Conclusion

Pelvic fracture and straddle urethral injuries are no longer the hopeless problem that burdened the urological surgeon in prior decades. Optimal outcome still depends on an early, accurate diagnosis including an understanding of the type of injury, the associated comorbid events, and a flexible approach to the method of management. Type I and partial type II urethral tears are indisputably best managed initially by a stenting urethral catheter or suprapubic cystotomy. The complete type II and...

Flap Classification

Flaps can be classified either by their vascularity or their elevation techniques. Flap classification based on vascularity includes random and axial flaps 9 . A random flap (O Fig. 4.9) does not have a defined cuticular vascular territory it is carried on the dermal plexuses and its dimensions can vary greatly between individuals and body sites. An axial flap (O Fig. 4.10) has a defined vessel in its base. Fig. 4.7A-E. Illustration of the first-stage mesh graft urethroplasty (as described by...

Info

Great care is also needed in the use of any sort of permanent device, either the Urolu-me or the Memotherm device. These should not be used in children and should be avoided in young adults. The majority of strictures in this age group are in any case treated more easily by single-stage urethroplasty procedures. The use of permanent epithelial covering stents should be limited to the bulbomembranous urethra, with the possible exception of carefully selected...

The Use of Flaps in Urethral Reconstructive Surgery

Urethral Surgeries

Physical Characteristics of the Flap - 131 Flap Vascularity - 131 Mechanics of Elevation and Flap Transfer - 131 Preoperative Evaluation and Preparation - 132 Surgical Technique - 133 Generalities of Using Nonhirsute or Epilated Skin Island Onlays Generalities of Using Penile Skin Islands - 134 Postoperative Course - 135 Although excision of a strictured anterior urethral segment with primary spatulated reanastomosis is the best and most durable repair, its application can be limited by the...

Surgical Positions

Surgical position and retraction are important for good results. Whenever possible, the patient should be in the supine or split leg position. The time spent in the litho- tomy or exaggerated lithotomy position should be minimized however, appropriate padding for the foot and positioning without pressure on the back of the leg will reduce the incidence of complications with the low lithotomy position. Venous compression stockings can be used for the supine, split leg, or low lithotomy...

References

Amenta PS (1987) Elias-Pauly's histology and human micro-anatomy. Piccin, Padua. pp 473-476 2. Martini FH, Timmons MJ (1995) Human anatomy. Englewood Cliffs, NJ, Prentice Hall, pp 689-696 3. Oelrich TM (1980) The urethral sphincter in the male. Am J Anat 158 229-246 4. Quartey JKM (1983) One-stage penile preputial cutaneous island flap urethroplasty for urethral stricture a preliminary report. J Urol 129 284-287 5. Quartey JKM (1992) The anatomy of the blood supply of penile skin and its...

Surgical Technique Early Realignment

The technique of early realignment can be accomplished either by open or endoscopic techniques. Open surgical realignment needs to be selectively chosen for injuries with marked urethral separation ( pie in the sky bladder ), concurrent vesicle neck or bladder wall lacerations, or the presence of rectal perforations where a colosto-my will be required. Open realignment entails surgical exploration of the retropubic space on day 5-7 when hemostasis is secure and the urine has been diverted with...

Superficial Arterial Supply

Subdermal Plexus

The superficial (superior) and deep (inferior) external pudendal arteries, branches of the first part of the femoral, supply the skin and subcutaneous tissues of the penis and anterior scrotal wall. In most bodies, the deep external pudendal is the dominant artery, but in a small proportion the superficial external pudendal is dominant. They pierce the deep fascia to run in the membranous layer of the superficial fascia across the femoral triangle to the base of the penis. Here they divide into...

Resecting the Stricture

Penile Stumps

The stricture is resected into the healthy corpus spongiosum, i.e., when blood begins to drip from the urethral stumps. Note that the spongiofibrosis may extend beyond the actual stricture itself, in which case it must also be resected (O Fig. 14.7). O Fig. 14.5. Incising the bulbocavernosus muscle O Fig. 14.7. Resecting the stricture O Fig. 14.5. Incising the bulbocavernosus muscle O Fig. 14.7. Resecting the stricture

Incising the Bulbocavernosus Muscle

The bulbocavernosus muscle is split down the middle and the urethral bulbus is laid open in the area of the stricture. Although the urethral injury is rarely the main problem of these often multiple and severely traumatized patients, consequences of the urethral trauma such as urethral strictures, erectile dysfunction, and sometimes urinary incontinence are potential problems with lifelong ramifications. The stricture may be localized using a 20-Fr curved metal probe or with a flexible...

