Bulbar Urethral Necrosisssssssssssssssssssssss.pptx

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1. Bulbar Urethral Necrosis (BUIN) Dr Nuru B (USR IV) 5-minute presentation .

2. Contents Introduction and definition Case discussion Epidemiology Anatomical Considerations Pathophysiology Evaluation and Dx Management

3. Introduction and definition Pelvic fracture urethral injury (PFUI) occurs in 10% of those who suffer from pelvic fractures. Bulbar urethral ischemic necrosis (BUIN) Is an iatrogenic entity which results from previous failed anastomotic repairs in patients with PFUI. Was used for the first time in 1986 by Turner-Warwick. Historically, was defined as “long gap” or “unsalvageable” bulbar urethra after previous failed repairs. BUIN is defined as ( Pankaj .et.al) A compromised or complete absence of a segment of bulbar urethra. The etiology is always vascular.

4. Case discussion

5. Anatomical Considerations

6. Pathophysiology Over mobilization of distal urethra during anastomotic urethroplasty. Lack of retrograde blood supply. Hypospadias Iatrogenic Primary trauma Extensive spongiofibrosis resulting from multiple previous surgeries. Awareness of this pathophysiology helps prevent BUIN and its sequelae.

7. Epidemiology The exact incidence of BUIN is unknown. Incidence in 1 series – 9% (177/1700 PFUI patients) They had 2 or more prior failed attempts of repair. The incidence is rising in recent years

8. Evaluation Preoperative workup Assess presence of ED Using standardized questionnaires such as IIEF Examine penile vascular supply Penile Doppler u/s

9. Diagnosis CUG

10. Management Initial evaluation includes The identification of The type of injury, The extent of injury, Prior number and type of repairs, and Preoperative assessment of Antegrade and Retrograde blood flow to the urethra. All these parameters are of paramount importance.

11. Management Presence of lumen The amount of spongiofibrosis These determines the need for a vascularized flap as opposed to a buccal mucosal graft .

12. Management

13. Management The following surgical approaches are available. Pedicle preputial flap/tube: Oral mucosal flap: “Q” Flap: Scrotal drop back (Turner-Warwick): Entero-urethroplasty: Use of BMG dorsally and flap ventrally: Pedicled anterolateral thigh flap for reconstruction for urethral defects[ Forearm flap with microvascular anastomosis to inferior epigastric artery Dorsal BMG with ventral BMG on gracilis muscle Non-circumcised Circumcised

14. Management --- Pedicle preputial flap/tube This technique can be done using distal penile skin when patient is circumcised

15. Management --- Oral mucosal flap (OMF)

16. Management --- “Q” Flap

17. Management --- Scrotal drop back (Turner-Warwick)

18. Management

19. References