Urethral Stricture my treatment algorithm Sanjay Kulkarni Prof

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 6 Fr URS Non-obliterative Obliterative

Management Cure DVIU Trauma Anastomotic Dilation Bulbar Posterior CIC Stent 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 Augmented Substitution Perineal Anastomosis Oral Mucosa Flap Urethrostomy

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 urethroplasties

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 Supra Pubic Catheter Preserve the bladder neck 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 > 4 cm 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 Arezzo Italy Pune India Patients 18 172 Inferior pubectomy 4 22% 0 Transpubic 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, Hypospadias. Cripple -2 stage BMG

Bulbar urethra: Trauma 1 -2 cm Anastomotic urethroplasty

Bulbar urethra-Proximal Ventral Onlay BMG

Bulbar Urethra Transection • • • Trauma Anastomotic Success-90% Recurrence-Obliterative Augmented Anastomosis 5%Impotence No Transection • • 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