Posterior Urethral Erosion and Tissue Loss

Posterior urethral erosion and tissue loss conditions with fistulization tend to be less extensive than anterior erosions and lend themselves to repair with salvage of urethra sphincter function. As noted above, these conditions can be associated with chronic Foley catheter drainage, but they also occur after urethral injury associated with surgical procedures on the urethra or bladder. The difference here seems to be partly related to our ability to close the urethra posteriorly with a sling....

Intrinsic Sphincter Deficiency

Intrinsic sphincter deficiency (ISD) is defined by gynecologists with urethral profile data. If the maximum urethral closure pressure is less than 20 cm (sometimes 10 cm) then ISD is said to be present 23 . These profile values reflect activity of the midurethral high-pressure zone of the urethra and not closure of the proximal sphincter area. As such the condition ISD as defined by video uro-dynamics and leak point pressure testing is not the same condition as that defined by urethral pressure...

Deep Fascia Bucks

Buck Fascia

The deep fascia penis (Buck's) binds the three bodies together in the pendulous portion of the penis, splitting ven-trally to ensheathe the corpus spongiosum, and is closely adherent to the tunica albuginea. Distally, it is attached to the coronal groove. Proximally, it covers the crura and bulb with their overlying corpora cavernosus and corpus spongiosus muscles. At the junction of the pendulous and fixed parts of the penis, the suspensory ligament, a thickened sling of the deep fascia from...

P

Pars pendulans 162, 199 patch graft 177 patient selection 148 pedicled skin flap 190, 193 pelvic - instability 72 pendulous penis 12 penetrating injury 62 penile - fasciae 146 -fascial anatomy 149 - stricture 196 penis curvature 199 perineal - approach 110 -incision 112, 134, 200 - pain 96 perineum 132, 134 periprostatic tissue 71 Peyronie's disease 15, 61 physical finding 72 pie in the sky bladder 73 plexus of Santorini 16 poor-quality skin 193 postauricular graft 22 posterior - - second stage...

Endoscopic Urethroplasty

13.4.2 Critical Assessment - 98 13.5 Endoscopic Treatment of a Complete Urethral Occlusion 14.5.2 Critical Assessment - 100 13.6 Conclusion - 100 References - 101 One of the traditional methods for treating urethral stricture is internal urethrotomy by endoscopy. Unfortunately, this method is accompanied by a high rate of relapse. Various authors report of relapse rates between 24 and 68 8, 12, 13, 16, 22, 85, 93, 101, 119 . For this reason, various endourological methods have been developed in...

Deep Venous System

Pudendal Vain Help Food

Sinusoidal veins empty into veins that run between the spongy tissue of the corpora cavernosa and the tunica albuginea, pass through the tunica as emissary veins in the proximal third of the penis and join to form two to five large, thin-walled cavernous veins on the dorsome-dial surface of the cavernosa in the hilum of the penis.6 They run posteriorly between the crus and the bulb deep to Buck's fascia and drain into the internal pudendal vein. Some cavernosal veins may drain directly into the...

Cautery

Both monopolar and bipolar cautery can be appropriate depending on the procedure. Monopolar cautery can be used in superficial structures, whereas bipolar is better during dissection around the corpus spongiosum, elevation of penile and scrotal flaps, division of the perineal intracorporal space, and dissection of the dorsal neurova-scular structures. Bipolar cautery is also used exclusively in penile cases such as reconstruction of the fossa navicu-laris or correction of penile curvature.

Visual Urethrotomy

Urethral Strictures

Since its introduction in 1973, visual urethrotomy is the standard therapy for anterior urethral strictures. It is performed in local or general anesthesia. The urethrotome is positioned in the 12 o'clock position to cut the stricture. Some surgeons prefer incisions in the 10 and 12 o'clock positions and others in the 2, 6 and 10 o'clock positions. These varying proceedings have to be seen in relation to the anatomic situation of the erectile nerves to protect the patient from secondary...

Surgery in Hypospadias Repair

Stage Hypospadias Repair

23.2 Incidence and Etiology of Hypospadias - 190 23.3 Indications and Operative Technique for Hypospadias Repair 23.4 Preoperative, Intraoperative, and Postoperative Management 23.5 Buccal Mucosa Urethroplasty - 191 23.5.1 Harvesting the Graft - 191 23.5.2 One-Stage Hypospadias Repair with Buccal Mucosa - 191 23.5.3 Two-Stage Hypospadias Repair - 193 23.5.4 Severe Hypospadias Cases - 193 23.6 Results of Hypospadias Repair - 193 References - 194 The first case report on the use of buccal mucosa...

