Chapters Transcript Video Male Urethral Reconstruction - Anatomy, Surgical Principles, and Evolving Techniques Laura Horodyski, MD Good morning, everyone. Um, I'm gonna go ahead and get started since we have interviews today. That way, hopefully, we can finish on time or a little bit early. Um, today I'm gonna be talking about male urethral reconstruction. We're gonna review anatomy, surgical principles, and some evolving techniques. So our objectives today, um we're gonna describe anatomy of the urethra, review causes of urethral stricture disease, review the AUA guidelines on the topic, discuss approaches to urethroplasties, and then also new treatments um for urethral stricture disease in men. So first I wanted to start with a review of anatomy. So, um, hopefully you can see my mouth moving. So the penile urethra um includes the fossa navicularis, also the meatus, the fossa is the kind of wide area, um, just below the urethral meatus, um, OK, yours is in, um, you want me to bring it to? Penting thanks. Um, Uh, And so this is divided from the bulbar urethra um at about the suspensory ligament of the penis. Um, this, the penile and bulbar urethra comprise the anterior urethra, and then beyond the bulbar urethra there's the membranous urethra. This is where the urethral sphincter is, um, and then behind that is the prostatic urethra which runs up to the base of the bladder. The membranous urethra and the prostatic urethra constitute the posterior urethra. Now, I wanted to also review kind of dorsal and ventral cause this is very important when we're talking about um graft placement or flat placement. So if we're looking at a cross section of the penile urethra, um we'll see like up or towards the corpora is dorsal and down is ventral. And then compared to the bulbar urethra, um, it's kind of the same orientation, but if you're looking um from the perineum far away from us, is dorsal and towards us is ventral. And one of the important differences between the um ventral and um I'm sorry, the penile and the bulbar urethra is the location of the urethral lumen within the corpus fungiosum. So in the penile urethra, the urethral lumen is pretty much in the middle, um, versus in the bulbar urethra, it's off center, it's more dorsal than ventral, um, and this is important when we're considering um where to place the graft. Now reviewing AUA guidelines, we should be considering urethral stricture disease in patients that have obstructive lower urinary tract symptoms, recurrent UTI or dysuria. We can do some non-invasive tests like Euroflow and PVR to help increase our suspicion. Uh, here's an example of a PVR curve, uh, which would be more flattened as compared to a normal nice curve where we're seeing good flow. But then to actually make the diagnosis of urethral stricture, we need something like a cystoscopy, voiding cystourethrogram, retrograde urethrogram, or urethral ultrasound. So most common I would say diagnosis is on cystoscopy, you see some narrowing kind of a annular ring like this, and then realize that you can't pass your scope through it. To assess the urethra a little bit more, sometimes we need to do a retrograde urethrogram. So I think a lot of the residents have done this positioning with me, but we do a modified lateral position, and this is important because there's a curve to the urethra. So if you don't have kind of an oblique view, it's gonna be hard to image where the curve of the urethra is. So my preference, I put a big gel roll under one hip and then the lower leg is bent at a 45 degree angle and the top leg is straight, and we want to have the penis pulled straight while capturing images. So here's a couple examples of rugs and kind of where we're envisioning um the areas of the urethra in each. So the one on the left we can see that there's a bull bar urethral structure and you can really appreciate in both of these with the oblique view you can see that there's a nice turn um of the urethra. Now, with retrograde urethrograms, it is difficult to visualize the posterior urethra because the sphincter is present. And so sometimes the sphincter can be a little bit confusing and it can almost look like a stricture in the posterior urethra. And so if there's confusion, there's a couple ways to go about this. This can be assessed with a camera like a ureteroscope. Um, if the cystoscope is too big to pass through the stricture, you can also do a voiding cystourethrogram, so you see the posterior urethra open. Here's an example of a retrograde urethrogram that's not a great image, so we can see here the penile urethra kind of has these folds in it. And so you can get some artifacts, so it's almost looks like a little bit of like sausage linking here, and that can actually that can be a stricture in this case it's just a fold, uh, but if he did have a stricture in the penile urethra, with the penis not pulled, you might also underestimate the