Urethral Stricture Management in the 21st century.

MAXX GALLEGOS MD DIRECTOR OF UROLOGIC RECONSTRUCTION ASSOCIATE RESIDENCY PROGRAM DIRECTOR : 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 ? 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 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 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 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 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