Competent Proximal Urethral Sphincter

The most versatile procedure to close on open proximal urethra probably is a sling. The procedure is not done to achieve urethral support but rather to close the open urethra. In this circumstance, crossing the sling ends in front of the urethra provides more circumferential closure and seems to do so at lower pressures than a conventional posterior vector force uncrossed sling ( Fig. 7.7). This was first done in males with myelodysplasia where a standard sling failed to provide enough closing...

Selective Use of the Perineal Artery Fasciocutaneous Flap Singapore in Urethral Reconstruction

Basics of the Fasciocutaneous Flap - 154 Technique of Onlay Patch Urethroplasty - 156 Techniques of Tube Flaps Urethral Replacement Multistage Flap Urethroplasty - 158 Clinical Experience - 160 Complex bulbar and bulbomembranous strictures that are compromised by extensive periurethral fibrosis with avascular tissue beds, prior radiation, perineal decubitis, pelvic fracture, distraction defects greater than 6 cm or extensive perineal trauma present a surgical challenge that will not often...

Asymmetrical Penis

Circumcising the graft, special attention should be paid to ensure that the graft is well separated in the bulbous part and is not cut too widely, in order to prevent pouch-like diverticulation at this location (O Fig. 25.22). The neourethra is closed analogously to the method shown for the frontal stricture, using inverting running stitches, as an interrupted, running suture using 4-0 monofilament absorbable material (O Fig. 25.23). After the reconstruction of the neourethra, the penile shaft...

Jackknife Position

Jackknife Position Surgery

Patch plasty with buccal mucosa (alternative inner prepucial patch) We carried out buccal mucosa patch plasties in 22 cases and saw three relapsed strictures over a period of 7 years. Similarly satisfactory results were achieved in similar cases using one-stage penile flap urethroplasty in 18 cases, and two-stage posterior mesh-graft urethroplasty in 14 cases ( Fig. 14.26). All these methods are equally suited for reconstructing the posterior urethra today, buccal mucosa is...

Primary Urethral Obstruction

Diminish Scars Vaginal Area

Primary urethral obstruction is uncommon but a definite entity. The stricture process involves the distal urethra, and makes instrumentation difficult or impossible. The scar formation is circumferential, but is palpable posteriorly. The structured area impinges on the mid urethral sphincter zone but does not generally impair continence function. Often these patients have a history of repeated urethral dilations, and it is never clear whether the dila tions caused the problem or were necessary...

Jordan Flap Meatoplasty

Meatoplasty Penis

The ventral penile skin is dissected from the fascial pedicle in the plane between the superficial fascial plexus and the deep subdermal plexus of the skin ( Fig. 17.5). With the skin island oriented transversely, the broad dartos fascial pedicle is created from the entire Fig. 17.4. The ventral transverse skin island as described by Jordan. A urethrostomy defect is created to the level of normal urethra. The dimensions of the skin island is outlined transversely on the ventral...

Loss of Both Continence and Conduit Function Related to Neural Dysfunction

Urethral Reconstruction Surgery

Most neural lesions that result in loss of proximal urethral sphincter function are associated with decentralization of the bladder. That means there is no neural mechanism to drive urethral responses to either bladder filling or reflex detrusor contractile activity 4, 5 This is a situation identical to that encountered in most patients with myelodys- O Fig. 7.1. Upright cystography at a bladder volume of 300 ml as part of a video study from a patient with S1-S4 sacral root loss. Note the...

Triangular Ligament In Urethroplasty

Urethral Flap

The perineal artery medial thigh flap is a vertically oriented composite of skin, subcutaneous tissue, deep fascia, and adductor epimysium that measures 15x6 cm, with its proximal base in the male located at the level of the mid perineum 3 cm distal to the anal margin (O Fig. 19.1). The medial border is the crease of the groin lateral to the edge of the scrotum. Wee and Joseph 6 described the maximal safe dimensions of the flap as less than 6 cm in width from the base and 15 cm in length...

Urethral Closure

Ureter Reconstruction

In those cases where the proximal margin of the urethral erosion is the anterior bladder neck, or even more proximal bladder, secure closure depends on mobilization Fig. 7.11. A Preoperative study in a 34-year-old myelodysplastic patient incontinent around a Foley catheter placed because she could not manage intermittent catheterization. B Postoperative study after a crossed sling and ileovesicostomy. The bladder neck is closed and the ileovesicostomy provides for low pressure drainage Fig....

