Center for Reconstructive Urethral Surgery Guido Barbagli Center for Reconstructive Urethral Surgery Arezzo - Italy

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1 Guido Barbagli Arezzo - Italy info@urethralcenter.it Website:

2 One-stage substitution urethroplasty

3 Oral mucosal grafts 22 cm x 2.5 cm

4 Oral mucosal grafts cheek lip tongue

5 Harvesting oral mucosal graft from the cheek Advantages Available in all patients Two grafts, thick, long and large Donor site scar is concealed Disadvantages Harvesting procedure may require nasal intubation or special retractor

6 Harvesting oral mucosal graft from the lip Advantages Available in all patients Harvesting procedure is simple and quick and does not require nasal intubation or special retractor Disadvantages One graft, thin and narrow Donor site scar is not concealed Negative aesthetic consequences

7 Harvesting mucosal graft from the tongue Advantages Two grafts available in all patients Donor site scar is concealed The harvesting procedure is simple and quick and does not require nasal intubation or special retractor Disadvantages The grafts are thin Few reports in the literature

8 The use of oral mucosa in urethral surgery Why? Its biological and histological characteristics Its elasticity, it is adaptable for any kind of urethroplasty (onlay-inlay) (one-stage - two-stage) In the literature (years ), articles on the use of oral mucosa for urethral reconstruction have been reported

9 The use of oral mucosa in urethral surgery Why? The patient doesn t want to be considered an exeperimental animal

10 Penile urethra Basically, the surgical technique for the repair of penile urethral strictures is selected according to stricture etiology

11 Etiology of penile urethral strictures Failed hypospadias repair Lichen sclerosus Trauma Instrumentation Catheter Infection Other causes

12 In penile urethral strictures due to: Failed hypospadias repair Lichen sclerosus The penis is abnormal: two-stage repair

13 In penile urethral strictures due to: Trauma Instrumentation Catheter Infection Other causes The penis is normal: one-stage repair

14 One-stage penile urethroplasty Flap or graft?

15 One-stage flap urethroplasty ORANDI JORDAN McANINCH

16 Dartos fascial flap with skin island

17 Jordan s flap Penile urethral stricture involving external urinary meatus

18 Jordan s flap

19 Jordan s flap

20 Jordan s flap

21 Jordan s flap

22 Jordan s flap

23 Dorsal Orandi s flap Penile urethral stricture in the middle part of the shaft

24 Dorsal Orandi s flap

25 Dorsal Orandi s flap

26 Dorsal Orandi s flap

27 Dorsal Orandi s flap

28 Dorsal Orandi s flap

29 Dorsal Orandi s flap

30 Asopa s graft Penile urethral stricture involving the external urinary meatus or located in the middle part of the shaft

31 Asopa s graft

32 Asopa s graft

33 Asopa s graft

34 Asopa s graft

35 Asopa s graft

36 One-stage penile flap or graft urethroplasty Results patients type of repair success 18 flap 66.7% 22 oral graft 81.8% 23 skin graft 78.3% Barbagli G. et al, BJU Int 2008

37 flap? graft Basically, the choice between flap or graft one-stage urethroplasty should be made according to the status of the urethral plate and according to the surgeon s background, training and preference

38 Bulbar urethra Basically, the surgical technique for the repair of bulbar urethral strictures is selected according to stricture length

39 Which type of urethroplasty? 1-2 cm: end-to-end anastomosis 2 4 cm: augmented anastomotic repair > 4 cm: substitution urethroplasty stricture associated with local adverse conditions: two-stage urethroplasty

40 Bulbar substitution urethroplasty using oral mucosa graft Surgical tips and tricks

41 Two surgical teams work simultaneously

42 Two sets of surgical instruments Oral mucosa Urethroplasty

43 Appropriate mouth retractor Only one assistant is needed to harvest the oral graft

44 Advantages of the double team decrease in surgical time of ~ one hour decrease in contamination in surgery provides training opportunity for the young assistant interested in learning urethral surgery

45 > 4 cm bulbar urethral stricture Substitution urethroplasty

46 Substitution urethroplasty ventral dorsal

47 Ventral onlay graft urethroplasty

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53 Results of 143 patients who underwent ventral oral mucosal onlay graft urethroplasty Mean follow-up 38 months ( months) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% success 126 (88.1%) failure 17 (11.9%)

54 Dorsal onlay graft urethroplasty

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63 Results of 19 patients who underwent dorsal oral mucosal onlay graft urethroplasty Mean follow-up 52 months ( months) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% success 14 (73.7%) failure 5 (26.3%)

64 One-sided Anterior Urethroplasty: A New Dorsal Onlay Graft Technique Sanjay B. Kulkarni and G. Barbagli BJU Int, 2009, in press

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73 Results of 24 patients who underwent one-sided anterior urethroplasty Mean follow-up 22 months (12 55 months) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% success 22 (91.6%) failure 2 (8.4%) BJU Int, 2009, in press

74 Onlay urethroplasty End-to-end Augmented repair ventral graft dorsal graft 88.4% 88.1% 79.2%

75 No traumatic urethral strictures: to transect or not to transect the urethra? That is the question!

76 To transect! End-to-end or augmented repair

77 To not transect! Ventral Dorsal Substitution onlay graft urethroplasty

78 Scientific Session at the AUA Annual Convention Chicago, USA - April 25-30, 2009 Topics to be presented and discussed: Failed hypospadias repair presenting in adults: a new outbreak? Bulbar urethroplasty: to transect or not to transect the urethra? Does penile length affect surgical steps and outcome of posterior urethroplasty?

79 Conclusions Reconstructive surgery for urethral strictures is continually evolving and the superiority of one approach over another is not yet clearly defined The reconstructive urethral surgeon must be fully able in the use of different surgical techniques to deal with any condition of the urethra at the time of surgery

80 Next month, this lecture will be fully available on our website Thank you!