is the ease with which the proximal urethra can be identified and spatulated-AR Mundy

Bulbo-prostatic gap Bulbar urethral length Less than 1/3 Less chance of pubectomy More than 1/3 More chance of pubectomy MM Koraitim, J Urol 2008, 179: 1879-81

Anastomotic urethroplasty for posterior urethral trauma

Patients Inferior pubectomy Transpubic

Arezzo Italy

18 4 22% 0

Pune India

172 100 58% 28 17% 75%

Success rate of Anastomotic urethroplasty for posterior urethral injuries Primary 95% Redo 85%

Multiple failed urethroplasties Incontinenent

Anastomosis to a False passage

Recto Urethral fistula

Urethral injury in a Girl

Penile Urethra: Normal Penis 1. Asopa 2. Kulkarni-Barbagli

Penis not normal,HypospadiasCripple -2 stage BMG

Bulbar urethra: Trauma 1-2 cm Anastomotic urethroplasty

Bulbar urethra-Proximal Ventral Onlay BMG

Bulbar Urethra Transection No Transection • Trauma • Anastomotic • Success-90% • Recurrence-Obliterative • Augmented Anastomosis • 5%Impotence • No Trauma • Dorsal BMG • Success 85% • Recurrence- Non Obliterative • Ventral BMG • 2% Impotence • Andrich,Mundy • 2003 JUrol Vol 170,1,90-92

Long obliterative Bulbar urethral stricture Trauma-Augmented Anastomosis

Long Obliterative Bulbar urethral stricture No Trauma-Double face BMG

Double Face BMG

Bulbar Mid-Distal Kulkarni-Barbagli Dorsal BMG

Bulbo-Spongiosus muscle preserved One side dissection

Pan urethral stricture repair Kulkarni-Barbagli

Harvesting oral mucosa: Buccal Lip Lingual

Fellowship in Reconstructive Urology GURS 13 Centers in USA, London, Pune Indian School of Urethral Surgery www.strictureurethra.com