urethroplastyprinciplesandpractices-221228235505-4a661ae6 2.pptx

basics of urethroplasty

1. Urethroplasty: Principles and Practices

2. Objective Principles History Definition Diagnosis Basic principle for urethroplasty Current recommendation for urethroplasty Practices Which technique to choose How BMG is applied in different technique Medium term / long term success What is the future

3. Epicurus, a Greek philosopher, was known to commit suicide when he could no longer dilate his own stricture

4. History Development of the Duplay -Denis Browne principle , buried, ventral or dorsal, strip of oral mucosa becomes an epithelialized tube. In 1980, Monseur fully applied Duplay’s principle and described the first dorsal urethroplasty. opening the dorsal urethral surface and fixing the opened urethra over the underlying corpora cavernosa, and leaving a catheter in place for a long period Devine and collaborators popularised the use of genital and extragenital free skin grafts for urethral reconstruction

5. History Barbagli Combined Devine’s technique with Monseur’s and described a new technique for dorsal onlay graft urethroplasty

6. History First described at the end of the 19th century by the Russian surgeon Kirill Sapezhko (1857–1928) He published his experience of four cases of urethral stricture disease treated in men using oral mucosal grafts in the Russian medical journal Chirurgicheskaya letopis Sapezhko KM. To the treatment of urethral defects using mucosa grafts [in Russian]. Chirurgicheskaya letopis 1894;4:775–84. Vasiliyev KK. K.M. Sapezhko —the professor of Novorossiysk University

7. Blood supply

8. Modern History of Urethroplasty by Anatomical Segment Anterior Urethra Penile Urethroplasty • 1953: Johanson staged urethral repair without grafting • 1999: Hayes and Malone OMG dorsal inlay technique for hypospadias • 2001: Asopa one-stage OMG dorsal inlay urethroplasty in adults Bulbar Urethroplasty • 1996: Barbagli dorsal onlay OMG bulbar urethroplasty • 1996: Morey and McAninch harvest technique of OMG and OMG ventral onlay urethroplasty • 1998: Webster augmented dorsal graft anastomosis • 2006: Barbagli fibrin glue urethroplasty • 2008: Barbagli bulbospongiosus muscle and nerve sparing bulbar reconstruction

9. Pan-urethroplasty • 1953: Johanson two-stage urethroplasty: penile ventral marsupialization followed by second stage retubularization 6 months later • 1993: McAninch distal/preputial circular fasciocutaneous skin flap • 2000: Kulkarni penile invagination technique with OMG dorsal onlay • 2009: Kulkarni one-sided penile invagination technique to preserve lateral neural and blood supply to urethra • 2010: Barbagli supported perineal urethros - tomy with Blandy flap technique for complex/ irreparable urethral strictures or unfit patients for surgery

10. Posterior Urethra • 1962: Pierce total abdominal pubectomy for exposure of posterior urethra • 1968: Paine and Coombs end-to-end anasto - mosis after resection of scar and pubic bone (abdominal approach) • 1973: Waterhouse combined abdomino -peri- neal approach. • 1976: Turner-Warwick use of omentoplasty for transpubic primary anastomosis. • 1986: Webster and Goldwasser perineal anas - tomotic urethroplasty with infrapubectomy .

11. Definition Urethral stricture refers to urethral luminal narrowing with associated spongiofibrosis , which occurs in the anterior urethra (distal to the external sphincter). Urethral stenosis is an obliterative, fibrotic process that occurs in the posterior urethra or bladder neck, usually secondary to pelvic fracture urethral distraction (PFUD) injuries or surgery such as radical prostatectomy

12. Principles true hybrid of urologic and plastic surgery Do no harm Urethral tissues are very delicate and improper handling may lead to further damage and compromised tissue quality The tissue planes must be respected, and meticulously dissected layer by layer Hemostasis must be quick and precise Bipolar cautery is preferentially used Proper visualization is key Good retractor Surgical loupes Proper lighting and Knowledgeable surgical assistant

13. Urethral Anastomosis Principle (1) tension-free (2) watertight (3) well-vascularized tissue (4) Stented urethral anastomosis using (5) Resorbable sutures.

