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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