Sanjay Kulkarni

Lichen Sclerosus of the Male Genitalia and Urethra: Surgical Options and Results in a Multicenter International Experience with 215 Patients

BACKGROUND Surgical options in male patients with genital lichen sclerosus (LS) involving the anterior urethra still represent a challenging issue. OBJECTIVE To review the outcome of surgical treatment in patients with genital and urethral LS. DESIGN, SETTING, AND PARTICIPANTS Multicenter, international, retrospective, observational descriptive study performed in two specialized centers. Two hundred fifteen male patients underwent surgery for histologically proven genital LS involving the foreskin and/or the anterior urethra. INTERVENTION Circumcision (34 cases), meatotomy (15 cases), circumcision and meatotomy (8 cases), one-stage penile oral mucosal graft urethroplasty (8 cases), two-stage penile oral mucosal graft urethroplasty (15 cases), one-stage bulbar oral mucosal graft urethroplasty (88 cases), and definitive perineal urethrostomy (47 cases). MEASUREMENTS Primary outcome was considered a failure when any postoperative instrumentation was needed, including dilation, or when recurrence was diagnosed. RESULTS AND LIMITATIONS The average follow-up was 56 mo (range: 12-170 mo). Circumcision showed 100% success rate with no recurrence of the disease; meatotomy, 80% success rate; circumcision and meatotomy, 100% success rate; one-stage penile oral mucosal graft urethroplasty, 100% success rate; two-stage penile oral mucosal graft urethroplasty, 73% success rate; one-stage bulbar oral mucosal graft urethroplasty, 91% success rate; and definitive perineal urethrostomy, 72% success rate. Limitations include short follow-up for recording neoplastic degeneration and no instrument to investigate quality of life. CONCLUSIONS Patients with LS disease restricted to the foreskin and/or external urinary meatus showed a high surgery success rate. In patients with penile urethral strictures or panurethral strictures, the use of one-stage oral graft urethroplasty showed greater success than the staged procedures.

One-sided anterior urethroplasty: a new dorsal onlay graft technique.

To investigate the feasibility, tolerability, safety and efficacy of using a new surgical technique for the repair of anterior urethral strictures to preserve vascular supply to the urethra and its entire muscular and neurogenic support.

A geographic analysis of male urethral stricture aetiology and location.

The incidence of specific aetiologies of urethral stricture disease has been reported from a variety of series throughout the world. Most reported urethral stricture series are from single institutions or from a specific region of the world. We provide a multi‐centred series to compare aetiologic incidence between differing regional populations.

Management of Panurethral Stricture Disease in India

PURPOSE Panurethral stricture involving the penile and bulbar urethra is a common urological problem on the South Asian subcontinent. It represents a particularly difficult challenge to manage and there is a relative paucity of literature on the subject. In India lichen sclerosus is the most common etiology of panurethral stricture, followed by iatrogenic causes. We present our experience with panurethral stricture repair using 1-stage, 1-side dissection dorsal onlay repair with oral mucosa grafts. MATERIALS AND METHODS We retrospectively reviewed the records of 117 consecutive men who underwent treatment for panurethral stricture from June 1998 to December 2010. Median patient age was 47.8 years, mean stricture length was 14 cm and median followup was 59 months. The stricture was approached through a perineal incision, limiting dissection to only 1 side of the urethra. The penis was invaginated to provide access to the entire length of anterior urethra in 1 stage. Two oral mucosal grafts were placed dorsally. RESULTS The outcome was considered a success if the patient required no further instrumentation, including dilation or urethrotomy. The overall success rate was 83.7% with a success rate of 86.5% for primary urethroplasty and 61.5% in patients in whom urethroplasty had previously failed. Most recurrent strictures developed at the proximal end of the graft. CONCLUSIONS Repair of panurethral stricture in 1 stage with 1-side dissection and dorsal onlay of oral mucosa graft is a minimally invasive technique that is simple, fast, safe, effective and reproducible by any surgeon.

A Multi-institutional Evaluation of the Management and Outcomes of Long-segment Urethral Strictures.

OBJECTIVE To evaluate the treatment options and surgical outcomes of long-segment urethral strictures-a review of the largest, international, multi-institutional series. METHODS A retrospective review was performed of patients treated with strictures ≥8 cm at 8 international centers. Endpoints analyzed included surgical complications and recurrence. RESULTS Four hundred sixty-six patients were identified. Treatment intervals ranged from December 27, 1984 to November 9, 2013. Dorsal onlay buccal mucosal graft (BMG) was the most common procedure (223, 47.9%); others included first- and second-stage Johanson urethroplasty (162 [34.8%] and 56 [12%], respectively), fasciocutaneous (FC) flaps (8, 1.7%), and a combination flap and graft (17, 3.6%). Overall success was achieved in 361 patients (77.5%) with a mean follow-up of 20 months. Second-stage Johanson urethroplasty was found to have a higher recurrence rate compared with that of 1-stage BMG urethroplasty (35.7% vs 17.5%, respectively; P <.01). This was also true in cases of lichen sclerosus (14.0% vs 47.8%, respectively; P <.01). Otherwise, success rates were similar. Urethroplasties performed with FC flaps had a higher complication rate compared with those without (32% vs 14%, respectively; P = .02). Prior dilation or urethrotomy, higher number of prior dilations or urethrotomies, abnormal voiding cystourethrogram, and skin grafts all portend a higher recurrence rate. On logistic regression analysis, only second-stage Johanson had an increased odds ratio of recurrence compared with that of BMG (2.82 [1.41-5.86]). CONCLUSION Long-segment strictures can be treated with high success rates in experienced hands. BMG was more successful than second-stage Johanson urethroplasty. FC flaps, although successful, had high complication rates.

