Japanese Neurogenic Bladder Society Meeting. Kofu - Japan. September 29th - October 1st, 2010

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2 Japanese Neurogenic Bladder Society Meeting Kofu - Japan September 29th - October 1st, 2010

3 Reconstruction of penile and bulbar urethra

4 Evaluation of anterior urethral stricture Urethrography Retrograde Voiding Ultrasonography Urethroscopy

5 Evaluation of anterior urethral stricture Site Number Length Spongiofibrosis Associated conditions

6 Retrograde urethrography Site penile or bulbar? bulbar: distal or proximal?

7 Retrograde urethrography Number single or double? penile and bulbar?

8 Retrograde urethrography Length

9 Retrograde urethrography Spongiofibrosis wide urethral plate scarred urethral plate

10 Retrograde urethrography No-obliterative obliterative

11 Retrograde urethrography Associated conditions diverticulum stone

12 Voiding urethrography retrograde voiding

13 Voiding urethrography retrograde voiding

14 Voiding urethrography delayed treatment retrograde voiding No-delayed treatment

15 Voiding urethrography in patients who underwent bulbar urethroplasty: evaluation of the result good satisfactory poor

16 Urethral sonography

17 Stricture length and spongiofibrosis

18 Urethroscopy No-obliterative obliterative obliterative

19 The pre-operative evaluation of urethral stricture using all these standard investigations showed 2% of failures, and the intra-operative management of stricture may present different features.

20 Anterior urethral stricture Urethrotomy or urethroplasty? Easy and quick procedure or complex and long procedure?

21 Stricture etiology Urethrotomy? NO failed hypospadias repair lichen sclerosus traumatic stricture YES congenital instrumentation infection unknown

22 Success rate of urethrotomy based on stricture etiology congenital 66% trauma 16% Pansadoro V. and Emiliozzi i P, J Urol 1996; 156:

23 Success rate of urethrotomy based on stricture site penile urethra 16 % bulbar urethra 42 % Pansadoro V. and Emiliozzi i P, J Urol 1996; 156:

24 Success rate of urethrotomy based on stricture length stricture < 1 cm 71% stricture > 1 cm 18% Pansadoro V. and Emiliozzi P, J Urol 1996; 156:

25 Associated adverse conditions stent t tumor Urethrotomy stone diverticulum abscess fistula

26 How many times can I repeat urethrotomy?

27 It depends on how long the patient has been disease-free < 1 year I can t > 1 year I can

28 Which type of urethroplasty?

29 Preparation of the patient for oral mucosa urethroplasty Two teams work simultaneously Two sets of finstruments t

30 Appropriate mouth retractor with its own light

31 Only one assistant is needed to harvest the oral graft

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

33 Etiology of penile urethral strictures Trauma Instrumentation Catheter Infection Other cause Failed hypospadias repair Lichen sclerosus

34 In penile urethral strictures due to: Trauma Instrumentation Catheter Infection Other cause The penis is not involved in the urethral disease: one-stage repair

35 In penile urethral strictures due to: Failed hypospadias repair Lichen sclerosus The penis is fully involved in the urethral disease: two-stage repair

36 One-stage penile urethroplasty Flap or graft?

37 One-stage flap urethroplasty ORANDI JORDAN McANINCH

38 Dartos fascial flap with skin island

39 Jordan s flap Penile urethral stricture involving external urinary meatus

40 Jordan s flap

41 Jordan s flap

42 Jordan s flap

43 Jordan s flap

44 Jordan s flap

45 Orandi s modified flap Penile urethral stricture in the middle tract of the shaft

46 Orandi s modified flap

47 Orandi s modified flap

48 Orandi s modified flap

49 Orandi s modified flap

50 Orandi s modifed flap

51 Orandi s modified flap

52 Asopa s graft Penile urethral stricture involving external urinary meatus or in the middle tract of the shaft

53 Asopa s graft

54 Asopa s graft

55 Asopa s graft

56 Asopa s graft

57 Asopa s graft

58 Complications following one-stage penile urethroplasty penile hematoma skin necrosis fistula penile-glans torsion sacculation meatal stenosis

59 One-stage penile flap or graft urethroplasty Results patients type of repair success 18 flap 66.7% 22 oral graft 81.8% 8% 23 skin graft 78.3% Barbagli et al, BJU Int 2008; 102:

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

61 Two-stage urethroplasty using oral mucosal graft Penile urethral stricture in patient with failed hypospadias repair or lichen sclerosus