stricture length. In this case we can see that there's a short stricture in the um in the bulbar urethra here. Reviewing ideologies of strictures, so most common is idiopathic. There also are usually if if we do have a culprit, it's something that causes inflam an inflammatory condition or decreases blood flow to the stricture. When I'm explaining this to patients, I tell them that the urethra is like an insulated pipe, and so anything that disrupts the insulation, so inflammation or something that decreases blood flow, then leads to stricturing. So things like sexually transmitted infection, like chlamydia or gonorrhea, um, these can be iatrogenic, so after surgery, most common with uh like a prostate procedure because of a prolonged time with a rigid scope. Uh, or TURBT also with radiation and trauma, so a straddle injury where someone falls and hits kind of underneath their, um, the perineal area that's gonna cause a bulbar stricture. Pelvic fracture can cause a condition called um where there's a disruption of the membranous urethra. This is referred to as PFUI or pelvic fracture urethral injury. Finally, you can have inflammatory conditions like lichen sclerosis. Now, the most common location of urethral strictures is bulbar, and some of these conditions have kind of characteristic locations. So sexually transmitted infection is usually anterior. Prior surgery, you can really have any location anywhere from meatas all the way to the bladder neck. For radiation, it's usually in near the field, so most of the time this is for either prostate cancer, bladder cancer, or rectal cancer. So you're gonna be looking somewhere in the proximal bulbar urethra or closer to the bladder. Trauma, as I mentioned, um, straddle injuries can cause bulbar strictures, and pelvic fractures cause membranous strictures, and lichen sclerosis, uh, is the most common cause of pan urethral stricture disease. This condition gives a stricture that starts at the muss and then moves proximately. A little bit more about lichen sclerosis. So I think a lot of times you, you can see this on exam, you see whitening, thickening of the skin, you can see neatal stenosis. It is important to remember that this is a pre-cancerous lesion. So, um, sometimes I, I've even seen cases where I was worried about penile cancer and it came back as lichen sclerosis. And a retrograde urethrogram in this case is going to show a um kind of this panurethral structure. So we see here that contrast is passing there pretty much the whole urethra is abnormal. There's kind of an area in the proximal bulbar urethra that looks a little bit wider, but overall it's quite narrow, and you can appreciate here in this photo on the right. If the urethral meatus is that small, you can imagine like the rest of the urethra can get also extremely tight and narrowed. Now, following the AUA guidelines, the recommendations for initial management of urethral stricture. So if it's an urgent setting, a patient's in retention, the emergency room, or you need to get a catheter in for surgery, you can kind of do anything that you need to do to um get the bladder drained. So whether that's dilation, DVIU, or a suprapubic tube placement, if you're treating it non-urgently, you want to know the length and the location of the stricture. If the patients depending on dependent on a catheter or CIC, you can consider doing a suprapubic tube for urethral rest. This is something that I really believe in because if you have someone who's catheterizing 3 times a week or has an indwelling catheter, when you go in with a camera, a lot of times you can kind of see where some stricture disease is present, but if you're doing a urethroplasty. The fact that the urethra has been kind of propped open by a catheter will cause you to underestimate the severity of the urethral stricture and might put you at increased risk of recurrence. They also recommend that you can remove a catheter after 72 hours following an uncomplicated DVIU or dilation. Again, with the guidelines, so recommendations for penile urethral strictures, for strictures of the meatus or fossa, you can do initially meatotomy or dilation, and you should offer urethroplasty if it recurs. I just want to back up and um make the point that in the guidelines, you can always offer urethroplasty first. You do not need to do endoscopic management. It's and then you should be offering urethroplasty in situations where the stricture does recur. And you should offer urethroplasty for penile strictures. This is because there's a very high recurrence rate with dilation or DVAU. This little blue, um, call it an ice pick dilator on the right, it's something that I use sometimes in patients that have metal strictures. It's tapered on one end and then gets a little bit wider and patients can self-caterize with it. Surprisingly, a lot of times patients that have recurrent um structure disease actually do really well