L Zinman MD

Sachse Urethrotome

The treatment of urethral stricture is among one of the oldest medical activities practiced by humankind. In approximately 600 bc, Egyptians and Indians used bougies made of wood, papyrus, feathers, and metal to widen constricted urethras. Early attempts at external urethrotomy (Aretheus, 80 ad) and internal urethral incision (Heliodorus, 90 ad, Opera chirurgica) are also described in the literature. In 1561, Ambroise Par developed a lead bougie with a file-like tip for internal urethrotomy....

Dvog Proximal Bulbar Urethroplasty

Meatotomy Repair

Configuration of the meatus is often lost with the dorsal Y-V flap procedure. 17.2.1 Isolated Stricture of the Fossa Navicularis Following Transurethral Resection of the Prostate Patients who present with an isolated meatal fossa stricture following transurethral resection of the prostate generally gain little from repetitive dilations however, reliable reconstruction of the meatus and fossa navicularis with nearly perfect functional and cosmetic results can be accomplished using several...

Endourethroplasty

Acunas B, Acunas G, Gokmen LC (1988) Ballon dilatation of iatrogenic urethral strictures. Europ J Radiol 8 214-216 2. Adkins WC (1988) Argon laser treatment of urethral stricture and vesicalneck contracture. Las Surg Med 6 600-603 3. Appel RA, Lebenson BS (1989) Endoscopic management of ure-throvesical anastomotic obliteration following radial retropubic prostatectomy. J Urol 142 818-820 4. Ashken MH, C. Coulange C, Milroy EJG, Sarramon JP (1991) European experience with the urethral wallstent...

10years Results Buccal Bulbar Urethroplasty 2015

Bulbar Urethroplasty Surgery Image

Scrotum, covering the proximal perineum and urethral reconstruction with the pudendal flap and transferring the scrotal bridge laterally O Fig. 19.5 . A small, round Jackson-Pratt suction drain that exits through the thigh incision is inserted for 4 days. The urethral catheter is removed in 10 days and the suprapubic diverting cystotomy in 3 weeks pending normal results on voiding cystourethrogram. A retrograde urethrogram is obtained every 3-6 months and repeat uroflows are checked every 4...

Urethrocystography Voiding

Catheter Lab Abnormal And Noramal Scans

Moudouni SM, Patard JJ, Manunta A et al 200l Early endoscopic realignment of post-traumatic posterior urethral disruption. Urology 57 628-632 2. Husman DA, Wilson WT, Boone TB, Allen TD l990 Prostatomem-branous urethral disruptions management by suprapubic cystotomy and delayed urethroplasty. J Urol l44 76-78 3. Podestai ML, Medek R Castera, Duarte A 1997 Immediate management of posterior urethral disruptions due to pelvic fracture therapeutic alternatives. J Urol 157 1444-1448 4....

Two Stage Meshgraft Urethroplasty

Mesh Graft

25.2 Basic Considerations in Complex Urethral Strictures - 206 25.4 Preparing for Surgery - 206 25.5.1 Posterior Urethroplasty - 207 25.5.2 Posterior Urethroplasty with Partial Replacement of the Urethra - 211 25.5.3 Complex Strictures Along the Entire Length of the Urethra -212 25.6 Tricks and Pitfalls in Mesh-Graft Urethroplasty - 214 25.6.1 Dressing Technique - 214 25.6.2 Postoperative Care - 215 Most uncomplicated strictures of the anterior and posterior urethra are successfully treated...

Marion Urethroplasty

Replacement Urethra

Flaps of omentum majus to cover the end-to-end anastomosis at the membranous urethra. The elasticity of the preputial skin was already being used for pediculated grafts to make a tube to create a new urethra by Rochet in 1899 and C. H. Mayo in 1901. But it was Duckett who introduced his transverse preputial island flap technique in 1980, a method that enabled a repair of long parts of the urethra in one session Fig. 2.6 . In contrast to pediculated flaps, the use of free grafts, pioneered...

Penile Circular Fasciocutaneous Flaps for Complex Anterior Urethral Strictures

Buck Fascia

18.1 Penile Fascial Anatomy - 146 18.4 Preoperative Preparation - 148 18.9 Postoperative Care - 152 References - 152 Surgical reconstruction of complex anterior urethral strictures, 2.5-6 cm long, frequently requires tissue-transfer techniques 1-8 . The most successful are full-thickness free grafts genital skin, bladder mucosa, or buccal mucosa or pedicle-based flaps that carry a skin island. Of the latter, the penile circular fasciocutaneous flap, first described by McAninch in 1993 9 ,...