62 First stage

63 Complications following the first stage of urethroplasty 10-39% of patients showed scarring of the initial iti graft, requiring i new grafting procedures Barbagli G et al, Eur Urol 2006; 49:

64 Second stage

65 Second stage

66 Complications following the second stage of urethroplasty fistula glans dehiscence meatal tlstenosis 30% of patients showed complications following the second stage of urethroplasty, requiring surgical revision Barbagli G et al, Eur Urol 2006; 49:

67 Two-stage penile urethroplasty using oral graft is not a simple procedure and requires great expertise to avoid a lot of traps Moreover, this two-stage procedure, also in the hands of the skilled surgeon, showed a high complication rate, either following the first stage or the second stage Barbagli G et al, Eur Urol 2006; 49:

68 Bulbar urethra Basically, the surgical technique for the repair of bulbar urethral strictures tit is selected tdaccording to the stricture length

69 Preparation of the patient for bulbar urethroplasty Simple lithotomy position Allen stirrups Sequential inflatable compression sleeves

70 Preparation of the patient for bulbar urethroplasty Pre-operative urethroscopy Insert Sensor guide wire

71 Preparation of the patient for bulbar urethroplasty Inject methylene blue inside the urethra (G. Webster)

72 Preparation of the patient for bulbar urethroplasty Calibrate the distal urethra Identify the distal stricture site

73 Which type of bulbar 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

74 1-2 cm bulbar urethral stricture End-to-end anastomosis

75 End-to-end anastomosis

76 End-to-end anastomosis

77 Results on 153 patients who underwent end-to-end anastomosis Mean follow-up 68 months 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% success 139 (90.8%) failure 14 (9.2%) Barbagli G et al, J Urol 2007; 178:

78 2-4 cm bulbar urethral stricture Augmented anastomotic repair using oral graft

79 Augmented anastomotic repair using oral graft

80 Augmented anastomotic repair using oral graft

81 Augmented anastomotic repair using oral graft

82 Results on 24 patients who underwent augmented anastomotic repair using dorsal oral mucosal graft Mean follow-up 31 months 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% success 19 (79.2%) failure 5 (20.8%) Barbagli G et al, Eur Urol 2008; 53:

83 > 4 cm bulbar urethral stricture Substitution urethroplasty

84 Substitution urethroplasty ventral? dorsal

85 Ventral onlay graft urethroplasty

86 Ventral onlay graft urethroplasty

87 Results on 93 patients who underwent ventral onlay graft urethroplasty with oral mucosa Mean follow-up 36 months 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% success 85 (91.4%) failure 8 (8.6%) Barbagli G et al, Eur Urol 2008; 53:

88 Dorsal onlay graft urethroplasty

89 Dorsal onlay graft urethroplasty

90 Dorsal onlay graft urethroplasty

91 Dorsal onlay graft urethroplasty

92 Dorsal onlay graft urethroplasty

93 Results on 22 patients who underwent dorsal onaly graft urethroplasty with oral mucosa Mean follow-up 41 months 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% success 17 (77.3%) failure 5 (22.7%) Barbagli G et al, Eur Urol 2008; 53:

94 Ventral onlay graft No-traumatic uncomplicated proximal bulbar urethral strictures 3-4 cm in lenght with limited spongiofibrosis

95 Dorsal onlay graft No-traumatic long distal bulbar urethral strictures

96 Bulbar urethral stricture associated with local adverse conditions i Two-stage urethroplasty

97 First stage: perineal urethrostomy Barbagli G et al, J Urol 2009; 182:

98 First stage: perineal urethrostomy Barbagli G et al, J Urol 2009; 182:

99 Webster s technique Barbagli G et al, J Urol 2009; 182:

100 Barbagli G et al, J Urol 2009; 182:

101 First stage: perineal urethrostomy Barbagli G et al, J Urol 2009; 182:

102 First stage: perineal urethrostomy Barbagli G et al, J Urol 2009; 182:

103 First stage: perineal urethrostomy Barbagli G et al, J Urol 2009; 182:

104 First stage: perineal urethrostomy

105 Second stage: closure of perineal urethrostomy

106 Second stage: closure of perineal urethrostomy

107 Second stage: closure of perineal urethrostomy

108 Second stage: closure of perineal urethrostomy

109 Results on 62 patients who underwent two-stage urethroplasty Mean follow-up 84 months 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% success 38 (61.3%) failure 24 (38.7%)

110 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

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