Vessel sparing and Non transecting EPA 2024.pptx

Vessel sparin

1. Non transecting urethroplasty and Vessel sparing EPA vs classic EPA Amr Elkady , MD Assistant Professor of urology Cairo University

2. Main points Classic EPA D o we need to shift from classic EPA to other new urethroplasty techniques? Vascular supply of the male urethra Vessel sparing EPA NTAU  1. Stricturoplasty ( Heineke-Mikulicz principle)  2. ntEPA  3. ANTA Which is better? Classic EPA or Vessel sparing and non transecting urethroplasty ? 16/5/2024 Amr Elkady, MD

3. Classic EPA Transecting E xcision and P rimary A nastomotic urethroplasty ( tEPA ) Full transection of the urethra and the surrounding spongious tissue containing the urethral vasculature at the site of the stricture. 16/5/2024 Amr Elkady, MD

4. Classic EPA Diagnosis VIU and Urethral dilatation Timing Staging Fibrous tissue excision Inferior pubectomy Proximal urethra identification Tension free anastomosis Hemostasis Specialization 16/5/2024 Amr Elkady, MD

5. Classic EPA Gold standard treatment 1 Success rate: 85–95% 2,3,4 1- EAU Guidelines 2019 2- Mundy AR, Andrich DE. Urethral trauma. Part II: types of injury and their management. BJU Int. 2011; 108: 630–650 . 3- 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 4- Barbagli G, Montorsi F, Balò S, Sansalone S, Loreto C, Butnaru D, Bini V, Lazzeri M.  Treatments of 1242 bulbar urethral strictures : multivariable statistical analysis of results . World J Urol . 2018 16/5/2024 Amr Elkady, MD

6. Classic EPA Effect of tEPA on the patient’s sexual function 1,2 . The spongiofibrosis surrounding the urethral stricture does not usually affects the whole thickness of the corpus spongiosum 1. Xie H, et  al. Evaluation of erectile function after urethral reconstruction: a prospective study. Asian J Androl . 2009;11(2):209–14 . 2. Beysens M, et  al. Anastomotic repair versus free graft urethroplasty for bulbar strictures: a focus on the impact on sexual function. Adv Urol. 2015;2015:912438. 16/5/2024 Amr Elkady, MD

7. Vascular supply of the male urethra 16/5/2024 Amr Elkady, MD Internal pudendal artery common penile artery central cavernosal dorsal penile bulbourethral artery The urethral artery runs longitudinally along the urethra at the 4 and 8 o ’ clock position

8. Vascular supply of the male urethra 16/5/2024 Amr Elkady, MD D ual blood supply to the urethra has been described: 1 . B ulbourethral (or bulbar and urethral ) artery  antegrade urethrospongiosal blood flow. 2 . D orsal penile artery  retrograde urethrospongiosal blood flow. ?? third vascularisation due to connecting vessels from the corpora cavernosa .

9. Vascular supply of the male urethra 16/5/2024 Amr Elkady, MD Ivaz , Stella Leah et al. “The Nontransecting Approach to Bulbar Urethroplasty.”  The Urologic clinics of North America  44 1 (2017): 57-66

10. Vessel Sparing EPA Jordan et  al, 2007 B ulbar urethral stricture after radical prostatectomy All scenarios possible benefits: 1) AUS 2) Sexual 3) Urethral anastomosis 4) Hypospadias 5) Elderly, DM 16/5/2024 Amr Elkady, MD

11. Vessel Sparing EPA The space between the membranous urethra and the proximal vasculature is developed and a vessel loop is used to retract on the vascular structures, exposing the membranous and proximal bulbar urethra. In this step, the bulbar arteries are preserved 16/5/2024 Amr Elkady, MD

12. Vessel Sparing EPA 16/5/2024 Amr Elkady, MD

13. Vessel Sparing EPA 16/5/2024 Amr Elkady, MD

14. Vessel Sparing EPA 16/5/2024 Amr Elkady, MD

15. Vessel Sparing EPA The bulbar arteries are located using a Doppler ultrasound and then the bulb is mobilized from one side only , without detachment from the perineum. The artery from that side is sacrificed to preserve the contralateral one Gomez RG, Campos RA, Velarde LG. Reconstruction of pelvic fracture urethral injuries with sparing of the bulbar arteries. Urology 2016; 88: 207–12. 16/5/2024 Amr Elkady, MD

16. Non-transecting anastomotic urethroplasty (NTAU) “With his technique, the perineal body was dissected away from the bulbus and the bulbourethral arteries are identified and encircled with vessel loops during dissection. These maneuvers are not necessary and might even cause damage to the bulbourethral arteries. Therefore, it must not be performed”* * Andrich DE, Mundy AR.  Non-transecting anastomotic bulbar urethroplasty : a preliminary report. BJU Int. 2012;109(7):1090–4. 16/5/2024 Amr Elkady, MD

17. Non-transecting anastomotic urethroplasty (NTAU) Lumen et al. in 2010  ventral approach . Andrich et al. in 2012  dorsal approach The stricture is opened at the dorsal side in a longitudinal fashion Degree of spongiofibrosis , stricture location, stricture length: 1 . Stricturoplasty ( Heineke-Mikulicz principle) 2 . ntEPA 3 . ANTA 16/5/2024 Amr Elkady, MD

18. Stricturoplasty ( Heineke-Mikulicz principle) 16/5/2024 Amr Elkady, MD

19. Stricturoplasty ( Heineke-Mikulicz principle) 16/5/2024 Amr Elkady, MD

20. Stricturoplasty ( Heineke-Mikulicz principle) This technique is only possible for  very short strictures (≤1  cm )  not too narrow  without substantial underlying spongiofibrosis 16/5/2024 Amr Elkady, MD

21. Non-transecting excision and primary anastomosis ( ntEPA ) 16/5/2024 Amr Elkady, MD The scarred urethral mucosa with the underlying spongiofibrosis is fully excised

22. Non-transecting excision and primary anastomosis ( ntEPA ) 16/5/2024 Amr Elkady, MD reconstruction of the urethral plate ventrally

23. Non-transecting excision and primary anastomosis ( ntEPA ) 16/5/2024 Amr Elkady, MD Heineke-Mikulicz principle dosally

24. Augmented non-transecting anastomosis (ANTA) 16/5/2024 Amr Elkady, MD The length and width of the dorsal urethral opening is measured and a graft is harvested according to the measured dimensions

25. Chapman et al. 2018  352 patients non-transecting 4.3 % vs transecting urethroplasty 14.3 % Outcomes of non-transecting techniques are comparable to transecting techniques in terms of urethral patency, somewhat decreasing the fear that scar tissue excision may be incomplete in these approaches 1,2 Breyer BN, et  al. Multivariate analysis of risk factors for long-term urethroplasty outcome. J Urol. 2010;183(2):613–7 . Lumen N, et al. Nontransecting anastomotic repair in urethral reconstruction: surgical and functional outcomes. J Urol. 2016;196(6):1679–84. 16/5/2024 Amr Elkady, MD

26. Which is better? Classic EPA or Vessel sparing and non transecting urethroplasty ? 16/5/2024 Amr Elkady, MD

27. Thank you 16/5/2024 Amr Elkady, MD