Urethral Stricture Management in the 21st century.
MAXX GALLEGOS MD DIRECTOR OF UROLOGIC RECONSTRUCTION ASSOCIATE RESIDENCY PROGRAM DIRECTOR Urethral stricture: Scope of the problem u Overall incidence u The highest rate of stricture found in VA patients who are also Medicare patients 0.6% (1999)
u Rises sharply after age 55
u Strictures are Expensive
Costs:
u Individual costs of $6,500 per afflicted person (yearly health expenses rises from $3,713 to $10,472)
u Cost of 2 DVIU is $6,700 compare to $7,522 for one- stage urethroplasty (Greenwell et al, JU, 2004) Why Urethroplasty at all? u Why not urethrotomy? u Published 47-61% failure rate first urethrotomy Italy Pansadoro and Emiliozzi, J Urol, 1996
u Dilation even worse: 88% failure rate Heyns et al., J Urol, 1998
u 100% failure rate second, third urethrotomy in all studies London Greenwell et al, J. Urol, 2004 Very poor success of first urethrotomy
Success of different urethroplasties
6 Urethroplasty: Too many operations
u More than operations for urethroplasty u Cecil. Three stage urethroplasty with first stage as Johanson, bury defect in scrotum for second stage, third stage release with scrotal skin coverage. u Denis-Browne: second stage is achieved by tying skin over lead bolsters/shot. u Devine: one stage distal skin graft urethroplasty u Horton-Devine: minimal pull-through of normal urethra after division of fossa navicularis stricture u Johanson: staged linear urethroplasty with or without buccal grafts for skin grafts in first stage u Jordan: split glans technique of rotational onlay fasciocutaneous flap for the treatment of distal strictures u McAninch 1. glans tunnel technique of rotational onlay fasciocutaneous flap for the treatment of distal strictures u McAninch 2: circular fasciocutaneous flap for treatment of any location strictures (“preputial island flap”) u Orandi: longitudinal penile fasciocutaneous flap for use in penis u Quartey: Q shaped circular fasciocutaneous flap u Schreiter and Noll: Johanson with meshed skin graft in first stage u Steward: two stage with exteriorization of normal urethral ends and burying of the stricture in first stage. Second stage, as in second stage Johanson u Turner-Warwick 1: roof strip anastomotic with fasciocutaneous onlay u Turner-Warwick 2: two stage with scrotal flap in first stage u Turner-Warwick 3: perineal “push in” procedure u Waterhouse: combined perineal and transpubic approach for posterior urethral strictures u Wyland-Leadbeter. Perineal Johanson u Zinman: muscle augmented skin graft (bulb)
Guidelines statements to know:
u 11. Surgeons should offer urethroplasty, not 12. Surgeons who do not perform repeated endoscopic management for urethroplasty should offer patients referral to recurrent strictures (Moderate surgeons with expertise. (Expert Opinion) Recommendation; Strength Grade C)
u 16. Surgeons should offer urethroplasty as the initial treatment for long (≥2cm) bulbar strictures, given the low success rate of (DVIU) or dilation. (Moderate Recommendation; Strength Grade C
u 15. Surgeons should offer urethroplasty to patients with penile urethral strictures (Moderate Recommendation; Strength Grade C) Penile/Pendulous Strictures:
u Dorsal Onlay Urethroplasty:
u Most Experts agree Penile/Pendulous Strictures: u Dorsal Onlay Urethroplasty:
u Can be used in case of Hypospadias strictures.
u Can be done in staged fashion.
u Can also be fixed with modified Kulkarni style Exposure in one stage.
Meatal or Fossa N. Strictures: u Dilation?
u Meatotomy?
u Transurethral Ventral Onlay BMG: Bulbar Urethral Strictures:
u Excision and Primary Anastomosis(EPA):
u Very effective
u 88% to 95% patency long term
u May have Sexual Complications
u Buccal Substitution Urethroplasty(BMG):
u Very effective
u 88% to 95% patency long term
u May have Oral Morbidity
Long Urethral Strictures:
u Buccal Substitution Urethroplasty(BMG):
u Double Buccal Urethroplasty
u Very effective
u Even for long strictures
u Avoids the risk of Tension on repair.
u Nontransecting Augmented Urethroplasty:
u Very effective
u Combines Nontransecting EPA and BMG techniques
u Avoids the risk of Tension on repair.
Really long Strictures:
u Kulkarni Style Urethroplasty:
u Effective
u 80% patency long term
Urethral Stricture/stenosis
Location Posterior Anterior Panurethal of Stricture or Stenosis Bulbar Penile Fossa N. History of Hypospadiasɵ * TURBNC <2cm >2cm Transurethral no yes Ventral Onlay
EPAˠ Dorsal Staged Onlay Urethroplasty
Ventral Very long Or stricture Onlay One stage Double Penile Inversion Buccal Onlay Kulkarni * Consider Mitomycin C instillation during the time of TURBNC Or ˠ Employ caution as this technique has high sexual complication rate Operationµ ɵ Also applicable in the event that urethra is completely obliterated Roof Strip µ Dorsal Onlay Buccal Urethroplasty with Unilateral Urethral Dissection and Penile Inversion Through a Perineal Incision Buccal Onlay WARNING!!!!!!!
u The views are mine but I tried to be as objective as possible. I am sure my biases came out a bit. I hope the way I go about fixing urethral strictures make sense though. Out of Honduras