14. RUG + MCUG Modified lateral decubitus position, Hips placed at a 45° angle Lower leg bend and the upper leg straight Penis must on full stretch Patient is in a correct oblique position, only one obturator foramen should be visualized on the scout image. (a) Scout film and (b) retrograde urethrogram showing a bulbar urethral stricture • assess the continuity of urethra • length of gap between the proximal and distal ends • State of bladder, presence of diverticulum, stones bladder capacity • Bladder neck—open or closed

15. Urethral Rest For anterior urethral strictures, the urethra should not be instrumented for 6–12  weeks prior to the urethroplasty. This allows the scar to mature and declare itself appropriately

16. Pelvic fracture urethral defect [PFUD] Should undergo a preoperative examination under anesthesia, as estimation of the length of the defect requires an antegrade flexible cystoscopy via their suprapubic cystotomy site, while a RUG is performed simultaneously Recommend repeat imaging after the period of urethral rest as the surgical plan may differ once the stricture has fully declared itself Pre-operative urine culture performed

17. For PFUD, a 3-month period of urethral rest is traditionally recommended although recent data has shown that a 3–6-week resting period has similar outcomes. Reconstructive urologist must ensure that Patient’s other injuries have been appropriately addressed Patient is physically able to be placed in the lithotomy position

18. Surgical Equipment Surgical loupes Headlight Scissors.. Retractors

19. EAU 2021

20. Nontraumatic bulbar strictures Site of graft does not alter the outcomes for bulbar urethroplasty (LE‑3, GR‑strong ) In obese patients, young sexually active and post-TURP proximal bulbar strictures ventral onlay urethroplasty remains the first‑choice (LE‑5, clinical principle) Proximal bulbar strictures with healthy, spongiosa ventral onlay urethroplasty is the first choice procedure (LE5, clinical principle) Dorsal approaches include Barbagli -Circumferential mobilization or Kulkarni -One side dissection for dorsal onlay and Asopa for Dorsal inlay (LE3, GR moderate). Kulkarni , et al.: USI guidelines on urethral stricture

21. Traumatic bulbar strictures There is no role for DVIU (LE‑3, GR‑strong ) Short stricture-excision with anastomotic urethroplasty (LE‑3, GR strong) Long stricture/failed anastomotic  ‑Augmented anastomotic urethroplasty is recommended (LE 4, GR strong). Kulkarni , et al.: USI guidelines on urethral stricture

22. Define the term: Augmentation Urethroplasty Substitution Urethroplasty Augmentation anastomotic urethroplasty

23. Why BMG? Cosmetically superior incision Hairless Decreased operative time Accustomed to a wet environment Resistance to infection, compatibility with a wet environment has a thick epithelium and a thin lamina propria , making it tough and easy to handle -----encourage graft imbibition and inosculation LONG-TERM FOLLOWUP OF THE VENTRALLY PLACED BUCCAL MUCOSA ONLAY GRAFT IN BULBAR URETHRAL RECONSTRUCTION SEAN P. ELLIOTT, MICHAEL J. METRO AND JACK W. M C ANINCH

24. Technique of graft selection Harvest a rectangular graft that was 20% longer and 15% wider than the urethral defect in order to compensate for spontaneous elastic retraction. Care was taken to avoid damage to the orbicular muscle and, to the Stensen’s duct, the facial nerve and the buccinators muscle.

25. Anesthesia Nasal intubation is not mandatory, but it is helpful for surgeons who are not familiar with this technique.

26. Urethroscopy attempted with a 6Fr pediatric cystoscope / URS in all patients. Warner JN, Malkawi I, Dhradkeh M et al. A multi-institutional evaluation of the management and outcomes of long-segment urethral strictures. Urology 2015; 85: 1483–7.

27. Selection of technique In the bulbar urethra, the surgical technique selected Stricture length Stricture aetiology Density of the spongiofibrosis tissue

28. Why EPA? Urethra is the best substitute for urethra - Turner- Warwick’s opinion is still true Indication Penile: sharp cut Bulbar: Traumatic Posterior: Progressive perineal approach

29. Pillars of a successful anastomotic urethroplasty An adequate urethral mobilization without tension an excision of scar tissue a precise mucosa approximation

30. Advantage of EPA Urethral reconstruction with excision of the strictured area and end-to-end anastomosis is successful in >95% of patients with a stricture of<2 cm Webster GD Et al.

31. EPA: Disadvantage Compared with BMG patch techniques EPA has penile curvature (36% vs. 8%) penile shortening (38% vs. 11%) impaired erection (79% vs. 15%) impaired sexual life (57% vs. 19%) Overall satisfaction about sexual life was 74% vs 97% Eltahawy EA, Virasoro R, Schlossberg SM, McCammon KA, Jordan GH. Long-term followup for excision and primary anastomosis for anterior urethral strictures. J. Urol. 2007; 177: 1803–6.