using something like this. I think I find a lot of times that the hardest part of self-catheterizing is passing the catheter past the sphincter up into the bladder, and so, uh, doing intermittent catheterization or intermittent dilation with something like this where they're just going in through the Tip of the penis or into the penile urethra, a lot of times it's much better tolerated than actually having to fully self-catheterize to drain the bladder. Moving on to bulbar urethral strictures, so if the stricture is under 2 centimeters, the first treatment can be uh something endoscopic or straight to urethroplasty. Now we should be offering urethroplasties as the initial treatment for strictures that are 2 centimeters or longer, and then if DVIU or dilation fails, the next step you can either do a urethroplasty or a dilation with a drug coated balloon. That's if the stricture remains less than 3 centimeters. This is something called optoum that I'll touch on a little bit more later. They recommend not repeating DVIU or dilation. And then if the a patient's not a candidate for urethroplasty, you can consider clean intermittent catheterization as a means of maintaining urethral patency after dilation or DVIU. Going back to the patient discomfort, um, I will also say that when patients self-catheterize regularly, That also tends to lead to decreased pain. Uh, it seems like when they're passing the catheter and you, they meet resistance and have to kind of push past it, that tends to be more of a culprit for pain versus just kind of dilate uh passing the catheter to maintain the lumen's patency. Now, moving on to PFUI structures, so pelvic fracture, urethral injury. I like this little illustration on the left cause I think it gives a really good Kind of uh visualization of what can happen during urethral injury like this. So the prostatic urethra kind of just like separates from the bulbar urethra, you end up with a distraction, so it's not just a a stricture or a scar, the tissue actually separates from each other, which is one of the reasons that um the urethroplasty for these can be a little bit challenging sometimes. Preoperatively, you should use a rug with a VCUG or retrograde integrate cystoscopy for surgical planning. You wanna kind of um estimate how far apart the the lumens are from for each other. And then you should be performing delayed urethroplasty, not delayed endoscopic treatment. I think most of the time you can't do delayed endoscopic treatment because there's no lumen, um, but you shouldn't be trying. And then plan for reconstruction after the major injuries have stabilized and patients can be positioned in lithotomy. But for treatment of bladder neck contractures or vesicourethral anastomotic stenosis, so issues with the posterior urethra, prostatic urethra. Just wanna clarify some um uh These terms, so bladder neck contracture refers to cases where the prostate is still in place, so after a turp or after a hole up or robotic simple or whatever it may be, if there's scar tissue that forms then it would be called a bladder neck contracture. Vesicourethral anastomotic stenosis or VUAS refers to after prostatectomy, so, um, when there's narrowing in that case. The guidelines are pretty general for these recommending endoscopic treatment for either initially and then you can do a robotic or open reconstruction if it recurs. Graft use is recommended to be oral graft use for the first choice, uh with equivalent outcomes between buckle and lingual graphs. For longer strictures, you can reconstruct in a single stage or multi-stage, and then you can use a combination of graphs, fascio or fasciocutaneous flaps, kind of whatever is best for the patient and the surgeon's comfort. We recommend not doing hair bearing skin, using any allograft, xenograph, or synthetic materials, um. unless you're doing some sort of experimental protocol, and you should also not be doing a single stage tubularized graph. So this is referring to like taking a wider graph and then kind of like rolling or folding it into a tube in one stage. The outcomes for this are poor. For special situations, so like in sclerosis, you can biopsy if it's suspected, and you should biopsy if cancer is suspected. And in these cases, you need to use graft. So buckle is resistant to lichen sclerosis, so that's pretty much what what is exclusively used. You would never want to use um a fasciocutaneous flap from skin because it will restricture. For female urethral stricture, you can reconstruct with oral grafts, vaginal flap or combination. I think just thinking about this, it makes sense. You're not gonna wanna cut out a stricture and then anastomos the ends because the female urethra is already short. And for patients that require chronic CIC, you can offer urethroplasty if they have a stricture that causes difficulty with CIC. And finally, you can offer perineal urethrostomy as a long-term