Urethral Problems After Stress Incontinence Surgery

Urethral Sling Problems

Anterior colporrhaphy has a very low rate of postoperative voiding dysfunction, and almost never causes obstruction. On the other hand the procedure is rarely effective for stress incontinence. The needle suspension procedure, or variations of the Pereyra procedure, are not done very often because of a reported high failure rate over time. These procedures are also rarely obstructive, and most of the problems related to the procedure, other than a lack of efficacy, are inflammatory or...

Anterior Urethral Stricture Repair and Reconstruction in Hypospadias Cripples

Pars Pendulans Pars Membranosus

20.2 Patient Preparation for Surgery - 162 20.4 Surgical Procedures According to the Type of Stricture - Step by Step - 163 20.4.1 One-Stage Meatoplasty - 163 20.4.1.1 Buccal Mucosa or Foreskin Graft Urethroplasty - 163 20.4.2 Pedicled Flap Urethroplasty Jordan -164 20.4.3 Pedicled Penile Flap Urethroplasty Quartey-Orandi-Devine - 164 20.4.3.1 The Quartey Technique - 164 20.4.3.2 The Orandi-Devine technique - 164 20.4.4 Dorsal Buccal Mucosa Graft Barbagli -164 20.4.5 Two-Stage Buccal Mucosa...

Instrumentation

To minimize tissue injury from manipulation and permit more precise dissection in genital reconstructive surgery, appropriate instruments are those typically used for plastic or peripheral vascular surgery, including fine tenotomy scissors, fine forceps, skin hooks, and delicate needle holders. In addition, bougie a boule sizers V. Mueller are needed to check the caliber of the urethral lumen. McCrea urethral sounds are a good addition to the typical Van Buren sounds available in the usual...

Suturing the Bulbocavernosus Muscle

Posterior Urethroplasty

Finally, the bulbocavernosus muscle is reconstructed over the urethra. If there is enough cavernous tissue, it may be sutured across the anastomosis as a Turner-Warwick plasty. The wound is drained with suction drainage, and the perineal incision closed layer by layer Figs. 14.12, 14.13 . O Fig. 14.8. Spatulating the urethral stumps O Fig. 14.8. Spatulating the urethral stumps O Fig. 14.9. Suturing the posterior wall O Fig. 14.9. Suturing the posterior wall O Fig. 14.10. Suturing the anterior...

Environmental Strictures

Balanitis Xerotica Obliterans

Thermal, chemical, and electrical burns and exposure to radiation make up the environmental sources of urethral injuries that can lead to strictures. The emergency treatment of thermal burns to the genitalia is similar to that for any burn however, extensive debridement should be approached cautiously, with the goal of preserving as much viable tissue as possible. Thermal and chemical burns to the genitalia are treated similarly to any burn, whereas management of electrical burns to the...

Acute Management of Posterior Urethral Trauma

Rail Road Technique Urethral Injury

Although the urethral injury is seldom the main problem of these often severally and severely traumatized patients, consequences of the urethral trauma such as urethral strictures, erectile dysfunction, and in some cases urinary incontinence may be problems with lifelong ramifications for these patients. In this connection, primary urological treatment should be directed at preventing early complications and minimizing the risk of the aforementioned potential problems. A satisfactory outcome is...

Reconstruction of the Fossa Navicularis

Penile Block Technique

Reconstruction of Acquired Meatal Stenosis and Strictures of the Fossa Navicularis - 138 Reconstruction of Childhood Meatal Stenosis - 138 Isolated Stricture of the Fossa Navicularis Following Transurethral Resection Resurfacing of Fossa Navicularis - 139 Transverse Ventral Penile Skin Island - 139 Stricture Associated with Early Balanitis Xerotica Obliterans - 142 Stricture of the Fossa Navicularis with Redundancy of Dorsal Penile Skin - 142 17.1 Reconstruction of Acquired Meatal Stenosis and...

Diagnosis and Evaluation of Urethral Strictures

Normal Retrograde Urethrogram Images

Patients with urethral strictures most often present with obstructive voiding symptoms or urinary tract infections, such as prostatitis or epididymitis some will also present with urinary retention. On close inquiry, many of these patients have tolerated obstructive voiding symptoms for prolonged periods before progressing to complete obstruction. If a patient cannot void, an attempt should be made to pass a urethral catheter if the catheter does not pass, dynamic retrograde urethrography...