32. EPA disadvantage Success outcome in urethral repair should be assessed not only by objective voiding parameters but also by subjective parameters influencing satisfaction Culty T, Boccon-Gibod L. Anastomotic urethroplasty for posttraumatic urethral stricture: previous urethral manipulation has a negative impact on the final outcome. J. Urol. 2007; 177: 1374–7.

33. Substitution Urethroplasty Substitution urethroplasty is therefore the procedure of choice for a long stricture in the proximal bulbar urethra or a stricture of any length located anywhere from the distal bulbar urethra to the penile urethra.

34. 3 Options of one stage urethroplasty

35. Rationale for dorsal graft The corporeal body is a healthy host for graft Graft fixation by decrease graft shrinkage and sacculation Ventral urethral opening may create serious bleeding from particularly thick and highly vascular spongy tissue Periodic stretching during erection, thereby reducing the risk of patch retraction Andrich DE, Mundy AR. Substitution urethroplasty with buccal mucosal-free grafts. J Urol 2001;165:1131–3.

36. Dorsal Onlay Augmentation Urethroplasty 1996 Barbagli`s Technique

37. Barbagli`s Technique

38. Barbagli`s Technique

39. Barbagli`s Technique

40. Disadvantage of dorsal technique Extensive mobilization of the urethra is necessary Surgical technique is more difficult Operation time is longer Ischemic damages secondary to the dissection is higher

41. Success rate Dorsal onlay BMG urethroplasty has shown a success rate from 87.5% to 100% with a follow-up ranging from 22 to 41 months . 24. Metro MJ, Wu HY, Snyder HM 3rd, Zderic SA, Canning DA: Buccal mucosal grafts: lessons learned from an 8-year experience. J Urol. 2001; 166: 1459- 61.

42. Success rate Barbagli et al., published a retrospective study of 50 cases with bulbar urethral stricture Grafts were placed as ventral, dorsal and lateral onlay in 17,27 and 6 patients respectively After a mean follow-up of 42 months, showed the similar success rate

43. Ventral Onlay Augmentation Urethroplasty

44. Ventral onlay : Advantages Limited urethral mobilization with preservation of perforating arteries Shorter operative time and easier technique compared with the dorsal onlay procedure Simple technique and the phases of imbibition and inosculation are facilitated

45. Ventral onlay : Disadvantage Carried out only for midbulbar and proximal bulbar strictures Not suited for traumatic bulbar urethral stricture severely scarred corpus spongiosum Lack of spongiosum support reduces the likelihood of graft survival, and increases the risks of ballooning and urine pooling.

46. Tips ventral placement The use of a larger caliber catheter has the advantage of exposing the entire graft surface to the recipient bed provided that no tension on the sutures is exercised

47. Lateral Onlay Augmentation Urethroplasty

48. Kulkarni`s Dorsolateral onlay procedure 2000

49. Advantages Avoiding excessive circumferential mobilization of the urethra reduces the vascular damage occurring during urethroplasty .

50. One-sided dorsolateral onlay ( Kulkarni technique) Done for complex panurethral strictures Kulkarni et al. reported an excellent result of a one-stage procedure by dorsolateral onlay : with a median follow up of 59 months the overall success rate was 83.7%.62

51. Dorsal Inlay Augmentation Urethroplasty Asopa`s technique

52. Advantages: Asopa technique Eliminates the outpouching and ballooning of the graft The two halves of the urethra derive their blood supply from the circumflex and perforating vessels The sizing of the graft is accurate and hence pooling of urine and semen is minimized. DORSAL FREE GRAFT URETHROPLASTY FOR URETHRAL STRICTURE BY VENTRAL SAGITTAL · uRETHROTOMY APPROACH HARi S. ASOPA, D , LAKHAN SOTI ASOPA

53. Limitations : Asopa`s technique The urethral plate needs to be more than 1 cm wide The graft that can be inlayed is typically narrower than the wide grafts that can be achieved with an onlay procedure

54. Obliterative stricture In obliterative or nearly obliterative segment Neither EPA nor an onlay procedure is possible, because such a stricture contains a significant amount of spongiofibrosis Length of excised urethra would result in too much tension on anastomosis

55. Options for obliterative Combination of EPA and primary anastomosis and onlay augmentation, a combination called an augmented anastomotic urethroplasty . Onlay augmentation using two grafts (two-sided dorsal plus ventral onlay urethroplasty , Palminteri technique Palminteri E, Lumen N, Berdondini E et al. Two-sided dorsal plus ventral oral graft bulbar urethroplasty : long-term results and predictive factors. Urology 2015; 85 : 942 – 7.