treatment, um, as an alternative to urethroplasty, and you should offer it to patients at high risk of failure for urethral reconstruction. So patients who have had multiple hyposphedia surgery, consider it with like sclerosis. And this is a um a question that sometimes appears on the in-service. They'll give you an example, they'll show a rug and give you a patient with multiple comorbidities. The rug shows a pretty long stricture somewhere in the penile urethra. They'll say the patient has cardiac issues and some other things. What's the best treatment in this situation, they're trying to get you to pick a perineal urethrostomy cause it's a shorter surgery, um, and less potential morbidity for the patient. Other guidelines, so patients should be referred to a specialist if their surgeon doesn't perform urethroplasty, and then you should be monitoring for recurrence after intervention, whatever it was, whether it's endoscopic or urethroplasty, um, usually this is with something like a uro flow, um, or sometimes cystoscopy. Moving on to surgical approaches, so we want to be considering the stricture length and the location. These are the two most important factors when trying to determine the plan for reconstruction. Then you'll be deciding whether you can do a one-stage repair or a two stage, and then if you're doing an anastomotic, you're either plasty or substitution, substitution referring to either a graft or a flop. So for penile urethral strictures, you're gonna either use a graft or a flap. This is because of the risk of COI. The bull bar urethra, if it's less than 2 centimeters, you can do anastomatic or substitution, and then if it's longer than 2 centimeters, you're gonna do substitution. For pelvic fracture, urethral injury, it's gonna be anastomotic. And then there's kind of less clear guidelines farther back, um, kind of more case specific. So placing a graph for a penile urethroplasty, you're going to place it dorsally, so it's gonna lie between the urethra and the corpora. Whenever you're placing a graft, you need to have a place for it to adhere to to get new blood supply. Um, so the corpora is commonly used. You can place a dorsal graft anywhere on the urethra, so when in doubt, dorsal is a great approach. So in this case, so pretend there's a structure here, you're gonna cut kind of right in the after mobilizing the urethra, you're gonna um open it, make a 12 o'clock incision into the urethral lumen, which kind of allows the area to spring open, and then you'll harvest a buckle graft and place it dorsally here and then anastomos it to the um the tuica of the um spongiosum and the urethral lumen. You have to fenestrate and quilt the graft in these cases, so because you're depending on the blood supply, you're gonna quilt it, so you're gonna throw stitches to adhere it to the corpora, and then the graft is also gonna be penetrated, so you will poke holes in it to avoid a hematoma building up behind it, which can then lead to poor healing. In the penile urethra, you're generally calibrating it to about 22 to 24 French. You can also use local flaps. So this is an example of an Arandi flop. I'm sorry, these pictures are a little funny to look at, but this is basically a vertical flap, and when you're developing a flap, the principle is you're dissecting the blood supply in two different planes that way you can then rotate the flap around and lay it in. So in this case, there there's an open urethral stricture, and then there's um um. An area outlined here on the penile skin that will then line up kind of with the penile urethra. And this is dissected that the dartos is dissected here, so, um, more laterally it's just dissected under the skin and then um more medially it's dissected down to bucks fascia, so you end up with like um the drtos being able to move and then that can be rotated over to cover the urethra. You can also do a propecial flop, so this is like a horizontal flop for patients that are uncircumcised, um, so similar principle where you're depending on the dartos on the side, um, the first side where you in inside kind of like you're doing a circumcision, you're gonna go all the way down to box fascia and then dissect that down. And then you'll, um, after isolating the skin that you need to take, you're going to go just under the skin, so you end up with uh a nice piece of darttos that will give the blood supply, and then you will divide this usually like at 12 o'clock, and then this can be rotated around and passed to wherever you need it. This can actually reach all the way down to the sphincter if you do enough mobilization. Um, this is a nice case from um last week, so, uh, an example here you can see that the um the Dartus is pretty beefy, I think, um. You almost don't realize how much tissue is under under there, but it it does work very well, um, and so then this is brought down from the penis into the bullbar incision and