Kulkarni Sanjay - Art of Urethral Reconstruction

First Edition

Sanjay B. Kulkarni, MS, FRCS(UK), Dip Uro(London) Professor, Urology

KEM Hospital, Pune, India, Chief, Center for Reconstructive Urethral Surgery, Pune, India

Guido Barbagli, MD Head

Center for Reconstructive Urethral Surgery, Arezzo Italy

A division of Reed Elsevier India Private Limited

Anastomotic Urethroplasty for Posterior Urethral Trauma

Harvesting the oral mucosa graft (DID)

One stage ventral onlay graft bulbar urethroplasty muscle-nerve sparing technique (M)

Pelvic Fracture Urethral Distraction Defects (PFUDD)

Art of Urethral Reconstruction

Kulkarni and Barbagli

ELSEVIER

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Reed Elsevier India Private Limited

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2012 Elsevier

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ISBN: 978-81-312-3054-1

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For many years, urethral reconstruction was considered a complex problem for urologists, requiring complex position of the patient on the operative table (exaggerated lithotomy position), complex heavy retractor (Bookwalter retractor), and complex set of instruments (TurnerWarwick instruments). Only few urologists were trained and specialized in this surgery; the surgical procedures were not codified, and the choice of surgical techniques was primarily based on personal opinion and experience of surgeon. Introduction of new surgical approaches and techniques were infrequently reported. Moreover, the results, in the hands of a general urologist, were unsatisfactory with high incidence of postoperative complications. The surgical techniques suggested by the urologists involved in this difficult reconstructive field were difficult to understand and to reproduce in the hands of other urologists. For many years, simple urethral surgery was considered complex. The main aim of our work and this book is to transform complex surgery into simple, to render urethral surgery easily and safely reproducible in the hands of any surgeon.

This seems possible with the advent of new surgical instruments (e.g., simple retractor, silicone catheter, and excellent suture material), techniques, approaches, and substitute materials, and the widespread use of Internet.

In the past, urethral reconstructive surgery was mainly based on tissue transfer techniques using genital skin flaps. Today, genital skin flaps may be required occasionally in complex reconstructions.

In our book, we have not included the use of genital skin flaps because in the era of robotic surgery, we prefer to promote minimally invasive techniques to preserve penile cosmesis and anatomical and functional integrity of the genitalia.

Using the techniques we have presented in this book it will be possible to repair the majority of urethral strictures. With some modifications, these techniques may also be used in selected patients with failed hypospadias repair and lichen sclerosus, which represent the most difficult population to treat. Of course, modifications of these procedures are available in the literature or should be suggested by the reader.

Here we present the standard procedures for treating strictures in different parts of the urethra due to various etiologies.

We hope the book achieves its goal and is of use to the reader.

Sanjay B. Kulkarni, KEM Hospital, Pune, India, Center for Reconstructive Urethral Surgery, Pune, India

Guido Barbagli, Center for Reconstructive Urethral Surgery, Via dei Lecci, 22, 52100 Arezzo Italy

For many years, oral mucosa has been used in the reconstruction of oral and maxillofacial defects, in repairing the conjunctival mucosa of the eye, in oral pharyngeal reconstructive surgery, and in reconstructing vaginal defects.

In 1941, Humby described, in the British Journal of Surgery, the use of oral mucosa in an 8-year-old boy with penoscrotal fistula after failed hypospadias repair.

Current publications always credit Humby as being the first surgeon to perform urethroplasty with oral mucosa.

In 1992, Burger et al. re-introduced oral mucosa as a tissue source for urethroplasty procedures reporting its use in a canine and a small (six cases) clinical population.

A month after the results of Burger et al. were published, Dessanti et al. reported 8 combined bladder mucosa and oral mucosal grafts for hypospadias repair.

After Burgers and Dessantis articles, the use of oral mucosa graft was popularized mainly in pediatric urological reconstructive urethral surgery.

The first article on the use of oral mucosa for repair of penile and bulbar urethral strictures in adult patient was published in 1993 by El-Kasaby et al. from Egypt.

The modern era of the use of oral mucosa for anterior urethroplasty began in 1996, when Morey and McAninch fully described the technique of harvesting oral mucosa from the cheek, using a special mucosa retractor and stretcher.

The mouth is a valuable source of substitute mucosal material for urethroplasty. The urologist must be familiar with all of the various surgical techniques suggested for harvesting graft from the mouth. The oral mucosa is architecturally similar to the stratified squamous epithelium of the penile and glandular urethra, making it exceptionally adaptable for urethral substitution. The cheek is an irreplaceable donor site for any kind of one-stage bulbar onlay graft urethroplasty or for two-stage urethroplasty, when an abundant and resistant substitute graft material is required to replace a diseased penile or bulbar urethra. In adult patients, we do not use a graft from the lip because we have experienced negative aesthetic consequences; none of our patients were satisfied with the procedure performed using this harvesting site.

Some patients, who underwent oral mucosal graft urethroplasty, showed stricture recurrence requiring new grafting procedures. In these patients, urologists should consider tongue as an alternative donor site, when cheek harvesting is not possible. Moreover, the surgical technique for harvesting single or double oral grafts from the cheek or the tongue is simple, safe and reproducible in the hands of any surgeon, with no significant postoperative complications.