56. Combined Dorsal plus Ventral Double Buccal Mucosa Graft in Bulbar Urethral Reconstruction Palminteri technique

57. Palminteri technique

58. Palminteri technique

59. Palminteri technique

60. Palminteri technique

61. Palminteri technique

62. Palminteri technique

63. In 2001, Guralnick and Webster introduced the term “augmented anastomosis ” Most obliterated segment of the stricture is excised, and stricturotomy is carried out Either the ventral or dorsal wall is then anastomosed , and the remaining defect on the other side is repaired with a graft They also suggested that strictures longer than 5 cm are amenable to repair using this technique

64. Augmented anastomotic urethroplasty

65. Graft failure Graft failure at the proximal anastomosis attributed to under staging disease during surgery. Proximal anastomosis is deep in the bulb, which is a more difficult site technically in which to ensure epithelium-to- urothelium placement. Further study is necessary to clarify the true etiology of this kind of repeat structuring (ischemia, suture line or suture material),

66. Graft failure Early failure of a free graft can result from a poorly vascularized recipient bed or infection hematoma. Late re-stricture may owe to progression of the original disease. Grafts fare poorly in the pendulous urethra where the corpus spongiosum is less vascular. Graft failure at the distal anastomosis may represent poor inosculation owing to poor graft bed vascularity . Important to incise the urethra well into normal tissue proximally and distally to ensure complete stricture incision

67. Case of graft failure remains uncertain …..poor healing and graft incorporation at one or other end of the patch. poor graft ‘take’, deficient vascularity of the graft bed, poor surgical placement of apical sutures, or insufficient dissection proximal and distal to the stricture site to expose normal Other series suggested that most failures occur in the first year , implicating technical operative errors , whereas the present data suggest a peak at 2 years Andrich DE, Dunglison N, Greenwell T, Mundy AR. The long-term results of urethroplasty . J Urol 2003; 170 : 90–2

68. Complication of BMG Urethrocele with post-void dribbling and semen sequestration are common Yucel and Baskin reported that perineal nerves innervate the bulbospongiosus muscles and send fine branches to penetrate the corpus spongiosum , muscles in the midline. Rhythmic contractions of the bulbospongiosus muscles and other perineal muscles expel semen and from the urethra

69. Recurrence Stricture recurrences can, however, occur despite using an adequate surgical technique and substitution material may deteriorate over time Armenakas NA. Long-term outcome of ventral buccal mucosal grafts for anterior urethral strictures. AUA News 2004;9:17–8. Elliot SP, Metro MJ, McAninch JW. Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction. J Urol 2003;169:1754–7.

70. Recurrence After bulbar substitution onlay urethroplasty Extensive fibrous tissue involving the entire grafted area or Short fibrous ring stricture at the distal or proximal anastomotic sites Use of fibrin glue in a new technique of dorsal onlay buccal mucosal graft urethroplasty to reduce the time of postoperative catheterisation , the risk of postoperative urinary leakage, and to reduce the incidence of postoperative anastomotic rings at the apices of the sutures between the graft and the mucosal urethral plate

71. Glue The application of fibrin glue in urology mainly relates to Sealing power Adjunct to sutures for closing wounds and promoting healing because it increases tissue plane adherence, accelerates revascularization, Reduces haemorrhage , prevents seroma formation, and decreases inflammation 22] Hick EJ, Morey AF. Initial experience with fibrin sealant in pendulous urethral reconstruction. Is early catheter removal possible? J Urol 2004;171:1547–9.

72. DVIU after BMG Well- vascularized grafted area usually develops a short and soft stricture, which responds better to incision than primary strictures surrounded by abundant scar tissue

73. Stage urethroplasty The diseased corpus spongiosum is excised and proximal urethrostomy is performed. The dartos fascia is then sutured in the midline and buccal mucosal grafts are spread fixed onto the corporeal bodies. The patient is discharged home between postoperative days 8 and 10 after ensuring graft take. Stage 2 urethroplasty is performed after 6 months

74. Required volume Low-volume surgeons that the learning curve is long and never reaches a plateau, even after 20 years. (at least 15 cases a year) could treat bulbar urethral strictures in less specialized centers. Figler BD, Malaeb BS, Dy GW, Voelzke BB, Wessells H. Impact of graft position on failure of single-stage bulbar urethroplasties with buccal mucosa graft. Urology 2013; 82: 1166–70.

75. Future With the advent of tissue engineering, artificially produced grafts might also find a place in the arsenal of the reconstructive surgeon.

76. Conclusion “ primum non nocere ” (“first, do no harm”) Currently the best technique is probably the one with which the urological re-constructive surgeon is most comfortable

77. Thank you