then rotated around. So, um, you have the dartus coming down with the prep piece kind of wrapped around and then you can see the catheter there. So for bulbar urethroplasty, one of the techniques that is, you know, very common and good to know about is excision and primary anastomosis. So this is for strictures that are less than 2 centimeters. So the idea is that you're cutting it out. You're going to spatulate either end um on opposite sides, and then you'll repair it, so it's kind of going to make like a diagonal incision so that if there's always a little bit of narrowing that occurs, you want the narrowing to um not cause a stricture recurrence. You can also do something called an augmented anastomotic urethroplasty. So this is where you would cut out the scar, but rather than satulating it on opposite sides, it would be satulated on the same side, and then you're gonna put a graft over top, that area that's satulated. This works if the scars uh of the stricture is a little bit longer. Um, usually in the bulbar urethra it's quite stretchy, so if you mobilize it, things can pretty easily reach, but if you're kind of on the fence about it, this is something that you can do. In general, I think there's been a little bit of a move away from doing anastomotic urethroplasties, um, just a lot of people are really trying to do more graft-based urethroplasties because Anytime you're doing anastomotic, you're just disrupting the um the blood flow that goes linearly down the urethra. If you're going to do a graft, you can do either dorsal or ventral um in the bulbar urethra. It's generally calibrated to about 24 to 26 French. So if you're gonna do it dorsally, it's gonna be very similar to a penile urethroplasty where you're gonna place um the graft on the corpora and quilt it there. Um, if you're going to do a ventral inlay, so dorsal onlay, you're putting it on the tissue, ventral inlay, you're gonna put it into the corpus fungiosum, so you would open up the fungiosum and the mucosa, um, and then put the graft in, um, attaching it to the mucosa, and then you're gonna close the uh spongiosum over top of it. You may choose dorsal versus ventral based on the location of the stricture, so, um, in this case, the stricture is quite proximal. When it starts to turn, sometimes it can be hard to see to do um a ventral inlay, so you might wanna choose dorsal in this case versus in this one, this is more like mid bulbar, and so if you open up the stricture, it's gonna be right in front of you and it's pretty easy to do a ventral inlay a little faster and takes less dissection. Some cases you need to do a two-stage urethroplasty, so this is um when the urethral plate is too narrow, this is most commonly is from lichen sclerosis because you also can't do a flap because there's um you can't use penile skin. The idea of having an adequate plate, so you need something to be able to sew the graph to, and you also don't want the graph to be like nearly a circle, cause that's very close to a tubularized um graph and then has worse outcomes. So in this case, you would open up the urethra in the midline and take a graft, um, usually like 2.5 centimeters wide or something like that, and then you're going to um You're gonna dissect down here, so you have corpora exposed and then you're just going to quilt the graft um onto this and you're gonna also bring the graft to the skin edge. These patients have to heal for 6 months and then they can get tubularized, so um you're gonna basically dissect between the the graft and the skin edge and mobilize that so you can close that in a couple layers. For pelvic fractures and urethral injury, like I mentioned before, so you need to um excise the scar. This is an example of an injury. So even though the membranous urethra is quite short, you can see with the distraction that there can be a pretty big distance that you have to cover. For these patients, these are the ones that are gonna be in hylothotomy, um, and you need to be able to see kind of underneath the pubic bone. The challenge is getting attention for anastomosis, so there's kind of a set of steps that you can use to help to um get the urethra to reach. So first you're gonna fully mobilize the bulbar urethra. This is gonna be to the suspensory ligament, then you can split the corpora. um, so here's an example. So you're, you have, um, It's not the greatest drawing, but it looks pretty. So, um, so you would be opening up the midline and then splitting the corpora. The idea is that you're making less space um or in a quicker turn for the bulbar urethra. So when you split the corpora that allows it to kind of tuck in sooner, um, then if that isn't adequate, you can resect the inferior pubic bone. Um, so here this would be an example, you'd be kind of opening this area up, um, and then usually that would allow it to reach. The last step, which I've personally never seen, is when you would