Posterior Urethral Stricture After Pelvic Fracture Urethral Distraction Defects in Developing and Developed Countries, and Choice of Surgical Technique

PURPOSE We compared posterior urethral strictures after pelvic fracture urethral distraction defects in India and Italy. MATERIALS AND METHODS We retrospectively analyzed the records of patients in India and Italy who underwent repair for posterior urethral stricture after pelvic fracture urethral distraction defect. We investigated etiology, emergency treatment type, the specialist involved in emergency treatment, the type of stricture resulting from trauma and primary repair, posterior urethroplasty techniques and results. RESULTS Of 255 patients with a median age of 33 years 117 (45.8%) and 138 (54.2%) were evaluated in India and Italy, respectively. In India the most common causes of pelvic fracture urethral distraction defects were pedestrian (35%), motorcycle (26.5%) and bicycle (12.8%) accidents. The most common emergency treatment was suprapubic cystostomy (79.5% of cases). Of the patients 70.1% were treated in emergency fashion by a surgeon and 85.4% had complex posterior urethral strictures. The most common technique was anastomosis with inferior and total pubectomy in 56.4% and 15.3% of cases, respectively. In Italy the etiology was mainly automobile accidents (39.2%). The most common emergency treatment was endoscopic realignment (49.2% of cases). Of the patients 92.7% were treated in emergency fashion by a urologist and 68.1% had simple urethral strictures. Perineal anastomosis and laser urethrotomy were the most used techniques (38.4% and 21.1% of cases, respectively). In India 92 cases (78.6%) were successful and 25 (21.4%) failed while in Italy 120 (86.9%) were successful and 18 (13.1%) failed. Median followup was 74 months (range 12 to 239). CONCLUSIONS Differences in emergency treatment for pelvic fracture urethral distraction defects influence the choice of delayed posterior repair and results.

Single‐stage reconstruction of complex anterior urethral strictures using overlapping dorsal and ventral buccal mucosal grafts

Study Type – Therapy (case series)

Complex posterior urethral injury

Abstract Objective: To assess treatment strategies for seven different scenarios for treating complex pelvic fracture urethral injury (PFUI), categorised as repeat surgery for PFUI, ischaemic bulbar urethral necrosis (BUN), repair in boys and girls aged ⩽12 years, in patients with a recto-urethral fistula, or bladder neck incontinence, or with a double block at the bulbomembranous urethra and bladder neck/prostate region. Patients and methods: We retrospectively reviewed the success rates and surgical procedures of these seven complex scenarios in the repair of PFUI at our institution from 2000 to 2013. Results: In all, >550 PFUI procedures were performed at our centre, and 308 of these patients were classified as having a complex PFUI, with 225 patients available for follow-up. The overall success rates were 81% and 77% for primary and repeat procedures respectively. The overall success rate of those with BUN was 76%, using various methods of novel surgical techniques. Boys aged ⩽12 years with PFUI required a transpubic/abdominal approach 31% of the time, compared to 9% in adults. Young girls with PFUI also required a transpubic/abdominal urethroplasty, with a success rate of 66%. In patients with a recto-urethral fistula the success rate was 90% with attention to proper surgical principles, including a three-stage procedure and appropriate interposition. The treatment of bladder neck incontinence associated with the tear-drop deformity gave a continence rate of 66%. Children with a double block at the bulbomembranous urethra and at the bladder neck-prostate junction were all continent after a one-stage transpubic/abdominal procedure. Conclusion: An understanding of complex pelvic fractures and their appropriate management can provide successful outcomes.

Management of Long-Segment and Panurethral Stricture Disease

Long-segment urethral stricture or panurethral stricture disease, involving the different anatomic segments of anterior urethra, is a relatively less common lesion of the anterior urethra compared to bulbar stricture. However, it is a particularly difficult surgical challenge for the reconstructive urologist. The etiology varies according to age and geographic location, lichen sclerosus being the most prevalent in some regions of the globe. Other common and significant causes are previous endoscopic urethral manipulations (urethral catheterization, cystourethroscopy, and transurethral resection), previous urethral surgery, trauma, inflammation, and idiopathic. The iatrogenic causes are the most predominant in the Western or industrialized countries, and lichen sclerosus is the most common in India. Several surgical procedures and their modifications, including those performed in one or more stages and with the use of adjunct tissue transfer maneuvers, have been developed and used worldwide, with varying long-term success. A one-stage, minimally invasive technique approached through a single perineal incision has gained widespread popularity for its effectiveness and reproducibility. Nonetheless, for a successful result, the reconstructive urologist should be experienced and familiar with the different treatment modalities currently available and select the best procedure for the individual patient.

Harvesting oral mucosa for one-stage anterior urethroplasty

Oral mucosa has been the most popular substitute material for urethral reconstructive surgery because it is easy to harvest, is easy to access, has a concealed donor site scar, and obviates most of the problems associated with other grafts. However, the success of using oral mucosa for urethral surgery is mainly attributed to the biological properties of this tissue. Herein, the surgical steps of harvesting oral mucosa from the inner cheek are presented with an emphasis on tips and tricks to render the process easier and more reproducible and to prevent intra and post-operative complications. The following steps are emphasized: Nasal intubation, ovoid shape graft, delicate harvesting leaving the muscle intact, donor site closure and removal of submucosal tissue.