reroute the urethra, so you would actually, um, bring it on the other side of either corpora to um decrease the distance, and apparently that can give you like an extra 1 centimeter. Looking at urethroplasty outcomes, so anytime the um repair is more complicated, there is a higher risk of recurrence. In general, um, an excision and primary anastomosis is about 90 to 95% success rate. Buckle graft is usually 85 to 90%, but if you're having to Something like a two stage or using a flap or um doing a pelvic fracture urethral injury where you have to um do a lot of mobilization. I think if you have to pass the corpora around the excuse me, the urethra around the corpora that can increase your risk of recurrence. Complications can include urethro cutaneous fistula, diverticulum, post-void dribbling or spraying. Spraying is very common if you do anything um to the fossa or urethromius. The risk of ED is reported to be at about 1% after one year. The risk is probably higher with excision and primary anastomosis versus a non-transecting graft or flat-based approach, and then there's also a risk of incontinence with pelvic fracture, urethral injury repair because the external sphincter is compromised. Here's an example of the urethrocutaneous fistula. You can see these two openings here. Um, and then there can also be graph site complications, pain most commonly, um, tightness, some numbness, occasionally impaired speech, but generally these heal very well. Now, there's kind of been some new evolving approaches, um, so this has come about because with traditional endoscopic management, the success rate isn't great. So it's usually if you're doing a less than 2 centimeter stricture in the bulbar urethra, the success rate is about 50%. Most patients recur. Um, in the 1st 6 to 12 months, and if they require then repeat endoscopic therapies, especially if it's after a short interval, um, the success rate becomes lower. So if they require a third DVIU or dilation within the first year, there's a 0% success rate at 4 years. So this has led to um exploring and developing the optimum which is drug coded balloon dilation. Optimum has a paclitaxel coating, and that's the big difference between it and conventional dilation. So this is an antimitotic chemotherapy agent, which is not absorbed systemically, so some patients get nervous when they hear about it. Um, and this is also used in vascular surgery, so, um, they use it for balloon angioplasty, um, mostly for peripheral artery disease and the lower legs. I think it's always very interesting when there's some technology pulled from another specialty and then brought into urology. This is what the balloon looks like, so this kind of white area is where the medication is. And the approval was based on the robust 3 trial, so this was looking at patients with recurrent anterior urethral stricture, less than 3 centimeters in length and less than 12 in diameter. They had to have an IPSS of at least 11 and a Qax of under 15 on Euro flow, and it was a prospective randomized trial with optimum compared to standard of care endoscopic treatment, either DVIU or dilation. And this study found that the freedom from retreatment was higher in optimum versus control, so it's about nearly 78% versus um about 24%. Uh, important to note that the study, the majority of the patients had bulbar urethral strictures. It was about, um, I think like 90 to 95% of them were bulbar strictures. So there's some people for sure have been using it in penile strictures, but there is definitely not as much data, but in the bulbar urethra, it definitely works very well. So if anyone is thinking about doing it, which I would encourage you, if you have someone who has a stricture and you're doing something else, this is an easy thing to add on if it's recurrent. Um, the main key if you do the procedure is you just want to get the medication to the tissue and then you don't want to do anything to disrupt that. So, in the study, all these patients were pre-dilated or had a DVIU of the stricture first. You want to align the balloon with the stricture, and you want to overlap it um by 0.5 centimeter to 1 centimeter on either side. I usually use the 24 French balloon for the penile urethra and the 30 French for anywhere else. There have been some studies that show the recurrence rate risk is higher for the smaller balloon. And then you want to go to a pressure of about 10 ATM, the medication starts to release after you get to 6. Key point, you don't want to go back in with a cystoscope after you deploy the balloon. You, anything that you can do to avoid the medication, um. Washing away is key. So, uh, the residents that have done this with me, they know like what you don't want to touch the balloon, there's a protective sheath that you pull back right before you put it inside. If I'm doing it um in a rug position, I don't go back in with the camera afterwards. If I'm doing it with a cystoscope, I try to turn down my flow, um, and then take the camera out once I get the balloon deployed. This stays in for 5 minutes, 10 minutes if you're doing it somewhere radiated, and then the patients need a catheter for 2 days, again, to keep the medication from washing away. Here's an example of um doing the optimum, so we can see um a bulbar stricture here. And the optimum has radio opaque markers, so I use bony landmarks to align things, and then the balloon will inflate. Usually you can see a waste earlier on if you um take floral images before you consistently maintain the pressure of 10 ATM. Another new area um of exploration is minimally invasive urethroplasty. This is something that has kind of been around and then kind of comes back, but I think that there have been development of new techniques and technology that make it easier now than it has ever been and more broadly applicable. One example is for a short distal penile urethral stricture, so this is something called a Nikollovsky urethroplasty. So the idea here is that we're gonna put holding stitches on the glands and kind of like a triangular configuration, and then basically do a ventral DVIU at at 6 o'clock and going all the way through the stricture into an area of normal urethra. Then there's gonna be a resection of kind of like a triangular shaped wedge of tissue from 3 to 9 o'clock, so you end up with a sort of like a triangular defect. Then you'll take a triangular shaped buckle graft and you'll pass um some small needles like a double armed suture through the apex of the graft, then you'll pass the same needle through the apex of the opening of the stricture, um, and then the graft gets parachuted in by pulling on these um sutures that were placed in the apex. And then once the graft is brought in, you will anastomose it to the skin and then also place some additional quilting sutures. Um, so in this case you end up with some knots that are tied on the uh um outside of the skin. Some people do a small skin incisions so the knots can be buried and then close over that. And then you're gonna leave a catheter in for about 2 weeks afterwards, I think. Maybe in this picture, although it's a little bit zoomed in, you can appreciate one of the challenges of this approach is the number of hands that you need helping for retraction. It's a little bit awkward, but it's really nice, especially for narrow strictures, because this can allow you to do a single stage approach um in cases that used to require a two stage, and it seems to work well. I mean, we need more data, but um so far the results have been good. There's also a technique um that Doctor Warner, who was here last year, was discussing, which was transurethral incision and transverse mucosal realignment. Unfortunately, it doesn't have a great acronym like HOA, it's tweeter T I TMR, um, and so this is primarily for bladder neck contracture or VUAS. And the idea of this is that there is the scar is open and then there's kind of a raw edge, um, and then a flap of bladder mucosa is advanced and then sutured down um after opening the stenosis. So this is the device that's used to do this. So, um, it's a special sheet that Doctor Warner designed, um, so you pass a flexible ureterscope through um a top portion and then there's a suturing device. Here that you'll be able to see with the ureterscope. Um, and when you deploy the suturing device, it passes a little needle, um, between the top side and the bottom side, and then there is like a PDS suture there. And then there's, um, a device that, um, essentially like places a clip, um, in lieu of tying a knot on the two ends to bring the tissue together. So this is an example. It's not the prettiest, but um you can see here you have an area of stenosis near the bladder neck, you're going to make an incision here. Um, and then with the suturing device, so you can see kind of the underside there, um, you'll grab on the proximal side, so grabbing some mucosa and then coming out, um, through the raw edge of the tissue, and then a second bite where you're coming from the raw edge of the tissue towards the more distal mucosa, and then you'll use um the not placing device um that's gonna push down and put this little metal clip there. Um, these patients do need to have a cystoscopy about 3 to 4 months afterwards to make sure that they have passed the clip in the urine. It's really tiny. The sutures should dissolve and they should pass it, but of course if they didn't, they could get a stone in the area. The success rates for this are very good for non-radiated patients like 85 to 90%, um, and if it has to be redone, it's up to 100% with the second procedure. So I think it's a really great option. Um, and this has also been expanded this device, um, beyond what many urologists are doing, but Doctor Warner actually only does minimally invasive urethroplasties, and he actually uses this, um, and other devices to pass graphs, so he'll do basically a DVIU and then, um, use a suturing device to place a graft and then parachute it in. Um, so the, the trick with placing the grafts is that you have to pass the needle out from somewhere in the skin. So whether that's somewhere in the penile urethra or somewhere in the bulbar urethra or if you're going posterior urethra that has to come up through the bladder, so it's a little bit um. I think challenging to conceptualize, um, but it's a really cool idea and um kind of path forward because doing a minimally invasive urethroplasty, like either of these two techniques, avoids some of the risks of traditional urethroplasty, especially urethrocutaneous fistula, and if the outcomes are good and, you know, it can be widely adopted, I think it's great. Finally, I'm gonna talk about um alternative graphs which have been explored. So the if patient is like a heavy um like chewing tobacco user, if there's not enough oral mucosa or if they've had mouth radiation, you may need to consider doing a graft from another site. This has been published so um retro oricular, so like behind the ear, um, you can take a non-hair bearing graft which is quite successful, use abdominal skin like near the ASIS, a split thickness skin graft which has lower success rates, um, bladder mucosa has been tried but has been found to have relatively high rates of restricturing, especially if it Um, goes all the way down to the meatus, uh, and then some people have actually explored using colonic or rectal mucosa, which has been shown to have 85% success. This is using something um called TEMS transanal endoscopic microsurgical technique. This is something that's used for anal and rectal cancer. Um, I thought it was very interesting looking, kind of reminds me of the SP setup, but, um, you see some places where you can pass the instruments and cannulas from, um, and then this can go in and take a strip of the rash of mucosa and then over sew it, I presume, um, and apparently you can get up to 15 or 20 centimeters in a single piece of graph. I think, um, I personally haven't done it, that this has really been pioneered by um someone named Doctor Vonnie up at Leahy Clinic. And um I think I'd be a little bit worried about complications from it, but it is a nice to have alternative options. All right, so, um, with that, I'm gonna wrap it up and take any questions. It was a great talk, uh, Laura, um, fantastic. So one of the thing that I want to bring up is, you know, yeah, I do agree, uh, this significant amount of uh some mucosal fibrosis in somebody who is smoking or even chewing tobacco and other stuff. So, invariably, I find that the lingual mucozy um is a good source of, um, uh, you know, uh tissue. Uh, somehow strangely, this lingual mucosa is not affected. Uh, by the, the smoking, so. No, yeah, so. Yeah. It's interesting cause you think that they would be very similar, but then if you harvest them like the it it does look different, you know, it's um the lingual mucosa is much thinner uh compared to the pole mucosa. Um, yeah, it's a little tin tissue, but something that is not affected by uh smoking. How much, how, what size of graft are you usually able to get from lingual mucosa? Meaning lengthwise, yeah, you can harvest on both sides. The only thing you need to uh We need to really make sure that we're not affecting the sublingual salivary lines, uh, which of course are not specifically like how you see the stencil duct. It's not very, uh, evident, but it's, but it's more on the floor of the oral mucosa and so you're not going to really affect the uh celebrity glands. You just gotta lift up the entire tongue out and then take a triangular, um. Uh, piece of mucosa, uh, bilaterally and, and I've used this, uh, very extensive antiurethral strictures where I could not really get good buckle mucosa and so yeah. Awesome. Thank you. All right. We'll go ahead and end there. Have a great day, everyone. Bye. Um, I just, uh, sorry, someone had a question, steroid injection, um, at the time of primary DVIU, um, so I know some people have tried it, um, to my knowledge, the data isn't great on it. Um, the idea is that you're trying to modify the um microenvironment of the scar and try to prevent restricturing. Um, uh, you know, I think it, it is an option if you're redoing it, I probably wouldn't recommend it and would just go to something like optimum, which has more proven efficacy, um. I think if you're people have done it like at the bladder neck as well, so um like a catalog or mitomycin, um, my preference because of the potential morbidity of mitomycin, um, and the steroids probably not being as effective. I actually prefer optimum in that area, um, and then if it recurs and they're non-radiated, I like the transurethral incision and mucosal realignment. All right, everyone, have a great day. Bye. Published November 13, 2025 Created by
